ARTES
LIBRARY
VERITAS
SCIENTIA
OF THE
UNIVERSITY OF MICHIGAN
TCEBOR
CIRCUMSPICE
The
George E. Wantz
(UM Medicine 1946)
Collection





HERNIA:
-ITS-
PALLIATIVE AND RADICAL TREATMENT
-IN-
Adults, Children and Infants.
By THOMAS H. MANLEY, A.M., M.D.
VISITING SURGEON TO HARLEM HOSPITAL, CONSULTING SURGEON TO FORDHAM
HOSPITAL, MEMBER OF NEW YORK ACADEMY OF MEDICINE, AMERICAN
MEDICAL ASSOCIATION, NEW YORK STATE AND COUNTY MEDICAL
ASSOCIATIONS, INTERNATIONAL MEDICAL CONGRESS,
PATH. SOCIETY, NATIONAL ASSOCIATION
OF RAILWAY SURGEONS,
ETC., ETC.
PHILADELPHIA, PA.:
THE MEDICAL PRESS CO., LIMITED,
1725 ARCH STREET,
1893.

aubman/Rare
BOOK Room
RD
621
M36
COPYRIGHTED 1893,
BY MEDICAL PRESS CO., LIMITED.

DEDICATION.
AS
S a tribute of respectful admiration to one, to whom, for his
many sterling traits, his unique genius, his tireless energy,
and his disinterested, but deep concern in my progress and ad-
vancement; both as his student, and as a practitioner; besides,
in grateful remembrance, for the many and inestimable favors,
which he has generously bestowed on me, during my life, I re-
spectfully dedicate this monograph; to my preceptor, Dr. Francis
Charles Plunkett, of Lowell, Mass.
NEW YORK, January 1st, 1893.


A
PREFACE.
S there has been a most noted revival in the study and treat-
ment of hernia, particularly within the past twenty years,
it is important for the rank and file, as well as the most
noted teachers of the surgical art, to have a clear comprehension
of the position which the question occupies at the present time.
My own reading and observations incline me to believe that
there is a very wide-spread misconception with regard to what a
hernia really is; its precise origin, and its morbid anatomy.
Thousands of onerations have recently been, and are being,
performed for its radical cure; some operators claiming that in-
telligent surgical intervention will cure all, while on the contrary
there are not a few, equally eminent, who deny that sanguineous
methods ever effect a permanent cure. In this chaotic state it is
but rational that we inquire just what surgery can do to relieve
the infirmity, without danger to the patient's life.
It is only too evident to any observer who has made a study
of the subject, that too much instrumentation-the indiscriminate
application of the truss in infants-is productive of as much or
more harm than too much operating in the adult.
The present aim of the writer is to endeavor to give to each
therapeutic resource its due merit, and strive to indicate the pre-
cise limitation of each. Necessarily, tautology will be unavoid-
able, as there is no word in our language which wholly defines
the condition for which the word hernia is commonly employed.
NEW YORK, June 27th, 1892.


PART I.
CHAPTER I.
GENERAL CONSIDERATION.
In these times of lightning progress, when steam, electricity
and the printing press have brought the whole civilized world
into an intimate communion of thought; when news, information
and knowledge, are flashed across a continent with as great ease and
promptness as from one city to another in the same county or
State, the whole world is becoming rapidly cosmopolitan in cus-
toms, manners and thought; and hence this diffusion of lay and
professional knowlege has rendered it easy for every one, to keep in
touch with the greatest revelations of science, and to be constantly
correctly informed of the best and latest achievements of those
who occupy advanced positions in the various scientific and pro-
fessional pursuits. So that now the garnering of material, of such
a character as will bring a treatise up to our own times, becomes
altogether a much easier task than was the case in the near past,
7

8
HERNIA.
when complete medical libraries were scarce and scattered, and
current general medical news was scarce and difficult to obtain.
Naturally, with a greater number, in proportion to our population,
of medical men in the field, and the increased facilities for compi-
lation and writing, this has become an age of book-making.
Notwithstanding this plethoric state of the book-market, there
never yet was a time when an opportunity for reward, for honest
substantial work, was greater than in ours.
Until the period when the antiseptic treatment of wounds
was introduced, there was a scarcity of standard works on
hernia.
With the exception of Astley Cooper's work there were few in
the English language, though several French and German
authors had published, from time to time, short, but very incom-
plete works on this subject. Cooper's work, too, deals with little,
except the morbid anatomy and treatment of the strangulated
variety.
Latterly, however, since surgeons have essayed to directly
attack and deal with the incarcerated and the reducible varieties,
many productions have been offered on the subject of hernial dis-
ease. Although restricted by the title to only the treatment of
the malady, yet in order to render this comprehensive and practi-
cable, etiology and morbid anatomy must necessarily be considered
here, though in abstract only, when possible. There are but few
American treatises on the subject of hernia, the history of the
malady being most commonly considered by our authors, as an
integral part of ordinary, surgical text-books.
At the present time, what is particularly desirable is to ascer-
tain, what the precise status of hernial treatment is; what class of
cases are curable; and, what incurable. With a view of endeavor-
ing to classify hernial cases, and by describing those which are
legitimate subjects for surgical intervention and those which are
not, and indicating the methods most appropriate in given cases
for treatment, this work is offered to the medical profession; the
views, opinions and deductions being based on a moderate expe-
rience in private and hospital practice, and on what could be
gathered through a diligent perusal of the latest literature,
domestic and foreign.
MILI

HERNIA.
9
The treatment of any given disease, infirmity or deformity,
mainly resolves itself into two principal divisions, viz., the radical
and the palliative, or that, in which the physical ailment or imped-
iment may be eradicated and the parts restored to their normal
structure and functional activity; and, that class of cases in which,
through organic changes or inherent, intrinsic conditions, a rever-
sion to full health is out of the question, an effort being directed
only to securing the greatest medium of comfort, and we so pre-
scribe remedies that not only is physical discomfort overcome but
the prospects of ultimate recovery are greatly enhanced. Hence,
we will see that to intelligently direct measures of relief or cure
of hernia, it is quite indispensable that we have a correct knowl-
edge of what may be properly designated its natural history,
or, as it is more commonly designated, the clinical history of hernia
and its causation. For without giving due importance to this,
it is easy to understand how one might be induced to institute
active surgical measures for the cure of a protrusion which,
under certain circumstances, if left alone might disappear of
itself.
Radical resort in hernial infirmity, then, may be instituted
for palliative purposes, as in cases in which the wandering viscera
may be so freed and restored that truss-pressure will readily and
safely confine them. And, per contra, in many, palliative agents
alone may occasionally effect permanent cures.
There is, however, not only a fundamental distinction in these
two phases of treatment, but an enormous difference in the con-
sequences resulting from them. For, when conservative measures
alone are judiciously employed in the reducible non-strangulated,
no harm can possibly result. But radical means, when the open
incision is resorted to, are not only attended with danger to life,
but as they always entail the division of supporting structures,
there can be no question but in many, improperly selected cases
the means instituted undoubtedly leave the part in a state favor-
able to a relapsing escape; and one more difficult to manage than
the original.
A general impression prevails that the detection of hernia,
its diagnosis and recognition, are simple. This is anything but
correct.

10
HERNIA.
"We must catch the hare before we can cook him," and let
it be remembered that we must first positively assure ourselves
that we are in the presence of
a genuine hernia before we pro-
nounce it as such, or attempt to
cure what may not exist. The
diagnosis is often attended with
great difficulties. Indeed, it may
be said that many pathological
conditions in the inguinal or in-
guino-femoral regions in the
male, and the inguino-labial re-
gions of the female, so strikingly
simulate hernia that it may be
utterly impossible to recognize
one from the other. A medical
practitioner not long ago came
under my observation, who had an oblong sausage-shaped mass in
his right inguinal region, which presented so many puzzling fea-
tures that, though carefully examined by several experienced sur-
geons, no accord of opinion was reached. I have seen more than
one spermato-hydrocele in the male adult tortured with truss-
pressure and the aponeurotic structures, so weakened by years of
pressure against them that, when the true state was discovered,
there was great danger of an intestinal protrusion making its
appearance after this was removed.
FIG. 1.
It is notoriously the case, that cysts are met with in the in-
fundibulum of the round ligament of the female, where it splits
up at the external aperture of the canal of Nuck, in the in-
guinal region. To the unwary or inexperienced, these might be
mistaken for hernia, and the unfortunate victim of them be
doomed to the painful embrace of a truss, to relieve her of a
mythical hernia, a disease; while a simple puncture would not
only give her mental rest, but likewise forever cure her of this
cystic affection.
It would be well if the pathological condition under consider-
ation could be defined by some more definite term than hernia,
for, strictly speaking, etymologically it means the offshoot or

HERNIA.
11
sprouting forth of something. A strict adherence to this defini-
tion would include neoplasmata, which might originate inside of
or within a canal, and present externally. A prolapse of the rec-
tum, bladder, or uterus, would also be included in the same cate-
gory. The common, vulgar term rupture, is wholly inappro-
priate, as there never is rupture of any structure whatever in any
description of hernia, if we except that variety in which its de-
velopment follows very great violence, immediately applied to the
abdominal walls.
In this instance nothing will be regarded as hernia, other
than that pathological state arising from the escape of some
organ or normal structure from within the cavity of the abdomen.
Hernia is essentially an infirmity or a deformity, without
doubt, in the majority of cases, of a congenital origin. Although
the mass itself may not always appear at birth, or at least be no-
ticed immediately after delivery, the causes which lead to it, non-
descent or mal-descent of the testis, want of obliquity in the
canal, prolapse of the infundibular process, etc., obstruction or
stenosis of the emunctory passages, etc., are there. It is in
essence a freak of evolution, one of the many so often observed
on a rigorous scrutiny at birth, and which, under a favorable en-
vironment, like the others, in the majority of cases will correct
itself and disappear with the growth and maturity of the body.

CHAPTER II.
CONGENITAL HERNIA AND THE HYGIENE OF INFANCY.
Hernia is quite common in newly-born males. In many it is
not of sufficient volume to attract notice until the first year is
past, and the youngster takes the upright attitude and com-
mences to walk. It usually is accompanied by no special symp-
toms, and only excites apprehension in the minds of the parents
by its size and position. At birth the spermatic vessels are deeply
covered by a thick layer of adipose tissue. The dartos and cre-
master are then highly developed, giving the scrotum dimen-
sions quite out of proportion in size to what they are in adult life.
Serous cysts of the tunica spermatica and of the tunica vaginalis
being very common, this condition also, with the scrotal fullness,
may mimic hernia so closely that it is only by a most pains-
taking examination we are enabled to exclude them. On the
other hand, a small fringe of omentum may come down
with the cord and be completely overlooked. In congenital
hernia proper, anatomical conditions favorable to visceral escape,
always tend to amelioration or permanent spontaneous cure in
12

HERNIA.
13
infancy and early childhood. It is a law of evolution, that
in the growth and development of the body, the economy will
invariably obliterate by assimilation or absorption such super-
perfluous structures as serve no physiological function. It is in
harmony with this law that the greater part of those diminutive,
simple, uncomplicated herniæ, undergo obliteration during the
period of early growth. The testis arrested in the inguinal canal
continues its journey downward to the base of the scrotum; the
vermicular action of the bowel and the contracting mesenteric
ligament aiding in directing upward and retaining the displaced
loop.
The change in the pelvic lines, curves and angles, and the
transmutation of tissue; the widening lumina of the emunc-
tory canals, in obedience to the incessant though intermittent
movement of their contents, each and all contribute their share
towards effecting a symmetry of perfection, and the firm closure
of the inguinal, femoral and umbilical portals.
INFANTILE HYGIENE.
Nature's efforts in the direction of restoration or restitution
may, however, be much retarded or accelerated by infantile hy-
giene.
It is certainly quite inexplicable why, in our times of wide-
spread scientific research and extended independent observation,
so little attention has been given to hygiene as a factor in effect-
ing relief or cure of infantile hernia.
Every child born, regardless as to whether he be herniated or
not, immediately after delivery is put through practically the
same routine; while on the contrary, in every instance in which
a hernia or a suspected hernia is discovered in the new-born, we
should invariably direct special attention to it. In every case the
prevalent vicious custom of applying a band or binder around
the abdomen should be condemned. It conserves no useful pur-
pose; the only excuse for it at all is that it retains the envelopes
of the funis in position. If this firm, inelastic compression does
not in many cases directly cause a hernia in those predisposed to
it, I am confident it often very seriously interferes with spontane-
ous cure, by the increasing pressure which it produces against

14
HERNIA.
the abdominal walls. In the herniated baby this, then, should be
cast aside, the dressing for the navel string being held in position
by adhesive straps, or tapes passed around the body. After the
desiccated remnant of the cord has dropped off, nothing whatever
in the way of a girth should be worn around the abdomen; but
the garments, when the erect attitude is taken, should be all car-
ried from the shoulders, thereby the freest possible action being
given to the diaphragm and the organs of digestion. If the
patient be a male, stenosis of the urethra or atresia of the pre-
puce should be looked for and relieved. It is well to keep this
class of patients on their backs, as much of the time as possible,
and, in no case, encourage or permit them to walk, until after the
first year.
Their diet should be simple; devoid of a rich or indigestible
aliment, but be ample and nourishing--the mother's of course be-
ing preferred. A large proportion of the ordinary variety of
hernia of infants will disappear by hygienic measures alone be-
fore the end of the first year. For them no sort of mechanical
apparatus should be for a moment thought of. There can be
scarcely a question but that the chances of recovery are very
much enhanced with this minor class, by employing no support or
pressure of any kind, while a badly fitting or a strong truss may,
by induced inflammation, render the prospects of cure, quite impos-
sible without a surgical operation.

CHAPTER III.
THE TREATMENT OF HERNIA IN INFANTS BY TENTATIVE MEASURES
AND MECHANICAL APPARATUSES, IN SINGLE OR DOUBLE HER-
NIE; THEIR INDICATIONS OR CONTRA-INDICATIONS IN SIMPLE OR
COMPLICATED HERNIE.
Unhappily, in a considerable proportion of hernial cases,
there are such complicating or painful factors present that we
must occasionally resort to art for their amelioration or cure, as in
those voluminous in size, in which a large part of the intestinal
canal occupies the scrotum or labium; those which give rise to
much pain, and those, too, in which there is incarceration with
agglutination of the imprisoned viscera. The inguinal canal may
be entirely wanting in very large protrusions. In others, there
seems to be an excess of intestine, or an elongation of it or the
mesentery. In others again, the omentum is in excess.
15

16
HERNIA.
With a few, there will be an adhesion between the sac, testis
and intestine, while with others the abdominal viscera are either
FIG. 2 (Maclise).
B
អង្គត ក
Congenital inguinal hernia with adherent testicle,
rendering reduction impossible.
crowded down after the testi-
cle, or, contracting adhesions
to it on its way downwards,
an independent, serous in-
vestment is wanting, and all
occupy the cavity of the
tunica vaginalis.
Occasionally, we will en-
counter a most complicated
pathological condition, as,
when there are simple or com-
pound cysts within the sheath
of the cord; varicose sper-
matic veins, and a visceral
protrusion. As a rule, herniæ
follow later, after the genera-
tive organ is lodged in the
scrotum; but the reverse is
met with in early infancy,
one side of the scrotum being occupied by a hernia, while the
testicle is yet in the inguinal canal or above it. Sometimes the
monorchid state remains through life. Double herniæ may be
complicated by the same morbid arrangement and pathological
changes as the single.
Congenital, inguinal, or crural hernia in females is rare,
though the umbilical variety is common. This latter, however,
with them as with the male, is readily cured by simple means. It
is only when a hernia manifests a tendency to rapidly increase in
size, or is painful in the female infant, that a retentive apparatus
is necessary. As their urethræ are short, straight, capacious and
distensible, permitting small urinary excretions to pass through
without great straining, the protrusion, when of moderate size, is
disposed to spontaneous reduction. With female hernia there is
a singular tendency to the escape of the generative organs of the
pelvis, through the "canal of Nuck." Strangulation is rare and
almost unknown in infants and young children.

HERNIA.
17
Complications then may be present, or may develop, which
will render the wearing of an artificial support a necessity.
Unless such complication is present, of a clearly accentuated
character, then the best apparatus is worse than none of any
kind.
The mere fact that a child under a year old, free from cough
or any disease entailing a severe strain on the abdominal wall,
has a small, painless hernia, is no justification for the use of a
truss. Certainly, should the protrusion fail to disappear under
the first year, or should measles, whooping-cough, or acute bron-
chitis develop, a truss must be applied.
A truss on a diapered infant is a great nuisance. It is con-
tinually smeared and soaked, cannot well be kept clean, and if not
perfectly adjusted, or if pressing too firmly at points, is a ceaseless
source of misery to the helpless little sufferer.
Phymosis or atresia of the urethral canal, or a calculus in the
bladder or the urethra, when a hernia is present, by the forced and
frequent contraction of the abdominal muscles which its presence
causes, seriously interferes with spontaneous return. If the hernia is
of the inguinal or umbilical variety, and the impediment caused by
preputial adhesions at the meatus is slight, the frequent erections
of the penile body will unfold the tightened fore-skin and permit
a free jet of urine to pass through, when the fullness in the groin
will often vanish by slow stages. It is only in the aggravated
phases of preputial adhesion that we must interfere. With many,
however, if there seems to be an increase in the volume of the
hernia we should not delay, for the procedure for relief is com-
monly a perfectly harmless one, which in any event will rather
favor than retard cure.
Urinary calculi, by their size or shape, when lodged in any
region of the urethra, by the obstruction which they cause, re-
quire forcible straining in micturition. A case has been under
my care in which there were three calculi so lodged as to almost
completely block up the urethra. Before relief was secured by
the urine making its way through a perineal fistula, the little fel-
low would so strain as to prolapse from five to six inches of the
rectum every time he tried to urinate. He had no hernia except
of the rectum, and this long continued straining in no way favored

18
HERNIA.
the evolution of one. It is easy to understand that should a hernia
be present such straining must greatly increase its volume.
It may be repeated that herniated infants should be kept on
their backs or buttocks as long as possible. By the prone attitude
of the body the parts are placed in a position most favorable to
recovery. As the infant advances in age he commences to notice
objects, and is incessantly active while awake and cannot be kept
quiet. But we can prevent him from walking and we can com-
pel him to either sit or creep. In sitting he so crowds up the
inguino-femoral fold as to cause a moderate pressure on the
extrusion, which favors its absorption or return. In creeping the
body is carried nearly horizontally, and abdominal pressure is so
distributed as to relieve tension on the herniated region.
Very many hernia which no doubt would disappear by a
tentative therapy, often become chronic, incurable cases when
children are permitted to walk too early; hence in all cases of
hernia in infants, they should be permitted to creep for a consid-
erable time before the upright position is taken, and at first be
allowed to walk only for a few paces at a time until the body is
accustomed to the change in attitude, and the super-incumbent
weight of the floating viscera will not fall on the weakened areas
too abruptly.
SIMPLE, NON-OPERATIVE MEASURES IN THE TREATMENT OF INFAN-
TILE, UMBILICAL, INGUINAL, OR CRURAL HERNIE.
As so-called ruptures are quite commonly met with in the
new-born and young children, and the parents are naturally solic-
itious for their recovery from a condition which, if it continues
into adult years, will occasion very frequently a crippling, pain-
ful infirmity, and disqualify them for many occupations of
emolument or honor, they at once cast about them for means
of cure.
The family physician is first looked to. He may, perhaps,
assure them that the youngster will outgrow it, at all events
that it is not dangerous to life. But it remains, it may grow no
less in size, possibly it increases. He is again reminded, and now,
as a matter of course, orders a truss. But it may give so much
iscomfort that it cannot be worn, or if it can, it effects no

HERNIA.
19
diminution in size, and is worn only with the hope that in time
it will cure the infirmity. Nevertheless, the hernia is still there.
A traveling charlatan has come to town, and with mammoth
posters and innumerable hand-bills scattered broad-cast, boldly
advertises that he can cure every sort of rupture. His position
will also probably be fortified by a column in a local paper,
filled with testimonials of divers individuals, happy of the oppor-
tunity to publicly acknowledge to suffering humanity the extent
of their gratitude.
The stay of the "great man " in town is limited; hence those
in need of his wonderful skill must hasten.
The little one, with a multitude of others, is spirited away
for the treatment. "Advice free," but pay for the medicines!
Yes, medicine, for a hernia; plus something else nevertheless.
Now, this itinerant, though he may know little of anatomy and
less of pathology, understands human nature; he knows his busi-
ness and he produces many cures.
He gives purgative pills or powder, fluid medicines and oint-
ments. He orders his patients on their backs, eschews farinaceous
diet, with no milk, sugar or fats. Directs persistent friction, mas-
sage, and perhaps applies a roller bandage. In babies, when they
had but simple, serous cysts along the spermatic fascia or congeni-
tal hernia proper, he promptly cures them all.
With the adult he doesn't fare so well, though he is often able to
put their herniæ out of sight, until they cheerfully give him a testi-
monial, and he has an opportunity to pack his traps and decamp.
That this is no overdrawn picture is attested hy the fact
that even now, in our midst, there are "institutions" (?) adver-
tised, wherein the medical corps claim that they can cure hernia
of any description "without either truss or operation."
Indeed, we find in the tenth century that Guy de Chauliac, of
Montpellier, treated hernia by astringent plasters and other topi-
cal applications; as the white of an egg for a vehicle, crushed nut-
galls, alum, antimony, yellow amber, etc. On a certain species
the following mixture was supposed to possess great virtue: It
was composed of turpentine, litharge, the fæces of an eagle freshly
roasted, human blood, the hair of a ram, all blended together in
rain-water and vinegar.

20
HERNIA.
Some years ago a man came to me with his son, then one
year old, who had large scrotal hernia on the right side, which no
truss would contain. I found, on examination, that it was of the
congenital variety of anatomists, with the testis, intestine and all
in one common investment. It was shortly before the death of
the late Dr. Henry B. Sands. He had seen the case before me, and
advised against an operation. I recommended it, but the case was
brought to a traveling quack, who agreed to cure the case in one
week. He was paid a large fee before he would commence.
gave the patient one ounce of simple cerate, with a bottle of mint
water. Of course, a cure did not result. He was again sought
for, but in vain; his time was too precious for him to linger longer
about New York.
He
It must be always remembered, in the treatment of infantile
hernia in particular, that the therapeutical armamentarium is
not limited to a truss or the scalpel, but that each case must be
treated on its merits; and that as there is every conceivable phase
of hernia, or conditions simulating the genuine, so are the reme-
dies for its relief or cure are varied and diversified. True, in
many, when we are quite assured that the inguinal or scrotal full-
ness, is nothing more than a simulated hernia, we have performed
our duty when we have clearly set forth the innocuousness of the
condition, and assured the parents of its ultimate, probable disap-
pearance with the advent of time. Unfortunately, this is not
always enough. Some old women may insist on it, that the
child is ruptured, that the doctor has neglected it, etc., until the
case comes under the care of a less scrupulous practitioner, anxious
to make a name for himself, who will affirm that there is a rup-
ture, but that he can cure it. It will take time, and it will take
money, etc. And, he does cure the child, much to the loss of
his neighbor.
ENCYSTED HERNIA AND SERO-CYST FORMATIONS IN INFANTS AND
CHILDREN.
In the vast majority of cases of infantile hernia in the male,
we will, on examination, discover that it has formed adhesions
from its sac to the elements of the cord, or what is rarer, the
contents of the envelope, and all are locked up in one or more

HERNIA.
21
compartments, and are incarcerated or rather encysted, forming a
sort of accessory-cavity to that of the general peritoneum.
These may appear on one side, or on both, simultaneously. One
may consist of the bowel alone, or omentum, or both. Encysted-
hernia, however, most commonly appears singly, and consists of
omentum.
It is of considerable importance to recognize a fixed epip-
locele in the infant, for if it has formed no adhesions and hence
does not draw its blood-supply from the serosa, it will, in general,
so completely atrophy or amalgamate with the cord, as to quite
disappear of itself; so that when small, painless and uncompli-
cated, no sort of severe or long-continued compressive force should
be recommended or permitted to remove it. If we are dealing
with capricious, unreasonable parents, we may always cut the ca-
reer of those masses short, by various means which we will con-
sider later. Cystic-formations are of frequent occurrence in both
male and female inguinal-tracts, in infancy and early-life. In the
male, anywhere from the point, at which the spermatic-artery
makes its final turn and enters the lower margin of the internal-
ring, down to the base of the scrotum, these cystomata may
form. In the female they have very often been confounded with
hernias. With women, their habitat is along the canal of Nuck,
having their origin in the loose, cellular-tissue which forms the
round-ligament, the analogue of the spermatic-cord. As these cysts
so closely mimic a hernia in form, outline and consistence, it re-
quires, at times, one of more than ordinary experience to differ-
entiate them. They are painless, diminish in volume when
the patient lies down, are reducible on moderate pressure,
and can often, be kept out of sight, by the bulb of a firm truss.
They may appear as mono-cystic or multi-cystic, the former
being the most frequent.
As they seldom attain to a great size, but have very firmat-
tachments, they are not easily recognizable. They may be asso-
ciated with visceral protrusions. These masses are often desig-
nated hydroceles or spermatoceles, terms which are permissible
in the adult, but, as their pathology differs radically at the two
epochs of life, we must not confound these pent-up accumulations
of a natural secretion with what are essentially of a neoplastic

22
HERNIA.
origin. For with the former the natural tendency is towards
aggravation, while the latter, should the little-one not be cut off
by some intercurrent malady, in time will invariably disappear;
the only exception being with the female, in whom after the
menopause these serous cysts of the round ligament occasionally
take a fresh start and give much inconvenience. When cystic
disease is suspected, we should determine its presence with defi-
nite certainty. For, by accomplishing this we can allay the ap-
prehension of the parents and avoid such treatment as may do
harm. In this class, if the parent or patient, is not content to
wait, as in the preceding, we may institute such measures as will
effect a prompt cure; though ordinarily it is better to leave things
alone, depending on time to correct the difficulty.
The ancients were not so far out of the way in their treat-
ment of hernia before the spring-truss was invented; consequently,
in many particulars, it may be safe and prudent for us to imitate
them, when we aim to treat epiploceles or hernial-masses along
the inguino-femoral furrow. Hence, low diet, the restricted use
of liquids, rest on the back, the employment of mild purgatives,
friction, salves, counter-irritation, appropriate bandaging, em-
ployed alone or in combination, may be relied on in hastening
the obliteration of many of those pathological conditions now
being considered. These measures all possess the merits of safety
and simplicity. Reduction of the aliment, fluid and solid, is ex-
ceedingly efficacious in first diminishing the volume of the in-
testinal contents and relieving tension; moreover, in inducing a
species of auto-assimilation of the superfluous adipose elements,
which give to the omentum its weight and consistence. Deprived
of its fat, the omentum is but a delicate, transparent, gauze-like
structure. An occasional purgative serves the purpose of un-
loading the bowel and diminishing intra-abdominal pressure.
The dorsal decrubitus, along with equalizing the circulation, favors
restoration of functions, and the quiet so necessary.
We will not delay to inquire into the virtues of any special
poultice, plaster or salve, though it is absurd to deny them any
worth at all, for if they serve no other useful purpose, they act as
placeboes and give mental rest; afford an assurance that we are do-
ing something in simple cases, and commend themselves, inas-

HERNIA.
23
much as they will do no harm. Revulsives are efficient, however,
whether as plasters, liquids or ointments. In those cases in which
the envelope of a cyst or the structure of an epiplocele derives
its nutriment from the vessels of its periphery and the adjacent
tissues, anything which stimulates the lymphatics will contribute
towards their absorption. Kneading with the fingers and mas-
sage, possibly moderate electrolysis as a stimulant, may each by
their stimulating powers act with great energy in scattering these
masses, as they do in various neoplasmata or inflammatory-de-
posits, in different regions of the body. Warm or cold com-
presses so adjusted as to maintain firm, but interrupted pressure,
are a valuable adjuvant.
Since aspiration has been applied in surgery with great suc-
cess, we might take advantage of it, to empty those cyst-like
pockets along the cremasteric vessels in the male, and those in
the interstices of the round-ligament of the female child. The ob-
jections to its general employment are that the cyst quickly re-
fills, unless some irritant liquid is injected after it is drained;
besides, this may be attended with serious consequences, when
the processus-vaginalis is continuous with the general-cavity
of the peritoneum. Further, as the bladder itself may make its
way into a hernial sac, the puncture of its wall might give rise to
severe cystitis. The most formidable objection against the aspi-
rating-needle is the danger of septic infection or penetration of a
blood-vessel. Hence, unless in simple cysts, in the event of press-
ing necessity, or in the hands of the experienced, this expedient
should be ignored.
CONDITIONS IN HERNIATED INFANTS AND CHILDREN, WHICH REQUIRE
THE EMPLOYMENT OF THE TRUSS.
The presence of any physical deformity or infirmity is always
a source of humiliation to the parents of an afflicted child; as
much, or more, than it may be to the patient when the age of
reason is reached. If a well-fitting truss serves no other purpose
in the growing youth, it effectually conceals this unsightly blemish
without detriment to the general health. Besides, the truss prop-
erly adjusted and changed, according to circumstances of growth,
exercise or occupation, is an invaluable therapeutical apparatus.

24
HERNIA.
Theoretically, a truss is a support only. This is but one, however,
of its functions, when the circular-spring variety is employed.
It presses, as well as supports. Now, in some herniæ, this press-
ure produces a most salutary effect, while in others it induces
many complicating and painful changes, which may render a
simple hernia quite incurable, or insufferable, without ultimate
surgical intervention.
It goes without saying, that a badly-fitting truss on the
young or old is worse than useless. I am convinced that a truss is
very seldom needed on the suckling infant, whether he have one
or more herniæ, and regardless of its size or situation. It would
seem, too, that those inguinal tumors remedied by the truss in
early-infancy were not herniæ, or if they were they would have
disappeared, if nothing had been applied in the way of prothetic
appliance. At this epoch of existence, the infant being almost
constantly in a prone posture, or sitting, no strain is made on the
hernia; there is nothing to aggravate it, or in any way increase
its volume. It is only when he takes the upright attitude and
commences active exercise that factors are called into play which
will force the abdominal-viscera downward. Now, with the in-
fant's wearing apparel cast aside, and the child able to make known
the demands of Nature, we may apply a truss with advantage
and comfort. Before this time, nevertheless, in rare cases, the
truss must be taken up. When we encounter a hernia which is
reducible, which we are quite sure is enteric, and when the tes-
ticle is well down; moreover, when the pathological condition is
a source of pain or considerable discomfort to the little-one, and
when prothetic retention is borne with comfort, then we should
not fail to give him the comfort which a truss does secure when
applied at the right time. A truss is quite a manageable machine
in the walking child.
Very naturally with him, as age advances and reason de-
velops, he materially assists us. He can tell us when the truss
unduly presses or chafes, and he can remove or replace it himself.
It is always well in those cases of large, single hernia in children,
to apply a double-truss. For, if this precaution is not taken,
another hernia, in nearly every instance, will follow on the un-
supported side.

HERNIA.
25
My preference is for the circular spring-truss, with a well-
padded, adjustable bulb. Unfortunately, the properly manufac-
tured truss is so expensive as to be quite beyond the means of
the working-people to purchase. Every one knows that the in-
tegral parts of a common truss are, simply a circular brace of
indifferent steel, a strap and a bulb. The component parts
and workmanship of the proper apparatus are quite differ-
ent. Indeed, the former is but an imitation of the latter.
When it is not within the means of one to secure the right
sort of a truss for his child, then the bandage, properly ad-
justed, makes a valuable substitute. It is inexpensive, can be
washed or cleansed without impairing its texture and can any
day be cast aside and renewed without much loss. Very many
simple herniæ may be comfortably returned, with a considerable
proportion cured, by this simple means. The obstacle in the way
of its more general adoption is the deep-rooted impression with
the laity, that every hernia must have a truss, and the indisposi-
tion of parents to employ it over a sufficient period of time.
The so-called hank-truss is an application of bandage press-
ure; as efficient as it is simple. It consists in a couple of hanks
of yarn, or worsted, the centre of each so overlapped as to form
a knot, which is brought to bear over the hernial-orifice.
It exercises a gentle, elastic pressure, of the ideal descrip-
tion, for very many children's herniæ. It is within the reach of
every-one, and requires no special skill for its application. It is
highly recommended by Dr. David Milliken of New York. Truss-
pressure or support is impracticable in these small umbilical
herniæ, so commonly seen during the first year of life, in which
the employment of the bandage greatly aids their hasty disap-
pearance. It is only when an umbilical hernia is present that
the employment of any sort of binder or girth around the infant's
abdomen, is ever justified or useful. And even here, unless the
exomphocele is very large and growing, with the evolution of de-
velopment, it will retract without any sort of artificial pressure.
This has been very fully dwelt on by Dr. Frank T. Parsons, of
Northampton, Mass., in his valuable essay on "The Hygiene
of Infants' Clothing." (Jour. Am. Med. Asso., August 12th,
1890.)

26
HERNIA.
CONSTRUCTION AND APPLICATION OF TRUSSES FOR INFANTS AND GROW-
ING CHILDREN.
The truss for an infant or growing child must possess quali-
ties quite different from those of the ordinary adult.
1st. It should be as light as is compatible with ample strength.
2d. It should be so constructed as to supply a local and cir-
cumferential support.
3d. It should be so made that the pressure which it exercises
may, from day to day, be graduated.
Most trusses are needlessly weighty. This is unavoidable
when the springs are made from an inferior quality of steel, as
more of it must enter into their composition, than when the metal
is of a superior quality.
A light, circular spring of properly tempered steel, plated
with some non-oxidizing material, covered and padded, meets the
requirements, when the object in view is to simply retain or sup-
port an easily reducible hernia.
Those knitted, elastic-belt trusses are to be preferred to any
other, in diminutive reducible hernia; but as they absorb moisture-
readily, the rubber soon loses its elasticity and breaks, so that they
must be frequently renewed.
The broad, elastic belt which goes with this truss, as it has its
point d'appui over the lumbo sacral region of the spine, and passes
low down over the weak aponeurotic areas of the abdomen, on
either side, lifts the superincumbent weight of the abdominal
viscera and transfers it to the back.
The second essential, local and circumferential support, is pro-
vided by this truss; the latter though in greater measure than the
former. Hence, if we have a hernia which demands considerable
local pressure over the rings, we must employ the springtruss.
The spring-truss, to supply the fullest measure of success,
should be so adjusted that the inguinal, or circular pressure, can
be readily changed or adjusted. The circular form is the most
useful, for the reason that an abdominal support may be necessary
for a period after a hernia has returned; when very slight, if any,
pressure is needed from the bulb.
To meet the third indication; to provide a truss for the grow-
ing child, it must be so constructed as to admit of easy adjustment

HERNIA.
27
4
when the hernia needs more or less pressure, as the case may be,
and the increased proportions of the body require alterations in its
dimensions or firmness. This is a desideratum difficult to meet,
though a truss possessing those adjustable qualities, and of suffi-
ciently low price, would be a great boon to the deformed poor.
GENERAL DIRECTIONS WHICH SHOULD BE OBSERVED IN THE PROTHETIC
TREATMENT OF INFANTILE HERNIA.
It will generally be admitted that all hernia in infancy and
early childhood, with few exceptions, may be cured, in which a
properly selected truss is worn. But in exceptional cases the
adjustment of any sort of apparatus will accomplish no good. A
poorly constructed, a defective or badly applied truss, over any
description of reducible hernia, may render it irreducible.
1t would be worse than folly to apply an apparatus on that
anatomical type, known to surgeons as "congenital hernia," when
the testis and viscera are bound together by adhesions, or in the
incarcerated. Nor, should it ever be applied in any case of the in-
guinal type until we are certain that the testis is lodged in the
tunica-vaginalis of the scrotum; nor, in the condition, known as
ectopic testis; unless, we have some object in view, other than re-
taining the protrusion in position.
In the female infant or child, before the steel-spring truss is ad-
justed, to avoid submitting her to its bondage and the agonizing
distress sure to follow if an oversight is committed, let one be
quite sure, that there is a hernia; that the fullness which we see is
not a simple, harmless cyst; or that the incarcerated mass does not
consist of a prolapsed ovary, or the uterus itself. Many, not well
acquainted with the common, anatomical-elements of a hernia, or
the evil consequences liable to follow the needless application of a
truss, acting under the assumption that the instrument will pre-
vent the growth of an incarcerated mass, as a routine custom
apply it, in every case which comes before them.
It may be laid down as a rule, that when we are in doubt
what the precise composition of a hernia is, the safest course to pur-
sue is to apply no apparatus of any kind until further advice is
sought. The badly adjusted truss, by exerting undue or mis-
directed pressure on a reducible hernia, excites adhesive inflam-

28
HERNIA.
mation, a thickening of the sac, a binding together and interlock-
ing of what was, before it was applied, free and isolated. As the
inguinal-canal is much shorter in youth, than in adult age, and as
the orifices are proportionally much larger, the surface of the
pad should be applied close to the insertion of the conjoined ten-
don, in convenient proximity to the symphysis-pubis, over the
external-ring. In crural hernia, pressure should be applied, even
lower down.
The action of truss-pressure in early, infantile life, should be
intermittent. In proportion to the volume, age and position of a
hernia, truss-pressure should be considerable, moderate or inter-
mittent.
In direct inguinal, or indirect hernia of great size, the truss
must possess sufficient firmness and stability to securely compress the
viscera within the abdomen. If the hernia be of recent origin, the
prospects of complete and rapid cure will be greatly enhanced; if
a truss be uninterruptedly employed day and night; a strong truss
in the day; while the lad is on his feet in active exercise, and a
lighter and more flexible one, for the night. By this course, an
opportunity is afforded for the relaxed mesentery, to regain its full
contractile power; besides, as the rings and canal have been cleared
of any extraneous substance, which acts as a wedge in maintaining
a dilatation, an opportunity is afforded them to close in, as the
canal with the growth of the body assumes a marked obliquity.
It has been alleged by many, that the truss does more than sup-
port in these cases, that it excites a gentle irritation along the inner
surfaces of the fascia propria, which tends to an atresia or stenosis
of the escape-vent.
In diminutive, controllable herniæ, moderate truss pressure
only, is all that is called for. Anything more than this, with
these, rather weakens than strengthens, besides causing atrophy of
the testis, hydrocele or varicocele.
Truss-pressure must be intermittent. This cannot be too
strongly emphasized. This does not necessarily imply that we
must at any time wholly discard it in special cases, but that the
volume of pressure be intermittent. In many we will encounter
hernia which are large and manifest no tendency to cure, in which
the daily employment of the truss is necessary. With these it

HERNIA.
29
should be taken off at night, on retiring, and again applied on rising.
It will be noticed that after a varying interval of truss-wearing,
the hernia has disappeared. This is the common rule in children
Is it well, in this class, as a prophylactic against relapse or
strangulation, to advise the patient to employ some sort of in-
guinal-support for the remainder of his life, or at least until adult
years are attained?
My impression is that it is not. Very many of these hernia
return from the 20th to the 30th year, and evidently cannot
be prevented by any sort of truss-support, which can be worn over
a long period of time without doing damage to the elements of
the spermatic cord.
In concluding this consideration of hernia and allied condi-
tions in infants and growing children, it may be well to state that
the permanency of the cures which we effect with them, depends
on certain factors, some of which we can control, and others we
cannot. Bearing in mind that the defective, anatomical condition
which leads to hernia is often inherited, the cure of the infirmity
is frequently only temporary or transient, which on slight provo-
cation gives way to a relapse.
With those who, when they arrive at man's estate, make
their living with their heads rather than their hands, and are
never called on to perform severe or protracted physical exertion,
the prospects of an abiding cure are greatly enhanced.
With all young, active children, who have been cured of
hernia, by whatever means, the weak abdominal girth should
be supported for the remainder of life by the use of a broad, com-
fortably-fitting canvas or leather belt. This should be light,
broad and strong, so made and applied as to extend to the hori-
zontal border of the pubis, and laterally backward over Poupart's
ligament, on either side of the sacral spine. It may be tightened
or slackened to suit the varying capacity of the abdomen.
It is needless to say that with the children of the poor, who
have been herniated, some sort of trade or occupation should be
sought for them which does not entail great strain on the abdom-
inal muscles; and with all youths who have ever had a hernia,
they should be warned against all sorts of severe athletic exercise
which put a severe strain on the abdominal-muscles.

CHAPTER IV.
SURGICAL OPERATIONS FOR INFANTILE AND CHILDREN'S HERNIA.
Surgical operations in simple, reducible herniæ of children
are to be deprecated. With this class they are seldom permanently
curative, and when they relapse, are difficult to control with any
sort of apparatus.
Very many of such operations have been reported; and one of
my own cases was but four weeks old. In fact, it was declared not
long ago by not a few that herniæ of every description should be
promptly and radically dealt with "regardless of age." But
time has incontestibly demonstrated that this is an error; that it
is as extravagant and absurd as to affirm on the contrary, that none
should be surgically dealt with.
The truth, is that there are cases of infantile-hernia in which
it is altogether impossible to effect a cure without surgical inter-
ference. These cases, however, are not common, though they are
sufficiently often encountered to demonstrate the importance of
their early recognition.
*Championniere, Mercredi Med., May, '90.
30

HERNIA.
31
VARIETIES OF HERNIA IN CHILDREN WHICH RENDER SURGICAL
OPERATION DESIRABLE.
1st. Infantile-hernia proper, in which adhesions with the
testis or spermatic cord render reduction impossible.
2d. Incoercible, painful, incarcerated hernia.
3d. Female hernia which contain within their sacs any of the
generative organs.
4th. Impending or actual strangulation.
1ST. INFANTILE OR CONGENITAL HERNIA.
That which anatomically is recognized by an absence of an
independent serous-investment, and in which the spermatic-pro-
cess has remained inclosed, and the processus-vaginalis with
the cavity of the peritoneum are continuous, is occasionally met
with. By keeping. the infant on his back as much as possible,
and applying either a special bandage or hank-truss over the
canal, and allowing the emptied lumen an opportunity to con-
tract, a cure is generally speedily realized. But, in some of these
cases, the testicle in its descent, becomes glued to the omentum or
intestine, so that the latter become irreducible by tentative
methods. There can be little doubt, but many of these herniæ
contract adhesions through the undue pressure exercised by badly
adjusted trusses.
If the truss be too weak, or be indifferently applied, the
hernia slips down, in such a way that it has to bear pressure to
such an extent as to excite adhesive inflammation, or a serous
effusion, which in a short time organizes and knots the intes-
tines, omentum, testis and serous wall into one confused mass.
This species of chronic, scrotal-hernia is the most painful and
lamentable known. When the child commences to walk, it
steadily increases in size to such an extent as to render its con-
cealment impossible.
Its pressure on the testis causes pain and an atrophy of this
organ.
In an aggravated case of this description, which came under
my care for operation, the reflex irritation transmitted to the
vesical and genital nerves had caused an enuresis and uncontroll-

32
HERNIA.
able masturbation in a lad of seven years. Both promptly disap-
peared on releasing the imprisoned intestine by radical-operation.
When this type of hernia is recognized there is nothing to be
gained by temporizing, but surgical intervention should be
promptly resorted to. In the event of whooping-cough or measles
succeeding, the dangerous strain which these may cause may be
overcome if the seat of hernia is well trussed up, until they have
passed away.
2D. INCOERCIBLE AND INCARCERATED HERNIA IN THE YOUNG.
Children with incoercible, or painful incarcerated hernia, are
proper subjects for operation. If, for no other purpose than secur-
ing the patient comfort and placing the rupture in such a posi-
tion that its growth may be arrested, and that it may be there-
after, readily retained by the truss or bandage.
When a hernia is rebellious to truss treatment of every de-
scription, or, is a source of pain; when, it manifests a tendency
to rapid increase in volume, then we may consider the propriety
of an operation. Diminutive, incarcerated herniæ are the least
detrimental of all. But, when they contain the undescended
testis, ovary or uterus, or are associated with cystic disease of the
cord, and cause a constant sense of discomfort, then the question
arises, whether it is not the duty of the surgeons or medical-
attendant to advise radical-measures for their relief, or their pos-
sible cure. In this event, much will depend on circumstances
and environment.
Female hernia of every description is more favorable to
early operation and permanent cure than any other.
3D. HERNIA IN THE FEMALE CHILD.
With a hernia in a female child, in which we are quite as-
sured that any of the genital-structures have come down with
the sac, there should be no delay in cutting down at once. As
we have no structure functionally like the spermatic-cord to
deal with in the female, in obliterating the inguinal canal, a
cure is almost invariably assured in operations on their inguinal-
herniæ.
Besides, during the early epoch of life, before menstruation
or pregnancy, when the vascular-apparatus of the lower-extremi-

HERNIA.
33
ties is not periodically disturbed, the chances of cure resulting,
after operation on crural-hernia, are greatly increased. As female-
hernia, of all others, is commonly the most distressing, during
adult-life, if the young female have an inguinal-protrusion which
fails to disappear during the early years of growth, and which
is at all painful, or incoercible, an operation may be advised.
As umbilical-hernia in either sex very rarely resists moder--
ate pressure, during the early stages of life operative interference-
for its cure must be very rarely called for.
4TH. IMPENDING OR ACTUAL STRANGULATION DURING CHILDHOOD
Strangulated-hernia during the years of bodily development
is a very rare occurrence. I have never seen it, nor am I acquainted
with any recently reported cases. A few instances of this patho-
logical state are recorded through surgical-literature. They con-
stitute some of those pathological curiosities, met with, perhaps,
once in one's life-time, by those who have had the greatest op-
portunities to observe cases.
With these cases reported, but few of the authors have men-
tioned whether the patient had worn a truss or not. It doesn't
appear that they were of more frequent occurrence before the seven-
teenth century, when the circular, spring-truss was first invented
and worn, than they have been since. It is easy to conceive how
a viciously constructed truss might set up an active inflammation,
with resulting strangulation.
Impending strangulation in the child should be treated by
immediate, radical operation, without any resort to taxis whatever.
One warning should be sufficient not to again jeopardize life, by
a condition which can be remedied without serious danger, when
proper skill and caution are employed.
CONTRA-INDICATIONS TO SURGICAL TREATMENT OF CHILDREN'S
HERNIA.
The number of cases in children, taken as a whole, which call
for radical measures must be reduced to a narrow limit, but with
even those, there are events and circumstances which in many
should cause us to postpone the time of operation or decline to
interfere, altogether. With a child who is suffering from an or-
3

34
HERNIA.
ganic disease, or who is in a feeble state of health; unless, life is
immediately imperiled by strangulation, nothing should be done
until health is restored.* Félizét in a general way advised non.
interference until the tenth year, or until the child had passed
through measles and whooping-cough. In selecting cases for sur-
gical-intervention we should carefully discriminate, and take none
in hand, except those which we are assured will receive the intel-
ligent and patient attention of the parents, until the permanency
of cure is secured.
In no case will we resort to surgical means until every con-
ceivable description of tentative expedients has failed, and which
have been assiduously employed over a very considerable period
of time.
If a patient be presented who has a very large irreducible
hernia, we will not forcibly press this immediately back into the
abdomen, until we have first put the patient through a preparatory
course of treatment.
When an operation for the radical cure of hernia is under-
taken in a child, the operator must always have it distinctly under-
stood, that he is never able to guarantee against a possible relapse,
and that operative-interference is not wholly free from danger to
life.
We have now arrived at the consideration of operative-tech-
nique, but as this differs in no essential particular, in the different
stages of life, it will be generally considered in another chapter.
It may be repeated, in conclusion, that the number of cases in
children of hernia which are proper for operation, is comparatively
few; that with very few exceptions, all hernias in the years of
growth may be temporarily or permanently cured by safe and
simple methods if intelligently employed over a sufficient period
of time; although, occasionally, cases will be encountered of such
an anatomical type, or presenting such pathological features, that
sanguinary methods must be resorted to to relieve them.
*Cure Radicale Des Hernies, etc., page 30.

PART II.
A PRELIMINARY
HERNIA IN THE ADULT.
CHAPTER V.
CONSIDERATION OF THE METHODS EMPLOYED IN
ANCIENT AND MODERN TIMES FOR THE MANAGEMENT OR CURE OF
HERNIA.
The ancient history of hernia is full of interest to the student
of medicine, as illustrating, after all, how slow the wheels of prog-
ress moved in the early era of Christian civilization, and that even
under the eyes of the keenest, many simple infirmities passed be-
fore them without relief.
Indeed, it seems quite beyond one's comprehension that the
unfortunate, afflicted with a strangulated hernia, was always inev-
itably doomed to die unrelieved unless, perchance, an abscess formed
and intestinal obstruction was relieved by an artificial anus, until
a comparatively recent date. Or that the unfortunate victim of
reducible-hernia had no other means of controlling or carrying
his large eventration than by the use of a bandage or a bag. In-
35

36
HERNIA.
deed, until the time of Franco-the commencement of the sixteenth
century-the strangulated were all abandoned to themselves to die.
The spring-truss was unknown until the latter part of the seven-
teenth century. The victim of hernia was an object of scorn and
ridicule, denied access to society, and shut out from positions of
honor or rank, and was always truly a deserving object of commis-
eration and sympathy. But as the scepter of the chirurgical art
passed from the hands of the Arabians of Asia to the Greeks,
thence to the Romans, to be, in turn, handed over to the polyglot,
progressive, tireless, modern races of Europe, an enormous awaken-
ing was imparted to all the arts. Science, in response to the Ba-
conic philosophy of modern times, made gigantic strides, until now
it would seem that we were approaching the millennium. Applied
art has enormously improved our treatment of hernia.
The spring-truss will cure the majority of the herniated. And
with the greater part, of those on whom it fails, it will, along with
securing comfort and security besides, so effectually conceal the
infirmity as to prevent detection under the ordinary clothing.
The treatment of strangulation has reached such a degree of
perfection that to-day surgery, early and judiciously resorted to,
should save every life. It will be seen then, that modern-art has
wholly revolutionized the management of hernia; has stripped it of
many of its dangers; has obliterated its unsightly proportions, and
even made its total and complete cure the rule and not the exception.
With the history of the past before us, the marvellous advances
made in the treatment of hernia in the past two centuries, who
should despair of realizing the time in the near future when an
incoercible, incurable hernia will be a very rare infirmity?
How, indeed, was it possible that surgery could make any
progress whatever in those times, when the dissection of the dead
body was sternly prohibited, and the profession knew nothing of
the thousand expedients which modern therapeutics have placed
within our reach? Let it not be forgotten that systematic, me-
thodical chemistry is a product of the nineteenth century. Of
electricity, the anaesthetics and antiseptics, even our eighteenth
century brethren knew, practically nothing.
Surgery itself, could scarcely, have been said to rest on a secure
superstructure, until the present century. Celsus, in the first cen-

HERNIA.
37
tury, as far as we can learn, was the first who essayed to cure
hernia by the incision; as, we will see later on; but the agonizing
torture necessarily connected with an operation involving such
sensitive parts as are concerned with the anatomical-elements of a
hernia, was so great, that few could muster courage to undergo
it. And, of them we are told, so few survived the tetanus,
hemorrhage, or inflammation which followed, that operations of
this description soon fell into disrepute.
With the advent of the anaesthetic-era radical-operations
were again revived, and finally individuals proclaimed that they
could cure every sort of hernia. One of the most blatant and
notorious of this class, has but quite recently passed from among
us. A considerable mortality, however, attended those operations;
and, moreover, many of the hernia relapsed. From the early days
of Velpeaue until about twenty years ago, but few sanguineous
operations were undertaken for the cure of reducible-hernia.
Lister had promulgated his doctrine of antiseptics. If, before
this time, surgeons were chary of instituting procedures which
entailed the opening of serous cavities, the division of muscular-tis-
sue, or the loss of blood, now the way seemed clear for surgically
sweeping away, everything which could be reached by the scalpel or
saw. Much mutilation was done, in the reckless impatience of
the surgeon to obliterate at once what might have been disposed of
by safer and simpler means. Very naturally hernia was given no
quarter; its etiological factors, anatomical composition, or patho-
logical changes, counted for nothing. What was simpler, than the
cutting down on, liberating and releasing, a loop of intestine and
closing the gap? At first thought, to the most skeptical or con-
servative, this question would seem difficult to answer. A score or
more different techniques were devised in Italy, Germany, France,
England and America, which each inventor alleged, seldom, failed
in his hands.
It seemed at one time, that the truss would be cast aside alto-
gether, as a barbaric relic of a by-gone age; as it could certainly,
have no place in hernial maladies, when they all were radically,
remediable by the scalpel. Promiscuous hernial operations, how-
ever, have had their day, at least for the present. The most san-
*Heaton, of Boston, Massachusetts.

38
HERNIA.
guine operators, with few exceptions, have made it a sine qua non
that always after operation for a considerable period of time, a
truss should be worn, or some sort of bandage support. Those
who opposed operations; facetiously inquired where the "cure
came in, when the continuous use of the truss was necessary after,
as well as before, operative procedures.
The temptation to perform these operations is very great.
They are attended with but very slight danger to life, and for the
time, at any rate, effect an apparent cure. In the succeeding
pages, after tentative methods have been considered, an effort will
be made to indicate the class of cases which justifies sanguinary-in-
tervention, and describe the various methods in vogue, in the past
and present, for the radical-cure of hernia.

CHAPTER VII.
INDICATIONS AND DIRECTIONS FOR THE EMPLOYMENT OF THE TRUSS
AND OTHER SUPPORTS DURING ADULT LIFE.
It is evidently, demonstrable to every-one, that as there is a
wide distinction, structurally, between the hernia of a child and
that of an adult, it follows that there must necessarily be a corres-
ponding difference in the mechanism and adjustment of the ap-
paratus worn by the latter.
There is this fundamental difference in the purposes for which
the truss is employed in the years of growth and in middle life.
In the former, truss-treatment is applied, not only to support the
hernia but to cure it. With the latter, however, the apparatus is
employed mainly to confine the protrusion, so that it cannot escape
during active or forcible movements of the body.
Adult hernia with few exceptions, are relapses of the cured
infantile. They may return gradually or suddenly. If the term
rupture" is appropriate in any phase of hernia, it is with some
of these recurring cases. For, it is scarcely conceivable that the
fibrous columns of the inguinal apertures can, on the application
39

40
HERNIA.
of abrupt violent force, sufficiently yield and stretch without lacera-
tion of the inner or most exposed fibres, and evolution is abrupt.
As intra-abdominal force, particularly, in the upright position, is
very considerable, it constantly tends to increase the bulk of a reduc-
ible hernia, which widens the gap in the abdominal wall; when a
truss which exerts a firm, steady grip, is demanded. With the
active, or those employed in laborious occupations, this is all the
more imperative.
The child may, with perfect impunity lay aside the truss, from
time to time; but, this is a hazardous practice with an adult,
unless, he employs great caution. The greater part of strangulated
cases, which have come under my direct care for operation, has
been among those who had laid aside their trusses, and in an un-
guarded moment, of sudden strain, the intestine came down and
was strangulated.
The truss for the adult should have a considerable but an
adjustable, compressive force, so that the wearer, after his day's
toil, may slacken the pressure to such a degree as is compatible
with comfort and safety.
There is a limit to the strength and pliancy of even the most
superlative quality of a spring truss. The wearing of a truss in
the adult male should be relatively intermittent. The wearer
and the instrument itself are benefited by relaxation. As the
man lies down and removes the superincumbent weight of the ab-
domen's contents from the weakened inguinal walls, the truss is
loosened and laid aside. This should be done only when the hor-
izontal decubitus is assumed. And the truss should be read-
justed by observing the same precaution on rising.
It would be a great advantage to truss wearers if they could
have a change of apparatuses, as they have a change of shoes or
other wearing apparel; one for severe, protracted every-day
strain, and one for evenings or holidays. It would afford them
infinite comfort, and no doubt the apparatus would wear much
longer.
The manufacture of well-made trusses is an industry which
entails a very high degree of skill. In most of the nations of
continental Europe the truss-vendor confines himself solely to
the manufacture of this one prothetic apparatus. A great many

HERNIA.
41
factors should be considered in the proper selection and adjust-
ment of trusses. The volume, position, age and peculiarities of
the special hernia must be considered; the complications, sex, oc-
cupation, etc. Does the patient, preach, orate, sing, or play wind-
instruments? Has he asthma, or chronic bronchitis? Is he con-
stipated habitually, or has he a stricture? If a woman, is she
single or married, suffering from a tumor or pregnant? Indeed,
as no two herniæ are quite alike, so must the mechanical adjust-
ment vary.
The same general rules which should be observed in the
application of a truss to inguinal hernia, apply to the crural
variety. As this rupture is most common in women, and seldom
attains a great volume, it is often borne without any support.
Although, it is small it is more unmanageable than the inguinal,
and it requires a firm truss, the bulb of which should be applied
low down and farther in, than with those occurring above the fe-
moral arcade. By a wise provision of Nature, strangulation is not
liable to occur during the throes of labor. In a diligent search
through hernial-literature I can find no case of stragulation
occurring simultaneously with the parturient act. This is ex-
plained by the changes which take place during the progress of
pregnancy within the abdominal-cavity. We will notice, that as
the uterus expands under the stimulus of conception, it balloons
upward and backward, out of the pelvic basin, thereby raising
and carrying posteriorly the intestine; the anterior, massive wall
of the uterus itself lying in almost direct contact with the fascia-
Cooperi, on either sides.
There are many herniæ located in the inguinal and crural
districts which will not tolerate a spring truss or any sort of
severe pressure. These constitute what are known as painful or
incoercible herniæ.
Besides these, are others which are complicated with sperma-
tocele, hydrocele, sarcocele, or other pathological complications of
such a character as to interdict the employment of a truss. When
there are circumstances in the way of radical operation for this
class, they commonly continue gaining in volume, until there is
almost a total eventration of all the floating viscera. The case
represented in this plate, No. 3, is one in point.

42
HERNIA.
It will be noticed that the penis is obliterated, nothing but
a dimple in the integuments remaining to mark its former site.
The patient carries this immense
mass in a canvas pouch, which is
supported by a strap passing over
the neck and shoulders. In order
to secure this photograph, the
support had to be removed, and
in consequence it will be noticed
that the spine is inclined inward
and the shoulders are stooped.
The scrotum has the appearance
of containing a double hernia,
but it does not. It is wholly un-
ilateral and limited to the right
side. The right spermatic-cord
has lengthened to more than two
feet, in an upward direction
from the testis, which is lodged,
immediately, under the skin at
the base of the scrotum, by the
inguinal aperture. On the left
side, although the constant drag-
ging of the scrotal bag has
greatly deranged the normal anatomical landmarks, yet it is clearly
apparent that the inguinal and crural canals are hermetically
sealed on that side. The left testis is within four inches of
the corresponding external aperture, at the summit of the her-
nia. This man suffers no inconvenience from this condition,
which entails, the nearly complete digestion of food outside the
cavity of the abdomen. Its weight alone annoys him, though
when it is well swung, he has no discomfort of any kind. This is
an aggravated example, of a not very rare class in old men. These
mammoth herniæ are peculiar to the male sex in advanced
life.
FIG. 3.
The cuts on the preceding page illustrate the enormous dimen-
sions which hernial masses may attain, and what modern surgery
may accomplish in their management.

HERNIA.
43
This case was recorded in the London Lancet of December
12th, 1891, by Dr. B. Murray.
The hernial tumor commenced with a small, inguinal-epiplo-
cele on the right side; the glands in the folds of the extended
FIG. 4.
Right Inguinal Epiplocele. Weight before
operation a little more than 100 lbs.
FIG. 5.
Same, after operation.
omentum undergoing hypertrophic, adipose changes; until, a neo-
plasm was formed, which, on its ablation, weighed a little more
than one hundred pounds. The cutaneous structures covering the
lower segment, were cut away, but the external genito-urinary ap-
paratus was entirely spared. This man must have had something

44
HERNIA.
more than an average muscular development to carry himself
about. It appears that he always wore a shoulder harness, with
which he lifted and deposited his ponderous scrotum.
FIG. 6.
It is interesting to note, the
broad attitude of the lower limbs,
assumed in order to make room for
the mass; and, besides, to broaden
the surface of pedal support. That
singular power which all tubular
structures possess of contracting
and lengthening out, is here beau-
tifully demonstrated; the elong-
ated urethra, vasa deferentia and
spermatic vessels immediately re-
turning to their normal length,
on the weight which dragged them
down being removed.
There are a considerable num-
ber of herniæ in old men, which no truss can control, or on which
it cannot be borne with comfort. Little can be done for these
cases, except to apply a suspensory bandage. The more rest the
better.
As these herniæ, seldom cause strangulation, and the victims
of them are advanced in years, nothing more than a palliative-
therapy is ever permissible.
There are many tumors, of a hernial character, consisting
mostly of fat lodged along the external apertures of the femoral
and inguinal canals. They are of small volume, firmly incar-
cerated, and occasion little or no inconvenience. They cause
mental worry rather than physical pain, and give apprehension
only, because, those who have them feel the humiliation of being
ruptured.
When the protrusion is within the inguinal-canal, this bubono-
cele is generally so situated that, unless a very cautious examination
is made, a mistake in diagnosis may be committed, and a lymphatic-
adenitis of the groin may be treated for a hernia. And, on the
contrary, a genuine hernia may be mistaken for enlarged glands.
Such a case came under my care in my Harlem-hospital service, in

HERNIA.
45
the spring of 1891. I was called in the night, to operate on a
young woman who had been just sent in, by her physician for
treatment of internal-obstruction of the bowels. I found her col-
lapsed, cold, and almost pulseless. The house-surgeon informed
me that there was no hernia, but my hand passing under the
clothing came on to a firm mass
in the left groin. This, she said,
she had since childhood. The
tissues over it, however, had an
oedematous, doughy feel, and,
on moderate pressure, it was ex-
quisitely painful. She admitted
that for a day or two it had
considerably increased in bulk.
As her general condition did not
admit of a pulmonary anaesthetic,
the tumor was opened under
cocaine. An old, omental pro-
FIG. 7.
trusion was found anteriorly, firmly adherent to the femoral
vein, and behind it a fresh mass, which nipped a coil of the intes-
tine as it entered the crural canal. Fortunately, her recovery
was uninterrupted. There is a large number of hernia which are
greatly benefited by the rest treatment, conjoined with manipu-
lation, massage, or pressure and electricity.
To this class, belong, the recently incarcerated, the incoercible,
rapidly-growing, and those presenting symptoms of approaching
strangulation. We have seen, how the recumbent posture, favors
the cure of hernia in the infant, by aiding nature in her process of
evolution, and it is well to ascertain if, after the growth of the
body, we cannot rely on this agency as a useful therapeutic factor.
We will invariably observe, that when the general-health is
seriously disturbed, when an organ or a limb is compromised by
disease or accident, Nature immediately forces the body into a
state of rest. It is not perhaps, as well known as it should be, that
rest, is an adjuvant of incalculable value in a great variety of func-
tional and organic ailments. If travel (recreation, change of air
and exercise) is the "positive pole" in hygienic-therapeutics,
rest is the "negative," and this is particularly true in hernia.

46
HERNIA.
Certain varieties of adult-hernia may be cured by rest alone;
physiological rest.
sense.
Rest must be utilized in a relative, rather than its positive
The patient, to secure a cure, if following a laborious pur-
suit, must discontinue it. If an athlete, he must discontinue feats
of agility. If a performer on a wind-instrument, he must lay it
aside. In other words, if he would give rest to his hernia, he
must discard everything, which exercises undue pressure on it, or
which, perhaps, even caused it.
It is said, if you would cure disease, first remove the cause.
But there are many maladies, the cause of which cannot, always
be removed. This certainly is the case with many phases of
hernia. Unhappily, too, there are not a few, among the poor, suf-
fering from hernia, who cannot abandon a trade or occupation,
on which, perhaps, a family depends for its sustenance. By a wise
provision of Providence, however, most herniæ are not encoun-
tered among hard-working people, but rather among those best
able to comply with a necessary hygiene.
Many times it has been my good fortune, to see herniæ
which had suddenly become painful and irreducible, by the aid of
rest in bed, a soothing inunction, and a sleeping draught, quietly
retract and disappear in one night. With others, of greater age,
volume and sensitiveness, by the employment of massage, knead-
ing, bathing and graduated pressure with a flannel bandage, after
a varying period from a day to a week or more, they too have re-
turned; and, if not, they have been greatly reduced. Dr. J.
Collins Warren, of Boston, at a meeting of the American Medical
Association, in Newport, R. I., reported several cases of unman-
ageable, large, old hernia, which were rendered quite coercible and
comfortable under the truss, by treating them with rest on the
back and intermittent pressure.
With those rapidly-growing in spite of supporting measures,
when the escaping mass threatens to attain great dimensions, we
may often interfere in this way with the most salutary results.
But, in order, to derive the greatest benefits, it may be necessary
to confine our patient in the recumbent posture over a consider-
able period of time; besides, methodically, directing treatment to
the immediate seat of the hernia.

HERNIA.
47
It is almost needless, to again speak of the marvelous power
of rest in aiding the restoration of a strangulated intestine; for, it
is well-known to hospital-surgeons that often, when taxis has
totally failed, by the use of a hypodermic of morphine, elevation
of the hips and a few hours undisturbed repose, the constriction
at the neck will slacken and the hernia disappear of itself.
Before leaving this part of the subject, it may be desirable
that we have a correct knowledge of the therapy of rest, when
applied to the treatment of hernia. Exclusive of the manner in
which change of occupation and cessation of active muscular ex-
ercise act, rest relieves and sometimes cures:
1st. By relieving the herniated area of the weight of the in-
testines, which, in the erect posture, falls on a weak vent, on an
opening in the over-strained, thinned, aponeurotic wall.
2dly. By clearing the dilated canal of the visceral plug, which
tended to constantly widen it, an opportunity is given to the
fibres of it, to contract, and hence, narrow the portal of escape.
Although, it is assumed that aponeurotic, fibrous-tissues possess
but slight, if any contractile power, it is not so, with the
cremaster muscle in male, inguinal hernia. In this variety of the
malady, we will invariably find the fibres of the cremaster-muscle
enormously hypertrophied; so that, it is but reasonable to sup-
pose, that when once the viscera are returned, this will so contract,
as to aid very materially, in closing the lumen of the sac.
The dorsal decubitus favors the equalization of the circula-
tion and relief of the congested state, which previously con-
tributed towards enlarging and fixing the hernia. In the hernia
of females it is notorious, that the distress in standing just before
menstruation is always very marked, while great comfort comes
from rest on the back at frequent periods.
When a hernia has been recent, and its sudden passage down-
ward has started up a sharp inflammation over the entire surface
of the sac, if it can be now returned and fixed without strain,
until these plastic surfaces become glued together and obliterated,
a cure may be affected.
3dly. In those massive herniæ we must commence our at-
tack, by placing the body at rest, then by massage and gentle press-
ure, continued until the rings through which this mass escaped,

48
HERNIA.
relax and permit its return. They will very often severely test
one's patience; but if we are gentle and persistent, we will often
conquer them.
An opening through which a hernia escapes,
should permit its return; and it generally will, except in certain
strangulated, and in cases, attended with promiscuous and in-
timate adhesions; though, we should always remember, that
its escape was gradual, almost by imperceptible stages, and now
its return must likewise be slow and cautious. Having re-
duced it, it must be confined to the abdomen until the hernial
orifice has had time to contract. A most aggravated case of this
description, I have seen wholly disappear after three weeks treat-
ment in bed; though as a prophylactic against its return, a truss
was worn. Local bathing, douching, massage and galvanism,
each serve a useful purpose, conjoined with rest in many cases
in which there is a vascular stasis of the cord and in the loose
tissues enveloping the sac. In many, old herniæ, no hope need
be entertained of effecting the return of the serous envelopes or sacs;
for their adhesions are firm and extensive; nevertheless, a prac-
tical cure of them may be secured with the sac in situ. If we, in
any manner secure the obliteration of its lumen, the end is at-
tained, just as effectually as if the fascia propria itself were com-
pletely enucleated. This closure of the lumen is brought about
by contraction, by plastic inflammation, and by atrophy. Physio-
logically, the contraction of the circular fibers at the orifices of
a hernial canal retain the viscera in their position, while patho-
logically this same contraction may induce interstitial changes
in the escaping structures which it embraces, and they may even,
by spasmodic action, induce serious symptoms through the vio-
lent pressure which they bring to bear on the imprisoned viscera
in strangulation.

CHAPTER VII.
MECHANICAL TREATMENT OF VENTRAL PROTRUSIONS, IN ADULTS,
MALE AND FEMALE.
In this class are grouped:
1st. Umbilical hernia.
2d. Hernia in the upper abdomen, the umbilicus, central and
lateral.
3d. Hernia through the abdominal walls, below the umbili-
cus, but above the inguinal zones.
These might be further subdivided into those of a pathologi-
cal and those of a traumatic origin.
This group taken as a whole, in both sexes,
after adult years
are attained, is the most unmanageable and incurable of all herniæ.
UMBILICAL HERNIE.
These are rarely met with in men, but in child-bearing
women are not very uncommon.
4
49

50
HERNIA.
Many of them though hopelessly incurable, are nevertheless
borne without serious inconvenience, and comparatively rarely
jeopardize life.
Of late years, since neoplastic formations have become so
common in women, and very many pathological conditions of the
female, internal generative organs have been radically dealt with,
through incisions in the abdominal walls, hernia has occasionally
occurred through the incision cicatrix. These I have designated
laparotomy herniæ.
These protrusions, commonly known as umbilical, strictly
speaking should not be so designated; for, but a very few of them
emerge through the centre of the navel orifice or carry with them
the urachus or round ligament of the liver.
On the contrary, they usually emerge either immediately
above or on either side of the umbilical scar.
The accompanying (Fig. 8) is a photograph of a very aggra-
vated case of umbilical hernia in a woman thirty-eight years old,
which came under my care. She did not notice any umbilical de-
formity till the birth of her first child, ten years previously. With
FIG. 8.
each of her successive, four con-
finements it increased in volume,
till now, when unsupported, it
hangs down on the pubes. It
will be observed, that it protrudes
through the median line, and is
spherical in outline. The integu-
ment which covers it is as thin as
parchment. Its contents are intes-
tinal, which are wholly irredu-
cible. She carries it in a sling,
and without much inconvenience,
and performs the duties of a house-
keeper.
This anatomical arrangement
is not of much consequence in
prothetic treatment, but, as will
be observed later, it has its im-
portance when a surgical operation is undertaken. We seldom
Mammoth Typical Umbilical Hernia in
Female.

HERNIA.
51
see hernia through the muscular planes, above the umbilical hori-
zontal line, except in the child-bearing. This area of the abdomi-
nal enclosure is least exposed to pressure, or to the surgeon's
scalpel in laparotomies.
In certain child-bearing women, however, with loose, flabby
fibre, in whom the foetus during pregnancy attains a rapid and
considerable development, as the uterus mounts upward the float-
ing viscera are confined within reduced limits. The same occurs
in dropsy of the amnion. Should the patient in this condition
make a sudden strain, or be subjected to vomiting or coughing,
something is apt to give; to rupture; and we will have a thinning
and expansion of that wedge-shaped plate of aponeurotic sub-
stance, which lies between the diverging ascending recti, or else
a tear through its inner lamina,
to be succeeded by a genuine
rupture, with a bagging forward
over the umbilicus of the viscera.
This may be of limited propor-
tions, or of considerable extent.
As a rule, after confinement,
when the gravid uterus is emp-
tied the umbilical viscera recede,
backward, into their normal
abode, all morbid pressure is re-
moved; when, if moderate sup-
port is provided over the weak-
ened gap, all traces of the defor-
mity disappear, until another
pregnancy; when, it may return.
In neglected cases with wo-
men bearing many children, this
condition may remain, though it
rarely gives much inconvenience.
FIG. 9.
A Voluminous. Exomphocele with its Invest-
ments dissected away.
In my service at the Nine-
ty-ninth Street Hospital, in the
autumn of 1885, an elderly woman came under my care who had
a large projecting mass extending from the ziphoid cartilage down-
ward. Below the navel the abdomen was rather retracted and flat.

52
HERNIA.
We could secure, but an imperfect history from the woman.
The physical qualities of the fullness inclined me to regard it as
a new growth. But at the autopsy it was discovered that it con-
sisted of a hernial extrusion, which had split the inner fibers of
the aponeurotic fascia; and, in this manner made its way outward.
The sac contained the gastro-hepatic omentum, all of the transverse
colon, and the greater part of the small-intestine, from the pylorus.
IRREGULAR VENTRO-ABDOMINAL HERNIA OF CHILD-BEARING WOMEN.
The inner surfaces of the abdominal recti, from the umbili-
cus down to the pubes, lie flush to each other, nothing separating
them except their sheaths in the male sex and in non-child-bearing
women. On the contrary, however, with the mothers of one or
more children, there may be a well-marked interval dividing
these muscles, varying from one to several inches. Pregnancy in
many women of modern life, over-fed and under-exercised, whose
fœtuses are large, fat and plump, puts the muscular planes of the
abdomen on a great strain, often so much over-stretching them
that they never quite recover their tonicity after labor, or the
fibrous structures are so far over-stretched that a complete return
to their former integrity is quite impossible. The mother then is
left "pot-bellied." The belly hangs over the pubic brim. The
recti muscles have so far diverged, as to permit the greater part of
the abdominal contents to occupy this hiatus, caused by the want
of muscular support. With women so burdened, if there be but
little adipose tissue present, we may at times quite distinctly feel
the vermicular movements of the intestine through the thinned
integument. These bulging masses in the lower mesial plain, like
those above, are not attended with any danger to life. They are
not commonly classified as herniæ, though ætiologically and pa-
thologically they are quite identical.
They derive their greatest interest from the deforming effects
which they produce, and from the fact that many of the most ag-
gravated cases of this description, if seen early in young women,
may be averted or wholly cured by simple means.
LAPAROTOMY-HERNIA.
Laparotomy hernia constitutes a distinct type. It may de-
velop in any region of the abdomen into which a blade has

HERNIA.
53
entered. I have seen a hernia follow a stab wound, inflicted by
the smallest blade of a penknife, in the left lumbar region. The
wound was a mere puncture, yet when the patient recovered and
took his feet he had hernia. One case occurred in a boy who had a
well defined perityphlitic abscess, which was opened directly down
on end, and drained through a small opening. There is no manner
by which they can be completely obviated, when the fascia pro-
pria is penetrated. Many devices have been suggested to prevent
them, such as cutting through muscular-tissue rather than apo-
neurotic, when selection of site is permitted; the homologous and
independent approximation of tissue in closing in the incision;
but none of these expedients will always secure the patient against
their development, though without doubt, when drainage can be
dispensed with, the latter is the most reliable and efficient. They
have a morbid-anatomy of their own. They are the most ungov-
ernable of all hernia, and exhibit a persistent tendency to increase
in size if the greatest vigilance is not exercised. As they possess no
independent, serous investment they are not prone to strangulation.
PALLIATIVE TREATMENT OF ADULT VENTRO-ABDOMINAL HERNIA.
The treatment of ventral-hernia resolves itself into mechani-
cal and preventive measures.
Umbilical herniæ of small size, as they commonly give no
discomfort, require no special treatment. It is only when they
manifest a tendency to increase in size, or threaten strangulation,
that they require a truss or support. A simple flannel or canvas
broad belt, with a pad adjusted, is usually as efficient as any-
thing. With those of great volume, all that an apparatus can do
is to support them.
Large, irregular protrusions, occurring above or below the um-
bilicus, arising in consequence of the long-continued intra-abdomi-
nal pressure of pregnancy or parturition, require rather preventive
than direct treatment, though the latter, in many, is efficient.
If the abdominal girth is put on a great strain, by a distend-
ing uterus, then an auxiliary, circular support, which will trans-
mit the superincumbent weight from the muscles and aponeurosis
to the strong, powerful column of the spine, should be applied, and
its use continued till after confinement.

54
HERNIA.
It has been seen, when the remedial-agencies of infantile-
hernia were being considered, that the protracted rest on the back
or side during lactation in the infant, was a potential element in
cure. It is interesting to inquire, as to the utility of rest, after con-
finement as a preventive against hernia or visceral displacement.
We are told that among savage, non-civilized races, the
mother is on her feet the day after the birth of her child. This
is the common custom with North American Indians, living in
their natural state. As the mother during enciente life pursues her
usual, active occupation, and is sustained on the non-stimulating,
precarious diet of the prairie or forest, her muscular system
preserves its firm fiber, and her offspring is born small, lanky and
devoid of fat; its average weight being from two and a half to
four pounds.
With many, too, of our own working women, they rise after
the second or third day.
The conventional period is nine days. In average cases this
probably is long enough. But with the easy classes and with
those who have borne many or very large babies, no doubt by pro-
longing the time and giving the abdominal muscles an opportu-
nity to contract and recover their full tonicity, the tendency to
median, aponeurotic expansion and bulging forward of the vis-
cera would be largely overcome. Obstetricians are divided in
their opinion on the necessity of the post-partum binder. The late
Professor Charles A. Budd used to say, that he could never see
that it served a useful purpose, but he advised its employment
nevertheless, because it always gave the patient comfort.
Surgically, the binder is an artificial girth, which affords rest
to the abdominal muscles, now thoroughly fatigued from long-
continued violent muscular effort.
It is essentially a bandage, fulfilling the same functions in
this instance over a temporary traumatized region of the body,
and to my mind always serves an invaluable purpose in civilized
communities.
There can be scarcely a doubt but a considerable number of
those large hernial pouches which appear along the median-plane,
as well as in those attributable to a free lateral sagging of the
oblique and transverse muscles, are in the greater number of cases

HERNIA.
55
caused by improper adjustment, or too early discontinuance of
the bandage or binder after confinement.
Embonpoint is pronounced, the body fills out in normal preg-
nancy after the fifth month. The intestinal-canal itself no doubt
also shares in this hypertrophy. Constipation is common, and
the intestine in order to overcome the impediment from uterine
weight enlarges in its calibre and is much thicker in its muscular
coat, so that there is an actual and positive increase in its volume.
Labor ended under favorable conditions of hygiene, involution once
more effects full restoration.
Many of these cases here described may be remedied, and the
normal symmetrical outlines be restored by treatment.
The individual should be placed on a light, easily-digestible
diet. The bowels should be kept open, and plenty of exercise
may be taken when the flabby abdominal walls are trussed up.
Electrization of the muscular walls, with small hypodermic injec-
tions of strychnine into the muscles, massage and douching sedu-
lously employed in selected cases, each and all contribute towards
re-establishment of tonicity in the abdominal walls. In those
obliged to do laborious work, or in women considerably advanced
in years, little can be done.
TREATMENT OF LAPAROTOMY-HERNIA.
For laparotomy-herniæ we can accomplish little when they
have attained a considerable size. As they are not reducible gen-
erally, they cannot be confined by any adjustment. And having no
independent fibro-serous investing wall or sac to limit them, after the
viscera have left the cavity of the peritoneum, they wander in every
direction under the integuments between the muscles and cellular
tissues. When they first appear, if they consist of omentum
only, should adhesive inflammation fix them in the opening
which they have made, and all severe straining be avoided, they
may not swell in volume or advance any further. But when
they are large and swing over the abdomen, the best we can do
for them in the way of prothetic support, is to substitute an arti-
ficial for the peritoneal sac.
There are aggravated types of this infirmity in young, healthy
women or men, which may be successfully dealt with by operative
measures, but to be effective they should be employed early.

PART III.
CHAPTER IX.
THE RADICAL CURE OF REDUCIBLE AND IRREDUCIBLE HERNIA BY DIRECT
SURGICAL INTERVENTION. ITS ORIGIN, PROGRESS AND PRESENT
POSITION.
We have already, in a general way, dwelt on what retarded
and what accelerated many great scientific truths, and what has
cleared the way for the pioneers in the healing-art, who, by their
industry, toil and genius, have earned for themselves an imperish-
able fame in teaching mankind the art of preserving health, over-
coming deformities and prolonging life.
An historical description of ancient methods, devised and
practiced in the early times, though attractive and full of inter-
est, would have but little practical value in this century. For in
those days little was accurately known of structure or function,
and the facilities of the nineteenth century were wholly un-
known. Yet, withal, as many are under an impression that the
56

HERNIA.
57
operative-field in hernia was a terra incognita until the very recent
past, and as hernial-operations, with different objects in view, have
at various epochs been performed on a large scale, a superficial
perusal of the more ancient literature,* may not be without inter-
est and some advantage.
In reviewing this part of the subject, we discover that for cen-
turies those afflicted with hernia were objects of scorn and con-
tempt. The victims of the infirmity were degraded, and what
was the most lamentable of all, when a hernia became strangulated,
if palliative means failed to overcome it, it was was left undis-
turbed, and the patient allowed to perish unrelieved, as it was
only in the beginning of the sixteenth century that strangulation
was treated by division of the tissues. Encouraged by the suc-
cesses which obtained by intervention with the scalpel, reducible
and complicated hernia were promptly treated by sanguinary
measures, which caused a large mortality. In the seventeenth
century the spring-truss was invented; and now it was discovered
that with several, simple support would efface many herniæ.
Operations became unpopular. In the beginning of the nineteenth
century, in spite of the claims of the spring-truss, it was in many in-
stances being cast aside, when Gerdy, Wood, and others intro-
duced a cure by invagination. This method, however, was short-
lived, and passed into oblivion with its authors.
The history of the radical cure of hernia is contemporaneous
with the time of Celsus.
This famous surgeon was not an extreme partisan of surgical
interference, although he operated many times with successful re-
sults. The precepts which he formulated eighteen centuries ago
cannot be much improved on, even now.
Not only did he pre-
scribe the age most favorable to success, but he likewise indicated
the modification of procedure in the varying types of the infirm-
ity. He directs a few incisions, resects the sac, and jealously
guards against doing injury to the elements of the cord or testis.
The omentum was cut away, and the surface of the stub was
charred with the hot iron. We do not gather that he operated on
*I am indebted largely to M. Paul Segond's valuable treatise for many data on the histori-
cal part of this subject. "Cure Radicales des Hernies," edition 1st.

58
HERNIA.
exomphocele. We find no mention of crural hernia by him, or
any other author until the eighteenth century.
It would appear that he regarded all hernia as having a peri-
toneal investment, though he clearly distinguishes two varieties,
viz.: One, in which the protrusion is caused through a slipping
and stretching of the peritoneum; and, another, by a rupture, or
tearing of this membrane.
Oribase appears in the fourth century. He makes no men-
tion of operation for strangulation, nor does he speak of elastic-
pressure, which was a very ancient expedient; but confines
himself to only the reducible, incarcerated, and adherent, which
he dealt with by means of a keen-edged instrument. His writ-
ings, however, reveal a remarkable fertility of genius, and many
of the features of his technique have been utilized by operators
of our time. Like Ball, of Dublin, "he twisted the neck of the
sac and resected the dependent part." His directions as to the
manner in which we should proceed in complicated cases are
very minute and precise. He made a counter-opening in the scro-
tum. He does not say how durable his cures were, but it appears.
his mortality was large; some dying from hemorrhage, others.
from peritonitis, and many more from pyæmia. Oribase regarded
a lively inflammation over the seat of operation, as indispensable
to secure permanent results.
Etius and Paul, of Egina, in the fifth century, recom-
mended and practiced operations on reducible-hernia. They di-
vided hernia into two grand varieties, to which they attached great
importance, viz.: One, by rupture of the peritoneum with a brusque-
advent and violent symptoms; the other, occurring by an elon-
gation and distension of the peritoneum, of a slow, imperceptible
and painless development. Umbilical-hernia of every description
they undertook to cure. Their steps in operation varied but
slightly from the latest we are familiar with. In inguinal hernia,
when the intestine came down into the scrotum, they removed
the testis on that side, but when the omentum appeared this was
exsected and the testis retained.
In enterocele, after a long incision was made, and the testicle
stripped, it was confided to an assistant, and the spermatic cord
moderately drawn on, when a double threaded suture was passed

HERNIA.
59
through the inner pillar of the ring and out above, in such a man-
ner as to firmly close the canal and tightly compress the vessels of
the cord. The cord was now divided and the incision closed.
With bubonoceles a similar incision is made through the in-
tegument; the omentum drawn well down and cut off; its vessels
ligated and then returned. The divided sac is now closed, in-
vaginated on a sound passed up the inguinal canal. After remain-
ing in situ from three to six days the sound is withdrawn and the
opening closed by granulations.
From the time of Eginus, which witnessed the fall and de-
struction of the Alexandrian school, the art of surgery passed
from the hands of the Greeks to the Arabs and Europeans. With
the latter until the sixteenth century, the time of the Reformation,
medical science and religion were associated together. Departing
or driven from Toledo, a number of physicians, mostly Jews, scat-
tered through the south of Italy and founded the school of Salerno,
which gave to the world the celebrated Constantine, who enriched
the treasures of surgical knowledge by the translations of Hippo-
crates and Galen. Salerno became the most celebrated of the
Italian schools, the recognized scion of its Arabian predecessor.
It was this great centre which produced Roger of Palermo,
Roland and the "Four Masters." But towards the end of the
twelfth century Salerno had to encounter a formidable rival at
another extremity of Italy, in Bologna.
In Italy, in the time of Roger and Rowland, surgery had
largely fallen into the hands of empirics. The greater part of
those, says Brunus, who practiced the healing art in those times
were rustics, fools and imbeciles, the most depraved and the vile,
presumptous women, who feared nothing. At this time, the same
state of affairs prevailed in Paris, where nearly all the surgeons
were clergymen; who regarded any sort of surgical operation
as beneath their dignity, and every description of manual function
as beneath them; leaving to the barbers, scarifying, leeching and
bleeding. Lanfranc himself never opened the abdomen for ascites,
never operated for hernia, nor cut for stone.
A surgeon then had to prepare to deal with a reign of empir-
ics, charlatans, and traveling operators; the "cutter for stone,"
Hernialists, those who "punctured for cataract," "bleeders,"

60
HERNIA.
"extractors of teeth," men and women. They cut and slashed,
mangled and mutilated the inhabitants of ancient cities and vil-
lages. They promised to cure every sort of hernia, castrating
every patient, and to such an extent that they threatened to strip
the country of its most virile and useful citizens. Now those in
authority interfered, and, by the severest edicts, the progress of
those merciless mutilators was arrested.
Nevertheless, in spite of imperial edicts, castration was in
vogue for a long time. In Montpellier, Balésere de Tarante cas-
trated lepers, and Peter of Borsia, castrated for simple hydrocele.
Indeed, castration was practiced not only among charlatans, but by
accredited surgeons, and was so well recognized as a cure for
hernia, that in the eighteenth century kelotomy, literally speaking,
was understood as synonymous with castration.
Guy de Chauliac represented the surgery of the fourteenth
century, and in him was incarnated Arabian science. Not only,
had he given the precise methods for radical cure of hernia, but
also clearly and fully set forth appropriate cases, with their im-
mediate dangers and probable results.
He divided hernia into two great classes: (1). Umbilical. (2).
Inguinal. As his predecessors, he recognized hernia by stretching
of the peritoneum, and by rupture of it. Though a frequent opera-
tor for hernia, he had great faith in the efficacy of bandaging,
plasters, topical applications and regimen. He is said to have
cured patients of sixty and eighty with local medicaments alone.
It is reported, however, that he resorted to methods which
savored of quackery, for he claimed to possess a secret preparation,
compounded by himself alone, which he administered in a peculiar
fashion. His patient being placed on his back, with a metallic
plate over the hernial tumor, which was firmly compressed by a
bandage, he commenced to dose the patient with his favorite
powders, which, he claimed, after their full therapeutic action
was developed, would, by a violent attractive power which they
possessed for the metal, draw the hernia upward into the abdomen.
Theodorus, Crevez, Piérre and Lanfranc each, in various
ways, resorted to caustics, chemical and thermal.
Arsenic was the favorite ingredient applied directly over the
ring when the hernia was reduced; beginning on the surface its

HERNIA.
61
erosive action, it ceased only when it had divided the spermatic
cord and penetrated deeply. The patient was confined a long
time to bed, and when he survived the ordeal, he was required to
wear a support for thirty days. Others ligated the
sac, removed
it and then freely cauterized the pedicle and adjacent tissues with
the potential cautery.
Franco, after having removed the sac, staunched the hemor-
rhage and freely exposed the canal; lightly touched over the
nude parts with caustics, in order that the succeeding inflamma-
tion might be rich in plastic, cicatricial material, and therefore
offer a more solid and resisting barrier against the re-descent of
the hernia.
The Point Doré was devised, it is said, by a Swiss named
Metheus, in the eighteenth century. Master Metheus operated
by pursuing similar steps to his predecessors, in exposing the
canal, liberating the spermatic cord, and dividing the sac; but he
employed a suture of gold, with which he approximated and
fixed the inguinal rings in such a manner as to seal the canal, yet
preserve the cord. It is said that Ambrose Paré gave it a trial,
but soon laid it aside and condemned it.
At this time (the fifteenth century) two traveling charlatans
went through England curing hernia. Their method was essen-
tially the same as those of Metheus, employing a metallic suture
to approximate the pillars of the ring.
It is evident, that for a very long time the principle of
pressure, as an auxiliary, to the cure of hernia was known;
hence, we find Marcus of Pavia, Bartholomew of Padua, and
others contemporaneous with them, employing a wooden-pad of a
conical form, secured in an elastic-bandage to overcome the most
refractory hernia.
Ambrose Paré was a warm partisan of the massage-treatment
in the hernia of young adults; when they were recent, an emolli-
ent aromatic ointment being always employed in conjunction
with it.
In the more rebellious, he reduced the intestine by taxis, and
then closed the breach en masse by carrying the suture from side
to side, through and through, all the while guarding the vessels
of the cord.

62
HERNIA.
Paré also resorted to a species of invagination, for the cure of
inguinal-hernia. He employed an ivory plaque with a strong
curved needle, the eye being in its convexity. This was fixed in
a firm holder.
Having reduced the hernia, he seized the integument and
adherent sac, pressing the cord aside, and introducing his ivory
between the cord and the sac, carrying his needle around with
heavy silk, behind this, through all the tissues. In this way the
lumen of the sac was closed and the suture firmly tied, remaining
in place fron ten to twelve days.
This simple method is said to have been introduced and first
successfully practiced, on a large number, by Benditti, a Spanish
empiric.
In 1665 a Dane named Scullet, described a new procedure for
hernial cure. This consisted in reducing the bowel, then, imbed-
ding and fixing the testis in the canal. This was so successful
as to receive the royal approval, and was regarded as an infallible
measure. We are informed that he gathered in an immense
fortune through its employment.
Louis XIV, purchased at a high price, from Prior Cam-
briéres, a remedy which he engaged to keep a solemn secret, until,
the death of the prior, so that the secrecy of the remedy was
sacredly guarded.
The distribution of this "royal-remedy" was made with great
pomp before Blégny, and the royal procurator. The famous rem-
edy (?) consisted simply in nitrate of potash dissolved in spirits of
wine, which was to be taken for twenty-four days; and, an astring-
ent plaster was applied over the hernia.
During the treatment, the patient might be about, on foot, but
he must not ride horseback, or in a carriage, but always walk or
go in a boat, in the meantime, wearing a firm bandage.
George I, of England, on discovering so many men in his
army with hernia (1 in 8 soldiers), didn't hesitate to give £5,000
and a pension of £500 to a notorious empiric named "Little John,"
who claimed to possess a "sovereign remedy" against hernia.
"Little John" after being idolized in England, crossed the
straits with his remedy, to France. In this country, he met with
bad results from the start. His method was a brutal and tortur-

HERNIA.
63
ing one.
He scarified over the sac, applied vitriol and pressure.
He operated unsuccessfully on one patient three times, finishing
by inducing a slough of the scrotum and loss of the testis.
In the seventeenth century Nicholas Seguin introduced a
truss, which he alleged would cure hernia so effectually that
sanguineous-operations should no longer prevail. Saviard The-
vinin, became engaged in a dispute about the priority right to a
certain apparatus worn in hernia, with curative effects. Blégny
was proceeded against as a charlatan, and under an injunction
(une lettre de cachet) was for eight years confined in the Bastile.
The ambulant operators for this infirmity, castrated so generally,
at about the middle of the eighteenth century, in Holland, that
the authorities ordered every-one, publicly lashed, who operated
without special permission for the cure of hernia; or unneces-
sarily castrated. At about the same time, in France, Robert de
Housse was sentenced to three years servitude in the galleys, for
ligating the spermatic cord in ten cases; in which, mortification of
the testis followed. Mary Ann Presse, of Rheims, who had prac-
ticed castration on four herniated infants, in each case followed
by death, was publicly castigated and imprisoned for seven years.
Hernial operations were again revived with great ardor in
the middle of the eighteenth century, by Petit, Garengeot, Le
Dran, Richter and Heister. The various symptoms of hernia, the
anatomical mechanism and pathological changes were minutely
and exhaustively studied by these eminent surgeons. Richter,
in his famous treatise on hernia, lays it down with great em-
phasis, that bloody operations are out of the question in every de-
scription of reducible, non-strangulated hernia.
Jean Louis Petit denounced operative procedure for every
species of hernia, except strangulated, and in those uncontrollable
and painful. The views of his contemporaries, Gauthier, Maget,
Bodenhan, La Condamine, and Bicêtre, were in like respect
conservative. Desault and Boyer operated on none, except those
located in the umbilical region. They used the ligature in effac-
ing the fibrous pouch, and required their patients to wear a sup-
port for six months, after the parts had healed.
Reneuline, Lagavanne, and Fabricius Hilandus, all had
abiding faith in the efficacy of rest. The latter reported a man of

64
HERNIA.
ninety, who had been cured of a large incoercible hernia, by re-
pose alone; he having been confined to bed continuously for six
months.
It may be said, that at the beginning of this century (nine-
teenth), the radical cure of reducible hernia by sanguinary opera-
tions had been definitely abandoned.
It was the general opinion
dangerous to life, and that
Percival Pott would have
at the time that all the operations were
none of them were radically curative.
every one hung who undertook a hernial operation, unless life was
threatened.
It would seem, however, from the writings of Lawrence,
Bichat, Scarpa, Beaumont, Schumacker, and others, at the begin-
ning of the present century, that they had in certain rare cases
resorted to hernial operations for reducible hernia. Operations
sustained a crushing blow in the classic writings of Boyer, who
explained in great detail the modus operandi of truss action,
and of Astley Cooper, who operated in his lengthy career on
nothing but strangulated hernia, and generally disapproved of all
others. Very naturally, the inventors of trusses profited by the
cessation of operations. "Medicated" trusses came into vogue,
"possessing marvelous healing powers." A plant, possessing "won-
derful properties," John Dubois had discovered. The tree grew in
Cyprus. Dubois was a graduate in medicine, and wrote a lengthy
brochure on the subject. The book closed with testimonials of
cure from many of the leading citizens of the realm.
This is something like the Chinese system of curing hernia,
as described by Mr. Duhalde, in the fourth volume of his travels
in China. The Chinese commence by reducing the protrusion,
washing the integuments and then applying the juice of gin-seng
and another plant named keon-ki. The patient is then restricted
to a diet of rice, bread and water, with sheep's kidney. The
patient is said to be radically cured in six days.
In France the most singular claims were made for the cura-
tive properties of various medicaments. Verdier, a hernial sur-
geon, published in 1818 an article in which he claimed radical
cures of hernia by pills of the muriate of mercury.
Hernial operations, however, were again pressed on the
notice of the profession in 1855, when there appeared the pro-

HERNIA.
65
cedures of Velpeau, Leroy D'Etoilles, Bonnet, Malgaigne,
Mayor, Guerin and Thiérry. These distinguished surgeons con-
fined themselves to the inguinal variety mainly, although Boucha-
court described a method for treating umbilical hernia. In Ger-
many and England operations for reducible hernia failed to be--
come popular at this time.
When Gerdy died, the loss of his powerful advocacy and sup-
port of intervention was felt, and in a short time again little was
heard of surgical intervention in simple hernia.
Wood, in England, in 1865 commenced to cure hernia by in-
vagination. Heaton, of Boston, had attained to great notoriety
in curing hernia in 1855, by subcutaneous injections into the in-
guinal canal. In 1875 and later Schede, Nussbaum, Czerny,
Reisel and Socin, taking advantage of anesthetics and antiseptic
protection, began to treat many cases of reducible hernia by sur-
gical intervention. In France Championniére was the first to treat
reducible hernia by operation on a large scale. The invagination
operation was practiced on quite an extensive scale in England
and Germany long after it had become unpopular in the country
in which it originated.
It possessed the merits of being a bloodless procedure, was
not very dangerous to life, and when it did not cure it generally
left the hernia in a position by which it was more easily managed
by a truss. But it was a painful and tedious method, and caused so
much irritation in many that it could not be completely carried out.
Wützer, of Bonn, Rothmund, of Munich, Spencer Wells and
Mr. Redfern Davies, of London, treated many by the invagination
of the scrotum. Each had a peculiar mechanical device of his own,
yet all aimed at essentially the same object. The treatment
lasted from seven to fourteen days, after which the patient must
wear a light truss for three months, and abstain from all active
exercise for a considerable time.
THE MANAGEMENT OF THE SAC IN REDUCIBLE AND STRANGULATED
HERNIA.
Heister, in the eighteenth century, was the first who recom-
mended and practiced the preservation of the sac. The theory on
which this was introduced was, that as the cavity of the peritoneum

66
HERNIA.
was not opened there was less tendency to shock or danger from
consecutive peritonitis. There were many adherents of this plan
who persevered in its practice until very recent times, but for
reasons which will be later detailed it finally became unpopular.
Birkett, in Holmes' System of Surgery, cites the views of
Lawrence on the question of the radical cure of hernia, as viewed
in the time of this distinguished surgical authority, who said:
"The subject of a strangulated hernia submits to an operation in
order to save his life, but he whose hernia is reducible endangers
his life to get rid of an inconvenience, for which an operation
affords no greater prospect of entire recovery than he had without
it. For after he had undergone an operation at the hazard of his
life the complaint may return, and the only protection against a
relapse is to wear a truss."
Velpeau* tells us that Garangéot and Steffens dissected up
the sac, folded it into a peleton (pad) and fixed it in the canal as a
plug, in all operations for strangulated inguinal hernia. This is
what Professor McEwen, of Glasgow, is doing in our time with
reducible hernia of the same type. Kocher's operation is essen-
tially the same. The only exception which Garangéot made was
in epiploceles, when, instead of the sac he employed the omentum
to block the passage.
Their aim in more ancient times was, as is ours at present, to
obliterate or plug the outlets with new tissue, with the omentum,
testis, sac, or integument.
The venerable Gross, in the seventh and last edition of his
famous treatise on surgery, speaks thuswise of radical cures of
hernia: "Various methods besides the truss have been suggested
for promoting the radical cure of hernia. Some date back to a
very remote period of the profession, and partake largely of the
rude nature which characterized the practice of the older surgeons.
To this category belong excision of the sac at its neck; its in-
cision, with the application of irritants, for the purpose of inducing
its obliteration; all of which resulted in much suffering, besides
the loss of many lives. What surprises one is not that these oper-
ations have been practiced in ancient times, but that they should
have been repeated at a comparatively recent period. In scrotal
*Malad Chirurg., Vol. II, 3d Ed., p. 224, Velpeau.

HERNIA.
67
hernia the testes were often extirpated with the sac, and so com-
mon had this practice become in the seventeenth century that
Dionis asserts that a certain itinerant operator was in the habit of
feeding his dogs with the organs thus removed. Hardly less.
cruel and unscientific are some of the more modern devices for
radical cure of this complaint, especially that of Belmont, which
consists in exposure of the neck of sac and introducing gold-beat-
er's skin, with a view of exciting adhesive inflammation."
Bonnet recommended acupuncturation of the sac in reducible
hernia, after the intestine had been returned into the abdomen.
After the needles had excited suppuration pressure was applied.
This was in 1836. Of fourteen cases thus treated, eight failed,
four were cured, and two died.
Pancoast, of Philadelphia, and Velpeau, of Paris, invented a
method for radical cure, which was based on the same principle as
that employed in treating hydrocele. The intestine was reduced,
and strong iodine tincture injected into the sac, after which firm
pressure was maintained. Of these operations, Gross says, suc-
cesses were few and far between."
66
About twenty years ago, Dr. Joseph H. Warren, of Boston, at-
tempted to revive the operation of Heaton, though he injected the
tincture of iodine, instead of extract of oak bark.
By an ingeniously constructed syringe the liquid was sprayed
either along the interior of the empty elongated neck, or into the
walls of it, or just outside, into the interspace.
Dr. Gay, of Boston, in 1870, gave this mode a thorough trial,
operating on eighteen cases, with the following results: Five
cures, eight benefited, and five failures.
Dowall, of Texas, thought he had discovered a manner of
operating which would cure reducible hernia, and so enthusiastic
was he at the beginning that he wrote a lengthy monograph on
its technique and results, but like many others of its predecessors
it was ill-fated and short-lived.
Dr. Jamison, of Baltimore, described a singular and unique
method of treating hernia many years ago. He operated on a
young lady, who had a large inguinal hernia, with an immense
outlet. Stripping the sac, he returned it into the abdomen; then
he took a tongue-shaped flap of skin from the region of the Fal-

68
HERNIA.
lopian ligament, and having pared the edges of the ring, he se-
cured this with many sutures, in the breach, between the pillars.
The graft became imbedded firmly in the hiatus, and this auto-
plastic procedure is reported to have cured her infirmity. Although
this venture can be regarded as little better than a barbarous mu-
tilation, yet, so great an authority as Velpeau spoke in high terms
of it. The late Professor Amsby, of Albany, employed setons,
passed through the sac. They were occasionally moved "to and
fro," to excite adhesive inflammation.
Karnochan employed this plan on six patients. It was shortly
discontinued.
MISCELLANEOUS METHODS EFFECTING OR FAVORING RADICAL CURE.
Different authors mention various severe cases of reducible
and incarcerated hernia, which underwent permanent cure, while
those who had them, were confined to bed, suffering from serious
desease or injury. Many cures of reducible hernia have been
reported through the "rest treatment" by Hilandus, LeDran,
Pott, Hey, Earle, Cloquet, Bramsby and Astley Cooper, Heister,
Schmucker and others.
Dr. J. Collins Warren, in Boston, recommended for treatment
of adult non-strangulated hernia, that the patient be placed on
the back, the bed partly inverted, i. e., the head lowered and the
feet raised, a sort of Trendelenburg position, with constant elas-
tic graduated pressure over the hernia. This same identical
mode was first introduced] thirty-five years ago by Maisson-
neuve, for large, recent inguinal or femoral hernia. This had been
designated "Cure by Posture and Pressure."
Mr. Kingdom, of the London Truss Co., and Dr. V. P. Gib-
ney, of the Hospital for Ruptured and Crippled in New York,
both report a large number of cases, as coming under their notices
for trusses, who had been reported as cured by operation.
One of the most notorious and remarkable charlatans that
ever posed before the American public, was Heaton, of Boston,
Mass. For fifty years he was known far and near; and during
that time plied his craft with such a large measure of success that
the herniated, from all sections of the United States and Canada,
of all castes and classes, flocked to him for succor and to be cured,

HERNIA.
69
so that in a short space of time he reaped a large fortune. He
claimed that hernia of every description was curable; and at least
convinced the people that such was the case. Not finding the
West a congenial atmosphere for his progress, he immigrated to
Boston; and on his arrival had the audacity to invite the repre-
sentatives of the medical profession to see him perform his ope-
rations. They did not accept his invitation, and he at once
became a martyr.
The public press espoused his cause, and he soon derived the
benefit of being gratuitously advertised the world over. He made
a triumphal tour through England; was wined and dined in
London, as one of the greatest benefactors of the age, and re-
entered the "Hub," a more popular man than he ever was before.
Little wonder that he was lionized, for those who came to him
with large old incoercible hernia, for which the most eminent sur
geons could offer nothing better than a stiff truss, left Heaton
cured.
Like Prince Mattei, of Bologna, he kept his method a pro-
found secret.
It certainly is inexplicable; this strange fascination of man-
kind for the mysterious. In no instance in medical history was
this more conspicuously demonstrated than in the case of
Heaton.
Dr. Heaton was a regularly qualified physician, and one
would think, that inasmuch as certain types of hernia are by their
very nature absolutely incurable, he would not have the unblush-
ing effrontery to proclaim to the profession and public alike, that
none were beyond his skill, when they applied early for relief.
So deep-rooted and widespread was the faith, which even the
medical profession had in this strange individual, that finally the
American Medical Association was forced to take action.
It was regarded as puerile folly, to expect men to close their
eyes to the evidence of their own senses, and allow their preju-
dices to stand in the way of the acquisition of knowledge.
Heaton had the secret. "He might die without revealing
it." Hence a committee of the American Medical Association
was appointed to wait on Dr Heaton, request permission to see his
operations and report their observations on their utility and value.

70
HERNIA.
This was in the year 1851. The committee was composed of
Drs. Geo. Heywood, J. Mason Warren and Samuel Parkman.
Heaton declined to permit the committee to witness any of
his operations, or give them his secret nostrum.*
The committee, though they were unable from any inspec-
tion made, either to admit or deny the efficacy of any of Heaton's
claims, reported at the next annual meeting, "that there is no
surgical operation at present known, which can be relied on with
confidence, to produce in all instances, or even a large proportion
of cases, a radical cure of reducible hernia," *
menting on which, later, Dr. Heaton says: "I affirm to be false
in toto."
*
*
*
com-
In 1872 Heaton's work appeared, edited by Dr. Davenport.
The spell was broken. He gave to the world his precious (?)
discovery which, when stripped of the charm of secrecy, no one
seriously noticed. In this monograph he says: "I lay it down
as a cardinal principle in all operations for the cure of hernia
that any inflammation, except the mildest grade, must be carefully
avoided. If the surgeon cannot operate without producing the
four cardinal principles of inflammation, as laid down by Celsus,
viz.: "Pain, heat, redness and swelling, he had much better let his
patient alone, for such a result can not do good. Gradually con-
vinced of the truth of the above consideration, I have, for a long
time, patiently sought for practical means of avoiding inflamma-
tion, and after eight years of discouraging experiment have dis-
covered a process which I call the method of tendinous irritation."
He claimed that active inflammation prevented the wearing of
the truss or bandage, something so necessary in his radical cures,
to be worn six months or more. It is better, he said, to wear it a
long time than for too short a time.
His injection fluid was composed of one-half ounce of fluid,
extract of quercus alba, with 15 grains of the solid extract of the
same. To this was added a grain of morphine.
Sparton's operation for radical cure consisted in invaginating
the sac, perforating it with a corkscrew which had a wide spiral,
bringing the point out through the upper wall of the canal and
threading it with a suture, leaving it in situ from four to five days,
*J. C. Warren, on Hernia. Introductory.

HERNIA.
71
then withdrawing it and filling the canal with a metallic plate,
which was secured by two sutures and retained in place until the
parts consolidate. According to Spanton, this operation is specially
suited to congenital inguinal hernia of young children.

CHAPTER X.
THE MORE ANCIENT METHODS OF TREATING STRANGULATED HERNIA.
It has been seen that, until a comparatively recent date, the
victim afflicted with strangulated hernia, in those cases which did
not admit of relief by other than simple means, was left to die with-
out operative intervention.
As the anesthetic properties of ether were wholly unknown
till the fourth decade of the present century, surgeons were often
driven to other expedients when called to relieve this always grave
class of cases.
Simple and tobacco clysters, purgatives, general bleeding,
emetics, baths, postural treatment, and other expedients were re-
sorted to with the hope of overcoming resistance.
It was seldom that an operation was undertaken until all
other measures failed. Surgeons possessed of even ordinary skill
were comparatively rare in those times. Besides, in the absence
of anesthetics, dexterity and rapidity of execution were a sine qua
non, but few who had unusual opportunities ever acquired these
faculties. In consequence, a hernial operation on one bordering on
72

HERNIA.
73
collapse always entailed so much torture, and was attended with
such an enormous operative mortality, that few could steel them-
selves to put a patient through the ordeal, except the stout-hearted,
or the adept.
Indeed, Saviard tells us that but few left the table alive after
this operation, in the eighteenth century.*
Heister had such faith in the relaxing power of tobacco that
he declared if it were employed early enough every strangulated
hernia could be reduced without cutting.
An interesting incident is related of the manner in which he
became an advocate of cold-water douching as an expedient in
strangulation. Being called to a young man who had a strangu-
lated hernia, he brought several of his students. Tobacco clysters
and taxis were tried in vain, and the hernia could not be reduced.
While hesitating as to what course to pursue, an old woman came
along, and quickly poured a pitcher of cold water over the tumor,
when it suddenly disappeared from sight in the presence of the
much chagrined surgeon.
Taxis, or digital compression with forcible reduction, is an
expedient of great antiquity. And to-day, in spite of all which
we have accomplished in the operative therapy of hernia, we must
regard it as the safest of all measures in the treatment of stran-
gulation, judiciously exercised. In former times it was often at-
tended with more pain and distress, and with, perhaps, less suc-
cess in affecting reduction than now.
However, it is obvious that when the patient was brought to
a state of collapse by exhaustive emesis, by phlebotomy or
tobacco narcosis, he must have been rendered quite insensible to
moderate pain.
We have been unable to devise anything yet which will re-
place digital taxis, and from what can be gathered, the same essen-
tial technique prevailed in the past as at the present.
THE MANAGEMENT OF THE SAC IN FORMER OPERATIONS FOR STRAN-
GULATED HERNIA.
While the earlier operators for reducible hernia, usually, with
detail and clearness, described their management of the sac in
*Saviard Leçons Chirurgicales, Ed. 1st, p. 134.

74
HERNIA.
cases for radical cure, we are left in ignorance of how the sac was
treated when kelotomy was first performed for strangulation. It
would appear, however, that until the time of the illustrious
Petit, the beginning of the present century, that the seat of steno-
sis or stricture was always regarded as being in the neck of the
sac. Hence, in all cases this was freely opened and the constric-
tion divided from the inside.
But Petit wrote with great force and conviction against the
practice, and proved that in the majority of cases the constriction
was in the tissues external to the pedicle of the tumor; that the
opening of the sac was not only unnecessary, but was fraught
with danger, and greatly added to the peril of the operation. He
also claimed that in those cases in which sac and all were re-
turned en bloc, relapse of the hernia was less frequent.
His writings in Continental Europe greatly influenced opera-
tions, so that with few exceptions this reduction en bloc was
generally thereafter adopted. In the British Isles, however, Petit's
views were only adopted by but very few, until 1850, when the
question was again revived, and was powerfully advocated by
Aston Key and Mr. Luke. Their appeal to the mortuary tables
appeared to speak with such conclusive force against penetrating
the serous pouch in strangulation, that many had to admit that
it unquestionably added an element of danger to operations for
relief.
In Gay's statistics on hernia in Guy's Hospital, for 1856, it
appears that when the sac was opened in operation for strangu-
lated hernia, the mortality was 60 per cent., and in those in whom
reduction was secured under operation without opening it, but
twelve to the hundred died. It must be understood, that those
cases in which the sac was opened were the most serious. One
would have supposed that the introduction of antiseptic methods
in more modern times would have removed the objection against
dividing and exploring the sac, as older operators were restrained
from exposing the viscera through a fear of consecutive inflam-
mation following. Such, however, is not the case. Speaking on
this point, in his latest edition on surgery, when the antiseptic
theory was in full blast, Gross says: "Since Aston Key's essay, the
method of returning the hernia en bloc has met with much favor,

HERNIA.
75
both in this country and in Europe, and is now justly regarded
as one of the established operations in surgery." In the United
States it has not attracted as much notice as its real merits de-
This eminent author, nevertheless, did not hesitate to
open the sac, though he was never in accord with antiseptic
methods.
Erichsen, writing in his "General Surgery," 8th edition,
(1885), page 788, says: "If in operations for strangulation,
on division of the fasciæ, overlying the neck of the sac, the hernia
can be reduced, it of course would be unnecessary to lay open
the sac, and the patient's chances of recovery would be greatly en-
hanced, more particularly if the operation be performed on old
scrotal hernia of large size."
Thomas Bryant promulgates essentially the same views,
3d edition (1882), page 471, declaring, "that when the cause
of the constriction is found outside of the sac, as is usual in
femoral hernia, the opening of the sac is rarely necessary, division
outside being all that is required. The surgeon who opens the
sac in every case, clearly often does what is unnecessary.
In the very latest and one of the most valuable works which
we possess on operative surgery, that of Frederick Treves,
Manual of Operative Surgery, edition 1st, page 512, volume
II, it is affirmed," that as a general rule the sac should be opened.
In a few cases in which the strangulation is recent, and the symp-
toms not severe, and in which but slight attempts at taxis have
been made, the sac may be left unopened and the hernia reduced,
without inspecting the gut. In every doubtful case, however, the
sac should be opened."
THE SUBCUTANEOUS SECTION OF THE STRICTURED NECK OF THE STRAN-
GULATED SAC OR DIVISION OF CONTRACTED RING.
Bouchut,* of Paris, was the first who recommended this
method of treating constriction by subcutaneous division of the
stricture. He advised it only when the operator was quite assured
that the contractions were in the circular fibers of the ring outside
the sac. He reported many successes in operations for strangulated
femoral hernia in women by his method.
*Bouchut, Oper. Chirurg., Hernie, etc.

76
HERNIA.
In 1852, the Pancoasts, father and son, and a few others in
America, adopted the operation, after Bouchut's directions, but
they soon gave it up as unsatisfactory and attended with more
than ordinary danger.
THE MANAGEMENT OF MORTIFIED OR GANGRENOUS INTESTINE OR OMEN-
TUM IN THE PAST.
From what can be ascertained through a search of ancient
literature, it appears that for a time after operations came in vogue
for strangulation, the suspected or actually gangrenous intestine
was treated in two ways only. It was either returned into the
abdomen, or it was opened and an artificial anus secured.
Sir Astley Cooper, and many others contemporaneous with
him, advised that in all instances in which the gut was suspected,
or only in the incipient stages of gangrene, it should be replaced
in the cavity of the belly.
There has been, for a long time, much difference of opinion
about the proper treatment of the omentum in strangulation.
Some returned it en masse, when free from mortification, while
others not fearing hemorrhage or subsequent inflammation, which,
it was alleged, it might give rise to, excised it at the inner
outlet.
In the latter part of the last century surgeons commenced to
open the intestine and empty it, in those cases in which its in-
creased volume rendered its return difficult after the sac was ex-
posed in strangulation. This practice was initiated in Germany
by Mohedenkon, and practiced by Mein, Roggenbau, Krüger,
Kollrenter, Graffe, Ludwig, Roeke, Lofler, Dax, and Kelacker;
in France, by Lenoir, Nélaton, Gosselin, De Roubaix, and others.
Resection of the intestine for gangrenous hernia has been
successfully practiced, says Gross, since 1727, by Ramdohr, Dieff-
enbach, Koberle, Kocher, Haggedorn, Nichodain, Czerny, Mohe-
denkon, Miner, Roggenbau, and Bird, of Illinois.
Early in the nineteenth century, Astley Cooper, Callisen,
Guthrie, and Brodie, had successfully experimented in resecting
the intestine of the dog, but in every case in which this line of
practice had been applied to the sphacelated bowel of a patient
suffering from hernia, death speedily followed.

HERNIA.
77
CONCLUDING OBSERVATIONS ON THE OLDER OPERATIONS.
So far has been traced the history of hernial treatment for the
simple, reducible, incarcerated and strangulated, in the infant and
adult, and in the male and female; in times when the means for
readily effecting hæmostasis or combatting inflammation were un-
known or imperfectly understood; before pulmonary anesthesia
or the analgesic properties of cocaine were thought of. This
review has been indispensable, before the subject of the vari-
ous operations of our time for reducible or strangulative can be
studied. By it we have seen what has been done in the way
of curing reducible and irreducible hernia, the degree of success
attending interference and the extent of mortality.
In strangulated hernia an endeavor was made to reach the
consensus of opinion on the question of the treatment of the sac.
When anæsthetics came into vogue and the antiseptic theory
became practically a doctrine, an immense impetus was given to
operative surgery, and of all the regions of the body there is none,
perhaps, if we except the generative tract of women, in which a
greater revolution has been wrought than in the hernial regions
--the inguinal and femoral-of men and women when occupied
by hernia. Yet with all this advance, it must be said with all
candor, that we can permanently cure but few reducible herniæ
by operative interference, and that the mortality following opera-
tion for strangulation is considerable yet. Nevertheless, some
substantial progress has been made of late, and methods have
been devised which favor cure in proper cases, and operations for
strangulation are being followed by a greatly reduced mortality,
so that a great incentive remains for us to continue our efforts
with a view of finally devising such a technique as will be at-
tended with the least danger to life, and the greatest prospects of
permanent relief of the infirmity.

CHAPTER XI.
A FEW GENERAL OBSERVATIONS ON OPERATIONS FOR RADICAL CURE OF
REDUCIBLE AND IRREDUCIBLE HERNIE, AS PRACTICED AT THE
PRESENT TIME.
Although there is a considerable number of operations
for the cure of hernia, in Europe and America, at the present time
being performed, still there can be little doubt but their number
has been markedly diminished within the past two years; in
other words, that a reaction, definite and pronounced, has set in
against the utmost indiscriminate surgical interference, which was
the rule with a larger number of operators in the recent past.
This is attributable to the firm position which many occupied
against a so general resort to sanguineous methods, for the perma-
nent cure of an infirmity, which in general may be cured or borne
by prothetic measures, and which is not very often attended
with danger to life. Besides, as time passed, the number of re-
lapses in those cases which had been reported cured, were becom-
ing very numerous. And with not a few of them, the recurrent
rupture, which had tumbled through a recently closed hernial out-
78

HERNIA.
79
let, had become more unmanageable and of greater volume than
the original. In not a few, when a hernia of considerable size had
been returned and confined on one side, another appeared on the
sound side.
With some, the scar-tissue along the canal had caused
so much pressure on the efferent vessels of the testis, as to in-
duce a painful varicosity of them, or atrophy of the gland. In
three of my own cases, in which there had been no return of the
hernia, the patients, all males, seemed to be haunted by an oppres-
sive, unaccountable melancholia, a mental alienation, which I inter-
preted to arise from irritation of the spermatic filaments of the
sympathetic and other nerve branches compressed in ligating the
omentum or sac. The incompleteness or imperfection of the
cure in many so-called successes was only too manifest by the subse-
quent necessity of wearing the truss, spica-bandage belt, or ceinture.
Again, after a time, as the structures which enter into a her-
nia were more critically studied, a better acquaintance with the
ætiology of the infirmity was had, and it was seen that many of
the radical operations demanded an extensive division or mutila-
tion of important structures in their continuity, confidence was re-
placed by skepticism, and, in many cases, approval by condemna-
tion.
Notwithstanding, however, the vicissitudes through which
modern operations for the radical cure of hernia have passed, the
impartial, progressive and experienced must admit that they
occupy a legitimate position in surgery, and in proper cases, skil-
fully performed, serve an invaluable purpose.
But the cases which are suitable or justify intervention are
comparatively few, as already stated.
For the purpose of being able to recognize those of the non-
strangulated variety, which are appropriate for operation, it may
be well to first describe those in which mild, tentative measures
suffice to effect a cure; next those in which relapse is almost cer-
tain to follow, and lastly, those patients suffering from a species
of hernia, the removal or reduction of which is attended with
great danger to life.
We would not operate on the infant or growing child unless
his hernia was ungovernable to truss-pressure, or was so painful

80
HERNIA.
that no support could be borne, or unless he were a cryptorchid or
were suffering from a hernia in the unclosed vaginal process.
The tissues of the infant are tender and highly vascular. The
structures are at this stage of life in but their formative stages of
development. The infant has practically no inguinal canal, both
apertures being directly opposed to each other until nearly the
third year.
In large adult herniæ, particularly direct inguinal and every
other type of the malady of long duration and of considerable
volume, which causes extensive pathological changes at the rings,
in the canals through which they pass, in the sacs within which
they lodge, and lastly in the viscera, the mesentery, omentum or
intestine, no sort of operation can, in many of such cases, be re-
garded other than a relief measure of doubtful propriety. Histo-
logical, interstitial changes have advanced; pressure, tension,
strain and disturbance of nutrition have irretrievably altered the
supportive girths of the lower abdomen. The mesentery has
elongated or lost its tonicity, and the intestine itself has increased
in length,
The valvular property of the canals is lost, and their ob-
liquity has disappeared, nothing remaining but one large,
common portal, through which the protrusion emerges directly..
Those employed in occupations of a very laborious character are
not a desirable class on which to undertake the radical cure.
With them the hernia is almost certain to return in a short time
in an aggravated form, so that unless there are special and pressing
reasons, hernia with this class should be left to bandage-pressure-
or the truss. Radical cure as an elective measure should never,
except for some special reason, be recommended in those whose
occupations are sedentary, with those of abundant means and pos-
sessing every facility to secure expensive and perfected retentive-
apparatuses, unless they endanger life. Nor is it often a justifi-
able procedure in those very advanced in years.
Relapse is almost inevitable in musicians who play wind
instruments, in public speakers, or those afflicted with asthma or
chronic bronchitis, unless the broad belt is constantly worn.
Operations are dangerous in all cases of voluminous hernia,
unless they have been reduced by taxis before operation is com-

HERNIA.
81
menced on them. To this class particularly belong umbilical and
large laparotomy herniæ.
The danger arises from the sudden return of large eventrations,
which have, for a long time, been domiciled outside of the ab-
dominal cavity, and have acquired their nutritive supply mainly
from the vessels which ramify through tissues, among which the
viscera have strayed.
When pulmonary anæsthetics must be employed, we should
not overlook the dangers attending their administration in those
laboring under organic disease.

CHAPTER XII.
THE RADICAL CURE IN STRANGULATED HERNIA.
There is no unanimity of opinion among surgeons on the
question of combining measures for radical cure with the liberation
of a strangulated hernia.
Those who oppose every sort of unnecessary manipulation
when one proceeds to operate for this desperate condition, do so
on the ground that as our patient is generally in a state of collapse
we should compress the time for operation into the narrowest pos-
sible limits. No statistics are extant which might determine the
validity of this allegation, as to whether the mortality is actually
increased in operations for strangulation with radical cure com-
bined. However, it is rational to assume when our patient is in a
state of great prostration and shock, the more quickly we can re-
lieve the stricture the greater would be his chances of recovery.
I have had one patient who was brought in for operation for
strangulation die almost at once after he was placed in bed.
82

HERNIA.
83
Another, a middle-aged woman, died under our eyes, on the table,
before the house-surgeon could complete the division of the con-
striction. Three have died within an hour after they were re-
turned to bed from the operating-room.
But there is a large number of cases of strangulations which
come under our treatment comparatively early. Since it is be-
coming more generally known that early operations are safer, and
the prospect of cure is held out by surgical intervention, this num-
ber is rapidly increasing.
Even in those cases presenting the most unfavorable symptoms,
when we can dispense with pulmonary anæsthetics, we may pro-
ceed with more deliberation, and extend the period occupied by
adding the necessary steps which favor a radical cure.
Since McBurney's operationwas first devised, about three years
ago, I have operated on twelve cases of strangulation, in every in-
stance combining measures for radical cure, though not always
employing the above-named method. The mortality in my hands
has not been as high as it was previously, when nothing was
attempted beyond reducing the strangulation.
COMPARATIVE MERITS OF OPERATIONS FOR NON-STRANGULATED AND
REDUCIBLE HERNIA, BY MODERN METHODS.
It would be impossible for one to enumerate the almost infi-
nite number of operations for the treatment of non-strangulated
hernia, which have been devised and described during the past
ten years. Every country has scores of them; America, probably
taking the lead. But comparatively few of them have been ap-
proved of, or have been adopted by the profession, while many of
those which were at first most eagerly accepted, and have been
most extensively practiced, are becoming unpopular, and are found
wanting in the qualities claimed for them.
Many were taken up because of their novelty and the manner
in which those who first elaborated them claimed that they were
almost never-failing successes. When reports commenced to come
in, that they were found wanting in the hands of others, their
authors, at times, resorted to Heaton's tactics, to the subterfuge,
alleging that in those cases of failure they had not been properly
performed.

84
HERNIA.
Dr. William T. Bull, of New York, presented a brochure at
the annual convention of the "American Surgical Association," in
1890, the most interesting and valuable that has been written by
any one, in any country, on the subject of modern operations for
non-strangulated hernia. But in his essay he went to such ex-
treme lengths as to deny that any operation whatever could be
relied on to cure reducible hernia.
He would regard no case as cured, which had not stood the
test of three years. These he claimed were uncommon. He col-
lected his elaborate data from widely separated sources, and in-
discriminately analyzed all the most modern and popular opera-
tions, particularly condemning in unmeasured terms the so-
called "open operations."
Commenting on the varied, simple and complex technique of
different operators, and the results of the cases treated by himself,
after different methods, he concluded that the safest and most use-
ful in the greatest number of cases was that one which was easiest
and simplest of performance.
This essay of Bull's has been followed by a reaction, for the
views which he enunciated were something more than theoretical
deductions, but were the outcome of a very large and extensive
experience in the service of hospitals, which furnished him with an
abundance of clinical material with which to support his con-
clusions. He raised a forensic question, too, inasmuch as he
practically condemned as unjustifiable those operations which
were being performed on painless, harmless hernia.
So that now
surgeons in America are more circumspect, and employ more cau-
tion in selecting cases appropriate for sanguinary measures.
The objective point with all surgeons in all operations is
fundamentally the same, viz., the restoration and retention
within the abdomen of escaped protrusions. This object is con-
summated only by removing the causes which lead to them, and
restoring such a structural arrangement as will permit of normal
physiological functions. The operation which will accomplish
these purposes with the least danger to life, and the least mutila-
tion of tissue, in the end, must survive and endure as the most
acceptable. Surgeons are not in accord on the means by which
this end may be best attained.

HERNIA.
85
THE ESSENTIAL PRINCIPLES ON WHICH ALL OPERATIONS FOR RADICAL
CURE OR SURGICAL TREATMENT OF REDUCIBLE, NON-STRANGULATED
HERNIA ARE PERFORMED.
The fundamental, vital phenomenon indispensable to success,
in the majority of hernial infirmities in adults, is local, adhesive
inflammation, cell-proliferation, ultimately undergoing condensa-
tion, and fibrous sclerosis.
This phase of inflammatory hyperplasia is an active factor in
the etiology of hernia, but now it must be excited artificially, by
the surgeon, in all direct operations for the relief or cure of it.
In this particular, lime has brought no change in the therapy of
hernia.
THE AGENTS BY WHICH INFLAMMATION HAS BEEN INDUCED TO CLOSE
THE APERTURE.
These may be divided into chemical and physical. To the
former belong subcutaneous injections of irritating liquids, the
direct application to the tissues of caustic solutions, or actual
cautery. As for mechanical agents their name is legion. Among
them we may enumerate direct and indirect pressure; the seton,
the suture or ligature, animal, vegetable or metallic.
The mechanical technique of operation has undergone but
trivial changes for centuries. The peritoneal investment or the
sac has not yet been definitely dealt with in anything like accord
among operators. Some leave it undisturbed, except at its neck,
which they ligate. Some twist it, others reel it up and clamp it
in the passage; others inflate it with a rubber bag. By some, it
is caught up and woven into the divided rings. It is pulled down
and pushed up. Finally, others have no use for it, and cut it off
inside the inner ring.
Many have aimed to obliterate the inguinal canal, and at the
same time preserve it, paradoxically as it may seem, for the passage
of blood-vessels and other tubular structures. Efforts have been
made to permanently approximate the tendinous pillars of the
inguinal and crural outlets, and effect their union by the employ-
ment of sutures, or by plastic inflammation.
Many cut directly down on the breach, turning back the in-
vesting tunics, layer by layer, until the sac is exposed or opened.

86
HERNIA.
When the toilet of the sac is completed and the apertures dealt
with, they are again homologously replaced, sewn together, and
covered in by what is known as the buried suture. Others, on
the contrary, deliberately prevent primary union, and stuff the
gaping wound with some irritating fabric which induces abundant
cell proliferation, granulations, and adventitious tissue.
The same diverging lines are pursued with the crural canal.
The aim of many operators is to carefully preserve or restore it,
while our latest completely destroy it.
Diverse and manifold as are the methods by which reducible
hernia has been and is treated surgically, the keystone of the arch
of success is the utilization of a plastic solder, or cement sub-
stance, the product of inflammation, which is designated scar or
cicatricial tissue.
The results of such operations, in a very large measure, de-
pend on the perfection or permanence of the cicatricial welding of
the divided parts together. Do such structures as the integument,
the aponeuroses, muscle, tendon, or serous membrane ever regain
their pristine retentive strength and elasticity after complete
division and subsequent reunion by cicatricial tissues? And if
they do in a measurable degree, which is the most durable and
firm, that which succeeds prompt, primary union, or that which
is yielded by granulation tissue?
If the first question can be answered in the affirmative, then,
indeed, the range of hernial operations for radical cure is a wide
one.
On the contrary, if the opposite obtains, then such operations
must be confined within very restricted limits.
If granulation tissue is firmer and more unyielding than that
which succeeds primary union, then the open treatment, with a
suppurative sore, should be encouraged in every operation for the
cure of hernia.

CHAPTER XIII.
THE MECHANISM OF HERNIA FROM A STANDPOINT OF STRUCTURE, FUNC-
TION AND ABNORMAL CONDITIONS.
However desirable it may be, yet it is quite impossible in a
treatise which deals with the practicability or the possibility of
curing hernia, to avoid a brief reference to that deviation from
normal anatomy and physiology in the apertures prone to this in-
firmity in the abdominal walls.
The inguinal-canal in the male is said to be caused by the de-
scent of the testis, which occurs between the sixth and seventh
month of utero-gestation. How it is formed in the female, the so-
called canal of Nuck, is not capable of explanation. For here,
surely, the generative glands do not leave the abdominal cavity.
The testis in its march outward pushes before it from within,
the parietal peritoneum, or transversalis fascia, which becomes
the processus vaginalis; some of the muscular fibers of the internal
oblique, constituting the suspensory muscle of the testis, the cre-
master; the aponeuritic fibers of the external oblique, from which
87

88
HERNIA.
those dense felted fibers of the inter-columnar fascia are derived;
the superficial fascia, or cellular membrane; and the integument.
Three arteries, several veins, nerves, and the vas deferens form
the spermatic cord. These, as they emerge through the internal
ring, are more or less bound together by fibro-cellular tissue
very frequently, from the point at which the spermatic canal be-
comes obliterated above; and they are so adherent to the walls of
their common, serous investment as to be separated only with
difficulty. Frequently this is quite impossible without laceration.
The external or fibrous layer of the vaginal process is a thick,
elastic sheath, which, unlike the inner peritoneal layer, is always,
throughout life, an open sheath above; the interval between it and
the serosa being loosely occupied by connective tissue. In form it
is that of a double funnel, being widely expanded above at its
origin and again below for the testis. Some anatomists designate
it the infundibuliform fascia.
The inguinal canal is an oblique slit, which, including the
rings in the male adult, is about three inches long. It commences
internally about the middle of Poupart's ligament, or in the center
of that line, which begins at the anterior superior spine of the
ilium and the spine of the pubis. It occupies an oblique position
from above downward; commencing in the fascia transversalis, as
it advances forward and downward passing anterior to the inter-
nal oblique and transversalis, and posterior to the external oblique.
The internal epigastric artery passes up between the peritoneum
and fascia transversalis posteriorly, midway between the rings.
The inguinal canal is always, in the normal state, completely filled
by the elements of the cord or round ligament at its origin. This
valvular vent is so adjusted that the greater the intra-abdominal
or extra-abdominal pressure, the more completely is it closed. In
this respect it is not altogether unlike the ureteral inlets to the
bladder.
In the infant both rings are so apposed that there is practi-
cally no canal. In the adult the canal is funnel-shaped, being
much narrower at its inner than at its outer opening, so that by
invaginating the scrotum the tip of the index finger readily en-
ters for two inches or more, until it is arrested at its inner ter-
minus.

HERNIA.
89
The external tendinous margins of its outlet are named pillars.
Their anatomical elements consist of white fibrous tissue, and are
hence quite destitute of blood-vessels. The normal state of the ex-
ternal ring is open, the viscera being amply walled back from pro-
truding by the combined tendon of the oblique and transversalis
muscles. The triangle of Hasselbach, in the normal state, ren-
ders development of certain descriptions of inguinal hernia quite
impossible.
CONGENITAL DEFECTS OF DEVELOPMENT IN THE SPERMATIC CORD, THE
INGUINAL CANAL AND OUTLETS, AND THOSE ARISING FROM PATHO
LOGICAL CHANGES.
There is no region of the body in which nature so frequently
fails in perfecting her processes of evolution as she does in that
through which traverse the external
parts of the male generative appa-
ratus. Had the male generative
glands been retained in the abdo-
men, as they are in some of the
quadrupeds, man would have been
spared much misery. Why it is
that they have been lodged exter-
nally, is a mystery that our most
astute physiologists have been
powerless to solve.
We
In the chapters on hernia in
children it has been noted that
the complicating changes that in-
vite hernia are mal-descent or non-
descent of the testis and cystic
disease of the cord (Fig. 10).
now come to deal with pathological
conditions of the cord and its
sheath, which have persisted with-
out relief into adult life, or which,
having been apparently cured in
FIG. 10. (Félizet.)
childhood, have relapsed in an ag- Congenital Hernia Before the Operation.
graved form later in life.

90
HERNIA.
It has been seen that normally, after the testis is lodged, the-
open, serous tubular strutcure becomes obliterated from above
downward. But it may remain open, so that the tunica vaginalis
and the peritoneal space become one common cavity.
In this instance we will have a free passage for the omentum,
or intestine, from within, outward into the scrotum. Hence, the
intestine has no independent sac. In this class of hernia, the
presence of a sac gives the operator no concern, for there is none..
The fascia propria may close at the internal ring and remain open-
below, when the lower segment becomes distended by a serous-
accumulation; a hernia may come down, and while, though, there-
appears one common tumor, there are two independent sacs in this
state.
A small omental mass may engage in the canal of the sper-
matic fascia, producing a genuine congenital hernia, while the
peritoneum has given way to pressure at the inner ring, and
another hernia is on its way in the same direction. Large hydro-
celes and voluminous spermatoceles, if unsupported in time, cause a
great elongation of the cord and weakening at this internal portal.
The relative positions of the rings have an important bearing
as an ætiological factor in the production of hernia; and as of late-
much is being done by surgeons to reproduce the displaced or
dilated canal, it is well to endeavor to estimate to just what extent
surgical manipulation or ingenuity may succeed in this direction.
There can be little doubt but that with those strongly predis-
posed to inguinal hernia, and when the infantile type is perpetuated,
one ring lies in almost immediate juxtaposition with the other,
and there is and has been practically no inguinal canal at any
time. If there ever has been a normal inguinal vault in the her-
niated, a large protrusion continually occupying it soon effaces-
every trace of it, and nothing remains but an immense, common
orifice, a large open portal. Unhappily, with this derangement or
destruction of the normal architecture in the inguinal region, though
we may in many cases partly prevent it, we are, as a rule, power-
less to wholly repair the damage resulting from it.
It is obvious, then, that in many cases it is absurd for opera-
tors to lay down any common rule for the techinque of inguinal
hernial operations, which will apply to all. For instance, to de-

HERNIA.
91
scribe the management of the sac, when there is no such pouch
present; to tell us how we must deal with the canal, when there is
none, or how the rings should be encountered, when, in fact, there
is but one.
Much has been written on the manner in which we must pro-
ceed in order to preserve the cord. But as there is neither cord
nor testis in the cryptorchid, this it would seem should not em-
barrass us in those cases. It is said that in about one in a hun-
dred the testis has not cleared the inguinal canal in the new-born
male, and that in one in five hundred it never leaves the abdomen.*
Hence, in every case of hernia in the male infant the testis should
be sought for. If it engages in the inguinal canal, and fails to com-
pletely descend through the lower outlet, it is a constant source of
hernia, as by its presence it keeps the passage widely opened and
favors the descent of the viscera.
There can be scarcely a doubt but this irregularity of descent
of the testicle is responsible for a very large proportion of ingui-
nal hernia in the male.
Camper, in dissecting 17 infants under three months old,
found the fascia propria or peritoneal investment of the cord, con-
tinuous with the general cavity, freely open on both sides in 11.
It was open on the right side in 4, and on the left side in 2.
Hence, in the 17 it was completely closed on both sides, at this
age, in but one. There was no hernia.
*Curling, on the Testis, page 203.

CHAPTER XIV.
INGUINAL AND FEMORAL HERNIA IN THE FEMALE, WITH OBSERVA-
TIONS ON MALE FEMORAL HERNIA.
The canal of Nuck, so called, which penetrates the musculo-
aponeurotic planes of the lower abdomen of women, differs from
the male inguinal canal in transmitting through it no large
tubular structure, but rather a fibro-cellular inpermeable cord,
one of the supporting stays of the uterus, the round ligament.
As Dr. W. C. Wile, of Connecticut, pointed out, in an extensive
series of observations on apparent hernia in the inguinal region
of the infant and adult female, that these protrusions consist very
often, mainly, of cystic formations along the inner laminae of the
infundibulum. Cystic changes in all the elements of the female
generative apparatus are very common, not even the non-vascular
ligamentous structures escaping.
When those serous cysts undergo spontaneous absorption,
during infancy or early childhood, no harm comes; but when they
attain considerable size and persist into adult life, their presence
weakens the inguinal walls and leads to hernia.
92

HERNIA.
93
FEMORAL HERNIA IN THE MALE AND FEMALE; ITS MORBID ANATOMY
AND PECULIARITIES.
The pathological basis of femoral hernia is always, primarily,
dependent on defect of development. Many theories have been
advanced to explain the morbid anatomy and structural devia-
tions in evolution,which are attended with visceral protrusion under
the femoral arcade; yet, for the most part, they remain unsupported;
hence our knowledge of them still rests largely on hypothesis.
In inguinal hernia in the male, the descent of the testis
so clearly accounts for the breach in the abdominal walls, the
canal, and rings, that the modus operandi of this hernia is at once
comprehensible and obvious.
But with a hernia which insinuates itself on either side of or
between the femoral blood-trunks, as they leave the pelvis, we
can advance practically nothing as a causation. Nor is there,
substantially, any good reason why femoral hernia should be more
common with women than with men. The crural arch is composed
of the same structural elements in
both sexes, though it is broader in
females.
As we study the physical con-
formation of the parts concerned,
and note the extreme obliquity of
the course through which a hernia
must pass before it clears the sa-
phenous opening in the fascia lata,
we can appreciate the obstacle
which this sharp curve must offer
to an extrusion and circulation of
the ingesta through a prolapsed coil
of the intestine in this situation.
Normally, as the vessels leave
the pelvis in this situation, and
occupy the femoral sheath, they
are so protected by reduplica-
-12
FIG. 11.
Femoral Hernia.
tions of the parietal peritoneum, and are so firmly apposed and
walled in by the cribriform fascia, that it is wholly impossible
for any external substance to penetrate between their walls.

94
HERNIA.
In many subjects, however, we will notice at the point where
the vessels leave the cavity of the peritoneum, there is a layer
of adipose tissue mingled with fibro-cellular elements, through
which the vascular channels pass. This has been named by Cloquet
the Septum crurale. Now, in not a few, we will discover a fringe
of this fat, extending from the so-called septum along the inner
surface of the common sheath to the saphenous opening. The
cabiber or diameter of the femoral canal depends on the presence
and quantity of this substance, for without it there is no canal.
The deep layer of the superficial fascia, which is extended
over the boundaries of the saphenous opening, sometimes desig-
nated the cribriform fascia, varies in thickness and density.
The saphenous opening in the fascia lata, like the external
outlet of the inguinal canal, has diameters very much out of
portion to the tubular structures to which it gives passage.
pro-
Its superior and inferior borders, as well as its falciform pro-
cess, the deep femoral fascia and the ligament of Gimbernat, are
composed wholly of fibrous tissue.
It is seen, then, that the femoral sheath, which corresponds
with the spermatic process, is a very much simpler organ in its
construction, position, arrangement and relations than its proto-
type, which passes over the arcade immediately above it; for it has
no independent muscular envelope, nor does it transmit the duct
of any secreting organ, but the great blood-trunks which pass
through it. After the crural sheath reaches the saphenous open-
ing, it acquires such firm and intimate adhesions with the walls
of the vessels which it encloses, as to completely obliterate that
interspace, which, when caused by disease or artificially produced,
is known as the femoral canal. Accordingly, when any extra-
neous substance enters the canal from above, it is arrested at the
entrance of the saphenous tributary, and here it must remain; or
else in time make its way through the saphenous opening, carry-
ing before it its mural support, the cribriform fascia and deep fe-
moral, in which latter event we will have a complete femoral, and
with the former an incomplete femoral, hernia.
The numerous large absorbent glands which encircle the
saphenous vein between the two layers of the superficial fascia,
and are often found imbedded along the plane of the blood trunks

HERNIA.
95
between the septum crurale and the cribriform fascia, are nor-
mally so adjusted as to give solidity and support to the walls of
the femoral canal.
In cases of lymphadenitis, which extends to the deep chain of
the groin, the free plastic exudate, which is thrown out over the
surface of the glands capsules, often causes such an extensive ex-
travasate, that when it is not completely absorbed, then its resi-
due undergoes fibrous condensation and firmly welds all the
tissues in the vicinity of the inflammatory changes into one mass,
more particularly the envelope of the glands to the outer walls of
the vessels.
The position as well as the diameters of the saphenous open-
ing varies, for it will be observed that it was many years ago
pointed out by Bichât, that this portal in a large number of sub-
jects did not always correspond in diameters or size in proportion
with those of the subject. This same famous anatomist also
noticed its varying obliquity and position.
In women it will be found
placed further inward, with less
obliquity in position and of greater
dimensions than in men. It is
clearly evident, accordingly, that
femoral hernia is wanting in that
complexity of construction SO
characteristic of the inguinal
variety. Hence, we will not ex-
pect to encounter those complica-
ting pathological conditions so
often here as we do in kelotomies,
performed over Poupart's liga-
ment. Yet they are sufficiently
numerous to demand of us a famil-
iarity with them before an opera-
tion is undertaken for their relief or cure.
FIG. 12.
Femoro Inguinal Region.
It is well to remember that we may have a femoral and in-
guinal hernia on the same side.
The structural changes in the component parts of the femoral
canal, necessary to make the advent of a hernia possible, involve,

96
HERNIA.
first, the apertures; secondly, the lumen of the femoral sheath,
and thirdly, the contents of the canal itself. It is self-evident.
that with the canal hermetically sealed, nothing can possibly
escape. But when it is remembered, that even under normally
physiological conditions, the volume of what enters and leaves the
canal is constantly changing, its diameters must likewise change,
so that while they are under these conditions closed, they are not,
so to speak, always filled completely.
Second, the varying capacity of the femoral sheath. There can
be no doubt but the diameters of the femoral artery are quite constant.
The column of blood in this vessel is subject even in health to many
influences, which modify its volume and movement. The most con-
stant influence perhaps is gravity; the next is ever-changing ca-
pacity of the peritoneal cavity, particularly in married women.
Pathologically, any impediment in the inferior cava, by tu-
mors or enlargement of organs along its course, disease of its
valves, or in its own walls, leads to a dilatation and weakening of the
FIG. 13.
femoral vein.
The fringe of
adipose tissue,
which in health
fills the inter-
space between
the wall of the
sheath and the
vein, may un-
dergo a sudden
hypertrophy,
and cause a
widening of the
canal; so that in
the event of it taking on atrophic changes, it leads to a widen-
ing of the canal, and a descent of the viscera.
The third, that which has reference to the contents of the fe-
moral sheath independent of the vessels, is probably the most proxi-
mate and direct of all exciting agencies, as a causative of hernia.
In the greater part of diminutive, incipient femoral herniæ,
we will discover on division of the tissues, and on exposure of the

HERNIA.
97
canal, that the extrusions consist of omental tissue; that they are
epiploceles.
Through some fault of evolution during the formative
stages of development in early foetal life, in some inexplicable
manner a portion of omental tissue makes its way into the
femoral sheath, after which it may remain at the inlet, descend
further down, or pass directly through beneath the falciform pro-
cess. It may be assumed that it often undergoes degenerative
changes, or atrophies, and disappears. This is the only hypothe-
sis on which we can account for the frequency of epiplocele in
femoral hernia. Normally, the omentum is above the horizontal
plane of the internal femoral opening, so that the double perito-
neal sac, which we may occasionally meet with in inguinal her-
nia, is seldom seen here.
It is true that there are, at times, in cases of acute strangula-
tion of a femoral hernia, no evidences of anything in the sac except
a pinched knuckle of intestine; still, upon releasing the impris-
oned bowel, we will rarely fail to find along the track either free
or adherent omental tissue of a varying volume, contour, or con-
sistence. When this is firmly adherent to the walls of the canal,
or is restrained by a short, inelastic pedicle, it securely blocks
the passage against intestinal transit. But when, if it be loosely
movable, and has, by its wedge-like action, widely spread apart
the walls of the canal, then under a diversity of circumstances
the free intestine, in close proximity, may slip down through,
advancing onward beyond the situation at which the adipose
mass itself is lodged. In chronic old femoral, many of the land-
marks of the surgical anatomist are practically lost. It is very
often quite impossible to diagnosticate an incarcerated inguinal
from an old femoral hernia. This is particularly true of the female,
whose integuments are often under-padded by a very thick layer
of fat. And in many cases of large, impacted, chronic femoral
epiploceles, it is quite impossible to recognize them from enlarged
lymphatic glands.
7

CHAPTER XV.
MORBID ANATOMY AND PATHOLOGY OF EXOMPHOCELES, EPIGASTRIC HER-
NIA, EVENTRATIONS, OR LAPAROTOMY HERNIA.
Umbilical hernia in the adult is seldom seen, except in infants
and child-bearing women. It is well to have a clear compre-
hension of its gross constituent elements, if we would the better
appreciate what may be accomplished by surgical measures in seri-
ous cases of this infirmity.
While hernia in this situation in the male is rare, it is not
entirely wanting; though it is with them usually of a small size,
and is entitled to the designation only because it is in close prox-
imity to the navel scar, for of its essential elements it contains
none, and is outside of the umbilical aperture in many.
With women it is attributable either to a rupture, or an elon-
gation of the circular fibers which close in on the urachus and the
round ligament of the liver at the umbilicus. In many the fusion
of the muscle, aponeurosis and peritoneum are so firmly blended
together at the annular aperture here, that the protrusion can
advance in but one direction, and that is against the thin, wrinkled,
98

HERNIA.
99
integumental covering of the navel. It is marvelous how this can
spread and expand, so as to reach a size as big as the fist, or even
larger, when its coverings may become as thin as tissue paper. The
contents of an umbilical hernia are omental or intestinal, or both.
The reducible are usually enteroceles. Epiploceles are the most
common in this situation in adult life, and are irreducible. The
mechanism of a hernia here is altogether unlike that which occurs
above and below the ligament of Fallopius.
In the latter situation we have canals and rings, through
which tubular structures pass, which have a peritoneal invest-
ment. In the umbilicus none of these are practically present.
Here we have simply a weak spot in the upper abdomen, depen-
dent on defective development and other causes. As there is no
obliquity to the passage of emergence, and no bony supports,
it is obvious that unless the opening, through which a hernia
passes, is well buttressed by powerful ligamentous or aponeurotic
tissues, rapid eventration must often follow. In this situation,
theoretically at least, one would suppose that a radically curative
operation would offer the best prospects of success; as there is
no impediment in the way of completely and solidly closing in
the hernial vent. Strangulation is not very frequent in umbili-
cal hernia, though these herniæ are commonly painful and are
always sensitive, owing to their attenuated, integumental cover-
ing; besides, they are quite prone to peripheral inflammation,
ulceration and hemorrhage, when their contents are omental. In
aggravated cases, the protrusion by causing a constant, well-sus-
tained strain on the umbilical opening, in time so stretches or
lacerates its borders that they give way, and any parts of or all
the abdominal viscera except the fixed organs, may pass directly
out of the abdominal cavity into this ad ventitious pouch. If we ex-
clude the omental investment, it cannot be said that hernia of
any description in the upper abdomen has an independent peri-
toneal covering. In this situation, also, we perceive that patho-
logical condition which may be designated, rupture.
As soon as the viscera leave the abdominal cavity en masse,
they by their presence excite irritation in the layers of the cellular
membrane, subcutaneous tissues, or intermuscular spaces. This in
turn causes an inflammatory plastic exudate, which binds the

100
HERNIA.
wandering organs to the parts into which they have trespassed.
As a consequence of this new alliance, the source of their nutri-
tive supply is changed, and hence, instead of the intestine being
wholly provided by the vessels which course through the mesen-
tery, it draws freely from the vascular supply of the cellular mem-
brane of its new domicile.
Those hernial protrusions of the greatest volume, however,
which issue through at the umbilicus, most frequently make their
escape by a breach in the abdominal wall itself; although, as
they emerge, they so press the tegumentary coverings of the navel
forward as to mask their real origin.
Epigastric herniæ, or those which are located anywhere be-
tween the umbilicus and the tip of the ensiform cartilage, are most
often encountered in the male sex. They may be so small as to
quite escape detection, unless they become inflamed, or threaten
strangulation. They are wholly of a congenital origin. In some
manner, not understood, a small nodule of adipose tissue directly
connected with the omentum makes its way through the medi-
an line, imbeds itself with an adventitious sheath of cellular tissue,
with which it forms adhesions. I met with such a case last
winter, in a man fifty-six years old. For a short time he had
symptoms of strangulation. There was vomiting, colicky pains
and constipation. As he declined operation, by the hypodermic
employment of morphine, warm applications and rest, the symp-
toms passed away. Over the tumor the tissues were swollen
and exquisitively sensitive. He had it as long as he could remem-
ber, and though he was all his life engaged in a laborious em-
ployment it had never given him the slightest inconvenience
before.
Eventration or laparotomy hernia is essentially a traumatic
infirmity. Since laparotomy is becoming so generally practiced
in America by surgeons, particularly for treatment of diseases of
the internal generative organs of the female, and for pathological
conditions of the cæcum and its appendix, these herniæ are be-
coming common sequelae of those operations.
There can be no question of doubt about it, but a free incision
into the abdominal wall or the peritoneal cavity is invariably fol-
lowed by a weak bond, at any time liable to stretch or rupture.

HERNIA.
101
It has been claimed that when the incision is made through
the muscular planes, instead of the aponeurotic tissues, the chances
of hernia following union of the parts is considerably diminished.
This has not been my experience, for the most intractible that I
have met with were of the muscular variety, as has been stated.
The morbid anatomy of a laparotomy hernia is very simple.
There is a giving way or sundering of the parts the more deeply
lodged, a gaping of the edges of the peritoneum, and an eventra-
tion through the gap into the parts offering the least resistance.
The pathological changes resulting are what make many of them
the most serious species of the infirmity that we have to deal
with in the whole category of hernia. As the intestine leaves the
peritoneal cavity it produces a considerable elongation of the
mesentery; besides, by pressure and strain, it interferes with the
mesenteric circulation and impedes peristalsis. As a consequence
the general health suffers. The appetite fails and constipation
follows. Along with this the necessary point d'appui in defecation
is wanting, in consequence of the breach in the abdominal walls
and defective muscular action. The eventrated parts become ad-
herent to the tissues in which
they are lodged, which renders
them irreducible, and, when ex-
posed in operation, difficult to
separate and free without danger
of damage to the viscera and con-
siderable loss of blood. It is
readily apparent when observing
the broken irregular scar conse-
quent on many laparotomies, that
a hernia must follow if the parts
are not braced constantly. (See
Fig. 14.)
FIG. 14.
Three weeks after a Laparotomy for large
Uterine Fibroid.

CHAPTER XVI.
LUMBAR, OBTURATOR, PERINEAL, PUDENDAL AND ISCHIATIC HERNIA.
Besides the above, there are many other phases of structural
defects or pathological changes which lead to those conditions
which are designated as hernia. They are those which are wholly
internal, as diaphragmatic, and those which involve Meckel's
diverticulum, besides internal and external types, which belong
to the province of gynecological surgery, such as prolapse of the
bladder, the ovary, uterus, broad ligament, fallopian tubes, or the
intestine into the vaginal outlet; or those cases of prolapse of the
rectum through the anal sphincter, with or without strangulation.
But, with the exception of those which involve the female
generative organs and the terminus of the rectum, these others of
an internal order are so rare that many surgeons of large expe-
rience have never seen them.
Hence, this epitomized review of those protrusions which are
limited to the abdominal cavity, with a brief consideration of their
elementary constituents, with morbid anatomy of lumbar, obtura-
tor and perineal, pudendal and ischiatic hernia, will close this
division of our subject.
102

HERNIA.
103
LUMBAR HERNIA.
This is a pathological rarity. Sir Astley Cooper says he saw
but one case.
Lawrence does not mention it. The most complete
and valuable contribution which we have on the subject is from
the pen of Dr. Claudius Mastin, of Mobile, Alabama, to whom I
am deeply indebted for his notes on this infirmity.
In his brochure presented at the annual meeting of the Ameri-
can Surgical Association in 1890, he was able to report thirty-
three cases of lumbar hernia which he had gathered from widely
separated sources.
But three were from American literature. Seventeen occurred
in females and sixteen in males. Four followed accidents; two
from spinal caries, one from old age, eleven came from injuries,
three were congenital.
Although Petit's triangle would seem to favor hernia, yet, as
the obliquus internus and the latissimus dorsi so closely overlap
on either side, and the lower convex surface of the kidney
covers it in, its weakness is more apparent than real.
The primitive causation is said by all authors to be congenital
defect of development.
Of course, in traumatic cases following punctured wounds,
we have a direct, unequivocal factor in their ætiology. Some of
those recorded by Dr. Mastin were of this character.
Of the latter, I have had one under my care in the Ninety-
ninth Street Hospital, of New York, in 1886.
The patient, a young man of 20, was stabbed in different
parts of the body; though but one incision penetrated the abdomi-
nal cavity. This one apparently transfixed Petit's triangle. When
the patient entered the hospital he had lost much blood through
the wounds; and, besides, had hæmaturia. He made a good re-
covery, though a small hernia appeared at the site of the lumbar
wound. After he left the hospital I lost sight of him.
History of Dr. Mastin's Case.-Dr. Mastin's patient was a boy
seven years old, who had a lumbar hernia, which measured nine
and one-half inches in its long axis and nine inches in its trans-
verse diameter. He had also had a direct inguinal hernia on the
same side (the left). It was partly reducible, and contained in-
testine. It was comfortably controlled by a truss. In this case

104
HERNIA.
it was apparent that there was a loss of substance in the obliquus
and the latissimus dorsi muscles.
This phase of hernia, like others of an unusual development,
derives its greatest interest from a diagnostic standpoint, as en-
largements here may often defy detection, and one may often be
in doubt as to whether he has a neoplasm, hæmatoma, or hernia
to deal with.
Second Illustrative case.-My patient, a derrick-man, was acci-
dentally, violently struck by the fly beam of a derrick, just over
the right hip, on the inner side.
He was able to rise and go home unassisted. A few days after,
he came to me, when I found a large spherical mass on the inner
side of the quadratus lumborum muscle, on left side.
I was at first in doubt as to its real nature. It seemed more like
a traumatic hernia than anything else. It appeared to be slightly
reducible and had a doughy feel. But there were no constitu-
tional symptoms. Passing in an exploratory needle it was found
to contain a limpid serous accumulation, which I finally aspirated,
and it did not refill.
LUMBAR HERNIA IN FEMALE WITH CONTENTS OF SAC UNDERGOING
MALIGNANT CHANGES.
Dr. James Moran, of New York, sent a case into my service,
at Harlem Hospital, in January, 1891, for operation, of this de-
scription.
The patient was a married woman of 45 years of age. She
had a fullness in the right lumbar region as big as her fists.
She said that it had been there for several years, but that it
never gave her any trouble until six months previously, when it
became harder, painful, and was increasing rapidly in volume.
After carefully examining her I concluded to make an ex-
ploratory incision, and act according to what it revealed. Mak-
ing a long, free sweep of the scalpel, in an oblique direction from
above downward, over the convexity of the fullness, I divided the
integuments, and at once came down on a thick inelastic capsule,
which had fused distinctly with the superficial fascia and the
lumbar aponeurosis. After a difficult and tedious decortication it
was freed, until the broad aperture it had made through the fibers

HERNIA.
105
of the oblique muscles was reached, Here the detachable parts
were dissected away, after which a double row of sutures trans-
fixed its sessile pedicle. As it was traced into the cavity, it was
found to be continuous with the omentum.
Now a drainage tube was inserted, and the parts closed, layer
by layer, as in the radical cure of ventral hernia. Her recovery
was uneventful. Since she left the hospital there has been no her-
nial return. Her former colicky pains have never annoyed her
since, and the troublesome constipation of the bowels has given
way to regular painless stools.
Although this case was not one on which an operation was
deliberately undertaken with any definite end in view, yet I can
find no other cases on record of the same character, which had
been operated on for the radical cure; and as these hernia only
in the rare event of strangulation or neoplastic changes ever de-
mand radical measures, we can understand why operations on
them are almost never required.
THYROIDEAN OR OBTURATOR HERNIA.
Comparatively little was known of this hernia until the
remarkable memoir of Garangéot was presented to the French
Academy, in the early part of the present century.
A considerable opening is left in the uppermost segment of
the thyroid-foramen for the passage of a nerve, artery and vein.
Sometimes this space is incompletely filled, so that the omentum
or intestine may crowd the peritoneum through it and produce a
hernia.
The following account is given by the author of a case which
he saw post-mortem.* "I found," he says, " on dissecting a woman,
in her pelvis two portions of intestine, which had forced the peri-
toneum through the superior part of the femoral foramin, and had
each formed a tumor about the size of an egg between the anterior
head of the triceps muscle, and, as these tumors were not suffi-
ciently advanced to produce a projection of the subcutaneous fat,
by which they were thickly covered, no tumor could be per-
ceived from without." Among many other highly interesting
cases, the same author mentions one of a woman who, after a fall,
* Garangéot.

106
HERNIA.
felt an extremely violent pain at the upper part of the right thigh,
over the course of the obturator nerve, near the labium pudendi,
which lasted three days, before he saw her. Garangéot discovered
a hard, flat, painful tumor on the inner side of the thigh, about
six inches in diameter. Raising the body and the knees, and
gently but firmly rubbing the surface of it, it soon returned to
the abdominal cavity with a distinct gurgling sound. The
woman's nausea, colic, and retching, at once, ceased, and, within
half an hour she had a free alvine discharge.
Cooper said that up to his time no operation had ever been
performed for strangulation of this variety of hernia.
Malaval reported the case of Arnaud of a reducible, obtu-
rator hernia. On account of the situation of the artery, in opera-
ting, the incision of the stricture must always take an inward and
upward direction.
In " Ashhurst's System of Surgery" we learn that Hilton un-
successfully opened the abdomen in search of an internal strangu-
lation, and found a knuckle of the intestine in the obturator fora-
men. His patient, who lost his life, had had pain along the course
of the obturator nerve, but this important symptom had unfortu-
nately been overlooked.
M. Obré had made an exploratory incision down on the
saphenous opening, over a mass which was lodged under the ad-
ductor portion of the fascia lata. On dividing the fascia the pec-
tineus muscle came into view, and under this a peritoneal
sac, as large as a hen's egg, was seen. This was opened, when a
loop of the small intestine was exposed. The strangulated edge
of the obturator was divided, and the intestine returned. In the
course of the operation the saphenous vein was opened, but was
readily ligated. The patient made a good recovery.
Roesel attaches much importance to the value of rectal ex-
ploration as an accessory aid in these herniæ.
Dr. John Chiene, of Edinburgh (Ed. Med. Journ., Jan., 1887),
reports a discovery on dissection of a double obturator hernia in
a female. In the sac of one was small intestine and in the other
the ovary and fallopian tube.
Of late years many operations have been reported for this
hernia, though the mortality has been high.

HERNIA.
107
PERINEAL HERNIA.
This hernia presents about the same frequency in both sexes.
In men it descends between the bladder and rectum, and in
women between the rectum and vagina. It usually advances as far
as the integument, though seldom sufficiently to cause a bulging of
the perineum and a visible tumor. Commonly, its existence can
be made out in the male only by an examination through the rec--
tum, and in the female through the vagina.
Mr. Bromfield (Chirurg. Observ., page 264, 1857) cites quite a
unique experience in a lad of seven years, on whom he was cut-
ting for stone. "I divided the perineum," he says, "and was
about to enter the bladder, when a thin, diaphanous membrane-
made its appearance. The lad gave a scream when it broke, and
a quantity of clear fluid escaped. After another scream the small
intestine came down, through." He replaced the intestine, removed
the calculus, closed in the parts, and the boy made good recovery;
no subsequent hernia following.
In Astley Cooper's work, an interesting case is reported from
the practice of John Limme, of Manchester.
History of Case.-Patient was a lady who, though married
several years, never had a child. She complained of vesical tenes-
mus, difficult defecation, and occasional nausea, and came to this
surgeon for an examination. He found a large swelling at the
posterior part of the vagina, which compressed the os uteri later-
ally. By firm and steady pressure he was able to return it com-
pletely. She soon after conceived and suffered no more from her
former infirmity.
Dr. Smellie, in his work on Midwifery, cited the case of a
woman who, five weeks before she fell in labor, had a tumor of
this description, which previously she could reduce herself, but
now it was of increased size and very painful. He found her in
great agony. The tumor was livid, with fiery, painful edges.
She was lying on her back when he saw her. Now he di-
rected her to turn on her side. As she did the tumor broke in
the middle, when it gave issue to more than a pint of bloody ichor.
She now exclaimed that the rupture had gone up, and her relief
was great. Later he delivered her. Her rupture returned, though
she was always, thereafter, able to reduce it herself.

108
HERNIA.
PUDENDAL-HERNIA.
This hernia, as its name implies, is seen only in women. I
believe it is not uncommon in the child-bearing woman; although
as it almost never gives rise to serious inconvenience, it escapes
notice. It must be remembered that hernia here, may become
strangulated, nevertheless. It is usually situated in the inferior
segment of the labium majus. Its cause is similar to that of peri-
neal hernia, except that instead of passing by the vaginal wall it
penetrates and passes through it. Like the latter, too, it descends
in the erect posture, and ascends on the dorsal decubitus. Cooper
reports one such case, which he successfully reduced by taxis.
REPORT OF CASE SIMULATING PUDENDAL HERNIA.
This case I was called in consultation to see by Drs. Rass-
man, and George E. Hubbard, of this city, in the winter of 1888.
The patient, a young woman, while hanging a picture, slipped
from the chair on which she had been standing, in such a way that
when she fell her crotch came astride the sharp back of the chair.
A very large, extremely painful tumor immediately appeared in
the right labium, which it was thought might be hernia requiring
reduction or operation. This opinion was all the more rational,
because of the situation of the fullness, its impulsion on coughing,
and the fact that it could be partly reduced by taxis. On ex-
amination, I found no constitutional symptoms pointing to hernia;
besides, by examination through the rectum and vagina, I definitely
ascertained its true character. It was a large hæmatoma, which
disappeared in a few days.
CASE 2.-PUDENDAL HERNIA, RIGHT SIDE.
Patient, young woman, leading a "fast life," brought to me
by her uncle (?). She had a large mass, nearly as big as a goose-
egg, in the right labium, so that it now interfered with inter-
course, which made it painful. It had been examined by others
and pronounced a fatty tumor. But her history, the manner in
which it came and disappeared, and a rectal examination, assured
me that it was a hernia.
There was a most pronounced impulse on coughing, and the
straining of defecation always increased its volume. By laying

HERNIA.
109
her on her back, with the shoulders depressed, and the hips raised,
it could be almost entirely reduced. I advised her to keep this
position in bed for a week. In the meantime, applied a compress
against the pubic ramus, and kept the bowels well opened. It
completely disappeared, and four years after treatment I saw her,
and there had been no return.
ISCHIATIC-HERNIA.
This is the rarest of all those herniæ protruding through the
lower pelvic outlet.
Cooper reports one, having occurred in the practice of Dr.
James D. Jones, of the Barbadoes, and one of his own.
History of Cooper's case.-Patient was twenty-seven years
old, with all the symptoms of internal strangulation. Purgatives,
clysters and emetics were given in vain. Cooper questioned his
patient closely to elicit whether he had hernia. He denied that
he had any. This eminent surgeon, embarrassed and perplexed,
demanded an examination, which was granted, but nothing could
be discovered. Patient was ill from the 18th to the 25th of June.
On the 24th he felt much better, and on the morning of the 25th
got up. In the evening all his symptoms relapsed, and he sank
before morning. It was only on dissection post-mortem, that
Cooper discovered the seat of the trouble, in a strangulated coil of
the intestine, lodged in the ischiatic notch.
A FEW GENERAL OBSERVATIONS ON THOSE UNUSUAL VARIETIES OF
HERNIA HERE ENUMERATED.
It is not customary in all treatises of this description to
enumerate those of so rare a type as these here cited, as some of
them have been omitted, in every work on hernia and general sur-
gery that I have been able to peruse, both by the older and more
modern writers.
Nevertheless, I am convinced that they constitute a very
important class, not of a kind perhaps, which may be radically
treated by surgical means, but are those, which, undiscovered, may
lead us to assume that in a given case the obstruction originates.
from within, when the real seat of strangulation is external,
to the peritoneal cavity; hence more readily and safely ap-

110
HERNIA.
proached by relief measures. They all have many characters in
common.
1st. They are more common in the female sex.
2d. When they do exist, being so deeply lodged in such
unusual situations, unless a special and most thorough examina-
tion is instituted, through the absence of a distinct prominence,
they may be overlooked.
3d. They seldom lead to strangulation.
4th. When they are painful, are increasing in size, threaten
obstruction, and cannot be controlled by a truss, they should be
operated on.
In all cases of sudden obstruction of the bowels, before the
question of a median-laparotomy is for a moment entertained, all
the hernial-apertures should be rigidly scrutinized. It is not
enough that we question our patient; we must feel, with our own
hands and see with our own eyes that all the portals of escape
from every district of the abdomen are free and unimpeded. If
one is in doubt, then, though the practitioner may imagine that a
consultation may detract from his merit and imply that he is not
competent to cope alone, with the case, yet he owes it, not only to
his own conscience, but to the poor, helpless sufferer who has com-
mitted his life into his hands, to leave nothing undone which
might unmask the possible concealed seat of the malady and open
the way to its safe and prompt relief. It is hardly necessary to
add, that the only way to properly and thoroughly examine for
hernia is on a table, with the trunk well exposed in a bright, clear
light. Much may be learned in these rare cases, by a cautious ex-
amination through the rectum and vagina.

PART IV..
CHAPTER XVII.
MODERN OPERATIONS FOR NON-STRANGULATED HERNIA, REDUCIBLE
AND IRREDUCIBLE.
Since the advent of the antiseptic epoch, a large number of
operations of diverse technique have been devised; in most cases
those who devised and practiced them, claiming excellent results
and few failures when they commenced to practice them.
In many important respects they were all alike.
The mortality attending their performance was almost nil.
In inguinal hernia the aim sought for, was to obliterate the
hernial canal, without compromising the elements of the cord.
As this was commonly known among operators, very many cases
came under the scalpel for treatment, which would not have done
so had there been much risk to life attendant on interference.
Larger open incisions were now the rule, and subcutaneons invagi-
nations were wholly cast aside.
In order that each step in operation should be fully carried out,
111

112
HERNIA.
it was necessary that the parts be laid widely open. Without
this, it would be quite impossible to lay bare the rings, isolate an
adherent sac, or manipulate the cord.
In cases of complete inguinal hernia in the male, it is in-
teresting to note the diverse manner in which the sac is treated.
The majority of operators regarding its presence as a menace-
to permanent cure, as always being an extraneous substance, cut
it away on a line with the parietal peritoneum. Others permitted
it to remain, after its division, on a plane with the internal ring.
Again, some allowed it to remain intact, but with one or two rows
of sutures run through its walls, from the base to the utmost sum-
mit, undertook to radically efface its lumen. The operation of
utilizing the entire sac and fixing it as a pad in the hernial aper-
ture was again revived.
The rings too have been treated in diverse ways. Many re-
gard an operation for radical cure incomplete without solidly
suturing the pillars of the external ring, while others freely
divide it in opening the canal to the inner ring, as in the open
operation introduced by Dr. Charles McBurney, of New York,
and others, who make it a sine qua non that the pedicle of the sac
be extirpated at the internal ring. As has been noticed, the rings
have been cleared of the sac in some cases, while others have at-
tempted to plug them with the displaced sac. For the latter pur-
pose, also, in epiploceles, a portion of the omentum has been an-
chored in the canals and fixed with sutures. One of the most mod-
ern operations, that of Bassini, of Italy, contemplates the entire
destruction of the inguinal canal, by free division of the rings,
the spermatic cord being lifted out, and made to pass through
another opening made for it.
It has been recommended by Lawson Tait, that when an
operation is undertaken for the removal of an abdominal tumor,
any hernia present should be dealt with from within, drawing
the protrusion upward, and closing the canal with sutures passed
through the peritoneum. Indeed, he even suggested this internal
route for the treatment of strangulated hernia (British Med. Asso...
1891). Many have regarded the presence of the spermatic cord
as an insurmountable barrier to radical cure, inasmuch as its
presence prevented the total obliteration of the inguinal canal..

HERNIA.
113
But when one carefully studies all the etiological factors of an in-
guinal hernia, this must be denied. Besides, we are informed that
in those times when indiscriminate castration was permitted, a.
considerable number relapsed.
The same general principles are applied to the treatment of
femoral hernia as in inguinal, except of course such as apply to
the management of the tubular structures. Though in our opera-
tions on the inguinal canal we may by a wound or by cicatricial
pressure, weaken the functional vitality, or cause atrophy of the
testis, its fellow being preserved, virility remains, while the same
damage to the contents of the femoral canal might entail the loss:
of a limb. Hence, here any solid plugging of the canal, its firm
approximation with sutures, or entire obliteration is quite out of
the question. Its anatomical and physiological properties reduce
within very narrow limits, our efforts to radically deal with her-
nia in this situation. In uncomplicated, adult umbilical hernia,
on the contrary, there is practically nothing in the way of our
endeavors to hermetically obliterate the vent; for, normally, there
is nothing here that can, under any circumstances, be regarded as
a canal, the patency of which must be maintained.
COMPLICATING ELEMENTS IN HERNIAL OPERATIONS.
Before entering into the consideration of operation of selec-
tion in cases which present various anatomico-pathological ele-
ments, it may be appropriate to first consider the impediments
which often nullify our best efforts, or at all events prevent satis-
factory results.
It must generally be conceded that we are yet without the
ideal suture material.
us,
Aseptic, absorbable suture is so liable to slip, tear, or melt
away before firm or solid union is effected, as to be unreliable for
general purposes. Using heavy, chromicized strands will not help
for their introduction into the tissues entails a vast amount of
tearing, and, after being lodged, if not disposed of by absorption,
they are sure to be a source of irritation. With a ligature on the
stub of a divided neck of the sac, should absorption occur before
permanent fusion of the overstretched serosa, as this glides back
into place an enormous breach in the peritoneal wall is certain to
8

114
HERNIA.
occur, and the most ungovernable description of relapsing hernia
is sure to follow.
To secure large vessels in the omentum with cat-gut is to
needlessly imperil our patient's life. This material, while often
serviceable in peripheral hemorrhage, is not the safest in the sur-
gery of serous cavities.
If the soft parts, the muscles, ligaments, or aponeuroses in
the abdominal walls, would tolerate foreign substances with the
same impunity that the gums do mineral or metallic in dental
surgery, then indeed we might proclaim to the world that practi-
cally all herniæ were safely, rapidly, and radically curable.
But there is the rub. They will not. True, some of the
tissues, particularly the sero-cellular, often possess a singular toler-
ance to insoluble materials, but the muscular structures, bones,
and ligaments promptly resent their intrusion.
What would be simpler than the free division of the peri.
hernial structures, return or excision of the viscera, shutting off
the general peritoneum with a strong silk-knot, solidly closing in
the canal and rings with the same material, and burying all under
the surface-suture?
But this subtance, by mechanical irritation, so often gives
rise to ulceration when imbedded in the subcutaneous tissues, that
it makes its way to the surface, or is a source of painful swelling.
When this is not a sequence of the employment of the subcuta-
neous silk suture it often cuts its way through the tense edges
which it approximates.
The French surgeons have attempted to overcome the diffi-
culty in using silver and gold, the "suture d'or" and "suture
d'argent," but with the same result. Furthermore, as will be
noticed later, there are anatomical reasons why, unless permanent
tolerance can be secured to an insoluble suture, the absorbable of
any species whatever can serve nothing more than a very transient
purpose, when utilized to obliterate a hernial hiatus.
In our time, when anesthetics afford us ample leisure, and
inventive genius has placed within our reach perfected mechanical
implements, a dangerous hemorrhage is not a common accident in
hernial operations.
Nevertheless, in those operations in which an adherent sac is

HERNIA.
115
dissected, a considerable loss of blood by parenchymatous oozing
is unavoidable. In detaching an extruded mass of omentum in a
crural hernia I have accidentally opened the femoral vein, but
moderate pressure controlled it, and it gave us no trouble during
the healing of the wound.
During the performance of a hernial operation for radical
cure by Bassini's method, in Rome, I have seen the internal epi-
gastric artery cut across. For an instant there was an enormous
jet of blood, but the cool and skilful operator (Dr. Bastianelli)
quickly seized the mouths of the vessel and promptly secured
them.
Owing to the manner in which the sac is often intimately
blended with the cord, in its separation the spermatic artery has
been torn; or one may, without the exercise of great caution, di-
vide it for an adventitious band. As this vessel, when freed from
the testis, is marvelously elastic, in a second after division its
mouth may be drawn up beyond the internal ring, and permit of
a very dangerous bleeding before it can be secured.
As the presence of free hemorrhage constitutes one of the
most formidable dangers in all hernial operations, ample provision
should be always made for effective hæmostasis in every instance,
before they are undertaken.
Next to hemorrhage in importance, in herniotomies, is inflam-
mation, mechanical and septic. It is absurd to assume that by
any sort of chemical solutions, or exclusion of infecting elements,
we can wholly prevent inflammatory reaction, local or general,
when we perform an operation which entails an extensive mutila-
tion of the tissues. Inflammation may not run into suppuration;
but free cell hyperplasia, tumefaction and tenderness, will invari-
ably follow. And the inflammatory products, in the rapidity of
absorption, are as much dependent on the general condition of
the patient as the local treatment of the wound.
In the old and cachectic I have seen it more than once run
into gangrene. This usually was limited to the edges of the in-
cision, which were thrown off by a slough, the parts healing from
the bottom, by granulation. Gangrene of the testis is one of
the consequences attendant on serious damage to the spermatic
artery.

116
HERNIA.
I have never seen general peritonitis follow herniotomy for
radical cure. In this age of aseptic surgery it is needless to em-
phasize the cardinal importance of rigorous cleanliness of every-
thing in the region of the wound, when we are manipulating
structures immediately continuous with the peritoneum. It is
difficult to conceive of septic infection following an incision into
healthy tissues, except through the grossest sort of neglect.

CHAPTER XVIII.
ANESTHETICS AND ANALGESICS IN KELOTOMIES FOR STRANGULATION
AND IN OPERATIONS FOR RADICAL CURE.
To any one who has carefully studied the history of hernial
operations in the past, and who compares their status at the be-
ginning of this century, and in our own times, it must be appar-
ent that there has been nothing which has given them the position
which they occupy to-day, in any manner whatsoever, compared
to anæsthetics and analgesics.
We have seen that the mortality from kelotomy in pre-
anæsthetic times was enormous; perhaps because operative relief
was sought only when the patient was in extremis.
The mental agony and horror at the very thought of surgical
interference, no doubt, in many exceeded the physical sufferings.
The operator must have been rapid in execution in these
times. In many intricate, complex hernial cases safety is only
possible in deliberation and a cautious dissection. But anæsthetics
came and the patient was sent into dreamland.
There were no more forebodings of pain nor of the infliction
of it. Yet surgeons, for a long time, clung to the impression that
117

118
HERNIA.
the patients' prospects of recovery largely depended on their
celerity of action and rapidity in execution; accordingly, an ope-
ration for strangulation was but the work of a few moments. Old
convictions die hard. In fact, one can scarcely be said to ever
quite outlive them. And so it was with surgery and anæsthetics,
as it was only in very recent times that a younger generation ex-
tended minutes into hours and completed the full details of every
step, so that to-day in all simple and complicated cases, so com-
plete is the technique of an operation for hernia that a single dress-
ing often suffices until healing processes are practically complete.
Notwithstanding the inestimable boon of painless operations in
hernia, in ordinary cases of strangulation as they come into the
surgeon's hands, their mortality when pulmonary anæsthetics are
employed after operation is yet very great. This was a startling
revelation to me in my student days, when I so often saw death
so promptly follow relief of strangulation by the most skilful
operators of that time.
The mortality attending my own operations, on four strangu-
lated cases, in my early hospital experience, was so appalling that I
had come to regard kelotomy for strangulation as always an opera-
tion of first magnitude.
If we should encounter a gangrenous intestine, cause a great
loss of blood, or if general peritonitis supervened, we might account
for the loss of life; but when an operation was simple, rapid and
bloodless, and the intestine was healthy, yet death supervened
within twenty-four or forty-eight hours; and to say that it was
caused by septic peritonitis was not satisfactory, because we know
that general peritonitis rarely cuts off life in so short a time;
besides, it has not been demonstrated that the operative mortality
has been reduced since the advent of antiseptics in strangulation
cases.
No doubt the deplorable condition that some of those cases
often present before the attending physician turns them over to
the operating surgeon, often precludes any possible hope of relief
by the intervention of art. For cases have been sent into our
service at the Harlem Hospital in which, after violent protracted
taxis, the intestine has been found ruptured in the sac, and pressed
up through the rings to drain its contents into the peritoneal

HERNIA.
119
cavity. In one woman the sac and bowel were bursted by bruis-
ing and pressure, so that, as the fascia propria was divided, intesti-
nal gas and fæces welled up through the incision. Again, more
than once, the patient has barely survived transportation to hos-
pital, and was moribund, or dead, before preparations to operate
were completed. Further, we will find not a few coming in, more
or less collapsed, on whom but moderate and cautious taxis has
been practiced, yet after a hypodermic of morphine, artificial
heat, and a few hours perfect quiet, the spasmodic grip at the
neck of the sac relaxes, and the hernia returns of itself, or by very
moderate taxis, and in a day or two the patient is himself again.
So deep-rooted and general is the fear of death from opera-
tions on strangulated hernia with medical attendants, that many
advise or approve of them only after every sort of palliative ex-
pedient is exhausted.
We very naturally inquire then why, in simple strangulated
cases, the mortality is so great? But a limited breach in the tis-
sues is made, no blood is lost and the operation is not a protracted
one; yet we often lost our patients.
My observations during the past ten years have convinced me
that pulmonary anaesthetics very greatly added to the dangers in
operations in strangulated hernia. I am not prepared to say in
what manner their lethal action is more manifest in this class of
abdominal operations than in any others; yet that total suppres-
sion of the urinary secretion and secondary mortal shock often
follow, cannot be denied by those called on to perform these opera-
tions.
As I have never used chloroform in an operation for strangu-
lated hernia, I am unable to say whether these mortal sequelæ are
so common when it is employed. But from what we do know of
the greater danger always attendant on its employment in other
surgical operations, there is no apparent reason why it should be
preferred to ether, the pulmonary anesthetic which we always
employed.
Since Paul Réclus first called attention to cocaine analgesia
as a valuable agent in operations in the peripheral structures, I
have almost invariably employed it in all operations for strangu-
lated hernia. In twelve operations for strangulations with cocaine,

120
HERNIA.
ten promptly recovered. The cause of death in the one who suc-
cumbed is a mystery to me. No post-mortem was permitted. In
two of those ten which recovered, they were in such profound col-
lapse that there was little prospect of their being able to come out
of the coma of an anesthetic. In one it was employed on a man
bordering on the moribund state, who had been operated on im-
perfectly two days previously, in whom stricture at the neck of the
sac had been overlooked. His pulse was 140, weak and thready,
the belly ballooned up by the imprisoned gases, and vomiting was
incessant. The wound was reopened and the intestine liberated,
the patient in full consciousness, but devoid of pain as the edge of
the scalpel went through the tissues. He experienced immediate
relief, and had a large movement from the bowels within two
hours after the operation, ultimately fully recovering.
Cocaine is of priceless value in operations for strangulation.
It certainly seems incomprehensible how it is, that an agent of
such unique usefulness in this operation, has not, before this time,
become better known in the ranks of the profession.
By its judicious employment, as Réclus pointed out, we may
dispense with skilled assistance in an emergency, the patient him-
self giving the greatest aid. If he has diseased organs, their in-
tegrity is not imperiled by the saturation of the system with a
noxious agent. It is a positive hæmostatic. There is no stage of
suffocation and struggle, so common under ether; and no violent
retching or vomiting after operation, a time when it is so import-
ant to prevent sudden strain on the blood-vessels, or agitation of
the traumatized intestine.
Effective cocainization, however, demands a precise technique,
every detail of which must be observed, if we would not utterly
fail, and throw it aside in disgust, after our first trial.
In a work on hernia it might appear that pulmonary anæs-
thetics are of sufficient importance to merit a full and separate
consideration; but, as these are fully described in the current
text-books, it is unnecessary to refer to them in detail at present,
except in a cursory manner, and only the clinical phenomena often
attendant on their administration."
It goes without saying that in an operation which entails a
tedious dissection, it necessitates as perfect immobilization of the

HERNIA.
121
body and the part to be operated on as possible. It is also par-
ticularly desirable that all violent movement in the abdominal
muscles be restrained after hernial operations.
Now, with pulmonary anæsthetics, it is notoriously the case
that a considerable number take ether or chloroform very badly.
In some it is quite impossible to induce profound, protracted nar-
cosis without inducing asphyxia. This may recur any time the
anaesthetic is forced, so that it is impossible to operate on them
with safety while under profound coma.
With another class a general muscular rigidity ensues
through all the stages of anæthesia. As this involves the abdomi-
nal as well as the respiratory muscles, it is easy to understand
what an embarrassing complication it is, after the peritoneal
cavity is opened and the intestine bulges through the opened neck
of the sac.
Violent emesis almost invariably sets in, as our patient comes
out of ether in many of our most docile cases.
But few escape
this sequela, while a considerable number vomit freely in the
initial stages of anæthesia. No doubt the escape of the bitter,
acrid ingesta into the trachea and lungs while the patient is in
the stupor of early anæthesia, is responsible for many mortal cases
of post-operative pneumonia.
Indeed, it would seem that the administration of an anæs-
thetic, and its sequelæ, are among the greatest dangers attendant
on operation for strangulation.
Chloroform is not attended with so many inconveniences,
perhaps, as ether, but its lethal action is so often and so suddenly
deadly, that unless there is some special condition present per-
mitting its employment, it should never be employed.
In my experience in strangulated hernia, pulmonary narcosis
is always attended with a deepening of the collapse in the most
serious cases. The ideal agent in hernial operations is one which
will temporarily deaden sensation without effecting consciousness,
and the employment of which is not followed by vomiting or
violent muscular contraction. Such an agent is the alkaloid,
cocaine, though its range of application in hernial cases is limited.
In strangulated hernia its use should wholly supplant pul-
monary anathetics. In non-strangulated herniæ the operations

122
HERNIA.
for their radical cure, to complete in all their details, consumes so
much time that the transient action of cocaine will not suffice,
except in a very limited number of cases. In those who manifest
a marked repugnance to ether, and are willing to suffer a little
pain, an operation may be performed with the greatest satisfac-
tion, as I have, on different occasions, demonstrated on men and
women.
Before describing the technique of cocainization in hernial
surgery, it may be well to briefly notice the phenomena attendant
on its application or administration.
Cocaine gives a sense of exhilaration, buoyancy, and pleas-
ure; stimulating the brain to an extraordinary degree, and, at
the same time, strengthening the heart's action, supplying pre-
cisely thereby in the constitution what the despondent mind and
flagging pulse most urgently need in all cases of strangulation.
Locally, it paralyzes the periphery of the sac, sensory nerves;
causes a marked contraction of the capillaries, through its action
on the vaso-motor filament, and thuswise exerts a marked hæmo-
static action.
It is needless to remark that when administered locally, its
action is not strictly concentrated on the parts into which it is
injected, but it is also taken up by the general circulation; and
hence, acts in a dual capacity: First, as a local analgesic; and
secondly, as a general stimulant.
TECHNIQUE OF ADMINISTRATION OF COCAINE IN HERNIAL OPERATIONS.
CONDITIONS TO BE OBSERVED, ETC.
Before we cocainize there are certain preliminaries necessary
to observe of a special character. Contrary to the usual custom
of administering the anesthesia, on an empty stomach, some hours
after a meal has been eaten, with cocaine it is always well to
operate under it as soon after a meal as possible. The patient
should be given freely of an alcoholic stimulant, if the stomach
can bear it, immediately before we commence to introduce the
analgesic.
It is now assumed that everything at the seat of operation
has been rendered aseptic; that a pure drug and a good hypo-
dermic syringe are provided. The needle of the syringe should be

HERNIA.
123
from four to five centimeters long, and of sufficient firmness not
to bend in going through aponeurotic structures. It should have
a keen, smooth point. A one per cent. solution is of sufficient
strength. I have never employed less than sixty drops, nor more
than a hundred in a hernial operation. In other words, it is well
never to go far beyond the average dose by the mouth-from one-
third to one grain-when using cocaine subcutaneously.
If we wish to cocainize without inflicting but the minimum
of pain, and secure our patient's confidence, it must be done with
as few punctures of the integuments as possible. This is to be
particularly desired in strangulated cases, in which the tumefied,
contused parts are extremely sensitive. Hence, in order to effect
this, the punctures through the skin should not exceed three or
four in number, and should be in a continuous line over the long
axis of the tumor; so situated, from above downward, that the
edge of the scalpel, as it is carried down through the integument,
will intersect them. The syringe should carry, at least, from
twenty to thirty drops. After having been sent deeply into the
tissues, the downward motion of the piston is commenced; at
which time the withdrawal of the needle must begin, in an oscil--
lating movement, at such a pace that from three to five drops will
have been sprayed in the tissues before the needle has reached
within six or eight millimeters of the deep layers of the integu--
ment. Now, gently turning the needle on its axis-its heel being
the pivot-it is again and again sent in until an area, including a
considerable radius, is effectually sprinkled. The needle, then,.
by this procedure, is made to penetrate in many different direc-
tions, though we puncture only once. With but a few such punc--
tures from four to five or six centimeters apart, a considerable
district can be dealt with.
Certainly one must hypodermize the tissues with as little-
delay as possible, when he commences; or else its local effects will
have passed away before we commence the severance of parts, or
we will observe, rather, symptoms of its constitutional action,
which in women and children we wish to avoid. Hypodermica-
tion completed, the integuments and underlying soft parts are care-
fully but quickly kneaded with the fingers, in order to thoroughly
diffuse the cocaine through the tissues. Now everything being

124
HERNIA.
ready, just before the scalpel is taken in hand, if a syphon of car-
bonated water is convenient, which has been well chilled, splash
its contents suddenly over the surface of the integument. In cases
when this has not been within reach I have found a pitcher of
cold water, emptied from a height of two or three feet, answers very
well as a substitute. Hypodermication should not occupy more
than three or four minutes; from its completion, until the division
of the tissues is commenced, not more than five minutes should in-
tervene. It may be well to note in hernial operations, that par-
ticular caution must be observed not to puncture the extruded in-
testine or the spermatic cord in male inguinal, nor the femoral
vein or artery in crural hernia.
Cocainization is an invaluable aid in subduing muscular
spasm, early resorted to in those strangulated cases, in which
operation is refused. For this purpose it is much to be preferred
to ether or chloroform.
Cocaine analgesia lasts about thirty minutes. Any operator
of moderate experience can go through the necessary steps of an
operation to relieve a strangulation in that period of time. If he
cannot, then he assumes considerable risk, and scarcely does jus-
tice to his patient, if an experienced operator is convenient and
can be had.

CHAPTER XVIII.
VARIETIES OF OPERATIONS FOR THE RADICAL CURE OF HERNIA IN
MODERN TIMES.
Perhaps it might be alleged, inasmuch as it has been de-
clared in a previous chapter, that as no operation has yet been
devised which would effect a permanent cure in all cases of
hernia, or in every case of any single phase of it, that there would
be no room for choice; that one would be equally as efficient as
another.
This, however, is illogical reasoning, and only emanates from
those prejudiced against every operation for hernia, and every
species of sanguinary intervention in non-strangulated cases, or
even a strangulated hernia when its reduction is impossible by
taxis.
But when it is remembered that almost no two hernial pro-
trusions are precisely alike; that many are of a most complex
type; that age, sex, occupation, anatomical structure and general
bodily health each has an important bearing in every case, in
inclining us to such a line of procedure as is most appropriate, it
125

126
HERNIA.
is apparent that we must treat the various cases in a technique
on essentially different principles.
In the monorchid of early age, in which the testis and intes-
tine are lodged together in the inguinal canal, our efforts will be
directed rather toward freeing the adherent testis and bringing it
into the scrotum, than to meddling in any manner with the dis-
placed protrusion, which we know usually with the growth of
the child will finally lodge within the peritoneal cavity. With
the female, whose rudimentary inguinal canal contains no import-
ant tubular structures, a technique will succeed with them that
has no place in the male.
As the dangers of doing damage to the elements of the cord
are great, in separating the tough fibrous wall of the sac from
them in many inguinal herniæ, we can see why, in the femoral
type, this enucleation of the sac may be invariably advised, while
in many of those protrusions passing over the crural arcade it
should not always be permitted.
It is clearly evident, too, that we must vary our procedure in
the small, easily reducible, and the large, old incarcerated variety.
One man, for cosmetic or other reasons, humiliated by his
deformity, about to be married or undergo a physical examina-
tion, requests a radical operation; but if his general condition
suggests syphilis or tuberculosis, few would care to make a
breach in the tissues to expose the sac when the same end might
be attained by rest, puncture and pressure.
So, too, with exomphaceles and eventrations, we must resort to
different operative measures for them under varying circumstances.
Of recent years we have had what are known as "open
operations" for the cure of non-strangulated hernia.
OPEN OPERATIONS FOR HERNIA.
These may be divided into two classes: First, those in which
a large, open rent is made in the soft-parts, thereby enabling us
to expose and manipulate under the eye all the elements of the
hernia. With these, as soon as the viscera and sac have been
dealt with, the divided parts are so approximated, layer by layer,
with a view of closing in the parts, by primary-union. This is
the most common.

HERNIA.
127
The second class are those essentially, of the same, in the ex-
tent of incision, but the wound is purposely prevented from imme-
diately uniting, by a gauze packing, introduced with a view of
securing a filling in by granulation tissue and a cicatrix. The
latter, except, in cases of strangulation attended with infection,
has now,
been quite generally discarded. These operations are
essentially laparotomies. There are a great many derivatives of
them, as a detailed description, of some of the most current of
them described later-will show.
The fundamental objection against these, so-called open opera-
tions is the extensive mutilation or division of the anatomical-
structures which their performance entails. The groin and scro-
tum must be widely opened to enable us to free an adherent sac.
To excise the neck on a plane with the general parietal peritoneum,
the anterior wall of the inguinal-canal must be split through its
entire length to the internal ring.
Now, if the divided parts on reunion regain their pristine
mobility and strength, as little or no danger to life is attendant
on the incision, the closed-open operation, so to speak, is the ideal.
But whether they do or not, in many phases of hernia of an im-
pacted character, nothing approaching an effacement of the pro-
trusion is possible, without such free dissection. The antiseptic-
theory gave an immense impetus to free and perhaps one might
say, without straining the truth-not infrequently needless and
destructive, gashes into the soft parts, in this and other surgical,
maladies. We certainly do know, that a divided bone or tendon,
never again, entirely recovers its full strength when cut through;
though, such division often serves invaluable purposes. Nor is
there any reason why a free splitting through the ligament, 'ten-
don, aponeurosis, and muscles of the lower abdomen may not
leave a weakness in the abdominal wall.
HYPODERMICATION IN EFFECTING RADICAL CURE.
The hypodermic syringe, shortly after its invention, was
promptly utilized as an apparatus which had a place as a therapeu-
tical aid in the treatment of hernia.
It is one of the few agents employed in modern times for the
treatment of hernia which was not well known centuries since.

128
HERNIA.
We find the germ of it in the writings of Julius, in the third cen-
tury, who recommended, after the hernia was reduced, the tract
over which it traveled should be opened, lightly seared with the
red iron, or with spirits, and be then closed in with the suture.
It appears, that when this method was first introduced it was
so awkwardly employed that, though a few were cured of their
hernia by it, yet the majority operated on developed peritonitis;
not a few suffered from erysipelatous inflammation and gangrene
of the scrotum. And, as might be supposed, it was soon condemned
and cast aside.
We will see that after an interval, when the syringe became a
perfected instrument, and when the pathological processes super
vening after subcutaneous injection of pungent chemical solu-
tions became better understood, hypodermication again came into
use. Saturated solutions of chloride of sodium, concentrated alco-
hol, tincture of iodine, extract of oak bark, and other irritants
were employed.
cases,
When we study the principles, on which the claims of this
peculiar therapy rest, and when it is utilized in special selected
it cannot be denied that it has a place and must be regarded
as a most valuable adjuvant. It lost ground, and was cast aside
for the same reason, that very many useful agencies have sunk into
oblivion, often before their full merits have been properly tested,
viz., because the champions of them made them a cure-all.
With those desirous of a cure of their hernia, without a muti-
lation, when this is an indirect, inguinal of small volume, and the
sac with the viscera can be wholly returned, it is certainly rational
to assume, that used in conjunction with other tentative measures,
it may succeed. Indeed, there are too many well authenticated
cases in which it has effected permanent cures to dispute its claims.
In our time, we can render the injecting fluid absolutely aseptic,
there can be little danger of infection, or of any accident,
except, directly charging a blood-trunk or penetrating the wall of
the bowel. Hence, this procedure, when devoid of accident, in
many, must claim preference to those, which entail the sacrifice of
tissue; and, as a result may be followed by a relapsing hernia,
perhaps worse than the one which their employment intended
to cure.

HERNIA.
129
The range of hypodermication as a means for treating hernia
is very limited, for with the exception of such phases of inguinal
hernia as stated, it is of doubtful, if any value. I am acquainted.
with no reported successful cases of femoral or umbilical hernia.
treated by this means.
MODE OF ADMINISTRATION AND CONDITIONS TO BE PRESERVED IN HYPO-
DERMICATION OF HERNIA.
As in the hypodermic administration of cocaine the integu-
ments must be thoroughly disinfected.
We have a set of hypodermic needles of various lengths,
strong and unyielding for different cases; as we will meet with
those who have immense layers of abdominal fat, as well as the
lank and lean. Warren, of Boston, invented a special syringe for
these cases, which, when introduced by a movement of the piston,
underwent a rotatory motion, which in this way was supposed to
have effectively saturated the peritoneo-vaginal canal. The or-
dinary syringe, nevertheless, is equally useful, and not so liable to
get out of order.
Of the many solutions recommended, probably the prepara-
tion of the charlatan, Heaton, is the most useful of all. For the
basis substance, oak bark, is a powerful astringent; the pure alco-
hol in it, an antiseptic with the morphine included, nulls all im-
mediate pain. But a few drops of this solution, from three to
ten, are ample to employ.
Now the finger having fully reduced the hernia, its tip is
pushed still upward and backward, until the aperture of the in-
ternal ring is felt, when the point of the needle is introduced over
the nail, care being observed not to injure the cord, and to lodge
the fluid in the loose, connective tissues, between it and the
fibrous walls of the infundibulum.
After the fluid has been deposited, a narrow pointed conical
pad must be applied, under a firm spica bandage, over the ex-
ternal ring and canal. So much for technique; now there are
many things which must not be overlooked when this line of treat-
ment is selected.
Undisturbed, protracted rest, is indispensable. This must be
carried out with rigor, or all fails, after the injecting fluid is
9

130
HERNIA.
lodged. Accordingly, in order to secure quiet to the inferior
segment of the intestinal canal, for five or six days after opera-
tion, the patient should have been freely purged the day before we
operate, and occasional small doses of opium are needed after the
intestine is cleared.
To attain this same purpose the patient should be kept on
Iow diet, and all solid food prohibited for ten days. As there is no
wound inflicted in the procedure, there is none to dress. Yet,
immediately over the internal ring, firm, methodical pressure
must be continued uninterruptedly for four weeks to ten or
more. In young subjects, with recent hernia, confinement to bed
for a shorter time will suffice than in older subjects, who have
had large protrusions.
The success of this simple expedient is dependent on two
principles.
1st. With restitution of the viscera, with all weight and
drag removed from the elongated mesenteric ligament, it regains
its normal, contractile power, and swings the rolling intestine
far enough away from the rings to prevent it from again engaging
and slipping outward.
2dly. The injected fluid when properly lodged, affects the solid
cementing of the hernial vent; 1st, by its pungent irritating prop-
erties, exciting inflammatory exudate; and 2dly, by a condensa-
tion and fibrous infiltration of this plastic material into the
meshes of the adjacent tissues, in such a manner as to firmly con-
tract and obliterate the pre-existing lax and open passage.
Were it not for the fact that the viscera are commonly ad-
herent in female inguinal hernia, for this type, in this sex, it
would be the ideal. In the reducible inguinal, complete, of young
women, this method should be fairly tested before any species of
sanguinous proceeding is entertained.
ACUPUNCTURE.
The introduction of pins or needles introduced subcutaneously,
transversely to the long axis of the canal, in simple, reducible male
inguinal hernia has been employed, and we are assured with
occasional success. The aim has been to secure adhesive inflam-
mation, when the sac was held down by adhesions. By this

HERNIA.
131
plan it is impossible in fleshy subjects to effectually obliterate the
lumen of the funicular envelope beyond the external ring.
It is an operation which, when performed with care, entails
no danger to life, and in certain simple cases unquestionably has
a place. In young children, in whom there is practically no in-
guinal canal, it may be employed with good prospects of success.
And if it should fail to cure the hernia, when proper precautions
are observed, it can seldom do harm.
The greatest danger attending its employment is the risk of
injuring the structures of the spermatic cord. Hence, before the
needles are introduced, the cord must be lifted out of its bed and
drawn aside, leaving the walls of the sac freely isolated. The
desideratum is to so adjust the needles with sufficient pressure
as to effect occlusion of the serosa, without having them cut their
way out to the surface. In certain patients they cause so much
pain as to require their early withdrawal.
As acupuncture must be practiced chiefly by the sense of touch,
and as tetanus or gangrene of the testis has been known to so often
supervene after its employment, its application is feasible only
within very restricted limits, and is justifiable only in the hands
of the adept and in exceptional cases.

FIG. 15.
CHAPTER XX.
INVAGINATION.
Besides the various means
heretofore noticed to effect an
obturation of the hernial portal,
in the early part of the present
century, none, for a time, en-
joyed greater favor, was more
widely employed, or was more
free from danger to life, than
the procedure first introduced
by Gerdy.
It will be observed that Gerdy's instrument
was a rather clumsy and formidable machine
(Fig. 15), consisting of a double lever, bulb and
screw, and two teeth. But it appears that he soon
cast this aside and substituted for it another more
simple contrivance, which consisted in a long,
concealed cannulated, curved needle (Fig. 16), the
FIG. 16..
132

HERNIA.
133
employment of which was not attended with difficulty and was
very generally employed.
In employing this method the patient was placed on his back
with the knees drawn up. The surgeon now, with the index-finger
of the left hand, reduces the protrusion, sac and all; after which,
after pressing upward and maintaining in position, close to the
internal ring, a double looped silk ligature is sent out through the
cannula, the finger serving as its guide, penetrating all the tissues,
from within outward, until it reaches the surface (Fig. 17), leav-
ing a loop above, fixed in an ammoniated pledget of cotton.
The point of the needle was withdrawn completely and again
sent through, coming out on the surface about twelve milli-
meters from the first, the loop presenting being engaged with
a tampon as the first. The loops, now below, are drawn on
firmly until the indented integu-
ment below, completely blocks the
canal, and the serous surfaces of the
sac and parietal peritoneum are com-
pressed in direct contact with each
other. It will be noted here that
the needle is passed inward, some
distance beyond the pillars of the
internal ring. It is not clear, whether
it was intended that the general
cavity of the peritoneum was to be
entered and transfixed, or that the
fascia was pushed forward by the
finger, the puncture being wholly
extra peritoneal.
FIG. 17.
First step in Gerdy's operation.
It is not stated how long the
ligatures were left in situ, though it
must have been considerable time,
as they often penetrated their way through, before they
were removed. Of this operation we are told, that with few
exceptions, within a few months after the patient took his feet,
the scrotum retracted, and the hernia returned. The author
claimed that it was not on the principle of mechanical oblit-
eration that a cure was sought, but rather, by a phenomenon of

134
HERNIA.
a retractive inflammation of the cellular tissues in the canal and
rings. Active inflammation, tumefaction and suppuration
FIG. 18.
were common sequelæ of this
operation. The patient was
always enjoined to wear a truss
for a considerable period after
this operation. This operation
was not applicable to femoral
hernia, nor the inguinal type in
the female.
INVAGINATION BY OTHER
PROCEDURES.
There have been since the
times of Gerdy very many de-
rivatives of his original scheme.
By Lehman, Wützer, Benns,
Gerdy's procedure completed: invagination Zeiss, Schuh, and others differ-
ent variations were essayed.
maintained by a double suture.
Signorone's operation was known under the name of "intro-
retroversio cornuta; or chilissochisorrhaphie." This bold operator
conceived the idea of so far invaginating the scrotum as to give
it a turn over Poupart's ligament, pushing the integument out
above or on one side of the femoral vessels, and fixing the scrotal
tissues in the falciform fascia, at the saphenous opening; a pro-
cedure, says Broca, as extravagant as it was barbarous.
Maisonneuve, inspired, it is said, by a successful operation
of Dupierris, of New York, after having invaginated the integu-
ment as far as possible, divided the tissues from without inward;
thereby opening the peritoneal cavity, sutured the deeper layers
of tissues together; and then secured the parts by a cutaneous
stitch. Thierry proposed the following modification of Gerdy's
operation: He invaginated the scrotum with the little finger,
then introduced a threaded, curved needle; which, after emerging
about six millimeters below the superior edge of Poupart's liga-
ment, was reintroduced through the same puncture. Finally,
the free ends were firmly knotted over a small pad of charpie and
retained, until adhesive inflammation contracted the canal.

HERNIA.
135
Coste, of Marseilles, proposed a cure for femoral-hernia by
invagination. There was nothing new in the principle applied,
or the technique employed. Yet Pétrequin once obtained a suc-
cess by it in a very severe case. The patient was a woman forty
years old, who had a voluminous hernia. The crural opening
would admit four fingers easily, as far as their roots. Pétrequin
after reducing the mass, cut away the superficial layers of the
skin and transfixed the broad edges of the ring with four heavy
pins. The cure was complete after a month; but, as there was
a tendency to relapse, it was rendered easily coercible with a truss.
Giraldès conceived and practiced a similar procedure for the
FIG. 19.
umbilical hernia of children. As seen in Fig.
19, it essentially consists in passing a suture
completely through all the planes of tissue,
encircling the umbilical operation, after
hernial reduction, and drawing the free
ends together over a pad of lint.
WÜTZER'S OPERATION AND ITS DERIVATIVES.
*********
Wützer conceived the idea of substituting a foreign body in
invaginating, instead of the finger;
and maintaining this in position
until the inguinal canal had con-
tracted adhesions. Broca and Leroy,
however, had anticipated this sur-
geon, in having presented to the
French Academy, in 1835, a memoir
on the subject of maintaining invag-
ination by special instruments. But
Wützer perfected the operation, and
through his writings popularized it.
Wützer's first operations were in
1838, and he named his instrument
an Invaginaterion Kelek-leison.
This instrument is applied in two
sections. One is a hollowed piece of
&
빵
​FIG. 20.
Rothmund's Operation.
wood with a smooth, conical point, which is introduced into the in-
guinal canal its entire length. Then a curved needle is made to pass

136
HERNIA.
over the upper surface of this tube, emerging through a per-
foration near the point, when it enters the second piece. At
FIG. 21.
Invaginator of Valette.
this stage, a notch in the
second plate fits into an up-
right screw, when it is firmly
fixed in position. Sigmund,
of Vienna, with Spencer
Wells and Bedford Davis, of
England, as late as 1861 were
partisans of this method, though Wells warned his patients to be
slow in discarding the bandage when this method is adopted.
Rothmund, of Munich, devised an arrangement very similar
to Wützer's, except that it was more powerful, and instead of
employing one suture in-
troduced half a dozen.
Valette made another
modification of Wützer's
operation, adding to it
cauterization of the ante-
rior wall. The instrument
in place, a paste of chloride
of zinc was applied in the
center, or fenestrum of the
anterior blade, and firmly
FIG. 22.
Valette's Invaginator.
held in position by a bandage until it had thoroughly destroyed
TY
FIG. 23.
Valette's Process.
the underlying tissues.
Now, the clamp was
removed, and the slough-
ing parts healed by granu-
lation, after the slough was
thrown off.
This procedure cer-
tainly effaced the canal,
most surely, for the simple
reason, that by this cruel
device it was totally de-
stroyed, and it is difficult
to see how the spermatic cord escaped, or the peritoneal cavity

HERNIA.
137
was not invaded. It made havoc in the tissues, and when the
patient survived, left a painful, deforming cicatrix, and did not
guarantee a permanent cure. Valette operated on six patients,
losing but one, though there are no data showing the permanency
in cure of those who escaped with their lives.
Le Roy d'Etiolles, Langenbach, Wattman, Christopher Heath
and others, each have made various modifications on Wützer's
and Valette's operations, which in no essential manner varied from
each other, except in unimportant particulars.
All of these operations, embracing the principles of Gerdy's
FIG. 24.
Kinloch's Kite-tailed
Tampon.
FIG. 25.
Kinloch's Process. Passage of the Thread.
invagination, have been repeatedly performed by a past generation
of American surgeons, notably by Mott, Pancoast, Wood, Nathan
Smith, Bigelow, Kimball and Post.
The late Dr. R. A. Kinloch, the first surgeon in North
America to successfully laparotomize for a gun-shot wound in the
intestine, in his lifetime also competed for honors in hernial sur-
gery. Kinloch's operation in principle and detail but slightly
differed from Wattman's and others. He had operated when he
had submitted his essay but twice; and, as neither patient had
returned, he was unable to report on the permanancy of the cures
effected.

138
HERNIA.
Symme, Davies, Fayrer and Egea have reported operations-
performed by them by a special technique in invaginating-
ரேம்
FIG. 26.
Kinloch's Tampon being inserted into
the canal.
FIG. 27.
Kinloch's Process. Tampons in place maintain-
ing Invagination.
Sotteau, by a special contrivance of his own, maintained invagi-
کی
FIG. 28.
Invaginator of Sotteau.
nation by the aid of an instrument,
which permitted the mechanical
apposition of the hernial orifices.
The fundamental difference
between this operation and those
for invagination, already de-
scribed, is that the author aimed
to effect obliteration rather by se-
curing closure of the portals, and
rejuxtaposition of the fibrous walls
by mechanical aids, than by ad-
hesive inflammation.
Sotteau's instrument is very
complicated. Sottean commenced

HERNIA.
139
by anointing the wooden invaginator with an ammoniated po-
made, which was then pressed firmly against a fold of the skin
and carried far up the canal. A suture is now carried across the
pillars and fibrous walls of the canal several times, when the in-
vaginator is withdrawn and the suture tightened.
To secure continuous compression, the instrument here pre--
sented is applied, when the hernia is very large and chronic.
Roubaix reported a very remarkable case of an enormous
crural hernia in a woman sixty-four years old. She was suffering
from strangulation. There was gangrene of the intestine, and an
artificial anus followed, which closed after four years' time. After
a sudden strain, however, the old
cicatrix in the abdominal wall gave
way, and a very large hernia fol-
lowed, which no truss could control.
Now the case came into Roubaix's
hands, when, by employing the
operation of Sotteau, he succeeded in
entirely closing the hernial aperture,
dividing and cutting away the
redundant integuments.
FIG. 29.
Sotteau's Invaginator with the wooden
compressor in position.
We are not informed as to the
durability of cure, as the patient
was lost from sight after leaving the
hospital; though it is fair to assume
that this enormous deformity (Fig. 30)
was entirely restored to its normal
abode, and rendered at least coercible.
FIG. 30.
Hernia operated on by Roubaix.
In the second cut (Fig. 31), we see the deep shotted clamps in
place, which effectually hold in place the inverted edges of the
skin, and the superficial harelip pins.

140
HERNIA.
It would seem from this illustration that as soon as the power-
ful metallic braces were removed, after union of the parts, unless
some sort of a strong, well fixed support were adjusted, there
would be great danger of another eventration.
Wood, of London, in 1858, made another modification yet, or
rather added a new feature to
0000
FIG. 31.
Roubaix's patent with the clamped pins in posi-
tion.
the technique of hernial cure by
invagination, for his method
embraces the invagination of the
sac and direct suture of the her-
nial orifice. In 1863 he de-
scribed in detail the various steps
of his new procedure. Wood
aimed at obliterating the track
by adding to obturation by
invagination the contraction by
suturing the pillars.
It is a subcutaneous opera-
tion, delicate and difficult of
performance. Many have claim-
ed that although Wood wrote
at length on this operation and
modifications which he made in
it, yet his style or language was
so ambiguous and confused, that
a full and close description of it
from-him has never been ren-
dered. To myself I must confess
it has not been easy of compre-
hension.
In Wood's first operation
he employed two transfixion
pins in each case. The pins
were rather short, strong and
curved. One passed below, through the integment, sac and ex-
ternal pillars. The other pin entered in a more oblique direction
to the inclined plane of the body, and included the neck, internal
aperture and skin. By this dual procedure of invagination and

HERNIA.
141
approximation enough of adhesive inflammation was hoped to
follow to insure an obturation of the passage. Many English sur-
geons have testified to the immediate curative effects of this opera-
tion; but we have no proof that the truss could be dispensed.
with after cure followed.
The same author devised a second procedure by invagino-.
suture.
The instruments necessary for its performance consisted of a
curved needle perforated near its point, mounted on a handle; a
bistoury, a strong copper or silver wire suture and a glass com-
pressor.
The operation was commenced by making an incision through
the scrotum, introducing the index finger and invaginating the
sac as high as possible, then introducing the needle, armed with a
wwwww ww
FIG. 32.
Radical cure by Wood's needle.
FIG. 33.
Radical cure in inguinal hernia. Wood..
strong hempen thread; first transfixing the sac, then the internal
pillars then the posterior and external walls. The free loop being
brought out, it was securely tied. Now a conical, smooth block
of non-corrosive substance was firmly applied to effect steady pres-
sure. After two weeks the compress was removed, but the suture
was continued longer (Fig. 32). Wood soon abandoned the use of

142
HERNIA,
hemp, and on the last two hundred and seventy-five patients em-
ployed silver wire instead.
FIG. 34.
Radical cure of Inguinal Hernia. Wood's method by simple suture. Suture in place; knotted
on a compressor.
This suture greatly simplified the operation; first dividing
the aponeurotic tissues, then liberating and exposing the sac, in-
FIG. 35.
Radical cure of Inguinal Hernia. Wood's
procedure with silver wire in position.
FIG. 36.
Another procedure of Wood's.

HERNIA.
143
vaginating it from below, when the wire sutures were again em-
ployed, passing deeply through each pillar; the ends being secured
with sufficient firmness to approximate the edges of the pillars
and obliterate the infundibulum (Fig. 33).
Wood made various modifications of his operations, which
were set forth, at length and in detail, in the London Lancet, of
May 29th, 1858.
Dr. D. Hayes Agnew, of Philadelphia, Pa. (U. S.), made a
modification of Wood's operation. Agnew devised a sort of bivalve
speculum; one blade of which, the
under one, was concave on its in-
ferior surface. The outer blade
was convex on its outer surface.
The center of the lower blade was
grooved for the passage of the
needle. The blades could be opened
and immobilized by a screw in the
FIG. 37.
Invaginator of Agnew, after Ashhurst.
handles. The operation is begun
by incising the integumental cov-
erings of the scrotum, for two or
three inches, just below the exter-
nal ring. Now, by the use of a
finger, the underlying structures
are liberated or detached from each
other, when the closed speculum is introduced as far upward as
possible into the inguinal canal.
Procédé d'Agnew.
FIG. 38.
Three sutures are
in place.
The speculum is so placed as not to injure the cord. Now,
the blades are widely separated and fixed in an open position.
After this a long curved-needle is made to traverse the grooved
track on the surface of the anterior valve, which, at its extreme
end, pierces and passes out through the skin.
Another suture is, in a similar manner, sent in on the lower

144
HERNIA.
conductor. At this stage, the free ends of the suture alone are
secured over a roller, while those inside, as in Valette's operation,
are passed over a pledget of lint, and are firmly secured. Then
three or four sutures are passed through the integuments along
the plane of the inguinal canal. They are now tied, when the
speculum is slackened and withdrawn. For suture material,
silver was employed for the long deep suture, and silk for the
superficial parts. Over all a firm spica bandage was applied.
The operations of Chisholm, Van Best, Jessett, Field and
Thompson, are all derivatives of Wood's.
Spanton invented a sort of cork-screw instrument, with which
he traversed the inguinal canal, after effecting invagination. In its
application, as in Wood's operation, the skin over the superficial
ring is divided, and the deep tissues detached with the finger. Now,
the index finger of the left-hand securing complete invagination and
protecting the cord, this spiral
arrangement is twisted alter-
nately through the integu-
ment, sac, and pillars until
its point has made its way out
above. The instrument is left
in place until active inflam-
FIG. 39.
Instrument of Spanton.
FIG. 40.
Introduction of Spanton's Instrument.
mation is developed from ten to fifteen days. Spanton
operated on thirty patients with twenty-six successes and four

HERNIA.
145
ameliorations. Many of his patients, it is said, could entirely
dispense with the truss, after cure.
Invagination of the sac and suture of the ring has been
recommended for crural and umbilical hernia.
In Bryant's and Gant's
treatises on "Practical Sur-
gery" the technique and illus-
trations by cuts are fully set
forth. In umbilical hernia
this method has been exten-
sively employed. In early
times the wire suture was
employed; but latterly after
FIG. 41.
Spanton's instrument in place.
FIG. 42.
Radical cure of femoral hernia, by Wood's method,
the skin was incised and the hernia was reduced, a heavy absorb-
able suture was substituted, to draw the margins of the hernial
orifices together, after which it is buried in the tissues.
Mr. Bennett, of London (Med. Press, August 10th, 1892), has
recently contrived another invaginating plan. It might be des-
ignated "pedal invagination," as by it the sac is stripped and ex-
cised, the remaining stub or neck being invaginated. It is another
modification of Wood's operation. By it the sac is cut off just
outside the external ring, after being ligated, then a heavy needle,
armed with strong silk, is passed downward from without,
10

146
HERNIA.
through the abdominal walls, making it traverse the neck and
project below the obturated part. The needle is then withdrawn,
leaving the silk, one end coming out through the abdominal parie-
tes; the other, the outer side of the pedicle just above where it
had been ligatured. The needle was then again passed, without
thread, through the abdominal-walls, but at a point just opposite
to the first needle-puncture, and on the inner side of the ring, but
ด
FIG. 43.
Radical cure of femoral hernia by Wood.
Introduction of the suture.
FIG. 44.
Suture in place in Wood procedure for radical
cure of femoral hernia.
at a point opposite the first needle-puncture, the needle being this
time made to project on the inner side of the neck, opposite to where
the thread came through it, the silk is now passed through the
eye of the needle and the latter withdrawn, leaving the free ends
of the silk projecting from the abdominal parietes, the result
being a loop thrown over the obliterated end of the pedicle. Trac-
tion is now exercised with the effect of turning the remains of the
sac outside in, the apex being fixed to the peritoneum by securing
the two projecting ends of the silk.

HERNIA.
147
Mr. Bennett claimed for this procedure the advantage of
the complete invagination of the remains of the sac, the re-
sult being that the posterior portal was protected by four
layers of peritoneum, while, by their consolidation, a firmer
form of barrier is secured than by any other. In large, old her-
nia, he always employs silk, but in mild, recent cases, cat-gut.
In completing the operation, he sutured the pillars before closing
the wound.
Indeed, the number of operations for invagination, which are
all derivatives of Gerdy's, Wützer's, Valette's, and Wood's, is almost
interminable; which, though to rehearse them here, might be of
interest to any one desirous of securing all the literature on the
subject of invagination, in the therapy of hernia, as I conceive that
it will serve no useful purpose, and as space will not permit, will
not be considered.
OBSERVATIONS ON INVAGINATION.
Invagination, as an operation for radical cure, for a long time,
alone, held the field against all others in reducible hernia. Its
application, indeed, constitutes a distinct epoch, but its cause was
suddenly cut short, when, in 1873, John Chiene, of Edinburgh,
and Charles Steele, of London, at about the same time, revived
the "radical cure" by the free," open incision," employing, for
the first time, antiseptic solutions and dressings in hernial opera-
tions.
This was the beginning of a revolution, which gave invagina-
tion a staggering blow, and it seemed, for a time, that it had for-
ever driven Gerdy's operation, and its manifold derivatives, into
oblivion. Hence, if operations by invagination were noticed here,
it would seem that anything approaching a full description of
them would be a needless consumption of time, as a mere refer-
ence to them for historical purposes should suffice. But, as Se-
gond* so aptly expresses it," antiseptic surgery will not radically
cure hernia." And it is a question by no means yet decided among
the most extensive operators, whether our more modern operations,
in all cases, are any improvement on some of the older and simpler
methods. As a matter of fact, Dr. William T. Bull, at the meeting
*Cure Radicale Des Hernies, p. 170.

148
HERNIA.
of American Surgeons in 1890, declared that, after an extensive
experience, he had concluded that in ordinary cases of inguinal
hernia the simplest operation was as efficient in securing a per-
manent cure as the more complicated. Besides, in support of this
position of Bull's, which was regarded as most preposterous at the
time, the old-time simpler operations by invagination are coming
to the front again.

CHAPTER XX.
THE RADICAL TREATMENT OF NON-STRANGULATED HERNIA BY SUCH
MODERN METHODS AS REQUIRE AN OPEN INCISION AND FREE DIS-
SECTION OF THE SAC.
In recent times, until the Listerian epoch of antiseptics, when
the theories of the distinguished Scotch surgeon were very gener-
ally accepted and put into practice-about fifteen or eighteen
years ago we can find no modern author on surgery recom-
mend or justify a free division of the tissues in any description
of hernia whatever, except strangulated, or such as immediately
imperiled life or invalided the patient. For the reducible, the
congenital or incarcerated, the principles on which they should
be treated, on tentative lines, are given in fullness and detail,
though in general, except, perhaps, in invagination in exceptional
cases, no reference is made to any sort of sanguinary measures.
The first to apply antiseptics to the surgery of hernia were the
English. They were promptly followed by the Germans, who
became extreme antiseptists, and commenced to cut freely on
reducible herniæ. The Americans, who are now largely influ-
149

150
HERNIA.
enced by the German school, soon followed, while the French and
Italians have been the latest in adopting kelotomy for the non-
strangulated. Indeed, as recently as ten years ago, M. Paul
Ségond, from whose work I have so freely drawn in the historical
parts of this monograph, in Paris, wrote with great energy and
convincing argument against every variety of operation for
hernia, unless the patient's life was in danger, or the hernia was
incoercible to the truss and a source of constant distress.
This distinguished author, however, at the French Surgical
Congress in 1888, reported fourteen operations on non-strangulated
hernia, and besides has since written to me that he now regards
those operations in a different light, and considers them, in non-
strangulated hernia, in appropriate cases, as a very valuable sur-
gical expedient.
M. Félizét, three years ago, wrote a special monograph on
the "Radical Cure of Hernia in Children," a translation of
which, by me, has run through several issues of the Southern
Medical Record.
Dr. Justin Lucas-Championniére, of the Tenon and St. Louis
hospitals, of Paris, early in this year published the most complete
work that has yet appeared in any language, on the subject of
hernial operations on non-strangulated cases (Cure Radicale des
Hernies avec une Etude Statistique), in which he reports 270 opera-
tions by himself, from June, 1881, to February, 1892. It cannot
be said, however, that French surgeons, as a rule, favor radical
intervention, or approve of the enthusiastic recommendations of
Championniére. With the Germans, English and Americans,
those operations are not now advocated so indiscriminately as
they were but a few years ago. Nevertheless, to one going
through the surgical hospitals of the British Isles and the conti-
nent even now, the number of cutting operations for reducible
hernia, which he will daily witness, is something enormous. They
furnish an immense abundance of clinical material for operation.
But, as thousands of the herniated have been treated by radical
intervention within the past ten years, it would seem that by this
time some sort of consensus of opinion should be reached as to
which operation is the simplest in technique and permanent in its
effects. Besides, the precise extent of danger to life should be

HERNIA.
151
indicated, and the proportion which has not relapsed. From
what can be gathered from authentic sources, it appears that the
mortality is about one per cent. on non-strangulated cases.
Bull says the mortality is practically nil. It is assumed that
he must have reference to those recent cases occurring in the
hearty and vigorous. In my own fifty-seven cases for radical
cure in the strangulated and non-strangulated, in the past six
years, there has been no death except in those of the former,
which were collapsed when operation was undertaken.
Juillard maintained that as relapse occurred after all opera-
tions for radical cure, it was immaterial what special method was
adopted.
If this surgeon intended to convey the impression that no
case was permanently cured by operation for radical cure, it is
quite needless to say that such a sweeping assertion will not be
supported by any impartial observer of considerable experience.
But if he wished to be understood as claiming that no operation
could guarantee against relapse in all cases, his declaration cannot
be disputed.
It is important that we are fully sensible of all the con-
sequences which may ultimately attend these radical operations
before we undertake them, or make any promises to our patients.
In this connection it may be inquired: In the event of hernia re-
lapsing after operation, is it as coercible as before anything
was done by the surgeon? With reducible, trussable hernia, when
the open operation with free division of the tissues is performed,
there can be no question but that with a considerable number,
when they relapse, they are more unmanageable than they ever
were before. I have seen a few of this description, which no sort
of prothetical appliance could comfortably control.
The open method, however, in certain cases, is the only one
which will enable us to deal successfully with many phases of
hernia.
In order that a reasonable estimate may be made of the pre-
cise or approximate value of the numerous modern operations
which have been recently alternately vaunted, severely criticised,
or condemned, and with a view of according to each its just
merit, and demonstrating their defects and shortcomings, a brief

152
HERNIA.
notice of a few of the more common and popular will be described
here.
For the purpose of reducing their description to a simple an-
alysis, they may all be divided into-
1st.-Those in which the sac is ligated at the external ring, and
permitted to remain in situ.-Reisel.
2d.-Those in which the sac is freely and completely dissected;
the canal in inguinal hernia divided from the external to the internal
ring; the sac ligated and cut away; the parts again closed in, layer
by layer. Championniére.
3d.-Those in which essentially the same steps as in the preceding
are carried out; but the divided inguinal canal is kept open, and the
healing is by granulation.-McBurney.
4th.-A complete detachment of the sac from its adhesions, and its
utilization as a plug, to serve as a barrier against relapse.-McEwen.
5th.-The isolation and section of the sac and its excision at the
internal ring; splitting the internal ring and lifting the spermatic cord
entirely out of the inguinal canal; then wholly obliterating the canal by
tendinous approximation.-Bassini.
It will be apparent that this quintuple division, in the man-
ual of operations, applies chiefly only to typical, indirect, uncom-
plicated inguinal hernia.
In large bubonoceles, in direct inguinal, in those inguinal of
a congenital type, or in those in which evolution of the hernia
through direct rupture of the sac has been sudden, as well as in
femoral, umbilical, or many other phases of hernia, it has little or
no application.
The first feature of all those modern "open operations" which
attracts one's notice, is the extensive division of sound, anatomical
structures in their continuity. If we could but assure ourselves
that this free cutting across or through muscle, tendon, or apon-
eurosis were not in a certain sense a mutilation, and that the re-
sulting cementing together of the divided parts would not dimin-
ish the strength or pliancy of the traumatized structures, there
would be little hesitation in deciding on the most appropriate
course to pursue in any case. If in inguinal or femoral hernia
we could obliterate a canal, and yet leave one, a difficult problem
would be solved, as we will see further on.

HERNIA.
153
THE MANAGEMENT OF THE SAC IN OPERATIONS FOR RADICAL CURE.
Very much diversity of opinion yet prevails as to the man-
agement of the sac in hernial operations for radical cure.
As a
In the operation recommended by Socin, Nussbaum and
Reisel, the viscera are reduced, an incision is made through the in-
teguments, the neck of the sac is isolated, ligated at the external
ring and cut through. This course of incomplete dissection of the
sac, or hernial cavity proper, is observed on the ground that as
it is almost always intimately adherent to and incorporated with
the elements of the spermatic cord, its enucleation is not always
possible, without doing serious damage to this organ.
matter of fact in all cases, with few exceptions, in reducible, irre-
ducible and incarcerated complete inguinal hernia, the sac extends
down to the testis, and if it is so lodged, not alongside of but in
the midst of the vessels, nerves and duct of the cord, it will always
require a tedious dissection to entirely disengage it from the cord.
This is of prime importance to remember when the modern opera-
tion is undertaken, and the proper manipulation of the adventitious
structure is considered.
There does not appear any valid objection to leaving the sac
lodged, when it is firmly held by old adhesions, and through
which its nutriment supply is drawn. As now the sac has no
further function to conserve, in obedience to a well-known law in
the economy, it undergoes contraction with disintegration and
absorption. In crural and umbilical hernia it is always considered
important to completely enucleate the sac, as in these districts its
walls are generally free and its entire extirpation is supposed to
permit the more complete consolidation of the tissues, on the per-
fect sclerogenis of which the barrier against relapse is secured.
This operation, commonly known as Reisel's, though it was many
times performed before he described it, is the simplest of all open
hernial operations, and applicable to certain definite phases of the
infirmity. With these, it should be preferred to any other open
operation. It is simplest of performance, entails the least mutilation
and effects all that any operation can, without the dangers of many
others. By it the elements of the cord are but slightly disturbed,
the scrotum is not opened, nor the cavity of the peritoneum ex-
posed to the risk of infection.

154
HERNIA.
THE CLASS OF CASES IN WHICH CERVICOTOMY AND DELIGATION SHOULD
BE SELECTED.
1st.--Every case of non-adherent ventral, crural, and umbil-
ical hernia.
2dly. In all inguinal hernia in which there are: (a) great
distention of the inguinal canal (large incarcerated bubonoceles);
(b) those which have no canal; (c) in all direct inguinal hernia.
3dly. In those cases in which, for various reasons, it is im-
portant that we must operate with haste.
1st.-Although with very rare exceptions hernia is never met
with, except as a visceral escape through some natural outlet of
the peritoneal cavity which serves as a passage to a tubular
structure, yet it is quite unusual that the peritoneal investment
which encloses it, is intimately fused with contiguous parts or
vessels, except in the inguinal variety, so that, except with the
latter, it is always well, unless special contra-indications prevent,
to lift the sac out of its bed and amputate it high up.
2dly. In large, old incarcerated bubonoceles, in which it is
discovered that the vessels and nerves of the cord are spread over
the entire circumference of the sac, like so many strands or cords
over the dome of a parachute, and have become, through fibrous
changes, so adherent as to be detached with difficulty and danger,
enough has been accomplished when the sac is opened up to the
internal ring or near it, its contents freely liberated and re-
turned, its neck freed, twisted, stretched, and transfixed, and
firmly secured by the multiple chain suture of Championniére,
and cut across. With a view of destroying the epithelial and
glandular coats of the sac, this having been well opened, the
serous surface is freely sponged with strong alcohol or a solution
of the chloride of zinc, so that its lumen may be immediately
destroyed and an active reactionary inflammation excited, which
will firmly weld everything outside the spermatic cord into one
dense plaque of fibrous tissues.
Those which have no canal.-In the infantile type of inguinal
hernia, as there is practically but one ring and hence no canal,
other tissues must be utilized as a tampon. With them we will
find a condition which will strike one as rather singular who is
accustomed to regard rupture and hernia as synonymous terms, or

HERNIA.
155
who has an impression that all hernial infirmities, with few excep-
tions, do not present their initial morbid anatomy at or even be-
fore birth, for, even within a week or two from birth, we will
nearly invariably meet with a thick, dense, adherent sac. In chronic
scrotoceles of those advanced in years, we will meet a practical
obliteration of the canal through the pillars having given way,
and either orifice having so spread out, that all obliquity is lost
and nothing remains but one large hiatus into which three or four
fingers may be readily introduced. When the radical operation
is essayed in this undesirable class, we are not concerned with a
physiological inguinal canal, for there is none. Marcy, in his
work entitled the "Radical Cure of Hernia," however, describes
a technique by which, with the employment of the buried kan-
garoo suture, the obliquity of the canal may be restored. It is
obvious that with these chronic, or senile herniæ, pathological
changes have wrought such a radical alteration in the position,
consistence, and relation of the gross structures and the minute
histological elements, that we need hold out no hope for a cure
by radical operation; as the most which we may expect to accom-
plish is the comfortable reposition of the parts in such a manner
that they may be painlessly and securely retained by a prothetic
support after operation. As the greater part of these cases are
complicated with spermatocele or hydrocele, and are irreducibly
incarcerated, besides, as their abode has been so long in an acces-
sory cavity, their sudden and complete return may react mortally
on the respiratory organs. When, however, strangulation may
threaten, or for other reasons an operation is decided on, having
a full appreciation of the conditions before us, the question may
arise as to whether or not it may be as well to cut at once down
on the broad, thick neck of the sac. If it contains mesentery
and intestine, cautiously isolate and reduce as in the case of bubon-
ocele, and if we should meet with a mass of adherent omentum,
free it well above from the inner surface of the infundibulum;
make traction on its proximal pedicle, so that on division the
ligated stump may mount high in the abdominal cavity and leave
the mass of the epiplocele outside in the scrotum where it was.
There is no danger of a slough, for its nutrition is rather from its
adventitious connections, than the linear vessels which course

156
HERNIA.
downward through the pedicle. This procedure has answered
admirably in three cases in my hands. One was a woman, and two
men. It spares an immense effusion of blood through capillary
oozing, attendant on decortication; and the undisturbed parts
below give rise to no further annoyance. With this hernia the
sac must be carefully closed with strong silk in divided sutures,
and to my mind it is the only hernia in which the vivifying and
solid suturing of the pillars is a judicious or useful procedure.
It would be absurd to suppose that this immense open chasm,
only covered in by the peritoneum and integument, could resist
the re-descent of the extrusion. Hence, the pillars must be brought
together and firmly closed with silver-wire sutures. It is true
that these may later give rise to irritation, but occasionally, as
when buried in the fibro-osseous tissues of the patella, unless they
cut through, by lateral tension, they may remain imbedded in
the tissues almost indefinitely; but of this more later.
DIRECT INGUINAL HERNIA.
This form of hernia is said to be more common in women,
and to occur about once in five of all the inguinal cases. This is
the figure as given by Cloquet.* My own observations convince
me that these statistics are erroneous, as I have never met with
but two cases, which by any stretch of the imagination could be
regarded as of this type. On the contrary, even with these I
had my doubts, as the parts through lapse of time and interstitial
changes had so altered that it was quite impossible to say just
precisely the type we had before us. It appears of late years
that surgeons, or those whose province it is to deal with the
morbid anatomy of hernia, quite generally ignore direct inguinal
hernia as a pathological entity; for in none of the latest and most
complete works on hernia, by American and foreign authors, is it
at all barely mentioned. And with American surgeons the con-
fusing, cumbersome nomenclature of Cloquet or Gray is rarely
adopted in their descriptions of hernial coverings.
The intercolumner fascia may be very thick, or the conjoined
tendon very thin, so that in a general collapse of all the aponeu-
rotic coverings of the inguinal region, the isolation and recognition
*Cloquet, Anatomies des Hernies.

HERNIA.
157
of these independent structures will often be quite out of the ques-
tion. Fortunately, in the surgical therapy it will, in any event,
in no way effect technique.
For we will deal with the pouch of the conjoined tendon
precisely as we do the intercolumner fascia. The essentials in
operation, then, are practically, identically the same in direct in-
guinal as in large, ancient indirect.
3D.-CASES IN WHICH URGENCY DEMANDS HASTE IN OPERATING.
Probably we can conceive of nothing in life which to a greater
degree is an unknown quantity than a surgical operation. The
way may seem clear of every possible obstacle or accident; the
patient's general condition is excellent, and everything points to
consummate success at every step. We have studied our case;
have over and over examined the field, and, mentally, have repeat-
edly gone through all the stages of an operation; provided ample
assistants, and anticipated, we imagine, all possible emergencies.
But from the start everything goes wrong. It may be quite im-
possible to narcotize, or our patient may have violent, uncon-
trollable muscular spasm. He may have incessant vomiting, a
suffocative, respiration, or heart failure. Besides, at a time we
need light the most, it is the worst. Our patient may be a bleeder,
etc. All or any of which may necessitate the bringing of an
operation-particularly one which involves the peritoneum-to a
hasty close.
Under these circumstances, although it may be desirable to
enucleate the sac, yet the operative procedures may be simplified
and shortened by the simple division of the neck of it, in the
manner as previously described. In extremes of age and those
suspected of crganic disease, the reduction of the operative time
is of great importance. Under these circumstances and in the
class of cases here described as appropriate, cervisotómy may be
utilized instead of another operation which entails a tedious and
difficult technique.
Championnière attaches great importance to the necessity of
full anesthesia before we commence any sort of hernial operation,
and rigorously excludes those afflicted with asthma and bronchitis.
And Félizét, invariably as a prerequisite in herniated children,

158
HERNIA.
insists that they should have passed through measles and whoop-
ing-cough before any operation is undertaken on them; and for
the same reason, fearing bronchial troubles in winter, prefers the
warm weather of summer for herniotomies performed with a view
of radical cure.

SECOND DIVISION.
THOSE OPERATIONS IN WHICH THE SAC IS COMPLETELY DISSECTED AND
CUT AWAY AFTER THE INGUINAL CANAL HAS BEEN DIVIDED THROUGH-
OUT ITS ENTIRE LENGTH; AFTER WHICH, THE CANAL, EXTERNAL
RING, FASCIA AND INTEGUMENTS ARE CLOSED, LAYER BY LAYER.-
(CHAMPIONNIERE.)
This is the operation which Championniére has performed
on 274 patients, with slight modifications, on children and adults,
males and females, in strangulated and non-strangulated hernia.
His mortality in the non-strangulated, non-complicated, was prac-
tically nothing. He has reported but few relapses, though it would
seem from his writings, that he had not put his cases to an ordinary
test, for he always required his patients to immediately wear a
broad belt, with a metallic plate applied, immediately over the
traumatized area. It practically serves the purpose of a truss,
though it acts on a somewhat different principle. He recom-
mends it indiscriminately after all radical cures, though it is not
quite clear, whether it was to be worn continuously through life
or not. Many are reported to have laid it aside after a time, with-
out relapses.
159

160
HERNIA.
This is essentially the same operation as first practiced by
Reverdin; only the former always extirpated the sac, something
which the distinguished Belgian sometimes omitted.
Before detailing the various steps in this operation, it is well
to fully appreciate the possible
and probable results, which may
ultimately result from the exten-
sive dissection and mutilation,
which this operation renders im-
perative, when performed on a
complete, indirect inguinal her-
RAINAL FRERES
FIG. 45.
Championnéire Belt and Support,
worn after operation.
nia on the male, on the lines laid
down by its originator.
FIG. 46.
(Championnéire.)
First, the sac, the perito-
neum, the cellular membrane, and
infundibuliform layer of the fascia-transversalis, which is not, as
many anatomists teach, either anterior or posterior to the sper-
matic, but in nearly all cases of reducible and incarcerated herniæ
rather thrown in among the strandlike structure of the cord, so
that, as we endeavor to roll out the sac, we must begin by endeav-
oring to enucleate them with the finger-nail and scalpel, which
we may, perhaps, accomplish in many; but in not a few, this de-
bridement or detachment, without doing irretrievable damage to
the neural or vascular structures, is quite impossible. As one comes
on the sac and finds it encased in those linear, cordlike chan-
nels, on their way to or from the testis, there are none of them
which can be definitely distinguished, except the artery of the
testis, the pulsations of which may be felt, and the thick, resistant
sperm duct of the same organ. It is quite impossible to recognize

HERNIA.
161
the veins, when not varicosed; the cremasteric, or artery, of the
vas deferens, as is also the spermatic nerve, and other branches.
from the external pudic and obtu-
rator, which must be encountered
on the way to the base of the scro-
tum. Hence, in the tearing, teas-
ing and picking which must be
done, to divest the peritoneal pouch
from those elements which belong
to the cord and testicle, extreme.
care must be observed. This step
of the operation is always attended
with more or less loss of blood, and
laceration of nerve filaments. But the
sac is finally freed; though we may
have had to go down and peel it off
the testis itself, as was done in one of
my own cases in a congenital hernia.
FIG. 47.
And let it be noted here that
the fibrous elements of the sac possess great contractile power,
PERITONEUM
FIG. 48.
PERITONEU..
MUSCULO APONEROSIS
INFUNDIBULUM
WALL
SAC.-HERNIA
which must wholly disappear on
Three independent layers of sutures after
incision of the sac; inclosing incision.
a proof of which we always observe.
For, while before reduction of the
hernia the sac may be distended as
large or larger than the fist, when
empty its volume is no larger than
the finger, or is even less at times.
The scrotal adhesions being liberated,
the cremasteric and intercolumnar
fascia being laid widely open, we
arrive at the external ring. Here it
is well to hesitate a moment and
recall a few points in the anatomy
of the inguinal passage. As has been
pointed out under a description of
structure and function elsewhere, the
external ring is normally widely
Diagram indicating the peritoneal pouch, open; the canal from without, inward,
operation for radical cure.
(Championniére.)
taking the form of an inverted cone;
11

162
HERNIA.
the base of which corresponds with the pillars or the borders of
the conjoined tendon and the upper border of Poupart's ligament.
Invaginating the integuments we can conveniently pass the
finger along the entire length of the inguinal canal, which pursues
an oblique direction to the internal ring, so miscalled, for there is
no analogy whatever in the structural arrangement of either ring.
As the finger is in the canal we will note, that as the abdominal
contents were directly against the abdominal walls, their advance
is opposed by the obliquity of this canal, which, the greater the
resistance from within, the more closely it is closed, and next the
canal itself, which is essentially a hollowed tube, having two
distinct walls, the outer of which is composed of more muscular
tissue than the inner. As we advance up the canal, it will be
noted that the inner wall becomes thinner, and the outer more
dense and muscular.
Now, in following up the sac with the scalpel to the internal
FIG. 49.
ring, all this delicate architec-
ture is seriously deranged, if not
for all time destroyed.
An incision is made through
the entire length of the canal,
from the external to the inter-
nal aperture, in order that the
pedicle of the sac may be liga-
ted on a level with the general
peritoneum. It will be seen
that by this act the obliquity of
the inguinal slit is lost; the
anterior, the thickest wall, is
opened, and the canal is de-
stroyed as a barrier againt ven-
tral pressure.
Having cut away the neck
of the sac, the proximal lumen
Adjustment of the chain suture before division is closed with the chain suture
of the neck. (Championniére.)
(see Fig. No. 49), and returned
when the parts are closed in by three layers of cat-gut sutures, and
the external ring is closed with the same material. The late

HERNIA.
163
lamented Parkes, of Chicago, at the American Surgical Congress of
1888, declared that the suturing of the pillars was of no value as
a prophylactic, as he had seen the walls expand, and relapse occur
as frequently when they were sutured as when they were not.
Reverdin later expressed similar sentiments. When relapse or
recidivation does follow after the operation, as the canal is gone,
we must have practically a ventral hernia; a phase of the infirm-
ity at once the most intractable and unmanageable, as now the
the escaping viscera wander in any
direction offering the least resistance,
intruding themselves in the intermus-
cular spaces and subcutaneous tissues,
acquiring adhesions and becoming in
time incarcerated and irreducible.
FIG. 50.
Proximal pedicle after ligation and
division.
In crural, umbilical or ventral
hernia this operation, when the sac is devoid of adhesions, is the
ideal. In the inguinal hernia of the female, in whom the external
ring is large and the passage very short, and in whose inguinal-
canal there are no important structures analogous in function to
those met with in the male, it no doubt may have a place, and
serve a useful purpose in a considerable number of cases. As the
incision with them to expose the canal will be near the median
line, the hair of the mons veneris will often effectually conceal
the scar.

THIRD DIVISION.
AN OPEN OPERATION WHICH ESSENTIALLY EMBRACES THE SAME STEPS
AS THE PRECEDING, BUT THE DIVIDED INGUINAL CANAL AND THE SOFT
PARTS UNITE BY GRANULATION TISSUE INSTEAD OF PRIMARY UNION.
-MCBURNEY.
Although this operation was first practiced by Langenbeck,
it was more fully elaborated and instituted on an extensive scale
by Dr. Charles McBurney, of New York.
The fundamental objects claimed to be obtained by this "open
operation" are the complete isolation of the sac on the same plane
as the general peritoneum, and the filling in the breach in the tis-
sues, made by the scalpel, with cicatricial tissue. McBurney claimed
for the operation that it prevented any dimpling or funneling of the
peritoneum, and hence the tendency to relapse, so common after all
those operations which left a remnant of the sac in the canal. It was
also maintained that the resulting ridge of scar tissue would serve
as an efficient barrier against relapse. Of course this procedure
would scarcely apply in any other than in typical inguinal hernia,
for it presupposes the presence of a sac, a canal, etc.; hence in a
164

HERNIA.
165
sacless hernia, in direct inguinal, infantile crural, it is not so prac-
ticable, or in umbilical. If other operators have aimed at curing
hernia by stuffing the canal or closing its lumen, the New York sur.
geon proceeded in a diametrically opposite direction to accomplish
the same end, as every vestige of the sac is swept away, the inguinal
canal is opened from end to end, and deliberately kept so by sew-
ing its divided edges above and below to the integument; and pack-
ing the interspace, through which the spermatic cord passes, with
a tamponade of gauze.
Dr. McBurney reports a very large number of cases treated by
this plan, nearly, if not all, for the non-strangulated. My own six
cases in which this operation was employed for strangulated, as a
radical measure, reported in the Journal of American Medical Asso-
ciation, for June 17th, 1889, were the first in this country in which
it had been utilized for this phase.
Inasmuch as it afforded the surgeon every facility for manipu-
lation and provided for ample drainage, it at first favorably im-
pressed me as being specially adapted for strangulated cases.
This operation par excellence demonstrates the marvelous re-
sisting power of the peritoneum; for, exclusive of it and the con-
joined tendon, there is nothing to hold back the contents of the
abdomen until cicatrization is complete. The obliquity of the
canal is not only destroyed, but the canal itself, with its coverings
as well; so that in the event of relapse the hernia is only prevented
from coming directly into space by the cicatrix. If this should
rupture or sunder we would have precisely the same phenomena
as we sometimes witness spontaneously occur in exomphaceles,
when the umbilical scar spreads out as thinly as tissue-paper, erodes
or bursts and allows the intestine to pass directly through.
Soon after Dr. McBurney's thesis on the technique of his opera-
tion at the New York Academy of Medicine, Dr. William T. Bull
made a vehement attack on all sorts of radical operations for reduci-
ble coercible hernia. McBurney's operation came in for a large
share of his condemnation. This, he said, was conceived on vicious
principles, and was based on views of reparative processes not in
accord with the sound tenets of pathological changes, etc., that
relapses must be inevitable, and when they did occur, they must
be quite unmanageable.

166
HERNIA.
Dr. James E. Kelly, of Charity Hospital visiting staff, how-
ever, reported several cases treated after this plan, and reported
good results as to permanency of cure of the hernia, but mentioned
that the cicatricial pressure on the cord had produced, in some
cases, very painful sensations when the patient' stood long. It
does not appear that this operation has been very generally adopted.
Although in my own hands it yielded quite good results in
strangulated cases, the few relapses after it, which did occur, were
of a most intractable character, which almost no truss could com-
fortably retain.
If we can depend on cicatricial tissue to permanently replace
muscle and tendon, then, indeed, this operation offers many advan-
tages, and might be utilized with benefit for those not belonging
to the laboring classes. But we do know that the tendency of
proliferation of connective tissue cells is always in the direction of
resorption and condensation, and that scar tissue possesses neither
the strength nor pliancy of a muscular sac; but that, on the con-
trary, when it finally ultimately undergoes complete fibrinous
changes, and parts with its vascularity, it acquires a brittleness
and fragility unable to withstand a sudden strain. The author of
this procedure insists on it that a truss must not be worn after
operation. In Championniére's operation the same rule is pre-
scribed. But in contradiction of this injunction the Parisian surgeon
insists that a ceinture, an encircling belt, with concave plate, must be
immediately adjusted, and constantly employed as a prophylactic
against relapse. Although it is denied that this is constructed on
the same principles as the truss, or serves a similar purpose, its
close analogy is too apparent to be regarded in any other light
than a mechanical appliance, which serves essentially the same
purpose.
Dr. Bull, in his tirade against hernial operations, ridiculed
the pretensions to radical cure when a truss must be applied on
taking the upright position, and sarcastically remarked, that those
only who were well trussed up could make any claim to be cured.
Abbé, Wyeth, Weir, and others, who have performed the Me-
Burney, have advised the application of a light truss. In all my
own cases I have taken the same precaution. In my first cases,
in which I omitted it, relapse appeared early. Perhaps, when the

HERNIA.
167
precise technique of McBurney is better understood and applied,
we may dispense with this support after operation. Nevertheless,
whether it, or any other surgical operation, effects a closure of the
opening, a tendency to relapse will always remain here, which
requires a support; and, besides, as a hernia is so apt to occur
on the other sound side, after one portal is plugged in a large
hernia, a double truss should be worn in the absence of a firm
bandage.

FOURTH DIVISION.
COMPLETE DETACHMENT OF THE SAC FROM ITS ADHESIONS, AND ITS
SUBSEQUENT UTILIZATION AS A PLUG, TO SERVE AS A BARRIER
AGAINST RELAPSE.-MCEWEN-KOCHERS.
The preservation and utilization of the sac as a tampon, we
have seen in the historical part of this contribution, is a very an-
cient procedure, and belongs, with anchorage of the testis, ovary,
omentum, or intestine, to those procedures which might be desig-
nated "obturation of the canal by autoplastic implantation."
Dr. Wm. McEwen, of Glasgow, has recently revived and
modified the operation. He has reported a considerable number
treated by peritoneal occlusion, in which there have been, as far
as he could learn, but few relapses.
The operation, however, has not met with very much favor,
and is not now as extensively practiced as it was when first intro-
duced. Reisel in 1877 performed an operation quite similar to
this. He dissected the sac away, and then, by invagination, pressed
it up to the internal ring, and sutured it in the canal with catgut.
With what result is not stated.
168

HERNIA.
169
The operation of McEwen, which may be excellent in its re-
sults when all the conditions are present to favor its success, is,
nevertheless, in a general way, opposed by all orthodox principles
in surgery. Independent of the necessary amount of tearing and
laceration inseparably connected with the decortication of an old
adherent sac, and impacting a foreign, heterogeneous mass in the
canal, when the cardinal aim in all hernial surgery is to restore
normal relations and clear the passages of such substances as may
favor, by their presence and irritation, the re-establishment of a
condition which an operation is undertaken to remedy.
This procedure has no place as an adjuvant to kelotomy for
strangulation-a condition in which, alone, the sac is usually free
from adhesions-for the investing peritoneal pouch in these cases
is often more or less necrotic, as the result of inflammatory or
other degenerative changes, which make its extirpation neces-
sary. Then it often must be left free in the breach to contract or
close in by granulation, if not exsected. As the nutrition is pro-
vided, in all cases of adherent sacs, largely by the vascular supply
through the perihernial tissues, when this is totally cut off, as
it always is in enucleation, the sac may undergo rapid atrophic or
ulcerative processes and disappear; hence, in a short time leav-
ing the canal about the same as though nothing had been done to
obturate it.
The varying capacity and consistence of the sac may be an
embarrassing feature in a given case, as we will sometimes find
this very large, thick, and tough, so that its gross volume is very
much in excess of what we require or can utilize; while, again,
it is very diminutive and of a gauzelike thinness, so that it breaks
down on even very moderate manipulation, and there is so little
of it as to render it quite useless as a plant in the inguinal tract.
This operation, without modification, certainly cannot be util-
ized in the congenital type of hernia, or in a monorchis, in whom
it is important that the inguinal canal be preserved clear of every
impediment.
In properly selected cases, with the young in sound health,
and in uncomplicated inguinal hernia, particularly the female type,
keeping the conservative aim in view of sacrificing nothing, but
utilizing everything, we must admit that this operation may be

170
HERNIA.
applied with advantage. Dr. McEwen has personally informed
me that this operation was not indiscriminately recommended for
every phase of hernia, and had his sanction only in appropriate
cases.
In it, as in others already described, the pillars of the rings are
approximated and sutured, after the wad of peritoneal tissue is
turned on itself and imbedded in the canal. This step, in the
event of the implanted sac undergoing homologous assimilation,
can certainly serve no useful purpose; while, on the contrary,
should this fail, and permanent obliteration of the hernial opera-
tion follow, we would have still, anatomically, an incomplete
hernia resulting, with all the discomforts and ultimate dangers
which might ensue.
When, then, this species of peritoneal grafting, to fill in
dead spaces" or to wall back hernial re-descent, is resorted to,
as much or more may be accomplished by leaving the external
orifice open and dependent.
McEwen, from 1879 to 1890, operated sixty-four times; five
being crural hernia, seeing but one unfavorable result.

FIFTH DIVISION.
ISOLATION OF THE SAC, WITH SECTION AT THE INTERNAL RING;
SPLITTING THE INTERNAL RING, AND LIFTING THE SPERMATIC CORD
ENTIRELY OUT OF THE RINGS AND CANAL, AND THEN OBLITERATING
THEM TOTALLY BY TENDINOUS APPROXIMATION.-BASSINI.
The presence of the spermatic cord, the round ligament of
the testis, has always been regarded as an insurmountable barrier
to the radical cure of inguinal hernia; and, accordingly, different
operators, since very early times, have either resorted to castration
while herniotomizing or else endeavored to destroy the spermatic
channel, from end to end, by displacement of the cord.
Most certainly, when this operation, as performed by Bassini,
of Padua, is carried out in all its details, we can never again have
a relapse of an inguinal hernia, for by it every remnant of the in-
guinal architecture has been swept away; and, surely, we cannot
have a hernia through a structure or parts which no longer exist.
But we may inquire, can the spermatic cord be raised and trans-
ported without traction on the slack below, or without further
weakening the abdominal wall, in making another breach through
sound parts?
171

172
HERNIA.
The tubular structures of which the cord consists, each
approach the internal orifice at different angles, from different
directions, and only converge and follow the same plane as they
emerge from the abdominal wall externally. The cord is pro-
tected throughout by a peritoneal investment, which though above
it is sealed, is yet, nevertheless, continuous with the cavity of the
peritoneum. We cannot, therefore, raise the cord from within
the abdomen, for there none exists, and hence, in order to displace
it, dangerous traction must be made on those delicate elements of
it, which, at the internal ring, have effected a permanent lodgment.
Besides, as it is only free from the outside of the ring, this is the
part which must be raised and placed into the gap made in the
abdominal wall to receive it.
The displacement of the cord by raising a loop of it into the
slit in the tissues, causes a double incurvation of it, so that in its
new situation it takes the shape of the letter S. And hence this
double curve, with the contractile compression liable to ensue as
the soft parts close in around it, are physical causes which one
would think would, in time, cause grave functional and organic
disturbances in the vessels of the cord and testis. However, if
these cause no changes other than a painless atrophy, as one testi-
cle is ample for the preservation of virility, this is a sequela of
little consequence, and our patient would be left a whole man, as
FIG. 51.
First stage in Bassini's operation.
far as appearances went. This effort
of preservation of the testis in hernial
operation by the surgeon is always
appreciated by the laity. Curling,
in his treatise on "Diseases of the
Testicle," cites an instance in which
a distinguished French surgeon was
murdered by a patient from whom
he had removed a testicle.
In the case of an old, painful, in-
carcerated hernia, in a clergyman of
middle age, in whom I was invited
to do the radical operation by Dr.
Frederick G. Kneer, of this city,
when I explained to the gentleman

HERNIA.
173
that when I exposed the parts by a deep incision, I might find it.
necessary to sacrifice the testicle on that side, he vehemently pro-
tested against it, that it would unsex him, and impair his man-
hood. Bassini's operation is intended to always obviate the
necessity of castration.
The next step in this operation, after the cord is fixed in
the new opening, is to close the canal, bringing the divided
end above and sewing it into the
upper border of Poupart's ligament,
thereby completely and solidly closing
both rings and the canal, after which
the cord is carried outside the deep fas-
cia or fascia lata, and covered in with
the superficial fascia and integument.
If the cicatricial bond which
closes in the largest rent in the tissues
could be depended on, this should be
one of the most radically curative of
all operations. If some sort of non-
corrosive material could be found
which could be left imbedded in the
tissues to permanently lock the gap-
ing edges together, and should the
reparative material provided by the
economy prove adequate, our patient
against return of his hernia.
FIG. 52.
Second stage in Bassini's operation.
might be fairly guarded
In Rome I was permitted the privilege of witnessing Prof. Leoni
and Dr. Raphael Bastianelli perform several hernial operations in
the surgical hospital of the Via Corsa by this method. They em-
ployed silk suture for the tendinous structures, as they said that.
any sort of absorbable material could not be trusted, for it gave way
before solid union was effected. They always employed vigorous
antiseptics, and had practically no mortality which could be attrib-
uted to the hernial operations. Dr. S. E. Milliken, of New York,
has largely employed this operation, and speaks well of the results.
My own observations of its technique, and a study of the
principles on which its claims rest, have led me to take a decided
position against it. No doubt it has given many operative suc-

174
HERNIA.
cesses,
but in the event of relapse the succeeding hernia must
be quite unmanageable. Bassini reported 251 cases of reduci-
FIG. 53.
Third stage in Bassini's operation.
ble inguinal hernia operated on by
him, in which he says there were but
seven recurrences, though 198 of
these cases passed from under his ob-
servation within six months and a
year after operation.
The mortality in those cases
treated by modern methods has been
reported as very light. Svesson and
Erdman had but one death in 106
cases (Nord. Med. Wek., Bd. 18);
Champonniére, one in 120; McEwen,
one in 98; in Kocher's operations,
119, but one death. Indeed, this
author goes so far as to say that there
in no danger at all, and that when
fatal results follow these open opera-
tions, they are imputable to antecedent conditions which would
have cut off life if nothing had been done.
Ségond's* figures, however, do not bear out this view. He
collected 219 cases up to 1880 with 20 deaths, or nearly a
mortality of 10 per cent. The same author, in 113 cases, in which
the results were published, found that 44 of them almost immedi-
ately relapsed. Schede, Reisel, Weinlechner, Reverdin, Czerny,
Esmarch, and McEwen have each reported post-mortem demon-
strations of the perfection of curative consolidation by their various
operations. Maas, of Fribourg, examined, after varying intervals,
his own and Czerny's cases, and reported that they all had relapsed.
Schede, Czerny, Socin, Tilanus, Langenbeck, Reverdin and
others, ridiculed the pretensions of those surgeons who never ad-
mitted relapses. Juillard candidly admitted that in his 22 opera-
tions for radical cure he had had but one permanent cure. In this
case he found it necessary to resect 18 centimeters of the intestine.
After she recovered from operation, she had mental alienation,
though two years after there was evidence of relapse of the hernia.
*Cure Radicale des Hernies, page 206.

CHAPTER XX.
MISCELLANEOUS OPEN OPERATIONS IN INGUINAL HERNIA AND THOSE
APPROPRIATE FOR STRANGULATION; FOR FEMORAL, UMBILICAL AND
OTHER VARIETIES OF HERNIA.
In the recent "System of American Surgery" (Diseases and
Operations of the Abdomen, p. 177), an author says, "Many opera-
tions have been devised for the cure of hernia, which have for a
time been popular, and then forgotten, or have fallen into disuse.
The operations of Wood and Wützer are never practiced now, as
these since the introduction of aseptic surgery have been entirely
superseded by that of the open incision."
This statement is practically correct; though the operations
of Gerdy, Wützer and Wood in modified ways are yet being per-
formed, as is seen by Bennett's operations. And, it might be added,
that "open operations" for reducible hernia in America during
the past two years are decidedly on the wane.
To enter into a full and detailed description of the almost
endless variations in the "open operations" would occupy a con-
siderable space, and as the principles which underlie them all
175

176
HERNIA.
are fundamentally identical, no effort will be made to describe
them here.
It may be said, however, that in different cases no precise
technique will answer for all, and that the operator must accom-
modate his dissection to the manifold phases of the infirmity pre-
senting in divers cases. Probably, if every surgeon would publish as
his operation; one, who when he found
it necessary to so far deviate from the
usual course and resort to a novel ex-
pedient to accomplish his purpose,
the names of operations for radical
cure would occupy a very long list..
For instance, in one of my own cases
in which I had a very thick stalk of
omental tissue, after securing sepa-
rately its vessels, and cutting off the
main mass, I passed a strong curved
needle through the inner pillar of the
ring (for there was but one ring),
through the mass underneath, and
out through the opposite pillar. I
then re-introduced the needle at a
point a full half inch below, and re-
turned it in the same direction until
it came out a little distance from
where it entered, when I firmly
twisted the free ends and turned
them in, covering in the parts by
Congenital Hernia before the operation. sewing the fascia and integuments in-
dependently. This was a good case to test this plan on, as he
had been operated on before for radical cure, with a prompt.
relapse. He was a hod-carrier, and now, after three years, there
has been no trace of relapse. I have since seen practically the
same operation performed in London by Dr. Barker. In another
case of a child with an enormous ring and no inguinal canal,
I have solidly sealed in the breach, employing large harelip
pins, which penetrated the integuments on either side, using
silk suture over the pins. I left three of them in for three weeks.
FIG. 54.
(Félizét.)

HERNIA.
177
The gave rise to no irritation and served a most admirable
purpose.
No doubt many others have employed similar devices to ac-
complish the same end. In open operations for congenital hernia,
where there is no independent serous investment, we must utilize
the spermatic fascia.
In multiple hernia on the same side, direct, indirect, or
inguino-femoral in encysted or neoplastic, a special and peculiar
technique is required for each; hence, no formal operation will
answer for all species, or but a very few simple types of them.
Hence, it would be preposterous to allege that a specific proced-
ure must be devised for each.
Accordingly, this part of the subject will be closed with a
few notes on two or three operations recently recommended. One
is by Félizét, which applies particularly to children's inguinal
hernia, and another one will be given in full, because it is the
very latest procedure devised up to date for radical cure by the
open incision. The latter is by Theodore Kocher, of Berne.
Félizét's operation in no way differs from all ordinary ingui-
nal operations, which require the enucleation of the sac and its
severance at the neck. It is unlike these operations only in
technique.
In this operation an incision is at once made down to and
through the sac, into which a sort of oblong
bag is inserted and is then inflated. (Fig. 55.)
The author designates this a ballon or
balloon. Having been inserted, an inflating tube
is connected with a stop-valve, and blown into
until it is fairly distended, when the blow-pipe
is disconnected and the operation of decorticat-
ing the sac is commenced.
The advantages which the Parisian sur-
geon claims for this device is that the empty
sac, after the viscera are reduced, is rendered
tense, so that the work of enucleation of the
elements of the cord and adjacent tunics is
more safely and expeditiously performed.
As there is a firm resisting surface to cut
FIG. 55.
(Félizét.)
12

178
HERNIA.
on, and besides the red color of the gold-beater skin gives such
a tint through the gauze-like overlying tissues, one can easily
escape doing damage to the sper-
matic vessels.
In fact, it is said that the opera-
tion time is reduced one half or more.
In spite of its apparent advan-
tages, nevertheless but few sur-
geons have utilized it, claiming that
its introduction in itself was not
without danger to life, and that in
many cases its employment would
be quite impracticable. The danger
of infecting the peritoneum by intro-
ducing this foreign body into the
caudal protrusion of it was alleged
against it. The inequality of capac-
ity and want of uniformity and con-
tour in the hernial sacs, besides scat-
tered adhesions within them, ren-
dered its use quite impossible and
undesirable in a considerable number
of cases. Félizét had the most happy.
results following its employment.
As it, however, must demand some
special practice on the cadaver before it can be readily adopted in
average cases, it has failed of that success which was hoped for it.
In the "Annals of Surgery," for December, 1892, there ap-
pears yet another new open operation for radical cure of hernia,
invented by Kocher, which the author claims has no analogue in
surgical literature. That this assumption cannot be supported,
is abundantly demonstrated to anyone who critically examines
the plates and description of the operation, which are here given
unchanged, as it comes from the pen of the translator.
53
FIG. 56.
(Félizét.)
"We wish to describe a new procedure for the radical opera-
tion for hernia, which we perfected, and, after sufficient study, per-
formed upon a series of cases and demonstrated before a number of
surgeons. For it appears from the not yet completed observations of

HERNIA.
179
our final results by Dr. Leuw, that the method which we had em-
ployed has not fulfilled all of our cherished hopes. We have
already explained to what degree this view has been modified.
This procedure, which, in the literature known to us, has no
analogue, is best explained by the accompanying cuts, which were
made after drawings by drawing-master Kiener, taken from nature
during one of our operations. The method suffices to make tense
the peritoneum in the region of the inguinal canal, and to fix it
MAIL
FIG. 57.
FIG. 58.
The primary incision in Kocher's method for Forceps introduced along inguinal canal and
the radical cure of hernia.
grasping the sac at its lower end.
against the anterior abdominal wall. This is accomplished after
the same manner as in the methods of Barker, Ball, and McEwen,
with the difference that the stretching of the peritoneum is done in
a direction opposite to the direction of the inguinal canal and the
course of the hernia; and that the fixation of the peritoneum is
done much more firmly, and in a more permanent manner.
The skin and superficial fascia are divided over the inguinal
canal and laterally outward in the direction of Poupart's liga-
ment (Fig. 57), and the sup. epigastric artery ligated. At the
anterior inguinal ring only the thin fascia of Cooper, which, as

180
HERNIA.
a continuation of the tense aponeurosis of the external oblique
muscle, covers the spermatic cord, the cremasteric loops and the
tunica vaginalis communis, which is especially well developed
FIG. 59.
external oblique aponeurosis.
in hernia, are also divided. The struc-
tures of the spermatic cord are now
separated, in which, by holding them
towards the light, the border of a
very thin hernial sac can be recog-
nized. This is then carefully dis-
sected and isolated from the struc-
tures of the cord until it can be
strongly drawn down and its pedicle
exposed.
The index finger of the left-hand
is now introduced into the inguinal
Sac drawn out through lateral opening in canal; and laterally from the poste-
rior inguinal ring, a small opening is
made through the aponeurosis of the external oblique muscle (see
Fig. 60). A slender pair of artery forceps is passed through
this opening and through the lower muscular fibers of the in-
ternal oblique and transversalis mus-
cles, following the left index-finger
as it is withdrawn through the in-
guinal canal and finally out of the
external inguinal opening (see Fig.
58). With these the isolated her-
nial sac is grasped and drawn
through the inguinal canal and
through the narrow opening in its
anterior wall-that is, in a lateral
direction from its upper end.
The hernial sac now hangs
through a narrow opening above
Poupart's ligament (Fig. 59.). It is
FIG. 60.
the aponeurosis covering the in-
guinal canal.
drawn out as much as possible, and Sac twisted and laid down external to
then, as Heliodorus did, and as Ball
has recently advised, it is energetically twisted. The sac is, how-
ever, not removed, but strongly drawn down and laid over the

HERNIA.
181
outer surface of the aponeurosis of the external oblique muscle
against the external inguinal ring, and in the direction of the in-
guinal canal (Fig. 60).
By this tension on the sac, as is shown in Fig. 60, the anterior
wall of the unopened inguinal canal, and especially the tense
aponeurosis of the external oblique muscle, are pressed inward
and backward into a gutter.
As the twisted sac lies tensely stretched in this manner, be-
ginning at the upper and outer extremity, deep sutures are applied.
The sutures are passed above the twisted sac, through the oblique
fibers of the aponeurosis of the external oblique muscle and
the underlying muscle fibers of the external oblique and trans-
versalis, through the hernial sac itself and including the ligament
of Poupart beneath it. These sutures-five to seven or more-
bring together also the pillars of the anterior ring, to which the
lower end of the hernial sac is fastened. In case of a long sac, all
that extends below the external ring is cut away.
In this manner a firm and solid pad or roll is secured over the
entire length of the inguinal canal, which forms a better dam
against the
pressure of the intestines than an implanted patch of
skin or periosteum. Furthermore, the peritoneum is drawn lat-
erally on the stretch and firmly pressed to the abdominal wall in
the region of the posterior inguinal ring, where it is held by the
torsion of the sac and the deep sutures. The operation is more
certain when the upper suture can be deeply applied laterally
from the place of entrance of the spermatic cord into the abdom-
inal wall.
We have employed the same method in cases of femoral
hernia in this manner. The sac, having been completely isolated
and twisted as strongly as possible, is drawn through a small
opening above Poupart's ligament, and, in the manner above
described, included in the sutures which are passed through the
pectineal fascia and Poupart's ligament for the purpose of closing
the femoral ring.
This, the latest fruit of an ingenious mind, and a distinguished
surgeon, combines the steps of various operators. It embraces
essentially nothing original, and is based on principles totally at
variance with sound surgical doctrines; for of all the open opera

182
HERNIA.
tions, so far recommended and practiced, this one must be par-
ticularly proscribed, as it possesses all the weak points which sur-
geons have criticised in others without any of their redeeming
features.
The time has come when surgeons should "speak out," and
let their blows fall where they will, when new procedures are
submitted to them for their approval or rejection.
The contributions of this distinguished German surgeon, here-
tofore, have been numerous and valuable, but as to this last essay
on a new operation, it must be said that the cases which require
or justify its performance must be few and rare.
It will be seen by the cuts that the first step is to make a
free incision over the internal inguinal district to the base of the
scrotum, in all complete inguinal hernia. The second requires
the division of all the coverings, down to the sac, until the outer
ring is wholly freed, when the sac is entirely detached and hangs
free. The third step includes an opening through the external
and internal oblique muscles, down to the internal ring, when the
wall is again weakened by the division of the entire canal. The
third and last step is seizing the sac, now free to the internal ring,
and twisting it into a spindle, then transfixing it with interrupted
sutures, and firmly closing in all the outer wall of canal and sac by
securing the sutures, and closing the incision in the integument.
The fundamental objections to this operation, are: 1st. The
enucleation of the sac in old, incarcerated hernia; 2d, The
division of the entire anterior wall of the canal; 3d. The imbed-
ding of the sac in the inguinal canal, for the reason that it is a
foreign body, cut off from its former peripheral circulation, and
being submitted to severe torsion, twelve twists, is almost certain
to either slough or atrophy, and in no way, under the most favor-
able circumstances, possibly compensate for the extensive mutila-
tion, which its transportation to its new abode must entail. Per-
haps, after all, these objections to this and other kindred open
operations, the effects of which have been to secure a homologous
tamponing of the abdominal apertures, may be and are rather
visionary than practical, for it appears from recent writers that
bone cavities may be safely and hermetically plugged with dead
bone, sterilized cotton, or iodoform gauze.

HERNIA.
183
Perhaps the next thing we will hear of will be a silver plate,
or hard rubber plaque, to seal a hernial aperture, as was once
done with shot holes through the cranial vault.
Lawson Tait's operation for the radical cure of hernia deserves
something more than passing notice, not so much because it pos-
sesses any practical value, as that it emanates from the brain of
one who has been an epoch-maker and a breaker of new ground.
The procedure, like most of Tait's best work, is strikingly bold,
and decidedly original. Recognizing the basic principle that
nothing in the way of cure can be accomplished in open operations
for hernia, without opening the peritoneal cavity, this giant mind
conceived the idea of doing the laparotomy at some distance away
from the inguinal district, thus obviating the resulting weakness
which follows so frequently these modern cutting operations over
the rings. Another new principle was added, in drawing up the
hernia from the inside, instead of pushing it from with out, and
applying the sutures and closing the ring from within. The
author acknowledged that he had never employed this new plan
on any cases, except those on whom he had performed a laparotomy
for an abdominal disease, in whom, when a hernia was present, he
always utilized the occasion to withdraw it into the abdomen, yet
he would advise it for all ordinary and strangulated hernia.
Tait's essay presented at the annual meeting of the British
Medical Association, at Bournemouth, in 1891, did not receive the
support of his fellow-surgeons. It cannot be said that the operation
is impracticable, but there are such formidable objections to it that
it is under special and peculiar circumstances only that it is at all
permissible.
The opening of the cavity of the general peritoneum is always
attended with danger to life, and is liable to be followed by ventral
hernia at the site of the scar. Could these objections be overcome,
yet no guarantee can be given that the hernia will not return at
its former site.
If Mr. Tait or some other surgeon can show us how the visceral
fault can be eliminated in hernia by a surgical operation through
the abdominal walls, which will not seriously imperil life, a great
gain will have been made. For with all our modern operations,
the mural element alone is dealt with; while the prime etiological

184
HERNIA.
factors of intra-abdominal capacity and [pressure, with excess
of intestine and elongation of the mesentery, are entirely ignored.
At the late meeting (92) of the Southern Surgical and Gynæco-
AB
AB
M
FIG. 61.
A B-Deep superficial or forcial sutures.
C-Curved or crucial sutures.
logical Society, Dr.
George A. Baxter
presented an opera-
tion which he claimed
was essentially differ-
ent in principle to any
yet performed. There
is, however, nothing
radically new about
the procedure, al-
though the free di-
vision of sound mus-
cular tissue above the
D-Sutures closing the canal and scrotal openings. The sutures internal ring must be
criticized as unwar-
to the lower border of the canal traversing the tissues.
(Baxter.)
rantable as a common practice, as is recommended by the author.
The operation has yet had practically no statistical support.
DALLAS' INSTRUMENT FOR THE CURE OF HERNIA.
Dr. Alexander Dallas, of New York, claims to have devised
an apparatus which will simplify the process and improve the
result in the cure of hernia. By this method the patient is placed
G.TIEMANN & CO.
FIG. 62.
The Dallas Instrument.
on his back, the parts cleansed and cocainized, when a transverse
incision is made through the integuments and the cord exposed.
Now, the instrument is introduced and pressed upward until its
point has passed into and through the internal ring, into the ab-
domen, where the rasp-like surface of the instrument is exposed
and the instrument is withdrawn. This gives rise to irritation
which is supposed to aid in exudation of lymph and occlusion of
the canal. Dr. Dallas tells me that it is simple and always safe,
and is usually radically curative. He denies that it is a derivative

HERNIA.
185
of invagination, as I regard it, and that it is wholly new in prin-
ciple. This instrument may serve a useful purpose, possibly, in
certain selected cases, but we can see many formidable objections
in many others, and can imagine not a few in which its indiscrim-
inate or unskilful employment might work incalculable damage
on the spermatic cord or in the peritoneal cavity, and yet give no
promise of radical cure.

CHAPTER XXI.
OPERATIVE TECHNIQUE IN STRANGULATED HERNIA AND ITS COM-
PLICATIONS, MANUAL AND INSTRUMENTAL.
The dangers attendant on strangulation chiefly arise from:
1st.-Obstruction of the bowel.
2d.-Hemorrhage.
3d.-Inflammation and Gangrene.
INTESTINAL OBSTRUCTION.
One of the most prominent and constant symptoms of stran-
gulation is constipation attended with colicky pains. If stran-
gulation is sudden, vomiting and great prostration are also present.
But this is not always the case. I have known of a few cases, in
which the patient has kept on his feet for one or two days after
the initial colic was first noticed.
As mechanical obstruction in the vast majority of cases is
extra-abdominal, bearing this clinical law in mind when such a
condition is encountered, we will look to the portals of emergence
for hernia. And this examination cannot be too thorough, or we
186

HERNIA.
187
may overlook the seat of impediment, until its discovery is too
late.
Two years ago I was called to see the widow of a physician,
who was supposed to be suffering from enteritis.
She was
being diligently poulticed and treated for inflammation; but
stercoraceous vomiting setting in with threatening symptoms,
I was called in. My first step was to examine for hernia.
None was found in the crural or inguinal regions, but as my
hand reached toward the umbilical scar, it came on a strangu-
lated exomphocele which had been overlooked. As she was now
in extremis, operation was out of the question, and she succumbed
a few hours later.
In 1885 I was attending a man who had intestinal obstruc-
tion. Nothing would open his bowels, either by the mouth or
rectum. I invited Prof. Dennis to aid me. Assuming that our
man had internal obstruction, he was sent to the Ninety-ninth Street
Hospital to be operated on that evening. When Prof. Dennis and
myself arrived, the house surgeon, Dr. Weldon, informed us that
he had discovered a small femoral hernia. Our patient now was
in a bad state to undergo a capital operation, and hence, immedi-
ately after kelotomy, he went into mortal collapse.
Let it be supposed that a hernia has been discovered; when
symptoms of strangulation arise, clearly the course to pursue is
comparatively simple, as the end to attain is to remove the ob-
struction.
Now, the promptness and manner in which this is best at-
tained, will in a large measure depend on circumstances.
With women, in whose sex strangulation is less common,
though terribly mortal, interference must be judicious and prompt,
or else all is lost. For of all operations she seems to bear kelotomy
worst, when strangulation is not relieved early.
The measures of relief for strangulation may be reduced to three.
1st.-Rest.
2d.-Pressure (taxis).
3d.-Incision.
REST.
One, the subject of strangulation, should be at once put to bed,
and be given sufficient morphine to secure relief from pain and

188
HENNIA.
relaxation of spasm; unless there are some special indications, no
topical applications are necessary.
After two or three hours when repose is secured, pressure
may be commenced.
TAXIS.
Taxis is a valuable expedient in strangulation. But it is
capable of doing a vast amount of damage if employed without
discretion. It may be likened to the urethral bougie, which, when
gently and skilfully employed, will more safely and radically
cure urethral stricture than any other known means; yet is capa-
ble in rude hands of not only destroying the passage but life as
well.
So with taxis, moderate intermittent pressure will usually
overcome most strangulated herniæ, and effect reduction. The
application of great force, or very long continued taxis, will not
only be resisted, but will subject the extruded viscera to great
danger. Hence, we need tact, as much as taxis, to succeed. When
a hernia resists taxis we may chill the inguinal region with cold
douching or iced applications applied at short intervals.
Quite precise rules have been laid down in different text-
books for the successful and safe application of taxis, in general
surgery. But, practically, they have little or no application. In
those directions laid down for the student and practitioner, a
considerable degree of importance is attached to the manner in
which the intestine is manipulated in the different phases of
hernia; i. e., that the return of the hernia must be just the reverse
of its descent, etc.; that the pressure must be applied in different
directions in order to clear the various curves and angles, which
the viscera take in the evolution of the hernia. These directions
I have never found of any practical value. Indeed, when it is re-
membered that in the vast proportion of strangulated hernia, the
greater part of the volume consists of effused serum, and the sac,
the integral parts of nearly every hernia are almost invariably
adherent, and hence entirely irreducible, attention must be
directed to something more than the bowel.
The cardinal points to be remembered in the application of
taxis are not to employ too great force, nor make its application
too protracted. If one séance fails, nothing will be lost by waiting

HERNIA.
189
awhile, when, often, on the second or third effort, the mass will
return with surprising ease. There is a singular and striking an-
alogy between the erratic, spasmodic action of an organic urethral
stricture and the spasmodic grip of a hernial constriction. At
one time the stricture is wholly impassable to the finest bougie, of
even a hair's diameter, while after an interval of rest, by a little
coaxing, an instrument of considerable diameter may readily glide
on to the bladder. And likewise with a strangulated hernia, our
approach must be gentle, gradual and intermittent. Moderate,
safe taxis should be unattended with pain, and hence, when manip-
ulations are of such violence as to make our patient "cry out
with agony, we are doing harm.
The use of pulmonary anæsthetics, as an accessory means in
reducing a strangulation, should be condemned as a general ex-
pedient.
It is well before taxis is commenced to empty the rectum and
colon, and clear the stomach by a free emetic. These measures
reduce inter-abdominal pressure, and effect, more or less, muscular
relaxation.
How long can one safely permit strangulation to remain with
safety to the patient?
This will depend. Though, in a general way, it may be said,
when there are no very pronounced constitutional symptoms,
from twenty-four to forty-eight hours is the maximum in men,
and in women not more than twelve hours at the most.
If we incautiously administer morphine, its narcotic action
may mask various symptoms; hence, except in the initial dose,
to secure primary relief at the moment of strangulation, if given
at all afterwards, it should be in very small doses.
The symptoms which portend great gravity are pronounced
bodily prostration, reverse of the peristaltic wave of the intes-
tine, with fæcal vomiting and immense ballooning of the bowel.
These symptoms should be anticipated by surgical interven-
tion. But the medical attendant is often so hampered by divers
considerations, that often the opportune moment for prompt action
is past before he decides to turn the case over to the sur-
geon for operation. If the patient be a person of means, the
physician may hesitate, fearing that the presence of the surgeon

190
HERNIA.
may imply a want of skill on his part, or that he may lose the
family through it. With the poor, their deep-rooted horror of
all hospitals prevents them from yielding until the last moment,
at a time when their lives are greatly endangered by transporta-
tion itself.
In our times, when kelotomy of itself is comparatively a safe
procedure, and by combining radical measures with those for re-
lief of strangulation, in a general way it may be laid down almost
as an axiom that in all cases in which taxis fails, or serious symptoms
threaten, twelve hours is the maximum time to wait, when immediate
operation should be advised.
Every practitioner should be competent to perform a kelotomy
for strangulation.
By this it is not to be supposed that all should be equally
proficient, but that all, in an emergency, should be capable of im-
mediately relieving constriction and releasing the bowel.
PREPARATIONS AND DETAILS IN OPERATIONS FOR STRANGULATED
HERNIA.
The technique of operations for strangulation have, during
the past fifty years, been enormously simplified and revolutionized.
The change dawned on the profession with the discovery of
anæsthesia, the tolerance of the peritoneum, the introduction of
asepsis, and the crowning achievement of all cocaine analgesia.
There are but few things necessary in operation for strangu-
lation. They are: 1st. Good light. (At night I prefer candle
light to any other.) 2d. Plenty of pure water. 3d. A warm,
clean room. 4th. Assistants, medical, if possible; one at least, if
not one or two intelligent, cool-headed women.
Our operative arsenal is simple. A good table, towels, sponges
with dressings. For instruments we need but a scalpel, a long-
curved scissors, artery clamps (two or three), suture material,
needles, retractors and needle-holder.
We have mentally calculated on contingencies and are pre-
pared to meet them.
Now we are ready for our patient. The operative areas have
been properly prepared, and we have complied in every detail, as
far as possible, with what modern surgery demands in the way of

HERNIA.
191
aseptic precautions in their broadest sense, and we are ready to
commence our journey to the hernial envelope or the cavity of
the peritoneum. The objective point, let it be remembered, is the
constriction at the neck. All is lost if this is overlooked. Now,
with amateur operators, who cut in an emergency, I would advise
them to adopt somewhat different tactics to those who are com-
monly accustomed to perform capital operations.
*
It will be noted in this monograph that very much has been
said on the subject of the sac, and that in all the older treatises on
the operative surgery of hernia it occupies an important position.
Yet, notwithstanding all this, I would recommend the general
practitioner not to worry himself in the least about it in strangu-
lation cases. If the sac were a free, isolated pouch-the impres-
sion which usually prevails-if its presence were constant, or if
strangulation always occurred within it, then, indeed, a familiar
knowledge of its anatomical structure would be of prime import-
ance. But as a free sac it has no place in the hernial anatomy of the
body; it is almost never free from adhesions; it is not always
present in strangulation, and it is yet a disputed question whether
the point of strangulation is within it or not.
The first step then after a free incision is made, carrying this
from the internal ring downward from four to six inches, is to
divide and gently separate the parts, layer after layer, as one would
open the coats of an onion, until he comes down on the imprisoned
viscera.
All hemorrhage being staunched, the index finger of the left
hand is introduced over the nude viscera, which are gently
pressed and everything divided over it, until its tip is arrested at
the point of strangulation. Now, at this stage, the older opera-
tors would introduce a grooved director and split the annular
constriction with a probe-pointed hernia knife, having due regard
in the meantime in inguinal hernia for the internal epigastric
artery, which latter vessel they seem to have had a morbid fear of
dividing.
For convenience in operating and safety I have for some
time, discarded the probe, scalpel and grooved director, and instead
of making one incision with a blade,.I employ a scissors and
notch the constriction in different directions; in other words,

192
HERNIA.
when the precise seat of strangulation is reached and amply
exposed, I take up a common dressing forceps, and seizing the free
edge of the strictured ring, draw it downward and nick it with
the point of a blunt-pointed scissors, in one or more places, until
I am assured that resistance is amply overcome. To assure my-
self of this, I again re-introduce the tip of my finger and make
traction in the direction of the stellated gaps in the rings, when I
withdraw it and attempt reduction. If the bowel refuses to re-
turn I make a few more nicks with the scissors and again dilate
the ring, when all succeeds and the hernia is reduced.
This multiple nicking of the ring is a great advantage over
a single clean deep cut, for by it one is enabled to avoid opening
the deep epigastric artery. Cut in what direction we may, the
ring is not weakened to that extent it is when its fibers are severed
completely through, with one gash through its fibers. When the
free border is well drawn down with the forceps, as we close the
cutting edges of the scissors, the entire operative field is under the
eye, and should hemorrhage occur, it can be subdued in an instant
by the same measures which we would employ should it occur
elsewhere.
After the intestine is reduced, the finger should be passed
into the peritoneal cavity, and all adhesions in every direction
freely liberated.
It is of vital importance, before the wound is closed, to be
positive that liberation has been ample and complete, or else the
symptoms will persist, and our patient is lost.
Now that the hernia is reduced, a drainage tube is fixed in
the lower angle of the wound, and the parts sewed up en masse
with a continuous suture. When the case goes well, as it should,
after the second day the drainage tube is removed and another
dressing applied. This will be the last, and should remain in for
a week or ten days.
This operation is one of emergency, which is recommended
when the object in view is relief of strangulation.
It is recommended for its safety and simplicity in every phase
of strangulation wherever situated. Certainly, it is not a com-
plete measure in any sense, and would not fulfil the requirements
of advanced surgery as a measure of perfection, but it is recom-

HERNIA.
193
mended only in imperative cases and with the inexperienced. After
recovery a truss must be worn, or the hernia may return. But
this may happen after any of our operations which have been
praised the loudest.
COMPLICATIONS IN STRANGULATED HERNIA.
If a large extruded mass in the inguinal region becomes
strangulated in incision, we may come into a double inguinal
(plate No. 63), of which but one has become strangulated. In this
instance the condition of the
overlying, investing, tunics will
indicate in which the obstruc-
tion is lodged. In old, incar-
cerated hernia, undergoing
strangulation, we must be pre-
pared to deal with possible ad-
hesions between the viscera and
their investing pouch (the sac),
and in this species of femoral
hernia find the omentum firmly
adherent to the femoral vein.
Such a case was sent into my
service at the hospital, in June,
1891. The physician sending
her in, supposed that she had
an internal strangulation, and I
was sent for to perform a laparot-
omy to relieve it.
FIG. 63.
Direct and Indirect Inguinal. (Maglise.)
In examination I found that she had a large mass, over the
right saphenous opening, which she assured me she had from
childhood, and which our house surgeon, Dr. Hammond, from its
outline and consistence, assumed was an enlargement of the lym-
phatic glands.
My examination, however, convinced me that it was a hernia.
At any rate, as she was in a collapsed state, a laparotomy was
quite out of the question. Cutting down under cocaine, we came
on to a mass of omentum, which had no sac, but was so intimately
adherent to the saphenous vein that its isolation necessitated
13

194
HERNIA.
rupture of this vessel. This, however, was easily sutured, and after
liberating a small knuckle of intestine, nipped in the septum
crurale the parts were closed in, when she made a good recovery.
The most formidable complication in all operations for
strangulation, is gangrene of the bowel.
In many cases of strangulation in which we operate we will
come on to a suspicious intestine. Its wall has a dark, chocolate
hue, and it has parted with its pearly, glossy surface. It is want-
ing in that soft, resilient feel, of the normal intestine.
In the presence of such a condition the safest course to pursue
is to return the bowel to the cavity of the abdomen, at once
fix it in the wound, make an artificial anus, do an enterotomy, or
enterectomy.
Sir Astley Cooper advised that when we came to an intestine,
the vitality of which was in question, the best place for it was in
the cavity of the peritoneum. This was the generally accepted
course, until Professor Nicholas Senn, in 1887, at the International
Medical Congress, produced his great work on experimental intes-
tinal surgery on the dog, and recommended a revival of intestinal
anastomosis in man for conditions causing obstruction of the in-
testine lumen.
Since that time many operations have been performed for
gangrenous intestine in strangulation.
Those operations have been immediate and consecutive; i. e.,
some have resected the bowel at the time of hernial operation,
while others have made an artificial anus, and waited until the
patient had survived the shock of the primary operation before
attempting resection of the intestine and reconstruction of its
lumen.
It was hoped that with the new devices for rapid anastomosis
that resection of the suspected part would be a simple and rapid
procedure, so that we might always assume that nothing except
the healthy intestine would be replaced. However seductive and
promising the theory of intestinal anastomosis was, practice
has abundantly demonstrated that it is one of the most formidable
procedures known to surgical art, when applied in strangulation
cases. Indeed, there are almost insurmountable impediments in
the way of its performance; and, in fact, in those cases in which a

HERNIA.
195
bursted, necrotic intestine has been found and an immediate anas-
tomosis has been performed, there are but few cases on record
which have survived. When local changes have so far advanced
as to induce complete gangrene of the constricted intestine, great
constitutional depression is always present, which few rally from
after the shock of a capital operation.
Unless the bowel has given way and fæcal extravasation is
present, the operation of primary resection of the intestine is an
unwarranted procedure, in but very rare cases.
I have many times returned the strangulated intestine when,
at the point of constriction, the pressure had cut a ring through
the serous coat, and the constricted coil presented a most unpromis-
ing aspect; yet in none has extravasation followed, and most of
them recovered. I am acquainted with no recorded case of re-
covery, in which a primary resection and enteroraphy have been
performed after gangreneous perforation had occurred in the stran-
gulated intestine, within the abdomen.
At the late meeting of the American Medical Association
(Detroit, May, 1892), Dr. J. Rausahoff, of Chicago, presented one
of the fullest and most valuable contributions on this subject
(Treatment of Gangrenous Hernia), from which I will give such
parts as are pertinent to this part of our subject. He reported
having performed 27 operations for strangulation, of which 4 were
grangrenous, 3 enteroceles, and one epiplocele. It does not appear
that any of them had ruptured at time of operation, but all were
suspected. He reported 170 operations for strangulation, in which
real or suspected gangrene was present in 25. From various
operators in the past twenty years 486 cases of strangulation, 14
per cent. were gangrenous or suspected.
Dr. Rausahoff reported his own four in detail.
His first case omental. Gangrenous part ligated and cut off.
Result: death in twenty-four hours.
Second case: Was restrained from operating because he was
afraid the patient would not safely survive shock, and because he
was ignorant of the precise pathological state in the sac. Gan-
grenous perforation discovered only after death.

196
HERNIA.
Third case.
A gangrenous patch was discovered in the wall
of the intestine. Intestine was reduced, but the suspected part was
fixed against the incision in such a manner that should perfora-
tion occur, the fæces could make their way outward, unhindered.
Perforation occurred, though after a time the opening spontane-
ously closed.
Fourth patient, a woman of 56. Here he resected fourteen
inches of the suspected intestine, bringing the ends into immediate
contact. Patient recovering; alive and well nineteen months after.
It seems that Raushdor was the first to resect the gangrenous in-
testine successfully, in 1727. Poulsen has reported twenty-seven
cases with four recoveries. Of thirty-five so treated in St. Bar-
tholomew's, but four were saved. (Brit. Med. Journal, June, 1891.)
In England, Baker, McCormick, Banks and Treves oppose
immediate resection of the gangrenous intestine.
In America, McCosh, Richardson and Dawbarn each reported
a successful case. The Germans are divided in opinion on the
subject of immediate resection, while the French generally op-
pose it.
The question then lies between one of three things, when we
cut down on an intestine suspected of gangrene, as to what shall
be done.
1st.-Shall it be immediately returned?
2d.-Shall it be fixed in the wound and an artificial anus
established?
3d.-Shall it be resected, sutured and returned?
It must be remembered that the suspected intestine alone, is
being now considered.
My experience would incline me to recommend the first al-
ways as a routine practice, particularly with those unaccustomed
to performing capital operations, or those who cannot command
every possible facility to favor a successful effort, and that means
a great deal.
My next choice would be the second. For by it we are given
time to prepare and observe how our patient rallies from the first
operation.
The third should be regarded as an extreme and last resource
Truth, candor and personal experience compel me to regard the

HERNIA.
197
resection of the intestine for gangrene as one of the most desperate
undertakings in surgery. In the hands of the most skilled and
adapt it is a most trying ordeal, and when it succeeds such un-
pleasant sequelæ may occur as to destroy the permanency of cure
Perhaps if the "anastomatic button" of Dr. J. B. Murphy,
of Chicago, which promises to reduce these operations for intestinal
continuity to a few moments, will accomplish what is promised
for it, resection may become an established procedure in gangren-
ous hernia. Perhaps I cannot do better in closing this part of
the subject than quote further from Dr. Rausahoff, who, by the
way, is an advocate of primary resection, who says: "Whan delay
has brought the patient to the verge of collapse, and when shock
from prolonged anæsthetics cannot be ventured, that must be done
which most readily gives relief to strangulation; for whatever be
the procedure adopted in the condition indicated, the result will
probably be the same: death within a few hours or days."
With these sentiments I am in hearty accord. My own ex-
perience with, not suspicious cases, but positive gangrenous per-
foration, and one for resection of a suspect, is limited to four. The
first was a woman in profound collapse, so that but little ether
could be given. Coming on the sac, the intestine was found
broken down by necrosis and fluid fæces, with gas welling up
through the incision, and in a moment she was dead on the table.
The second was in a young man, in whom the bowel was
ruptured, after it had been down two days by the medical attendant
in forcible taxis.
When I cut down on the sac it was found full of blood and
fæces, the bowel having slipped up into the peritoneal, cavity,
carrying the incision up through both rings, the abdomen was
found full of leaking fæces. Our man survived scarcely an hour
after the mortified intestine was found and fixed in the wound.
Third case, another young man, in whom a strangulation was
actively poulticed for an abscess before he was sent into hospital.
When I saw him he had pronounced septicemia from fæcal absorp-
tion. Under cocaine the tissues were opened, when it was found
that the bowels had burst, the fæces making their way through
the sac into the subcutaneous tissues. It was hoped that as the
artificial anus would permit a free vent to the pent-up fæces, he

198
HERNIA.
might overcome the toxæmia, but we were disappointed, and he
died on the seventh day.
Fourth case. This patient was a middle-aged man, who had
strangulation but ten hours. He entered the hospital in the
middle of the afternoon. When I was notified of the case, not
feeling well that day, I sent word to the house surgeon to do
the operation for strangulation. Three hours later, feeling a
little uneasy about the case, I telephoned, inquiring how the
patient had survived the operation, etc., when I was rather con-
founded to hear that the operation was not then completed. I now
left for the hospital myself, reaching there about a half an hour later,
and when I entered the operating room the scene presenting was
enough to startle and confound the stoutest. Our young internel
by recent reading the current medical literature, was imbued with
a notion that modern experimentation had so simplified intestinal
surgery that it needed no apprenticeship or special practice to succeed
with it, had cut away nearly three feet of this man's bowel. Indeed,
there was nearly a wash-basin of viscera, steaming fresh in a vessel,
when I entered. But now the trouble came, the proximal divided
end was so close to the fixed cæcum that he had found it quite impos-
sible to dam back the fæces, or bring the separated edges together.
Blood and fæces issued promiscuously from every direction, so
that our young operator was at his wit's ends, and badly rattled
when this stage of the operation was reached.
It was clearly apparent that if the blood torrent was not
promptly arrested death must quickly end the scene. Hence,
without any thought of antiseptics, after quickly washing my
hands, I pulled the bleeding mesentery into the wound and clamped
off the vessels. Thus, by carrying the incision further up, I was
enabled to restore the continuity of the wound and complete the
operation.
Our patient survived three days, sinking finally from second-
ary shock.
The suspected intestine which was cut away, except for one
or two small patches of necrosis, which occupied only the peritoneal
coat of the outer wall, was sound and everywhere intact.
Indeed, for one to undertake an enterorraphy on a gangrenous
hernia, without ample experimentation on the lower animal, and

HERNIA.
199
a thorough, practical knowledge of the physiological anatomy of
the intestine, its relation and appendages, is little short of crimi-
nality.
POST-OPERATIVE
TREATMENT IN STRANGULATED HERNIA WHEN
TREATED ON THE LINES HERETOFORE INDICATED IN EMERGENCY
CASES.
It will be noted that the simple rudimentary technique, so far
described for strangulation, is intended only for the purpose of re-
lieving the constriction and averting immediate danger to life.
However, for all practical purposes, particularly in old people or
those following sedentary pursuits, it is quite complete enough,
unless there are complicating elements present, providing that
thereafter a truss is constantly worn. But in our times an experi-
enced operator is presumed to do something more than divide the
constriction. In fact, in all ordinary cases, he is expected always
to combine measures for radical cure with relief of strangulation.
As the technique of these are essentially the same in strangulated
and the non-strangulated, they will be considered in the following
chapter.
Immediately after operation for strangulation the patient
should be returned to a warm bed.
If the operation has been performed at the right stage, and
liberation of the intestine has been complete, there should be no
severe pain. On the contrary, a great sense of relief should be
experienced. Vomiting should wholly cease, tympanitis subside,
and bodily strength return. The patient should be given nothing
but a bland, fluid diet during the first forty-eight hours. The
less, the better. On the second day, if a drainage tube has been
employed, it should be removed, when other final, permanent
dressing should be applied, not to be disturbed for ten days or two
weeks, when union should be entire. I think it is well, in all
cases, to keep the patient in bed for four weeks, in order to permit
of entire consolidation of the deeper layers before permitting the
weight of the superincumbent viscera being thrown on them when
the upright attitude is again assumed.
Unless there is some special reason, laxatives should not be
given after operation. At this time it is important to give nature

200
HERNIA.
repose, rest. The bruised, traumatized bowel needs undisturbed
quiet, and when the proper time comes, will empty itself without
being whipped into action, as it were, prematurely by irritants.
On the contrary, in those suspicious cases, properly so called, opium
should be given freely, until we are quite certain that the suspi-
cious plagues in the serosa of the intestine have taken on adhesive
inflammation, and the danger of leakage on the re-establishment
of peristalsis is past.
In any case of strangulation in which there has been a per-
sistance of grave symptoms, which indicate a continuance of
obstruction after operation, it must be assumed either that our
patient has developed general peritonitis, or else that the opera-
tion was incompletely performed, and a mechanical stenosis yet
remains. The following is an illustrative case:
During the past month of October ('92) I was sent for to per-
form a kelotomy for strangulation in a young man. It was mid-
day when the message came and I was not at home.
The physician in attendance, a gentleman of superior acquire-
ments and considerable experience, believing that it would be
unsafe to delay the operation until my return in the evening,
invited in a neighboring practitioner, and with his assistance per-
formed an operation. This was on Friday.
At noon, the following Sunday, another message came for
me to see the case, when a condition was discovered fully detailed
in a preceding chapter. The case is re-introduced here for its per-
tinency, as illustrating how a life may be lost in those operations
when incompletely performed; as in this case must have been the
result, had the unopened sac and undivided constriction not been
discovered and properly treated when the patient was on the
verge of the moribund state. When general peritonitis follows a
kelotomy, in nine cases out of ten it must be charged to perforation.
When it does occur, that paretic state of the intestine which is an
integral part of the malady is apt to delude the unwary into
regarding it as a mechanical obstruction, and instituting a line of
surgical interference both mischievous and dangerous for its relief.
But, should it appear with the continuance of grave symp-
toms, that an impediment to the intestinal contents remained,
then we must at once seek out the point of obstruction, re-entering

HERNIA.
201
the cavity of the peritoneum by reopening the original in-
cision. Sometimes when the intestinal coils have been reduced
en masse, there may have been a matting or webbing of their
walls just inside the internal ring, which may be easily detached
with the finger with in the cavity of the peritoneum. These con-
secutive operations should be painless and bloodless, and per-
formed with all possible haste. Hence, for this secondary meas-
ure, as for all hernial operations of every description, one should
make in its largest possible measure ample and thorough prepara-
tion. Preparation of himself, his instruments, dressings and his
patient, before the first step of operative manual is commenced.
COMPLICATIONS IN STRANGULATED HERNIA.
It is well to remember that a hernial sac may contain any of
the floating viscera, and that in extruded omentum, in epiploceles,
neoplastic changes may occur in its adipose or glandular elements,
when we will encounter lipomata, or sarcomatous tumors.
Some time ago (two years) I gave my house-surgeon permis-
sion to operate on the next case of strangulation which came into
my service. Soon after, a young Italian was admitted. When
notified of his entrance, the house-surgeon was directed to proceed
with the operation. Inquiring by telephone, in the evening, how
the operation succeeded, I was informed that, when the second
stage of the operation was reached, such a complex condition of
things was discovered that it was considered best not to advance
further with the operation, but to close in the primary incision
and wait until I came up.
The house-surgeon further added that since the man came
out of ether, the vomiting had ceased and he was feeling very
much better. The following day, when I saw him, his colicky
pains had disappeared and his general condition was good. Re-
opening the incision of the day before, I came down on a large,
sarcomatous mass which enormously distended the scrotum,
though it had not penetrated the tunica vaginalis, nor involved
the spermatic cord. Following up its pedicle, it was seen to be
continuous with a fringe of the omentum extending into the peri-
toneal cavity. This was ligated high up and cut off, when the
large pyramidal mass was rolled out of its bed in the inguinal

202
HERNIA.
tissues. On microscopical examination it was found to consist.
mainly of multi-nucleated giant cells. The wound healed
promptly.
Dr. W. H. Link, of Petersburg, Indiana, has called my at-
tention to the sparcity of hernia in many fat men. I am not
prepared to say that males with a large "corporation" are less prone
to hernia than their leaner brethren, but in my experience with
women the fat are more liable to the infirmity than others of their
sex. However, fatty tumors are not uncommon in men of every
build. And not unfrequently, when a person is the subject of one
in the inguinal region, and is suddenly taken with renal, gastric,
or hepatic colic, if the medical attendant is not circumspect and
guarded, he may imagine that his patient has a strangulated, in-
carcerated hernia, and hasten to do an operation for a condition
which does not exist. Such a case was sent into the Harlem
Hospital for operation in 1888.
After the house-surgeon, Dr. E. A. Williamson, had given
the patient a small hypodermic injection of morphine, all the
symptoms of strangulation vanished, though the hernial tumor
and the overlying cellular tissues, which had been rather roughly
handled, in forcible taxis, had not reduced in volume.
The mass was very hard and well calculated to deceive the
inexperienced. The clinical history convinced me that it was not
a hernia.
Cutting down on it, it was found to be a benign fibro-lipoma.
which had developed in the loose cellular tissues along the cord,

CHAPTER XXI.
OPERATIVE TECHNIQUE FOR INCARCERATED, NON-STRANGULATED, REDU-
CIBLE HERNIA WHEN TREATED BY OPEN INCISION.
At the outset of this important part of our subject, it cannot
be too plainly stated, that no special operation will answer in
every variety of any one given type of hernia, wherever situated.
Hence, in almost every case our technique must be so adapted as
to meet special requirements.
In all operations for inguinal hernia, we should carry our in-
cision through sound structures only to such an extent as special
indications require. This is of cardinal importance to observe.
It is certainly to be hoped that no one can so far deceive himself
as to believe that a united fractured bone, a divided tendon or
muscle, ever possesses the same flexibility and strength as in their
normal, unbroken continuity. For scar tissue, nature's solder or
cement substance, a derivative of connective tissue bears little or
no analogy in tensile power or elasticity with normal structures.
Another reason why we should cut as sparingly as possible
through tissues in continuity is because, as a rule, the wider the
203

204
HERNIA.
breach when the open incision is made, the more unmanageable is
the hernia in the event of relapse.
MANIPULATION OF THE SAC.
Before the special disposition of the sac is discussed, it may
be well to have a clear understanding as to what we wish to ex-
press when we speak of this adventitious pouch. Hence we in-
quire: What is the sac?
Judging from the various diagramatic illustrations of dif-
ferent operations and descriptions of different surgeons, we must
conclude that all have not quite agreed on what constitutes a
hernial sac.
One would suppose, from the average description of
this structure, that it is usually a mere pouch-like bag of serous
membrane, which slips up and down through the inguinal canal,
and which, every time we reduce a hernia, it, with the viscera,
returns to the cavity of the peritoneum.
All this, however, is very far from the truth. The sac is
something more than a serous membrane, for its fascia propria,
sometimes called the fascia Cooperi, is a dense fibrous substance,
separated from the serous by a cellular membrane, but always in-
timately adherent to it.
The serous investment of the viscera, except in recent cases
of strangulation of primary hernia, is always more or less adhe-
rent to the circumjacent tissues, the tunica vaginalis, and the
tubular elements of the cord. Hence, in the vast majority of cases
of inguinal hernia, it is absurd to speak of reducing a sac, which
is every where adherent, which can in no way possibly be isolated
and reduced without a free open wound and a tedious dissection.
The elements of the cords are often imbedded and quite intimately
incorporated between the different layers of the sac. Hence, un-
less its investments are peeled off with most delicate attention,
the cord must suffer serious damage. When this is properly ac-
complished, the serosa must be exposed by a linear incision running
parallel with the long axis of the tumor, and be stripped by a
process of decortication, which gives us, not one, but two sacs;
one, the large, fibrous pouch from which the serous investment
has been raised, and one, the serosa, or true sac.
Now, should the sac en masse, without this dissection, be

HERNIA.
205
isolated or cut off, the neural and vascular supply of the testis can-
not escape serious injury.
When an operation is performed in which only the serosa is
preserved, free and deligated above, the thick, fibrous investment
of the sac, an integral part of it remains in the incision. Should
this fibrous-the outer tunic of the sac-layer be cautiously sepa-
rated from the cord, it can be cut away or it can be reeled up
and fixed anywhere along the canal, as a tampon. If a her-
nia can be permanently reduced, there would seem no good reason
for its further retention, as it should have no further purpose to
serve. Unfortunately, operators have not been clear, in all cases, in
detailing the precise toilet of this infundibular process of the fascia
tranversalis. But those who oppose resection of the sac, base their
objections in clear and unmistakable terms. First, because of
the danger to the ultimate nutrition of the testis in isolating the
serosa from the separated strands of the spermatic cord; and, sec-
ond, because, when it is retained in the event of relapse, this dense-
tissue serves once more as a protecting and limiting envelope to
the descending viscera.
Let not the new beginner perplex himself in searching for
parts which often do not exist-those independent investments of
the anatomists. In some he will search in vain for the spermatic
fascia, when time, degenerative, and atrophic changes have assim-
ilated all into one homogeneous, dense, inseparable wall of tissue.
In ancient, very large, old scrotoceles the investments of a di-
rect and an indirect inguinal are quite indistinguishable; as all
the ordinary landmarks are lost and pathological degeneration
has wrought such changes that the remnants of normal structures
have so altered as to be quite beyond recognition.
Nevertheless in order to perform an open operation with a
high cervisectomy, the serous envelope must, if possible, be freely
isolated. If not entire, then as completely as possible.
In reducible hernia it is always important if possible, to-
operate while the viscera occupy the sac, for they steady it, and
enable us all the more readily to proceed with the work of de-
cortication.
The importance of detecting the serous sac in all inguinal
hernia, has been dwelt on at considerable length here, because its.

206
HERNIA.
recognition and proper manipulation is practically the keystone to
the arch in all hernial operations in which it exists.
It should not be forgotten that we may find two serous sacs
in an operation, or none at all. In the first, when the intestine
pushes down before it an investment of omentum, this is seen. In
the congenital hernia of anatomists the viscera tumble directly
into the tunica vaginalis, side by side with the testis, when, of
course, no independent sac is present.
As there is no important tubular structure in the female in-
guinal canal (the canal of Nuck), the operation and isolation of the
serous investment of their hernia is not attended with the dif-
ficulty or danger which we encounter in the male.
But, in the inguinal hernia with a woman, as all her genera-
tive system is internal, a prolapse of any or many appendages
of it, often make their way into an inguinal hernial sac. Thus,
in a young lady sent to me, for the treatment of a small, but very
painful inguinal hernia, when the sac was opened an adherent
ovary came into view, and was excised after its artery and the
pedicle were ligated. Up to this time her life had been one of
FIG. 64.
Hernia.-Dr. Barber's (ase.
misery and pain from wearing a truss.
Always during her menstrual epochs,
the protrusion became swollen and ex-
quisitely sensative, giving her great
distress, until menstruation ceased. A
most remarkable case is recorded in
the "American Journal of Gynæ-
cology," June, 1892, by Dr. D. P. Bar-
ber, of Saginaw, Mich. The patient
was a woman, 46 years old, who con-
sulted the doctor one year before, for a
protrusion in the left inguinal region,
which was growing larger and more
painful, so that a truss which she had
worn for years before had to be cast
Exsected Uterus in a Strangulated aside. As she complained of vague,
indefinite pains in the uterine and
ovarian regions, the doctor made a vaginal examination, but could
find no uterus. She was a married woman, though had been

HERNIA.
207
barren; menstruating, however, with great regularity. An operation
for cure of her hernia having been decided on, when the mass was
exposed, it was supposed to be a new growth; hence, ligating it
high up it was cut off, when it was found to consist of a portion of
the left broad ligament, an ovary and the uterus. The patient
made a good recovery, and was entirely relieved of her former
distress.
Boyer (Tome IV, Chirurg. Malad.) cites several remarkable
and extraordinary cases of the escape of the viscera in males. He
had seen himself four in which the bladder had escaped through
the inguinal apertures in males, in which it had been cut on and
opened, under the supposition that it was the sac.
In one case of a young artillery officer he performed a lithot-
omy, and removed a stone through the inguinal incision from
the extruded bladder weighing three ounces; and cites several
similar cases in the practice of others. The most marvelous of
all which he records was the case of a lady of rank, who con-
ceived after marriage in a herniated uterus. As time went on the
hernia increased in volume until, as the time for her accouchment
approached, the enormous hernia, now with its great weight and
mammoth proportion, totally disabled her from exercise. At
term a living infant was delivered through the divided hernial
walls, but, as a great quantity of blood was lost and inflammation
followed, the mother sank on the third day after delivery.
MANIPULATION OF THE CONTENTS OF THE SAC WHEN THIS IS PRESENT
Having opened the sac and liberated the adhesions to it from
the contained viscera, if such exist when the intestine protrude,
there is but one course to pursue, which is to return it into
the peritoneal cavity. Should, however, the hernial contents
be omental, then there are two or three different courses open
to us.
The first is to reduce this as the bowel within the ring.
The second is to draw it and the slack in the canal well
down, ligate it after multiple transfixion, cut it off after the plan
of Championniére, and permit it to return.
The third is to fix its pedicle in the canal or ring as a tampon,
and close the integuments over it.

208
HERNIA.
The first is the simplest course, and the most secure from
immediate danger or ultimate unpleasant psycical phenomena.
By this procedure the danger of hemorrhage from the stump
is obviated, as are also the chances of septic infection diminished.
But it is not to be practiced, for the reason that it is one of the
original ætiological factors of the infirmity. It lies just inside
the ring after reduction, only waiting for another favorable oppor-
tunity to re-descend. The second, when carried out with extreme
attention to detail, is the most rational and successful. But very
great care must be exercised in ligating the neck to securely close.
all the vessels in the omentum. If the vessels can be isolated and
separately ligated without including the nerves, it would be the
ideal procedure in hernial treatment of epiphoceles. For by it
two important, fundamental, ætiological factors of the infirmity
would be removed. First, it reduces by excision of the omentum
intra-abdominal pressure; and, secondly, with its complete excision,
the visceral element in causation has been permanently eliminated.
The third, omental tamponage, entails excision of redundant
omentum, while its pedicle is imbedded in the canal or ring.
This procedure I have once utilized to advantage in a case, and
many other similar, scattered cases are recorded in the modern
literature of hernia, a recapitulation of which would serve no
useful purpose at the present.
RADICAL CURE OF FEMORAL HERNIA.
The technique in operations for strangulation and radical cure
in femoral hernia is essentially the same as for inguinal, except
that while it is possible to wholly obliterate the inguinal canal, as
when castration is practiced, this is quite impossible with the
crural canal or saphenous opening through which the femoral ves-
sels pass to and from the lower extremity.
It is a matter of common observation with femoral hernia
that, as a general rule, it is more incoercible to the truss than in-
guinal. It is also well known that it is a hernia in which relapse
is almost invariable, regardless of how treated by radical meas-
ures.
In operations for radical cure in this situation, Gerdy's prima-
tive invagination and all its derivatives are eutirely inapplicable.

HERNIA.
209
The operation which should give the greatest success as a radical
measure in enteroceles is the tamponage of the canal with the
folded sac.
The sac here can be rapidly and completely isolated,
though when imbedded in the canal it may give rise to ulceration
and slough away, as it does sometimes in McEwen's operation for
inguinal hernia, yet its results, from a theoretical standpoint at
least, should give the best results. My own experience in femoral
hernia, in which I have attempted radical cure with relief of
strangulation, is limited to four cases. One died. Two on whom
I operated for strangulated femoral enteroceles had relapses within
six months. In one, the last who had an epiplocele, the cure was
complete and permanent after two years. In all femoral epiploceles,
when we are assured of their real anatomical character, and they
are painful and uncontrollable, a radical operation may at times
effect a permanent cure.
TECHNIQUE IN OPERATIONS FOR RADICAL CURE OF FEMORAL HERNIA.
A large, free incision is necessary in operations for radical
cure, or strangulation in femoral hernia. In the majority of cases
we will find that the sac has formed intimate adhesion, when it is
present with the femoral vein and the septum crurale. In women,
and in fat men, we will find the constriction in strangulation at
a great depth from the surface, and in cases in which radical cure
is attempted, owing to the extreme obliquity and depth of the
canal, the neck of the sac is manipulated and deep sutures are in-
serted with considerable difficulty.
In all cases of large femoral hernia it is a good practice to
close the upper free borders of the falciform process with the
fascia lata, and in this manner reduce and narrow the diameters of
the widely gaping saphenous opening, thereby in a certain measure
constructing a barrier against future relapse. In all cases of opera-
tions for this phase of the infirmity, the truss should be immedi-
ately applied on leaving the bed, and worn at least for six
months.
This operation in femoral hernia is adopted in the majority
of cases, rather for the purpose of rendering a painful, unmanage-
able hernia comfortable and coercible than to expect an "out and
out" permanent cure. The former usually succeeds, while the
14

210
HERNIA.
latter with this type of viscual protrusion has not yet been realized
in but few exceptional cases.
RADICAL OPERATIONS FOR UMBILICAL, VENTRAL, AND LAPAROTOMY
HERNIA.
Pathological hernia are common in the walls of women's ab-
domens, though they seldom occasion much inconvenience or
danger to life. But they may become strangulated, or they may,
as we have seen, burst and bleed, or ulcerate. Besides, they may
occasion so much inconvenience, in rare cases, as to render one's
life miserable, and require something more than palliative meas-
ures to control them.
In the adult, umbilical, or ventral hernia, truss pressure is
not efficient. But as none of these operations on the abdominal
walls for hernia can promise a permanent cure, or are free from
danger to life, they will be undertaken only as an extreme resort.
Our patient in these cases is prepared as for a laparotomy,
which this operation practically is, and let us undertake no opera-
tions here on an old asthmatic, or bronchitis man or woman, if we
would be spared the humiliation of seeing a prompt and aggra-
vated relapse before our patient is fairly on her feet. It is a ques-
tion whether it is a justifiable procedure to undertake, as one of
selection, on a child-bearing woman. In a general way hernial
operations for radical cure are not to be recommended on one who is
likely to pass through the travail of child-bearing, for the violent,
spasmodic contractions of the muscles must almost inevitably tear
through cicatricial seams at the hernial portal, and reproduce a
condition much worse than the original. This must be especially
the case with exomphoceles.
Operations for umbilical hernia are much more difficult of
performance than those which we have considered. Often there
is no independent serous investment, but the viscera, spread in
different directions, and forms adhesions with everything in contact
with them.
Their cutaneous investment has spread out in old cases as thin
as tissue paper, and at the neck the recti muscles have so far spread
out as to be perfectly brought together and retained in apposition,
only with the greatest difficulty.

HERNIA.
211
Our patient having been finally prepared for a capital opera-
tion, we now proceed with its different steps.
We must commence with a free linear incision, carried imme-
diately over the convexity of the tumor. Some, having completed
this incision, bisect it with another crossing this in its center in a
diagonal direction. This second incision increases the area of
mutilation, but it simplifies the dissection; and, as the thin integu-
mental covering of the tumor is a redundant, useless structure, after
the hernia is reduced, it is cut away, no harm is done, in any event.
As so-called umbilical hernia seldom make their escape
directly through the navel aperture, we will only occasionally
come on to the urachus, or the round ligament of the liver. When
these have, however, engaged, and been carried forward, their
loose slack must be cut away; their proximal ends being fixed in
the opening. After liberating the sac, returning the intestine, its
neck is transfixed in one or more places, ligated and amputated.
When the mass is omental it should be cut away, and its
pedicle treated with great care before being dropped into the
peritoneal cavity. In one of my own cases, after excising the
omentum, and returning the ligated stalk, when dropped in, one
of the ligatures slipped, and, for a moment, there was an enormous
gush of arterial blood from the open vessel. In a moment the
peritoneal cavity was filled with blood. Passing in two fingers,
after quickly feeling in every direction, I came on the retracted
omentum, drew it out again, through the wound, and firmly
secured it before it was too late; our patient, ultimately, making a
good recovery.
The vessels in an umbilical epiplocele must be securely ligated,
each of the larger separately, with fine silk, and then the thin,
investing serous envelope should be drawn over the open surface
and its free edges sewn solidly together. This latter step renders
further leakage improbable, besides, in a large measure, ob-
viates the tendency to adhesions of the intestine with the free
surface returned.
any
All are agreed that, at least in umbilical operations, we must
discard all measures which interfere with primary union, hence,
prompt and solid agglutination of the edges of the wound should
be secured in every case.

212
HERNIA.
There is some difference of opinion as to the manner in which
this is most efficiently accomplished, some employing a "through
and through" suture, which includes the integument and the under-
lying tissues with the serous membrane. Others prefer to sew the
serosa with its fibrous coat in separate layers, and then close in
all the overlying planes with one heavy suture.
My own preference is for the latter, as by it we are the better
enabled to effect a homologous approximation of the divided
structures.
There is no unanimity of opinion yet on the material to be
employed for suture. Many employ the silk-worm gut, common
twisted silk, or silver-wire, while not a few prefer an absorbable
material, and accordingly use kangaroo or cat-gut suture.
In small non-adherent hernia in this region, it is quite im-
material as to which is employed. But when the hernia is large
and the hiatus at the ring is considerable, the parts must be
drawn together and held by some powerful, non-elastic suture,
which will hold them in close union until healing is complete.
For this purpose it has been recommended that silk be em-
ployed in the serous layer, and heavy wire through the muscles
and integument. In one of my own cases, in a large, fat woman,
with an enormous exomphocele, everything went well after opera-
tion until the second day, when a most irritable, violent cough set
in, when vomiting and abdominal pain commenced. On removing
the dressing it was found that primary union was nearly complete,
and there was no unusual fullness at the seat of operation.
It was supposed that general peritonitis had developed
After two days of great distress, which was only relieved by
large doses of morphine, she sank.
On post-mortem examination it was found that the internal
seam of sutures had completely torn through, and that a kuckle
of the small intestine had slipped through the opening thus made,
and had become strangulated.
The position of the umbilical opening is such as to interfere
with constant and direct pressure. Besides, its close proximity to
the diaphragm is so productive of such ceaseless motion, as to
seriously interfere with that repose so needful in the repair of
wounds.

HERNIA.
213
EVENTRATIONS, LAPAROTOMY HERNIA, ETC., AND THEIR OPERATIVE
TREATMENT.
Ventral hernia, following abdominal section, is a lesion of
modern times. It is one of those unhappy sequelæ so commonly
seen after an abdominal section performed in any part of the
abdominal walls. Tait and others have thought that it might be
avoided if operators cut wide of fibrous structures, and penetrated
the abdominal cavity through muscular tissues. My own expe-
rience, however, is not in accord with this view, for many of the
worst cases which I have met were those after operation in
the appendix, in which the incision entered through muscle only.
That they are becoming of an alarming frequency may be
gathered from the fact that a single surgeon has recently reported
one hundred operations, performed by himself, for this distressing
affliction.
*
Inasmuch as it is assumed that no operator escapes them,
there must at this time be an enormous number so herniated in
this country.
The technique of their treatment is precisely the same as for
laparotomy, but it is often greatly complicated by adhesions.
When they are of very considerable size, and the degree of separa-
tion is great, unless undisturbed coaptation of the refreshened,
separated edges can be maintained over a considerable period of
time, a prompt relapse on taking the upright posture is almost
inevitable; hence, in order to obviate this as far as possible, the
deep, aponeurotic structures should be brought together, and
retained with numerous silver wire sutures or strong silk, which
have a deep grip in the tissues on either side. A stout, firm band-
age should be applied, and the patient kept in bed, on a
restricted diet, for at least two months before being permitted her
full freedom again.
POST-OPERATIVE TREATMENT OF HERNIA.
When we clearly understand the groundwork of all abdomi-
nal hernia, and recognize the fact that our measures by direct
surgical intervention are directed to nothing but the mural element
in the etiology, it becomes at once apparent that the temporary
* Dr. Joseph Price, Annals of Gynecology, p. 141, Dec., '92.

214
HERNIA.
closure of the escape portal, and the retention of the bowel, can-
not be depended on as a permanent condition, without a supple-
mentary support. The elongated mesentery remains. I have
seen the small intestine of a large woman measure scarcely ten
feet, and the same gut in a short, thick-set man more than thirty-
two feet long.
This superfluous bowel and lax mesenteric ligament, then,
should be braced or trussed up, even after the hernia has been
cured. For this purpose, every person who has ever been laparot-
omized, or who has had a hernial operation performed on him (or
her), either for strangulation or radical cure, should for the re-
mainder of life wear a broad, strong abdominal girth or belt of
some firm, unyielding substance.
With those employed at manual labor this is an imperative,
necessity, while, with others following sedentary occupations or
living in ease or idleness, it may be in a few cases dispensed with; or
fabricated of a light, elastic material and worn intermittently only.
If the belt is worn there will be little need of a truss; yet,
when the tissues over the wound commence to bulge, and relapse
is threatened, we must make no delay in falling back on the old
truss apparatus, for under these circumstances nothing will take
its place.
MENTAL ALIENATION CONSECUTIVE TO HERNIAL OPERATIONS.
With the exception of Juillard's case I can find no record of
the above condition occurring in the practice of others, after her-
nial operations. It is a well-known sequence, after laparotomy in
many cases, particularly in those wherein an opening is made,
immediately over the solar-plexus, in the epigastric region.
But it has been my experience to see four well marked cases
of a mild type, after hernial operations. In three the extrusion
was omental. These were two men and two women. The phase
of mental aberration which followed took the form of a persistent,
oppressive melancholy.
One was a case of strangulation in a woman, in whom a per-
manent cure followed operation. The other three were operated
on for radical cure on reducible hernia. In one a permanent cure
following, the other two relapsing.

HERNIA.
215
I have no theory to offer as to the elementary pathology of
this condition, but it is rational to assume that it may be attribut-
able to mutilation of the sympathetic ganglia, caught up in the ex-
tended omentum, or to compression of the nerve filaments of the
solar system, within the ligature applied to secure the blood-vessels
in the pedicle.
Despondency is a well-known clinical symptom in all abdom-
inal visceral diseases. Now, whether this mental depression,
consequent on hernial operations is directly attributable to reflex
irritation, transmitted to the cerebral centers, or not, is a matter
of doubt; but, that a phase of melancholia is one of the sequelæ of
hernial operations, which involve the omentum, seems to
me, from
my own experience, an indisputable fact.
This consecutive phenomenon should be borne in mind as one
of the possible unpleasant sequences of radical measures, which
may follow in cases of non-strangulated hernia, when contem
plating surgical interference.
TREATMENT OF HERNIA, RELAPSING AFTER OPERATION.
The general indication for treatment here is essentially simi-
lar to those in which no operation whatever has been done; i. e.,
if they are small, painless, easily controllable, and not attended
by symptoms of strangulation, they should not be interfered with,
because the second operation, in many cases, affords no more immu-
nity from recurrence than the primary, and always entails an
additional mutilation of tissue.
But, when relapse has been prompt, after the first operation,
and the hernia manifests a tendency to rapid growth, then another
operation is a justifiable and commendable procedure. I have
operated on others' failures, and, I presume, on the other hand,
my cases of relapses have gone into the service of other surgeons
for further treatment.

216
HERNIA.
Operations for Strangulated Hernia, With and Without Combined Measures for Radical Cure.
ORDER.
YEAR.
AGE.
DATE OF
OPERATION.
INFIRMITY.
OPERATION.
RESULT.
1st case.
1885.
50.
May 14th.
2d case.
1886.
42.
44
(Inguinal hernia.)
Strangulated indirect.
December 12th. Strangulated inguinal
hernia.
3d case.
1887.
31.
June 27th.
4th case.
1885.
42.
47
Strangulated femoral
hernia.
July 13th.
Strangulated direct
inguinal.
5th case.
1886.
27.
February 10th.
Strangulated indi-
rect inguinal, right
side. Acute strangu-
lation.
Male. Open incision; division
of constriction at neck of
the sac, and reduction of intes-
tine. Wound packed from the
bottom. (Ether.)
Male. Open incision; excision
of gangrenous omentum;
with free gauze drainage. (Ether.)
Female. Entered hospital on
third day after strangu-
lation in state of great collapse.
Operation under ether. Open
incision; sac in situ. (Ether.)
Female. Free division of parts
and reduction of sus-
pected intestine. Open treat-
ment. (Ether.)
Male. Open incision with reduc-
tion of the sac. The
latter was unopened. Wound
healed by granulation. (Ether.)
As this man was in
collapse at time of op-
eration, he sank six
hours after return to
his bed, of shock.
Made a good recov-
ery, and left hospital
well three weeks after
operation.
Death from shock
and pulmonary edema
eight hours after oper-
ation.
Died of perforation
of gut and pulminant
peritonitis on second
day.
No mishaps; vomit-
ing cured, and patient
promptly recovered af-
ter operation.

HERNIA.
217
RESULT.
Operations for Strangulated Hernia, With and Without Combined Measures for Radical Cure-Continued.
ORDER.
YEAR.
AGE.
DATE OF
OPERATION.
INFIRMITY.
OPERATION.
6th case.
1887.
38.
April 12th.
Strangulated, incar-
cerated, left inguinal
Male. Open incision; sac di-
hernia.
7th case.
1888.
41.
February 12th.
8th case.
1888.
32.
May 20th.
9th case.
1888.
71.
Strangulated femcral
hernia of twenty-two
hours' duration. Right
side.
Strangulated, indi-
rect, inguinal, incar-
cerated.
Strangulated, ingui-
September 2d. nal, indirect. Twenty-
four hours' duration.
10th case.
1889.
29.
June 12th.
Strangulated, ingui-
Great
nal, indirect.
collapse.
Death from shock
vided in situ; omento- ten hours after opera-
enterocele firm, and extensive tion. (No post-mortem
adhesions. (Ether.)
allowed.)
Female. Long linear incision
over the convexity of
the tumor. Reisel's operation for
radical cure combined. (Ether.)
Male. Incision; excision of the
sac and quilled suture
of canal; no drainage. (Ether.)
Male. Usual long incision; de-
cortication of sac with
its torsion and division. Wound
healed by granulation. (Ether)
Male. Free hypodermic medi-
cation, and but partly
anesthetized with ether. Oper-
ation hurriedly performed for
relief of strangulation only.
(Ether.)
Patient made a good
recovery, and now, after
four years, hernia has
not relapsed.
Operation; recovery.
Relapse of hernia after
fifteen months.
Operation; recovery.
Relapse after six
months.
Never rallied from
ether coma, and died
two hours after opera-
tion.

218
HERNIA.
RESULT.
Operations for Strangulated Hernia, With and Without Combined Measures for Radical Cure-Continued.
ORDER.
YEAR.
AGE.
DATE OF
OPERATION.
INFIRMITY.
OPERATION.
11th case.
1889.
37.
(Right, with ectopic
testis.)
Strangulated, con- Male. Free incision; castra-
tion; obliteration of the
November 12th. genital, inguinal.
Death from shock six
infundibulum, and solid hermeti- hours after operation.
cal suturing of the ring. (Ether.)
12th case.
1890.
42.
March 16th.
Strangulated, umbil-
ical. Had existed since
first confinement.
Female.
Patient in a moribund
state when seen.
13th case.
1890.
66
29.
August 2d.
Strangulated, ingui-
nal epiplocele. Right
side.
Strangulated, femor-
al hernia. Left side.
Strangulated hernia,
right inguinal; com-
plicated with hydro-
cele.
Male. Free incision; decorti-
cation of the sac, with
complete excision of the omen-
tum, close to the inner ring.
(Ether.)
Female. Open incision; con-
striction at the falci-
form; process divided; hernia
returned; adherent sac left in
the wound. (Ether.)
Male. Open incision, with free
decortication and abla-
tion of the sac; and radical cure
by method of McBurney. (Ether.)
recovery,
Prompt
and no relapse since.
Death from shock on
the morning of the
second day.
Good recovery. Her-
nia relapse after four-
teen months.
14th case.
1891.
64.
February 15th.
15th case.
1891.
36.
March 12th.

HERNIA.
219
RESULT.
Operations for Strangulated Hernia, With and Without Combined Measures for Radical Cure-Continued.
ORDER.
YEAR.
AGE.
DATE OF
OPERATION.
INFIRMITY.
OPERATION.
16th case.
1891.
28.
June 12th.
Strangulated, femor-
al, incarcerated. Great
collapse and depress-
17th case.
1891.
52.
December 12th.
ion.
Strangulated, ingui-
nal hernia. Right side.
Patient subject to her-
nial disease.
18th case.
1892.
46.
Strangulated, right
tocele.
November 19th. inguinal. Large scro-
19th case.
1892.
40.
June 12th.
20th case.
1892.
96
26.
June 17th.
Cancerous infiltra-
tion of strangulated
epiplocele. Right side.
Strangulation with
perforation of bowels.
Right inguinal.
Female. Operation under co-
caine analgesia (thirty
minutes' duration). Radical cure
minutes' duration). Radical cure
by Championniére's procedure.
Male. Cocaine analgesia. One
assistant. Release of the
constriction, combined with
Ball's operation for radical cure.
Male. Operation by house-sur-
three feet of suspected intestine.
geon; resecting more than
(Ether.)
Male. Primary operation lim-
ited to incision down to
the sac.
the sac. After relieving stran-
gulation, McBurney's operation
for radical cure was performed.
Male. On opening the sac it
was found that by vio-
lence the intestine had been
burst, and returned, leaving
the thin pouch filled with the
intestinal contents. (Cocaine.)
Result- quite the
ideal in every particu-
lar.
lar. No hernial re-
lapse.
Good operative re-
sult; but hernia prompt-
ly relapsed.
Death from perito-
nitis after forty-eight
hours.
Prompt recovery
from operation. Has
been lost sight of.
As toxæmia was pro-
nounced when opera-
tion for opening was
made, he died after
forty hours.

220
HERNIA.
Operations for Strangulated Hernia, With and Without Combined Measures for Radical Cure-Continued.
ORDER.
YEAR.
AGE.
DATE OF
OPERATION.
INFIRMITY.
OPERATION.
RESULT.
21st case. 1892.
41.
May
22d case.
1892.
26.
-
Strangulated, ingui-
nal (left). Gangrene of
intestine.
Female. Open incision into the
broken-down bowel.
Artificial anus. (Ether.)
Strangulated, right
September 12th. inguinal. Duration two
days, not very tightly
gripped.
23d case.
1892.
29.
November 12th.
24th case.
1892.
26.
December 16th.
Strangulated, ingui-
nal (left). Gangrene of
gut, with fæcal infiltra-
tion.
Strangulated, ingui
nal (right). Six hours'
duration.
Male. This was a case in which
a second operation was
necessary, through the constric-
tion of the neck being overlooked
by first operator. Champion-
niére's r. o. (Cocaine.)
Male. Free incision, and drain-
age of fæcal matter. Arti-
ficial anus. (Cocaine.)
Male. Release of strangulation,
with Championniére's
operation for radical cure.
Death on the table,
before dressings were
complete.
Good recovery. Too
short time to speak of
permanency of results.
Death from toxæmia
on the fourth day.
Excellent operative
result.

HERNIA.
227
221
Operations for Radical Cure of Non-Strangulated Hernia.
DATE OF
ORDER.
YEAR.
AGE.
OPERATION.
INFIRMITY.
OPERATION.
Indirect, incarcer-
Male.
25th case.
1887.
67.
December 12th. ated, inguinal. Right
Reverdin's operation,
with sac left in situ.
side.
Male.
26th case.
1888.
2.
March 18th.
Congenital, right
inguinal. Incoercible
to the truss.
Decortication of the sac,
and its invagination in
the canal with deep cat gut su-
turing,
RESULT.
Satisfactory
opera-
tion. Relapse after thir-
teen months.
Recovery. Relapse
after two years.
27th case.
1888.
30.
June 10th.
Inguinal epiplocele,
left side; incarcerated.
28th case.
1888.
41.
October 7th.
Small, lacerated um-
bilical, giving issue to
free hemorrhage.
Male. Excision of the sac with
tamponing of the inter-
nal ring with omental tissue.
Female.
Excision of cellular
tissue investment.
Deep, harelip pins were em-
ployed, with cat-gut for deep
suturing.
Recovery.
No re-
lapse up to a month
ago.
Recovery.
No re-
lapse since operation.
29th case.
1889.
3 weeks.
June 10th.
Very large scrotal
hernia, unmanageable
to the truss.
Male.
Open incision; McBur-
ney's operation.
Recovery. Relapse
after ten months.
Recovery.
Relapse
Left inguinal; large Male. McBurney's open opera- after six months; but
tion.
now easily manageable
30th case.
1889.
71.
March 10th.
and uncontrollable.
to truss.

222
HERNIA.
Operations for Radical Cure of Non-Strangulated Hernia-Continued.
ORDER.
YEAR.
AGE.
DATE OF
OPERATION.
31st case.
1889.
27.
May 14th.
INFIRMITY.
OPERATION.
RESULT.
Recovery.
Relapse
Right inguinal her- Male. Championniére's opera- after six months; but
nia. Painful.
tion.
no pain.
32d case.
1889.
46.
July 17th.
Left inguinal her-
nia, complicated with
ectopic testis.
33d case.
1889.
14.
November 14th.
Right inguinal her-
nia, with encysted cord.
34th case.
1890.
9.
January 2d.
Right inguinal her-
nia; incarcerated.
Male. Fixation of the testicle
in the scrotum. Excis-
ion of the sac, and immediate
enclosure of the parts with three
layers of suture.
Male. Excision of cyst and in-
vagination of sac, with
direct deep suturing of canal.
Female. McBurney's operation.
Recovery. There has
been no relapse, though
truss is constantly worn.
Recovery. No re-
lapse. Constantly wears
a truss.
Recovery. No re-
lapse for two years,
when he was lost sight
of.
35th case.
1890.
8.
April 12th.
36th case.
1890.
26.
June 19th.
Small, left epiplo-
cele; irreducible.
Large, right scroto-
cele; incoercible to
the truss.
Reisel's operation; excision
of neck, but sac left in situ.
Male. Sac resected, and com-
mon ring closed with
buried silver wire suture.
Recovery. Relapse
after eighteen months.
Recovery. No re-
lapse. Constantly wears
a truss.

HERNIA.
223
Operations for Radical Cure of Non-Strangulated Hernia-Continued.
ORDER.
YEAR.
AGE.
DATE OF
OPERATION.
INFIRMITY.
OPERATION.
RESULT.
37th case.
1891.
43.
May 12th.
Direct, inguinal, left
side; enterocele.
Male. McBurney's operation,
modified by suturing the
internal ring with silk.
Recovery. No re-
lapse two years after
operation.
38th case.
1891.
2.
July 7th.
Incomplete, ingui-
nal, large. Right.
Cervicotomy. Sac left in situ,
pillars sutured. Wound closed
without drainage.
Recovery. Relapse
in eight months.
Male. Operation on one side
39th case.
1891.
3.
September 19th.
Double inguinal
only by Championniére's after eighteen months.
Recovery. Relapse
plan.
40th case.
1891.
24.
November 9th.
Femoral (right)
epiplocele.
Male. Tamponage of the fe-
moral canal and septum
crurale with omental tissue.
Recovery. Relapse
at the end of eighteen
months.
Umbilical hernia;
41st case.
1891.
2.
December 9th. irreducible.
Female. Free dissection and
liberation of viscera.
Recovery.
Refreshening and suturing ring. lapse as yet.
No re-
42d case.
1891.
4.
December 27th.
Inguinal
Right side.
hernia. Male. Championniére's 'opera-
No relapse after one
tion.
year.

224
HERNIA.
Operations for Radical Cure of Non-Strangulated Hernia-Continued.
ORDER.
YEAR.
AGE.
DATE OF
OPERATION.
INFIRMITY.
OPERATION.
RESULT.
43d case.
1892.
1.
January 12th.
Umbilical.
and irreducible.
Small
Female. Ligature of neck of
sac and closure of the
ring with cat-gut suture.
Recovery. No re-
currence January 1st,
1893.
44th case.
1892.
46.
Large umbilical her-
January 19th. nia. Painful and in-
carcerated.
Female.
Free dissection. Ex-
cision of the omentum.
Death fifty hours af-
ter operation, from
shock and peritonitis.
Small, painful in- Male. Championniére's opera-
tion.
Recovery. Relapse
after nine months.
45th case.
1892.
24.
January 27th. guinal. Left side.
46th case.
1892.
5.
February 2d.
Umbilical hernia,
large and painful.
Female. Reduction of hernia
and subcutaneous su-
turing of sac.
Recovery. No re-
lapse after January 1st,
1893.
47th case.
1892.
1.
February 14th.
Large scrotal. Right
side.
Male. Reduction of hernia, fol-
lowed by invagination
and suturing of the sac in the
ring.
Recovery. Truss
worn constantly since.
48.h case.
1892.
27.
Femoral
hernia.
February 21st. Right side. Incoerci- of septum crurale by deep buried
ble.
suture.
worn constantly. No
relapse.
Female. Excision of sac and
obliteration of lumen
Recovery. Truss

HERNIA.
225
OPERATION.
Operations for Radical Cure of Non-Strangulated Hernia-Continued.
ORDER.
YEAR.
AGE.
DATE OF
OPERATION.
INFIRMITY.
49th case.
1892.
51.
April 2d.
Small, painful, um-
bilical hernia.
RESULT.
Male. Open incision. No sac.
Small omental mass, ize
of a marble, resected. Deep silk
suture employed. No drainage.
Male. First complete retention
with truss for one month.
Second incision in ring and pil-
lars approximated with by silk
suture.
Recovery. Prompt
union. Wears a belt.
No relapse.
Recovery. No re-
lapse. Pad and belt
constantly worn.
50th case.
1892.
52.
April 16th.
Large scrotocele
(right), with hydro-
cele.
51st case.
1892.
3.
May 7th.
Small, painful um-
bilical.
Female. Reduction and subcu-
taneous suture with
chromocized cat-gut.
52d case.
1892.
32.
July 2d.
Incarcerated and in-
coercible inguinal her-
nia. Right side.
Male.
53d case.
1892.
24.
August 7th.
(In
Small, reducible,
right inguinal.
applicant for police)
Free incision. Body of
sac closed by quilled su-
ture. Its neck divided. Wound
closed in three layers of sutures.
Male. Small incision over in-
tercolumnar fascia; and
Recovery. No re-
lapse January 1st, 1893.
Recovery. No re-
lapse after six months.
Recovery. Success-
Wears
injection into the perivascular ful in every particular.
elements of the cord, in inguinal No relapse.
canal, of twenty drops of strong
alcohol.
belt.
15

226
HERNIA.
OPERATION.
Operations for Radical Cure of Non-Strangulated Hernia-Continued.
DATE OF
ORDER.
YEAR.
AGE.
OPERATION.
INFIRMITY.
RESULT.
Female.
54th case.
1892.
34.
August 29th.
Reducible hernia;
left inguinal.
Resection of a pro-
lapsed ovary in canal.
No drainage.
Recovery.
No re-
lapse.
Incoercible,
right
55th case.
1892.
6.
October 12th.
inguinal hernia.
Resection of sac and closure
parts in four layers. No
of
drainage.
Recovery.
No re-
lapse.
56th case.
1893.
45.
January 4th.
Incoercible,
inguinal hernia.
left
57th case.
1892.
23.
November 17th.
Exposure of sac, ligation of
its neck, and quilting of the
slack and solid suturing of rings.
Small, painful, fe- Female. Championniére's opera-
moral hernia.
tion.
58th case.
1892.
40.
December 2d.
Small, inguinal, pain-
ful epiplocele.
Reisel's operation.
Recovery.
Recovery. No re-
lapse in two months.
No re-
Recovery. No
lapse in one month.

HERNIA.
227
RECAPITULATION AND SUMMARY OF OPERATIONS.
In the recorded list of operation one of the first things that
will be noticed, is the great difference in the mortality of opera-
tions performed for strangulation, and for radical cure in the non-
strangulated.
In the former, since the general substitution of cocaine anal-
gesia for pulmonary anæsthetics, unless our patients have been
moribund, or the intestine is not gangrenous at time of operation,
there have been no deaths, both with those on whom I have oper.
ated in hospital and outside practice.
It will be observed, too, that the mortality in non-strangu-
lated cases in my experience bears out Bull's statement that it is
practically nil.
At the present time, my purpose in contemplation, when I
herniotomize, is not so much to secure a radical cure as to place
the hernia in such a position as it will give no inconvenience, and
may be safely controlled by truss support.
I have followed out no orthodox plan in operations, but am
guided here on precisely the same principles as I would in per-
forming an amputation, viz., totally disregarding all those specially
designated operations, and in each case select such an one, with or
without modification, as the conditions in each case may require.
The operations which I have latterly employed in adult, non-
incarcerated hernia have been instituted more as relief-measures
than as radical cures per se. And, hence, as an invariable rule, I
advise, as soon as the patient takes erect attitude, the immediate
employment of the broad belt or truss. The latter always when
the hernial operations are large and the hernia has been an old one.


INDEX.
A Few General Observations on Operations for Radical Cure of Reducible and
Irreducible Herniæ, as Practiced at the Present Time..
Agents by which Inflammation has been Induced....
Ancient Management of Mortified Hernial Contents....
Ancient Methods of Treatment of Strangulated Hernia....
An Open Operation which Essentially Embraces the same steps as the Preced-
ing, but the Divided Inguinal Canal and in the soft parts unite by Granula-
tive Tissue instead. (McBurney)........
PAGE
.
76
25
22
21
... 164
24
Class of Cases in which Cervicotomy and Deligations should be Practiced.... 154
Comparative Merits of Operations for Non-strangulated..
Comparative Merits of Operations for Non strangulated and Reducible Hernia
by Modern Methods
...
.. 80
Complete Detachment of the Sac from its adhesions and its subsequent utiliza-
tion, as a plug to serve as a barrier against relapse. (McEwen-Kochers).. 168
Concluding Observation on Older Observation on Older Operations....
Concluding Observations on the Older Operations.......
23
74
Conditions Requiring Truss in Children...
Congenital Defects of Development in the Spermatic Cord, the Inguinal Canal
and Outlets, and those Arising from Pathological Changes.....
Congenital Hernia...
Construction and Application of Truss in Children...
Contra-indications of Surgical Treatment in Children
6
85
2795
2
Encysted Hernia in Children and Infants.....
Essential Principles for Operation for Radical Cure.
25
Eventrations, Laparotomy Hernia and their Operative Treatment
....
213
Femoral Hernia in the Male and Female; its Morbid Anatomy and Pecu-
liarities....
... 89
General Consideration...
1
Hernia in the Adult.....
10
Hernia in the Female Child..
9
Hygiene of Infancy...
2
Incoercible and Incarcerated Hernia in Youth.
9
Indications for Truss in the Adult.......
Inguinal and Female, with Observations on Male Femoral Hernia..
In Hernial Operations....
Irregular Ventro-abdominal Hernia of Child-bearing Women..
Isolation of Sac, with Section of Internal Ring..
11
89
.. 215
. 50
.... 171
229

230
INDEX.
PAGE
Laparotomy Hernia
Laparotomy Hernia...
15
. 51
Mental Alienism Consecutive ...
Mammoth Hernia ....
Management of the Sac in Former Operations for Strangulation..
Mechanical Appliances, Indications, etc.
Mechanical Treatment of Ventral Hernia..
Miscellaneous Methods Effecting or Favoring Radical Cure....
Miscellaneous, Open Operations In; In Inguinal Hernia and those Appropriate
for Strangulation, Femoral, Umbilical and other Hernia.....
Morbid Anatomy and Pathology of Exomphaceles, Epigastric Hernia, Even-
trations, or Laparotomy Hernia
Neoplastic Hernia....
Observations on Operations for Radical Cure..
Operation Technique for Incarcerated Reducible Hernia when Treated by Open
Incision
Operation Technique in Strangulated Hernia and its Complications, Manual
and Instrumental
12
21
3
14
214
66
... 175.
..
95
12
23
.. 186
203
Palliative Treatment of Adult, Ventro-abdominal Hernia.
Palliative Treatment of Ventro-abdominal Hernia..
Post-operative Treatment of Hernia ...
52
15
213
Preparation and Details in Operation for Strangulated Hernia...
190
Radical Cure, Femoral Hernia.....
Radical Cure of Reducible and Irreducible Hernia
Radical Cure in Strangulated Hernia.....
Recapitulation and Summary of Operations..
Rest
Simple Non-operative Measures in Infantile Hernia...
Subcutaneous Division of Neck of Sac.....
208
16
24
Radical Operation for Umbilical, Ventral and Laparotomy Hernia...
210
227
187
4
22
Surgical Operation for Infantile and Children's Herniæ..
Taxis..
The Agents by which Inflammation has been Induced to Close the Aperture...
The Management of the Sac in Reducible and Strangulated Hernia......
The Management of the Sac in Former Operations for Strangulated Hernia..
The Management of Mortified or Gangrenous Intestine, or Omentum, in the
Past....
The Mechanism of Hernia from a Standpoint of Stricture, Function and
Abdominal Conditions...
The More Ancient Methods of Treating Strangulated Hernia....
The Radical Cure of Strangulated Hernia
8
188
81
64
71
... 73
. 84
70
..
79
The Radical Cure of Reducible and Irreducible Hernia, by Direct Surgical In-
tervention. Its Origin, Progress, and Present Position
The Radical Treatment of Non-strangulated Hernia, by such Modern Methods
as Require an Open Incision and Free Dissection of the Sac....
.. 55
. 149

INDEX.
231
The Subcutaneous Section of the Strictured Neck of the Strangulated Sac, or
Division of the Contracted Ring..
Those Operations in which the Sac is Completely Dissected and Cut Away, after
the Inguinal Canal has been Divided through its Entire Length, after which
the Canal, External Ring, Fascia and Integuments are Closed, Layer by
Layer. (Championniére).
Treatment of Infantile Hernia
...
Treatment of Laparotomy Hernia
Treatment of Laparotomy Hernia..
Umbilical Hernia
Varieties of Infantile Hernia
Ventro-abdominal Hernia in Child-bearing Women
PAGE
73
..
159
3
16
54
14
8
15


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