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THE TECHNIC OF 
 
 MODERN OPERATIONS FOR HERNIA 
 
 BY 
 
 ALEXANDER HUGH FERGUSON, M.B., M.D., CM., F.T.M.S. 
 
 Commander of the Order of Christ of Portugal ; Professor of Clinical Sur- 
 gery, Medical Department of the University of Illinois ; Professor of 
 Surgery at the Chicago Post-Gradnate Medical School ; President 
 of the Chicago Hospital ; Surgeon to the Chicago and Post- 
 Graduate Hospitals ; Fellow of the International Surg- 
 ical Association, American Surgical Association, 
 Chicago Surgical Society, etc. , etc. , Chicago, III. 
 
 Illustrated by Reproductions of Original 
 Drawings from the Author's Collection 
 
 CHICAGO: 
 
 CLEVELAND PRESS 
 1907 
 
/9oq 
 
 Copyright 1907 
 
 BY THE 
 
 CLEVELAND PRESS 
 
 CHICAGO 
 
THIS BOOK 
 
 IS 
 
 DEDICATED 
 
 TO 
 
 HON. DR. JOHN H. O'DONNELL 
 
 OF 
 
 WINNIPEG, MANITOBA, CANADA 
 
 IN GRATEFUL REMEMBRAKCE OP 
 
 ASSISTANCE GIVEN THE AUTHOR 
 
 BOTH AS A STUDENT AND 
 
 PRACTITIONER OF 
 
 MEDICINE 
 
PREFACE. 
 
 Believing that there is room for a book on hernia which presents onl\ 
 the purely surgical phase of the subject, the author has prepared this work. 
 All discussion of etiology, symptoms, diagnosis, prognosis and treatment 
 other than surgical has been omitted (because this can be found in all text- 
 books on surgery), and there has been gathered together here the re- 
 sults of twenty years of active work in surgery. These years have been of 
 great value to the experience of the author, and in the hope that others may 
 derive some small benefit therefrom he has set forth the following pages. 
 He bespeaks for this work the kindly consideration which his previous 
 writings have received at the hands of an indulgent profession. 
 
 ALEXANDER HUGH FERGUSON. 
 
TABLE OF CONTENTS. 
 
 PART I. 
 
 CHAPTER I. 
 
 Page. 
 General Considerations and Classification g 
 
 CHAPTER n. 
 
 The Technic of Operations for Hernias 30 
 
 CHAPTER HI. 
 Instruments Used in Hernia Operations j9 
 
 CHAPTER IV. 
 Materials Used for Hernial Operation (Ferguson) ■ 45 
 
 CHAPTER V. 
 The Chicago Hospital Operating Room Technic (Ferguson) 52 
 
 CHAPTER VL 
 Indications for Operation 58 
 
 CHAPTER VII. 
 Preparation of the Patient y^ 
 
 CHAPTER VIIL 
 Surgical Bacteriology 81 
 
 CHAPTER IX. 
 Infection 89 
 
 CHAPTER X. 
 Sterilization and Disinfection 100 
 
 CHAPTER XI. 
 Antiseptics and Disinfectants 109 
 
 CHAPTER XII. 
 Sterilization of Catgut 123 
 
 CHAPTER XIII. 
 The Wound 130 
 
 CHAPTER XIV. 
 Treatment of Wounds 144 
 
 CHAPTER XV. 
 Complications Incident to the Relief of Hernia 149 
 
 CHAPTER XVI. 
 Complications Incident to the Relief of Hernia (continued) 166 
 
 CHAPTER XVII. 
 General Complications Found at the Operation 194 
 
 CHAPTER XVin. 
 
 Results of Hernia Operations 200 
 
 CHAPTER XIX. 
 
 Results of Operations for Strangulated Hernia 209 
 
 CHAPTER XX. 
 Results from Ferguson Method 215 
 
6 TABLE OF CONTENTS, 
 
 PART II. 
 
 CHAPTER I. 
 Operations for Inguinal Hernia '. ^25 
 
 CHAPTER n. 
 Operations for Inguinal Hernia (continued) 25S 
 
 CHAPTER HI. 
 Operations for Inguinal Hernia (continued) 265 
 
 CHAPTER IV. 
 The Typic or Anatomic (Ferguson) Operation 280 
 
 CHAPTER V. 
 Radical Cure of Femoral Hernia 289 
 
 CHAPTER VI. 
 Radical Cure of Umbilical Hernia 304 
 
 CHAPTER VII. 
 
 Repair of Large Defects in Abdominal Wall 3^5 
 
 CHAPTER VIII. 
 Diaphragmatic Hernia 318 
 
 CHAPTER IX. 
 
 Internal and Inferior Hernias 324 
 
 CHAPTER X. 
 Strangulated Hernia 336 
 
 CHAPTER XL 
 Hernia in Infants -. 343 
 
 CHAPTER XII. 
 Unusual Forms of Hernia 345 
 
 CHAPTER XIII. 
 Local Anesthesia in Hernia Operations 358 
 
ILLUSTRATIONS. 
 
 Opposite page 
 PLATE I. — Interstitial Hernia, Oblique Inguinal Hernia, Epigastric Hernia, 
 
 Direct Inguinal Hernia, Femoral Hernia lo 
 
 PLATE II. — Inguinal Hernia, Femoral Hernia, Obturator Hernia i6 
 
 PLATE HI.— Petit's Triangle, Braun's Space, and the Anatomy of Sciatic Hernia 22 
 
 PLATE IV.— Sliding Hernia of the Sigmoid 26 
 
 PLATE V. — Sliding Hernia of the Sigmoid — laid open .' 30 
 
 PLATE VI. — Inguinal and Ventral Hernia with Suprapubic Vesical Fistula .... 34 
 
 PLATE VII. — Ventral Hernia Following Rupture of Rectus Muscle 40 
 
 PLATE VIII. — Posterior Hernia through Duodeno-jejunal Fossa 46 
 
 PLATE IX. — Pericardial Diaphragmatic Hernia of the Omentum 54 
 
 PLATE X. — Diaphragmatic Hernia 60 
 
 PLATE XI.— Ischiatic Hernia r. 66 
 
 PLATE XII.— Anatomical Parts 74 
 
 PLATE XIII. — Diagrammatic frontal section through the pelvis 82 
 
 PLATE XIV. — Femoral Hernia. Internal, Anterior, External 90 
 
 PLATE XV. — Congested Hernia — 2 hours 94 
 
 PLATE XVI. — Congested Hernia — ^4 days 102 
 
 PLATE XVIL— Inflamed Hernia ] no 
 
 PLATE XVIII.— Ulcerated Hernia 116 
 
 PLATE XIX. — Gangrenous Hernia 124 
 
 PLATE XX. — Gangrenous (Littre's) Hernia 130 
 
 PLATE XXI.— Instruments 134 
 
 PLATE XXII.— Instruments ; 138 
 
 PLATE XXIIL— Incisions 144 
 
 PLATE XXIV— Incisions 150 
 
 PLATE XXV. — Macewen's Operation for Inguinal Hernia 154 
 
 PLATE XXVI. — Bassini's Operation for Inguinal Hernia 160 
 
 PLATE XXVII. — Kocher's Operation for Inguinal Hernia — second step 168 
 
 PLATE XXVIII. — Kocher's Operation for Inguinal Hernia — fourth step 174 
 
 PLATE XXIX. — Halsted's Operation for Inguinal Hernia 180 
 
 PLATE XXX. — Halsted's Operation for Inguinal Hernia 184 
 
 PLATE XXXI.— Halsted's Operation for Inguinal Hernia 188 
 
 PLATE XXXII. — Halsted's Operation for Inguinal Hernia 194 
 
 PLATE XXXIII. — Halsted's Operation for Inguinal Hernia 200 
 
 PLATE XXXIV. — Fowler's Operation for Inguinal Hernia 204 
 
 PLATE XXXV. — Fowler's Operation for Inguinal Hernia 210 
 
 PLATE XXXVI. — Fowler's Operation for Inguinal Hernia 216 
 
 PLATE XXXVIL— Parks' Autoplastic Suture 220 
 
 PLATE XXXVIII. — Bassini's Operation for Inguinal Hernia with Imbrication of 
 
 Structures 226 
 
 PLATE XXXIX. — McArthur's Autoplastic Suture used in Bassini's Operation . . 230 
 PLATE XL. — McArthur's Autoplastic Suture used in Bassini's Operation 234 
 
8 ILLUSTRATIONS. 
 
 PLATE XLI. — M. L. Harris' aluminum bronze wire suture used in Ferguson's 
 
 operation ^3^ 
 
 PLATE XLIL— Davison's Removable Silkworm Gut Suture 242 
 
 PLATE XLIIL— Showing Deficiency of Internal Oblique at Poupart's Ligament. 246 
 
 PLxA.TE XLIV. — Ferguson's Operation for Liguinal Hernia 250 
 
 PLATE XLV. — Ferguson's Operation for Inguinal Hernia 254 
 
 PLATE XLVL— Fergtison's Operation for Inguinal Hernia 260 
 
 PLATE XLVII. — Diagram of the position of the transplanted rectus muscle, dem- 
 onstrating the slight change in the direction of its fibers. — Bloodgood's oper- 
 ation 266 
 
 PLATE XLVIII. — Ferguson's Operation for Inguinal Hernia 270 
 
 PLATE XLIX. — Ferguson's Operation for Inguinal Hernia 274 
 
 PLATE L. — Ferguson's Operation for Femoral Hernia 284 
 
 PLATE LI.— Fabricius' Operation for Femoral Hernia 290 
 
 PLATE LII. — Fabricius' Operation for Femoral Hernia 294 
 
 PLATE LIIL— Ochsner's Operation for Femoral Hernia 300 
 
 PLATE LIV.— Mayo's Operation for UmbiHcal Hernia 304 
 
 PLATE LV.— Mayo's Operation for Umbilical Hernia 310 
 
 PLATE LVI. — Large UmbiHcal and Post-operative Ventral Hernias 318 
 
 PLATE LVIL— Blake's Operation for Umbilical Hernia Completed 324 
 
 PLATE LVIII. — Ferguson's Modification of Blake's Operation in Suitable Cases 330 
 PLATE LIX. — Ferguson's Modification of Blake's Operation in Suitable Cases. . 336 
 
 PLATE EX.— Final Result of Operation for Umbilical Hernia 346 
 
 PLATE LXL— Hernia Into Ileo-cohc Fossa 350 
 
 PLATE LXII. — Loop of jejunum into lesser cavity of omentum 354 
 
PART I. 
 
 CHAPTER 1. 
 
 GENERAL CONSIDERATIONS AND CLASSIFICATION. 
 
 A hernia or rupture is the protrusion of any viscus from the cavity in 
 which it is normally contained. The term is usually applied to protrusions 
 of abdominal and pelvic viscera, although organs situated in otiier cavities 
 may become herniated. The author vrill limit his discussion of hernia en- 
 tirely to the abdominal variety. 
 
 The hernia may be a congenital or an acquired one. Its protrusion may 
 occur through openings in the abdominal wall, which were present in fetal 
 life and failed to close at birth, as. for instance, the umbilicus and the 
 funicular process of the peritoneum. These are congenital hernias. 
 
 The protrusion also may occur at points where the abdominal wall 
 is weaker than elsewhere, such as the inguinal region, where the spermatic 
 cord passes through the inguinal canal; at the umbilicus, where the musck 
 tissue is naturally deficient : in the femoral region, where the large vessels 
 and nerves pass out of the pelvis; and at other points where there is a 
 normal diastasis of muscle fibers, the space being bridged over by connec- 
 tive tissue only, as in Petit's triangle, between the latissimus dorsi and the 
 external oblique muscles, and in the diaphragm. Hernias occurring at these 
 points are of the acquired variety. 
 
 The traumatic hernias or ruptures occur at points in the abdominal 
 wall that have been weakened as the result of operation or trauma. Her- 
 nias following abdominal sections and appendectomies are well-known ex- 
 amples of this variety of hernia. When a viscus protrudes through one of 
 these weak spots in the abdominal wall, it pushes before itself the parietal 
 peritoneum and the various layers of tissue constituting the abdominal wall 
 at that particular point; but the innermost layer invariably consists of a 
 pouch of thin parietal peritoneum which is known as the sac of the hernia. 
 
 The sac is usually pear-shaped or pyriforni, although it mav be mxulti- 
 locular. or constricted, the so-called hourglass sac (en bissac}. Irregular- 
 shaped sacs, double sacs, invaginated sacs and sacs having diverticula are 
 also met with occasionally. The form of the sac depends in part on its 
 contents and in part on the duration of the hernia, its location and the 
 presence and extent of adhesions. On the other hand the sac may be absent, 
 although this .'occurs only in the rarer forms of hernia, such as the dia- 
 phragmatic, the foraminal, in hepatocele. nephrocele, etc., where the viscus 
 has only a partial investment of peritoneum, and is either parth^ or w-bolly 
 
10 GENERAL CONSIDERATIONS AND CLASSIFICATION 
 
 outside of it; or when the hernia occurs through a sht in the peritoneum. 
 When the sac has ruptured it is sometimes difficult to find it, and such 
 hernias may be diagnosed wrongly as having no sac. 
 
 The constricted part of the sac, the part that is engaged in the hernial 
 orifice, is known as the neck of the sac. The part beyond, the larger, dis- 
 tended part, is called the fundus or the body of the sac. The coverings of 
 the sac are the tissues outside of it, and they vary with the site of the 
 hernia. 
 
 The contents of the sac also vary (see ClassHication). Every viscus in 
 the abdominal cavity has been found to form the whole or a part of the 
 contents of the hernial sac. The small intestine and omentum, and then 
 parts of the large intestine, are most often found to form the contents of 
 the sac. Intra-abdominal pressure is an important factor in determining 
 not only the occurrence of a hernia, but also the contents of the sac. The 
 size of the opening is also an important etiologic factor that must be reck- 
 oned with clinically. It is evident that a large viscus cannot protrude 
 through a small opening until the intra-abdominal pressure, exerted for a 
 sufficiently long period of time, has converted the small opening into a 
 large one. 
 
 Patent fetal processes, weak spots, and intra-abdominal pressure are 
 the factors of paramount importance in the production of hernia. When 
 the hernial sac is closed by adhesions at its ring, it may be empty. It is 
 then usually converted into a cyst containing serous fluid. 
 
 There is no race or class of people that is free from rupture. It has 
 been shown, however, that hernia occurs most often among the Portuguese 
 and Spaniards, while the United States Indians are least often the subjects 
 of hernia. As mentioned above, hernias are met with early in life (in 
 fact the child may be born with a hernia), and very late in life, but hernia 
 occurs most frecjuently during the active period of life. 
 
 Various writers have endeavored to ascertain the prevalence of hernia 
 among certain peoples by studying the records of schools, workhouses, in- 
 firmaries, and recruiting offices, but inasmuch as many suffering from 
 hernia never apply for relief, it has been impossible to establish exactly the 
 percentage of occurrence. It was estimated by Marcy that from one-eighth 
 to one-sixteenth of the human race is afflicted with hernia. From the tables 
 of the late J. H. Baxter. Surgeon-General, U. S. A., we learn that of 334., 321 
 recruits, substituted, drafted and enrolled men of various nationalities ex- 
 amined, 16,901 were rejected on account of hernia. Of this number, over 
 half (8,598) had right inguinal hernia. Malgaigne estimated that in France 
 3.6 per cent, of the total population was ruptured ; while Berger claims 
 that in Paris only .44 per cent, are ruptured. 
 
 Hernia occurs more often in the male than in the female, the percentage 
 of frequency varying from 3 to 5. ]\Ir. Kingdon, of London, stated that 
 there are 6.y per cent, of males ruptured to i per cent, of 'females. 
 
 Many interesting points in connection with the etiology and occur- 
 rence of hernia might be dwelt on in this connection, but it is not the in- 
 tention of the author to do more than to call attention to a few of the more 
 
PLATE I. 
 
 I. Interstitial Hernia. 2. Oblique Inguinal Hernia. 3. Epigastric Eler- 
 nia. 4. Direct Inguinal Hernia. 5. Femoral Hernia. 
 
 (Author's Case.) 
 
GENERAL CONSIDERATIONS AND CLASSIFICATION 1 3 
 
 essential points, inasmuch as this v/ork is not designed to discuss the cHn- 
 ical history of hernia, but rather the operations for the rehef and cure 
 of hernia. 
 
 CLASSIFICATION. 
 
 In attempting to make a classification of abdominal hernias, one is 
 confronted at the outset by the fact that up to the present no one has made 
 a classification which is o"f any marked service to the clinician or to the 
 student. There are so many varieties of hernia and combinations of differ- 
 ent kinds that it seems almost hopeless to undertake to make any sort of 
 classification that would be of use to anyone. 
 
 It is customary to refer to hernias as being either congenital or ac- 
 quired. That is a classification based on etiology. It cannot be subdivided. 
 Then hernias are divided into inguinal, femoral, ventral, diaphragmatic, etc., 
 making it incumbent on the physician to memorize the various forms of 
 the aflr'ection without any systematic attempt at classification. 
 
 In presenting the following arrangement, the author has divided her- 
 nias of the abdomen and its walls wdth reference to their topography into 
 1 Anterior, II Posterior, III Superior, IV Inferior, V Lateral, and 
 VI Internal. This classification, although new, possesses the recom.men- 
 dation of being exceedingly simple and withal logical. It is an anatomic 
 classification. To the best knowledge of the author no other concrete and 
 complete classification of abdominal hernias has been made ; and the one 
 here ofl:ered may be somewhat crude and open to improvements. How- 
 ever, it will serve as a guide for future attempts at classifying these 
 hernias. 
 
14 
 
 GEXERAL CONSIDERATIONS AND CLASSIFICATION 
 
 (Direct. Throua-h fyt w 4.- • r, e ■.■,-. t. , 
 
 XT V, uj Internal passes to inner Side of obliterated 
 
 Hesseibach s , ^ • ^ \ 
 
 I trian^^le (in--| hypograstric artery). 
 
 I ternal ingui- | 
 nal fossa). 
 
 Ing-uinal(-upra- 
 pubic) Hernia 
 into inguinal 
 canal, through 
 internal and 
 external fossa 
 
 Oblique (through 
 internal 
 abdom in a 1 
 ring), 
 
 Pre-inguinal ( 
 
 Labial 
 
 External (passes to outer side of hypo- 
 I gastric artery). 
 
 j Congenital. 
 
 I Acquired. 
 
 ] Infantile (behind the funicular process of 
 
 I the peritoneum). 
 
 [Interstitial. 
 
 interstitial, sac protrudes external to 
 inguinal canal; mouth situated near internal abdoin- 
 inal ring) . 
 
 Sliding (hernia without a peritoneal sac, e.g., cecum and 
 sigmoid). 
 
 Cruro-properitoneal (Kronlein's). 
 \ Anterior. 
 / Posterior. 
 Parainguinal [Bruggiser's preperitoneal). 
 Intra-iliac (hernia of iliac fascia in internal iliac fossa). 
 Inguino-interstitial (Govrand's or Boyer's — hernia not 
 passed beyond external abdominal ring). 
 ^Scrotal (contents occupying the scrotum). 
 j'Saphenous (Beclard's — through the saphenous opening). 
 I Anterior (Velpeau's — in front of vessels). 
 Femoral (cru- j Posterior (behind vessels). 
 ral) Hernia ! y , , ,. -^r 
 
 into femoral i internal (inner side of vessels). 
 
 canal. 1 Pectineal (Clo:iuet — behind pectineus muscle) 
 
 I Lausier's (through Gimbernat's ligamem). 
 I Ascending subcutaneous. 
 Inguino crural (Holthouse— combined femoral and inguinal.) 
 Anterior retroperitoneal (Treves — sac lies along ilio-psoas muscle, inward 
 toward pelvis and upward from internal ring). 
 
 Congenital. 
 Acquired. 
 Ventral-^ Median: Linea alba hernia, congenital and acquired. 
 
 • ( Lateral: Linea semilunaris hernia, congenital and acquired. 
 Urachal (into urachu ) 
 Umbilical (om- f Supraumbilical. 
 
 phalocele). | Annular (paraumbilical). 
 
 Protrusion of ^ ^^ . , , ,, 
 
 bowel o r i ^"^^'^"'^^ ^'^o'"*^)- 
 
 omentum at ' In^raumbilical (coeliocele). 
 
 navel. i Interstitial (a) subcutaneous (b) subperitoneal. 
 
 Intersigmoid (protrusion ;-.t intersigmoid fossa in sigmoid meso-colon). 
 Sacro-rectal, also inferior. 
 
 1 Enterocele into lower fossa duodenojejunalis -j !^^^^'-' 
 
 J Duodenojejunal ] t:. . , ■ . 
 
 -" I Lnterocele into upper fossa, into the lesser cavity of the 
 
 '- peritoneum. 
 
 Retrocecal (small intestine beliind cecum or subcecal). 
 
 Ileo-cecal (into ileocecal fossa and extends behind the cecum). 
 
 Ileo-colic (into ileo- colic fossa). 
 
 Epigastric (just below xyphoid cartilage) 
 
GEXERAL COXSIDERATIOXS AXD CLASSIFICATIOX 
 
 ^ I Lumbar (emerg-ing from back of abio- / Cong-enital (Petit's triang-le). 
 n> I men between pelvis and last rib). \ Acquired. 
 
 H ■{ Hepatocele (hernia of the liver) 
 Splenocele (hernia of spleen). 
 Nephrocele (hernia of kidney). 
 
 c j 
 
 ^ I Diaphragmatic (through the diaphragm). 
 
 ^ 1 (Phrenic). 
 
 Perineal (ischiorectal — rests on floor of pelvis). 
 
 Obturator (infrapubic — into obturator foramen). 
 
 Ischial ic (sciatic — through sacrosciatic foramen). 
 
 Sacrorectal — due to defective ossification of sacrum (also posterior). 
 
 ^r ■ 1 i Rectovaginal, 
 jv Vaginal . ^ 
 S J ' Cystovaginal (bladder into vagina). 
 
 j Vesico-rectal (bladder into rectum). 
 
 Vesical -^ Vesico-inguinal (bladder into inguinal canal). 
 
 Vesico femoral (bladder into femoral canal). 
 
 Proctocele (may be mistaken for postanal duct). 
 
 Hernia into Douglas' Pouch. 
 
 r Foraminal (Winslowian — into lesser cavity of the peritoneum through foramen 
 
 H I of Win^low). 
 
 ^ I Mesenteric (Cooper's — retroperitoneal). 
 
 Oi -| (Passage of ponion of bowel through congenital weak spot in mesentery). 
 
 ^ I Diverticular (hernia through the mesentery of Meckel's diverticulum). 
 
 12; Omental (protrusion of a knuckle of bowel through a congenital weak spot in 
 
 '"' L omentum. 
 
 CONDITION OF SAC 
 
 En bissac (hourglass). 
 
 Multilocuiar (Cooper's or Hesselbach's femoral). 
 
 Lipomatous. 
 
 Sac absent (sliding). 
 
 Double Sac. 
 CONTENTS OF SAC 
 
 Diverticulum — Meckel's. 
 
 Sigmoid. 
 
 Rectum. 
 
 Cecum. 
 
 Appendix. 
 
 Colon. 
 
 , Small intestine \ [^J ^""'[^.^ 1°°P' , ,^ .,, , ' 
 I ( (b) portion of bowel (Littre). 
 
 Epiplocele (lipocele, steatocele, fat, omentum). 
 
 Entero epiplocele (intestine and omentum). 
 
 Gastrocele (stomach). 
 
 Cystocele (bladder). 
 
 Hysterocele (uterus): ] G-^avid. 
 
 ( Non-gravid. 
 Hepatocele (liver). 
 Oopherocele (ovary). 
 
 Tubocele (oviduct) ^ ^^o^mal tube. 
 ( Gravid tube. 
 Splenocele (spleen). 
 Nephrocele (kidney). 
 Pancreccele (pancreas). 
 
 Enterocele (intestine); 
 
i6 
 
 GENERAL CONSIDERATIONS AND CLASSIFICATION 
 
 Tumor 
 
 Hydatidocele (hydatid cyst). 
 Dermoidocele (dermoid cyst). 
 Benign. 
 Ma ignant. 
 Seminal vesicles. 
 
 i Blood (sanguinocele). 
 Fluid -\ Pus (puracele). 
 
 ( Serum (hydrocele). 
 Aneurysmocele (aneurysm). 
 Sarcocele (muscle). 
 
 [ Inflamed. 
 
 I Incarcerated (comp'ete obstruction of bowel) 
 
 CA, 1 J , ^ ■ 4. A\ \ Complete 
 
 I Strangulated (constricted) -^ incomplete 
 
 Cystic (cystocele). 
 
 Displaced (between layers of abdominal wall). 
 
 Concealed (not perceptible on palpation). 
 
 Reducible. 
 
 Irreducible. 
 
 Encysted (Cooper's sac is pu-hed into congenital opening in tunica 
 
 vaginalis). 
 Complete (sac and contents passed through orifice). 
 Incomplete (Bubonocele — sac does not protrude beyond external 
 
 abdominal ring). 
 
 CLINICAL 
 VARIETIES 
 OF HERNIA 
 
 Richter's. 
 Littre's. 
 
 Beclard's 
 Berketts 
 Boyer s 
 Bruggiser's 
 Cloquet's 
 
 Cooper's 
 
 Gerdy's 
 
 Goyrand's 
 
 Hesselbach's 
 
 Holthou«e's 
 
 Kroenlein's 
 
 Laugier's 
 
 Linhart's 
 
 Littre's 
 
 Malgaigne's 
 
 Partridge's 
 
 Petit's 
 
 Richter's 
 
 Treves' 
 
 Velpeau's 
 
 EPONYMIC HERNIAS 
 through the saphenous openirg). 
 
 into vaginal process of peritoneum — coming on late in life), 
 intrainguinal — Goy rand's) 
 properitoneal or parainguinal). 
 pectineal — behind pectineus muscle). 
 
 1. Crural, with protrusion through the superficial fascia. 
 
 2. Congenital, in tuaica vaginalis, 
 adumbilical). 
 inguino-interstitial — Boyer 's). 
 
 crural, with protrusion through the cribriform fascia). 
 
 inguino-crurai). 
 
 having both parietal and inguinal sacs, cruro-properitonea ). 
 
 crural throuijh Gimbernat's ligament). 
 
 retroperitoneal, parietal — a properitoneal hernia). 
 
 a portion of ileum strangulated). 
 
 congenital — inguinal). 
 
 femoral, anterior to or to the outer side of the femoral vein). 
 
 lumbar). 
 
 partial enterocele). 
 
 an'erior retroperitoneal — sac has made its way upward from 
 internal ring along ilio-psoas muscle, or in .. ard toward pelvis. 
 
 (femoral, anterior to vessels. 
 
PLATE 11. 
 
 I. Inguinal Hernia. 2. Femoral Hernia. 3. Obturator Hernia. 
 
 (Author's Case.) 
 
GENERAL CONSIDERATIONS AND CLASSIFICATION IQ 
 
 CONTENTS OF SAC. 
 
 Bladder. Quite a number of instances have been recorded in which 
 a diverticulum or pouch of the bladder formed the whole or a part of the 
 contents of the hernial sac. Personally, I have always felt that it is only 
 by accident that the bladder is found in the canal, either because of care- 
 less manipulation by the operator, or because of the formation of adhesions 
 which draw upon the bladder. However, I am free to admit that the blad- 
 der, or a diverticulum thereof, has been found inside the canal and must 
 be considered as a possible content of the hernial sac. 
 
 Charles Adams (Clinical Review^ Vol. 12, No. 4) reports an instance 
 where the tumor was quite distinct from the testicle, was easily reducible, 
 and presented all the indications of hernia without any vesical symptoms. 
 On incising what was supposed to be the sac, he encountered and opened, 
 inadvertently, a diverticulum of the bladder. This diverticulum which was 
 firmly adherent to the cord and canal, was cut away, its walls being too 
 thin to suture, and the opening into the bladder was closed by a continuous 
 suture. 
 
 S. C. Plummer (Jour. Am. Med. Ass'n., July 22, 1905) reported a 
 hernia of the bladder complicating an inguinal hernia, with an undescended 
 testicle on the left side. While operating for the hernia, he discovered a 
 second sac. He opened it and much to his surprise found it to be the 
 bladder. The wound in the bladder was sutured and primary union took 
 place. 
 
 Harrington (Annals of Surgery, September, 1900) cites a case of 
 hernia of the bladder tlirough the pelvic outlet caused by the traction of a 
 large subperitoneal fibroma of the uterus. The bladder was restored to 
 the pelvis, the tumor was removed, and the uterus was utilized to occlude 
 the opening, its appendages haidng first been removed. 
 
 A rather unique case is reported by Collier (Lancet, June 6, 1903). 
 The patient was being treated for a double reducible congenital hernia. 
 A truss failing to retain the hernias an operation became necessary. On 
 the right side the sac was found to contain the urinary bladder, and on the 
 left side it contained the cecum and appendix. 
 
 In another instance reported by C. E. Ingbert (Jour, of the Amer. 
 Med. Ass'n., Aug. 4, 1906), the patient had a right inguinal hernia for 
 seven years, but kept it in place with a truss. It finally became irreducible. 
 The tumor mass was three inches long, two inches wide, and one inch in 
 ■diameter ventro-dorsally. It was rather painful when pressed on or moved. 
 In the hernial canal was found a hard mass about the size of an egg, which 
 proved to be continuous with the bladder. It was pushed back and the 
 canal closed. 
 
 It will be seen from these recorded cases that unless the patient ex- 
 hibits symptoms of cystitis or distress referable to the bladder, it is almost 
 impossible to make a diagnosis of cystocele. F. Karewski (Archiv f. JClin. 
 Chir., Vol. 75) reports 5 cases, in one of which he succeeded in making a 
 clinical diagnosis. In two cases the diagnosis w^as confirmed by the cvsto- 
 scope. In one case the condition was not recognized until the sac was 
 
20 GENERAL CONSIDERATIONS AND CLASSIFICATION 
 
 opened, and in the remaining case the bladder was injured accidental}}-, its 
 presence in the canal not having been suspected. Three of the cases were 
 crural hernias occurring in women. Karewski states that no case of con- 
 genital hernia of the bladder has ever been reported. In 250 cases of 
 cvstocele reported the bladder was found forming a portion of the con- 
 tents of the sac of inguinal and crural hernias in five instances of the 
 former to one of the latter. H. J. Curtis (Brit. Med. Jour., July 11, 1903) 
 observed only one case in two years. 
 
 Xo matter whether or not hernia of the bladder is a genuine hernia, 
 the fact that it may be found in the canal makes it incumbent on the oper- 
 ator to exercise the greatest care when cutting down on the sac of a her- 
 nia, because of the possibility of finding a pouch of the bladder in the 
 canal. 
 
 Appendix — Enterocele. All parts of the intestinal tract may be 
 found within the sac of a hernia. Of course, the small intestine, particu- 
 larly the ileum, is usually contained in the sac. In 3,054 cases of hernia the 
 appendix was found in the sac 58 times, or once in about 33 cases. Of 
 100 cases of appendicular femoral hernia, 81 occurred in women and 7 in 
 men; no sex being mentioned in 12. The yoimgest patient was 19 years of 
 age, the oldest 87. More than one-half of the patients were over fifty years 
 old, and over 85 per cent, were past forty. 
 
 J. B. Hall (Brit. Med. Jour., June 28, 1902) reports a case of per- 
 foration of the appendix within the hernial sac, occurring in a man 23 
 years of age, who five days before his admission to the hospital, while lift- 
 ing a heavy sack of flour, was seized with a sudden acute pain in^ the right 
 groin. When operated ten days after the accident, the sac was found to 
 contain a mass of intestine together with lymph, disorganized blood clot and 
 pus. The appendix presented a perforation near its base through which 
 exuded pus, fecal matter and also two small concretions. The cecum was 
 so infiltrated, softened and septic that it was excised and an anastomosis 
 made with a IMurphy button. The patient recovered, the button being 
 passed on the seventeenth day. 
 
 C. J. Symonds (Trans. Loud. Clin. Soc., \"ol. 32) cites a case in which 
 the appendix occupied the sac of a right inguinal hernia. The tip of the 
 appendix was perforated by a pin. The patient was a woman, and the 
 diagnosis lay between its being a piece of incarcerated omentum and a pro- 
 lapsed ovary. When the sac was opened it contained some serous fluid 
 and a hard, elongated swelling looking like a piece of omentum. On rais- 
 ing this mass the end of a pin was exposed, protruding from the central 
 swelling. The mass proved to be the appendix. The canal was closed with 
 sutures and a drainage tube inserted into the superficial part. The appen- 
 dix occupied a patent funicular process. 
 
 In one instance cited by A. C. Wood (Annals of Surgery, May, 1906) 
 the patient, a woman, aged 70, had a painful, fluctuating swelling in the 
 right groin which was supposed to be a suppurating inguinal gland. On 
 incising the mass. Wood encountered a small, gangrenous, offensive mass, 
 
GENERAL CONSIDERATIONS AND CLASSIFICATION 21 
 
 which proved to be the appendix. It was contained in the sac of a femoral 
 hernia. 
 
 Four years afterwards he saw another patient who had a tumor in the 
 right groin, supposedly a femoral hernia. At the operation the swelling 
 was found to consist chiefly of serum, but the sac also contained the ap- 
 pendix, a portion of which was grasped so tightly at the neck of the sac 
 that its reduction was impossible until the constriction had been divided. 
 
 In 1900 I operated on a man 45 years of age for a swelling in his 
 right inguinal region. He had worn a truss for six years for his hernia. 
 Owing to increased swelling in this region the truss was discarded three 
 months before consulting me. The swelling continued to enlarge and finally 
 gave him discomfort while at work. The sac contained nothing but the 
 appendix in the condition of a retention cyst. The root of the appendix 
 w^as completely occluded. Almost an amputation of the appendix had 
 occurred. 
 
 Broughton and Hewetson (Lancet, June 16, 1906) report another case 
 of herniated appendix, the hernia in this instance being of the femoral 
 variety, occurring in a woman 63 years of age. After having been present 
 for twenty-four years, the small lump in the right .groin showed signs of 
 inflammation. A diagnosis was made of inflamed femoral epiplocele. An in- 
 cision over the mass was made, an abscess containing about two ounces of 
 fetid pus and surrounded by ragged, gangrenous walls was evacuated, and 
 a pin. incrusted with fecal matter, was found lying in the mass. Nothing 
 resembling a hernial sac could be distinguished up to this point. The whole 
 gangrenous mass was isolated down to the saphenous opening. After care- 
 fully covering up the gangrenous area with gauze, this was opened and 
 the contents were readily recognized as a thickened appendix and a small 
 mass of omental tissue. The appendix was withdrawn and amputated close 
 to the cecum, the omental loop was divided and both were pushed just 
 within the abdomen. A strand of iodoform gauze was inserted into the 
 femoral canal, partly to act as a drain to the appendical stump, but chiefly 
 to protect the peritoneum from becoming infected from the gangrenous 
 Scarpa's triangle. A large drainage tube was passed into the bottom of 
 the wound and the skin margin was approximated by silk-worm gut sutures. 
 
 My first (1885 J operation for strangulated hernia proved to be one 
 whose contents was the appendix and a portion (Littre-like) of the cecum. 
 The appendix was almost ruptured, greatly enlarged and inflamed. Its 
 root was so friable that a pressure forceps applied to it about half an inch 
 from the cecum cut it clear off, allowing fecal matter to pour over m)- 
 wound. I managed to ligate it with stout silk leaving the end long. The 
 cecum was adherent to the internal ring and I left it undisturbed, resting 
 content with cleansing the wound and packing it with iodoform gauze. He 
 made a good recovery and has not yet needed another operation. 
 
 This, no doubt, was a case of appendicitis, and not one of strangulated 
 hernia, as I diagnosed it. The appendix became inflamed while it was ex- 
 tending into the sac of the hernia. 
 
 Since that time I have removed the appendix through the hernial 
 
22 GENERAL CONSIDERATIONS AND CLASSIFICATION 
 
 opening- in a considerable number of cases. Before t3dng ofif the sac the ap- 
 pendix should always be inspected. A very useful instrument for dragging- 
 the appendix down into view is that devised by Dr. Barrett (F. 21). 
 
 Another instance of the difficulty of making a diagnosis when the 
 appendix is contained in the sac of the hernia is reported by Macewen 
 {Lancet, June 16, 1906). The patient presented himself for the relief of 
 a strangulated hernia which he said had existed for twelve years. A truss 
 had been worn until two weeks before the patient was seen. It was left ofif 
 because the man began to sufifer considerable discomfort, which eventually 
 turned into a distinct pain. On examination, Macewen found a large, 
 pvriform swelling afifecting the right inguinal region and scrotum. The 
 scrotal tissue was much inflamed. The testis appeared to be fused with a 
 mass which was firm in consistence and dull on percussion. No impulse on 
 coughing was elicited. The hernia was not reducible. At the operation the 
 hernia was found to consist of the appendix, the latter being held in posi- 
 tion by a pin, the point and about one-half the shaft of which projected 
 through a small ulcerative aperture in the wall of the appendix. 
 
 A unique case of femoral hernia was reported by S. Castellan! {Annals 
 of Surgery, Dec, 1898.) The sac contained small intestine, cecum, appen- 
 dix, ascending colon and transverse colon. He also reports a case of in- 
 guinal hernia in which he failed to find a sac. There had been intermittent 
 symptoms of strangulation, and one month before the hernia appeared an 
 abscess formed in this region and was opened. What was thought to be 
 the sac of the hernia turned out to be the lumen of the bowel. On incising 
 the external oblique aponeurosis it was seen that the knuckle of bowel ad- 
 hered to the abdominal wall opposite the external ring. 
 
 R. C. Turck {J our. Aincr. Med. Ass'n., April 26, 1902) reported a case 
 of hernia of the cecum, which was complicated by hydrocele and suppura- 
 tive appendicitis. The appendix, testis and sac were removed en masse, 
 together with a large amount of omentum. 
 
 Meckel's Diverticulum. — There is no end to the varieties of hernia 
 that one may encounter. R. E. Webster {Annals of Surgery, April, 1902) 
 reports a case of hernia of Meckel's diverticulum. The patient had svmp- 
 toms of intestinal obstruction, but examination showed a strangulated, left 
 inguinal hernia, and when the sac was opened a diverticulum measuring 
 three and a half inches in length v/as found arising from the ileum, which 
 was removed. 
 
 Liver. — Among the very rare varieties of hernia are the following: 
 A case of congenital hernia of the liver into the umbilical cord is reported 
 by J. W. Bullard {American Medicine, Nov. 8, 1902), as occurring in a 
 male child. Radical operation was attempted when the child was twelve 
 days old, but owing to the presence of extensive adhesions the operation 
 had to be abandoned. The child died twenty hours afterwards. 
 
 Pancreas. — Guimaraes {Progres. Med., Oct. 10, 1896) reported a 
 case of hernia of the pancreas following a bayonet wound. Forty-eight 
 hours after the accident the tail of the pancreas protruded from the in- 
 
PLATE III. 
 
 Petit's Triangle, Braun's Space, and the Anatomy of Sciatic Hernia. (After 
 
 Sanders.) 
 
 I. Latissimus dorsi muscle. 2. External oblique muscle. 3. Petit's 
 triangle. 4. Braun's space. 5. Gluteus muscle. 6. Gluteus maximus muscle. 
 7. Gluteal artery. 8. Gluteus minimus muscle. 9. Sciatic hernia. 10. Pyri- 
 formis muscle. 11. Great trochanter 12. Sciatic artery. 13. Gemellus su- 
 perior muscle. 14. Obturator internus muscle. 15. Gemellus inferior mus- 
 cle, 16, Sciatic nerve. 
 
GEXERAL COXSIDERATIOXS AXD CLASSIFICATIOX 25 
 
 •cision. It was restored to the abdomen and the wound closed. The patient 
 recovered. 
 
 Quenn collected 6 cases of hernia of the pancreas. In each case the 
 herniated portion of the pancreas was cut off. Five of the patients re- 
 covered. 
 
 Semixal A'^esicles. — Xogues recently reported a case to the French 
 Urological Association in which a periprostatic abscess was drained 
 through a perineal incision. Eight days later, while straining at stool, the 
 patient expelled both seminal vesicles through the wound. 
 
 HERNIA OF FEMALE PELVIC ORGANS. 
 
 Although the individual surgeon does not, as a rule, meet with cases 
 -of hernia of the female pelvic organs very often, the cases recorded in 
 the literature are quite numerous. Frank T. Andrews, of Chicago, has 
 made a very thorough study of this class of hernias, and his contributions 
 ■on the subject cover the field very well. 
 
 In 1905 (Jour. A. M. A., Nov. 25) he reported 366 cases culled from 
 the literature, including a full report of four cases of hernia of the tube 
 without the ovary. He found 46 cases of hernia of the tube without the 
 ovary; 80 cases of hernia of the ovary and tube,. 267 cases of hernia of 
 the ovary wdthout the tube ; 43 cases of hernia of the non-gravid uterus ; 30 
 cases of hernia of the pregnant- uterus. Of the 46 cases of hernia of the 
 tube alone, 2y were inguinal, 14 femoral, 2 obturator and 3 not stated. The 
 tube alone was found to be the contents of the inguinal sac in 23 cases ; tube 
 and intestine in 2 ; tube and omentum and tube and part of bladder in 
 one each. In eleven cases the sac contained fluid. Of the femoral hernias 
 the tube alone was contained in the sac 1 1 times ; tube and omentum once ; 
 tube and epiploon once ; tube and part of the bladder once. In seven cases 
 the sac contained fluid. 
 
 In 1906 {Jour. A. M. A., November 24) he reported 88 cases of in- 
 guinal hernia containing both ovary and tube, 80 of which were operated 
 on. In 18 of these 80 cases the ovary and tube were returned to the abdo- 
 men. In 2 cases the ovaries were removed and the tubes returned to 
 the abdomen. A tubal pregnancy within the hernial sac occurred in five 
 instances. In one case the uterus was pregnant in the pelvis while the 
 'Ovary and tube were in the hernial sac. There was strangulation in 11 
 cases; twisted pedicle in 13 cases; cystic ovary in 6; tuberculosis of the 
 tube in 2, and sarcoma of the ovary in one. In eight cases intestine or 
 lomentum was contained in the sac, and in two the appendix. 
 
 There were five cases of femoral hernia containing both ovary and 
 tube. There was incarceration and strangulation, with operation and re- 
 -covery in all. 
 
 There were four cases of obturator hernia and two of ischiatic hernia. 
 Regard (Archiv f. Klin. Chir., A'ol. Ixxv. p. 425) refers to four- 
 teen cases of hernia of the ovary reported by Deneux in 1814. Of this 
 number 9 were inguinal hernias ; 2 were ischiatic, and there was one hernia 
 «ach of the crural, vaginal, and ventral varieties. 
 
26 GENERAL CONSIDERATIONS AND CLASSIFICATION 
 
 In 1 871 English reported 38 cases, of which 27 were inguinal, 9 crural, 
 I ischiatic and i obturator. In 1892 Bitzako compiled the literature of 
 113 cases, 91 of which were inguinal, 17 crural. Puech in a series of 88 
 cases gives 54 congenital, 17 doubtful and 17 acquired cases. English be- 
 lieves that 17 of his cases were congenital. Bitzako states that 66 of his 
 series were congenital. Thus far the ovary has been found to constitute 
 the contents of the sac in 4 cases of ischiatic hernia. 
 
 Lockwood {Brit. Med. Jour., June 13, 1896) reports an unusual case 
 of hernia of the ovary that occurred in an infant only six months of age. 
 The child became ill suddenly, and two days later there appeared a swell- 
 ing which was tender to touch but was easily reducible. It was about 
 three inches long and one and a half inches broad. The skin over it was 
 inflamed. There was no impulse on crying, but the child vomited occa- 
 sionally. There w^as no obstruction of the bowels. A diagnosis was made 
 of strangulated hernia and at the operation the sac was found to contain 
 the ovary, the fimbriated end of the Fallopian tube, and a grumous fluid. 
 There were no adhesions at the internal ring. The tube and ovary were 
 replaced, the sac was ablated, and the wound closed. Mr. Owen reported 
 a similar case. 
 
 P. F. Morf {Annals of Surgery, ]\Iarch, 1901) reports one case of 
 hernia of the Fallopian tube, without hernia of the ovary, occurring in a 
 woman who had suffered from a congenital hernia in the left inguinal re- 
 gion. The case illustrates the extension of the inflammation from the 
 vagina through the uterus and then through the tube into the sac of the 
 hernia where it caused suppuration. A portion of omentum was also found 
 in the sac. Of 24 cases recorded in the literature, 13 were inguinal, 10 
 crural and one obturator. Strangulation was present in 14 cases. Of these 
 six were inguinal, seven femoral and one obturator. 
 
 J. H. Jopson (Annals of Surgery, July, 1904) reports the case of a 
 woman, aged 27, multipara, who had had a sm.all right inguinal hernia as 
 long as she could remember. It was of about the size of a walnut, a small^ 
 hard, painless protrusion, which always descended when she was on her 
 feet and disappeared on lying down. It always was reducible ; it gave her 
 no trouble, and she never wore a truss. Suddenly, while washing, a large 
 protrusion appeared in the right groin, accompanied by severe pain. There 
 was neither vomiting, constipation, fever or chill. The swelling then was 
 of about the size of a fist, situated in the right inguino-labial region, coming 
 from the external abdominal ring; hard, irreducible and somewhat tender. 
 A probable diagnosis was made of omental hernia. The tumor was pear- 
 shaped, the wide end presenting. The sac was adherent, except at the con- 
 stricted base. While endeavoring to unfold the sac, it suddenly split longi- 
 tudinally and about three-quarters of an ounce of a yellow, odorless pus 
 escaped. An ovary was seen to protrude from the canal to the right of 
 the neck of the mass, also the broad ligament and tube. It was then 
 discovered that the herniated mass was the uterus turned over forward, 
 the supravaginal portion running backward, downward and inward toward 
 the cervix. The necrotic and infected condition of the body of the uterus 
 forbade its reduction and it, with the ovar}^ and sac, were removed. To se- 
 

 PLATE IV. 
 
 Sliding Hernia of the Sigmoid. 
 (Author's Case.) 
 
GENERAL CONSIDERATIONS AND CLASSIFICATION 29 
 
 cure drainage, to exclude the peritoneum and to close as far as possible 
 the canal, the pedicle was fastened in the external abdominal ring, the pil- 
 lars of the latter being sutured with chromicized catgut above, around and 
 below it. A small gauze wick was laid over the stump and the wound was 
 closed in its deeper portion by a continuous chromicized catgut, and the 
 skin with silkworm gut. The patient made an uneventful recovery. 
 
 Hilgenreiner (Berliner Klin. Woch., xliii, No. ii) reports a case 
 of inguinal hernia of the uterus, and refers to 39 similar cases reported in 
 the literature. In the majority of these cases the defect was congenital and 
 was accompanied by other anomalies. In four instances the patients were 
 men and in another a male hermaphrodite. In eight cases the uterus was 
 pregnant. In the case personally observed the patient suffered from mel- 
 ancholia, which subsided completely after the operation. The uterus and 
 right adnexa with some loops of intestines were found in the hernia. They 
 were adherent and, on account of shock, the operation was done in two 
 stages. The psychosis developed during the interval of about nineteen 
 months. 
 
 In a case of hernia of the female pelvic floor reported by Keiller 
 (Anier. Jour, of Ohstet., March, 1906), the whole vagina was everted, the 
 intravaginal cervix uteri and its os occupying very nearly the center of 
 the tumor. There was no marked erosion of the vaginal mucosa. The 
 hernia contained two-thirds of the contracted bladder, the lower three 
 inches of the uterus, and half of the urethra; the whole vagina, which was 
 completely everted, at least four inches of a much-elongated uterus, the 
 canal, and 5 cm. of rectum, as well as the uterovesical and rectovaginal 
 pouches of peritoneum. The fundus of the uterus was only slightly lower 
 than normal. 
 
CHAPTER II. 
 
 THE TECHNIC OF OPERATIONS FOR HERNIAS. 
 
 The Patient, (a) Physical Condition.. Before attempting to per- 
 form an operation for hernia, it is of paramount importance to establish 
 definitely the exact physical status of the patient. A thorough physical 
 examination should be made of the heart, lungs and other vital organs, in- 
 cluding the determination of the renal functions and the condition of the 
 nervous system. The patierit's habits and mode of life ought also to be 
 looked into. It is a good rule to make it a routine practice to conduct this 
 examination just as carefully as one would in the case of an individual ap- 
 plying for life insurance, particularly as there is more at stake. 
 
 There is no operation for hernia that is not attended by more or less 
 risk, although the vast majority of operations are accompanied by only a 
 minimum risk, and do not endanger life. Some operations are attended by 
 special dangers. These will be discussed later on. When the operation 
 is not done in an emergency, to save the life of the patient, it is the duty 
 of the surgeon to estimate and choose between the danger to life incurred 
 by operating and the danger to life if the hernia is left uncured. If the 
 patient is in good health, the danger attending an operation for the relief 
 of a small, acquired, reducible hernia should be slight; but if the patient 
 is the victim of a chronic nephritis, or some other equally serious affection, 
 the operation might prove fatal. A form of hernia that is attended by con- 
 siderable operative risk is the ventral hernia which follows appendicectomy 
 or abdominal section, especially when many adhesions have formed. It 
 is here that the operator must possess keen judgment of the conditions 
 present and a full knowledge of possible results, in order that he may 
 decide wisely before advising operative intervention. 
 
 Another factor that must be reckoned with is the occurrence of sup- 
 puration in the wound following a herniotomy, because this is the principal 
 cause of relapse of the hernia. We know that some patients are more 
 prone to infection than others, and it is not only advisable, but necessary, 
 to determine this fact before operating. Sometimes it is well not to operate 
 on such patients. It is to be hoped that before long it will be possible to 
 forestall the occurrence of suppuration by immunization done before 
 operating. 
 
 It is wrong and inadvisable to promise the patient a cure, because even 
 under the most favorable circumstances relapses have occurred. Of course, 
 the operator is expected to express an opinion as to the outcome of the case, 
 but this opinion should be given only after weighing carefully all the evi- 
 dence he may have obtained by thorough examination and careful observa- 
 tion. 
 

 PLATE V. 
 
 Sliding Hernia of the Sigmoid — laid open. 
 (z-\nthor's Case.) 
 
THE TECHXIC OF OPERATIOXS FOR HERXIAS 35 
 
 When strangulation of the hernia has occurred, and efforts at reduc- 
 tion made by the patient himself (or by others) have failed, operation is 
 mdicated, except in most rare instances and only under the most unusual 
 circumstances. Then the operator should resort to taxis, under anesthesia, 
 before doing anything else. Here, again, we must not overlook the dan- 
 gers which attend the giving of an anesthetic. 
 
 Another affection which is likely to prove serious is that peculiar 
 dyscrasia known as hemophilia — the bleeder's disease. Under no circum- 
 stances should the victim of hemophilia be operated on (strangulation ex- 
 cepted) until he has been under treatment looking toward the relief of this 
 condition. Short and easy operations on hemophiliacs have resulted fatally. 
 While a herniotomy usually is not a serious operation, yet it is apt to be a 
 long one, which would surely prove fatal under the conditions just re- 
 ferred to. 
 
 In contrast to the "bleeder" is the man whose blood vessels are too 
 full, whose functions are too active. His tissues are producing a large 
 amount of waste which requires a correspondingly increased activity on 
 the part of the emunctories to remove. As a rule, such individuals have 
 been accustomed to an active life and they rebel when thev are compelled 
 to remain in bed for a few weeks while recovering from the eft"ects of an 
 operation. In such cases the chances of recovery are not as good as they 
 are in the less robust patient, the less active individual, whose meta- 
 bolism has not been over-active, and whose emunctories have not been 
 over-taxed. Before an operation is undertaken on these robust persons,, 
 or what at one time was called a condition of plethora, the patient should 
 be dieted and purged freely for a week or two, if necessary, so that all his 
 functions may be balanced. It is not often, however, that more than four 
 or five days of such treatment are necessary. Each individual is a law unto 
 himself, and must be treated accordingly. 
 
 (b) Age. The resisting and recuperating powers vary at dift'erent 
 periods in life. Experience has sho^v■n that between the ages of five and 
 fifteen major operations prove more successful than at any other period 
 of life. The death-rate is higher both before and after that time. 
 All wounds heal more rapidly in children than in adults. In the former 
 regeneration of lost tissue takes place more quickly because all the tissues 
 are in a state of growth, whereas in the adult, regeneration means the 
 awakening of a dormant process. 
 
 Another factor in favor of the child is that worry and anxietv be- 
 cause of the impending operation do not exist. Children also stand the 
 confinement better ; they are not so restless ; they are more easily amused 
 and entertained than the adult. On the other hand, however, children 
 cannot endure pain without suffering markedly ill effects. They are very 
 prone to suffer profoundly from shock. In the case of very young children 
 ^nd infants, the dressings, if not protected properly, become soiled with 
 the discharges and suppuration ensues. 
 
 If possible, an operation should not be performed during the time of 
 first dentition, because gastro-intestinal disturbances, convulsions, and 
 pyrexia are apt to develop on the slightest provocation. 
 
34 THE TECHNIC OF OPERATIONS FOR FIERNIAS 
 
 It cannot be denied that from the time of maturity to the termination 
 of life the mortality after major operations for hernia increases with each 
 year of life. The aged patient, however, who is well-preserved mentally 
 and phvsically will withstand the operative cure of hernia without any 
 .material danger to life.- Of course, the old are much more likely to suc- 
 cumb to the effects of shock, because the vitality of their tissues has been 
 undermined, so that in some instances the risk to life is greater from the 
 convalescence than it is from the effects of the operation itself. 
 
 It is not in the highest interests of surgical advancement to perform 
 an operation for the cure of hernia on an octogenarian unless it is under- 
 taken for the purpose of relieving actual suft'ering or to prolong life. Old 
 age of itself is serious enough as a contra-indication to operation, but 
 senile degeneration of the arteries and internal organs is to be dreaded by 
 the surgeon. Nevertheless, in taking a retrospective view, the surgeon can- 
 not be otherwise than impressed by the fact that the comfort of the body 
 has been increased and many lives saved by timely operations on hernias. 
 
 (c) Sex. Sex, on the whole, seems to exert but little influence on 
 the outcome of operations for the relief of hernia. This is particularly 
 true in both the young and old in the comfortable walks of life. Fem.ales, 
 between the ages of fourteen and forty, usually stand the stress of an oper- 
 ation better than do males between those ages. Women lead less active 
 lives ; they are more patient and tolerant to house life ; they bear pain bet- 
 ter; thev are more easily encouraged, and they are less affected by hemor- 
 rhage, pain, shock, vomiting, etc., than are men. The only conditions 
 that must be considered in connection with sex are those of menstruation, 
 pregnancy, lactation, and the climacteric ; but as the time for operations 
 for the cure of hernias can in most instances be chosen, it is unnecessary 
 to operate during the periods mentioned, except when the hernia has be- 
 come strangulated, when operation is positively indicated. 
 
 (d) Habits and Disease. Alcoholism. Tiiere are two classes of 
 alcoholics that demand the serious consideration of the operator, (i) the 
 confirmed drunkard, and (2) the man wdio takes his "nightcap" and his 
 "eye-opener" every day. In both these classes the operative mortality is 
 much higher than it is in the temperate individual. Delirium tremens com- 
 plicates any operation. It is advisable to refuse all except the most urgent 
 operations in heavy drinkers. It takes more than two weeks to eliminate 
 alcohol from the system of one who uses it every day, and a still longer 
 time to tone him up before he can be operated on safely. 
 
 Tuberculosis. Tuberculous patients suffer from hernia quite fre- 
 quently. As a rule, it is best not to recommend an operation for the cure 
 of hernia in this class of patients unless strangulation occurs, when it is 
 necessary to operate in order to save life. Then a cure of the hernia should 
 be eft'ected at the same time. If the victim of the hernia is also suffering 
 from a tuberculous peritonitis or a tuberculous condition of the hernial 
 sac, an operation is not only justifiable, but commendable for the treat- 
 mcni of both the tuberculous disease and the hernia. Such operations 
 should be performed through the hernial area, even at the risk of infecting 
 
PLATE \l. 
 
 Inguinal and Ventral Hernia with Suprapubic Vesical Fistula. 
 
 (Author's Case.) 
 
THE TECHNIC OF OPERATIOXS FOR HERXIAS . 3/ 
 
 the wound with tuberculosis. In the case of phthisis and tuberculosis of the 
 joints, the operation for the relief of hernia should be deferred until such 
 time as the tubercular condition has been relieved. When the tuberculosis 
 is confined to the lymph glands of the neck, and a hernia also exists, the 
 glands should be removed first, and the hernia not operated sooner than 
 three months afterward. Children who are puny and poorly-nourished 
 should not be operated on, even though no positive evidence of tuberculosis 
 is found, unless it is certain that the hernia is materially interfering with 
 the child's well-being. Of course, strangulation always is a positive in- 
 dication for operation. 
 
 Syphilis. This afi:"ection, in an}- of its stages, is a contra-inuication to 
 operation for relief of hernia, except when strangulation has occurred. 
 While it is true that, as a rule, wounds of the tissues of a syphilitic heal 
 well, still there is the exceptional case that does not heal up promptly, but 
 breaks down with local manifestations of specific disease. 
 
 Rheumatism, Gout, Diabetes IMellitis ax^d other Coxstitutioxal 
 Diseases. What is true of tuberculosis and sypiiilis also applies to these 
 constitutional diseases, especially during their acute stage. Operations on 
 diabetics are always to be dreaded because of the uncertainty 'of the out- 
 come. The tissues are not in a state that favors prompt and uncomplicated 
 regeneration. Their condition favors sepsis and gangrene. Therefore the 
 subjects of such diseases are not to be operated on, except in an emergenc}'. 
 Rheumatism is not so serious a complication as is diabetes, yet it is ad- 
 visable to put the patient under energetic medical treatment before attempt- 
 ing to perform an operation for the cure of the hernia. Sometimes it is 
 necessary to operate on a patient who is suffering from some acute infec- 
 tious disease, but it will be understood that these are only emergency cases. 
 The judgm&nt of the operator must be the sole guide in determining v. hen 
 and when not to operate. 
 
 Mental Coxditiox. The mental condition of the patient always mate- 
 rially affects the prognosis after a surgical operation. The patient who 
 has a nervous temperament always dreads an operation. He is afraid of 
 the anesthetic; he is afraid of the knife; and he fears being hurt. Often, 
 however, it is these patients who display most courage when there is no 
 alternative. They are more calm and more considerate than the average 
 patient, because they yield to the inevitable, knowing that it is the only 
 way to avoid a fatal issue. The sullen, gloomy and apathetic person, who 
 is filled with an indifference to all. that is going on about him, and who is 
 convinced that there can be only one outcome, a fatal one, is the most un- 
 favorable to operate on. I recall one case, that of a man who deliberately 
 starved himself to death. He stood the operation well, and the wound 
 healed nicely, but he absolutely refused either to drink or eat. He would 
 not even retain food passed into the stomach through a stomach tube. 
 Although his hands were tied, he succeeded in vomiting up the food by 
 persistent voluntary efforts. Nutrient enemeta were expelled at once. Nor- 
 mal salt solution kept him alive for two weeks. 
 
 The epileptic and the insane bear all operations well because their men- 
 
38 THE TECHXIC OF OPERATIONS FOR HERNIAS 
 
 tal condition in no way interferes with the outcome. Operations have been 
 known to cure epilepsy. Two such cures have occurred in my own ex- 
 perience. The statistics of operations on the insane show a remarkably 
 low mortality and the surgeon need never hesitate to operate on this class 
 of patients, although operations done for the cure of hernia in the insane 
 are undertaken only in an emergency. 
 
 (e) Preparation. The preparation of patients for operations is both 
 deliberate and emergent, and at the same time local and constitutional. The 
 deliberate preparation consists in allowing from one or t^vo to <:even or four- 
 teen days, before the patient is safely submitted to the operative cure for 
 hernia. As a rule, patients are in the hospital twenty-four hours before 
 an operation is performed. Those who earn their living by hard manual 
 labor, who indulge excessively in athletic sports, as well as those who lead 
 an automobile and club life, had better be dieted, purged and generally 
 strengthened by suitable tonics before being operated. 
 
 When a surgeon consents to shorten the time of the preparatory treat- 
 ment, contrary to his usual and special practice based on his experience 
 and knowledge, regretable complications and results may have to be borne 
 with chagrin, disappointment and sorrow. In the surgical treatment of 
 hernia, as in that of all other surgical conditions, let him not be dissuaded 
 from carrvine out the dictates of his conscience. 
 
CHAPTER III. 
 
 INSTRUMENTS USED IN HERNIA OPERATIONS. 
 
 The instruments employed by the author in performing operations for 
 the cure of hernia are shown in illustrations Nos. 21 and 22. 
 
 Ferguson's straight and curved — large and small — angiotrypsic 
 
 forceps (i, 2, 3). 
 Halsted's mosquito forceps — straight and curved (5, 6). 
 Barrett's bowel holder (7). 
 Needle holder — Ferguson. 
 Scissors: One Mayo (dissecting), and two smalls-curved and 
 
 straight. 
 Three retractors — Byford, Mayo, Ferguson. 
 Forceps. 
 
 Three sets needles — 
 Mayo (bowel) (i). 
 Ferguson, round and cutting (2). 
 Straight skin needles for horsehair (3). 
 Knives — Two center-pointed for dissecting. 
 
 Two back-pointed for making incisions, using one for skin in- 
 cision, and the other for incising the remaining structures 
 down to the sac. 
 Sterile Instruments in Reserve. 
 
 Several sharp knives, 3 or 4 scissors, and a razor. 
 An assortment of needles. 
 Two dozen forceps, small and large. 
 Catheters — silver, glass and rubber. 
 Retractors — sharp and blunt. 
 Transfusion needles, etc. 
 In addition to the above, the surgeon should have in readiness a trans- 
 fusion apparatus, Downes' transformer, a thermo-cautery, and a stomach 
 tube. 
 
 While an expert surgeon can perform the operation for the radical 
 cure of hernia with a very few instruments — a knife, or scissors, tissue 
 forceps, and a needle and thread — better, safer and cleaner work is done 
 by him with a suitable supply, as here enumerated. 
 
 The knives chosen should, above all things, be sharp. A dull-cutting 
 scalpel worries the operator and unduly traumatizes and also endangers 
 the tissues. An instrument that cuts clean affords the artistic operator 
 an opportunity to sweep along so lightly that even the small branches of 
 blood vessels are brought into view, clamped, and then severed, thereby 
 
40 INSTRUMENTS USED IN HERNIA OPERATIONS 
 
 preventing blood-staining of the tissues. In order to obtain the best results 
 in operations for inguinal hernia, it is absolutely essential to differentiate 
 and study the structures involved, and this cannot be done accurately when 
 the tissues are stained with blood. 
 
 A large-bellied scalpel should not be used while a careful dissection 
 is being done around the spermatic cord. This work demands a knife 
 whose point is in its center, and then the operator knows and feels where 
 the cutting point is all the time. 
 
 Halsted's mosquito forceps are sufficient to check the subcutaneous 
 hemorrhage, but when the superficial epigastric, superficial pudic, or super- 
 ficial iliac vessels are exposed, and have to be severed (usually only the 
 superficial epigastric), the Halsted forceps are not powerful enough to 
 permanently check hemorrhage without the use of ligatures, and the fewer 
 the ligatures the better, consequently it is better to use the author's angio- 
 trypsic forceps, the smaller size, straight and curved, which should be left 
 holding the vessels until the sac is ablated, and then removed, when 
 hemostasis is complete and permanent. When we consider that every liga- 
 ture is a tax upon the tissues to care for it, and that it may be an addi- 
 tional source of infection, it is an advance in surgical technic when the 
 number of ligatures is limited to a minimum by using efficient crushing for- 
 ceps, such as those mentioned. The author has repeatedly performed such 
 operations as herniotomies and breast amputations, and trusted entirely 
 to these forceps for hemostasis, and he has never been disappointed. 
 
 A larger vessel than is severed in operations on hernia, such as all the 
 arteries and veins below the upper third of the leg, may be trusted to the 
 angiotrypsic crush of the large forceps for hemostasis. Vessels situated 
 inside the body, as, for example, the ovarian and uterine vessels which 
 are onl}^ secured in intermediate hemorrhage at great risk to the life of 
 the patient, are not trusted to the angiotrypsic force of the large forceps, 
 but this much is gained, and that is. that a very small-sized ligature may 
 be used efficiently on the vessels thus crushed, say No. oo, and o, or i, 
 formalin chromic catgut, instead of Xo. 2 or 3, when no such crushing is 
 done. 
 
 Barrett's bowel holder is a useful instrument to drag out, hold and 
 replace bowels, appendix, omentum, ovaries and tubes. It greatly facili- 
 tates inspection of intra-abdominal contents Vvuthout undue manipulation. 
 
 The three retractors mentioned (Fig. 22), Byford's, Mayo's and Fergu- 
 son's, have each an especial application in different hernial localities. 
 
 The Byford retractor is suitable to raise up and retract the abdominal 
 wall after the abdomen is opened in umbilical or ventral hernias, without 
 tearing the peritoneum. This simple act of raising the abdominal wall 
 and looking at the abdominal contents before passing the hand is a useful 
 source of information as to the position of organs and as to the existence 
 of pathologic conditions. 
 
 Mayo's retractor is the best to protect the spermatic cord while oper- 
 ating on inguinal hernia. The cord is placed in the broad space between 
 the two blunt prongs of either end of the retractor, and is held there with- 
 out fear of injury. 
 
.•4s 
 
 fP^h^//^ 
 
 PLATE VII. 
 Ventral Hernia Following Rupture of P.ectus Muscle (Thos. Pickering- 
 Pick.) 
 
INSTRUMENTS USED IN HERNIA OPERATIONS 43 
 
 The Ferguson retractor has a blunt and a sharp end. Occasionally 
 a sharp retractor is needed. The needles selected should be both round 
 and cutting.' The author, of course, prefers his own in all hernial opera- 
 tions. The cutting needles are used only to sew the skin. When the 
 bowel has to be sutured or the appendix removed, bowel needles of Mayo's 
 kind had best be employed. The be?t needles for inserting wire are those 
 devised by M. L. Harris. 
 
 When it is necessary to remove adherent or strangulated omentum, 
 the electro-thermo-cautery of Downes is the most efficient instrument for 
 this work. At the selected site for ablation, seize hold of the om.entum 
 with one or two of Downes' clamps and turn on the current, which in a 
 minute or so heats the blades and cooks a strip across the tissues within its 
 grasp, and permanently forestalls any hemorrhage. The mass is then cut 
 off, care being taken not to cut outside of the center of the cooked, ribbon- 
 like tract. Inasmuch as the end of the omental stump has lost its vitality 
 by heat, no adhesions can take place to it. 
 
 In dealing with extensive omental and fibrous adhesive bands, and 
 when it is clear to the surgeon that the separation of these adhesions by 
 foi'ce would leave many or extensive raw surfaces on the parietal peritoneum 
 or elsewhere, then Downes' electro-thermo-cautery is an instrument of 
 great value. It is applied to the adhesions, a ribbon-like tract seared, and 
 in the center of the cooked tissues the scissors is applied and passed through 
 the stump or stumps proximal to the viscera. These are allowed to recede 
 and the distal stump or stumps left to cling by their adherent ends, with- 
 out the danger of new adhesions forming. Should, however, the elaborate 
 apparatus of Downes be not at hand or out of order, and adhesions, as 
 above mentioned, are encountered, then the angiotrypsic forceps come in 
 well ; clamp en masse in two places ; release the forceps ; tie in the crushed 
 grooves, and cut between them. Then bury the raw stumps between 
 omental or peritoneal folds which will prevent the formation of extensive 
 new adhesions. 
 
 In hernial cases the omentum sliould not be amputated because it is 
 found within the sac. If it is not attached and it appears normal, it should 
 be left alone. It is singular but true that it takes two raw surfaces to 
 create adhesions. A wonderful example in nature is to be foimd in the 
 ovary, whose surface, w"here the follicle ruptures, becomes raw once a 
 month during menstruation, and no adhesions follow, but- let infection 
 come on the scene of operations, and cause traumatism to the surrounding 
 structures, and the ovaries will soon become buried in adhesions, only 
 limited by the nature and virulence of the special bacteria in the field. 
 
 The operator must not forget how delicate the peritoneum is, and 
 that even handling bowels with gloves is liable to cause dangerous trauma- 
 tism and paresis of the muscular coats, with subsequent distention, which 
 favors the transmission of bacteria from the mucous to the peritoneal mem- 
 brane, sufficient to agglutina.te many coils of bowel, perchance permanently. 
 
 The dissecting scissors, devised by Mayo, or Greig-Smxith's, greatly fa- 
 cilitate the delicate task of liberating one deep structure from another, with 
 
44 INSTRUMENTS USED IX HERNIA OPERATIONS 
 
 the least amount of danger. Seizing the tissues with a thumb and finger 
 forceps, the operator makes gentle traction. Then in a clear field a small 
 snip with the scissors makes an opening through which the closed point 
 of the scissors is inserted, and immediately opened widely, wdiich reveals 
 the structures sought for. In quick succession the scissors are used as- 
 above mentioned, until the dissection is completed, and all the structures 
 in the hernial area are differentiated and dealt wnth secundum artem. In 
 my most delicate operations I am very fond of using the knife and gauze, 
 but I am sure that I can work more rapidly and just as safely with the 
 scissors. 
 
 The only operation for hernia that requires special instruments to 
 carry out its original technic is MacEwen's. He devised a right and left 
 ligature carrier, but even in the performance of his operation they are no 
 longer required, because any large-sized, round-pointed needle, grasped 
 fi.rmly in a suitable needle holder, v."ill answer the purpose equally well. 
 
CHAPTER IV. 
 
 MATERIALS ISED FOR HERNIAL OPERATION 
 (FERGISON). 
 
 Formalin chromic catgut. 
 
 Chromic catgut — Xo. 00, o, i, and 2. 
 
 Silkworm gut — small size. 
 
 Horsehair — large size. 
 The chromic or the formalin chrom.ic catgut comes from the dealers in 
 alcohol in sealed glass tubes, which are boiled for forty-five minutes with- 
 out breaking the tubes. 
 
 Ligature and Suture Material. — In all surgical operations extended use 
 is made of various materials both for ligature and suture purposes. These 
 materials are classified according to their source into animal, vegetable and 
 mineral, but for surgical purposes the classification is made usually with 
 reference to the behavior of these materials in the tissues, so that we have 
 absorbable and non-absorbable materials, as follows: 
 L Absorbable. 
 
 1. Catgut. 
 
 2. Tendon. 
 
 a. Kangaroo. 
 
 b. Deer. 
 
 c. Ox. 
 IL Non-absorbable. 
 
 1. AVire. 
 
 a. Silver. 
 
 b. Gold. 
 
 c. Aluminum bronze. 
 
 2. Silkworm gut. 
 
 3. Horsehair. 
 
 4. Silk. 
 
 5. Linen thread. 
 
 6. Celluloidin thread ( Pagenstecher's). 
 
 /. ABSORBABLE SUTURES. 
 
 I. Catgut. — Catgut is obtained from the fibrous coat of the intestine 
 of sheep. The intestines are macerated until the serous and muscular coats 
 on the one side, and the mucous coat on the other, are easily scraped off. 
 The fibrous coat remains. This is cut into strips of different lengths and 
 thickness. These strips are then twisted spirally and are allowed to drv. 
 After they have dried thoroughly they are polished wdth pumice stone and 
 
46 MATERIALS USED FOR HERNIAL OPERATIONS 
 
 rolled into coils, when the catgut is ready for the market. This is dry or 
 raw catgut. 
 
 The ordinary commercial catgut (rawO is not sterile. It is therefore 
 unfitted for surgical work. Besides, it is too brittle. When it is j^laced in 
 water the catgut swehs,. becomes soft, slippery and elastic, and has a ten- 
 dency to curve upon itself. But its strength is not impaired. If catgut i* 
 boiled in water without having been put through a special process, it is 
 cooked and rendered useless for surgical purposes. In order to be used 
 for ligatures and suture material, the catgut must be made aseptic and 
 pliable. 
 
 Catgut is used in two forms, either as aseptic or antiseptic. The first 
 form is simply rendered sterile, while the second is permeated with some 
 antiseptic agent, such' as iodine, carbolic acid, chromic acid, etc. 
 
 The aseptic catgut is used either dry or moist. The dry form is soft- 
 ened in the tissues, swells and acts as a culture medium for bacteria. Be- 
 cause of this fact the dry form of catgut must not be used to suture the 
 skin or mucous membranes. The germs that are not removed from the 
 skin find this aseptic catgut a more suitable pabulum on which to multiply 
 than the wound secretion. This gives rise to stitch abscesses. Aseptic 
 catgut has no germicidal power, while the blood serum has a very marked 
 action in that direction, as have also the living tissues. x\septic catgut is 
 more suitable for tying blood vessels that are situated deeply in the tissues 
 where bacteria are not found normally. If, however, a large amount of 
 catgut is placed deeply in these tissues, infection is quite likely to occur. 
 Inasmuch as sterile or aseptic catgut has no advantage over antiseptic cat- 
 gut, and has many disadvantages, it has practically been discarded, especial- 
 ly in operations for the cure of hernia. 
 
 There is another reason why aseptic catgut cannot be used in hernia 
 operations, and that is because it is absorbed in too short a time, before 
 granulation tissue has become thoroughly organized, wdien the structures 
 yield readily to intra-abdominal pressure and relapse of the hernia is fa- 
 vored. 
 
 Antiseptic catgut may be prepared in a manner that either will hasten 
 or retard its absorption. Carbolized catgut remains antiseptic in the tis- 
 sues for only a short time. As soon as the carbolic acid is eliminated from 
 the catgut, the latter is converted into an aseptic catgut, and possesses the 
 same properties and disadvantages as does aseptic catgut. The same is 
 true of catgut that has been sterilized with bichloride of mercury and cer- 
 tain other agents. 
 
 The best catgut is that which has been prepared by the formalin method. 
 It becomes very hard and can be boiled safely without being cooked. This 
 is also true of chromic catgut. Catgut that has been treated with formalin 
 and with chromic acid, a variety that I have been using for some years, 
 does not swell in the tissues as does the plain sterile catgut, and the action 
 of the phagocytes on it is from without inward, so that the catgut remains 
 antiseptic while a shred of it is left. This catgut is not absorbed rapidly,, 
 and it is therefore very suitable for use in hernia operations. Even the 
 
PLATE Mil. 
 
 Posterior Hernia through Duodeno- jejunal Fossa. 
 Transactions of the Society (Pathological) of London, \'ol. II. 
 I. Sac of the hernia situated behind the folds of the meso-colon. 2. The 
 lower portion of the ileum, passing out of the hernial sac. 3. The caput 
 coli. 4. The displaced portion of the transverse colon. 
 
MATERIALS USED FOR HERNIAL OPERATIONS 49 
 
 finest strand of formalin-chromic catgut does not become absorbed before 
 the expiration of twelve or fourteen days. No. 6 catgut is not absorbed 
 until the expiration of six months. Nos. i and 2 are absorbed inside of 
 three or four weeks, just the time required in hernia work. Chromic cat- 
 gut, because of its greater strength, can be used in smaller sizes. I prefer 
 to use sizes No. 00, o, i and 2. 
 
 Iodine catgut and pyoktannin catgut are also used, in fact preferred, 
 by some operators, but this catgut, like that prepared according to the cumol 
 and abolene method, becomes aseptic when the agent used is abstracted 
 from the catgut by the tissue fluids. For some purposes the iodine and 
 pyoktannin catguts are very useful because of the color. 
 
 The fine catgut that is prepared by the formalin-chromic acid process 
 may be made so antiseptic that it can be used for suturing the skin and 
 mucous membranes with impunity, because before absorption of this very 
 hard material can take place the time for its removal has passed. 
 
 There is no operation for hernia of any kind in \vhich catgut cannot 
 be used without danger of infection, but it is not the most suitable material 
 to use for coapting the skin wound. 
 
 2. Tendons.- — The tendons that are used in surgical work are derived 
 from the kangaroo, the deer and the ox. Tendon has one vei?y great ad- 
 vantage that is not possessed by catgut — viz., when it is removed from 
 the body it is sterile. If, however, the tendons are not properly cared for 
 immediately after their removal from the body, or if they are not removed 
 from the body before decomposition takes place, they may be found loaded 
 with germs. 
 
 Because of these accidents which may render tendon septic, it is ad- 
 visable to asepticize it by the use of chemicals, such as alcohol, carbolic 
 acid, corrosive sublimate, etc. 
 
 Tendon has another advantage over catgut, and a very valuable one at 
 that, in that it is not readily absorbed, so that it does not require hardening 
 or any special preparation with formalin, or some other substance ; nor 
 does it require boiling. The natural asepticity of tendon, its durability in 
 the tissues, and the readiness with which it can be split up into small and 
 large threads, makes it a very suitable material for suturing together the 
 deep structures in hernia operations. To H. O. ]\Iarcy, of Boston, may be 
 given the credit of championing this material. 
 
 II. NON-ABSORBABLE SUTURES. - 
 
 I. Wire. — Wire sutures possess some advantages that make them 
 very useful for certain kinds of work, but, all things considered, they do 
 not take the place of either catgut or tendon. Wire is easily made aseptic. 
 It is pliable, especially the silver wire, and it is not affected by the tissue 
 fluids. Aluminum bronze wire is better than silver wire, because it pos- 
 sesses greater tensile strength. It does not break or kink as readily as 
 does silver. The only objection to gold wire is its cost. 
 
 Silver wire v/as at one time used very freely as a buried suture. It 
 does not cause any irritation of the tissues and in the passive tissues of the 
 body, such as bone, it remains for an indefinite period without causing anv 
 
50 MATERIALS USED FOR HERNIAL OPERATIONS 
 
 disturbance whatever. It is still used extensively for wiring bones. Ex- 
 perience has shown that silver wire when used in hernia operations will 
 work its way out to beneath the skin, necessitating its removal. This does 
 not occur until months or sometimes years after it has been placed in the 
 tissues, but this property makes the use of the wire decidedly objectionable. 
 Many cases have been reported where the wire was removed as long as 
 fifteen years after its insertion. If wire is used at all in operations for the 
 cure of hernia, it should be according to the method described by M. L. 
 Harris. This method makes it possible to remove the wire after it has 
 fulfilled the purpose for which it was intended. 
 
 2. Silkivorm Gut. — This is obtained from the silkworm in the larva 
 stage. It is small and strong, smooth and hard. It is sufficiently pliable 
 to stand the tying. It does not harbor germs in its interstices to any 
 marked degree, and does not readily carry germs to the deeper structures. 
 It is easily sterilized, and withstands repeated boilings. It must not be 
 used as a buried suture, however, experience having shown that it causes 
 irritation not unlike that produced by wire. This is followed by suppura- 
 tion, necessitating the removal of the material. Silkworm gut is very suit- 
 able for suturing skin wounds. If found necessary for suturing the deeper 
 structures it should be used according to the method recommended by 
 Charles A. Davison, so that it can be removed after the tissues have united. 
 Although silkworm gut is not elastic, it accommodates itself very nicely to 
 the shape and form of the tissues. It is sterilized by steam or boiling water 
 for half an hour, and is then preserved in suitable vessels. 
 
 Lockwood doubts its ready sterilization by one boiling", having found 
 it septic in two cases out of thirty-seven instances after it had been boiled 
 for twenty minutes. If silkworm gut is boiled with soda it is softened, 
 and its tensile strength is lessened. Inasmuch as Lockwood's observation 
 is no doubt true, it is better to sterilize silkworm gut by the fractional 
 method. Whenever hernial wounds have to be drained, several strands of 
 sterilized silkworm gut can be used advantageously. 
 
 3. Horsehair. This material is obtained from the manes and tails 
 of horses. It is smooth, elastic, and resilient. It is easily rendered aseptic 
 and is only slightly absorbable. It is very suitable material for coapting skin 
 wounds. It can be rendered aseptic without boiling. Boiling destroys the 
 elasticity of the hair more or less, and makes it very brittle. In order to 
 render it absolutely aseptic, it ought to be sterilized by the fractional method, 
 but this process destroys the hair and unfits it for use as a suture material. 
 Hair is the only material that nature allows to pass through the skin with 
 impunity. This is its normal habitat, and consequently the hair does not 
 cause any irritation. That is probably the rcaiuu why hair, though not 
 absolutely aseptic, can be used very freely as a superficial suture without 
 causing any infection. It is not suitable for buried sutures. Another 
 point in its favor is that even when it is tied too tightly, it accommodates 
 kself readily to the wound by stretching and thus does not cause the local 
 necrosis which occurs so often when silkworm gut, wire or other suture 
 material is used. 
 
.MATERIALS USED FOR HERNIAL OPERATIONS 51 
 
 Horsehair is prepared by first immersing it in a four per cent, boiling- 
 soda solution, which removes grease and other foreign substances. After 
 being brushed and washed it is boiled for fifteen minutes, and is then kept 
 in a weak solution of carbolic acid, 1-20. or bichloride, i-iooo. Horsehair 
 is also prepared by putting it through the same process as that used for 
 disinfecting the hands and then preserving it in alcohol. 
 
 4. Silk. Silk is employed in the form of twisted or braided silk. 
 The varieties of twisted silk used are ordinary surgical silk, cable twisted 
 silk, and saddler's silk. Surgical silk is used in sizes from No. 00 to No. 
 14, and in color is either white or iron dyed, the advantage of the latter 
 being its ^asy detection when deeply embedded in the tissues. 
 
 Cable silk, or Tait's silk, is more easily manipulated, is of firmer texture, 
 and is less liable to slip when knotted than ordinary silk on account of the 
 animal matter left in its meshes by the worm during the spinning process. 
 
 Saddler's silk, except for its cheapness, possesses absolutely no ad- 
 vantages over surgical or cable silk. 
 
 Braided silk is prepared by braiding together several strands of twisted 
 silk. It is very strong and has no tendency to kink. 
 
 Silk is very strong and pliable, and the smaller sizes of it are disinte- 
 grated by phagocytic action. The small particles are carried to different 
 parts of the surrounding tissues, where they become encysted. Applied to 
 the more passive structures, such as tendons and fascia, silk nearly always 
 becomes encysted. The objection to it as a buried suture is that it is a 
 foreign body, hence predisposes to suppuration. 
 
 Of all the suture materials used, silk follows the needle with the least 
 amount of traumatism ; but it is non-absorbable, and is likely to carry 
 bacteria in its w^ake. In my opinion, it should not be used as a buried 
 suture in any hernia operation. If its use is imperative from lack of choice, 
 the smallest size possible should be selected. Clinical surgery is replete 
 with so many instances of secondary suppuration following the use of buried 
 silk in hernia operations that it is practically discarded, although a few" 
 noted surgeons still use it. 
 
 5. Linen Thread. — Linen thread is a substitute for silk, but should be 
 used only in an emergencv. The same objections pertain to it as to silk, 
 even more so, because it is coarser and more easily absorbs germs in its 
 meshes. It also breaks more easily. If linen thread must be used for 
 ligature material, the smallest size possible should be chosen. 
 
 6. Celluloid Thread. — In the absence of catgut and tendon the celluloid 
 thread, or Pagenstecher's thread, mav be ased. It has the advantage over 
 silk and linen in that it is coated with celluloid and consequently is less 
 absorbent. It is impermeable to fluids. Like silk, it is easily manipulated, 
 and is readily sterilized. It is strong;er than silk and also is more durable. 
 While it will stand a few boilings,_ frequent repetitions of the boiling will 
 disintegrate the thread. It should not be used in operations for the radical 
 cure of hernia. Only catgut or tendon should be employed. The celluloidin 
 thread is used to some extent in intestmal sureerv. 
 
CHAPTER V. 
 
 THE CHICAGO HOSPITAL OPERATING ROOM TECHNIC 
 
 (FERGUSON). 
 
 Head Nurse. — The head nurse is the surgical nurse. She has charge 
 of the operating room, the daily work and instruction of the three nurses 
 under her, and during operations handles the instruments, and must wear 
 gloves. She prohibits visitors running in and out; and no lounging, 
 coughing, laughing, talking, whistling or singing at any time is allowed in 
 aseptic quarters. The head nurse is responsible also for the personal toilet 
 of the nurses. 
 
 Second Nurse, Daily Work. — Order drugs, muslin, gauze and cotton. 
 Keep front operating room in order. Keep clean labels on bottles. Work 
 quietly. 
 
 Before Operation. — Scrub up ; assemble materials ; have in place sur- 
 geon's gowns, visitors' gowns, rubber goods, caps and brushes. Help set 
 operating room, and keep surgically clean by covering all breaks in the 
 antiseptic chain. 
 
 During Operation. — Help fill basins, solutions and percolators. Keep 
 solutions proper temperature. Help scrub patient. Keep clean. 
 
 After Operation. — Ventilate rooms. Clean rubber goods, brushes, and 
 help with instruments. 
 
 Third Nurse, Daily Work. — Keep back operating room in order. 
 Sterilizers and sterilized. Fill boric and carbolic buckets. Boil soap, 
 brushes, and nail files. 
 
 Before peration.-^Scruh up. Set anesthetizer's tray ; help with oper- 
 ating room. Keep clean. 
 
 During Operation. — Help fill basins; place sponges. Take binder oft. 
 Help with stirrups. 
 
 After Operation. — Pick up soiled linen and help with basins. 
 
 Fourth Nurse, Daily Work. — Order soap (laundry and toilet), candles, 
 soda, sapolio, razors, matches, toothpicks. Keep preparatory room in order, 
 and sinks clean. Sterilizers and surgeon's bathroom, dressing chute, sup- 
 ply closet, cart, and wind clock. Keep quiet. 
 
 Before Operation. — Scrub up. Wash furniture with 5 per cent, car- 
 bolic. Tie door-knobs with gauze wet with bichloride. Fill glasses with 
 green soap (sterile), and put in place! Help set operating room. Keep 
 clean ; help to gown operator and assistants aseptically. 
 
 During Operation. — Wear gloves. Sponge when needed. When not 
 sponging, keep faces clean. Help fill solutions. Count sponges carefully 
 and count again when finished. Disgown operator. 
 
CHICAGO HOSPITAL OPERATING ROOM TECH NIC 53 
 
 After Operation. — Assist in putting' on dressings, changing gown, get- 
 ting in cart, blankets over patients. Go to room with patient, taking towels, 
 wet gown and record. See that porter conies to mop. Pick up dressings, 
 and clean basins. After each operation all basins are sterilized by live 
 steam for two hours under high pressure, and when used in septic cases 
 I in 20 carbolic acid solution as well, and kept in canvas bags. 
 
 CARE OF OPERATING ROOMS. 
 
 Por^^r.— Cleans floors after each operation. Every morning before 
 operations the floors and furniture are mopped \\ith carbolic acid (5 per 
 cent.). The walls are washed with soap and water and then with carbolic 
 acid solution (5 per cent.) or bichloride solution ( i to 500), at least once a 
 week. After a pus case the operating room is immediately fumigated with 
 formaldehyde for twelve to twenty-four hours. Once in three months the 
 walls are repainted. All the windows are closely screened and kept clean. 
 
 After pus cases instruments are boiled twenty minutes, allowed to 
 stand twenty-four hours, and boiled again. This is done three times, allow- 
 ing twenty-four hours' interval each time. A shorter method is to scrub 
 the instruments in lysol solution until they are thoroughly freed from pus, 
 blood, etc., then submerged in 95 per cent, carbolic acid for five minutes, 
 and transferred directly to the 2 per cent, soda solution, in which they are 
 boiled for twenty minutes. The instruments are then finally dried, polished 
 and returned to the instrument case. 
 
 For Sterilising Horsehair. — Ten minutes in ether; 10 minutes in alco- 
 hol; 10 minutes in bichloride. Then allow to stand in alcohol. Boil silk- 
 worm gut and wire with instruments, after being autoclaved or sterilized 
 fractionally by boiling in sealed glass tubes (chromic, Nos. 00, o, i, 2, from 
 dealers). 
 
 All catgut is to be boiled forty-five minutes before using. (This is 
 chromic or formalin chromic catgut that is bought in sealed glass tubes.) 
 
 Iodoform Emulsion. — Ten parts sterile glycerine, 1 part sterile iodo- 
 form. (Supply always on hand.) 
 
 Iodoform Gauze. — Glycerine, sterilized, oz. 2 ; iodoform powder, oz. 2 ; 
 alcohol, oz. 2 ; green soap solution, oz. 2. 
 
 Things necessary for making : Two sterile basins, i for hand solu- 
 tions, T for iodoform powder ; i sterile medicine glass ; i sterile sheet ; ster- 
 ile plain gauze. When finished, sterilize twenty minutes at fifteen pounds 
 pressure, then put in sterile jars. 
 
 Normal salt for filling flasks for transfusion: Dissolve 8 tablets (in 
 one bottle) in small amount of water; filter through sterile cotton into 
 sterile flask, which holds one quart ; sterilize in autoclave at high pres- 
 sure (fifteen pounds), for one hour. (1,000 cc. flasks always ready.) 
 
 Normal salt in hulk : Dissolve 8 ta-blets to each mark on normal salt 
 bottle ; filter through sterile cotton, after boiling, into sterile bottle. Add 
 enough sterile water to fill bottle. Sterilize in autoclave at high pressure 
 for one hour. 
 
 Carbolic, 5 per cent, in hulk: Take 12 ounces of 95 per cent, carbolic. 
 
54 CHICAGO HOSPITAL OPERATIXG ROOM TECHXIC 
 
 add 2 ounces of 95 per cent, alcohol, boil with small amount of water. Add 
 enough sterile water to make two gallons. 
 
 Carbolic^ P5 per cent., in bulk : Add 5 per cent, of water to carbolic 
 crystals, take cork out of can, place can in pail of water and boil until 
 liquid, or liquefy the crystals first in a water-bath and add the 5 per cent, 
 water afterwards. 
 
 One to 500 bicJiloride, in bulk : Dissolve 600 grains bichloride powder 
 in a small amount of water, add to make 4}^ gallons. Add enough picric 
 acid to give a distinct color. 
 
 Harrington's Solution: Commercial alcohol (94 per cent.), 640 c. c. ; 
 hydrochloric acid, 60 c. c. ; water, 300 c. c. ; corrosive sublimate, 0.8 grams. 
 
 Saturated Solution of Boric Acid (in bulk) : Place boric crystals in 
 gauze, then in pail or jar. Pour in hot water. Allow to stand and dis- 
 solve as much as possible, keeping more crystals in pail than possible to 
 dissolve. Strain and boil before filling percolators. 
 
 Green Soap Solution {in hulk) : Take 34 ounce of hard green soap 
 to one-half gallon of water and boil. 
 
 Sterilised Gauze: Measure five yard lengths of 18 pieces at a time; 
 loosely roll and place in sterile sheet, and sterilize in autoclave at high pres- 
 sure (fifteen pounds) for two hours. Then cut for dressings or for sur- 
 gical jars, after which each must be sterilized in autoclave for one hour. 
 Sponges and drawn gauze are sterilized by the same process as above. All 
 the sheets are loosely rolled and autoclaved for at least one hour. The 
 same sterilization is done with glass jars loosely filled with cat gauze. 
 
 Sponges are kept in 5 per cent, carbolic before using, are waslied by 
 gloved nurse in sterile water, and then boiled tw^enty minutes. All articles, 
 glass parts, catheters, rubber tissue, etc., kept in glass jars in solution of 
 saturated boric acid, except silk (95 per cent, alcohol), and again boiled 
 before using. 
 
 Brushes, when gotten out of sterilized jars, are kept in bichloride, as 
 are also the catgut tubes. 
 
 Floor laparotomy sets contain one large piece and two small pieces af 
 combination dressing, inclosed in a cotton cloth cover. 
 
 Operating room laparotomy set in cloth cover contains 15 safety pins 
 in a string, laparotomy binder, perineal straps, 2 large pieces of combina- 
 tion dressing (cotton and gauze), sterile gauze packages, one dozen in 
 each, supplied separately. 
 
 Floor dressing set contains one large piece of combination cut into 
 three pieces. Gauze in separate packages. 
 
 Operating room set contains in cover one binder, two pieces (^f com- 
 bination, 15 safety pins. 
 
 All specimens must be plainh marked with patient's name, floor, niui'!- 
 ber of room, and doctor's name. Put in 4 per cent, formalin, sealed, and 
 taken to laboratory without delay. Head surgical nurse responsible for 
 specimens. 
 
 Each full set of basi)is in a sterile bag contains: Hand solution basins, 
 7 for racks, 4 smaller, i specimen, 2 small for instrument table, I pitcher; 15 
 pieces. 
 
Pericardial Diaphragmatic Hernia of the Omentum. 
 Transactions of the Pathological Society of London. (M. Miirrant Baker.) 
 A. Pericardium laid open and reflected so as to expose the omentum, 
 which covers the front and sides of the heart. B. The diaphragmi. C. The 
 stomach. 
 
CHICAGO HOSPITAL OPERATING ROOM TECHNIC 57 
 
 Odds and ends in a sterile hag: Four pitchers; 2 long basins, one 
 for alcohol, for needles, knives, etc., and one for carbolic, for sterilizing 
 cutting instruments, needles, etc. ; 2 small round basins ; 2 hand solution 
 basins; i pus basin; i small basin, for Harrington's solution for hands; 
 14 pieces. 
 
 SERVICE STAFF — NIGHT SUPERINTENDENT. 
 
 Has charge of office ; answers telephone, bell calls, makes three rounds 
 of all the floors ; posts operations for following day ; instructs night nurse 
 in operating room ; reports births and deaths to Superintendent at once ; 
 looks after the comfort of relatives and friends ; assembles emergency 
 supplies, and takes charge of the operating room when emergency cases 
 are admitted for operation. While in the operating room, the head nurse 
 on the second floor takes charge of the office. The entire hospital is kept in 
 readiness for any kind of professional work by night as well as by day. 
 
 NIGHT SURGICAL NURSE. 
 
 Stays in preparation room between the two operating rooms all night. 
 In emergency work puts the room in order, boils instruments, prepares 
 solutions, etc., etc. ; in brief, assumes the functions of the day surgical 
 nurses. Her chief function outside of the above is to prepare gauze and 
 sterilize in autoclave or boil (fractional method) all materials used in opera- 
 tions. Usually both methods of sterilization are simultaneously carried out. 
 She also assists the internes when night dressings of wounds are imperative, 
 or transfusions are made. 
 
 Operator and assistants appear in sterile clothing from cap to shoes. 
 
 Fifteen Minute Method. — Scrub up with sterile brushes and sterile 
 .-soap for ten minutes, changing nail brushes two or three times, and using 
 running sterile water. The nail files are sterile and must be used before the 
 final scrub. The hands are then scrubbed in alcohol, 70 per cent., and 
 lysol (5i to §j), or bichloride solution (i to 2,000) consuming five minutes 
 with the antiseptics. Then sterile rubber gloves are filled with lysol solu- 
 tion and pulled on. This antiseptic permeates the skin of the hands while 
 thus gloved, acting as a continuous antiseptic, and should a glove be injured 
 there is no danger of infecting the wound from this source. Instead of 
 the alcohol, lysol or bichloride, the Harrington solution is preferable. 
 
 Ten Minute Method. — (a) Scrub up with soap and water for eight 
 minutes ; (b) scrub hands in Harrington's solution for two minutes. Ready 
 for operating with oi' without gloves. 
 
 Four Minute Method. — Two minutes with ether, using (a) brush for 
 one minute; (b) gauze for one mmute. Two minutes with Harrington's 
 solution. 
 
 In five minutes the surgeon can render his hands and operative field 
 practically aseptic : Ether oit hands, one minute ; ether on hands and field 
 of operation simultaneously for two minutes, and then Harrington's solution 
 simultaneously for two minutes. 
 
 Rubber gloves are used by the operator (Ferguson) in 70 per cent, 
 -of cases ; by his assistant internes and nurses in all cases in which contact 
 infection is possible. 
 
CHAPTER VI. 
 
 INDICATIONS FOR OPERATION. 
 
 OBLiaUE INGUINAL HERNIA. 
 
 Any person afflicted with an inguinal hernia is a surgical case, but the 
 mere presence of such a hernia does not invariably and indiscriminately 
 demand an operation. The general health of the patient, his age, occupa- 
 tion, obesity and various other conditions must be taken into considera- 
 tion. 
 
 General Health. — The presence of a hernia sometimes detrimentally 
 affects the general health of a child or of a youth. Because of fear of 
 mjury, chafing of the truss, pain or strangulation of the rupture, the af- 
 flicted one is not able to participate fully in the exercises, plays and out-of- 
 door sports so essential to good health and natural development. I have 
 frequently observed a delicate boy, handicapped in almost every muscular 
 movement, undergo a remarkable change in health and habits soon after 
 his rupture was cured, becoming a ruddy, romping, muscular fellow. 
 
 Age. — In infants an operation is indicated: (a) When the hernia is 
 very large (colossal) and constantly increasing in size. If an early opera- 
 tion is not performed the abdominal cavity is liable, in time, to become too 
 small to hold the hernial contents with comfort, (b) If strangulation oc- 
 curs, (c) Should the hernia be a source of continual annoyance, and not 
 readily controlled by pressure, it is not in the best interests of the hernial 
 area, nor beneficial to the general healtii and development of the child, to 
 defer operation until he begins to walk. Mechanical appliances have a 
 wide range of usefulness from birth imtil the time the child begins to walk. 
 A large percentage of cases are spontaneously cured with gentle support 
 to the hernial protrusion during this age. 
 
 Weak and undeveloped children bear the operation of radical cure bad- 
 ly. When surgical interference is acceded to, precautions should be taken 
 against contagious and infectious diseases. Children reduced in flesh by 
 diarrhea or other diseases should be attacked cautiously with the knife. 
 When a child begins to run about and still has a congenital or an acquired 
 hernia, as a rule I advise an operation. There is no valid reason for delay- 
 ing the operation until the school age is reached. Damage to the testicle 
 may be initiated by procrastination. In consideration of the minimum risk 
 to life, and the maximum good results ensured by the radical cure for 
 inguinal hernia, there is no age at which it cannot be safely offered as a 
 remedy. 
 
 All hernias of the inguinal variety in both sexes between two and forty 
 or fifty years of age should be cured by operation, if circumstances and 
 
IXDICATIOXS FOR OPERATIOX 59 
 
 physical conditions permit of it. No young man or woman is doing instice 
 to his or her development and health by nursing a rupture during school 
 and college life, let alone the many ri,sks incidentalh' encountered on the 
 playground and campus. 
 
 The wearing of a truss produces atrophy of the muscular and apo- 
 neurotic structures in the hernial region. It is the rule for hernias to 
 become more and m.ore unmanageable on account of the thinning out and 
 destruction of tissue thus caused. Those W'ho wear trusses are likely, sooner 
 or later, to ask for surgical relief, either on account of the inefficiency of 
 one truss after another, or owing to the increasing size of the hernia, and 
 the tenderness at the seat of the rupture. Active young boys and girls 
 and able-bodied men and women should be advised to submit to the oper- 
 ative treatment even when a truss is worn without comfort and efficiency, 
 because after a time the rupture, in the vast majority of cases, will enlarge 
 and become rebellious to a truss. 
 
 ]\Ien between fifty and seventy years of age, or older, depending on 
 their physical condition, need no longer hesitate to undergo an operation 
 for rupture, providing their vital organs are normal. It is occasionally 
 admissible to perform the radical operation for hernia at the same time 
 that a prostate is being removed, and such double operations as herniotomy 
 and appendectomy ; herniotomv and salpingectomy ; herniotomy and h}'s- 
 terectomy, etc., through the same incision, are not uncommon in my prac- 
 tice. 
 
 In operative procedures generally the routine of the operation should 
 be done rapidly ; in fact, almost automatically, while one should "hasten 
 slowly" when handling and dealing with the most important structures. It 
 must be remembered, however, that it is worse to be criminally rapid than 
 to be criminally slow. Be speedy at common technic and even tedious, if 
 need be, for safety. 
 
 Occupation. — The more laborious the occupation of the ruptured, the 
 more advisable it is to recommend an operation. Let them live, and live in 
 bodily comfort. The exertions at toil or sports increase intra-abdominal 
 pressure and force a rupture, inevitably, to increase in size. Considering 
 the extensive clinical services now universally afforded to the public, no 
 person, be he ever so poor, need continue to be partly or completely dis- 
 abled by a hernia. The well-to-do and wealthy classes can well afford to 
 be surely and safely relieved of their hernial at'Mictions. It is not many 
 years ago that an operation for the radical cure of hernia was accompanied 
 by manv dangers, complications, relapses and fatalities. It is a proud 
 achievement of surgery to chronicle that now deaths are less than one- 
 quarter of one per cent., complications seldom occur, and relapses are 
 exceedingly rare. 
 
 It is not uncommon for men in middle life, who are the subjects of (me 
 or two inguinal hernias, to present themselves for advice. Let us sav that 
 they are small, reducible, and controllable hernias, with but slight incon- 
 venience resulting from the wearing of a truss, and that their work is 
 not muscularlv laborious, and the dansrers of strangulation are guarded 
 
60 INDICATIONS FOR OPERATION 
 
 against as much as possible. It must be remembered that no person who 
 is wearing a truss is free from danger, for any extra exertion, as lifting, 
 running to catch a car, jumping off and on conveyances, and a thousand 
 other wavs that could be mentioned, is liable to pop the rupture bv the truss 
 and strangulation occurs, probably for the first tim.e. In consideration of 
 this one fact, it is safer for such mildly herniated cases to spend a vaca- 
 tion in a hospital for two or three v."eeks in obtainn-cg a cure, than to run 
 the risks associated with an ocean voyage, a railroad journey across the 
 continent or a hunting and lisliing trip into the wilderness. Men occupied 
 in the public service, especially in the army and navy, in whom an inguinal 
 hernia develops, should be operated on without delay. It is certain that 
 these acquired ruptures occur in men whose inguinal regions are congen- 
 itally deficient and weak. This predisposition being present, the exciting 
 cause is furnished by the fatigue and labor inseparable from their calling 
 in life. In this connection it would be interesting to ascertain how many 
 old soldiers and sailors receive a pension solely on account of the presence 
 of a hernia. Great care should be exercised in the physical examination 
 of applicants for the army and navy, and also for life and accident insur- 
 ance. The indication for operation on these individuals, when a hernia is 
 found, has been generally conceded. Some' insurance companies, to their 
 discredit, have been lax in this regard. 
 
 Obesity. — The fact that a person is obese does not Jiecessarily debar 
 him or her from the benefits of an operation for hernia, but it does call for 
 an early operation and a master hand. They are, of course, more difficult 
 to operate on than those who are spare or muscular. In the first place, they 
 usually take any anesthetic badly, and especially so when they are placed 
 in the Trendelenburg position, which is often necessary to keep the bowels 
 and great omentum well away from the field of operation. Owing to the 
 amount of superimposed fat, a longer incision than usual is also required, 
 in order to expose the aponeurotic and muscidar structures. On exposing 
 the internal ring, sac and cord, redundant fat is often found everywhere, 
 sometimes in rolls. The sac itself may be fatty or have fat on, along or 
 around it, making it difficult to differentiate the sac or suture it or tie it 
 off. Fatty degeneration of the aponeurosis of the external and internal 
 oblique muscles, and of the conjoined tendon, may be marked, which makes 
 the structures more delicate and friable than usual. The fatty degenera- 
 tion just mentioned does not exist so markedlv in a man of active habits 
 as it does in one who is sedentary. 
 
 This brings up the question of preparation for operation for hernia on 
 the inactive obese. It is wise to reduce the flesh by exercise and proper 
 diet, whenever circumstances and local conditions permit such a reduction. 
 Let the patient eat less, walk, run or work more than usual. If he is a beer 
 drinker,, exclude the beer. In behalf of surgeons in general, and espcciailv 
 in the interests of the patiexit, I am constrained to advise the novice in 
 surgery not to speak lightly of obesity in connection with the radical opera- 
 tion, or even to undertake the operation. The amount of fat to be removed : 
 the proper coaptation of the structures to ensure the success of the opera- 
 
A5 Cleave land. 
 
 PLATE X. 
 
 Diaphragmatic Hernia. 
 
 (Peacock's Case.) 
 
 Transactions Pathological Society of London. 
 
INDICATIONS FOR OPERATION . 6^ 
 
 tion; the prevention of dead spaces; the final suturing; when and when 
 not to drain ; the apphcation of a suitable dressing and the after-treatment 
 all demand and tax the experience, skill and dexterity of a master sur- 
 geon. A doctor is not a surgeon and only becomes one by having a natural 
 aptness for surgery, and by acquiring a paijistaking application of his en- 
 dowments. He must learn and have at his command a full and complete 
 knowledge of all of the macro- and microscopic conditions demanding 
 operation. He must then learn how to cut well, clamp nicely, tie quickly 
 and saf.^ly, mop at the right time, and sew not too loosely, not too tightly, 
 but just right. In surgery experience never teaches fools. I have seen 
 the ''would be" surgeons guilty of the same errors even when pointed out 
 again, again and again, ad inHnitum. 
 
 Conditions. — There are many conditions of an oblique hernia that de- 
 mand operation without delay. These will be taken up more fully later on 
 in this work. In the meantime it is v/ell to enumerate them, as follows : 
 
 1. Unmanageableness. 
 
 2. Irreducibility. 
 Inflammation. 
 Incarceration. 
 Strangulation. 
 Rupture by a blow or fall. 
 
 In regard to the size of the hernia, I must say that sometimes a small, 
 troublesome one is more dangerous than a large, quiet one. Quiet is a good 
 adjective when the hernia is easily reducible and immediately returns, lying 
 calmly in the scrotum without any pain whatever. The very large hernias, 
 those extending down on the thigh to near the knee, are usually classed 
 as inoperable. We sometimes are obliged to operate on them when they 
 become strangulated, and then we succeed in curing the hernia. An ex- 
 perienced, expert operator very seldom refuses to operate on account of the 
 large size of the rupture, even though it is incarcerated. 
 
 Cryptorchidism. — In retentio ingninalis testis a hernia is alwa\s pres- 
 ent, and it ought to be cured by operation. AVhen the testicle is retained, 
 within the abdomen surgeons differ as to whether or not an attempt should 
 be made to bring the organ down into the scrotum, even though a hernia is 
 not present. In my own experience, a congenital deficiency in the inguinal 
 region has always been present in the cryptorchid, hence I have not hesitat- 
 ed to enter this region, bring the testicle to its normal position, and cure 
 the hernia, even though it may have been of small size. 
 
 It is in this connection that I make use of the Fowler operation for 
 oblique inguinal hernia, with the exception of incising the peritoneum be- 
 hind the cord. The peritoneum is dissected away- from the transversalis 
 fascia and sutured, or tied separately. This allows the vas deferens a 
 shorter route than normal between the seminal vesicles and the testes. 
 
 It must be recognized that heretofore operations on the non-descended 
 testicle have not been very satisfactory. Failures in bringing down the 
 testicle were frequent and about fifty per cent, of the hernias relapsed, 
 consequently surgeons avoided the operation. Now that plastic procedures 
 
64 . INDICATIONS FOR OPERATION ' 
 
 can be used to strengthen this congenitally weak region, recurrences are 
 exceedingly rare. No relapse has occurred in any cases of hernia com- 
 plicated with cryptorchidism on which I have operated in the past seven 
 years. 
 
 DIRECT INGUINAL HERNIA. 
 
 The indications for operating on a direct inguinal hernia are prac- 
 tically the same as those given for the oblique variety, but inasmuch as a 
 truss does not well retain this form of hernia, the sooner the operation 
 is performed the better. A congenitally weak Hesselbach's triangle Is 
 weakened still more by the application of a truss, and when this condition is 
 permitted to exist for years the conjoined tendon becomes obliterated al- 
 most entirely. In order that this region may be strengthened, the sur- 
 rounding structures are made use of, such as the rectus muscle on the one 
 side or the sartorius muscle on the other. 
 
 UMBILICAL HERNIA. 
 
 Umbilical hernia in children under two or three years of age is often 
 practically cured by the application of a pad or truss. If, at any time, the 
 hernia becomes unmanageable, there is no valid reason for delaying opera- 
 tion. If the operation is not performed early in these cases, the diastasis 
 of the recti muscles constantly increases, and when the operation finally 
 is undertaken it is a much more radical and grave procedure. 
 
 The radical cure of a small umbilical hernia is a very simple procedure, 
 consisting merely of the removal of the umbilicus, an omphalectomy, and 
 splitting the sheaths of the two recti muscles, obliterating the linea alba 
 above and below the umbilicus. 
 
 No umbilical hernia should be allowed to become incarcerated. Just 
 as soon as it is irreducible, whether the hernia is small or large, operation 
 should be advised. All active young persons the subjects of an umbilical 
 hernia should be operated on at the earliest possible moment. 
 
 Women who are bearing children and who have an umbilical 'hernia, 
 even a large one, need not be operated on until the child-bearing period 
 is passed, provided the hernia does not give rise to any dangerous symp- 
 toms. Umbilical hernias giving rise to pain, intestinal disturbance or 
 symptoms of strangulation should be operated on without delay. Since the 
 overlapping operation of Mayo and Blake, and modifications of these opera- 
 tions, have been devised, excellent results are obtained. Even obesity is not 
 a contra-indication to operation for umbilical hernia. A large amount of 
 the abdominal fat may be removed at the same time and the patient thus 
 made more comfortable and placed in better physical condition. 
 
 Hernia into the umbilical cord (funicular hernia) is of very rare oc- . 
 currence, the author having seen only one case. It should be operated on at 
 once, because the child will surely die if operation is not done. 
 
 Supra- sub- and para-umbilical hernias when small may be cured with- 
 out removing the navel. 
 
INDICATIONS FOR OPERATION 05 
 
 FEMORAL HERNIA. 
 
 Of all the hernias of the anterior abdominal wall, the femoral or crural 
 hernia is the most dangerous because of its tendency to become strangulated. 
 A femoral hernia is not easily controlled by any form of truss or mechanical 
 device. It usually slips from under the truss several times a day until the pa- 
 tient becomes discouraged, leaves off the truss, and perhaps the very next 
 day the hernia becomes strangulated. Therefore, on account of the clinical 
 history of femoral hernia, operation should be advised in every instance. 
 
 VENTEAL HERNIA. 
 
 Ventral hernia, in mid-line, below the umbilicus, almost invariably 
 follows an abdominal section or an operation on the bladder. These her- 
 nias should be operated on as soon as they are detected. If possible, it is 
 better to remove the entire old scar tissue, split the sheaths of the recti 
 muscles and bring like-to-like structures in careful approximation. 
 
 In this region there are so many ways in which material can be used 
 to strengthen the abdominal wall that the surgeon need have no hesitation 
 in recommending operation. Inasm.uch as adhesions between the great 
 omentum and the abdominal scar are always present, care should be taken 
 not to denude the peritoneal surface in dealing with them. It is here that 
 Downes' electro-thermo-cautery is of great value. A strip of tissue is 
 cooked and severed in its center and both the proximal and the distal stumps 
 are allowed to drop back into the abdominal cavity, v/ithout the fear of 
 adhesions forming later on. However, a practical surgeon can always cover 
 over any raw surfaces so as to prevent these adhesions from again forming". 
 It is rare for a ventral hernia to develop in the linea alba beloAv the um- 
 bilicus, but when it does arise, operation is the only means of cure. 
 
 Ventral hernias through the recti muscles are very rare. They always 
 follow a trauma. These hernias are cured easily and there is no contra- 
 indication to operation. Hernias following gall-bladder and stomach opera- 
 tions are seldom encountered. 
 
 HERNIAS FOLLOWING APPENDECTOMY. 
 
 These hernias sometimes are verv difficult to handle on the operating^ 
 table. Unless the patient is in a condition to stand a prolonged anesthesia,, 
 of an hour's duration at least, he should not be operated on unless an opera- 
 tion is demanded because of the existence of strangulation of the bowel.. 
 In a case operated recently by the author the chief indication for operation 
 was pain extending down to the testicle. At the operation it was found 
 that the cecum, the ascending colon and several loops of small intestine and 
 some omentum were adherent to the ureter, kidney, liver, gall bladder and 
 stomach. 
 
 EPIGASTRIC HERNIA. 
 
 These hernias are usually quite small and consist of fat, although oc- 
 casionally a small knuckle of stomach or bowel is found in the hernial sac. 
 If they give rise to any considerable inconvenience, they should be treated 
 
66 INDICATIONS FOR OPERATION 
 
 surgically. It is very seldom that the transverse colon, omentum or stom- 
 ach form the contents of the hernial sac, except when the protrusion is 
 immediately above the umbilicus. 
 
 OBTURATOR. ISCHIATIO AND PERINEAL HERNIAS. 
 
 (Downward Hernias.) 
 
 So far as indication for operation is concerned in the case of these 
 hernias, they are the same as those given for the internal hernias, dia- 
 phragmatic hernia, hernia through the foramen of Winslow (foraminal), 
 through the jejunal fossa, the sigmoid fossa and through the ileo-cecal 
 fossa. The usual indication for operation in all these forms of hernia is the 
 appearance of symptoms of partial or complete obstruction of the bowel. 
 The abdomen should be opened without delay, the obstruction sought and 
 the condition rectified. 
 
 A few cases of obturator hernia have been diagnosed before operation 
 and cured without an abdominal section by cutting down on the femoral 
 region, going through the pectineus muscle, reaching the hernia in that 
 way and producing reposition of the bowel. 
 
 DIAPHRAGMATIC HERNIA. 
 
 Diaphragmatic hernia, the acquired variety, produces symptoms refer- 
 able to the thoracic cavity, which makes the diagnosis comparatively easy. 
 An operation should be performed without delay in all these cases, pro- 
 vided there is not a marked contra-indication, such as disease of the stom- 
 ach, intestines, peritoneum, kidneys or heart. 
 
 Lumbar hernia is diagnosed easily, but as it does not usually cause any 
 feeling of distress or discom^fort, an operation is not urgently demanded. 
 
 VESICAL HERNIA. 
 
 The urinary bladder may protrude through Hesselbach's triangle alone 
 or together with other abdominal viscera. An operation is always indicated 
 in this form of hernia, provided the patient is otherwise in good health. 
 
 Hernia of the bladder into the rectum is exceedingly rare. The author 
 has seen one case, and no case is recorded in the literature. 
 
 INTERNAL HERNIAS. 
 
 The indications for operations on hernias through the abdomen are 
 made most clear after the abdominal cavity has been opened or a post- 
 mortem has been performed. It is not in accord with the science of sur- 
 gery to rely entirely on these two sources for reasons why an operation 
 should be performed. It does not appeal even to the ordinary sufferer to 
 be told that the diagnosis of his case will be made after the abdomen is 
 opened. If we cannot make a diagnosis of these ruptures without expos- 
 mg the abdominal contents to sight and subjecting them to handling, it is 
 because of our ignorance of the multiple relationship between concealed 
 hernia and its symptoms and signs. I must admit that our present posi- 
 tion on this question is that too often we can only declare that our experi- 
 
PLATE XL 
 
 Isc'hiatic Hernia. 
 
 Parks' Surgery of American Authors. 
 
IXDICATIOXS FOR OPERATI(3X 69 
 
 ence and knowledge are too limited and scant to enable us to make a 
 positive and accurate diagnosis ; hence we advise an exploratory incision. 
 How can it be otherwise? 
 
 The exploration of the abdominal cavity should only be recommended 
 when by other means of investigation we have failed to clear up the case and 
 the patient is' in imminent danger of losing health, if not life, from want of 
 surgical attention. While it is of great value to the surgeon to hold a post- 
 mortem on a person dead of an internal hernia without an operation \vhich 
 should have been performed with the probability of having been discovered 
 and cured, it is clear, however, that no benefit whatever is given to that par- 
 ticular patient by a study of the changes that caused his death. It is often 
 more difficult to obtain the consent of relatives for an autopsy than it is to 
 secure that of a sufferer for an operation. To operate on all obscure intra- 
 abdominal conditions is more praiseworthy than to let a single person die be- 
 cause of failure to operate. The former may add something valuable to our 
 knowledge and may save life, while inactivity casts a reflection on the sur- 
 geon, and on his profession, and begets lack of confidence in medicine and 
 surgery in the minds of the general public. 
 
 When an abdomen is opened an object-lesson is at once presented, in 
 which are found conditions that are coupled with the symptoms and signs 
 previously complained of and manifested. If the patient recovers, the 
 subsidence of the manifestations of the disease affords us proof of the jus- 
 tification of the operation. During the operative procedure the etiologic 
 factors are caught red-handed, so to speak, and the living pathologic condi- 
 tions are revealed, each stage having reflected its shadowy symptoms and 
 signs, and the real cause is before our eyes and in our hands. Advantages 
 are here afforded for the development of a new^er pathology and the appli- 
 cation of bacteriology. In the abdominal surgery of hernias too many in- 
 stances of deaths from lack of a prompt and true interpretation of the 
 indicia are recorded in our annals. The strategy of the surgeon has more 
 scope in the abdominal field than elsewhere in the body, on account of the 
 many important organs within one cavity that are interdependent in health 
 and in disease. A bird's eye view% as it were, of the condition of the pa- 
 tient, and especially of the affected region and organ, must be taken by a 
 general surgeon, or surgeon general, before he can advise wisely and act 
 strategetically. 
 
 Pain is an important symptom in the diagnosis of intra-abdommal 
 conditions, and is present in almost every ailment. It is increased by pres- 
 sure in inflammation of any part of the body. Pressure on an over- 
 distended gallbladder, appendix. Fallopian tube, or internal strangulated 
 hernia, increases the pain. When it is "stitch-like" or "lancinating" in 
 character, the peritoneum is invaded, or a cancer may be present. 
 
 What is termed "reflected" and "radiated" pain is misleading. The 
 irritation of one branch of a sensory nerve may be referred (reflected) to 
 another branch of the same trunk and felt at its distribution, or may be 
 referred to all the terminations of all the branches of the main nerve. 
 
 The best illustration of a "radiated pain" is seen in connection 
 
70 IXDICATIOXS FOR OPERATION 
 
 with the trifacial nerve. A dying or intiamed nerve pulp of a tooth in the 
 upper jaw may cause pain to be referred to a tooth in the lower jaw, or 
 to all the teeth in both jaws, or finally to the entire distribution of all the 
 branches of the main nerve. In the abdomen the pain of an inflamed ap- 
 pendix is often referred to the whole abdomen ; that caused by obstruction 
 of a ureter to the testicle : that of an obstructed cystic duct to the back and 
 episgastric region. 
 
 Pain produced by a stone in the pelvis of one kidney and referred to 
 the other, kidney is explained by the irritation causing congestion of the 
 grav matter across the cord which forms a connection with the innervation 
 of the other kidney. When a nerve trunk is primarily irritated, peripheral 
 pain is felt of a neuralgic character, e. g., neuralgic pain in the distribution 
 of the genito-crural, ilio-hypogastric, ilio-inguinal and anterior crural nerves, 
 and this is indicative of pressure on or irritation of the lumbar plexus by a 
 perinephritic abscess or a tumor of the kidney. 
 
 In suppuration the pain is "throbbing," and in superficial inflammation 
 it is "burning" or "scalding." The older writers described no less than 
 forty-four dififerent kinds of pain, in accordance with the sensations ex- 
 pressed by various sufferers. 
 
 Pain is conspicuous in intestmal obstruction and in obscure hernias. It 
 is caused by the trauma to the peritoneum. Peristaltic action tries to over- 
 come the obstruction and increases the suffering. It comes and goes with 
 irregular contractions, and is known as 'colic." The colicky pain of inter- 
 nal hernias when obstructed is griping, twisting or dragging in character, 
 and is recognized by the patient to be in his bowels. During the paroxysm 
 he describes it as "fearful." Something is felt to raise, distend and move 
 within him, which always becomes arrested at a certain point. He knows 
 and feels that the bowels are obstructed. A firm conviction is expressed 
 that if flatus could be passed the pain would at once be relieved. This 
 description is characteristic of early and incomplete obstruction, but when 
 it becomes complete the pain abides constantly. The progress of the malady 
 can be .fairly well judged by the pain becoming more and more continuous 
 as the obstruction increases. 
 
 In the early stages the abdomen may be thoroughly manipulated and 
 pressed without much exaggeration of the pain. In fact, firm pressure is 
 often grateful to the patient. The coincidence of tenderness, pyrexia and 
 tympanites bespeaks the onset of peritonitis. A time comes toward the 
 termination of a fatal case when the pain is markedly diminished in sever- 
 ity. It may mean that perforation has occurred ; the sensorium has become 
 less active; or paralysis of the intestine has come on from over-distention 
 or peritonitis. If the bowel has ruptured, and its contents are poured into 
 the general peritoneal cavity, great collapse is present, but when the escape 
 is into some other part, the collapse may not be at all marked. When the 
 pain is increased by taking food, or after an enema or a rectal examination, 
 it shows that peristaltic movements are still capable of reflex excitation. 
 
 While in obstruction of the pylorus and large bowel the pain may be 
 accurately located by the patient at the seat of trouble, it is not so when 
 
INDICATIONS FOR OPERATION /I 
 
 the affection is in the small intestine. Distal, medial and proximal coils of 
 small bowel which lie side by side are constantly changing position, and 
 inasmuch as they are not supplied with special nerves, it is impossible for the 
 patient to locate his painful sensations. When the pain of a strangulated 
 hernia is associated with a tender and fixed spot early in the 
 disease, depend upon it that the constriction is in bowel. But 
 when the strangulated loop becomes inflamed and then fixed, a 
 tender and a fixed spot is to be found. The referred initial pain in intes- 
 tinal obstruction is usually in the region -of the navel, which corresponds to 
 the great nerve center of the abdomen — the solar plexus. Whether a loop 
 of jejunum is strangulated in the duodeno-jejunal fossa, in the iliac fossa, 
 or down deep in the pelvis, the first pains are usually referred to the umbil- 
 icus. Sometimes the early pain of obstruction of the bowel is referred to 
 the opposite side corresponding somewhat to the inferior mesenteric plexus. 
 
 Powerful intestinal contractions may cause unbearable pain, the suf- 
 ferer doubling up spasmodically and crying out. A few months ago I 
 was called to the Chicago Hospital after midnight to operate on a strong 
 young lady said to be suffering from obstruction of the bowels. A lady 
 friend told her twenty-four hours previously to take a couple of ounces of 
 cascara. She took it all in one dose, which produced a condition simulating 
 intestinal obstruction. She was purged, of course ; when I saw her she was 
 passing some blood and mucus per anum.' She was vomiting bile and the 
 contents of the small bowel every few minutes. Both knees were drawn 
 up. The abdominal muscles were retracted and extremely rigid. Paroxysms 
 of pain, torturing in character, came and went concomitantly with vomiting, 
 crying, increased muscular rigidity and straining to stool, v/ith inabihty to 
 ' pass flatus. At times the straining was not unlike that accompanying an 
 abortion, and the fact that she was menstruating added to the complexity 
 of the case. There was a constant diffuse pain in the abdomen as well. Her 
 facial expression was that of extreme suffering during the paroxysm, but 
 it was not anxious. The pulse, temperature, blood and urine were normal. 
 It required chloroform during the paroxysms to relax the intestinal and 
 abdominal contractions, in addition to large doses of morphine. The pain 
 and spasms did not entirely cease for over three days. I stayed at her 
 bedside for several hours, and were it not for the fact of the chloroform 
 allaying the vomiting, muscular spasms and rectal tenesmus, and restoring 
 mental quietude, which enabled me to make several careful examinations of 
 the abdomen by palpation, percussion and auscultation (not neglecting to 
 examine throug'h the rectum and vagina), I should probably have diagnosed 
 the case as one of intussusception or internal hernia. 
 
 Abdominal pains are often caused by extra-abdominal causes, such as 
 those of Pott's disease, spinal diseases, malignant disease of the vertebrae, 
 aneurysm of the thoracic aorta close to the diaphragm, and the abdominal, 
 hepatic, gastric and renal crises of locomotor ataxia must be considered. 
 
 Colic and pain are associated with intoxications from impure ingesta, 
 lead poisoning, uremia, morphin, etc. Hysterical abdominal pain simulates 
 peritonitis, appendicitis, gallstones, intestinal obstruction, hernias, and many 
 
72 INDICATIONS FOR OPERATION 
 
 other conditions. Pain is sometimes referred to the region of the appen- 
 dix in the initial stages of pneumonia and pleurisy. In angina pectoris the 
 pain is often felt below the ensiform cartilage. Pain arising from disease of 
 the liver, pancreas, suprarenals, kidneys, spleen and pelvic organs is not 
 infrequently referred to the abdomen. Osier {Johns Hopkins Hosp. Bulle- 
 tin, July and August, 1904) has grouped certain cases as follows: i. Those 
 in which the colic occurs in connection with a pure angio-neurotic edema 
 (Quincke's disease). 2. Those in which the skin lesion is simply an urti- 
 caria, and the pain supposed to be a colic may really be part of a nervous 
 affection. 3. A class which develops arthritis with erythema, purpura and 
 colic, defined by Henoch, and known by bis nam.e. 4. There are cases in 
 which the lesions are multiform erythema with or without edema, asso- 
 ciated with more or less redness and purpura. 5. A remarkable group of 
 cases with only recurring colic. 
 
 The surgical and neurotic aspects of these conditions are worthy of 
 serious consideration, in order to avoid a laparotomy for a case of doubtful 
 abdominal colic. 
 
 Pain is the most common cry of distress from the outraged highest 
 form of animate creation — man, and its meaning has been so frecjuently 
 misinterpreted, especially in cases of hernia, when a diagnosis can be made 
 only by abdominal section, that it claims the surgeon's most serious thought. 
 
 It is, of course, understood that abdominal pain of itself cannot be 
 taken as an invariable indication to open the abdomen in these cases. Many 
 other symptoms, as well as the signs of the condition, should be considered, 
 such as tenderness on pressure, hyperesthesia, colic, tympany, nausea and 
 vomiting, diarrhea, localized swelling, friction and gas sounds, increasing 
 leucocytosis, collapse, fever, spasm, visible peristaltic action, meteorism, 
 quantity of urine, indicanuria, and other symptoms too numerous to mention 
 here, as well as the onset, duration and clinical behavior of the disease. 
 
CHAPTER VII. 
 
 PREPARATION OF THE PATIENT. 
 
 Time. The time consumed for the preparation of the patient should 
 depend on the emergency of the case and the constitutional condition of 
 the patient. The emergencies met with in hernia cases are those which are 
 associated with strangulation. As has been stated before, when strangu- 
 lation exists the operation should be done at once, irrespective of whether 
 or not the patient can be prepared properl}-. In the vast majority of cases 
 twenty-four hours is sufficient time for proper preparation. When two or 
 three days are required, it is to counteract some constitutional condition. 
 
 Diet and Drink. In robust and healthy men and women, the diet 
 should be restricted for a few days before operation. A liquid diet is best 
 and stimulants must be prohibited absolutely. If the patient has been in 
 the habit of taking stimulants, sufficient time should elapse for the elim- 
 ination of the alcohol. It is better to operate when the circulatory system 
 of the patient is filled with water. 
 
 If the kidneys are not functionating properly, if the amount of urine 
 excreted is scanty, or abundant, the amount of liquids ingested should be 
 regulated accordingly. 
 
 Purgation. There should be neither too much nor too little purgation. 
 When the patient is purged too much, the system is depleted too rapidly, 
 and the endurance is lessened materially. When there is not enough purging 
 done, the alimentary tract is not emptied completely, thus favoring auto- 
 intoxication and bacillary infection. There are two varieties of bacilli in the 
 alimentary canal that are likely to cause serious disturbance in the wound 
 after operation. One of these is the colon bacillus, and the other is the gas 
 bacillus. When the latter germ is present death of the patient usually ensues. 
 
 Two ounces of castor oil administered on the evenmg before operation 
 is about as efficient and safe a purgative as can be given. The effect of 
 the oil is largely mechanical. It incorporates the germs within itself, thus 
 removing them from the intestinal tract. 
 
 If more than twenty-four hours have been required to prepare the 
 patient, purgation can be carried out in two stages. Calomel is given 
 seventy-two hours before the operation, and is followed by a saline. Pro- 
 vided no vegetables have been given the patient, any purgative may be used 
 just before the operation; but if vegetables have been allowed, the bowel 
 must be emptied thoroughly before the operation is begun. While the 
 patient is being purged it is advisable to give one-thirtieth of a grain of 
 strychnine three or four times daily. 
 
 Preparation of Hernia Area. In all cases of strangulation of the bowel 
 the patient is taken to the operating room without previous preparation of 
 
74 PREPARATION OF THE PATIENT 
 
 the hernial area, which is there cleansed thorong-hly with soap and water, 
 scrubbing vigorously, is then washed off with sterilized water, scrubbed 
 again before shaving. The reason for preparing the skin so carefully before 
 shaving is to obviate skin infection by the razor. After the parts have 
 been shaved they are again washed with soap and water and gauze, care 
 being taken not to use the brush too vigorously on the scrotum or labia, 
 for fear of blistering the skin. The soap and water is then washed off wdth 
 plain water, the parts dried with gauze, after which they are washed with 
 70 per cent, alcohol and a 1-1,000 bichloride solution, or some other suitable 
 antiseptic such as carbolic acid or lysol. All this can be done by the operator 
 while the patient is being anesthetized, and at the same time his own hands 
 are undergoing the same process of disinfection as that to which the her- 
 nial area is being subjected. If there is no dearth of assistants it is just 
 as well to relegate this process of disinfection to one of them. 
 
 In preparing the patient for a deliberate operation for hernia a general 
 bath is given first, then the parts are scrubbed, shaved, and otherwise 
 prepared as described above, and after being rendered as aseptic as possi- 
 ble, a compress saturated with a solution of bichloride, 1-2,000, is applied 
 and left on over night. This wet antiseptic dressing is sufficient to dis- 
 infect the skin and to prevent sepsis through any abrasions that might 
 have been made during the process of shaving. This is very important. 
 Experience has shown that if use is made of a solution of bichloride stronger 
 than i-2,OGO, and this left on for twelve hours, a dermatitis is caused in 
 many cases. Of course, this will interfere with primary union of the wound 
 edges after the operation. The use of a solution of carbolic acid, 1-20, or 
 of bichloride of mercury, 1-500, as is recommended by some operators, 
 has, in my hands, proven to be very deleterious to the skin when applied 
 for several hours by wa}' of a compress. Alcohol, when applied to the 
 external genitalia while the patient is awake, causes considerable stinging 
 and smarting, but when the patient is asleep it can be used very freely 
 and to good advantage. Ether, on the other hand, when used on the 
 scrotum, causes a most excruciating pain due to the contraction of the 
 dartos, and even when the patient is asleep, the irritation caused is sufficient 
 to awaken him, unless he has been anesthetized profoundly. 
 
 Painting the parts with iodine, as practised by some operators, is also 
 objectionable, because it produces a dermatitis which should be avoided. I 
 am convinced that Harrington's solution is excellent for disinfecting the 
 skin when the operation is an emergent one, but it is too strong and too 
 irritating to be applied in the form of a wet compress left on over night. 
 
 On the following morning the patient is brought to the operating room, 
 and while he is being anesthetized the compress is removed, and the field 
 of operation is gone over again, choosing any one of three methods : 
 (i) Soap, water, alcohol, bichloride; (2) Ether, alcohol, bichloride; 
 (3) Harrington's solution. The patient is then ready for the operation. 
 
 Clothing. Some patients object very strenuously to adopting the cloth- 
 ing commonly used in a hospital, and I am firmty convinced that the nervous 
 reaction caused by insisting on a complete change of raiment has often 
 
ted if led After Qrej , ASC 
 
 PLATE XII. 
 
 A. Rectus muscle. B. Transversalis fascia. C. Poupart's ligament. 
 D. Femoral fascia. E. Psoas and iliacus muscles. F. Pectineus muscle. 
 G. Pubic ramus. H. Gimbernat's ligament. I. Septum crurale. J. Iliac 
 artery. K. Iliac vein. L. Spermatic vessels. M. Deep hypogastric ves- 
 sels. X. Obturator nerve and vessels. O. Vas deferens. 
 
 I. Opening of internal oblique. 2. Opening for external direct hernia. 
 3. Opening for internal direct hernia. 4. Openmg for femoral hernia. 5. 
 Opening for obturator hernia. 6. Obliterated hypogastric artery. 
 
PREPARATION OF TIIE PATIEXT 77 
 
 interfered materially with a smooth convalescence after operation. I believe 
 also that I can trace several cases of broncho pneumonia and lobar pneu- 
 monia to this cause. Therefore it is advisable to take into consideration the 
 wishes and the habits of the patient in this regard, and if he insists on 
 wearing his under-garments this should be permitted, but they must have 
 been thoroughly disinfected first. 
 
 When everything is ready for the operation the patient should be in- 
 formed of it, not too soon and not too late, however. As a rule it is prefer- 
 able to set an indefinite time for the operation, so as to avoid undue excite- 
 ment. Tell the patient that the operation will be proceeded with when 
 everything is ready. In the case of a very nervous patient it is time enough 
 to tell him on the m.orning of the day set for the operation, thus not depriv- 
 ing him of a sound and restful sleep. Many patients, if informed of the 
 time of operation the day previously, spend a wakeful and restless night, and 
 hardly are in condition to be operated on in the morning. Then, too, it does 
 not give the patient a chance to procrastinate, as he usually is inclined to do " 
 if advised too soon of the time of operation. 
 
 The Operator. While the age of the surgeon does not per se always 
 play an important part in the successful conduct of an operation, still it 
 can be said that those who are too young in surgery are liable to rush in 
 heedlessly and, on the other hand, those who are too old are sometimes 
 over-confident in their ability, which breeds carelessness. In this country 
 the surgeon works in the operating room sometimes to a very old age, 
 when it is lamentable to see the shaking hand and to notice the incomplete 
 attempts at surgical dexterity. While these men would be excellent consult- 
 ants in an operating room, they are really no longer fitted to add to the 
 advancement of the art of surgery. In England the age limit for the 
 surgeon is placed at sixty ; in Germany at seventy ; in France at seventy- 
 five, while in Scotland he operates as long as he is able. It must not be 
 forgotten, however, that there are some men who are young in years and 
 old in surgery, and that there are many old men who are still excellent 
 operators. 
 
 The surgeon should have sufticient muscular strength to endure the 
 hardships encountered in performing major operations day after day, and 
 often night after night. ]\Ianual dexterity also is an essential requirement. 
 Some individuals possess naturally what is called a surgical hand, although 
 no person is endowed naturally with sufficient dexterity to do surgical work 
 without having had a great deal of preliminary training. The training of 
 the fingers to differentiate tissues is an acquirement which is of as much 
 importance as is the training of the mind to know what to do and when 
 to do it. 
 
 The skill, dexterity and nianpilative ability of the surgeon should be 
 acquired in the dissecting room, and not alone in the operating room. The 
 herniotomist should be not merely a good general surgeon, he should have 
 an accurate knowdedge of surgical anatomy, especially the surgical anatomy 
 of hernia. 
 
 The surgeon should always be in what is called the pink of condition. 
 
78 PREPARATION OF THE PATIENT 
 
 He must take good care of his health, and keep his mind and body clean. 
 While surg-ical cleanliness is of great importance, personal cleanliness also 
 counts for much if he would be a successful surgeon. Right living is an 
 essential to success in surgery. While in the hospital making his rounds, 
 just before performing an operation, the surgeon should not go around 
 and shake hands with everybody ; in fact, it is better not to visit any 
 patients at all. 
 
 The successful surgeon is he who observes all those small details which 
 mean so much. He should change all his clothing just before operating, 
 taking off not only the outer, but also the underclothing. All these things 
 have a direct bearing on the successful healing of wounds, and on the 
 ultimate result of the operation. After being thoroughly ascepticized, and 
 properly clothed, the surgeon should not touch anything except the instru- 
 ments and materials that are necessary for the performance of the operation. 
 
 At the operating table the surgeon should not stand stooped over his 
 patient, breathing on to the field of operation. This increases the liability 
 of infection. He should stand erect and as far away from the wound as 
 is consistent with the work to be done. His assistants should be taught to 
 stand erect and at arm's length from the table. Talking should be pro- 
 hibited and all the breathing should be done through the nose. When it 
 is necessary to make a request for something or to answer a question, the 
 surgeon should select a time when it is safe for him to turn his face away 
 from the wound. When these precautions are taken, it is- not necessary 
 to wear those hideous masks which soon become very foul, nor is there any 
 need of tying up the mouth with gauze. If the surgeon prefers to wear a 
 mask, it is advisable to change it several times during the operation. 
 
 Assistants, nurses and visitors should be prohibited from talking in 
 the operating room, especially when they are near the patient. Unnecessary 
 Avalking in the operating room also is conducive to infection. 
 
 In the amphitheatre the same precautions should be taken as in the 
 private operating room. Of course, there is in this case some necessity for 
 talking, because students are there for the purpose of being instructed. It 
 is not enough for them to see ; the steps of the operation must be explained. 
 The conduct in the amphitheatre resolves itself into three parts: (a) Be- 
 fore the operation; (b) during the operation, and (c) after the operation. 
 Before the operation a short lecture can be given on the nature of the case; 
 the anatomical structures involved ; the diagnosis ; the selection of the opera- 
 tion ; and the reasons for such selection. The operator can make the initial 
 incision and then allow his assistants to pick up and ligate bleeding vessels 
 while he explains to his audience what is being done. Then, turning to his 
 patient, he continues with the operation until he reaches a point in the pro- 
 cedure where it is possible to stop for a few minutes to permit of further 
 explanation. Finally, he completes the operation in its essential features, 
 and then turns the patient over to an assistant, who carries out the final 
 steps, such as suturing the skin wound and applying the dressing. 
 
 Surgical coolness is an admirable quality. Recklessness often is mis- 
 taken for it. Nervousness of the surgeon during an operation is inimical to 
 
PREPARATION OF THE PATIENT 79 
 
 good surgery. There are surgeons who are extremely nervous before an 
 operation, but who during the operation are cool and collected. The sur- 
 geon who always is under great mental and bodily strain while performing 
 a major operation should give up the work entirely. Anxiety and concern 
 for the welfare of the patient are all well and good, but the durgeon should 
 not carry them to the extent of getting rattled. It is rather ludicrous to 
 see a surgeon of international reputation perfonn an operation for the radi- 
 cal cure of hernia and become so confused as not to be able to differentiate 
 the vas deferens, the conjoined tendon, and most of the important struc- 
 tures in that area. Not long ago such an exhibition was given in one of the 
 large cities of this country when the surgeon spent fully half an hour try- 
 ing to push back the omentum and bowel with his fiagers, forgetting com- 
 pletely that these structures would recede of themselves bv merely placing 
 the patient in the Trendelenburg position. Not until this was suggested by 
 the anesthetist was it done. 
 
 As a rule, the instruments for the operation are selected by the sur- 
 gical nurse, the assistant, or the senior interne. While tnis lessens the 
 labor of the surgeon and saves time, it not infrequently leads to embarrass- 
 ment when the surgeon calls for an instrument and finds that it has not 
 been prepared. For this reason the surgeon should alwa3's look over his 
 instruments before commencing an operation. 
 
 The surgeon should learn to handle his own instruments during the 
 operation, so that he can get along without an assistant. By this means he 
 will arrive at a system in the operating room which will lessen the number 
 of assistants and nurses recjuired during operation. 
 
 The surgeon of to-day is quite a different individual from his proto- 
 type of twenty-five years ago. He gets better results. He does not oper- 
 ate on a time limit nor does he dash off a herniotomy without taking the 
 time necessary to examine into the case and determine the conditions to be 
 encountered. He does not perform his operations by routine, but adapts 
 the operation to the individual case. The most brilliant results can be ob- 
 tained if the surgeon is painstaking and operates only under proper condi- 
 tions. 
 
 Any visitors who may be present during an operation should be so 
 gowned that no part of the body, except the head and feet, is exposed. 
 The writer uses for this purpose a sleeveless gown, a sort of bag, that slips 
 over the head with a drawstring at the neck. It reaches down below the 
 knees and completely covers the body and prevents the use of the hands. 
 
 The Operating Room. At Home. — In the home the kitchen is us- 
 ually the most suited for an operating room. It is well lighted and is also 
 the cleanest room, unless one of the 9ther rooms in the house has been pre- 
 pared specially. Therefore emergent operations performed at home should 
 be done in the kitchen. If there is sufficient time to prepare for the opera- 
 tion any room can be gotten ready. Then the furniture and hangings of all 
 kinds should be rem.oved, and the wails, floor and windows scrubbed and 
 then gone over thoroughly with a 1-500 bichloride solution. The night be- 
 fore the operation the table to be used and the other furniture needed dur- 
 
80 PREPARATION OF THE PATIENT 
 
 ing the operation are gone over in the same way. During the night the room 
 should be fumigated with formaldehyde. A second room also should be 
 made reasonably clean. Here most of the preparatory work is done, such 
 as the sterihzation of sheets, towels, and water; but the instruments and 
 materials to be used during the operation, the sponges and the dressings, 
 should be prepared in the hospital. 
 
 The patient should not be carried into the operating room until he 
 has been anesthetized. If the room is large enough a bed may be put into 
 it on which the patient is placed after the completion of the operation, and 
 allowed to remain until he has recovered from the effects of the anesthetic. 
 Then he is carried to the room which has been specially prepared to re- 
 ceive him. » 
 
 In the Private Hospital. The room which is to be used for an oper- 
 ating room should be selected very carefully. Inasmuch as all the deliberate 
 operations are performed in the morning, there is no objection to selecting 
 a room with a west exposure. Nor is there any objection to selecting one 
 with a north exposure, except that it usually is more difficult to keep this 
 room warm in the winter. South and east exposures should never be 
 chosen. 
 
 The operating room should be properly constructed and ventilated, but 
 above all things it should be kept clean — that is, surgically clean. It should 
 be scrubbed and made aseptic every day with a bichloride solution. The 
 same thing should be done between operations, if more than one operation 
 is done on the same day, and especially after a septic case has been oper- 
 ated on. For these reasons, as well as for many others, it is advisable to 
 have two operating rooms in a private hospital. Neither of these should 
 be designated as the septic room, because if one room is selected for septic 
 cases, and the other is reserved for aseptic cases, there is the danger of 
 allowing the former to become foul, thus serving as a nidus of infection for 
 the clean room. Both rooms should be cleaned every day, so that they may 
 be ready at all times for any kind of an operation on any kind of a case. It is 
 a good plan, however, to reserve a room in which medicines and dressings 
 can be kept. This room may be situated between the two operating rooms, 
 for the sake of convenience. 
 
 After the completion of a septic operation the operating room should be 
 cleaned immediately and thoroughly disinfected with formaldehyde, so that 
 it will be readv for use. 
 
CHAPTER VIII. 
 
 SURGICAL BACTERIOLOGY. 
 
 Aseptic surgery is the ideal surgery. It assumes that before operation 
 the tissues of the patient are free from disease-producing germs, and that 
 the surgeon has destroyed the germs on his hands, instruments, Hgatures, 
 and other material used during the operation. The exhaled, vitiated breath 
 is prevented from entering the wound by means of shields of gauze, called 
 masks, which are placed before the mouth and nose. The air in the room 
 should be dustless, in order to reduce to a minimum the possibility of infec- 
 tion occurring from the entrance into the wound of bacteria contained in 
 the dust. There is no reason why there should be any inflammation, sup- 
 puration, septicemia, or pyemia, after operative procedures. Clean and 
 careful surgeons have eliminated the two last-named from their practice, 
 but inflammation and suppuration are still with us, although to a very lim- 
 ited degree. 
 
 Ideal aseptic surgery really does not exist, because, strictlv interpreted, 
 the term means that there are no germs, no infection, and no interference 
 with the healing of the wound by germs. The air is laden with millions of 
 germs ; beneath the finger-nails, in the crevices and folds of the skin, even 
 after vigorous scrubbing with soap and water for fifteen minutes, germs 
 are abundant. Therefore, there can be no such state as asepticitv of the 
 skin. The wound is always exposed, more or less, to air, which may be the 
 source of infection, to the contact of fingers, instruments, sutures, dressings., 
 etc. If the surgeon keeps all fingers, except his own, out of the wound., 
 the danger of infection is minimized, especially if he takes proper aseptic 
 and antiseptic precautions. In fact, if it were not for two things suppura- 
 tion of wounds would occur much more frequently than it does now. These 
 are (a) the antiseptic properties of perspiration, and (b) the resisting pow- 
 ers of the patient. 
 
 I will not now refer to the assistants, internes and nurses in this con- 
 nection, but will consider only the two parties involved primarily, the pa- 
 tient and the surgeon, because infection is due to one oi the other of these 
 two. The patient cannot help it, but the surgeon can. The surgeon should 
 hold himself responsible for everything connected with the operation, for 
 the work of the anesthetist and the mistakes of his assistants and nurses. 
 
 Long before the germ theory of disease was promulgated the ad- 
 vantages of moist dressings w^ere recognized. They keep the wound sur- 
 face clean and the secretions unsuitable as a culture medium for bacteria. 
 Before 1866 Lister had as much sepsis in his practice as most other sur- 
 geons. During the subsequent five years he reduced his mortality in major 
 amputations from 42.7 per cent, to 11.25 per cent. To-day the mortalitv 
 
82 SURGICAL BACTERIOLOGY 
 
 from infection occurring during- the performance of major operations is 
 practically nil. For a clear, accurate and vivid description of the surgery 
 of those days, contrasted with the surgery of to-da}', I refer the reader to 
 Nicholas Senn's most excellent work on "Practical Surgery." 
 
 The subject of bacteriology is so inseparable from the technic of 
 modern operations for hernia and other general operative procedures, that 
 the surgeon is no longer "a physician w'ho operates," but he must be one 
 who has specially prepared himself to do surgery, and no small part of his 
 training must have been in bacteriology. As many excellent books have 
 been written on the subject of bacteriology the author does not think it 
 necessary to discuss the subject at any great length, limiting himself only 
 to making such reference as will serve as a connecting link between bac- 
 teriology and clinical surgery. 
 
 When infection occurs following a herniotomy, it is the duty of the 
 surgeon to determine the source and the cause of such infection. Cultures 
 should be made from the discharges of the wound and from all materials, 
 including instruments, that were used during the operation. If necessary, 
 animal inoculation should be resorted to. As a guide in studying micro- 
 organisms, the following classification of bacteria {Zapffe's Bacteriology) 
 will be useful : — 
 
 First, as to their shape, v/e have three principal divisions or groups: 
 I. Micrococci. II. Bacilli. III. Spirilla. 
 
 I. The micrococci are spherical or slightly oval in shape, non-motile, 
 and do not form spores. They grow by binary division. This group is 
 subdivided further into the following varieties : 
 
 Diplococcus: Two micrococci remaining attached to each other, or an 
 imperfect division. They may be absolutely spherical or the contiguous 
 surfaces may be slightly flattened or concave, the "biscuit" coccus or '"sem- 
 melkokken." 
 
 Tetrad: A group of four cocci, the result of division in two directions. 
 
 Sarcina : A packet or cube of eight cocci, the result of division in three 
 directions. This form resembles in appearance a bale of cotton or a dice. 
 
 Staphylococcus : The most common form, in which the cocci occur in 
 irregular groups of varying numbers and without definite arrangement. 
 The name is derived from the Greek and is given to this form because of 
 its resemblance to a bunch of grapes. 
 
 Streptococcus: Chains of cocci. When division occurs in only one di- 
 rection, with adhesion or attachment of the individual members, chains of 
 varying length are formed. Some authors distinguish a streptococcus longus 
 and a streptococcus brevis — that is, long chain and short chain ; and a few, 
 a streptococcus conglomeratus. When the chain is composed of diplococci, 
 it is called a strepto-diplococcus. 
 
 Ascococcus and leuconostoc are two very unusual groupings of cocci. 
 In the former the cocci are associated in globular or lobulated miasses held 
 together by a firm, gelatinous, intracellular substance. In the second variety 
 the cocci grow in chains or masses, and are surrounded or enclosed by a 
 very thick and tough gelatinous capsule. 
 
PLATE XIII. 
 
 Diagrammatic frontal section through the pelvis, exposing the rec- 
 tum (A). 
 
 The pelvic diaphragm (B) is seen passing from the inner surface of 
 the true pelvis to the lower end of the rectum. This diaphragm is perforated 
 on one side by the protrusion of a hernial sac which is still situated within 
 the ischio-rectal fossa. 
 
 Inferior Hernia (Perineal). A. Rectum. B. Pelvic diaphragm. C. 
 Parietal peritoneum. D. Sac of a perineal hernia. 
 
SURGICAL BACTERIOLOGY 85 
 
 II. The bacilli are rod-shaped or filamentous bacteria, motile or non- 
 motile, flag^ellated or not, reproducing themselves both by fission and sporu- 
 lation. They are not subdivided into groups, but exhibit considerable varia- 
 tion of shape. Some are quite short and thick ; others are long and slender ; 
 some very large and some very small. They may be so short as to resemble 
 a coccus, hence the term oval coccus. Some have rounded ends ; others 
 pointed, squared or. slightly concave ends. They may be spindle-shaped, 
 rod-shaped, club-shaped, or of a Clostridium shape. Their arrangement is 
 in some instances characteristic. They may be seen to lie singly or in pairs, 
 in parallel rows or in chains of varying length, sometimes interlacing freely. 
 Very long, slender, and indistinctly articulated filamentous bacilli are known 
 as leptothrix ; when these filaments present pseudo-branchings, they are 
 termed cladothrix. 
 
 III. The spirilla are curved or twisted rods of varying length, en- 
 dowed with motility and a peculiar rotary movement, flagellated and repro- 
 ducing themselves by both fission and sporulation.. They may be very rigid 
 or exceedingly flexible. The short, slightly bent rods resemble a comma 
 so closely that they frequently are referred to as "comma" bacilli (cholera), 
 or as a vibrio because of their vibratory motion. The extremely long and 
 flexible forms are called spirochaeta (relapsing fever). A spiromonas is a 
 ribbon-shaped spirillum. When sulphur granules are found in the proto- 
 plasm of the organism, it is called an ophidomonas. 
 
 Several higher forms of bacteria also are recognized. They approach 
 the plant in structure and method of growth. Among these is the strep- 
 tothrix, the only form which is encountered in animal pathology. The strep- 
 tothrix actinoniyces (ray fungus) is the type of this class. The tubercle 
 bacillus and the diphtheria bacillus are included by some authorities in this 
 class. The streptothrix presents true dichotomous branchings and forms 
 very finely tangled m.asses. In the course of its growth many stages of the 
 germ are seen. Occasionally the filaments break up and resemble chains 
 of bacilli or cocci, or the free ends of the filaments form club-shaped masses, 
 which may be an evidence either of degeneration or sporulation. 
 
 Depending on their environment and habits, bacteria are divided into 
 saprophytes and parasites. 
 
 Saprophytes feed only on dead organic matter, and usually are not 
 disease-producing bacteria, unless by absorption of the poisonous products 
 formed by them from the breaking-down of proteids. Parasites always 
 feed on living organic matter. An organism may, however, be both para- 
 sitic and saprophytic, but a saprophytic existence precludes parasitism. 
 
 According to the results of their vital activity, bacteria are pathogenic 
 and non-pathogenic. A pathogenic organism is one which is capable of pro- 
 ducing disease. A non-pathogenic organism does not of itself produce dis- 
 ease. Pure saprophytes are always non-pathogenic germs; whereas para- 
 sites are usually pathogenic. 
 
 The terms ohligative and facultative are used to express the absence or 
 presence of the ability of accommodation to surroundings. For example, 
 organisms which may be either saprophytic or parasitic are said to be 
 
86 SURGICAL BACTERIOLOGY 
 
 facultative (typhoid and cholera bacilli). Obligative bacteria are those 
 which must be either one or the other; as, for instance, the lepra bacillus, 
 which is a strict or obligative parasite. 
 
 According to the products of their metabolism, bactaria may be clas- 
 sified as : 
 
 1. Aerogenic — gas-producers. 
 
 2. Zymogenic — fermentative bacteria. 
 
 3. Saprogenic — putrefactive bacteria.^ 
 
 4. Chromogenic — color-producers. 
 
 5. Photogenic — phosphorescent bacteria. 
 
 PYOGENIC BACTERIA. 
 
 ]\Ianv bacteria are responsible for the formation of pus, bvtt those 
 which are classed particularly as pus-producing germs are the following: 
 
 I. COCCL 
 
 I. Staphylococcus pyogenes: (a) aureus; (b) albus ; (c) citreus. 
 Streptococcus pyogenes. 
 ^Micrococcus gonorrhea (gonococcus). 
 Diplococcus pneumoniae (pneumococcus). 
 Diplococcus meningitidis (meningococcus). 
 
 II. Bacilli. 
 Bacillus pyocyaneus. 
 Bacillus coli communis. 
 Bacillus typhosus. 
 Bacillus tuberculosis. 
 Bacillus of Friedlander (pneumo-bacillus). 
 
 In connection with infection of wounds made by the herniotomist, it is 
 well to direct attention for a moment to those micro-organisms which J. 
 Collins Warren, of Boston, has named the surgical bacteria, because of the 
 frequency with which the surgeon has to contend with them. First among 
 these is the staphylococcus pyogenes aureus, an organism that is widely 
 distributed in nature, and is always found on the surface of the body, be- ' 
 "neath the finger-nails, in the saliva, in the dust of the street, on the floors 
 and walls of houses and hospitals, in the air and in the water, and wherever 
 it may have been deposited from a previous infection. The staphylococci 
 are about one micron in diameter and have an arrangement resembling a 
 bunch of grapes, from which they derive their name. The entire group of 
 staphylococci grows readily on all the various culture media and at tem- 
 peratures as low as 6° C, and as high as 44P C. The staphylococcus is an 
 exceedingly tenacious germ, retaining its vitality for a long time under the 
 most adverse circumstances. It is killed rapidly by exposure to live steam 
 and by 3 per cent, solution of carbolic acid. All the staphylococci cause 
 local suppurative inflammations, and while they exhibit but little tendency 
 to spread, they occasionally are the cause of a fatal septicemia or pyemia. 
 The aureus is the most common and also the most virulent of the staphylo- 
 cocci. The albus is the least virulent variety. The citreus is very uncom- 
 mon and is alwavs associated with the other varieties of staphylococci. The 
 
SURGICAL BACTERIOLOGY 8/ 
 
 Staphylococcus epidermis albus, which was described by W^dch, occurs con- 
 stantly on the skin and in its deeper layers. It is believed to be an atten- 
 uated form of the albus. Two feeble pathogenic forms of staphylococci 
 are the staphylococcus cereiis albus and the staphylococcus cereus flavus. 
 They are found on the skin and in the external auditory canal. The staphy- 
 lococcus viridis Havescens is met with occasionally. The micrococcus pyo- 
 genes tenuis resembles the aureus slightly, both biologically and morphologi- 
 cally. It is very uncomm.on. 
 
 The streptococcus pyogenes is an exceedingly virulent germ, possessing 
 but little vegetative power, and is the cause of almost all severe and rapidly 
 fatal infective inflammations. It is of about the same size as the staphylococ- 
 cus, but always occurs in the form of a chain, from whence its name. The 
 germ has been found in hospital wards, in operating rooms, in the mouth, 
 nose, pharynx, intestinal canal, vagina, urethra, on the skin, and in the infec- 
 tions caused by the germ itself. 
 
 The bacillus pyocyaneus, though not a pus-producing germ, is fre- 
 quently found in pus, to which it imparts a blue or green color. It has been 
 found on the skin, especially in the axilla, in the external auditory canal, 
 and in the intestinal mucus. It grows very abundantly in culture. 
 
 An organism in the same class with the bacillus pyocyaneus is the 
 micrococcus tetragenus, a germ that occurs in squares of four cocci, grows 
 abundantly in culture, and is seen most frequently in specimens of tuber- 
 culous sputum. It is also present in the mouth. It is not believed to be 
 pathogenic for man. 
 
 The bacillus pyogenes fetidus, which has been found on several occa- 
 sions in the pus in abscesses, also belongs to this class. 
 
 The bacillus coli communis, although ordinarily a non-pyogenic germ, 
 is not infrequently found in the contents of abscesses, especially in those 
 abscesses that occur in the vicinity of the intestinal tract. 
 
 ^lany other germs have been found more or less often in the contents 
 of abscesses, but without being necessarily pus-producers themselves. Other 
 bacteria with which the surgeon ma}- come in contact in connection with 
 his operative work are the streptococcus erysipelatus, bacillus tetanus, bacil- 
 lus tuberculosis, bacillus mallei, lepra bacillus, bacillus of syphilis, bacillus 
 of malignant edema, bacillus of pseudo-edema, bacillus anthracis, bacillus 
 acrogenes capsulatus, and the actinoniyces, or ray fungus. 
 
 Asepsis and antisepsis have revolutionized surgery to such an extent 
 that infection occurs very infrequently. In pre-antiseptic days, and during 
 the period of time that antisepsis and asepsis were being developed, that is, 
 before our technic was as perfect as it is to-day, wound infection was a 
 common occurrence, and any one of the bacteria mentioned above might 
 have been the cause of the infection. Particular attention is now paid to 
 these germs because of this. !Many patients who would have survived the 
 operation died from sepsis. In other instances the patient was inoculated 
 with the germ, such as the bacillus of tuberculosis, the bacillus of anthrax, 
 or the bacillus of leprosy, which, though it may not have caused death 
 immediately, produced severe systemic disturbances from which the patient 
 
88 SURGICAL BACTERIOLOGY 
 
 did not recover. Infection with the tetanus bacillus was dreaded particu- 
 larly, and malignant edema, anthracosis and local tuberculosis have been 
 reported many times as occurring after operations for the cure of hernia, 
 as well as after other operations. I have also seen one case of actinomycosis 
 caused by contamination of catgut which was used during the operation. 
 
 The occasional operator is much more likely to have infection because, 
 as a rule, he is obliged to operate under the most adverse conditions. He 
 cannot choose his operating room, nor can he choose the time of operation. 
 Most of his work is emergency surgery, but if he will be reasonably careful 
 in his technic, and allow nothing to come in contact with the wound that 
 has not been sterilized, he can avoid infection in the majority of instances. 
 
 The rarer varieties of infection, those in which the bacillus of leprosy, 
 the bacillus of syphilis, the bacillus of tetanus, are the causative germs, can 
 be ruled out entirely. If the operator has come in contact with a case of 
 erysipelas, he should exercise more than usual care, because, as has been 
 pointed out above, the streptococcus of erysipelas, like all other streptococci, 
 is a very virulent organism, and it is carried easily from one place to another 
 on the clothing or any substance that may come in contact with the patient. 
 Wound infection with the streptococcus is very likely to prove fatal. There- 
 fore, when an operation has been arranged for, the surgeon had better not 
 visit any cases of erysipelas on that day. 
 
CHAPTER IX. 
 
 INFECTION. 
 
 By infection is meant the multiplication of certain microbes in wounds 
 and in the body, causing local and constitutional disturbances peculiar to 
 them. When these bacteria enter a wound they multiply and cause what is 
 termed a local infection. A constitutional infection is said to occur when 
 the health of the individual is disturbed by the absorption of bacteria and 
 their products into the circulation. A blood infection, commonly called 
 blood poisoning, takes place when the bacteria enter the circulation and 
 multiply there. This always produces grave constitutional symptoms. In- 
 fectious diseases are those that are communicated from one individual to 
 another by the particular germs that cause them. 
 
 Infection may occur not only with the vegetable organisms (that is, 
 bacteria, moulds and yeasts), but also with the animal parasites, such as 
 the ameba coli and the malarial hematozoon. 
 
 Infection is often referred to as being primary and secondary. It is 
 primary when it occurs irrespective of other existing conditions. The 
 infection of a wound is always a primary process. A secondary infection is 
 one that is engrafted on a part of the body that already has suffered from 
 the ravages of another organism. A good illustration of this is the invasion 
 of a tuberculous abscess by pyogenic cocci. 
 
 The infection may also be local and general. 
 
 In the condition known as sapremia, or septic intoxication, the infection 
 is due to the absorption into the tissues of the ptomaines produced by 
 saprophytic bacteria (putrefactive bacteria), which, while not entering the 
 blood themselves (i. e., remaining in the focus of infection), yet produce 
 substances that are absorbed by the body and enter into the blood and lymph 
 channels. The absorption of fibrin formed in a wound produces effects that 
 are very similar to those produced by the absorption of these ptomaines. 
 
 By mixed infection is meant the "presence in the tissues of more than 
 one variety of organism at the same time. This is seen frequently in 
 tuberculosis, pneumonia, and in wound infections. 
 
 A terminal infection is one occurring in an individual suffering from 
 some chronic organic disease and which ends fatally. One infection may 
 subside and another take its place. 
 
 When the poison is generated within the body itself as the result of 
 faulty metabolism or the inadequate elimination of waste products and 
 their subsequent decomposition, a form of poisoning occurs known as auto- 
 . intoxication or auto-infection. Several interesting cases of blood infection 
 induced by latent infection becoming aroused by exposure to cold have 
 been observed by the author. 
 
go INFECTION 
 
 Before it is proven that a certain germ is the cause of an infection, 
 there are a number of conditions and requirem.ents that must be met. These 
 have been laid down definitely by Koch and by Henle, and are known as 
 Koch's law. I. The micro-organism must be found in the blood or lymph or 
 in the tissues of the person infected. 2. The germ must be isolated and cul- 
 tivated. 3. The infection or disease under investigation must be repro- 
 duced by inoculation of man or animals with the artificially cultivated germs. 
 4. The same bacterium must again be found in the tissues, blood or lymph, 
 of the person or animal inoculated. When an organism meets these require- 
 ments, it is accepted as the specific cause of the disease or infection that is 
 being investigated. 
 
 It is important for the operator to know of the sources from which 
 infection may come. The easiest way to keep these in mind is by remem- 
 bering the few tissues and organs in the body in which germs do not exist 
 normally. Bacteria are not found in any tissues or organs that have no 
 connection with the skin or with the mucous surfaces, such as the brain, 
 spinal cord, nerves, muscles, bones, joints, ligaments, tendons, adipose tissue, 
 heart, blood, l3aiiph glands and vessels, lymph, peritoneal cavity, spleen, 
 arteries and veins, and suprarenal bodies. There has been considerable con- 
 troversy on this subject, some investigators claiming that they found bacteria 
 in healthy normal organs and tissues, but it is now generally conceded that 
 these are free from germs. Germs are not found in normial secretory 
 organs, such as the salivary glands and their ducts, the liver, gall-bladder and 
 its ducts, pancreas and ducts, kidneys, ureters and bladder, ovaries, uterus 
 ' and Fallopian tubes, the mammary glands and their ducts, lungs, testes, 
 vas deferens and prostate gland. While germs are not present, normally, in 
 the sudoriferous glands (the perspiration being germicidal in its action), 
 still the skin and its appendages, the sebaceous glands and hair follicles, are 
 never free from bacteria. 
 
 SOURCE OF WOUND INFECTION. 
 
 Let us now enumerate the chief sources of infection of wounds made 
 by the surgeon. 
 
 1. The Atmosphere. Bacteria of all kinds, pathogenic and nour 
 pathogenic, are always to be found in the air. These germs being heavier 
 than air are deposited on objects in the operating room, on instruments, 
 dressings, sutures, as well as on the wound surfaces. Although the danger 
 of infection from this source is not very great, yet the atmosphere in which 
 patients are operated and cared for should be kept as free from dust as 
 possible. Where there is obvious dirt, there is dust, and when one can 
 see the dust in the air, or on articles of furniture, and other exposed objects, 
 there are sure to be swarms of bacteria, sufficient to infect an open wound. 
 An operation should not be performed under such conditions, if it is at all 
 possible to avoid it. 
 
 2. The Skin of the Patient. The skin of the newborn babe is germ 
 free (Nuttall), but it soon becomes covered with bacteria which, when they 
 enter a wound, will cause suppuration and even death. These germs find 
 
PLATE XR'. 
 Femoral Hernia. Internal, Anterior. External. 
 
INFECTION 93 
 
 their way into the various folds, crevices and appendage? of the skin, 
 making the task of removing them mechanically with soap, brush and 
 water impossible. Therefore, the patient's skin ma}- be the source of his 
 infection. 
 
 Different varieties of germs are found to inhabit various parts of the 
 skin and they often produce infectious skin diseases that are peculiar to 
 these parts. The skin of the pubis and of the groin is heavily laden with 
 germs. The staphylococcus epidermis alhus is always present everywhere 
 on the skin. It is not pathogenic, but will cause pus. The odor of sweating 
 feet is caused by the bacillus graveolens, also non-pathogenic. The red 
 sweat of some individuals is caused by the bacillus prodigiosiis (non-patho- 
 genic). 
 
 3. The Skin of the Hands of the operator and of his assistants, espe- 
 cially beneath the nails, is never free from bacteria and is probably the 
 greatest source of infection in hernial operations when these are performed 
 with bare hands, that is without rubber gloves. Xo one should operate or 
 assist who has an obvious infection of the hands, such as eczema or suppurat- 
 ing wounds. Internes and assistants coming in contact with suppurating 
 cases must take every care not to touch pus. Xurses should not be in the 
 operating room during menstruation, or while suffering from vaginal dis- 
 charges, because under those conditions it is rather difficult for them to se- 
 cure "surgical cleanliness" of their hands. 
 
 4. Water. There are too m.any bacteria present in ordinary tap water 
 to use it with impunity at operations, except for the primary scrubbing of 
 the hands. If even a trace of organic matter is found in it, bacteria are 
 always present, but water free from organic matter may contain live germs. 
 •■'Ordinary hydrant water usually contains from two to fifty bacteria per 
 cubic centimeter ; filtered river water from fifty to two hundred ; unfiltered 
 river water from 6,000 to 20.000 ; ground water may contain as many as 
 130,000" (Zapffe). 
 
 The bacteria in water are usually of the non-pathogenic variety. The 
 two most important pathogenic organisms are the typhoid and the cholera 
 bacillus. The bacillus coli comnnmis is found in water into which sewage 
 empties. The water obtained from deep artesian wells is free from germs. 
 Water from lakes and rivers is septic. Even distilled water may contain 
 germs. For surgical purposes the water must be sterilized, rendered free 
 from pathogenic microbes, and kept in bulk, both hot and cold. While 
 boiling is simple and efficient, it is a laborious process to cool and properly 
 retain water that is fit for all practical purposes. A special water sterilizer 
 should be installed in every hospital operating room. 
 
 Instruments and Materials Used at the Operation. These constitute 
 a frequent source of infection when not rendered aseptic. 
 
 An aseptic scalpel becomes septic upon severing the skin when its 
 
 ■ follicles are crowded with bacteria. This scalpel should not be used again 
 
 during the operation without being disinfected in carbolic acid and alcohol, 
 
 for fear of carrying the bacteria into the deeper structures, and thus infect- 
 
 ins- them. I am indebted to Flovd W. McRae, of Atlanta, Georgia, for this 
 
94 INFECTION 
 
 bit of surgical technic. It is not only a good plan to discard the scalpel, but 
 also to antisepticize the edges of the skin wound with some efificient anti- 
 septic solution. The most efficient solution is Harrington's, but it must 
 be used sparingly by gentle mopping; in fact, one sweep with a pledget of 
 gauze moistened in it is sufficient. 
 
 2. Catgut is a source of infection, and it must be rendered aseptic 
 before using. (See Chapter XII.) When aseptic catgut is used to check 
 hemorrhage and to coapt the deep structures in hernial operations (or in 
 operations for other conditions), it may become infected in the application 
 of such ligatures and sutures. It is during the operation that the germs 
 are accidentally introduced, and hence Kocher calls this "implantation in- 
 fection" {Operative Surgery, Trans. IV Ed., p. 33), and urges the use of 
 antiseptic material for buried sutures and ligatures instead of that which is 
 merely aseptic. 
 
 3. The manner of using the needles is sometimes a source of infection. 
 When a cutting needle is passed from without inward and strikes a nest 
 of germs in the hair follicles and sebaceous glands, they are undoubtedly 
 carried by the needle and suture to sterile tissues. It depends upon the 
 number, nature and activity of those germs whether suppuration follows or 
 not. The late G. R. Fowler, of Brooklyn, N. Y., is credited with this 
 observation. 
 
 4. The author holds the same objection to the subeuticular suture, 
 because the needle and suture must pass through the deep skin where hair 
 follicles, sebaceous and sweat glands abound and may be harboring pyogenic 
 bacteria. 
 
 5. Suturing the skin too tightly is a frequent source of stitch abscess 
 in the hands of many operators, by causing necrosis of the skin where the 
 stitch is applied. 
 
 6. Rough Handling. When an operator lowers the vitality of the 
 tissues by tearing, bruising, undue clamping, using too many ligatures, etc., 
 a predisposition to infection is created. Infection supposed to have been 
 caused by such rough handling of the structures has been called "lesion 
 infection" by Travel, and "necrosis infection" by Kocher. 
 
 7. Contact infection is a great source of inflammation, suppuration 
 and all infective diseases, from water, the skin of patient, hands of the 
 operator, the instruments, solutions, vessels, sponges, ligatures, sutures, 
 drainage tubes, dressing materials, and the mode of their application, drops 
 of perspiration, dust and dandruff from the hair, mucus droplets from the 
 mouth when talking, coughing, etc., the clothing of operator, his assistants 
 and nurses, eye-glasses or spectacles, insects, visitors, etc., etc. 
 
 8. Breath Infection. The expired air is sterile (Tyndall), conse- 
 quently the more respiration that goes on in a room, the greater the decrease 
 in the number of bacteria in it, even when the room becomes stuffy. It 
 has also been proven that micro-organisms are not given off' from moist 
 surfaces. The exhaled air does not carry with it the germs so numerous 
 along the respiratory tract. From these two facts, (a) that the exhaled 
 breath is sterile, and (b) that germs are not given off from moist surfaces 
 
PLATE XV. 
 Consrested — 2 hours. 
 
INFECTION 97 
 
 (Schimmelbusch), one can justl}^ say that the surgeon, his assistants and 
 nurses, and visitors cannot by the act of respiration infect a wound. There 
 is, however, a breath infection, and that is from speaking, coughing, laugh- 
 ing, and sneezing, during which efforts it has often been proven that drops 
 of mucus and saHva fly from the mouth, and particles of the secretions of 
 the Schneiderian membrane come from the nose, all laden with non-patho- 
 genic, pyogenic and pathogenic bacteria. No one who is suffering with a 
 cough should operate or assist at an operation. 
 
 9. Infected Wounds. The discharges from infected wounds carried 
 in various ways to clean wounds were at one time the most common sources 
 of infection. Anyone dressing septic wounds, by the careful use of his 
 hands, with or without gloves; by using dressing forceps, scissors, or other 
 instruments, as the case may require ; and by the complete sterilization of 
 these instruments before and after using, should be able to reduce this 
 source of infection to practically nothing. 
 
 10. Excreta, Urine and Feces. In hernia operations on children it is 
 important to protect the wound against contamination with urine or feces. 
 This may be done in several ways. A collodion dressing may be applied, 
 but it may cause irritation of the tender young skin. A double dressing 
 with rubber or oiled silk between, properly bandaged, affords a safe protec- 
 tion against infection from this source. The outer dressing can be changed 
 whenever it is soiled without endangering the wound. 
 
 Obscure Sources. Inasmuch as there is no method of surgical technic 
 that is absolutely proof against sepsis, we must not be over-sanguine in our 
 powers, individual or combined, to always prevent infection of the wounds 
 we make ourselves. Experience has taught that there is no known standard 
 of the resisting powers of any person against the invasion of living germs. 
 It is sometimes in the stalwart and robust that pyogenic germs find a suit- 
 able nidus for their multiplication, while the weakling is not assailed. In 
 such a case the sepsis cannot be attributed to a "lowered vitality of the tis- 
 sues." 
 
 There are some cases of infection caused by conditions which the oper- 
 ator appears to have no power to prevent. It may be in the fluids and tis- 
 sues of the patient, or it may be the virulence of the germs in certain known 
 conditions that when once introduced into the wound they cause acute 
 Inflammation, which, in turn, may cause septicemia and pyemia, as well as 
 local suppuration. The surgeon has no control over the nature, number and 
 virulency of germs that enter the blood by inhalation, ingestion, absorp- 
 tion from an infection elsewhere, or of the bacteria conveyed by insects and 
 sometimes vermin. Nature is wondrous kind in disposing of even a marked 
 constitutional infection from these sources without any interference with 
 the healing of a hernial wound. 
 
 The egress of germs from the system is by the emunctories, the feces, 
 urine, breath and perspiration, and many of the micro-organisms are ex- 
 terminated by the living blood and tissues of the body. When local sup- 
 puration takes place in a wound, bacteria are eliminated with the purulent 
 discharges. 
 
98 INFECTION 
 
 PREDISPOSITION TO INFECTION. 
 
 This is both hereditary and acquired. It is well-known that some per- 
 sons are more easily infected, locally and constitutionally, than others. 
 There is a personality that predisposes to infection which is handed down 
 from posterity, though not all the members of a family may show it. The 
 person so constituted has no natural immunity or innate power to resist in- 
 fections of some kind. It is strange that through animate creation one in- 
 dividual resists certain diseases and infections, and falls an easy victim to 
 others. The negro does not easily take yellow fever, but smallpox or 
 tuberculosis very swiftly overcome him. 
 
 The age of a person, which bears so clearly on the invasion of conta- 
 gious and infectious diseases as to justify us in making a classification on 
 this basis, viz., diseases peculiar to children, adults and to old people, has 
 also a distinct bearing on the predisposition to infections of wounds after 
 operations. It is noticeable that in young children and old people wounds 
 heal with but comparatively little tendency to infection. In the case of the 
 aged they possess thin skins, slow phagocytes, and feeble tissues. There 
 appears to be a lack of something in the wound and tissues of a vigorous 
 adult that is present in the wound of a child or an old man that predisposes 
 to infection. This practical observation is not certainly explained by the 
 "theory of phagocytosis", by Metchnikoff. It may be, however, that the 
 tissues of the very young and the very old are more blessed, than those of 
 the adult, with active germicidal properties in the form of alexins or pro- 
 tective albumins. 
 
 Although great progress has been made towards finding out the cause 
 of natural immunity, it is still manifest that its phenomena are not wholly 
 explained by either (nor by the combination) of the two theories now pre- 
 vailing, viz., the (a) "phagocytic", and (b) "humoral." 
 
 The observations of Metchnikoff are accepted as correct as far as they 
 go. There appears to be no doubt that the phagocytes are the scavengers 
 that materially clean up an infected wound. He proved that 
 
 1. Certain cells (wandering phagocytes — mono — and polymorphonu- 
 clear white cells and connective tissue cells) first enclose, then digest, anri 
 eventually remove infective bacteria from the body. 
 
 2. Cells destroy germs in all forms of infection, and particularly in 
 those instances tending to recovery. 
 
 3. Numerous leucocytes, either 
 
 (a) Migrate towards the infected part (positive chemiotaxis), or 
 
 (b) May avoid the infected area (negative chemiotaxis). 
 
 The cells are attracted by certain toxins and repelled by toxins of many 
 virulent micro-organisms. 
 
 It has also been demonstrated that the fluids of the body have germi- 
 cidal powers. Especially is this a property of blood serum. The fluids that 
 manifest bactericidal properties have been named alexins or protective al- 
 bumins. It is claimed also that the alexins are derived chiefly from leu- 
 cocytes. There is no doubt but that one attack of inflammation pre- 
 
INFECTION " 99 
 
 disposes to another. There are a great many conditions which we cannot 
 enter into here, as well as certain diseases, such as diabetes and scur\ry-, that 
 render the tissues of the body weakened in vitality and predispose to in- 
 fection. 
 
CHAPTER X. 
 
 STERILIZATION AND DISINFECTION. 
 
 Because of the ubiquitous presence of bacteria in the air and in rooms, 
 on articles of furniture and on tlie skin of the body, etc., and also because 
 of the dangers consequent upon these bacteria entering wounds, a very im- 
 portant part of bacteriologic technic on the part of the surgeon consists in 
 destroying these micro-organisms by sterilization and disinfection. 
 
 Sterilization is accomplished either by heat, filtration, or the action of 
 chemicals. Usually the term sterilization is intended to imply destruction 
 of bacteria by heat. Disinfection means the destruction of bacteria by the 
 use of chemicals. Any substance which is capable of killing bacteria is 
 called a germicide. One w^hich inhibits the development of bacteria is 
 called an antiseptic. An object is said to be sterile when it is entirely free 
 fro::i bacteria and their spores. An object is septic when it contains actively 
 growing bacteria or their poisonous products. Aseptic is synonymous with 
 sterile. 
 
 All bacteria have a thermal death-point, and the method of steriUz- 
 ing and time of exposure are regulated accordingly. Culture media, tluids, 
 and anything that can be subjected to it are sterilized by some form of heat. 
 
 Sterilization by Heat. This is accomplished by fire ; dry heat or hot 
 air; live steam; superheated steam, or steam under pressure; and boiHng. 
 
 Fire. Sterilization by the actual flame is absolutely certain in its re- 
 sults, because it completely destroys all infected matter. Naturally that 
 would limit its use considerably, but it is useful in surgical cases in or out 
 of the hospital when delay is an element of danger to the patient. 
 
 Steel instruments, knives, needles and hypodermic needle, should not be 
 held in the flame for any length of time, as it affects the temper of the metal. 
 They can be passed through the flame a few times and then used. 
 
 When a surgeon is so placed that surgical dressings are not available, 
 he can improvise sterile dressings by the use of fire. Cotton or linen fab- 
 rics (woolen, even straw or moss) may be burned and scorched, the burnt 
 material to be applied next the wound, and that w^hich is scorched as an 
 external dressing. The author secured primary union of an amputation 
 below the knee under a dressing prepared by fire, as above mentioned, two 
 pillow slips and a sheet being utilized for that purpose. 
 
 Dry Heat. This also has a very limited application; a very high tem- 
 perature is required, 150° C, and an exposure of at least one hour. This 
 wall kill all known bacteria and their spores. Its application is limited to 
 the sterilization of glassware used in the operating room and in the labora- 
 tory. Articles made of rubber, wood, or crockery cannot be sterilized by 
 drv heat. 
 
STERILIZATION AND DISINFECTION IQl 
 
 The hot-air chamber is a single or double-walled sheet-iron or copper 
 chest, having a door on one side and several removable shelves on the in- 
 side. The top of the chest is perforated by two holes, in one of which is 
 placed a thermometer to indicate the inside temperature. The other open- 
 ing is plugged with cotton. A large Bunsen burner is placed under this 
 chest, which rests on an iron frame. In order to distribute the heat evenlv, 
 a piece of wire gauze is 'placed over the burner. 
 
 The articles to be sterilized are placed on the shelves wnthin the cham- 
 ber, but not until the temperature has reached 150° C, so that they will re- 
 main in the chest exposed to that temperature for one hour. Frequently the 
 mistake is made of counting the time from when the tubes, etc.. are placed 
 in the chamber while it is still cold. 
 
 Steam. All woolen and cotton fabrics, gauze, and wood must be ster- 
 ilized by steam. Steam is very penetrating, and is, therefore, a most elTec- 
 tive sterilizing agent. 
 
 The Arnold steam sterilizer, or one patterned after it, may be used for 
 this purpose. It is simple in construction, easily employed, and inexpensive. 
 An exposure of one hour to 100*^ C. (212*^ F.) is sufficient to destroy bacteria, 
 but bacteria which are in the resting-spore stage may resist the action of 
 steam for hours. 
 
 As such a prolonged steaming would be impracticable, the intermittent 
 or fractional method of sterilizing is used. The dressings, gauze, etc., are 
 exposed to the action of the steam for thirty minutes on each of three suc- 
 cessive days. The first sterilization will kill all the fully developed bac- 
 teria. Any spores which may have survived this sterilization will develop 
 into bacteria in the course of the succeeding twenty-four hours, and these 
 are killed by the next sterilization. After the third sterilization the ma- 
 terials can safely be said to be absolutely sterile. 
 
 Steam is available for sterilization in four conditions: (a) Plain steam 
 or steam in equilibrium; (b) steam in active motion, called live steam; (c) 
 steam under pressure — high tension steam; and (d) superheated steam. 
 When steam (100*^ C.) is passed through over-heated tubes or chambers 
 and its temperature is raised above 100° C, it is said to be superheated. 
 This condition of steam is not very practicable for surgical purposes. When 
 steam is used under pressure (high tension) in an autoclave, it is the most 
 powerful and practical agent at our command to sterilize surgical dressings, 
 etc., in hospitals. It is a more potent germicide than live steam, and live 
 steam kills anthrax spores in less than fifteen minutes. 
 
 Sterilization by steam may also be efl:ected by exposing the article to 
 be sterilized to the action of streaming or live steam for one hour, or for 
 thirty minutes to the action of steam under a pressure of fifteen pounds in 
 the autoclave, which is sufficient to destroy the spores. The dressings are 
 placed in the autoclave loosely, the top is screwed down firmly, and the 
 escape valve left open until the steam has displaced the hot air. The 
 valve is then closed and steam is generated for thirty mmutes, or longer, 
 if desired. Cooling niust be allowed to take place gradually. 
 
I02 STERILIZATION AND DISINFECTION 
 
 DISINFECTION OF INSTRUMENTS AND MATERIALS USED IN THE OPER- 
 ATING ROOM. 
 
 Great care must be observed in the operating room. Everything 
 should be absohitely sterile. Any instrument, towel, sponge, or ligature 
 that falls to the floor or comes in contact with any unsterilized object should 
 be removed at once and re-sterilized before it is again used. 
 
 Instruments may be sterilized by dry heat ; but it is preferable to 
 subject them to steam or to boil them in a one or two per cent, solution of 
 sodium bicarbonate, which prevents rusting and does not dull the edge 
 of sharp instruments. They can either be placed directly in the water or 
 wrapped in towels or pieces of gauze. As soon as they are removed from 
 the sterilizer they are immersed in sterilized or distilled cold water. 
 
 Boiling water, at lOo" C. (212" F.), kills all forms of cocci 
 in at least fifteen seconds, and anthrax spores m two minutes. The 
 boiling point of water varies with altitude, and this must be considered in 
 using boiling water for sterilization in high altitudes, for pressure to raise 
 the temperature to 100° C. must be used, or the addition of sodium 
 carbonate (one per cent.) to boiling water at 100" C. raises the 
 temperature to 104" C, and increases its germicidal power, which 
 effects sterilization in high altitudes. Boiling soda water is a convenient 
 agent for sterilizing surgical instruments, suture and ligature material, 
 but it may also be employed to sterilize towels, sheets, gauze sponges, dress- 
 ings, gloves, caps and gowns. In the preparation for operations in homes 
 and in the country, what I should call the kitchen method of sterilisation 
 is safe and efficient. It makes a profound impression upon the relatives 
 and the friends of the patient to be operated upon to receive a demonstra- 
 tion for three days by the nurses of the sacred duties and responsibilities 
 of nurses in safeguarding some of the portals of danger to the person com- 
 pelled to go under the knife. We should on every available opportunity 
 educate the people regarding the importance of scientific surgical work. 
 
 CHEMICAL DISINFECTANTS. 
 
 In the form and strength in which chemical disinfectants can be put 
 to surgical purposes they are not to be compared with boiling water and 
 steam for efficient and safe disinfection of inanimate materials. While 
 they are valuable in the preparation of rooms, some kinds of instru- 
 ments, certain suture and ligature materials, for disinfecting the hands 
 and wounds, still they are not the best means of disinfecting dressings, 
 bandages, gauze sponges, towels , sheets, gowns, etc., in everyday use by 
 the surgeon. In this connection the reader is referred to the chapter on 
 "Antiseptics and Disinfectants." 
 
 The chemical disinfectants may be used either in a gaseous state or 
 in solution. The best gases are nitric oxide, chlorine, sulphur dioxide and 
 formic aldehyde vapor. The best of these is the last mentioned. Both 
 nitrous fumes and chlorine have many practical disadvantages and objec- 
 tions which I need not mention. If sulphur dioxide is used, the room should 
 be thoroughly moistened and about 4 pounds of sulphur burned to every 
 
PLATE XA'I. 
 
 Conafested — a clavs. 
 
STERILIZATIOX AXD DISIXFECTIOX IO5 
 
 100 cubic feet of space. The formic aldehyde vapor is the most trustworthy 
 known and its method of utilization has already been described. 
 
 Formaldehyde. — One of the most active disinfectants and germicides 
 is formaldehyde. It is obtained in the market under the trade name of 
 formalin or formalose, a 40 per cent, aqueous solution of the gas formalde- 
 hyde. The gas is extremely penetrating, and is very irritating to the 
 mucous membranes. This limits its use to the disinfection of inanimate 
 objects. A 15 per cent, solution at 150° C. kills anthrax spores in 
 one and a half hours. Used as a liquid it does not possess any advantages 
 over carbolic acid and similar preparations. W'hen vaporized, it is vastly 
 superior to all other agents. Robinson, of England, found that it will 
 penetrate a mattress and kill test tube cultures placed within it. The gas 
 is generated rapidly and continuously by any of the different styles of 
 formalin generators on the market. It is used in the form of a spray ; 
 or sheets saturated with formaldehyde solution are hung up in the tightly 
 closed room for twelve hours, after which the doors and windows are 
 throv^n wide open and the room thoroughly aired. The number of sheets 
 required will depend on the size of the room. In a room 10x10 feet two 
 ■sheets will suffice. All crevices, keyholes, etc., should be packed with cotton, 
 so that none of the vapor will escape. 
 
 Novy's and the "Central" formaldehyde generator, and Schering's 
 lamp, are exceedingly simple in construction and inexpensive. Others, like 
 Trillat's autoclave, are complicated and expensive Either the apparatus is 
 placed in the room, or the vapor is sent in through the keyhole by means of 
 a supply tube. The temperature of the room should be about 21" 
 C, and it should contain sufficient moisture 
 
 Sulphate of copper is an excellent and at the same time a very cheap 
 'disinfectant. It is not irritating in one per cent, solution, and has no odor. 
 It is especially valuable for the disinfection of typhoid stools. A pound of 
 the sulphate is dissolved in 2^ gallons of w^ater, and a pint of this solution 
 is kept constantly in the vessel which receives the discharges from both 
 bowels and bladder. The poison is destroyed in fifteen minutes if the in- 
 fected material is mixed thoroughly w4th the solution. 
 
 In cases of strangulated hernia occurring away from hospitals, where 
 no antiseptics are available but "blue stone,'' after cleansing the operative 
 area and hands with soap and water, the solid sulphate of copper may 1)e 
 ■efficiently used to disinfect the skin of the patient and the hands of the 
 •operator. 
 
 Harrington's Solution. — In this connection, the following excerpt from 
 an article by Charles Harrington of Boston {Annals of Surgery, October, 
 1904) is of interest. He says : 
 
 "After thorough brushing with hot soapsuds, what agent can be relied 
 on to kill the bacteria that have not been removed ? Not corrosive sublimate 
 i-iooo, if w^e soak the hands a quarter of an hour; not creolin, 1-20, if we 
 5oak them much longer; not lysol, nor solveol, nor bacillol, nor sulpho- 
 naphthol ; not peroxide of hydrogen ; not sublamin ; not mercuric cyanide ; 
 not even formaldehyde in 5 per cent, solution, even though the skin could 
 
TOO 
 
 STERILIZATION AND DISINFECTION 
 
 stand it. All of these agents and several others 1 have tested under the 
 most favorable conditions against the common pus organisms and all failed 
 to kill within reasonable periods. A little more than a year ago I pub- 
 lished the results of a series of experiments which demonstrated, among 
 other things, that corrosive sublimate, i-iooo, requires more than ten 
 minutes" contact to kill staphylococcus albus, and that weaker solutions 
 (1-5000) act far more slowly. Recently I tried 1-500, which solution is too 
 strong and irritating for general application, and fovuid that it would kill 
 staphylococcus aureus in from sixty to ninety seconds and the other pyo- 
 genic organisms in from forty to sixty seconds. With i — 100, I found that 
 the aureus was killed after twenty seconds. Now, if i — 100 cannot destroy 
 pus cocci in twenty seconds, and i — 500 can do so only after a minute, and 
 i-iooo only after ten minutes, what measure of disinfection does the sur- 
 geon attain who merely dips his hands into the solutions of corrosive sub- 
 limate in common use for only a few seconds and then rinses them off 
 with sterile water or salt solution? 
 
 "The following table shows the number of minutes that the organism 
 employed remained in contact with the several disinfectants without injury, 
 and also the shortest exposure observed that was sufhcient for its destruc- 
 tion : 
 
 Failed to Kill. Killed. 
 Agent. Strength. (Minutes.) (Minutes.) 
 
 Carbolic acid .n 1-40 3 4 
 
 Carbolic acid 1-20 i 2 
 
 Trikresol 1-40 2 3 
 
 Trikresol 1-20 i 2 
 
 Lysol 1-40 7 10 
 
 Lysol 1-20 2 3 
 
 Solveol 1-40 10 15 
 
 Solveol 1-20 10 15 
 
 Bacillol 1-40 4 5 
 
 Bacillol 1-20 3 4 
 
 Creolin 1-40 10 15 
 
 Creolin 1-20 10 ■ 15 
 
 Sulphonaphtol 1-20 30 45 
 
 Hydrogen peroxide Full strength 4 5 
 
 Formaldehyde i per cent. 60 . . 
 
 Formaldehyde 2 per cent. 30 45 
 
 Formaldehyde 3 per cent. 25 30 
 
 Formaldehyde 5 per cent. 15 20 
 
 Mercuric cyanide i-iooo 180 
 
 Sublamin i-iooo 10 
 
 Potassium permanganate Saturated 10 15 
 
 Potassium permanganate and hydro- 
 chloric acid ( Andre wes) i per cent, each 4 5 
 
 "My next endeavor w^as to find some preparation that will kill not in 
 minutes, but in seconds. First, I experimented with a mixture which 
 
STERILIZATION AND DISINFECTION lO/ 
 
 would kill staphylococcus aureus, albus, and. citreus and bacillus p\oc\aneus 
 in less than ten seconds. Then I tried weakening- it, first as to one, then 
 as to another ingredient, but always aiming to keep its limit of required 
 time at about ten seconds. The ninth combination tried appeared to be as 
 weak with respect' to each of the active constituents as could be made, 
 retaining- that degree of efficiency — that is, to kill the pyogenic bacteria on 
 silk threads, not in the skin — v.dthin ten seconds. I tried it against pus 
 from a carbuncle and against two other specimens of uncertain origin, 
 and at the same time I tried carbolic acid and trikresol, which had proved 
 to be the quickest in action of the twenty-two solutions above mendoned. 
 
 "The carbuncle pus was killed by trikresol (1-40) in five and a half 
 minutes and by carbolic acid (1-40) in four; my mixture kihed it in less 
 than a minute, though not in thirty seconds. The other specimens of pus 
 were both killed by trikresol and carbolic in two minutes, and by my mix- 
 ture in less than thirty seconds. 
 
 "I have repeatedly soaked my hand (without any preliminarv scrub- 
 bing) for two minutes, and then have had plantings made from material 
 removed from about each nail and from scrapings from the skin of each 
 finger and from the palm. Occasionally, I got a growth ; but, as a rule, 
 every tube of bouillon remained clean and sterile. A young man, whose 
 duties included the daily cleaning of cages in the animal room and whose 
 hands were not the subject of much thought or care, soaked his hand 
 (after ordinary washing) on ten different occasions for from two to five 
 minutes ; and each time each nail and finger was tested, i. c, ten cultures 
 were made In seven of the experiments there was entire absence of 
 growths ; in one, a growth was obtained from one forefinger ; in one, from 
 one middle finger ; and in one, from one thum.b. That is to say, of 100 
 plantings only three showed growths. 
 
 "At the Boston City Hospital, Dr. Monks immersed his hands for two 
 minutes without previous scrubbing ; the skin of both hands gave negative 
 results, but growths were obtained from the nails of the right hand ; the 
 nails of the left hand were sterile. Three of the assistants did the same 
 thing, but after scrubbing. The hands of all three were sterile ; the nails 
 of the left hand of one assistant gave a growth. 
 
 "For my combination, I make no claims whatever, and no assertions 
 that later might have to be recalled. To my hands and to those of my 
 assistants, the mixture has caused no irritation beyond the same 'Jegree 
 of biting that one notices when in contact with peroxide of hydrogen. 
 Two of the surgical assistants reported slight exfoliation two days after 
 trying it, but nothing more. I recognize that some skins may be more 
 markedly irritated, and that not sufiiciently numerous experiments have 
 been made to warrant unqualified recommendation. 
 
 "The composition of the mixture is as follows : 
 
 Commercial alcohol (94 per cent.) • 640 cubic centimetres 
 
 Hydrochloric acid 60 cubic centimetres 
 
 Water , 300 cubic centimetres 
 
 Corrosive sublimate 0.8 gramme 
 
I08 STERILIZATION AND DISINFECTION 
 
 "This mixture, then, contains 60 per cent, absohite alcohol, 6 per cent, 
 commercial (strong) hydrochloric acid, and 1-1250 corrosive sublimate. 
 Now, 60 per cent, alcohol will destroy Straphylococcus aureus in four min- 
 utes ; 10 per cent, hydrochloric acid is equally effective; and i-iooo cor- 
 rosive sublimate will kill it in three minutes. Why a combination con- 
 taining all three substances, but Avith lesser proportions of the acid and the 
 salt, is so much quicker in its action than any one of them alone, is an 
 interesting question of physical chemistry." 
 
CHAPTER XI. 
 
 ANTISEPTICS AND DISINFECTANTS. 
 
 It is impossible in the limited space at my disposal to enter into a de- 
 tailed discussion of the antiseptic value of all the known antiseptics. I 
 will, however, consider the most important and those commonly used. 
 
 Carbolic Acid. — On account of the great prominence that Lister gave 
 to this antiseptic, it should be considered first. 
 
 Pure carbolic acid (phenol) is obtained from, coal-tar oil by fractional 
 distillation, and occurs in colorless crystals which have a melting point of 
 38.8'' C. (104° F.). Carbolic acid crystals are soluble in water, i in 13; 
 in glycerine, 35^ in i ; in olive oil, i in 2 ; in chloroform, 3 in i ; in ether, 
 4 in I ; in alcohol, 6 in 1. 
 
 Carbolic acid is usually used in a 20 per cent, solution. This is too 
 strong for the hands of many operators without the immediate use of 
 alcohol. It forms insoluble albumen compounds which interfere Avith its 
 germicidal power. If, however, carbolic acid is combined with an equal 
 amount of hydrochloric acid, its germicidal action is greatly increased. A 
 95 per cent, solution of carbolic acid applied to the skin acts as an anesthetic, 
 giving a sensation of numbness and coldness wdth a loss of tactile sensi- 
 bility. Moist dressings of 5 per cent, strength have been known to 
 cause gangrene, due to the formation of thrombi in the arterioles. The 
 absorption of carbolic acid into the system is first made manifest by the 
 smoky appearance of the urine. If an overdose enters the circulation it is 
 shown by pallor, cyanosis of the mucous surfaces, shallow breathing, dilated 
 pupils, feeble pulse, sub-normal temperature and not infrequently delirium. 
 If the dose is fatal, convulsions and coma usually follow. N. Senn has 
 pointed out the danger of using strong solutions of carbolic acid, and men- 
 tioned a death following the injection of a few drops of pure carbolic 
 acid into the sac of a hydrocele. It is remarkable that when 95 per cent, 
 carbolic acid is swallowed in sufficient quantities to cause death coma is 
 one of the first manifestations. I have made it a practice for years to use 
 95 per cent, carbolic acid on account of its excellent anesthetic, antiseptic, 
 deodorizing and cauterizing effects without any deleterious results. If alco- 
 hol is used on the carbolized surface to neutralize the continued local action 
 of the acid, there is practically no danger of carbolic mtoxication. The 
 objection to using carbolic acid on the hands in sufficient strength to insure 
 complete germicidal action is that it corrugates and anesthetizes the skin. 
 
 The experiments made to determine the germicidal powers of car- 
 bolic acid are more or less contradictory. Sufficient evidence has been 
 adduced to show that carbolic acid requires too long a time to sterilize 
 
no ANTISEPTICS AND DISINFECTANTS 
 
 the skin of the patient or the hands of the surgeon. Solutions of carboHc 
 acid and oil are inert, so far as being bactericidal is concerned, and solu- 
 tions in alcohol and glycerine are less powerful than watery solutions. 
 Carbolic acid is now chiefly used in antiseptic surgery for the preserva- 
 tion of materials previously sterilized, such as gauze-sponges, sutures, liga- 
 tures, etc., etc. It is no longer employed for irrigathig purposes while 
 operating, for it only irritates the parts, induces a copious flow of serum, 
 and not infrequently causes superficial tissue necrosis. Ninety-five per 
 cent, carbolic acid disinfects instruments that have been rendered free from 
 fat almost instantaneously, and does not injure them. 
 
 Geppert demonstrated that anthrax spores lived in a 7 per cent, solution 
 for 38 days; then they grew in agar-agar and finally killed guinea pigs. 
 Christmas kept anthrax spores in a 20 per cent, solution of carbolic acid 
 for a month without lessening their vitality. It was shown by Klein that 
 anthrax bacilli are killed in five minutes by a 5 per cent, carbolic solution. 
 Pyogenic cocci are more easily destroyed by carbolic acid than are the an- 
 thi-ax germs. The staphylococcus aureus, on the other hand, is destroyed 
 in from two seconds to fifteen minutes by a 5 per cent, solution. 
 
 Other Coal-Tar Products. — Many coal-tar derivatives besides carbolic 
 are used as antiseptics in the operating room. Lysol is a brown liquid, alka- 
 line in reaction, made from tar-oils. It is used in solutions of one to two 
 per cent, strength for cleansing the hands or skin. It has a soapy feel. 
 I use it to aid in pulHng on rubber gloves. When the gloves are filled 
 with the lysol solution, the hands slip into them with comparative ease. It 
 is a feeble germicide and not so irritating to the skin as carbolic acid. 
 What remains of it in the gloves only renders the hands the more aseptic. 
 Lysol is incompatable with acids. It is highly toxic. 
 
 Creolin, cyllin, izol and other coal-tar products are more useful as 
 deodorizers than as disinfectants. 
 
 Alcohol. — Alcohol is used more freely than any other antiseptic. It 
 is a powerful germicide in the strength of 70 per cent., but is of no value 
 when pure (95 per cent.). In disinfecting the hands and the field of oper- 
 ation it removes epidermal scales and fat from the skin, abstracts water, 
 acts germicidally and prepares the field for some other and more pene- 
 trating agent. In conjunction with corrosive sublimate or biniodide of 
 mercury it is a most practical and efficient antiseptic. 
 
 Alcohol kills the tubercle bacillus after five minutes' exposure, and a 
 40 per cent, solution kills pus cocci in two hours. Sixty to seventy per cent, 
 is the most efficient strength. It is useful for disinfecting instruments, 
 basins, sutures and ligatures, and for preserving materials used in the 
 operating room. 
 
 Corrosive Sublimate (Hg CU). — Corrosive sublimate, also known as 
 bichloride of mercury, mercuric chloride, and sublimate, is an excellent an- 
 tiseptic and disinfectant. It is soluble in water, alcohol, ether and gl}'cer- 
 ine. It is soluble in water, i in 19 ; in absolute alcohol, i in 3 ; in ether, 
 I in 6 ; in glycerine, less than i in 2. It is a powerful poison and inay kill 
 by absorption from the skin or mucous cavity. It formr, an albuminate 
 
m^m^^ 
 
 PLATE XVII. 
 Inflamed Hernia. 
 
ANTISEPTICS AND DISINFECTANTS IIJ 
 
 when applied to the tissues, rendering it inert. Even in aqneous solutions- 
 of I to looo, it acts as a great irritant to the hands of some operators. It 
 restrains the development of anthrax spores in as weak a solution as i in 
 30,000, and it kills them in from 5 to 10 minutes in the strength of ]-iooo. 
 A i-iooo solution kills the tubercle bacillus in one minute. Growth of the 
 pus cocci is restrained by a 1-30,000 solution; i-iooo kills them in from 
 five to ten minutes. Sternberg advocates its use as a general disinfectant 
 in i-iooo or 1-500 solution for spore-containing material, and in 1-5000 
 or 1-2000 for non-sporulating pathogenic bacteria. Its action is increased 
 by the addition of hydrochloric, picric or tartaric acid. 
 
 Harrington, of Boston (as before stated), has demonstrated that in 
 combination with hydrochloric acid and alcohol the germicidal action is 
 greater than that of either one alone. The chief uses to which corrosive 
 sublimate is put to-day are: (a) To disinfect the hands of the operator; 
 (b) the skin of the patient; (c) to sterilize catgut, as well as in the 
 preservation and preparation of other ligature and suture materials. 
 
 Solutions of corrosive sublimate are poisonous, sometimes cause der- 
 matitis, lessen the resisting power of the tissues, destroy metallic instru- 
 ments, are easily decomposed by serum and purulent discharges, and are 
 incompatible with an alkali. Solutions of corrosive sublimate in distilled 
 water become reduced in strength from the formation of an oxide. 
 
 Geppert found by precipitating the mercury with amnionir.m sulphide, 
 thus getting the inert and insoluble sulphide, that pus organisms were not 
 killed by the bichloride solutions as was formerly supposed, but that thev 
 frequently retained their vital powers of infecting" animals. This was a 
 revelation to those operators who so thoroughly relied on sublimate sciu- 
 tions as a disinfectani in conformity with the bacteiToIogic findings of 
 former experimenters wiio asserted that staphylococci (yellow) were killed' 
 by i-iooo corrosive sublimate solution in a few seconds. Since Geppert's 
 experimental findings have been verified by Abbott m Welch's laboratory,, 
 and also by others, corrosive sublimate as a disinfectant is not considered 
 as being infallible. Sublimate solutions are very toxic, and it is icnown 
 that deaths have been caused by prolonged irrigation of wounds with these 
 solutions. I recall seeing a case 'of sublimate poisoning in consultation 
 where death followed the use of an intra-uterine douche (i-iooo) for sepsis 
 after a miscarriage in the third month. It is very dangerous to irrigate 
 raw surfaces with this poison. Even if constitutional symptoms do not 
 arise, local necrosis is sure to occur. In pus cases irrigation with bichloride 
 solutions is often indicated. One may begin with a solution of the strength 
 of 1-5000 and irrigate till one-third is used, and after that the solution 
 is diluted rapidly to i in 20,000, and then the wound is irrigated with nor- 
 mal salt solution. 
 
 ■ Corrosive sublimate as a disinfectant has stood a long practical test, 
 and while we no longer wash fresh wounds with it, still, in combination 
 with other agents, as Harrington's solution, it is the best practical germi- 
 cide at our command for disinfecting the skin of the patient and the hands 
 of the operator. 
 
114 ANTISEPTICS AND DISINFECTANTS 
 
 Sal-aleinhroth is an ammonic-merciiric-chloride. It is soluble in water 
 to the extent of less than its own weight. "While it combines with albumen, 
 it does not do so as readily as does corrosive sublimate. It is used in the 
 preparation of alembroth gauze, wools, antiseptic dressings, etc., but is 
 very objectionable. 
 
 Biniodide of Mercury (Potassio-Mercuric-Iodide). — This substance 
 is spoken of very highly as a disinfectant. Pearson {Modern Surgical Tec- 
 7iique ill Operations, page 76) says, "Biniodide possesses the following ad- 
 vantages as compared with sublimate : ( i ) It is a more powerful germi- 
 cide ; (2) it does not coagulate albumen; (3) it does not cause precipita- 
 tion with blood, except when the latter is in excess; (4) it is less irritat- 
 ing to wounds ; (5) it is much less irritating to the skin, save in exceptional 
 cases; (6) it is more penetrating; (7) it is safer for washing out septic 
 wounds and cavities, being less toxic; (8) it does not cause any immediate 
 corrosion of metallic instruments". 
 
 Kanthack and other bacteriologists have pointed out that biniodide of 
 mercury possesses superior germicidal powers than bichloride. It has 
 one practical disadvantage, however, as compared with bichloride, and that 
 is its much greater cost. 
 
 Biniodide Soliiiions. — Stock solution i in 1000. 
 
 Biniodide, 100 grams ; potassium or sodium iodide, 1000 grams ; dis- 
 tilled water, icxdo c. c. 
 
 By dissolving the potassium or sodium iodide in the water before add- 
 ing the mercury salt a clear solution is obtained. If a precipitate is thrown 
 down, the solution is not strong enough ; then add a little more biniodide. 
 The strength of the stock solution is about i in 600. If colored with eosin 
 it will not be mistaken for other clear fluids. The agent can be obtained in 
 tablet form. One tablet to a gallon of water makes a i in 1000 solution. 
 
 Alcoholic solution of biniodide, i in 500, is the one recommended 
 (Pearson) for disinfecting the hands. It is made by adding one tablet to 
 5 ounces of water (distilled), and 15 ounces of 90 per cent alcohol, or 
 methylated spirits. 
 
 A 70 per cent, alcoholic solution is obtained with the one, and 67.5 
 per cent, alcoholic solution with the other. A preserving solution, i in 
 1000, for the preservation of Hgatures and suture materials, is made by 
 adding 5 to 10 per cent, of sterile glycerine to the alcoholic solution. 
 
 Iodine. — Iodine is a very useful and efficient non-metallic element. It 
 is a solid at the ordinary temperature. It is slightly soluble in water, but 
 by adding a little potassium^ or sodium iodide it dissolves freely. It dis- 
 solves in alcohol, i in 10. When applied to the skin it produces a stain 
 and acts as an irritant, rubefacient, disinfectant or vesicant according to 
 the strength of solution used and the frequency with which it is applied. 
 For complete information regardhig iodine as a germicide I refer the 
 reader to Senn's article on 'Todine in Surgery, etc.'' {Journ. of Snrgery, 
 Gynecology and Obstetrics, July, 1905). Senn maintains that aqueous 
 solutions of iodine dest'-oy: (i) Actinomyces (bovis) (a) i in 500, in fif- 
 teen minutes; (b) i in 200, in one minute. (2) Staphylococcus pyogenes 
 
ANTISEPTICS AND DISINFECTANTS II 5 
 
 aureus, i in 200, in five minutes. (3) Streptococcus pyogenes, i in 500, 
 in two minutes. (4) Anthrax bacillus and its spores, i in 100, in ten 
 minutes. (5) Tubercle bacillus: (a) i in 200, in sixty minutes; (b) i in 
 100, in seven minutes. 
 
 Senn considers iodine the safest and most powerful of all antiseptics. 
 He uses it to disinfect the nails as the last step (tincture). It is used in 
 the preparation of catgut. 
 
 Iodoform. — In hernia operations iodoform has a place as a dusting 
 powder, although not used nearly as much as formerly. It is soluble in 
 ether, i in 7 ; chloroform, i in 14; alcohol, i in 120; olive oil, i in 30; 
 glycerine, i in 100. When absorbed through wounds it produces poison- 
 ing. Locally iodoform occasionally causes a dermatitis, vesicles or acute 
 eczema. It has many objections. It has a disagreeable odor, and it is a 
 poor antiseptic and does not kill germs, except under special circumstances. 
 In the tissues of the hand, in granulation tissue, especially in tuberculous 
 tissue, iodoform decomposes in from 3 to 5 da}s in the absence of oxvgen, 
 and is then germicidal in its action, destroying staphylococci and streptococ- 
 ci. Heile (An. of Surgery, Dec, 1905) thinks the decomposition of iodo- 
 form in the presence of oxygen sets free di-iodo-acetvlene — and that this is 
 the germicidal agent. 
 
 Potassium pcrmanganale, in 5 per cent, solution, kills anthrax spores 
 in twenty-four hours. The dilute solutions used for irrigating septic 
 wounds are absolutely worthless so far as their antiseptic action is con- 
 cerned. They are usually employed hot, and to the heat must be ascribed 
 their m»uch vaunted value as germicides. Potassium permanganate is de- 
 composed easily by wound secretions, and it is too slow in action for the 
 operating room. 
 
 Silver nitrate destroys anthrax spores in twenty-four hours in a i-io,- 
 000 solution. Behring says it is superior to mercuric chloride. It is very 
 irritating, and combines with chlorides and albumins to form insoluble 
 silver salts, which have no germicidal value. The various other silver salts 
 (organic) now on the market do not com.bine with the albumins, and 
 are less irritating than the nitrate, but the clinical reports are so contra- 
 dictory that it is impossible to determine their antiseptic value with any 
 degree of positiveness. Hardly any two men favor the same compound. 
 
 Boric acid is practically worthless as a disinfectant. A saturated solu- 
 tion fails to kill pus cocci in two hours. It is a very weak antiseptic. A 
 5 per cent, solution failed to destroy anthrax spores in five days (Koch). 
 It is used very widely as a dusting powder on w^ounds, but is sometimes 
 injurious. It is a good solution in which to keep soft rubber sterile cathe- 
 ters, etc. 
 
 Pyoktannin. — Many of the anilin dves are germicides, especiallv blue 
 pyoktannin or methyl violet. The pus cocci and anthrax bacilli are killed 
 in thirty seconds by a i-iooo solution ; the typhoid bacillus in thirty min- 
 utes. Malachite green possesses even greater germicidal value than > pyok- 
 tannin. The objection to these dyes is that they stain and discolor the tis- 
 sues. The author employs them to stain fistul?e and sinuses. 
 
Il6 ANTISEPTICS AND DISINFECTANTS 
 
 Chlorine. — All the haloid elements are active germicidal agents. 
 Chlorine combines readily with hydrogen and hberates nascent oxygen. It 
 is most active in the presence of moisture. A moist atmosphere, containing 
 the gas in the proportion of 1-2500, kills the anthrax bacillus in twenty- 
 four hours. In the proportion of 1-200 it kills the tubercle bacillus in an 
 hour. It is very irritating to the tissues. 
 
 Hydrogen Peroxide. — The solutions on the market are extremely varia- 
 ble i:i strength and the results of their use uncertain. They deteriorate very 
 rapidly. Peroxide is used principally for cleansing suppurating wounds, as 
 it possesse^^- the power of liberating nascent oxygen, which oxidizes the 
 purulent secretions. 
 
 In order to carry out the principles presented in this chapter, special 
 requirements must be met before aseptic surgical technic can claiip superior 
 results quite apart from the operator's skill in surgical procedures and his 
 knowledge of hernias. These requirements are the sterilization and disin- 
 fection of everything that may come in contact with the wound. The first, 
 if not the most important, is to render the hands and forearms of the 
 operator and his assistants surgically clean. The hands are always covered 
 with bacteria while performing their everyday functions. It is true that a 
 surgeon who knows the dangers of infection can and does keep his hancis 
 out of abscesses, and does not handle septic cases without rubber gloves, 
 or examine the mouth, vagina or .rectum with bare hands , but in spite of 
 all ordinary precautions that he can possibly observe against coming in 
 contact with virulent pyogenic organisms his hands v/ill get dirty and in 
 that dirt lurk the sources of inflammation and all that inflammation im- 
 plies. 
 
 It is a very difficult task to destroy all the germs and their spores on 
 the hands, under the nails, and in the follicles of the skin without destroy- 
 ing the skin at the same time. Indeed, so discouraging has this task been 
 that many authorities consider it hopeless to try to render the hands com- 
 pletely aseptic (Needham-Green "On the Sterilization of the Hands," 
 1904), realizing that a person can go so far and no farther. Year by 
 year a little more information has been gained until now we can say that 
 the hands of some persons at least may be disinfected so thoroughly in a 
 few minutes as to fail the detection of germs. A man who operates almost 
 every day and uses antiseptic reagents, such as mercuric chloride, has his 
 skin impregnated thoroughly with the drug. It is easy to see that his hands 
 are less liable to implant pus germs into the wound than are the hands of 
 one vv'ho operates only occasionally. In evidence of this sublimated con- 
 dition of the deep skin let me say that if such an operator will rub lanolin 
 into the skin of his hands and forearms for fifteen minutes, he will suffer 
 the symptoms of salivation. This observation I verified on myself. 
 
 THE TOILET OF THE HANDS AND FOREAEMS. 
 
 Keep them clean. Avoid scratches or abrasions by wearing gloves when 
 driving, fishing or hunting. If you receive scratches, disinfect them and 
 apply collodion for protection. Ungual tags should be removed and pro- 
 

 PLATE XVIII. 
 Ulcerated Hernia. 
 
ANTISEPTICS AND DISINFECTANTS II9 
 
 tected in the same manner. Any one who has a pustule or suppvirating 
 wound, be it ever so small, should consider himself incapacitated from 
 operating or assisting at an operation. The wearing of rubber gloves does 
 not excuse him for operating. The nails should be kept short to pre- 
 vent the accumulation of extraneous matter and to enable one to have 
 free access to the subungual spaces for their disinfection. 
 
 The forearms should be kept free from hair by shaving them every few 
 weeks. It always gives me a shudder to see a hairy arm enter the ab- 
 dominal cavity. There is no reason why this precaution should not be 
 practised. Rough and horny hands require more time for their disinfection 
 than those with smooth and flexible skin. A good plan to train assistants, 
 internes and nurses to take the time required to scrub the hands in soap 
 and water in order to remove gross dirt, is to ask each of them before 
 scrubbing first to anoint the hands and forearms with an ointment cf 
 powdered charcoal. It will teach them that it requires much more time, 
 patience and perseverance to rid the skin of black dirt than they anticipat- 
 ed. If germs were visible to the naked eye, what an interminable job it 
 would be to scrub them off ! 
 
 One secret of preventing the hands from cracking is to scrub them 
 carefully after each operation in order to remove all traces of blood, and 
 then rub any ointment that is sterile and feebly antiseptic into the crevices 
 and follicles of the skin, and with sterile towel rub off the redundant oint- 
 ment. I find this to be an excellent aid in keeping the hands in a cosmetic 
 state. If called in consultation, and it is deemed best to examine septic 
 places on or in the body, which would undoubtedly befoul my hands if not 
 protected, and if rubber gloves are not available, I feel that some security is 
 obtained by smearing the hands with sterile vaseline, or some cerate, before 
 making the examination. 
 
 While scrubbing the hands with soap and water preparatory to per- 
 forming an operation, care must be exercised not to reinfect the hands by 
 touching septic brushes, towels, water taps, etc. In every well-furnished 
 operating room an automiatic arrangement is provided to turn the water 
 on and off without the use of the hands. 
 
 The simple technic of scrubbing the hands is so frequently faulty in 
 aseptic precaution that I am constrained to dwell on it. In training ama- 
 teurs in surgical technic I have frequently given no instructions whatever, 
 but simply ask them to scrub up. Each in turn picks up a sterile nail 
 brush in one hand and a chunk of soap in the other and at once begms a 
 vigorous scrubbing of the one and then of the other hand. Is not this the 
 usual way to begin the scrubbing process? Yes, but it is wrong, and there 
 is danger of autoinfection from the germs beneath the nails and on the 
 skin being forcibly rubbed into an abrasion created by the brush or into a 
 raw surface previously present. It is only recently that an able surgeon 
 lost his life from auto-streptococcic infection received in this way. 
 
 The skin of the hands should be softened by washing them in soap 
 and water in the old-fashioned way before applying the brush. This process 
 not only renders the skin less liable to injury from a stiff bristle in the 
 
120 ANTISEPTICS AND DISINFECTANTS 
 
 brush, but it also removes the gross source of iufectioii. This 1 call a pri- 
 mary scrub, and it should be done with warm sterile running water in a 
 room used for this purpose. One may at once poke his fingers deeply into 
 the soapdish ; another sticks to the same brush throughotit 
 the entire process, or reinfects his nails with his penknife taken from his 
 pocket, or touches spectacles, or even wipes them with a clean ( ?) pocket 
 handkerchief, after finishing his scrubbing. A sterile nail file should be used 
 not after the cleansing process with brush, soap and water, but somewhere 
 in the middle of the process. The nail file removes softened masses not as 
 yet reached by the brush and thus its use should not be left to the last. 
 
 In order to receive the greatest benefit from soap and water cleansing 
 with brush, about fifteen minutes should be consumed in the operation. 
 
 1. Five minutes with soap and warm water. 
 
 2. Five minutes with fresh sterile soft soap, sterile brush and flowing 
 water. 
 
 3. Use nail file or scalpel. 
 
 4. Five minutes with fresh sterile soap ; fresh sterile brush and 
 water flowing freely on the forearms and hands. 
 
 It must be remembered that one man is capable of doing more cleans- 
 ing in five minutes than another does in double that time. It has been 
 proven bacteriologically that the hands are not freed from dangerous bac- 
 teria by scrubbing with soap and water, and in respect to this fact some 
 chemical germicidal reagent must be used to destroy the remaining bacteria 
 on the skin. The nails should be manicured once a week. Any abrasioi. 
 caused is at once protected with a drop or two of equal parts of iodine and 
 collodion. 
 
 Methods of Hand Disinfection : — 
 Pearson's Method. 
 
 1. Scrubbing with soap and water and changing brushes for five 
 minutes. 
 
 2. Methylated spirits rubbed on hands, nails and forearms for three 
 minutes. 
 
 3. Spirituous solution of biniodide (i in 500) for two minutes. 
 
 4. Biniodide wiped ofif with meth3dated spirits. 
 
 In the case of one whose hands are well cared for the process may 
 be accomplished in seven minutes, viz : "Washing stage three minutes ; 
 alcohol stage, two minutes; biniodide stage, two minutes." 
 Kocher's Method. 
 
 1. Wash the hands thoroughly with soap and brush under steaming 
 hot water. 
 
 2. Wash ofif the soap with flowing warm water. 
 
 3. Scrub with alcohol (85 per cent.) inch by inch. 
 
 4. Wash ofif alcohol with stream of warm sterile water. 
 
 This process is for hands cared for surgically. For hig-hly infected 
 hands he recommends an additional scrubbing and bathing with sublimate 
 solutions of I in 500, or i in loco, in strength. 
 Furhrino-ers Method. 
 
ANTISEPTICS AND DISINFECTANTS 121 
 
 1. Scrub with soap and water for three minutes. 
 
 2. Immerse hands and forearms in 95 per cent, alcohol for one min- 
 ute, using the scrubbing brush to remove fats, etc. 
 
 3. Wash hands and forearms in sublimate solution i in 1000. 
 
 In regard to the use of alcohol as a disinfectant, it has been shown that 
 70 per cent, alcohol is more germicidal than 95 per cent. Harrington has 
 proven that a sublimate solution, i in 1000, is not as potent a germicide 
 alone as when it is combined with 70 per cent alcohol and 6 per cent, hydro- 
 chloric acid. 
 Permanganate of Potash and Oxalic Acid Method. 
 
 This method does not stand the bacteriologic test, and is only men- 
 tioned to be condemned. (See experiments of Leedham-Green and Har- 
 rington.) It has been used extensively in Johns Hopkins' Hospital and 
 for a time most American surgeons employed it. 
 Chlorinated Lime Method. 
 
 This process is cumbersome, but is practised more or less. It con- 
 sists of the following steps : 
 
 1. Scrub as usual. 
 
 2. Take a handful of chlorinated lime and make a paste of it with 
 warm water. 
 
 3. Take another handful of crushed, crystalline washing soda and 
 mix it with the lime paste between the hands, and then thoroughly rub it 
 into the skin until the roughness of the soda is no longer felt but a 
 sensation of heat is felt, due to the liberation of chlorine gas. 
 
 4. Rinse the hands in a two per cent, solution of ammonia to remove 
 the odor. 
 
 Rubber Gloves. After the hands are sterilized the operator may use 
 rubber gloves for two purposes, (a) to keep the hands aseptic, and (b) to 
 guard against infection of the wound from the hands. In hernia opera- 
 tions and in all aseptic surgical procedures the latter is the prime con- 
 sideration. That they obtund the sensibility of the fingers there is no rea- 
 son to doubt and the thicker the glove the greater the loss of normal tactile 
 sense. 
 
 In consideration of the uncertain asepticity of the hands obtained by 
 scrubbing and by disinfectants, especially in the case of surgeons, assist- 
 ants and nurses who have not studied bacteriology to any great extent (and 
 these include the vast majority of persons who operate or who assist at 
 operations), and also in view of the rapidity wath which gloves on the 
 hands may be rendered aseptic with 95 per cent, carbolic acid, i in 200 
 bichloride; pure lysol, etc., it is reasonable to conclude that less infection 
 of wounds occurs during operations when rubber gloves are worn. When 
 the hands are not aseptic, the gloves are reinforced in pulling them on. 
 
 In cases demanding surgical interference so emergently that there is 
 no time to scrub up, an assistant may put the gloves on the septic hands 
 of the operator. If the gloves are not sterile and speedy action is a life- 
 saving element, then it is admissible to put the gloves on dirty hands and 
 sterilize them immediately as already mentioned. On more than one occa- 
 
122 ANTISEPTICS AND DISINFECTANTS 
 
 sion I have thus performed what might be called a cyclone operation 
 aseptically, saved my patient's life and secured primary healing- of the 
 wound. It is the man who knows most about the science of surgery who 
 generally carries out the best operative technic. 
 
 Rubber gloves were first used in America by Halsted. They are now 
 used by surgeons in almost every clinic room in this country. There is 
 no doubt in my mind but that the most recent data regarding hand disin- 
 fection will materially limit their employment. 
 
 Gloves should be worn when operating on septic cases and also when 
 dressing so-called pus cases. The assistants should wear gloves for the 
 same reasons. When the operator or his assistants have any abrasions on 
 the hands, it is to their own interest to wear rubber gloves while handling 
 or operating on an infected case. The gloves must be thin, as thin as 
 is consistent with durability, and they must fit. They should be boiled 
 in a I or 2 per cent, solution of soda, and before being put on the hands 
 they are filled with an aqueous solution of lysol in order to continue the 
 disinfection and to prevent their being torn. The objection to a dusting 
 powder within the gloves and on the hands is that it is an additional ob- 
 struction to the sense of touch. Most operators strip the gloves over the 
 fingers as they would a leather glove, but it is much better to use a soft hand 
 brush for this purpose. 
 
 The gloves when torn may be repaired very readily either by means 
 of a rubber cement or by applying a small patch. The cement is used 
 for very small tears and for punctures, while the patch is used for the re- 
 pair of larger tears and welded with the Paquelin cautery. 
 
 Although it is not quite as satisfactory to operate with the hands cov- 
 ered by rubber gloves as it is to operate without gloves, yet the interests 
 of both patient and operator outweigh the inconvenience that is caused by 
 the wearing of the gloves. Their use insures greater cleanliness, thus min- 
 imizing the danger of infection. The operator protects himself from in- 
 fections of all kinds, particularly from syphilitic infection, a matter of con- 
 siderable importance. 
 
CHAPTER XII. 
 
 STERILIZATION OF CATGUT. 
 
 Raw catgut is always infected. It has been demonstrated by Lock- 
 wood and others that when catgut is prepared for surgical ligatures and 
 sutures only with carbolic acid, juniper oil or chromic acid, ^growths of 
 bacteria from many specimens occurred in gelatine and agar-agar. Car- 
 bolic acid in oil loses much of its germicidal power and therefore carbolic 
 oil is no longer relied upon to sterilize catgut. The idea of employing 
 antiseptic suture and ligature material that is absorbable is indisputably 
 the correct one, but care must be taken to render the material sterile at the 
 same time. While raw catgut cannot stand steam sterilization or boiling in 
 water with impunity, it may be made sterile by boiling it in oil, such as 
 cumol, and after being prepared in formalin or chromic acid it will even 
 stand fractional sterilization in boiling water. 
 
 The catgut employed for ligating vessels and suturing in the per- 
 formance of operations for the cure of hernias must, first, not be a source 
 of infection; second, it must not be absorbed before nature's healing tissue 
 (fibrous tissue) is developed and is sufficiently strong to prevent an inter- 
 mediate breaking open of the wound by yielding to intra-abdominal pres- 
 sure. To forestall these two calamities the raw catgut must be sterilized 
 so that it will not infect the wound, and so that it will not be hardened or 
 its condition changed to withstand the action of the tissues for the required 
 time to prevent relapses of the hernia. 
 
 It is not my intention to present all or nearly all that has been developed 
 in the line of catgut sterilization, but I wish to describe the best and most 
 practical methods in vogue. We have the following at our command : 
 
 I. Aseptic catgut produced by 
 
 1. Dry heat sterilization. 
 
 2. Cumol (Kronig) method. 
 
 3. Alcohol. 
 
 II. Antiseptic catgut prepared by 
 
 1. Carbolic acid (now discarded). 
 
 2. Bichloride of merciu'v (Esmarch). 
 
 3. Biniodide (Lockwood). 
 
 4. Bergman method. 
 
 5. Iodine (Claudius). 
 
 6. Chromic acid. 
 
 7. Ochsner's method. 
 
 8. Heat and iodine (Bartlett). 
 
 9. Formalin (Hofmeister). 
 
 10. Formalin and chromic acid (Ferguson). 
 
124 STERILIZATION OF CATGUT 
 
 Dry Heat Sterilisation. — Benekiser and Boeckmann have siiccessfiiily 
 sterilized catgut by dry heat. I consider Boeckmann's method the better 
 of the two. The catgut, cut in suitable lengths, is wrapped in paraffin 
 paper and is then tightly sealed in small envelopes. A special box is filled 
 with these little envelopes placed on edge and is then packed in the steril- 
 izer. The temperature of the sterilizr is gradually raised until it reaches 
 284'' F. to 300'^ F., and it is maintained there for at least 
 three hours, which renders the catgut entirely free from germs and spores. 
 For very thick catgut, such as No. 5, the process is repeated. Plain dry 
 sterile Boeckmann catgut has been used for over a dozen years by many 
 of the most prominent surgeons in the United States and Canada. 
 
 Pyoktanin dry catgut (Boeckmann) is a later production. Small sizes 
 of Boeckmann's dry catgut are absorbed easily and for ligation of deep- 
 seated vessels in sterile localities this catgut is ideal. The smaller the 
 strand the shorter the time for its absorption. I have used it for several 
 years and have learned to respect the small sizes and to fear the larger 
 ones, either for ligatures or sutures. In my clinic at the College of Medi- 
 cine of the University of Illinois pyoktanin catgut has been used in all 
 kinds of hernial operations for several years with universal satisfaction. 
 
 Tlie Alcohol Method. — A strong metal cylinder with a closely fitting 
 screw cap is half filled with absolute alcohol. The catgut is cut in suitable 
 lengths, rolled and put into the cylinder with the alcohol. The cap is 
 screwed on very tightly and then the cylinder thus prepared is placed in 
 boiling water (100*' C), wdiere it is kept for half an hour. Inas- 
 much as the boiling point of alcohol is 78.3" C, and the heat ap- 
 plied is 100'^ C, the alcohol in the vessel is heated under pressure, 
 which is said (Jellett) to kill anthrax spores. When catgut prepared by 
 alcohol is left in the tissues of the body, the alcohol soon leaves the catgut 
 and then it is practically an aseptic catgut. The same objections that hold 
 good for the one pertain to the other. 
 
 Esmarch's Method. — Raw catgut is freed from fat by (a) brush, .soap 
 and water, and then water to remove the soap, or (b) by ether. When 
 wound on glass spools it is sublimated (1:1000) for 12 hours; it is then 
 transferred to sublimated alcohol, i to 200, for 12 hours, and finally is 
 preserved dry in closely fitting glass vessels Just before use it is placed 
 in sublimated alcohol, i to 2000. 
 
 Lockivood Method. — Catgut wound on a board is treated as follows : 
 
 I. Scrub with soap and water and remove the soap. 2. Submerge 
 in ether to insure removal of fat. 3. Keep in an aqueous solution of 
 biniodide of mercur}^ i to 250. This catgut is not to be used until it has 
 been soaked in water for "2 hours. 
 
 Von Bergiiiann's MetJwd. — This is described in detail by Schimmel- 
 busch. The essential features of it are the following : 
 
 Raw catgut is wound on glass and is placed in ether for 24 hours. 
 It is then allowed to lie in the following solution for 48 hours, the solution 
 being changed at the end of the first 24 hours : 
 
PLATE XIX. 
 
 Gans:renous Hernia. 
 
STERILIZATION OF CATGUT I27 
 
 Bichloride of mercury ■ lo 
 
 Absolute alcohol 800 
 
 Distilled water 200 
 
 The gut is kept in absolute alcohol if a hard product is desired, or in 
 alcohol (80 per cent.) and glycerin (20 per cent.) if a soft gut is wanted. 
 This preparation of catgut has stood both the experimental and clinical test 
 in Von Bergmann's clinic. 
 
 Cumol Method. — Kronig's method is the boiling of catgut in cumol 
 to effect its sterilization. Clark and Miller modified the process. The cat- 
 gut is cut, wound in loops and slipped into test tubes. The gut is gradually 
 heated up to 80'^ C, maintained for one hour; is then placed in 
 cumol and the temperature raised to 165'^ C, and there main- 
 tained for an hour, when the oil is poured off and the gut dried, either by 
 the heat of the sand-bath, or in a hot air oven for two hours. It has not 
 found general favor, especially in operations for hernia, and it is only 
 mentioned to be condemned. The same objections hold true to it as to 
 other forms of aseptic catgut. 
 
 Iodized catgut is prepared after the method of Claudius. The "raw" 
 catgut, rolled on a glass tube, is immersed in the following solution for 
 eight days : 
 
 Iodine, i part; potassium iodide, i part; water, 100 parts. 
 
 First make a solution of K I, gr. i to m. j., to which finely powdered 
 iodine and then the 100 parts of water are added. Commercial catgut kept 
 in this solution for a week will be antiseptic and ready for use. It is pre- 
 served in this solution or in an alcoholic solution of the same strength. 
 
 Abbott's chromic-iodised catgut is very simply prepared. The raw 
 gut is immersed in 1-2000 aqueous solution of chromic acid for 24 hours, 
 and is then iodized for eight days after the method of Claudius. It is then 
 transferred to 95 per cent, alcohol, in which it remains ready for use. 
 
 Aloschcovitz, of New York, transfers the iodized (Claudius) gut at the 
 end of eight days to a dry sterile jar, which prevents it from becoming 
 brittle. It is used dry from the jar. The advantages claimed for the 
 iodized catgut are : 
 
 (i) Absolutely sterile (dry) ; (2) not infectable; (3) not deleteriously 
 irritating; (4) not impaired in tensile strength; (5) prepared easily and 
 cheaply; (6) absorbable after serving its purpose. 
 
 Abbott's Iodized Catgut. — Abbott, of Minneapolis, has pointed out 
 that half the quantity of iodine used by Claudius will readily sterilize the 
 raw catgut, and that it is less brittle and irritating. He uses only two 
 sizes, fine and medium, and these may be used for sewing the skin, the fine 
 thread lasting for a week. An excellent test of the antiseptic properties of 
 catgut prepared with chemicals is that it may be used in sewing skin with- 
 out the formation of stitch abscesses. 
 
 Abbott's Chromic Catgut. — Raw catgut is immersed for 24 hours in a 
 1-2000 aqueous solution of chromic acid, after which it is sterilized in the 
 iodide solution (Claudius). After eight days transfer to 95 per cent, alco- 
 hol and use from that medium. Brittleness is avoided by preparing smaller 
 
128 STERILIZATION OF CATGUT 
 
 batches which will last a short time. After two years' experience Abbott 
 is perfectly satisfied with it. 
 
 Ochsner's Method. — After inmiersion in sulphuric ether for one month, 
 the catgut is placed in strong commercial alcohol in which gr. i to ^i ^f 
 corrosive sublimate has been dissolved. The solution is renewed once dur- 
 ing the month. It is then- preserved indefinitely in the following solution: 
 Iodoform, i part ; ether, 5 parts ; commercial alcohol, 14 parts. 
 
 This catgut remains intact in the tissues for from seven to ten days, 
 according to the size used. The above is used as a ligature and suture 
 everywhere, except in bone and hernia operations, for which ptu-poses 
 Ochsner employs chromicized catgut, which lasts from 15 to 30 days, ac- 
 cording to the size used. It is prepared as follows : 
 
 Ochsner's Chromicised Catgut. — The catgut is immersed in ether for 
 one month, then in a solution prepared in the following manner: (A) 
 Chromic acid, i part; water, 5 parts; dissolve carefully. (B) Take of 
 solution A I part ; glycerine, i part. 
 
 Soak the catgut in solution B for forty-eight hours or more, according 
 to the resistance wanted. Catgut soaked for forty-eight hoars will resist 
 absorption by the tissues for fifteen days, whereas catgut soaked for nine- 
 ty-six hours will resist absorption for thirty days. 
 
 (C) Take catgut out of B solution, rinse quickly but thoroughly in 
 sterilized water; wind on rods or slidei^ at least three inches in length, 
 and preserve indefinitely in the following solution : 
 
 (D) Carbolic acid, 95 per cent, i part; glycerine, 5 parts. 
 
 The catgut may remain in this solution for many months without de- 
 preciating in quality, or it may be kept for an indefinite period of time in 
 the same solution as the ordinary catgut: 
 
 Iodoform, i part; ether, 5 parts; strong alcohol, 14 parts. 
 
 The ''ar containing the ether in which the catgut is kept for one month 
 should be filled only about one-half with the loose coils of ligature, and 
 then it is filled with ether. The jar should be shaken in an inverted posi- 
 tion every day or two in order to wash ofif any substance which may accu- 
 mulate on the surface of the coils. At the end of two weeks the ether 
 should be replaced by fresh ether. The same precaution should 
 be taken with the solution of corrosive sublimate in alcohol. It 
 is especially important not to wind the catgut tightly before it is placed 
 in these solutions, because this may prevent the solutions from penetrating 
 all parts of the material. One precaution is necessary in the use of catgut 
 prepared in this manner — it must be placed in _water before it is used at 
 the time of the operation. 
 
 The Bartlett, or Heat and Iodine Method. — i. The raw catgut, thirty 
 inches, is coiled on itself ; several coils are strung together and hung in a 
 beaker glass, not touching sides or bottom. A thermometer enters the 
 beaker through a hole in the pasteboard covering it; Htjuid petrolatum is 
 now poured into the beaker sufficient to immerse the catgut and bulb of the 
 thermometer and the preparation for sterilization is complete. 
 
 2. The prepared beaker is now "set upon a pan of sand under which is 
 
STERILIZATION OF CATGUT I29 
 
 placed a tiny gas flame of merely sufficient intensit}^ to raise the tempera- 
 ture of the oil to 212'^' F. within one to two hours". This tempera- 
 ture is maintained over night (a variation of a few degrees does not mat- 
 ter). '"The heat is then increased to the extent that the temperature will 
 run up to 300'' F. in the course of an hour ; then the gas is turned 
 off and the temperature of the oil allowed to return to about 212'^". 
 The sterilization by heat is thus completed. 
 
 3. The catgut coils are lifted out of the beaker, the oil is allowed 
 to drop off, and then for chemical sterilization and preservation the coils 
 are dropped into the following mixture : 
 
 Columbian spirits, too parts ; iodine flakes, i part. 
 
 It is ready for use and will not deteriorate. When it is desirable to 
 make catgut last longer than usual, Bartlett recommends hardening the 
 catgut as above prepared in formalin vapor. He suspends the coils a few 
 inches above a 10 per cent, formalin solution in an air-tight vessel for 
 twenty-four hours. This process is simple and the catgtit requires no 
 washing. It is stated that No. 2 catgut so treated will last in muscle for 
 from two to three weeks. (American Practice of Surgery ^ Vol. I, p. 733.) 
 
 Formalin Catgut (Hofmeister). — It appears that formaldehyde effects a 
 change in raw catgut which enables it to withstand boiling in water, with- 
 out lessening its tensile strength. It also endows it with a property of 
 resisting phagocytosis. Formalin catgut may be sterilized fractionally by 
 boiling. This renders it absolutely sterile. 
 
 According to Pearson, whose method is a modification of Hofmeister's, 
 the formalin catgut may be prepared somewhat as follows : Raw catgut is 
 wound in single layers on large frames so that the formaldehyde may 
 have free access to it from all sides. It is then immersed for from 12 to 
 48 hours, according to the size of the catgut, in formalin solution, vary- 
 ing in strength from 2 to 4 per cent. In order to rid it of the formalin, v/hicu 
 is too irritating for the tissues, a stream of cold water is allowed to pass 
 through it for 24 hours. The gut is then wound on glass reels or slides, and 
 is boiled in water for from 10 to 25 minutes, according to the thickness of 
 the gut. It is then preserved indefinitely in alcohol. If an aseptic catgut 
 is desired, instead of preserving it in alcohol, it is preserved in sterile glass 
 vessels. 
 
 Formalin Chromic Catgut (Ferguson). — For the last seven or eight 
 years I have used a catgut known by the name of "Chromoform" catgut, 
 or Hollister's catgut, for which Air. Hollister received testimonials from 
 many of the best surgeons and gynecologists in Chicago and the West. 
 It was prepared after my direction and gave great satisfaction. It was 
 first put through the formaldehyde process and was then subjected to 
 chromic acid solution, ^ of i per cent., for 24 hours, then transferred to 
 alcohol in glass tubes, which were permanently sealed. This was rendered 
 both aseptic and antiseptic catgut in its preparation. 
 
 When a tube of this catgut v/as broken and only one or two ligatures 
 or sutures were used, the remainder could withstand boiling two or three 
 times with but slight diminution of its tensile strength. 
 
CHAPTER XIll. 
 
 THE WOUND. 
 
 In operations for the relief of hernia the wound is ahvays an incised 
 one, and is made deliberately by the operator. It may be defined as a 
 solution of continuity of the several structures necessarily encountered and 
 severed in hernia operations. When a wound is made under proper aseptic 
 and antiseptic precautions, it is called an aseptic wound, and it heals by 
 primary union. All wounds that are made with instruments not sterile, or 
 in skin not disinfected may be considered infected wounds. 
 
 If the surgeon implants living organisms into the wound by acci- 
 dental contact, and suppuration ensues, the wound is said to be primarily 
 infected, and this may be either superficial or deep. When an aseptic 
 wound is undergoing primary repair, and becomes infected accidentally 
 through a shifting of the dressings, or because of the patient passing his 
 hands over the wound surface in order to feel of the cut, infection is said 
 to be secondary. 
 
 As already pointed out in a previous chapter, wound infection may 
 be autogenetic or heterogenetic. A diseased wound is one in which some 
 pathogenic bacteria find a suitable pabulum for their multiplication, as, for 
 instance, in tuberculosis. The bacillus of tuberculosis must be lodged in 
 the wound before the disease manifests itself. A closed wound is one in 
 which the coaptation of the severed structures has been accomplished by 
 sutures. An open wound is one in which the edges have not been approx- 
 imated. It is usually packed with gauze. Many other appellations are 
 given to wounds according to their appearance and condition, such as a 
 healing, granulating and suppurating wound. 
 
 The terms femoral, inguinal, and umbilical are applied to a wound 
 because of its location. 
 
 The Incision. — It requires considerable art to make a correct incision 
 in the various hernial regions. Any one can slash, but it takes an artist 
 to cut. No matter what variety of hernia is being operated on, the primary 
 incision should be ample enough so that the operation can be completed 
 without tearing or bruising the edges of the wound. The skill of the 
 operator always is made manifest by the manner in which he handles the 
 knife, and the judgment he displays in deciding on the length and' depth 
 of the primary incision. 
 
 The first stroke of the scalpel should carry it through the skin only, 
 and for the full length of the wound (Figs. 23 and 24). Until the opera- 
 tor has gained sufficient knowledge of the requirements of the various 
 incisions, and until he gains by experience the force required to cut 
 
PLATE XX. 
 Gangrenous (Littre's) Hernia. 
 
THE WOUND 
 
 133 
 
 A wi 
 
 through the skin that is loose or taut, thick or thin, it is a good plan first 
 to outline the skin incision with the sharp point of the scalpel. Then an 
 assistant puts the skin on the stretch, while the operator makes his incision 
 in the line of the scratch previously made. 
 
 After performing this act two or three hundred times, the operator 
 may venture to cut loose skin and make a proper incision with one sweep 
 of the knife. It is, however, difficult to accomplish this. To cut more than 
 the skin with the first stroke of the knife shows a lack of surgical knowl- 
 edge and skill. It is not brilliant to sever all the structures down to the 
 hernial sac with one stroke. I have seen men of limited experience so 
 foolhardy as to attempt this, the result being that they cut through the 
 bowel. 
 
 An ordinary scalpel has performed its function during the operation 
 when it has incised the skin. Of course, this depends to some extent on 
 the quality of the blade, but usually making the incision dulls the knife 
 so that it is not fit for further use until sharpened. Another reason for not 
 using this scalpel again during the operation is that in passing through the 
 appendages of the skin it may become septic. 
 
 In operations for the cure of hernia, great care should be exercised 
 not to do anything that will tend to lower the vitality of the structures 
 that have been cut. Powerful retraction and forcible tearing of the tissues 
 with the fingers, with gauze or with the tissue comb must be avoided. Fre- 
 quent mopping of the wound with gauze also injures the tissues, and it is 
 quite unnecessary, provided the surgeon is careful in his hemostasis. Clean 
 cutting and clean dissection traumatize the tissues but little, thus favor- 
 ing primary union. 
 
 Exposing the Deep Structures. — The deep structures that must be 
 considered in these operations are situated immediately around and within 
 the sac. In oblique inguinal hernia care should be taken not to injure the 
 spermatic cord, the deep epigastric vessels, the internal iliac vessels, or the 
 deep abdominal muscles. Having split the aponeurosis of the external 
 oblique, the deep abdominal muscles can be exposed easily by locating the 
 conjoined tendon, and then the cremaster fibers may be dissected away 
 from the lower border of the internal oblique muscle. 
 
 The sac is best exposed at the internal ring by picking up its neck 
 with tissue forceps. It is then severed. It is not often that the cord is 
 front of the sac. It is usually situated behind or to the side of it. Be- 
 fore opening the neck of the sac the vas deferens should be located and 
 injury to it avoided. In stripping the sac from its surrounding structures 
 gauze must be used if the tissues have become blood-stained. If the sur- 
 geon is careful, however, this tearing with gauze is avoided. Once a clear 
 line of cleavage next the sac is obtained, it should be followed to the limit. 
 
 The deep epigastric vessels are situated immediately behind the root 
 of the cord. When exposing these vessels the cord must be draw^n to one 
 side and the transversalis fascia severed. This will at once uncover these 
 vessels, whicn7 however, fs" hot usually necessary. The point to remember 
 in exposing the deep structures outside of the sac is to do the work in such 
 
134 
 
 THE WOUND 
 
 ^vki 
 
 J t^ 
 
 a manner as to differentiate clearly every structure that is encountered. 
 The deep structures inside of the sac, the intra-abdominal structures, are 
 cared for according to the condition of the sac contents and the relation- 
 ship existing- between the sac and these structures. 
 
 If the hernia is strangulated, partially strangulated, or incarcerated, 
 the grooved director should never be passed underneath the strangulating 
 band, because it may penetrate the bowel and it also bruises the tissues 
 because of its being forced underneath the constricting band. This band 
 should be severed carefully by cutting from without inwards. If any ad- 
 hesions are present at the neck of the sac, the sac should then be opened 
 above the constricting band rather than below it. 
 
 Similar precautions should be taken when dissecting out the deep 
 structures in cases of femoral, obturator, umbilical or other forms of 
 hernia. 
 
 Hemorrhage. — The control of hemorrhage during operations, on her- 
 nia, no matter whether the hemorrhage is arterial, venous or capillary, is 
 not a difficult matter in normal subjects. The hemorrhage that comes 
 from beneath the skin should not be allowed to stain the structures, even 
 at the expense of somewhat lowering the vitality of these tissues. It is 
 good surgery to clamp the bleeding vessels with the mosquito forceps 
 represented in Fig. 22. Ligatures should be tised as little as possible in 
 hernia operations. In oblique inguinal hernia it is permissible, at times, 
 to ligate the superficial vessels. I have frequently, however, operated on 
 an oblique inguinal hernia without making use of a single ligature, ex- 
 cept that which surrounds the neck of the sac. The angiotrypsic forceps 
 shown in Fig. kJ is sufficient to arrest all bleeding, but I should not advise 
 clamping the deep epigastric vessels and trust to the crush thus made for 
 ^permanent hemostasis. These should be tied with catgut. Hemorrhage 
 from the omentum must also be checked by means of the ligature, or the 
 vessels may be cooked with the electro-thermic hemostat (Downes). Ac- 
 cidental injuries to the larger vessels must be dealt with on general sur- 
 gical principles. 
 
 Before attempting to close the wound, the operator must assure him- 
 self that there is no oozing from any vessels. The arrest of primary hem- 
 orrhage must be complete in order to get the best results. The applica- 
 tion of styptics of any kind is to be deprecated. I have, however, used an 
 antiseptic dusting powder, such as iodoform, in order to arrest capillary 
 hemorrhage by favoring rapid coagulation of the blood by means of a 
 substance that is feebly antiseptic. Experience has taught me that an 
 antiseptic powder which is feebly antiseptic, applied in small quantities, 
 does not interfere with primary union. If the wound is not carefully 
 closed and dressed, hemorrhage may take place, and this is particularly 
 liable to occur when the scrotum has been opened during the operation. 
 
 Closing the Wound. — The first structure to be closed is the perito- 
 neum. The sac is usually ablated below the ligature. In some hernias it 
 is preferable to suture the peritoneum exactly as is done in closing an or- 
 dinary abdominal section. The principal point to be remembered in clos- 
 
PLATE XXI. 
 
 I. Ferguson's angiotripsic straight forceps. 2. Ferguson's angiotripsic 
 curved forceps. 3. Ferguson's angiotripsic straight clamp. 4. Ferguson's 
 angiotripsic curved clamp. 5. Halstead's curved forceps. 6. Halstead's 
 straight forceps. 7. Barrett's bowel holder. 
 
THE WOUND 
 
 137 
 
 ing the peritoneal wound is that smooth surfaces must be brought in con- 
 tact, so that the raw edges are turned outward. Inasmuch as union of the 
 peritoneum depends, in the main, on the amount of traumatism inflicted, 
 the sutures should be placed closely together. It is preferable to use a 
 continuous suture. The rest of the wound may be coaptated in one of two 
 ways : First, by means of through-and-through sutures ; and. second, by 
 the insertion of deep and superficial sutures. 
 
 Xo matter what method of suturing is adopted, care should be ob- 
 served that no dead spaces exist after the wound has been closed. A 
 through-and-through suture in hernia operations v^as long ago found 
 wanting and it has been practically discarded, with the exception of the 
 through-and-through retention suture, which is fastened to buttons or 
 rolls of gauze placed at some distance from the incision. 
 
 In ventral and umbilical hernias occurring in very stout people, these 
 through-and-through retention sutures lend security to the deep and super- 
 ficial sutures. 
 
 The deep structures are either brought together edge-to-edge or they 
 are overlapped. Often in bringing them together edge-to-edge there is 
 more or less crowding of the tissues so that they form a ridge. When 
 union by first intention takes place these structures practically are as 
 strong as normally. Overlapping of the tissues is to be deprecated, except 
 when they can be imbricated without tension. 
 
 All the structures may be approximated either with absorbable or 
 non-absorable suture material. AA'hen the absorbable material, such as 
 catgut or kangaroo tendon, is used, it is safer to insert an interrupted 
 suture than a continuous one. If a continuous suture gives way under 
 the influence of overstraining caused by vomiting, or if it becomes absorbed 
 too rapidly, the breaking at one point will loosen the entire stitching. The 
 interrupted sutures, on the other hand, support one another, which is a 
 decided advantage. If one suture gives way, the adjoining sutures will 
 still keep the tissues in approximation. 
 
 The skin may be closed with chromic catgut, pyoktannin or formalin 
 catgut, or a combination of these. All catgut that is used for the skin must 
 be antiseptic or so hardened that it is not absorbed too rapidly. For clos- 
 ing the skin wound I prefer to use horsehair in the form of a continuous 
 buttonhole stitch. In fleshy people it is always necessary to coaptate the 
 fat by means of retention sutures because otherwise there will be a large 
 dead space between the sutured skin and the aponeurotic structures be- 
 neath the fat. If non-absorbable suture material is used to close the 
 wound throughout, the sutures must be applied in such a manner that they 
 can be removed easily after union has taken place. 
 
 The subcuticular wire or silkworm gut suture I do not favor at all 
 for the reasons already mientioned. 
 
 The wound should be closed as rapidly as possible, because the longer 
 it is exposed fo the air, the greater is the danger of infection, and a pro- 
 longed anesthesia is very likely to cause an irritation of the kidneys. 
 
 Drainage. — It is not very often that drainage is necessar}' after hernia 
 
138 THE WOUND 
 
 Operations. When it is, tubes of any kind should not be used. 
 When it is evident that the tissue wih be overtaxed in the 
 absorption of primary and secondary wound secretions, a drain should be 
 inserted. A capillary drain usually is all that is required to meet this in- 
 dication. In very large scrotal hernias, when a large sac has been dis- 
 sected out of the scrotum, and large raw surfaces are left, the cavity 
 readily becomes filled with blood serum. Here we have an indication for 
 capillary drainage, and silkworm gut, chromic catgut, horsehair or wire 
 may be used for this purpose. The drain is inserted in the lowest part 
 of the wound, and is passed down and out through the most dependent 
 portion of the scrotum, thus securing perfect drainage without interfer- 
 ing with the dressings in any way. If the wound becomes septic, drain- 
 age may have to be resorted to, and maintained by tubes or gauze. 
 
 Dressings. — Experience has taught us that after having completed 
 an operation for hernia, it is necessar}- to place a dressing on the wound, 
 (a) to prevent decomposition and infection, and (b) to support the parts 
 and keep them at rest while repair is in progress. For the simple protec- 
 tion of the wound a collodion dressing usually fulfills all the indications. 
 When the wound is not being drained and when there is no oozing of 
 blood serum, before the Collodion dressing is applied the skin must be 
 wiped off with ether or alcohol, so as to obtain an absolutely dry sur- 
 face to which the collodion can adhere. This dressing it is well to inter- 
 mix with thin layers of cotton or gauze or both, but care must be exercised 
 that the dressing is not too thick, for otherwise irritation and even vesica- 
 tion of the underlying skin may take place. If the dressing does not ex- 
 tend some distance, at least a couple of inches, beyond the edge of the in- 
 cision, it may become loosened and thus furnish an avenue through which 
 infection may enter the wound. If the collodion dressing does become 
 loosened, it should be removed at once. I sometimes use a sterile antisep- 
 tic powder in conjunction with the collodion. Equal parts of collodion, 
 and iodine may be applied to the wound and the surrounding skin as a 
 primary application. This antiseptic may prevent the formation of stitch 
 abscesses and suppuration underneath the collodion dressing. 
 
 Even in all those cases treated primarily with the collodion dressings 
 an external dressing of gauze pads should be employed to support the 
 abdomen for a few days at least until all tendency to retching and vomit- 
 ing has subsided. While the dressing is being applied it is important that 
 the patient should be kept sufficiently under the influence of the anesthetic 
 to prevent any struggling and to minimize the effect of intra-abdominal 
 pressure. The supporting dressings of gauze pads and so forth should be 
 of such a nature as to also protect the wound from infection. I use either 
 plain sterile gauze or gauze that is impregnated with some antiseptic 
 agent. It is then known as an antiseptic dressing gauze. Dressings, there- 
 fore, are either aseptic or antiseptic. 
 
 Nearly all antiseptic dressings have a tendency to irritate the skin. 
 I have seen an extensive dermatitis follow the use of iodoform gauze, car- 
 bolized gauze, and even bichloride gauze, but I have never seen dermatitis 
 
PLATE XXII. 
 
 8. Needle holder (Ferguson). 9. Mayo's dissecting scissors. 10. By- 
 ford's retractor. 11. ^^layo's retractor. 12. Ferguson's retractor. 13. In- 
 testinal needles (Mayo). 14. Ferguson's round needles. 15. Ferguson's 
 needles with cutting edge. 16. Tissue forceps. 
 
THE WOUND 141 
 
 follow the use of gauze prepared according to Lister's method, the so-called 
 cyanide of mercury gauze. The skin is never irritated if only plain ster- 
 ilized gauze is used. 
 
 When dressing hernia wounds in the region of the groin, especially 
 in children, I invariably place several layers of antiseptic gauze, prefer- 
 ably iodoform gauze, over the sterile gauze that is placed next to the skin. 
 The manner in which the gauze dressing is applied has both a practical and 
 a scientific bearing. The first three or four layers of gauze should cover 
 the wound only. The next few layers should extend slightly beyond the 
 edges of the wound, and so on with each succeeding layer, until the wound 
 is covered by a pad of gauze from one-half to three-fourths of an inch in 
 thickness, and extending beyond the edges of the wound for four or five 
 inches. The reason for placing the gauze in this manner is that absorp- 
 tion cannot take place from the periphery of the gauze directly into the 
 wound. Secretions of any kind are taken up by the upper layers which 
 override the lower, thus protecting the wound itself for a considerable 
 period of time from the irritating action of these secretions. 
 
 This gauze pad is then covered with an antiseptic dressing which 
 most effectually prevents infection of the wound even though the dress- 
 ings become soiled from within or from without. 
 
 In order to prevent this gauze dressing from shifting, a combination 
 dressing must be applied which extends completely around the thigh and 
 two-thirds around the body. 
 
 To prevent the wound from being injured by strain of any kind, it 
 is advisable to protect this external dressing with broad adhesive straps 
 sc arranged as to receive the bulk of the force from within, just as a truss 
 gives support to a hernial region. Take, for instance, a case of oblique 
 inguinal hernia. An extra pad is placed over the inguinal region and an 
 adhesive strap is applied, passing across the abdomen below the anterior 
 superior spines of the ilia, exactly in the truss line. This strip of plaster 
 v»'ill receive the force at the internal ring. Another strip of plaster should 
 extend from the ribs down over the line of incision, fitting closely the fold 
 of the groin, passing backward along the gluteal fold, and then forward 
 again across the upper portion of the leg, and over the inguinal region 
 immediately in front of the internal ring. This strap should extend up- 
 ward, crossing the umbilicus and ending on the opposite side of the body, 
 just beneath the ribs. Over these straps I wind a roll of broad gauze which 
 completes the dressing. 
 
 In children rubber tissue or oiled silk is placed over the dressing so 
 as to keep it dry. Some operators apply a plaster cast over the dressing, 
 but this is too heavy, and it may cause pain by pressing on bony promi- 
 nences, and when the edges of the cast become soiled they are exceedingly 
 irritating to the skin and the cast must be removed. 
 
 The dressing may remain in place for two or three weeks, if neces- 
 sary, but inasmuch as it becomes rather uncomfortable, and as the 
 stitches may have to be removed before that time, it is advisable to change 
 the primary dressing inside of a Aveek. If drainage has been established 
 
142 THE WOUND 
 
 the dressing should be removed within three days. Even though the 
 dressings may be saturated with blood serum within twenty-four hours after 
 operation, it is not necessary to remove them because of any danger of 
 infection occurring. Of course, it must be borne in mind that some bac- 
 teria travel along the skin more rapidly than others, and I have in mind 
 now particularly the streptococcus. 
 
 After the primary dressing has been removed, any drain that may 
 have been inserted should be withdrawn carefully. Silkworm gut drains 
 are cut off at the lower angle of the wound and are then withdrawn from 
 the opposite angle, so that contamination of the wound surfaces cannot 
 take place. 
 
 The same precautions are taken in the application of the primary dress- 
 ing in the femoral region, or in anv other hernial region. In ventral and 
 umbilical hernias, before the adhesive straps are applied, I place two rolls 
 of combination dressing, one on each side of the wound, running in its 
 long axis, so that the pressrire is exerted laterally instead of centrally. In 
 very large ventral and um.bilical hernias, instead of passing the adhesive 
 straps two-thirds around the body, I pass them completely around, over- 
 lapping the straps in the center, in which position they give a better and 
 a more rigid support. 
 
 The technic of removing the primary dressing is one of considerable 
 importance. The dressing should be removed in such a manner as not to 
 expose the wound to contamination any .more than is necessary. With this 
 end in view all the dressings are removed, except the primary gauze, which 
 was placed immediately over the wound. The skin surrounding this dress- 
 ing is then bathed with alcohol, or bichloride solution, or Harrington's 
 solution. Then sterile towels are placed around this area and not until 
 then should the wound be exposed by the removal of the primary dressing. 
 
 The wound is now inspected carefully ; stitch-hole infections are look- 
 ed for. If the wound is found to be in perfect condition, a second dress- 
 ing is applied with the same care as the first. It is left in place four or five 
 days, after which a pad of gauze and a spica bandage is all that is nec- 
 essary. 
 
 Removal of Sutures. — Catgut sutures that are not causing any irri- 
 tation may be allowed to remain in place until they are absorbed. Silk- 
 ^yorm gut sutures should be removed from the skin inside of twelve days. 
 Half of the number of stitches may be removed at the time the primary 
 dressing is changed, and the other half when the second dressing is taken 
 ofT. If these sutures are allowed to remain in the skin a longer time than 
 this, they begin to cut through, cause irritation, and favor the development 
 of stitch abscesses. 
 
 Subcuticular stitches of wire should be removed at the end of a week, 
 unless they are not loosened sufficiently at that time, when they are left 
 in place a few days longer. Deep wire and silkworm gut stitches that are 
 removable should be left in place for about three weeks, until wound heal- 
 ing has progressed to the stage of fibrous tissue formation. If these 
 stitches are removed too soon, while the wound is still granulating, a very 
 
THE WOUND ,^, 
 
 Slight degree of intra-abdominal pressure is sufficient to cause separation 
 or the wound edges. 
 
 The antiseptic dusting powder may be used freely over the stitch- 
 ho.es, so as to prevent abscess formation. If infection has occurred, two 
 thmgs must be done, (a) irrigate and wash the stitch holes with some anti- 
 septic solution and (b) cut the stitch at a point where it has been buried 
 and then withdraw it from the other side. 
 
 Horsehair sutures are removed at the end of a week. 
 
CHAPTER XIV. 
 
 TREATMENT OE WOUNDS. 
 
 ^^'ol.mds are either aseptic or septic, and the treatment required for 
 each is quite different. 
 
 Aseptic Wounds. A wound that is aseptic will heal by first intention, 
 if the treatment employed is such as to prevent secondary infection. The 
 sole aim of the treatment, therefore, is to prevent secondary infection. 
 The dressing must be applied properly as is pointed out under the head- 
 ing of Dressings. The wound and surrounding parts must be maintained 
 in a state of physiological rest, the stitches must not be tied too tightly 
 and the tissues of the patient must be in a healthy condition, and he must 
 have sufficient natural powers to carry on repair. If the dressings bear 
 too tightly on a wound immediate repair is delayed. If, on the other hand, 
 the dressings are too loosely applied they are liable to shift and expose the 
 wound, which is an indication to renew the dressing. 
 
 If the patient has passed the hand underneath the dressings, imme- 
 diate disinfection of the wound should be carried out, and new dressings 
 applied. If the patient complains of great discomfort and tenderness in 
 the region of the wound at the end of forty-eight hours the wound should 
 be inspected. This pain is not infrequently caused by an accumulation of 
 blood serum beneath the skin or in the tissues. If such is found to be the 
 case the blood serum should be allowed to escape and the wound dressed 
 aseptically and antiseptically, and a new dressing applied. If the dress- 
 ings become saturated with blood and blood serum, at the end of twenty- 
 four hours, it is better to change the external dressings. But a wound is 
 not in danger of infection from this source for about three days, when 
 all the dressings should be renewed. If the dressings become soiled from 
 without bv extraneous matter, urine, etc., that is an indication for their re- 
 moval. 
 
 In hernial cases, where a large semilunar flap is made at the time of 
 the operation, an accumulation of secondary wound secretion is liable 
 to take place beneath it, unless the dressings are properly applied. If 
 such a secretion is present at about the end of a week, when the first dress- 
 ing is changed, it should be allowed tO' escape through an opening made 
 by the removal of a stitch, and then the dressing applied so as to exert some 
 pressure on the flap. 
 
 After the removal of the stitches the wound is cleansed with a dis- 
 infectant, and the new dressing is applied. Whereas all hernias recently 
 operated on require support to the region for several weeks, it is best to 
 keep the wound protected with the dressing, even though there may be 
 
5 
 6 
 
 PLATE XXIII. 
 
 Incisions. 
 I. For diaphragmatic hernia. 2. "Supra" umbilical. 3. "Para" umbili- 
 cal. 4. "Sub" umbilical. 5. For ventral hernia following supra pubic cys- 
 lOtomy. 6. For inguinal, downward curve (Fowler). 7. For inguinal, up- 
 ward curve (Ferguson). 8. For hernia following gall bladder operation. 
 9. For hernia following appendectomy. 10. Straight incision for inguinal 
 hernia. 
 
TREATMENT OF WOUNDS I47 
 
 no avenue of infection visible, for about three weeks, when fibrous forma- 
 tion is fully established. 
 
 Septic Wounds. The infection of a wound is either primary or sec- 
 ondary, and the infection may be superficial or deep, mild or severe. If 
 on the removal of the first dressing the edges of the wound and the stitch- 
 holes look angry and red, ?.nd are tender to touch, the wound is said to be 
 infected superficially. If this occurs on the third or fourth day, there may 
 be no suppuration, but stitch-hole abscesses are sure to develop unless 
 counteracted by treatment, lliis treatment should be antiseptic in char- 
 acter. 
 
 The inflamed parts should be irrigated, preferably with bichloride 
 of mercury, i in looo, or Harrington's solution, and then a wet compress of 
 gauze moistened in i in 2000 bichloride, should be placed over the wound 
 and new dressings applied. This cleansing and dressing of the wounds 
 should be repeated every day for three days, when it will be found that 
 the inflammation has been subdued. If the dressing is not changed until 
 between the fourth and the eighth day, and if stitch-hole abscesses are pres- 
 ent, cultures should be made and the nature of the infection determined. 
 The treatment to be carried out under such circumstances is the same as 
 that already mentioned, with the exception that when the infection is 
 severe the irrigation and dressing may have to be done twice a day until 
 suppuration has ceased, then once a day until granulation tissue is healthy, 
 after which no antiseptics should be used on the healthv granulating sur- 
 face. 
 
 If this superficial infection is found to extend deeply into the wound, 
 it should be opened sufficiently to allow free drainage, and the wound 
 packed with iodoform gauze. If the suppuration is present for some time, 
 then the antiseptic solution used for irrigation should be changed. If a 
 sublimate solution is used in a strength of from i in icoo to i in 5000, and 
 is continued for several days, an intolerable burning pain will often arise 
 in the wound. Then the irrigating solution should be changed to an iodine 
 or normal salt solution. 
 
 The temperature of the irrigating fluid should not be less than 105° 
 F. and not more than 115° F. 
 
 There are many other antiseptic solutions that can be used, such as 
 lysol, permanganate of potash, carbolic acid, salicylate' of soda, the silver 
 salts, etc. 
 
 Wounds that are deeply infected from a primary source usually give 
 rise to constitutional symptoms between the third and fourth day. There 
 may be a temperature ranging from 99° F. to 103° or 104" F., with chilly 
 sensations, accompanied by pain, tenderness, rapid pulse, etc. If at the 
 end of seventy-two hours these symptoms are present, there is a clear in- 
 dication for inspection of the wound, and if there is any undue promi- 
 nence or tenderness, the deep wound must be explored with all aseptic 
 and antiseptic precautions, and if an accumulation is found the same should 
 be drained. 
 
 If the infection is saphrophytic in character it subsides under this 
 
148 TREATMENT OF WOUNDS 
 
 treatment within a couple of davs. But the pyogenic and pathogenic or- 
 ganisms are harder to kill. If the infecting germ is the streptococcus, 
 every effort should be put forth to prevent a dangerous blood infection by 
 frecjuent or continued irrigation of the wound. xA.nd the entire wound 
 should be laid wide open from top to bottom, removing all the stitches and 
 treating it most uncompromisingly. Any extension of the inflammation 
 into the cellular tissue should at once be followed and drained. If lymphan- 
 gitis arises, local applications of glycerine and ichthyol, 10 per cent, iodine, 
 Crede ointment, or formalin and glycerin, may be applied. If the con- 
 stitutional symptoms continue, the administration of the antiseptic strep- 
 tococcic serum may be considered. 
 
CHAPTER XV. 
 
 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA. 
 
 SHOCK. 
 
 After an operation for the radical cure of hernia, shock is not, in the 
 usual run of cases, a common complication. In large incarcerated hernias, 
 whether inguinal or umbilical, where the bowel sometimes has to be handled, 
 adhesions liberated or the abdomen explored, more or less, shock must 
 be expected, and it is sometimes present to a dangerous degree. A series 
 of shocks are caused on the operating table b}- the occasional rough handling 
 or tearing of the structures by the operator and his assistants. Surgical 
 literature is replete with "shock" — (descriptions of) — but there are so 
 many misconceptions of shock that scientific and practical data are diffi- 
 cult to obtain. The Cartwright prize essay for 1897, by G. W. Crile, of 
 Cleveland, "An Experimental Research into Surgical Shock," is the best 
 on the subject. Every surgeon should read it. 
 
 Any form of shock is due to injury or insult to some part or to the 
 whole of the body. In hernia operations it occurs either during or after 
 the operation and sometimes so suddenly and so rapidly increasing in 
 gravity as to be called a sudden collapse. The term collapse (impending 
 dissolution) means more danger than is ascribed to shock. It not infre- 
 quently comes on at the termination of a major operation, several min- 
 utes after the withdrawal of the anesthetic and at about the time that the 
 patient should begin to revive. It really seems as if when all reflexes are 
 being aroused the afferent impulses take on an avalanche action and tend 
 to overpower all efferent response. 
 
 The causes of shock are undue traumatism while operating; protracted 
 anesthetic ; exposure of the intestines and omentum ; and prolonged oper- 
 ation. Hemorrhage is a very rare cause of shock in this class of work, 
 because important vessels are not severed by careful operators. 
 
 Shock is more marked in operations for the cure of umbilical and 
 ventral hernia than in those for the inguinal or femoral variety. This 
 observation is supported by the experiments of Crile. If in abdominal 
 procedures the omentum is made to cover the viscera less shock occurs. 
 When a person is being ojjeraled on and the pulse increases rapidly (15 to 
 30 beats) the skin gets pale and cold, blood in the wound becomes more 
 venous in character than normal, with a decrease of the temperature, shock 
 may be said to be established. 
 
 Shock on the operating table must be differentiated from chloroform 
 asphyxia. In the latter the onset is sudden, respirations cease, the pulse 
 early become imperceptible, the face assumes a pale-yellowish hue and the 
 
150 COMPLICATIOXS IXCIDEXT TO THE RELIEF OF HERXIA 
 
 pupils dilate. By lowering the head, pulling- out the tongue, compressing 
 the chest wall for fully one minute before inhalation is allowed to occur, 
 thus expelling the chloroform from the respiratory tract, and then by in- 
 ducing artificial respiration, the efifect is soon overcome,, and the patient 
 begins to struggle. 
 
 The condition of the patient is often rendered more serious by the 
 improper establishment of a}-lificial respiration. The ver}- first effort "o be 
 made is to force an inspiration by raising the arms above the head, — the 
 column of uninhaled chloroform in the trachea and bronchial tubes is 
 forced into the circulation and the poisoning thereby deepened. The chest 
 should first be compressed for a minute, then the arms slowly raised, tak- 
 ing the time required to count deliberately up to three, and then hold the 
 upper extremities above the head with an upward and outward extension, 
 counting i, 2, 3, and again bring the arms flexed at the elbows down forci- 
 bly on the costal arches which sends the air out of the lungs with a 
 whizz; then again count i, 2, 3, and so on. Artificial respiration is thus 
 continued until reaction sets in. If artificial respiration is carried on too 
 rapidly the respiratory center becomes more than satisfied with oxygen 
 and respiration is suspended. 
 
 In overdoses of chloroform not considered serious, the passing of 
 the index finger behind the epiglottis and raising the larynx up and for- 
 ward will quickly induce respiratory acts. In many cases this is all I have 
 done to re-establish respiration. 
 
 One dram of ether, given hypodermically, is a powerful, safe and 
 useful stimulant for resuscitation from chloroform poisoning, and the ether 
 is usually at hand. When ether is the anesthetic administered an additional 
 quantity given hypodermically would, of course, do harm. 
 
 Shock is often delayed in very major operations, operations performed 
 svviftly and well, v^diere all means were taken to forestall a knockout on the 
 table with the hope of saving a life. There is in every person a limitation to 
 the amount of bowel that can be removed with impunity, and the number 
 of adhesions that may be broken down with safety to the patient's life. The 
 extent of work done in a given lime varies vastly with different surgeons, 
 and this is no mean factor in causing primary and secondary shock. 
 
 Crile, in his experiments, noticed that "On incising the skin over the 
 testes there was frequently a considerable fall in the pressure in keeping 
 with the phenomena attending injury of this organ." And again, "'All 
 the observations tend to show that the more specialized and abundant the 
 nerve supply to a part the more will it contribute to the production of shock 
 when subjected to injury." 
 
 Cutting through muscles and fascia has very little or no eft'ect on 
 the heart. On reaching the peritoneum, contact, touch, or tear of it 
 causes more or less disturbance indicative of shock. "The more severe 
 the injury, the greater extent of contact and exposure, the more quick and 
 rapid was the decline of the blood-pressure." (Crile.) 
 
 In regard to the testicles, Crile showed by experiments that "Cutting 
 
8 
 9 
 
 10 
 11 
 12 
 
 _ 5 
 
 PLATE xxn; 
 
 Incisions. 
 
 I. Epigastric hernia. 2. For hernia after nephrotomy. 3. For lumbar 
 hernia. 4. Semilunaris hernia. 5. For direct inguinal. 6. For obturator. 
 7. Ventral (rectus muscle). 8. aLongitudinal. 9. bTrans verse (Mayo). 
 10. For ventral. 11. bOblique (Ferguson) for femoral hernia; 12. aLongi- 
 tudinal (Ochsner) for femoral hernia. 
 
COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 1 53 
 
 the testicles, spermatic cord, tunica vaginalis, caused in most instances a 
 fall in the blood-pressure appearing after a short interval." 
 
 Latent or delayed shock is the depressed condition that occurs some 
 time after the operation. What probably has happened is that a ligature 
 has slipped and hemorrhage is taking place. This is not considering men- 
 tal shock caused by bad news, etc. 
 
 Treatment. — -Strychnin sulphate, gr. i-io to 1-30, should be given 
 every i, 2, 3, or 4 hours, according to the urgency of the case. It raises 
 and sustains the blood pressure. 
 
 Artificial respiration is demanded to supply oxygen to the blood and 
 to stimulate the heart to contract. If the patient becomes restless and 
 shock continues, gr. 1-16 of morphine and gr. 1-120 of atropine, hypoderm- 
 ically, every six or eight hours, acts splendidly by regulating the reflexes 
 and calming the patient, while gr. ^ of morphine would likely kill the 
 patient. 
 
 Nitroglycerine, gr. 1-150, every two hours, is of service as a rapid 
 cardiac stimulant. Camphor and musk I have found of very little use. 
 It is true I have only employed them when other drugs had failed, and 
 in only twelve cases (not hernia). Remember to apply heat, but do not 
 burn the patient. Boiling water poured into cans or rubber bags and 
 placed near the skin of the person will surely burn. The temperature of 
 the water should be about 120° F. In one instance (pylorectomy done in 
 1893) I kept my patient on a hot water rubber bed for seven days. This 
 aided materially in preventing, and at the same time in treating, the shock 
 which was well pronounced. Dry rubbing of the skin is of benefit, but 
 rubbing with alcohol does harm. The foot of the bed should be raised 
 and, if necessary, the lower extremities should be bandaged. If shock 
 is accompanied by hemorrhage 1000 c. c. of normal salt solution should 
 be given beneath the skin and repeated every four, six or eight hours 
 p. r. n. If, however, hemorrhage is not an element in the production of 
 the shock 500 c. c. is about the proper quantity. If very rapid action is 
 demanded the saline solution may be administered into a vein while the 
 patient is still on the operating table. The temperature of the normal salt 
 solution is important. It should not be less than 110° F. and not higher 
 than 118° F. as it enters the circulation. The temperature of the water 
 in which the flask containing the normal salt solution stands should be 
 kept at 120° F., which will insure the proper temperature for the salt solu- 
 tion. According to the mode of administration it loses i, 2, or 3 degrees 
 before it enters the blood. 
 
 If salt infusion is given at a temperature of 100° to 103° F., as is 
 often recommended, shock is invariably deepened. "The combination of 
 and frequently repeated hypodermic injections of strychnine, together with 
 saline infusion is most effectual." (Crile's experiments.) 
 
 Predigested nutrient enemas should be administered without delay 
 (milk, egg, coffee, brandy, etc.), every six hours. It is well to remember 
 that in shock absorption by the stomach does not take place to a great 
 degree, and for this reason only teaspoonful doses of hot water should be 
 
154 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 injected about every half hour. If the stomach is partly filled with liquid, 
 it should be washed out. 
 
 HEMORRHAGE. 
 
 In operations for the cure of hernia, hemorrhage, both primary and 
 secondary, may be alarming. 
 
 Primary Hemorrhage. When operating on hernias, primary hemor- 
 rhage must be guarded against carefully, and when it does occur it must 
 be controlled absolutely in order to obtain ideal results from the operation. 
 The vessels that may be injured and that give rise to dangerous hemorrhage 
 when operating on inguinal hernia are the deep epigastric and iliac arteries 
 and veins. Of course, it is impossible to avoid injuring the superficial 
 vessels, but hemorrhage from these is controlled easily by means of the 
 clamp and ligature. In Fowler's operation for hernia the deep epigastric 
 vessels are exposed, clamped, cut and tied, which last must be done very 
 carefully and securely. Any injury to these vessels produces quite a flow 
 of blood and no time must be lost in checking the same. 
 
 In hernias of long-standing, where there is a bulging out of the en- 
 'X tire inguinal region, the deep epigastric vessels sometimes override the 
 \ sac. They are then tied deliberately and cut. 
 
 Hemorrhage from the vessels of the cord, no matter how slight it 
 may be, should be checked by the application of the ligature. If the iliac 
 vessels are grasped carelessly by the needle, or if they are torn while dis- 
 secting out the sac, the injur}' is a dangerous one even though it is the re- 
 sult of a blunder. In twenty-five years I have seen two such cases in con- 
 sultation. 
 
 In large hernias of long standing', occurring in persons who have 
 very stiff arteries, persistent oozing may take place and unless the wound 
 is drained with silkworm gut the blood will accumulate in the deeper tis- 
 sues and probably cause serious disturbance later on. In cases in which 
 it is necessary to incise the scrotal tissues, hemorrhage is quite likely to 
 prove troublesome. It must be checked before the wound is closed, and a 
 capillary drain had best be inserted. 
 
 When it is necessary to liberate a strangulated hernia we no longer 
 do the old-fashioned herniotomy, using a knife and cutting on a grooved 
 director. Wounding of the vessels in the region of a femoral hernia is 
 an occasional accident. The vessels that are endangered most during an 
 operation on a femoral hernia are the long saphenous vein, the femoral 
 vein, and the obturator artery when it pursues an abnormal course along 
 the outer border of Gimbernat's ligament. When the obturator artery is 
 injured it is advisable at once to sever Poupart's ligament near the pubic 
 spine, exposing the artery at or near its origin. Let me say, however, 
 that Gimbernat's ligament may be severed carefully with the sharp point 
 of the scalpel on its under surface so as to avoid the obturator artery. 
 
 When operating for the relief of an obstruction of an obturator hernia, 
 the obturator vessels are in danger of being wounded. After passing 
 through the pectineus muscle and having exposed the hernia, the con- 
 
 2. 
 
PLATE XXV. 
 Macewen's Operation for Inguinal Hernia. 
 
COMPLICATIOXS IXCIDEXT TO THE RELIEF OF .HERNIA I57 
 
 striction is most safely severed without injury to the vessels by cutting 
 upward. They are injured occasionally, but by retracting the wound edges, 
 which can be done in a moment, the vessel may be caught and ligated. 
 
 Two sets of vessels may be wounded when operating on an ischiatic 
 hernia, (a) the gluteal vessels when the hernia protrudes through the 
 great sciatic notch above the pyriformis muscle, and (b) the sciatic ves- 
 sels when the hernia protrudes from beneath this muscle. 
 
 Secondary Hemorrhage. Sometimes it is extremely difficult to rec- 
 ognize a secondary hemorrhage, because there are so many degrees thereof, 
 and evidence of its presence is dependent on the source and rapidity of the 
 bleeding. In nearly every instance the hemorrhage is the result of some 
 error in the technic. such as tying a vessel improperly or too loosely; pull- 
 ing the ligature after it has been applied; severing the ligature too close to 
 the knot ; leaving too short a stump of tissue outside of the ligature ; trust- 
 ing too large a vessel to angiotrypsic pressure ; extensive capillary oozing, 
 or the tissue, if edematous, may shrink so that the ligature no longer com- 
 presses the vessels. These causes of secondary hemorrhage mav be met 
 with in connection with the ablation of a gangrenous omentum. When the 
 blood becomes overcharged with normal saline solution, or when the solu- 
 tion is administered too hurriedly or in too large quantities, serious and 
 sometimes uncontrollable secondary hemorrhage may occur. 
 
 The best means of controlling' capillar}- oozing from a loop of 
 bowel that has been strangulated but possesses suiiticient vitalitv to permit 
 of its being returned within the abdomen, is to dust its surface freelv with 
 sterile subgallate of bismuth. This powder, which is slightly antiseptic 
 and slightly astringent, checks the oozing from raw surfaces on the perjj 
 toneum anywhere, and prevents adhesions from taking place. -Tt favors 
 rapid coagulation of the blood, and the feeble astringent action which it 
 possesses is not harmful to the tissues. 
 
 Fine sewing with catgut, using figure-of-eight or cuxular stitches on 
 the raw and bleeding surface, is an excellent means of checking hemorrhage, 
 where it can be applied. It may be utilized in cases of hemorrhage from 
 the surface" of the large bowel, stomach, bladder, liver, spleen, and other 
 abdominal viscera. It cannot, however, be applied successfully on the bleed- 
 ing surface of a friable small bowel. The principal oozing points may be 
 picked up superficially with adjacent peritoneum by means of fine catgut. 
 A number of such .circular stitches may be inserted advantageously, the sur- 
 face then being dusted over with subgallate of bismuth. 
 
 If there is a persistent oozing from a loop of bowel, or from the omen- 
 tum, the bleeding surface may be w^rapped up in a dry dressing of gauze, 
 being first dusted with the powder, then proceeding with the operation. 
 When it is time to close the wound it will usually be found that the raw 
 surface that formerly bled is now dry. The electro-thermo-cautery 
 (Downes) is an excellent hemostat in cases where it can be applied, as on 
 the omentum. The actual cautery is practically useless for this purpose, 
 and so is hot water. 
 
 When the pulse quickens, the temperature falls, respiration becomes 
 
158 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 labored, the skin and mucous membranes become pale and cold, and there 
 is vertigo and restlessness, with tossing of the arms and legs and a desire 
 to get out of l)ed, it mav be too late to save the patient suffering from a 
 secondar}- hemorrhage or its effects. Never hesitate, however, even in the 
 face of these signs of death, to check the hemorrhage and institute treat- 
 ment to save the life of the paiietit, because sometimes you will be agree- 
 ably surprised. 
 
 TEMPERATURE. 
 
 When complications, such as collapse, shock, hemorrhage, or death, 
 are impending, the temperature, as a rule, becomes subnormal. The de- 
 pressing effect of the anesthetic cools off the surface of the body. A sub- 
 normal temperature occurring while the patient is on the operating table 
 is a sign of shock. If, after the patient is placed in bed, the temperature 
 falls suddenly, it is a sign of hemorrhage. If the temperature rises during 
 the course of the operation, it is an ill omen. A flight lowering of the 
 temperature after the operation and then a gradual or even a sharp rise 
 may not mean any complication ; but if the temperature does not subside by 
 the third day, the wound should be inspected and an infection looked for. 
 
 VOMITING. 
 
 Vomiting may be so persistent as to demand attention. If the patient 
 vomits while taking the anesthetic, it may mean, (a) food or liquids in the 
 stomach, or (b) an overdose of the anesthetic. Whenever a semi-conscious 
 patient begins to vomit profusely, there is danger of his being suffocated 
 by inhalation of the vomitus. Be ready to open the trachea, if necessary. 
 
 Nausea and vomiting are two great objections to the use of ether 
 and chloroform. I recall operating on several patients three or four times, 
 on separate occasions, who nearly died from vomiting, no matter what 
 anesthetic had been used. The ingestion of large amounts of liquids or 
 food soon after operations often induces vomiting. In such cases I have 
 frequently and to great advantage allowed the patient to drink hot water 
 freely, with about five grains of bicarbonate of soda added to each ounce 
 of water. If it is retained the nausea soon ceases; if it is ejected, the 
 stomach is thereby w^ashed out. It is difficult to make patients understand 
 that vomiting is increased b\' the drinking of liquids, and that drugs are 
 of no avail to relieve the vomiting. When vomiting occurs in the oper- 
 ating room, it is a good plan to wash out the stomach after the operation 
 has been completed. I am convinced that less stomach disturbance follows 
 v.'hen this is done, especially after hernia operations. 
 
 Owing to the strain to wdiich the stitches in the wound are subjected, 
 it is possible for the wound to burst open. Some time ago I operated on 
 a small umbilical hernia, removed the navel, and brought like structures 
 together with plain catgut (the supply of chromic catgut being exhausted) 
 and silkworm gut. through-and-through stitches were inserted to insure 
 success. On the eighth day, contrary to orders, the silkworm gut stitches 
 were removed and the wound was dressed. About half an hour after- 
 
COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 1 59 
 
 wards the patient began to A-omit, and she continued to retch and strain 
 for about three hours, when the entire wound burst open and coils of 
 intestine appeared beneath the dressings. The vomiting- was induced by 
 the removal of the stitches when the stomach was full of food, and prob- 
 ably was continued by the irritation of the wound and compression of the 
 intestines while they were being forced through the opening. Re-suturing 
 v.4th silkworm gut, without the use of an anesthetic, completely relieved 
 the condition. The lessons to be learned from this case are obvious. 
 
 Straining and vomiting are very deleterious to wounds made during 
 a hernia operation, even though the field of operation be well dressed and 
 strapped down with broad adhesive straps. When vomiting persists for 
 twenty-four hours, it is advisable to wash out the stomach because a cer- 
 tain degree of acute gastrectasis may be present which is not easily over- 
 come without the assistance of a stomach tube. After washing out the 
 stomach no food or liquid should enter it for at least tvrelve hours. Even 
 the holding of ice in the mouth and gargling with water induces nausea and 
 vomiting. In the vast majority of cases the administration of bismuth, 
 creosote, a few drops of chloroform or of capsicum, and iced champagne 
 does harm. Persistent vomiting after an operation for strangulated hernia 
 calls for stomach lavage repeatedly, and after each lavage sufficient mor- 
 phine (beginning with 1-16 grain, with 1-200- atropine, hypodermically, 
 and continually increasing the dose, if necessary) should be given to con- 
 trol stomach peristalsis. When the bowels have been obstructed and then 
 handled by the surgeon, slight pathologic changes and local shock suspend 
 peristalsis for several days, and the gastro-intestinal contents can receive 
 no aid in passing through the portion of the intestine whose function is 
 thus suspended. The consequence is that anything that is forced into 
 the stomach is quite likely to be forced back. 
 
 A stomach with residual contents after emesis should be washed out. 
 One of the alarming signs in connection with vomiting is the appearance of 
 blood in the vomitus — the naked eye appearance being like coftee. In 
 cases with no residual contents, or blood in the material vomited, a seda- 
 tive^ such as morphine, is indicated to allay action of the stomach, and 
 after being washed out once with a feeble solution of permanganate of 
 potash, absolute rest should be enjoined. If, however, the stomach is dilated, 
 the act of vomiting being insufficient to empty it, and blood appears in the 
 ejecta, the stomach must be washed out at once, but no morphine or other 
 sedative should be thought of, let alone administered, because the dilata- 
 tion of the organ would only be increased and leakage of blood from the cap- 
 illaries be favored. This very condition is caused by overdosing with mor- 
 phine a patient suffering from shock. It is strange, but true, that even doc- 
 tors suffering from the effects of a major operation not infrequently prefer 
 to be relieved by morphine at the risk of death, than to suffer and struggle 
 for life during one night. Along with this condition we usually find some 
 other grave complication, involving the heart, kidneys or liver, which car- 
 ries the patient off. 
 
 Bile iri the ejecta may mean (a) a retro-peristalsis due to the suspension 
 
l60 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 of normal peristalsis in some portion of the intestines on account of the 
 operation, or (b) when colicky pains are in the abdomen at the same time 
 more significance must be given to the appearance of bile — suspicion of ob- 
 struction. Should, however, bile and fecal matter be vomited, associated 
 with colickv pains in the abdomen, obstruction of the bowels is almost sure 
 to exist. No time should then be lost in examining the wound in the abdo- 
 men and exploring. Prompt action is a life-saving agent. 
 
 When vomiting is associated with tympany only, paresis of the bowels 
 is present, and stimulating enemata, hot turpentine stupes over the abdo- 
 men and large doses of strychnine are indicated, but no morphine or any 
 sedative. Associated with vomiting we sometimes find not alone tympany, 
 but a temperature as high as 102° to 104" F., with or without chilly sensa- 
 tions, chills, rigors or thirst : Then peritonitis is the most likely cause of all 
 the symptoms and signs. 
 
 TYMPANITES. 
 
 Nourishment bv bowel should be commenced immediately after all 
 major hernia operations. 
 
 Over-distention of the intestines with gas is a complication no less dis- 
 tressing to the patient to endure than to the surgeon to treat. It is, of 
 course, a sign of something being wrong. It may arise after the most sim.~ 
 pie operation for hernia and greatly disturb the patient and all in attend- 
 ance. If no temperature is associated with it, and although slight, it must 
 be treated. It is a common complication of operations for strangulated her- 
 nia, and, too, when the hernia was only incarcerated. The distention of the 
 abdomen causes not merely an extensive sensitive feeling of the abdomen, 
 coterminous with its boundaries, due to overstretching, but also the pressure 
 on the stomach and diaphragm interferes with digestion and impedes respira- 
 tion, much to the patient's discomfort. 
 
 Kelly, of Baltimore, has seen two deaths seemingly due to paralysis of 
 the diaphragm caused by excessive tympanites. The heart, kidneys and 
 liver are equally affected by tympany, but the heart and kidneys most mark- 
 edly. The heart begins to palpitate and becomes irregular in its action, on 
 account of the pressure. Tympanites alone is usually of no serious signifi- 
 cance, no more than is a fast pulse, fever, constipation, or vomiting, and 
 may be relieved easily, but when associated with these evidences it is one 
 of the prominent signs of peritonitis. When tympany appears soon after an 
 operation for hernia I look upon it with grave suspicion, for it may indi- 
 cate that the bov/els are obstructed. 
 
 In extreme tympany occurring within twenty-four hours after operation, 
 which is not relieved by a rectal tube, stimulating enema and purgation, 
 and which causes vomiting, no time should be lost in reopening the abdomen 
 and searching for the cause. If you wait for an elevation of temperature 
 your patient will be beyond relief. 
 
 I recollect traveling fifty miles from Winnipeg, in 1887, in a sled, when 
 the temperature was 45° F. below, to reduce a strangulated right oblique 
 inguinal hernia. Under chloroform anesthesia the reduction was effected 
 
PLATE XXVI. 
 Bassini's Operation for Tngminal Hernia. 
 
COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA IO3 
 
 to my own satisfaction, and to the apparent relief of the patient. Within an 
 hour I started on my homeward journey, but when twent}" miles distant a 
 telegram overtook me and I had to return, on account of "sudden bloating" 
 and the bad condition of the patient, who, by the by, was at one time a bare- 
 footed schoolmate of mine. Upon returning I immediately opened the ab- 
 domen in the right inguinal region, and found that the bowel and omentum, 
 alihough Lioth were reduced within the abdomen, were obstructed to a 
 considerable degree. The band was severed, the omentum and bowel lib- 
 erated, and the wound brought together with through-and-through stout silk 
 sutures, the best material at hand. A life was saved and a cure of the hernia 
 effected. 
 
 If no other sign except tympanites is present after an operation, it is 
 good practice to apply turpentine stupes to the entire abdomen (one in 
 twenty), changed every half hour to three hours, according to the protec- 
 tion afforded to the stupes, care being taken not to blister the skin. 
 
 Instead of using the ordinary rectal tube, which, on account of it5 
 size, gives rise to rectal contractions and discomfort, I insist on using a 
 No. 8 male self-retention bladder catheter. It carries off the gas and is 
 too small to irritate the sphincter of the rectum so as to cause it to contract. 
 The patency of the catheter should be tested occasionally by forcing air 
 through it. A good-sized dose of castor oil, with the addition of twenty 
 drops of turpentine, carries off the effete material causing gas. For gas 
 pains we usually begin by passing the rectal tube ; that failing, we use a 
 I, I, I enema (one ounce of glycerine, one ounce of sulphate of magnesia, 
 and one ounce of water). If this fails, we double the quantities (2, 2, 2 
 enema). This not being a success, an enema is given, consisting of an alum 
 solution, one ounce to the gallon. This last has often succeeded when the 
 glycerine and magnesium sulphate failed. 
 
 The late L. M. Sweetnam, of Toronto, directed patients suffering from 
 tyinpanites to assume the knee-chest position and then passed the rectal 
 tube. Kelly says (op. cit., 87) : "1 gave her complete relief by putting her 
 under chloroform and introducing, in the knee-chest position, one of my 
 long rectal specula; the bowel was collapsed until the speculum reached the 
 sigmoid flexure, when the gas began to escape freely, and she recovered." 
 
 Rather than allow a patient to die from tympany I have, under local 
 anesthesia, performed an enterostomy and saved my patient. 
 
 PAIN. 
 
 The temperament of the patient has mucii to do with the amount of 
 pain complained of after an operation for hernia, the iiighly nervous suf- 
 fering the most, and those of a phlegmatic nature the least. Self"Control 
 enables a person to endure any amount of suffering without complaint. The 
 most wonderful example of self-control in a child I met in the case of a 
 boy one year old, on whom I operated for mastoid suppuration, referred to 
 me by Dr. J. C. Cook. For some time afterward he was brought to the 
 hospital for dressings. While the packing was being removed, the wound 
 washed, etc., he would tightly grasp the hands of the nurse and never com- 
 
164 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 plain, even though the perspiration would roll off him. In explanation of 
 his excellent behavior, Dr. Cook told me that it was entirely due to the 
 training he received during the last three months from a nurse who makes 
 a specialty of training unruly children with kindness. 
 
 The pain resulting from a herniotomy usually subsides in twenty-four 
 to forty-eight hours, and no morphine or other anodyne should be given for 
 it. Pain of itself need cause no alarm, and it often subsides after the suf- 
 ferer is assured that recovery will be faster if morphine is not taken. AMien 
 the pain disturbs the patient to the extent of preventing sleep at night for 
 several hours, then toward morning I give % grain of morphine, with 1-200 
 of atropine hypodermically. After this sleep is usually obtained and no 
 more is required for at least twenty-four hours. 
 
 There are exceptions, however.. I have seen some patients whose lives 
 were saved by morphine. One case comes to my mind now. A man, whos^ 
 cecum I removed suffered so severely from pain in the right iliac region, 
 which was constant and excruciating, that he went into a collapse, became 
 cold, pale and pulseless. In this collapsed condition he complained of "that 
 awful pain." I then gave morphine, gr. }i, hypodermically. This eased 
 him ; his pulse returned ; color returned to his skin, and he felt well. In 
 four hours' time the pain returned and he began to get bad again, but for 
 two hours thereafter no morphine was given, not until it was clear to every- 
 body that he would die if the morphine was withheld. After this the mor- 
 phine had to be given regularly for four days. I am convinced that the 
 morphine saved his life. 
 
 Hyoscine-hydrobromate acts well for nervous disturbances other than 
 severe pain. Codeine should be tried for the pain first. A good, strong, 
 kind, sensible nurse can enable the patient to gain self-control and practi- 
 cally lull her or him to sleep, even though suffering. A nurse whose nature 
 runs counter to that of the patient should at once be removed, especially if 
 the patient is nervous or hard to control. 
 
 SKIN COMPLICATIONS. 
 
 At the time of the operation the skin near the rupture may be the seat 
 of an abscess, or an abscess may have formed in connection with strangu- 
 lation. Last year I had to operate synchronously on a suppurating lymphatic 
 gland in the groin, caused by truss-pressure, and on a strangulated hernia 
 on the same side. The incisions were not more than two inches apart, and 
 primar}^ union of the hernial w.ound occurred. I attributed this excellent 
 result more to the method of dressing the two wounds than to any particular 
 asepticity carried out at the time of the operation. In order to prevent in- 
 fection of the clean wound, I formed a long ridge about one inch broad and 
 one inch high, extending midway between the two wounds, composed of 
 collodion, cotton and iodoform powder. The cotton was first permeated with 
 the iodoform powder and then soaked in collodion. It acted as an antiseptic 
 and a mechanical barrier to spreading contamination. 
 
 In neglected and maltreated cases of strangulated hernia the skin may 
 become inflamed, edematous or even gangrenous, manifested by redness, 
 
COMPLICATIOXS IXCIDEXT TO THE RELIEF OF HERXIA 165 
 
 pitting on pressure and crepitation. These skin complications may follow 
 violent taxis or come on slowly. They usually bespeak infection from the 
 condition of the contents of the hernia. At first the skin becomes tense, 
 red and tender, and finally edematous, but with the lapse of time nature tires 
 of fighting pathologic changes, innervation ceases to register the condition 
 of dying or dead structures, and toxemia soon rules the entire economy: 
 then the swelling lessens, the pain practically ceases, and the patient, uncon- 
 scious of his perilous condition, sleeps his last sleep. AVhat an object lesson 
 to the student who was negligent in college I ! 
 
 Eczema of the skin, or a burn caused by the application of hot fomen- 
 tations, may complicate operative procedures. The skin over an umbilical 
 hernia thins out and is most liable to infection, sometimes causing ulceration 
 and sloughing. 
 
CHAPTER XVI. 
 
 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 (Continued). 
 
 SAC. 
 
 The sac is tense and full of straw-colored fluid at iirst, but as the stran- 
 gulation becomes sufficiently advanced to cause death of the contents of the 
 sac. the fluid becomes bloody, grumous or purulent in character. The sac 
 at the same time becomes correspondingly changed in color and constituency ; 
 it may be inflamed, ulcerated and gangrenous. In some instances the sac is 
 ruptured by taxis. The sac is not infrequently firmly adherent to surround- 
 ing structures, and its contents are often adherent to its inner aspect, all of 
 which must be taken into consideration when dealing with it surgically. 
 
 OMENTUM. 
 
 The omentum is either free or attached to the sac or to the bowel, or to 
 both. It may be inflamed or gangrenous in strangulated cases. . 
 
 BOWEL COMPLICATIONS. 
 
 The condition of the strangulated loop is the most important to observe. 
 It may be simply congested (Fig. 15), without destruction of any of its 
 coats. In this condition the peritoneum is red and smooth, the vessels en- 
 gorged to their limit. If the small bowel is constricted the state of conges- 
 tion is of short duration, vv^hile a large bowel may remain congested for 
 several days (Fig. 16) without permanent damage ensuing to the loop. 
 Sooner or later, however, the bowel becomes destroyed by inflammation 
 (Fig. 17), ulceration (Fig. 18), pressure atrophy (Fig. 19), or gangrene 
 (Fig. 20). The more hernias I see in consultation, and the m.ore hernias 
 I reduce by taxis, the more I am impressed witii this danger. I have prac- 
 tically come to the conclusion that with rare exceptions taxis should no 
 longer be practised. As so ably pointed out by Maurice H. Richardson, of 
 Boston, its dangers are 
 
 1. Rupture or bruising of the sac or intestine. 
 
 2. Tearing of adhesions. 
 
 3. Reduction en bloc. 
 
 4. Fatal delay. 
 
 ILEUS. 
 
 Ileus coming on after operations for hernia may be temporary or per- 
 manent. In the former a simple twist of a loop of bowel occurs, and when 
 peristalsis begins it uncoils itself and the patient is relieved of the colic and 
 
COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 167 
 
 obstruction. In permanent ileus the simple loop does not straighten out, or 
 a loop becomes obstructed in one of many ways, such as by a kink and ad- 
 hesion at an acute angle, coils adherent to coils and bowel to raw surfaces, 
 or a loop gets behind an adhesion, or through a hole in the omentum. It 
 sometimics happens that the vomiting due to the anesthetic forces a loop of 
 bowel into another hernial opening and strangulation occurs. Such an in- 
 stance occurred in my practice. I operated in the forenoon on a woman, 53 
 years of age, for a strangulated right inguinal hernia. She vomited furiously 
 in the middle of the afternoon, when she screamed and told the nurse that 
 her intestines were down again, and so persistent was she about it that I 
 was called hastily. Upon removing the dressings, a tense femoral hernia 
 was very prominently present. She then told us that the rupture would 
 sometimes come down on the thigh, but usually the bulging was higher up. 
 I used taxis in vain, but only for a short time, just before operating. Even 
 in this short time there was fluid in the sac, and the small bowel, which it 
 contained, was intensely congested, much more so than the small bowel and 
 omentum found in the inguinal hernia, although strangulated for about 
 twxlve hours. 
 
 The usual clinical picture of ileus is that of distress and suffering. The 
 patient usually knows that his bowels are obstructed and can point out the 
 exact spot where the pain began and where it has repeatedly returned in 
 paroxysms every two or three minutes since then. Nausea and vomiting 
 are distressing from the beginning of the pain. The patient first vomits the 
 stomach contents, then bile, and finally the contents of the small intestines. 
 The abdomen is flaccid at first, except the region of localized pain ; here it 
 is tumefied and tender on pressure, and as the pain returns the abdominal 
 wall here becomes more and more tense and rises like a ball, and has the feel 
 of a semi-solid tumor. It is not manv hours, however, before the bowels 
 become exhausted, dilated proximal to the stricture, and the abdomen be- 
 comes generally swollen, tympanitic and tender. 
 
 URINARY BLADDER. 
 
 Irrespective of hernias of this viscus complications aitecting the bladder 
 are liable to arise in the course of, or following, operations for the cure of 
 inguinal, femoral and ventral hernia. Retention of urine is a very frequent 
 complication following any operation done in the vicinity of the bladder. 
 This is easily corrected by means of the catheter and by altering the reaction 
 of the urine, giving alkalies, as is usually indicated. 
 
 In operations done for the relief of the direct form of inguinal hernia, 
 the bladder, on account of its close attachment to the peritoneum in this re- 
 gion, is likely to be partly extruded with the hernia ; indeed, a portion of the 
 bladder may form part of the sac wall. It is in conditions like this that the 
 bladder is likely to be injured during the operation. I have seen this viscus 
 opened by accident, and in one case, seen in consultation, a portion of the 
 bladder had been tied off with the sac, leaving a urinary fistula which had 
 to be remedied by a second operation. 
 
 It is mv belief that hernia of the bladder in the inguinal or femoral re- 
 
l68 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 gion is exceedingly rare, and that many of the cases that have been report- 
 ed as instances thereof are really instances where the bladder has been 
 dragged into the field of operation. It is a fact that surgeons who have the 
 greatest experience in this work meet with fewer hernias of the bladder 
 than do those whose experience is limited. 
 
 C. B. Lockwood (Trans. Loud. Clin. Soc, Vol XXXI) reports a case 
 of incomplete inguinal hernia on the left side. Four months previously, 
 while operating on the opposite side for hernia, another surgeon had opened 
 a fingerlike extension of the bladder which was closed with sutures. Later 
 two phosphatic stones which had formed on the sutures were removed by 
 lithotrity. 
 
 Verhoef (Jour, de Chir. et Annales de la Soc. Beige de Chir., No. 2, 
 1903) reported two cases of accidental wounding of the bladder during 
 operations for hernia. In one of the cases a portion of the bladder was in 
 the sac ; in the other it was not. 
 
 J. B. Harvie (American Medicine, April 4, 1903) reported a case in 
 which the entire bladder was found in the hernial sac. Before operation it 
 was thought that the condition was one of strangulated hernia complicated 
 by hydrocele. The upper part of the mass was very tender to touch. The 
 patient had had a reducible hernia for ten years, but had never worn a 
 truss. The hernia became irreducible during an unsuccessful attempt to 
 evacuate the bowel. Attempts at urination were frequent from this time on, 
 but only a few drops of urine were passed at a time. Subsequently all the 
 symptoms of a strangulated hernia appeared. When the sac was opened 
 about seven inches of gangrenous intestine were, found and resected, the 
 anastomosis being made with a Murphy button. A small opening made in 
 the gangrenous mass showed it to be the bladder. Considerable difficulty 
 was experienced in reducing this organ, but it was finally accomplished. 
 
 In ventral hernias the bladder occasionally has been found to protrude 
 immediately above the pubic bone, a position in which it is extremely likely 
 to be injured during the operation. 
 
 A urinary fistula may result from injury of the bladder wall made 
 during an operation for hernia. I have had occasion to close two such fis- 
 tulas, one in the suprapubic and the other in the inguinal region. 
 
 Cystitis may follow hernia operations, although it is in no way the 
 result of this particular operation. When it does occur, the treatment us- 
 ually employed for this condition should be carried out. 
 
 INJURIES OF THE CORD. 
 
 When the vessels of the cord are accidentally injured, the testicle 
 is likely to become congested and hyperplastic, eventually undergoing atro- 
 phy. The gland may also become gangrenous. 
 
 Even when the vas deferens is injured it is not always necessary to re- 
 move the testicle. In the fall of 1897, while operating for the relief of a 
 strangulated right-sided hernia, I injured the vessels of the cord to such an 
 extent that castration was the only recourse. This operation was done in 
 a kitchen, at about two o'clock in the morning, with a very poor light. 
 
PLATE XXVII. 
 
 Kocher's Operation for Inguinal Hernia — second step. 
 
 (Saunder's Medical Hand Atlas.) 
 
COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA I7I 
 
 Otherwise it would not have been possible to have produced such an extensive 
 injury. In another case I injured the vas deferens while operating for a 
 non-descended testicle and hernia, but I did not think it necessary to re- 
 move the testicle on this occount. The outcome of the case justified the 
 decision. 
 
 COMPLICATIONS INVOLVING THE TESTICLE. 
 
 Atrophy of the testicle has occurred much more often after Halsted's 
 operation for oblique inguinal hernia than after any other method of pro- 
 cedure. In sixty-one cases this complication occurred ten times (16.39 P^^ 
 cent.). Retraction of the testicle occurred four times in 269 cases (1.5 per 
 cent. ) . I have had two cases of retraction of the testicle after Bassini's op- 
 eration. In another case gangrene of the testicle followed removal of the 
 vas deferens. In both the cases of retraction of the testicle the gland even- / 
 
 tually returned to the scrotum. In three of Bloodgood's cases referred to I 
 
 above the testicle returned to the scrotum. \ 
 
 I encountered one case of atrophy of the testicle following an extensive \ 
 
 suppuration of the glands in the groin, which had extended to the cord. In 
 these cases there w^as not a hernia present. 
 
 Hydrocele of the tunica vaginalis testis has occurred in 10 per cent, of 
 the cases following Halsted's operation, where the vas was removed. 
 
 SECONDARY WOUND SECRETION. 
 
 I have met with this complication in operations for the cure of inguinal, 
 femoral and extensive ventral hernias. This complication can be obviated 
 easily by seeing to it that no dead spaces are left when the wound is being 
 sutured, and by the proper application of the primary dressing. In large 
 hernias where a sac has been removed from within the scrotum and no 
 drainage is inserted, the scrotum is liable to be filled with a secondary 
 wound secretion. This is prevented by drainage with silkworm gut. 
 
 In performing extensive plastic operations for the reUef of hernia any- 
 where in the abdominal wall, dead spaces are very likely to be left. The 
 surgeon must use his judgment in deciding when and when not to drain in 
 order to prevent secondary wound secretion. When it does occur, the fluid 
 should be withdrawn at once, because its presence in the tissues predisposes 
 to infection. 
 
 INFECTION. 
 
 Infection has been thoroughly described in previous chapters, so it will 
 not be necessary to take up this subject extensively at this time. 
 
 Infection should not occur more frequently than in one per cent, of the 
 cases. Before the use of rubber gloves infection did occur in about teti per 
 cent, of the cases. Halsted reported 42 cases out of 446 (9.5 per cent.). By 
 the use of rubber gloves the occurrence of infection was reduced to about 1.8 
 per cent. In looking over my own statistics, and those of other surgeons, I 
 find that they compare favorably with those of the Johns Hopkins Hospital. 
 During 1902 and 1903, at the Heidelberg clinic, 31 cases of infection oc- 
 curred in 198 cases (15.6 per cent.). 
 
172 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 PERITONITIS. 
 
 Trauniatic Reaction or Repair. In performing an operation for the 
 cure of hernia, the peritoneum is ahvays opened and handled, and thereby 
 it is subjected to the compHcations caused by trauma and by bacterial in- 
 vasion. Strangulated hernia carries its own infection with it, and if not 
 relieved sooner or later, the occurrence of peritonitis is inevitable, local or 
 general, or both. Until such time when a clearer distinction between repair 
 (traumatic or plastic peritonitis) and a disease (peritonitis) caused by bac- 
 teria is generally adopted. I am constrained to uphold the modern concep- 
 tion of the disease, viz., that germs are the cause of peritonitis. 
 
 It is commonly stated in textbooks that the peritoneum has great 
 powers of forming adhesions. This is a mistake. The normal peritoneum 
 has no tendenc}^ to adhere to normal peritoneum, or to any raw surface unless 
 that surface is inflamed. The omentum and bowels slide over and lie in 
 contact with the raw peritoneum of the ovary month after month and year 
 after year without forming adhesions. Why are adhesions within the ab- 
 domen frequentlv eradicated by merely breaking them down ? Simply be- 
 cause raw surfaces do not always happen to stay approximated, on account 
 of changes in locality of loops of bowel and omentum, but if a raw surface 
 stays only a short time in contact with another raw surface, repair (plastic) 
 takes place. It is just the same as occurs after the coaptation of the raw 
 surfaces of any wound in the soft parts of the extremities. 
 
 The redeeming attributes of the peritoneum are its power of rapid ab- 
 sorption and its smooth and slippery protection. Following exposure 
 and handling of abdominal viscera, even in what we call clean 
 cases, it is amazing the adhesions that may form within a week, and that are 
 demonstrable when the abdomen has to be opened for some other compli- 
 cation, such as the "vicious circle" following a gastroenterostomy. I have 
 seen new" adhesions in the form of bands at the end of three weeks (normal 
 time for their developm.ent), and they had to be cut with a knife. At the 
 end of one week they are friable and easily broken down. 
 
 I recall operating on two cases of hernia that a few days later demand- 
 ed appendectomy. The first patient was a boy, aged 18, with an uncon- 
 trollable (by truss) right oblique inguinal hernia. The omentum was firmly 
 adherent to the inner surface of the sac and to the small bowel. A portion 
 of omentum was amputated and the stump rolled within omental folds. On 
 the third day (60 hours) after the herniotomy the typical symptoms of ap- 
 pendicitis developed suddenly. I opened the abdomen (AIcBurney's incis- 
 ion) at once, and found the inflamed and almost ruptured appendix, but the 
 end of the omentum and peritoneum at the site of the herniotomy presented 
 no adhesions whatever. 
 
 I mention this case in contrast to the second one. A woman, aged 2)^, 
 mother of three children, had an umbilical hernia that had been strangu- 
 lated for six hours. Bile and chyle were being vomited. Omentum filled 
 the umbilical sac (incarcerated), while small bowel (strangulated) occu- 
 pied the sub-umbilical hernia. The abdominal wall was lax. The woman 
 
COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 1/3 
 
 was not obese. The operation was neither difficuh nor prolonged, and a 
 beautiful coaptation of the peritoneal surfaces was secured. 
 
 The omentum was dealt with by means of Downes' electro-thermo-cau- 
 tery, and nearly the entire omentum was rem.oved. On the fourth day after 
 the herniotomy a fourth recurrent attack of apendicitis came on. I opened 
 the abdomen through the right rectus muscle and removed a non-adherent 
 gangrenous appendix. I then had an opportunity to explore the internal 
 aspect of the seat of the herniotomy. There were no adhesions at the scar 
 nor of the omental stumps, but the bowels were glued together pretty thor- 
 oughly, and distended. Upon pushing the sigmoid (which was over on the 
 right side) back to the left and upward ( gas began to escape per anus. A 
 rectal tube was inserted to facilitate the emission of the gas, and with the 
 manipulation of the most distended section of bowel it was soon emptied. 
 I broke down many adhesions and feared the outcome, but the patient made 
 a perfect recovery. 
 
 The agglutination of the bowel was no doubt due to plastic material 
 thrown out on the surface of the peritoneum to repair the damage done to it 
 by strangulation and by the handling it received at the operation. When 
 the exudate is sterile there is no peritonitis present but the condition known 
 as traumatic inflammation does exist and certainly predisposes to an infec- 
 tive peritonitis. I presume every surgeon of experience in the surgery of 
 the peritoneum has demonstrated by operation 'the fact that sometimes ex- 
 tensive peritoneal adhesions vanish by absorption. 
 
 Primary intestinal agglutination gives rise to distressing and even dan- 
 gerous symptoms. The vomiting is more persistent than that usually caused 
 by the anesthetic, but is less persistent than that of peritonitis, and bile is 
 rarely ejected. The temperature is higher than normal, 99'^ F. to 101° F., 
 but rarely higher ; the pulse is accelerated but remains regular and of good 
 volume. Tenderness on pressure and tympanitis are less severe and exten- 
 sive than in peritonitis, the bowels functionate and the patient lacks the 
 facial expression and mental anxiety present in peritonitis. Leucocytosis is 
 not marked, if present .at all. 
 
 When the distended bowel presses upon the diaphragm, dangerous 
 respiratory and heart symptoms may arise and temporary ileus occasionally 
 occurs caused by the pressure of the tympanitis. The lymph is absorbed 
 in from 2 to 4 days, — in just about the same time that a traumatic swelling 
 and eden-ia of the hand or foot subsides. Indeed the traumatic exudates sub- 
 side sooner in the peritoneal cavity than in the hand or foot, unless the skin 
 is freely punctured to allow drainage. When recovery takes place the 
 tympanitis gradually subsides, the pain lessens, the temperature falls and 
 the patient feels more comfortable. 
 
 So closely do the symptoms caused by plastic or traumatic exudates re- 
 semble those of peritonitis that no one can positively differentiate the one 
 condition from the other during the first three days after the operation. It 
 is the prevention of the so-called "traumatic peritonitis" that should concern 
 the surgeon. The minimum exposure and handling of the peritoneum, 
 omentum and bowels ; the covering of raw surfaces ; the exclusion of anti- 
 
174 COMPLICATIONS IXCIDEXT TO THE RELIEF OF HERNIA 
 
 septic solutions from the peritoneum ; absolute control of hemorrhage and 
 proper purgation of the patient before operation are the main prophylactic 
 measures. 
 
 AMiile it is generally admitted that free saline purgation is the treat- 
 ment par excellence of traumatic (peritonitis) exudates interfering with the 
 alimentary canal, still when it is used at the wrong time much suffering is 
 inflicted upon the patient. It is a good plan to give three or four grains of 
 calomel 'three hours before the operation: wash out the stomach on the op- 
 erating table, if it is dilated, and then even before the patient is fully awake 
 administer citrate of magnesia. If purgation is not commenced im.mediately 
 after the operation, it is folly to attempt it during the second and third days 
 because the bowels are in a splint and purgatives do not produce peristaltic 
 action until the muscular coats of the bowel are more or less liberated by 
 the absorption of the traumatic exudates through the peritoneum and blood 
 vessels. Purgation during those two days usually causes vomiting and adds 
 to the distress of the patient. Beginning at the end of the third day, small 
 doses of calomel, gr. i-io, every 20 minutes, till gr. ii are taken, and then 
 citrate of magnesia, two hours after the last dose of calomel, is a practical 
 mode of dealing with the bowels in this condition. This does not exclude 
 the passing of a rectal tube or a large self-retaining, male, soft rubber cathe- 
 ter to carry off flatus. If it is deemed wise, and it usually is, administer 
 nutrient enemata alternately with stimulating enemata, and colonic flushings 
 everv 6 or 8 hours. (See Tympanitis.) Assafetida, turpentine, glycerin, 
 alum, etc., serve a good purpose, as soon as the tympany begins, in pre- 
 venting extreme bloating. The aseptic chemical inflammations are not in- 
 flammations at all, only an attempt on the part of nature to repair the dam- 
 age done by the destructive power of the drug. 
 
 PERITONITIS IN HERNIA. 
 
 Infection of the peritoneum is followed by peritonitis. The germs 
 causing this are the same as those that infect wounds in other parts of the 
 body. William H. Welch says, "It is apparent that while there is no reason 
 to doubt that pyogenic cocci are specific agents of infection, the effects which 
 they produce depend upon a variety of conditions, such as the source, the 
 number and the virulence of the micrococci, the accompanymg toxic sub- 
 stances, the part of the body invaded, the readiness of absorption, the pres- 
 ence of foreign bodies and the pathological products, the general state of the 
 patient and the condition and handling of wounded tissues." 
 
 The peritoneum is capable of destroying a larger dose of infectious 
 micro-organisms than are most of the tissues of the body. Great as is the 
 resistant power of the peritoneum, the vital resistance of the individual gen- 
 erally plays such a marked role in practical surgery that no surgeon can 
 give a guarantee that infection will not occur after any operation for the 
 relief of hernia ; but, on the other hand, the peritoneum more often escapes 
 inflammation than does the wound itself, especially in inguinal and femoral 
 hernias. 
 
 Ever}- patient should be placed in the best possible physical condition 
 
PLATE XXVI] I. 
 
 Kocher's Operation for Inguinal Hernia — fourth step. 
 (Saunders Medical Hand Atlas.) 
 
COMPLICATIO^;S IXCIDEXT TO THE RELIEF OF HERXIA \jj 
 
 before the operation is done. Inasmuch as the individual is more prone to 
 peritonitis after operation when suffering from any chronic disease of the 
 heart, liver or kidneys, and inasmuch as he is also more likely to have a post- 
 operative pneumonia, the surgeon should always examine into the condition 
 of the internal organs of the patient before any operation is done. In spite 
 of all care, micro-organisms enter the wound every time the peritoneum is 
 opened. 
 
 All consideration should be given to fa) the condition of the patient, 
 (b) complete sterilization, and (c) the technic employed. In. connection 
 wuth a hernia, the greatest factor in the causation of peritonitis is strangula- 
 tion of a loop of bowel within the sac or, more rarely, intra-abdominal 
 necrosis. 
 
 Symptoms. — The symptoms of post-operative peritonitis are both local 
 and general, and they vary in degree according to the severity of the infec- 
 tion. The onset may be insidious or the condition may be ushered in with 
 symptoms of shock. Kelly reports two deaths from peritonitis. In one case 
 the symptoms were so severe that the case was mistaken for one of sec- 
 ondary hemorrhage and shock, when in reality it was one of streptococcus 
 infection. I have seen the same thing occur with extension of the perito- 
 nitis after other abdominal operations, but I have never seen a case of peri- 
 tonitis following an operation for the relief of hernia when strangulation 
 was not present. 
 
 Pain. — The first symptom to manifest itself is pain, which may be re- 
 ferred by the patient to the site of the operation. If the affection is fulmi- 
 nating in character, the pain at first generally is something like that exist- 
 ing in the early stages of a severe appendicitis. The pain usuallv is remit- 
 tent in character. There are periods of calm and periods of unrest, accord- 
 ing to the direction taken by the inflammation and the structures involved. 
 It is not uncommon to have the pain disappear from its original seat by the 
 time the peritonitis has become general. 
 
 When the patient is at the point of death the pain sometimes ceases. 
 The pain met with in strangulated femoral hernia, or a hernia of the Littre 
 variety where only a part of the lumen of the bowel is shut ofif, is verv de- 
 ceptive. Death of the bowel takes place so rapidly that the patient com- 
 plains of very little or no pain. W^hen the peritonitis extends to the neigh- 
 boring tissues, then there appears the characteristic pain of peritonitis. 
 
 The pain of peritonitis followmg an operation must not be mistaken for 
 pain in the abdomen caused by other conditions, such as the referred pain 
 of pleurisy or pneumonia, angina pectoris and aneurism, or the radiating 
 pains of locomotor ataxia, and of many other conditions. 
 
 Tenderness. — Associated with the pain is tenderness. This is usually 
 local, but becomes general when the inflammation extends. The tenderness 
 is greatest at the point where the inflammation is most active. Light strok- 
 ing of the skin will sometimes cause great inconvenience. The tenderness 
 may be superficial or deep. 
 
 Muscular Rigidity. — Associated with this tenderness is muscular rig- 
 idity. AVhen the pain and tenderness disappear, the muscles relax, and this. 
 
178 COMPLICATIOXS IXCIDENT TO IHE RELIEF OF HERNIA 
 
 in many instances, may be taken as a sign of approaciiing dissolution. All 
 the abdominal reflexes are increased during the spread of the disease. 
 
 V^oinifing. — A'omiting is one of the early signs of peritonitis, but us- 
 ually it does not come on until about three days after the operation. Vom- 
 iting resulting from the administration of the anesthetic usually passes off at 
 about the time that the vomiting which is associated with peritonitis makes 
 its appearance. If the operation is done for ihe relief of an umoilical or 
 epigastric hernia, or any hernia in the upper abdomen, and peritonitis fol- 
 lows, the vomiting comes on very early, on account of the close proximity of 
 the inflammation to the stomach. The vomitus after a time becomes green in 
 color, then dark, and finally it becomes fecal in character. 
 
 Pulse. — The rapidity and the high tension of the pulse are very char- 
 acteristic of peritonitis, so much so that the older surgeons still refer to the 
 hard and wiry pulse of peritonitis. The pulse rate varies from no to 150. 
 The frequency of the pulse lessens as soon as the spread of the inflammation 
 is checked. Its frequency increases as long as the peritonitis is active. 
 Then acceleration of the pulse and the persistency of this acceleration are 
 more characteristic of peritonitis than is any other single symptom met with 
 in this disease. The pulse and respiration are increased in frequency and 
 the temperature rises, maintaining a' physiologic ratio while the inflammation 
 is spreading. As soon as the inflammation becomes limited or general the 
 temperature and respiration may vary in proportion to the pulse rate. 
 
 Temperature. — The temperature increases for about three or four days 
 after the operation. In cases of so-called traumatic peritonitis, in vvhich an 
 infection is grafted on the peritonitis, the temperature of the one condition 
 merges into that of the other . There may be gangrene of the bowel and 
 extensive peritonitis with a subnormal temperature. The temperature of 
 peritonitis is rather deceptive and considered alone cannot be relied on as a 
 pathognomonic symptom. 
 
 Shock. — Shock is always present to a greater or less degree in perito- 
 nitis. In cases where the onset is sudden and severe, shock may be very 
 marked. 
 
 Increased Peristalsis. — Increased peristaltic action is present early in 
 the disease, but is soon put in abeyance, so that the bowels become perfectly 
 motionless. At the margins of the inflammatory area peristalsis is most ac- 
 tive. If the inflammation invades the intestinal tract from below upward, 
 retroperistalsis is established, which produces nausea and vomiting, even 
 when the inflammation has not extended to the stomach. 
 
 By listening over the abdomen with a stethoscope one can usually locate 
 the most active area of the inflammation by the friction sound that is heard. 
 At the margins of the inflammatory area there is always more or less peris- 
 talsis, and it is here that one can hear the various noises that are produced 
 by the intestinal contents working to and fro in the lumen of the bowel. 
 
 Tympany. — Tympany is present v.'ith inflammation of the peritoneum. 
 The distention of the bowels becomes greater until eventually the abdomen 
 is like a drum, and a resonant percussion note is elicited. .This distention is 
 present even when there is no inflammation. 
 
COMPLICATIONS INCIDENT TO' THE RELIEF OF HERNIA I79 
 
 The facial expression of one suffering from post-operative peritonitis is 
 that of great anxiety. The mind remains clear until exhaustion occurs, or 
 when the temperature becomes high the patient may be found to be delirious 
 between the intervals of sleep. When the final collapse comes and the patient 
 is dying, he usually is unconscious. 
 
 Blood.— An aid to the early diagnosis of post-operative peritonitis is an 
 examination of the blood. The leucocytes are increased in number, espe- 
 cially the polymorphonuclear variety. The coagulability of the blood is also 
 increased. The presence of leucocytosis is not to be relied on too firmh', 
 however, as a diagnostic aid. 
 
 Treatment. — The treatment of post-operative peritonitis is both medi- 
 cal and surgical. The only medical treatment that is of any benefit at all is 
 that which drains the alimentary canal by means of cathartics, carrying 
 away the germs and their products, or the administration of opium, which 
 lessens the pain, prevents peristalsis, and also, to a considerable degree, ttle 
 spreading of the inflammation. During the early development of abdominal 
 surgery Lawson Tait instituted and practised free catharsis, beginning it im.- 
 mediately after the operation, as a prophylactic against post-operative com- 
 plications, such as peritonitis. Cathartics are of no avail, however, once the 
 inflammation is established. When peristalsis cannot take place the admin- 
 istration of cathartics may do harm. 
 
 Opiates are indicated for the relief of sufit'ering and also to prevent the 
 spasmodic contractions of the alimentary canal. If it is decided to give 
 opiates in the treatment of peritonitis, they ought to be pushed to the extern; 
 almost of poisoning the patient so that no tenderness is felt. 
 
 The medical treatment is also local in the form of turpentine stupes and 
 other methods of applying heat and moisture, these being verv grateful to 
 the patient by relieving him of his suffering. The ice pack is indicated earlv 
 in the disease and then only for a very limited time. 
 
 The large bowel should be kept emptv by means of colonic flushings. 
 Much relief is also afforded by stomach lavage, and it is a good routine 
 practice to wash out the stomach regularly. Patients who have had their 
 stomach washed out will frequently ask to have the procedure repeated be- 
 cause of the relief it gives them. The medical treatment usually is just as 
 successful as is the surgical. 
 
 In post-operative peritonitis the infection that causes the peritonitis has 
 been carried into the abdomen either by the operator or his assistants, or bv 
 the materials that were used during the operation. The only surgical treat- 
 ment in this condition is to open the abdomen and drain. When the patient 
 has a temperature and complains of local pain in the wound and tenderness 
 in the abdomen, with muscular rigidity, a rapid pulse, and a flushed face ; 
 on about the third day after the operation, the wound should be explored by 
 removing a stitch or two and inserting the gloved finger into its very depths. 
 The peritoneum is thus given an opportunity to take care of the germs that 
 are invading it, provided they are directed into another channel, and that is. 
 outward by drainage. 
 
 Of course, this procedure will have a tendency to nullify the radical 
 
l80 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 Operation for the cure of hernia, but infection is one of the causes of recur- 
 rence of the hernia and when it is present it is well to recognize the fact that 
 drainage is imperative, even at the risk of iiaving a recurrence of the hernia. 
 
 The most dangerous form of peritonitis associated wath hernia is that 
 which affects the Iood of bow^el that was strangulated after it is returned 
 within the abdomen and the rush of blood into it is so great as to cause a 
 local peritonitis which, according to the nature of the germs causing it, may 
 or may not become general. In the case of a peritonitis that comes on after 
 an operation for a hernia that was not strangulated, I cannot see very much 
 to justify opening the abdomen, washing out the peritoneal cavity, breaking 
 down adhesions, thus spreading the inflammation and hurrying the death 
 of the patient, unless it is done before the expiration of the first three days 
 of the disease, because after that any interference is useless. 
 
 I recollect operating on a young woman in the Winnipeg General Hos- 
 pital, in 1889, removing a dermoid cyst. The operation was a simple and 
 an easy one, and I had no anxiety whatever about the case, but immediately 
 following the operation severe gastro-intestinal disturbances manifested 
 themselves. Within forty-eight hours the temperature rose to 103'' F., the 
 pulse was 120, the face was flushed, there was vomnting and distention, and 
 all the characteristic sym.ptoms of peritonitis rapidly coming on. I inquired 
 about the materials that were used during the operation, and learned that 
 two extra sponges had been used, the asepticity of which could not be 
 vouched for. At two o'clock in the morning I opened the abdomen again, 
 and found the intestines congested, wuth flakes of lymph floating in the fluid 
 present inside of the abdomen. The small intestine imimediately above the 
 brim of the pelvis was involved quite extensively. The perit-oneum was not 
 yet denuded. I washed out the abdominal cavity with a considerable quan- 
 tity of plain sterile water, and finished the flushing with a couple of pitchers 
 full of normal salt solution. I left the abdomen full of the salt solution and 
 closed the wound with through-and-through sutures. Six hours afterward 
 the lady was free from pain and the abdomen was flat. All the fluid had 
 been absorbed and the temperature had fallen to 100° F. Immediately after 
 the washing out of the abdomen the temperature rose to 105'^ F., but fell 
 subsequently, as stated. The patient made a perfect recovery, the reason 
 being, of course, that the peritoneum was not destroyed by the inflammation. 
 
 The simple irrigation of an infected peritoneal cavity is worthless. If 
 anything at all is to be done in the nature of cleansing the peritoneal cavity 
 it must be done by flushing, pouring the fluid from a pitcher or carrying it to 
 the furthest parts of the abdominal cavity through a tube an inch in diame- 
 ter, and to be of benefit this must be done early in the course of the disease. 
 
 The practice of evisceration and flushing for the treatment of peritonitis 
 is accompanied by a great deal of shock. It lessens the vital powers of the 
 patient very much, and it should not be done in cases of post-operative peri- 
 tonitis. 
 
 If the abdomen is opened and accumulations of fluid or pus are found 
 in different parts of the cavity, the patient should receive the benefits of 
 drainage of those parts, Douglas' pouch, Morrison's pouch, the kidney re- 
 
PLATE XXIX. 
 Halsted's Operation for Ini^uinal Hernia. 
 
COMPLICATIOXS IXCIDEXT TO THE RELIEF OF HERNIA 183 
 
 gion, or wherever the accumulation happens to be. A drain should be in- 
 serted through a separate incision in the abdominal wall, taking the most 
 direct route. 
 
 Strangulation of the bowel following a localized peritonitis, post-opera- 
 tive or otherwise, should be treated by laparotomy, if the patient's condi- 
 tion will permit of it. If not, the bowel may be drained, a simple enterostomy 
 being performed on tbe most distended portion. This can be done under 
 local anesthesia. A self-retaining catheter is pushed through an opening in 
 the bowel and circular stitches are applied. If there is any complication in 
 which the surgeon is justified in doing anything, it is peritonitis, and every- 
 thing that promises the slightest opportunity of improvement to the patient 
 should be emplo3'ed. 
 
 Immunizing injections for the prevention of peritonitis liave been prac" 
 tised. This is a step in the right direction. When resection of bowel is 
 demanded in hernia, fatal peritonitis occasionally developes in spite of all 
 precautions and the degree of the infection overcomes the resistance of the 
 peritoneum. Since we cannot be certain of asepticity in intestinal anasto- 
 moses, it would appear that should something be found that would, when in- 
 jected into the circulation, aid the peritoneum in overcoming the bacteria 
 invading it a very valuable advance would be made. 
 
 It has been observed (Salieri) that normal saline solution injected in 
 small quantities increases the normal resistance of the peritoneum from 
 seven to sixteen fold against bacillus coli infection. Mikulicz-Radecki (West 
 London Med. Jour., July i, 1904) first demonstrated that hypodermic injec- 
 tions of 0.5 per cent, neutralized nucleinic acid produce artificial hyperleu- 
 cocytosis of bactericidal value, and increase the normal resistance of the 
 peritoneum from sixteen to twenty times. When repeated injections were 
 made intra-peritoneally. the increase was as high as forty times the natural 
 resistance. Robson {International Medical Annual, 1906, p. 361 ), as a pre- 
 paratory measure for operations on the gastro-intestinal tract, savs, "As a 
 rule 50 c. c. of a 2 per cent, solution was used. The adult man received 
 about I gram of nucleinic acid to 75 kilos of the body weight. Fiftv -eight 
 cases were treated in this way. In fifty-five the operations were abdominal. 
 In four cases the operations were postponed so that they did not take place 
 until more than thirty- four hours after the injection was given. As in ani- 
 mals there was constantly observed in man a hyperleucocytosis in the blood, 
 mostly preceded during the first hour or so by h}-poleucocytosis. The opera- 
 tions were mostly performed in from thirteen to nineteen hours after the in- 
 jection. The optimum for nucleinic acid injection is reached in animals in 
 seven hours, but it seems to occur in man considerably later. Twelve hours 
 is the time fixed by experience, which enables the surgeon to operate on the 
 rising tide of leucocytosis." 
 
 On page 2^2, he says, "The general impression gained from this method 
 is that while it gives no absolutelv certain immunization, it increases the 
 natural immunity and that the cases treated by it have given more favorable 
 results both as to ultimate recovery and smooth convalescence, than cases 
 where the operations were performed without this preparation." 
 
184 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 Arndt {Ceiitr. f. Gyu., March 5. 1904 j, after three years' experience, 
 recommends eserine sahcylate, 0,001 gram hypodermically, for post-opera- 
 tive intestinal paralysis. He has not used more than 2 mg. in 24 hours. If 
 the drug is not effective microbic infection is most likely present. It begins 
 to cause peristalsis in from 15 to 30 minutes, as is evidenced by borborygmi 
 and, finally, in about an hour by the passage of flatus. Eserine may be used 
 in doses of 1-40 of a grain. It is a spinal depresso-motor and counteracts the 
 inhibitorv reflexes of the splanchnics present in intestinal paralysis follow- 
 ing operations. Manipulations of tlie intestines necessarily carried out at 
 operations stimulate the splanchnic nerves to produce reflex inhibition along 
 the whole intestinal canal and paralysis is the result. 
 
 PNEUMOCOCCUS PERITONITIS. 
 
 This may occur after operation involving the peritoneum. Mathews 
 {Ann. Surg., Nov., 1904) reports live cases. Jensen records 106 cases of 
 pneumococcus peritonitis. Several observers have seen about half a dozen 
 cases. It may be much more frequent than is supposed. The only way to 
 determine the special cause of peritonitis is by means of a bacteriological ex- 
 amination of the inflammation products. The pneumococcus infects other 
 structures of the body more frequently than it does the peritoneum. In per- 
 sons dying of pneumonia (pneumococcus) Netter, Flexner, and others, have 
 regularlv demonstrated this germ in cover-slip preparations from the perito- 
 neum and no evidence of peritonitis. In peritonitis the pneumococcus was 
 found in 7 per cent. (2 cases in 140, Netter). It is more frequent in chil- 
 dren (2 to i). Mixed infection is rare. 
 
 The pathologic appearance is characterized, as in empyema, by an ex- 
 tremely fibrinous and odorless greenish yellow exudate. Large loose masses 
 of fibrin are often found floating in a liquid or semi-solid exudate. When 
 the inflammation is general the thick, fibrinous lymph covers the entire sur- 
 face of the peritoneum. The usual tendency of the process is to terminate in 
 localized abscesses with very thick walls. Some of them have been known 
 to rupture spontaneously even through the skin. Robson declares that 80 per 
 cent, of the patients ma}^ be expected to recover when the disease has be- 
 come localized. If the other form, (diffuse) is present there is no hope. 
 
 The majority of cases of pneumococcus peritonitis have been primary. 
 As might be expected pneumonia has developed secondarily. Although the 
 diagnosis has not been commonly made until the termination of the disease, 
 still its symptoms and course are quite different from other forms of peri- 
 tonitis. 
 
 Syiiipfor/is. Much prominence is given by observers to the sudden on- 
 set, early high fever, with vomiting, pain, tenderness on pressure and dis- 
 tention. The muscular rigidity, pain, and tympany are not comparatively 
 marked. In three or four days the vomiting usually stops, the temperature 
 falls and diarrhea, if not present from the start, as it sometimes is, comes on 
 with the amelioration of the above mentioned symptoms and signs. 
 
 Marked evidence of intra-abdominal exudates resembling a tense cyst 
 or cysts is next found. The high temperature returns, with morning and 
 
PLATE XXX. 
 Halsted's Operation for Ingumai Hernia. 
 
COMPLICATIOXS IXCIDEXT TO THE RELIEF OF HERXIA 187 
 
 evening remissions. The inflammation becomes localized. The surgeon 
 should not hesitate to at once drain the abscess or abscesses, as the case may 
 be. There are many avenues of infection. In one case the infection en- 
 tered through the wound, following a hernia operation (Jensen). Through 
 the intestinal tract secondary to intestinal ulceration (Flexner) or ulcer of 
 the stomach is another method of invasion ; or through the blood, or through 
 the diaphragm by extension from the thorax. 
 
 POST-OPERATIVE PYREXIA. 
 
 Post-operative pyrexia often occurs when bacteria are not an etiologic 
 factor. There are two distinct periods after operations when there may be 
 an elevation of temperature. One period is between the first and third days 
 and the other between the eighth and tenth. During the first period there 
 occurs what T call the primary fc7:cr. Von Bergmann and others designate 
 this as fermentation fever. It comes on soon after the operation and termi- 
 nates spontaneously within two or three days. I have seen an elevation in 
 temperature occur during the operation on cases of extensive hernia with 
 incarceration, or where there was much manipulation of the bowel. The 
 same thing occurs when extensive adhesions must be broken down. It is 
 certain that in cases such as these fermentation could not have taken place. 
 The fever must, therefore, be due to the absorption of fibrin and other pro- 
 teid substances. 
 
 An examination of the blood does not, as a rule, reveal any marked leu- 
 cocytosis, nor are bacteria found, either microscopically or in culture. 
 
 SECONDARY FEVER. 
 
 Secondary fever comes on usuallv about the eighth to the tenth day 
 after operation, especially in cases in which the omentum was removed ex- 
 tensively, or adhesions broken down, or vessels of considerable size ligated. 
 Apparently for no reason w^hatever the patient becomes feverish, his temper- 
 ature rises to 99'^ or lOQ-' F., or even up to 103". Within twenty-four to 
 forty-eight hours the fever subsides spontaneously. 
 
 This elevation of temperature is usually ascribed to an indiscretion in 
 the diet, to exposure, to too much mental excitement, etc., but secondary 
 fever occurs in patients v/hen no cause whatever is discoverable. 
 
 An examination of the blood, fails to reveal any bacteria, but sometimes 
 a marked leucocytosis is present ; so that some other explanation of the fever 
 must be sought for. I am of tne opinion that the fever is due to the absorp- 
 tion of thrombi and emboli which are undergoing fatty degeneration. The 
 organization of a clot is often accompanied by an elevation of the tempera- 
 ture. This phenomenon ip not always accompanied by chills or by other 
 symptoms of inflammation. 
 
 SEPTIC INTOXICATION. 
 
 Patients suffering from strangulation of the bowel, local peritonitis, or 
 abscess may have an increased temperature during the operation. This tem- 
 perature is due to the absorption of pus either by the peritoneum or by the 
 
 >. 
 
l88 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 wounded tissues. This septic intoxication is very noticeable in gynecologic 
 surgery. 
 
 Although auto-intoxication may be said to be a variety of septic intoxi- 
 cation, there is a difference between the two, particularly in cases of stran- 
 gulated hernia, although these terms are used interchangeably. The patient 
 may die from the absorption of toxins in the alimentary canal, even though 
 there may have been no peritonitis following the operation. Particular 
 stress was laid on this by the late Greig Smith. 
 
 Auto-intoxication from this cause may occur either immediately fol- 
 lowing the operation done to relieve the strangulated bowel, or it may not be 
 manifested until the end of a week or ten days, when the bowel again be- 
 comes active. 
 
 Sapremia may follow a hernia operation, and the germs causing it may 
 have been implanted in the wound by the operator. This condition is also 
 known as septic or putrid blood poisoning. It is invariably caused by 
 the entrance into the blood of the toxins produced by putrefactive bac- 
 teria. There are no germs to be found in the blood. Leucocytosis, if present 
 at all, is slight. The patient usually recovers within a day. There are cases 
 on record, however, where the poisoning is so violent that the patient suc- 
 cumbs. 
 
 SEPTICEMIA. 
 
 Septicemia has also been known to occur after hernia operations. It is 
 caused by the absorption into the blood of pathogenic bacteria and their 
 products. The condition is manifested by chills, fever, sweating, rapid pulse, 
 increased frequency of respiration, flushing of the face, etc. Except when 
 the causative germ is extremely virulent, when death occurs within twenty- 
 four to forty-eight hours, there is always a leucocytosis. Although the 
 germs are always contained in the circulating blood, it is not always possible 
 to find them, except when cultures are made. 
 
 The most severe forms of septicemia are those caused by the strepto- 
 cocci, because they continue to elaborate their toxins in spite of the bacteri- 
 cidal action of the blood serum. 
 
 Septicemia may :dso be caused by other bacteria such as the staphy- 
 lococcus pyogenes aureus and the bacillus acrogenes capsulatus (Welch), 
 which is the specific cause of a particularly virulent form of septicemia al- 
 most invariably causing death of the patient. The pneumococcus and the 
 members of the colon group of bacilli are not so fatal in their results. 
 
 The treatment of this condition consists in thorough and speedy elimi- 
 nation by kidneys, bowels and skin, and supporting the strength of the pa- 
 tient with stimulants. The antistreptococcus serum so far has proven a 
 failure for obvious reasons. 
 
 PYEMIA. 
 
 Pyemia is a form of septicemia with the accumulation of necrotic ma- 
 terial in different parts of the body in sufficient quantity to cause the forma- 
 tion of local abscesses. 
 
PLATE XXXI. 
 Halsted's Operation for Inguinal Hernia. 
 
COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA I9I 
 
 PLEURISY AND BRONCHITIS. 
 
 Pleurisy and bronchitis are two conditions that have been known to fol- 
 low operations for the cure of hernia, but not any more frequently than after 
 operations done for the relief of other conditions. 
 
 PNEUMONIA. 
 
 A number of operators have pointed out that pneumonia occurs not in- 
 frequently after operations done for the relief of hernia, especially when 
 ether was the anesthetic used. Kelly met with only one case of pneumonia 
 following chloroform anesthesia, but he has seen six cases following the use 
 of ether. Bull reports five cases of pneumonia with one death. Other op- 
 erators have informed me that they have met with post-operative pneumonia 
 in about the same proportion of cases. 
 
 In looking over my operative work of all kinds done since 1887, I find 
 that I have seen only one case of post-operative pneum.onia. This occurred 
 in a man, 65 years of age, who had a double hernia, one side being strangu- 
 lated and the other incarcerated. He had also been the subject of a very se- 
 vere bronchitis for a number of years. I have always made it a rule to give 
 my patients the best of care before, during and after the operation, and to 
 this, I think, may be ascribed the infrequency of the occurrence of post-oper- 
 ative pneumonia in my work. 
 
 Post-operative pneumonia is due to (a) exposure, which lowers the 
 vitality of the patient; (b) the irritating effects of the anesthetic, particu- 
 larly when ether is used; (c) the inspiration of mucus, blood or other fluids, 
 producing what is known as an inspiration pneumonia, and (d) septic em- 
 bolus, which produces a form of pyemic pneumonia. 
 
 Many other septic complications have been met with in connection with 
 the surgery of hernia, such as phlebitis of the leg, abscess of the parotid 
 gland, dysentery, acute otitis media, erysipelas, infection of a hydronephro- 
 sis, etc. 
 
 NEPHRITIS. 
 
 Nephritis is one of the post-operative complications which often proves 
 fatal. Before operating on a hernia the condition of the kidneys should be 
 ascertained. A very excellent article on this subject by Flexner appeared in 
 the Journal of Experimental Medicine, Volume T, No. 3, 1896, in which was 
 presented a statistical and experimental study of terminal infections. In 
 793 autopsies Flexner found that 255 subjects had had chronic heart or kid- 
 ney diseases, or both. Of this number, 213 were due to bacteria, the infec- 
 tion being either local or general. 
 
 In anticipation of a disturbance of the kidney function after operation, 
 we frequently resort to hypodermoclysis of normal salt solution during the 
 operation. If before the operation the amount of urine secreted is less than 
 normal, and if the urine contains albumin and a few hyaline casts, it is ad- 
 visable to extend the time of preparation, postposing the operation until 
 such time as the urine is again normal. Of course in cases of strangulated 
 hernia this cannot be done. The operation must be performed irrespective of 
 the condition of the kidneys. 
 
ig2 COMPLICATIONS INCIDENT TO THE RELIEF OF HERNIA 
 
 After the operation has been performed, the function of the kidneys 
 must be watched carefuHy. If suppression of urine takes place, and is per- 
 sistent, it is advisable to do a nephrotomy on one kidney. Then the anuria 
 cannot continue. I have seen a patient live without any kidneys at all for ten 
 days. The woman had only one kidney and it became necessary to remove 
 that. I am convinced that some patients who die with symptoms simulat- 
 ing those of uremia are leally suffering from an infection, the uremic 
 s\-mptnms being due to the inabijity of the kidneys to eliminate the infec- 
 tion. 
 
 TJUmAUY FISTULA. 
 
 A urinary fistula is the direct result of an injury to the bladder. Not a 
 few cases are recorded in which the bladder was injured during an opera- 
 tion for the relief of an inguinal, femoral or a ventral suprapubic hernia. 
 These fistulas should be repaired immediately. There is no justification for 
 delaying the repair of a fistula. Any operator of ordinary skill and ability 
 can close one. I have had two cases referred to me for operation, and I saw 
 one case in consultation where the urinary fistula caused extravasation of 
 the urine with peritonitis and death. 
 
 FECAL FISTULA. 
 
 The occurrence of a fecal fistula after a hernia operation is sometimes 
 unavoidable, especially when the hernia has been strangulated. When a loop 
 of bowel is strangulated to the extent that its viability is in doubt, the rule is 
 to return the bowel to the abdominal cavity, because it is more likely to live 
 there than inside of the sac. It is surprising how many of these doubtful loops 
 of bowel cause no symptoms whatever after they are replaced in the abdomi- 
 nal cavity. But when such a loop of bowel is returned to the abdominal cavity, 
 the wound should not be closed, and in these cases it is bette~r to leave a con- 
 siderable portion of the sac protruding beyond the skin. This forms a nice 
 funnel for packing the wound with gauze, and it also serves as an exit for 
 fluids and other material. If the loop or a portion of it dies, a fecal fistula 
 forms. It is a well-known fact that the loop of bowel does not wander away 
 from the field of operation until such time as peristalsis returns. We 
 consequently take advantage of this and leave the suspicious loop of 
 bowel immediately beneath tiie opening. Tins does not prevent the oper- 
 ator from inserting all the necessary sutures for the closure of the abdo- 
 men a few days later. 
 
 A fecal fistula occurring in this manner in connection with a strangu- 
 lated hernia is unavoidable. Indeed, a fecal fistula may occur in con- 
 nection with resection of the bowel and anastomosis either by means of 
 mechanical appliances or with the needle and thread. If, after resecting 
 the bowel, symptoms arise pointing to a perforation, and these occur visu- 
 ally on the third or fourth day, the wound can be opened, the loop of bowel 
 always being easily accessible. In this way tiie occurrence of a general 
 peritonitis is prevented, and the life of the patient may be saved. 
 
 A fecal fistula may also be caused by the accidental wounding of 
 the bowel during operation, either because the surgeon is not sufficiently 
 
COMPLICATIONS IXCIDEXT 'JO TlIK RELIEF OF HERXIA IQJ 
 
 familiar with the conditions present, or because he is not possessed of suffi- 
 cient skill. 
 
 ACTINOMYCOSIS. 
 
 In the autumn of 1898 I operated on a case of double oblique in- 
 guinal 'hernia with strangulation on the right side. For sutures I used 
 catgut which was furnished by the hospital authorities. About two or 
 three weeks after the operation the ray fungus appeared in. the scar. The 
 interne mistook it for an ordinary skin infection and dressed the wound 
 for several days before calling my attention to it. The peculiar appearance 
 of the wound and its secretion at once aroused m.y suspicion and a micro- 
 scopic examination showed the infection to be one of actinomycosis. I 
 immediately operated again and removed all the diseased structures, leav- 
 ing only the peritoneum and transversalis fascia to protect the bowels. 
 I also gave the patient rather large doses of iodide of potassium. 
 
 In spite of all I could do, the infection extended to the bow'el, and a 
 small fecal fistula developed. I repaired the fistula, but it reappeared 
 later. The man was sent to the almshouse, with a large pad over his abdo- 
 men, and for four or live years afterward, whenever I W'Cnt there to oper- 
 ate, he would be one of the first to greet me, show me the fistula, and tell 
 me that it was my fault. When I last saw him he still had a small fistula, 
 from which there came a slight discharge of fiuid, but there was no evi- 
 dence of the presence of the actinomyces. 
 
 The source of the infection in this case is still a mystery to me, 
 but I have always suspected that the catgut sutures used during the oper- 
 ation were responsible. 
 
 COPROSTASIS. 
 
 Obstruction of the fecal flow during the existence of a hernia is not 
 uncommon, especially in old, incarcerated cases. The onset of the ob- 
 struction is usually insidious. The patient may notice that the hernial 
 tumor is slightly increased in size, and on manipulation it feels quite 
 doughy. The hernia continues to increase in size until a regular train 
 of symptoms makes its appearance, such as meteorism, colic, nausea, vomit- 
 ing, and local tenderness. The vomiting may become fecal in character. 
 The local application of hot fom.entations, gentle massage,- and emptying 
 the lower bowel may re-establish the fecal flow% and the patient is then 
 in the condition in which he was before this complication occurred. Som.e- 
 times, however, strangulation may occur, and an operation be necessary. 
 
 Besides these more common complications, others are met with oc- 
 casionalty. For instance, Neugebauer {Centralbl. f. Innere Med., Nov. 21, 
 1896) reports a care of incarcerated inguinal hernia in which he discovered 
 a temporary glycosuria. The sugar was present both before and after the op- 
 eration, although the patient denied ever having had any symptoms of 
 diabetes. The glycosuria was present for only twenty-four hours. Ex- 
 periments on animals showed that incarceration or obstruction of the 
 duodenum or jejunum or other part of the intestine from any cause, may 
 produce a temporary glycosuria. 
 
CHAPTER XVII. 
 
 GENERAL COMPLICATIONS FOUND AT THE OPERATION. 
 
 The complications that have been encountered during operations for 
 hernia are so numerous that space forbids mentioning more than a few of 
 them. Every surgeon has encountered these compHcations, although ref- 
 erence is not always made to them in the literature. 
 
 W. G. Spencer (Lond. Clin. Soc. Trans., Vol. 30) rejaprts .two cases 
 in which there was an absence of the internal ring,, the deep epigastric 
 artery Iving in front of the hernia. Above the pubic spine there was an 
 extra-peritoneal protrusion of the bladder which was closely adherent to 
 the sac. In both cases the hernia was quite separate from the cord and 
 testicle. One patient was aged three years, the other nineteen. Both were 
 males. In the first case the sac contained fluid and omentum. The site 
 of the internal ring was occupied by a slit-like opening extending into the 
 abdomen the whole length between the pillars. The sac was separated 
 easilv from the cord, but attached to it on one side appeared a translucent 
 swelling which in the attempt to separate it from the sac was ruptured, 
 and urine escaped. It was composed of mucous membrane, except at its 
 neck, through which the finger was passed into the bladder. The bladder 
 pouch and the hernial sac were ligated and cut away and the wound filled 
 with gauze. The pati-ent recovered. In the second case the sac contained 
 omentum, which was firmly adherent to the inner surface of the sac. No 
 internal ring or line of demarkation could be found between the sac and 
 the abdominal cavity. 
 
 C. Goulding Bird {Trans. Clin. Soc. of Lond., Vol. 17) reports two 
 cases of hernia en bissac. 
 
 The first patient, aged 47, apparently had a strangulated hernia on the 
 right side. The tumor occupied the upper part of Scarpa's triangle, like 
 an ordinary femoral hernia, but from it a diverticulum passed down into 
 the adjacent labium. Both sacs were dissected out and found to have a 
 .. - . ^, common neck. The second patient, aged 60, had had a left inguinal her- 
 KT V nia for twenty years. She wore a truss for ten years, when, thinking 
 herself cured, she discarded the truss. For eight years she had attacks 
 of vomiting. She then noticed a swelling in the left iliac region, which 
 increased in size, causing considerable discomfort, but no constitutional 
 symptoms. Examination revealed two tumors, one protruding from' the 
 left external abdominal ring, of small size, and a large mass extending 
 four inches above Poupart's ligament subcutaneously. The two sacs had 
 a common neck at the internal abdominal ring. Nothing could be differ- 
 entiated of the aponeurosis of the external oblique in front of the large 
 hernia, it having been destroyed, apparently, by the pressure of the her- 
 
 Cn 
 
y^-^C.^fter^Ji^rodel 
 
 PLATE XXXII. 
 
 Halsted's Operation for Inguinal Ifernia. 
 
GENERAL COMPLICATIONS FOUND AT THE OPERATION I97 
 
 nial sac which lay external to it. The patient died in two days. No cause 
 of death was discovered. 
 
 T. H. Kellock (Lond. Clin. Soc. Trans., Vol. 33) reports a case of 
 stricture of the small intestine following a strangulated hernia in a boy 
 who had been suffering from an irreducible left mguinal hernia of about 
 the size of an orange. The hernia did not extend into the scrotum. The 
 right testis was in the scrotum, but the left could not be felt. The sac 
 did not contain fluid, but was occupied by a small piece of discolored 
 omentum, and about four and a half inches of small intestine, which was 
 almost black. The testicle was small and undeveloped. There was a good 
 deal of fluid in the tunica vaginalis which did not communicate with the 
 abdominal cavity, or with the sac of the hernia. The cord was ligated and 
 the testicle removed. The inguinal canal was closed with two silk sutures - 
 and the skin wound united with horsehair. Thirteen days after the opera- 
 tion the abdomen was a little distended and slightly tender. These symp- 
 toms disappeared after proper catharsis. During the next three weeks 
 the boy suffered at times from pain in the epigastrium, and on several 
 occasions vomited undigested food. It was thought the trouble was due 
 to adhesions about the bowel. One month afterward the abdomen was 
 opened, and a distended, hypertrophied intestine presented immediately. 
 There was no peritonitis. Lying in the right iliac fossa was a loop of small 
 bowel to which a tongue-shaped piece of omentum containmg large ves- 
 sels was closely adherent. A lateral anastomosis above and below the 
 stricture was made by Halstead's method. The patient died fifteen hours 
 afterward. The loop of the intestine which the anastomosis was designed 
 to put out of action was gangrenous. On opening this part of the bowel 
 an annular stricture w^as found at the apex of the loop almost completely 
 obstructing the lumen and involving about half an inch in length of the 
 bowel. The tongue-shaped piece of omentum was adherent to the bowel 
 immediately distal to the stricture. The hernia m this case appeared to be 
 an acquired one. 
 
 Marshall examined the records of ten thousand cases of hernia and found 
 that nine hundred of them had been complicated by an undescended testis. 
 Coley found four hundred such cases among 9,859 cases of hernia. Eccles 
 found 854 instances among 48,000 cases of hernia. 
 
 According to Odiorne and Simmons, sarcoma of the testes occurred 
 in II per cent, of the cases. 
 
 The conjoined tendon has been found obliterated in 27 out of 366 a ^ 
 cases, or 7 per cent. In 12 cases in which the conjoined tendon was ah- ^ 
 sent, recurrence of the hernia took place in 7, or over 50 per cent., thus 
 emphasizing the importance of knowing where the conjomed tendon is 
 and how to protect it. 
 
 Obliteration of the conjoined tendon occurs in the female about once 'X- '" 
 in 38 cases ; in the male, in about 50 per cent, of the cases. 
 
 Bloodgood records having met with the following complications : 
 Albumin and casts ; obstruction, temporary and permanent ; scrotal ab- 
 scess ; atrophy of the testis ; hydrocele ; emphysema of the wound. 
 
198 GENERAL COMPLICATIONS FOUND AT THE OPERATION 
 
 Although resection of a portion of the bowel often is necessary in 
 operations on hernias, it is not to be considered as a complication in the 
 true sense of the word. However, every now and then one meets with 
 a case where a large portion of bowel must be resected before it is possi- 
 bl to reduce the hernia. The bowel in these instances is normal in every 
 respect. For instance, A. B. Mitchell {British Medical Journal, Sept. 27, 
 1902) reported the case of a man, aged 57, who was operated on for a 
 long-standing, irreducible hernia, which had given rise repeatedly to symp- 
 toms of obstruction. Because of its size the hernia could not be reduced. 
 Mitchell resected all of the intestine contained in the sac, which was found 
 to measure six feet. 
 
 Monprofit {Revue de Chirurgie, November, 1899) reported a case of 
 inguinal hernia where during the operation it was found impossible to 
 separate the hernial contents and reduce the mass, tie resected seven 
 feet and six inches of the small intestine, and thirty-two inches of the large 
 intestine, the resected piece consisting of ileum, cecum, ascending colon and 
 half of the transverse colon. A curious fact in this case was that after 
 the patient recovered he was unable to digest meat. 
 
 Many similar instances have been recorded, but these two will suf- 
 fice to direct attention to the fact that in order to reduce a hernia it may 
 be necessary to resect a portion of the bowel. 
 
 Perforations of the bowel contained in the sac of a hernia have oc- 
 curred quite frequently, and this emphasizes the importance of examining 
 carefully all the intestine contained within. the sac before it is returned to 
 the abdominal cavity. 
 
 Corner {Trans. Loud. Clin. Soc., Vol. 36) reports a case of cellulitis 
 of the round ligament which was mistaken for a strangulated hernia. For 
 four or five days the woman complained of pain in the left groin, and a 
 small tumor was palpable. The pain increased in severity and there was 
 some vomiting and constipation. The tumor became exceedingly tender to 
 touch. It was situated over the external abdominal ring and gave an im- 
 pulse on coughing. There was a healthy round ligament at the internal 
 ring, but no sac. The round ligament in the canal was very much thick- 
 ened, and evidently inflamed. Examination of the incised mass disclosed 
 a lymph gland breaking down in the center, with surrounding cellulitis. 
 
 Corner {Id. ) also reported a case of atrophy of the testis following 
 a kick in the groin which gave rise to cellulitis with thrombosis in the veins 
 of the cord. The case was mistaken for one of strangulated hernia. 
 
 A. E. Halstead, of Chicago, reported a case of hydrocele of the canal 
 of Nuck, which simulated a hernia. Of course, this is not a complication 
 of hernia, but it is quite possible that it might give rise to hernia, and hydro- 
 cele may exist with a hernia. 
 
 Another very interesting case is the one reported by F. R. McCreery 
 {Medical Record, Sept. 9, 1906), where a suppurating omentum was mis- 
 taken for hernia. About five or six months after the patient had been 
 kicked by a horse in the right lower quadrant of the abdomen, a lump 
 appeared in the right inguinal region. When McCreery first saw the pa- 
 
GENERAL COMPLICATIONS FOUND AT THE OPERATION 
 
 199 
 
 tient he diagnosed the case as one of irreducible omental hernia with a 
 scrotal abscess distinct from the hernia and of unknown origin, but pos- 
 sibly tuberculous. At the operation a number of small collections of pus 
 were found. The pus was odorless and no tubercles were observed. The 
 entire mass of omentum seemed to be riddled with abscesses. About six 
 months after the operation a small hernia presented at the internal ring. 
 It was operated on successfully. 
 
CHAPTER XVIII. 
 
 RESILTS OF HERNIA OPERATIONS. 
 
 It is difficult to accurately estimate the ultimate results following 
 operations for- the cure of ■hernia. The skill and the diagnostic acumen 
 of the operator count for so much in determining these results. It is obvious 
 that the results of a poor operator cannot be as good as those of one who 
 is skilled. Furthermore, the operation done in a given case may not have 
 been the operation that was most suited to the case or that was indicated. 
 Thereby the results would be influenced very markedly. The results of any / 
 one operator are insufficient to draw conclusions from, because the same I ^ 
 operation done in similar cases by another surgeon would not be fol- ' 
 lowed by the same results. Therefore, in attempting to draw any conclu- 
 sions as to the value of an operation, it is necessary to consider the results 
 obtained by 'vcry many operators with all kinds of operations done on all 
 kinds of cases. A mass of statistics is often misleading. 
 
 Hilgenreiner (Beitrdge zur Klinische Chirurgic, 1903-4, Bd. 12) re- 
 ports 828 operations performed in Woelfler's clinic at Prague, from 1895 
 to 1902, on 770 patients. Of this number, 471 were free hernias, and 357 
 were strangulated. For the non-strangulated inguinal hernias, 446 opera- 
 tions were performed on 397 patients, while for femoral hernia 15 opera- 
 tions were performed on 13 patients. 
 
 The wound was closed in various ways. In 33 cases the cord was 
 transplanted into a slit in Poupart's ligament (Frey's method) ; in 17 
 cases a simple approximation suture (Czern3^-Banks) was used; in a very 
 few cases Bassini's method was employed and all the remaining cases 
 were operated on by Woelfler's method. Hilgenreiner points out the dif- 
 ference between the technic of Woelfler's operation and that of Bassini. 
 It is surprising with what facility some surgeons, from a lack of due con- 
 sideration of the principles involved, make unsupportable statements re- 
 garding operative procedures. No less an authority on hernia than Wil- 
 liam B. Coley, of New York, says {Progressive Medicine, June, 1905, page 
 25) that "In 125 cases the cord was not transplanted, but brought out at 
 the lower angle of the wound, and the external oblique being sutured to 
 Poupart's ligament, exactly the same as in inguinal hernia in the female. 
 This method is known in Germany as Woelfler's method without trans- 
 plantation of the rectus muscle. In this country it is frequently known 
 as Ferguson's method. W^oelfler's cases were not reported until 1895 ; 
 Ferguson's in 1899." Let us follow this statement farther. 
 
 On page 514, Vol. IV, System of Practical Surgery, by E. von Berg- 
 . mann, the only mention made of Woelfler's operation in connection with 
 
PLATE XXXIII. 
 Halsted's Operation for Inguinal Hernia. 
 
RESULTS OF HERNIA OPERATTONS 
 
 20' 
 
 hernia is, "In the course of time Woelfler passed the testicle through the 
 space between the two recti muscles." 
 
 No other author, even in Germany, makes any mention of Woelfler's 
 operation in connection with the cure of oblique hernia. 
 
 In the Reference Handbook of the Medical Sciences, Vol.' IV, page 
 674, 1902, in speaking of Bloodgood's method, this statement is made : 
 ''This method is superior to Woelfler's in that Woeltler slits the ventral 
 sheath, thus destroying the insertion of the internal oblique and trans- 
 versalis muscles at that point." 
 
 If what Coley says is true, then his procedure and that of Woelfler 
 are the same as mine, but I have failed to find a corroboration of Coley's 
 unqualified statement. 
 
 I believe that since 1902 Woelfler does not transplant the cord, but 
 leaves it in its normal position, strengthening the anterior wall of the canal 
 by utilizing the rectus muscle. I do not do this for oblique hernia when 
 there is a normal conjoined tendon. 
 
 In the 33 cases reported by Hilgenreiner that were operated on ac- 
 cording to the method of Frey and Czerny-Banks, there were 7 relapses, 
 and in 94 cases operated on by the Woelfler method, without the use of the 
 rectus, there were eight relapses. Coley does not appear to grasp the vast 
 difference between the principles and practices involved in the Czerny- 
 Banks operation (leaving the cord m its normal bed) and my operation 
 (also leaving the cord undisturbed). 
 
 Transplantation of the cord is ably dealt with by Connell {American 
 Journal of the Medical Sciences, March, 1905), who considers the author's 
 view the correct one — namely, that the cord should not be raised out of its 
 bed. Halsted, of Johns Hopkins Hospital, has discarded the transplanta- 
 tion of the cord. It is stated by Connell that Woelfler, in 1892, was prob- 
 ably the first to suggest that a radical cure might be effected without trans- 
 plantation of the cord. E. W. Andrews, in 1895, suggested such an oper- 
 ation, but did not recommend it. In 1S99 the writer presented his method, 
 which he had performed 64 times during the previous eighteen months. 
 
 Connell gives his reasons why the cord should not be transplanted, 
 while Coley {Progressive Medicine, June, 1906) tries in vani to offset 
 these. In support of his views, Coley says that the only reason whv the 
 Bassini operation should be discarded in favor of that of the author Avould 
 appear to be "the final result". Coley says that at the Plospital for Rup- 
 tured and Crippled Children, in New York, there was only one per cent, 
 of relapses in over seventeen hundred cases operated on. This is the best 
 apparent result ever obtained following Bassini's operation, and the rea- 
 son is that nearlj_aji,i;h.ese operations were done on children under four- 
 teen years of age, and by one operator. The results obtained from the 
 "writer's -operation are -.supeirior to those quoted by Coley, and this is par- 
 ticularly noticeable in view of the fact that the results are obtained after 
 operations done on both die young and the old by more than one operator. 
 
 In 446 cases operated on by the Bassini method and reported by Gold- 
 ner, there were 7.1 per cent, of relapses, all of them in adults. In 1,713 
 
' { 
 
 204 RESULTS OF HERNIA OPERATIONS 
 
 cases operated on by the same method and reported by Pott, there were 
 9.9 per cent, of relapses. In 450 cases of inguinal hernia occurring- in 
 adults and reported by Coley, there were 7 relapses, 1.4 per cent. Canister 
 reports 3 per cent, of relapses in 100 cases. 
 
 Pott collected the statisiics of 151 operators who employed the meth- 
 ods of Bassini and Kocher; and operated on all kinds of hernias and found 
 that there were 96.4 per cent, cures. He gives a mortality of 0.7 per cent, 
 in 2,401 cases operated on since 1895. In 86 cases Halsted had 9.3 per 
 cent, of relapses, 8 of these occurring at the position of the cord. The 
 veins were not removed in these 86 cases. In 712 cases operated on accord- 
 ing to the Bassini method {Laitcct, April, 1906), there were 2.9 per cent, 
 relapses. De Garmo reports 2.4 per cent, of relapses in 250 cases, while 
 Hutchison reports 6.5 per cent, of relapses in 500 cases. Thus it will be 
 seen that in 4,257 cases operated on by the Bassini method, there were 
 5.3-j- per cent, of recurrences. 
 
 Deanesly (B. M. J., June 17, 1905) believes that the real cause of her- 
 nia lies in a congenital or pre-existing sac, and that the operation that 
 effectually removes the sac is followed by radical cure in 95 per cent, of 
 the cases. He believes that the method of Kocher is the simplest, the most 
 rapid and the easiest to perform, and it is the method he employed in the 
 I majority of his 142 personal cases. The ages of his patients varied from 
 three months to 70 years. There was one death, exclusive of strangulated 
 cases, occuring in an infant of eighteen months. Eleven of the operations 
 were for femoral hernia. Six relapses were noted, all within twelve months 
 after operation. 
 
 Of 299 cases traced by Hilgenreiner (Bcitr. z. kiin. Chir., Bd. xli, p. 
 373) that is, yy upward of one year, the remainder from two to seven, 
 years, 266 were permanently cured. In 28 a relapse was noticed. Among 
 33 patients operated on according to the methods of Frey and Czerny 
 there were 7 relapses. Among 94 patients operated on according to Woel- 
 fler's method, without transppsition of the rectus muscle, there were 8 
 relapses. Among 163 patients operated on by Woelfler's method with 
 transposition of the rectus, 1 t recurrences were noted. Of 4 Bassini opera- 
 tions done, 2 resulted in a relapse. Counting only the cases of those pa- 
 tients traced upward of two years ooerated on by Woeiller's method with 
 transplantatii m of the rectus, there were 98 with seven relapses, about 7.1 
 per cent. Fi < v's method was employed successfully without relapses in 
 15 cases of no" -strangulated femoral hernia. 
 
 W. T. Bull and W. B. Coley {Medical Record, Alarch 18, 1905) re- 
 ported 53,686 cases of inguinal and femoral hernia observed during the 
 period of fourten years, from 1890 to 1904. Of these, 50,961 were in- 
 guinal, and 2,725 were femoral hernias. One-third of these, 15,375, oc- 
 curred in children under fourteen. They performed fifteen hundred opera- 
 tions for the radical cure of herriia. JVith the e xcepii on of t-a'enty opera- 
 tions, all have been in children under the age of fouriecii year^\ The 
 operative cases, it is claimed, represent the worst cases of rupture, the 
 largest, and those of longest duration. There were 4 deaths in the 1,500 
 
PLATE XXXR'. 
 Fowler's Operation for Inguinal Hernia. 
 Deep epigastric vessels ligated and posterior wall of inguinal canal 
 
 livided. 
 
RESULTS OF HERNIA OPERATIONS 20/ 
 
 Operations, or a mortality of less than three-tenths of one per cent. Of the 
 1,500 operations, 1,435 were for inguinal hernia, 39 for femoral, 13 for 
 umbilical, 8 for ventral, 2 for congenital hernia of the umbilical cord, 2 
 for epigastric, and 1 for lumbar hernia; 13 were strangulated, and 1,487 
 were not strangulated. The great majority of operations for inguinal 
 hernia were performed according to Bassini's method, with the substitu- 
 tion of absorbable suture, kangaroo tendon, for silk. There were 6 re- 
 lapses among 1,076 Bassini operations, and 5 in 125 cases in which the 
 cord was not transplanted. 
 
 From a study of 91 operations done for various forms of hernia, O. 
 Horwitz concluded that no one method of attempt at radical cure is ap- 
 plicable to every variety of hernia. The Bassini method is suitable to a 
 large majority; the Bloodgood method in cases in which there is present 
 a large abdominal ring, or a weak or atrophied conjoined tendon. He 
 says that the relief of special forms and conditions depends on the ingenuity 
 of the surgeon in selecting the operation indicated by the conditions present. 
 
 John O'Connor {Lancet, May 31, 1902) reported 350 operations, 140 
 of which were done according to Halsted's method, 12 accordmg to 
 Kocher's, and 90 by Bassini's and other methods. He observed that atrophy 
 of the testes and orchitis frequently followed the Halsted method, and he 
 thinks the transplantation of the cord is very questionable surgery. In 
 his experience Kocher's method has given the best results. 
 
 In the Johns Hopkins Hospital Reports, Vol. VII, Bloodgood reports 
 on 459 operations done from 1889 to 1899. Of 268 cases in which a typical 
 Halsted operation was done, 242 healed by primary union. The result was 
 perfect in 208 cases, and there were only 6 recurrences and one death. 
 There was slight weakness and scar in four cases, and 25 were not traced. 
 There was only one complete recurrence after Halsted's operation Avhere 
 primary union took place. 
 
 Of 39 cases of inguinal hernia in the female operated on at the Johns 
 Hopkins Hospital, 11 were lost sight of, and in the remainder there was 
 only one recurrence. Between 1891 and 1900, Coley operated on 119 
 cases of inguinal hernia in the female, 71 of which occurred in children 
 under fourteen years of age, and not a single relapse was observed. 
 
 W. B. De Garrno, in 1901, stated that among 611 operations for in- 
 guinal hernia by Bassini's method, there were only 8 recurrences. In 
 Carle's clinic, from 1889 to 1899, 1,120 operations were done according 
 to Bassini's method, 280 according to Kocher's method. Of 840 cases 
 that were traced, only 48, or 5.71 per cent., showed a recurrence. 
 
 Galeazzi collected 1,334 cases operated on by Bassini's method, with 
 2.16 per cent, recurrence. Erdmann (Jour. Am. Med. Assn., Alarch 12. 
 1904) reported 26 cases of strangulation in inguinal hernia, with 5 dea.ths, 
 and G. T. Vaughan {Medical Neivs, December 24, 1904) reported 25 cases 
 with 6 deaths, a mortality of 24 per cent. At The Johns Hopkins Hospital 
 64 operations for strangulated hernia were performed from 1889 to 1899, 
 with 19 deaths, or 29.68 per cent, mortality. Gibson in his collective sta- 
 
208 RESULTS OF HERNIA OPERATIONS 
 
 listics covering ten years, from 1888 to 1898, reported 226 resections of 
 gangrenous intestines, with a mortality of 26 per cent. 
 
 As regards permanent results, that is, sound at least two years after 
 operation, O. Pott's statistics (Deutsche Zeitschrift fi'ir Chirurgie, Novem- 
 her, 1903") siiow 82 per cent, for inguinal hernia, 70.5 per cent, for femoral 
 hernia, and 55 per cent, for ventral hernia. 
 
 Adatanowitsch (Beitrdge zuv KUnische Chirurgie, 1902) publishes 
 a very interesting table of comparison of results of observations done by 
 Bassini's and Kocher's methods respectively. Of 2,032 cases operated by 
 Bassini's method, 74 relapsed, 3.6 per cent. Of 528 cases operated by 
 Kocher's method, 19 relapsed, 3.8 per cent. 
 
 '^. Goldner {Archiv f. Klin. Chir., Vol. 68, No. i) reports 800 opera- 
 tions done by Bassini's method. He found that in 466 of this number ex- 
 amined from two to six and one-half years after operation, there were 35 
 relapses, or 7.5 per cent. There v/ere 3 deaths among the 800 cases. 
 
 W. B. De Garmo reported no femoral hernias, 28 of which were 
 strangulated. Only i death occurred, the patient, a wom.an, aged 70, 
 having a strangulated hernia and an intestinal perforation. Exhaustion 
 was the cause of death. There was only one actual recurr(?nce, eight months 
 after operation, in a w^oman of 75. All of these patients were operated on 
 according to De Garmo's method. 
 
 A study of the results obtained by operation on 500 patients led Hutch- 
 ison to draw the following conclusions. 
 
 I. In all but the simplest cases in children it is best to open up the 
 canal and to narrow it by deep sutures ; 2, suturing the conjoined tendon 
 to Poupart's ligament behind the cord by a series of interrupted sutures 
 is probably the best method of narrowing the canal ; 3, when the con- 
 joined tendon is deficient, in all recurrent cases, and in inguinal hernia in 
 women the canal should be obliterated ; 4, kangaroo tendon is admirably 
 adapted for the suture material, silver wire being probably the worst; 
 5, recurrence of the hernia in situ may possibly take place at any length 
 of time after the operation, but if tAvo years be adopted as the limit it 
 should not occur in more than from 5 to 8 per cent. ; and 6, the develop- 
 ment of a hernia at another site after operation may be expected in a pro- 
 portion of cases at least as large as that just given. 
 
CHAPTER XIX. 
 
 RESILTS OF OPERATIONS FOR STRANGULATED 
 
 HERNIA. 
 
 Weyprecht {Archiv f. Klinische Chirurgie, No. i, Bd. Ixxi) reports 
 observations made from June, 1890, to June, 1900, at the City Hospital in 
 the clinic of Professor Korte. Of 402 cases treated, 70 were reduced with- 
 out operation ; 307 patients were operated on ; 4 were admitted moribund 
 and no operation was performed, and one patient died without operation, 
 a small strangulated femoral hernia having been overlooked. There were 
 57 dealhs among 397 cases of incarcerated hernia, a mortality of 14.4 per 
 cent. Of 254 non-gangrenous cases, 230 (90.6 per cent.) were cured; 
 23 of the patients died (9 per cent.), and one patient left the hospital im- 
 mediately after operation and was lost sight of. Of 73 gangrenous cases, 
 39 were cured (53.4 per cent.), and 34 patients died (46.6 per cent.). 
 
 Of 7 cases of strangulated hernia occuring in 5 males and 2 females, 
 aged six months, there were 2 fatalities, 28.6 per cent. Among six pa- 
 tients, males, aged six months and ten years, there were no fatalities. 
 Among 61 cases of strangulation, occuring in 30 males and 31 females, 
 from II to 40 years old, there were two fatalities, 3.26 per cent. Am.ong 
 250 cases, occurring in 60 males and 190 females, aged from 41 to 80 
 years, there were 52 fatalities, 20.8 per cent. Of three females, over 
 eighty years of age, one died, a mortality of 33 1-3 per cent. 
 
 The total mortality after operation was 17.4 per cent.; loi deaths 
 occurred among men and 226 among women. Gangrene was present in 
 12 of the former and in 61 of the latter. The greatest number of deaths 
 occurred between the ages of 41 and 80 — 20.8 per cent (52 deaths out of 
 250 cases) ; 7 cases up to six months with two deaths; three over So with 
 only one death. 
 
 The fifth decade showed the largest number of operations — 81, vvith 12 
 deaths — 14.8 per cent. Incarcerated femoral hernia was observed more 
 frequently in women than in men — 174 against 18. Inguinal hernia oc- 
 curred twice as often in men as in women — yy to 36. The right side was 
 the seat of incarceration in 71 inguinal and 133 femoral hernias ; the left 
 in 42 inguinal and 70 femoral. Ninety-two (28 per cent.) of the patients 
 had worn a truss, while 42 (12.8 per cent.) were not aware of the pres- 
 ence of a hernia until strangulation occurred. Strangulation of two her- 
 nias in one person was seen once. The duration of the incarceration always 
 had an unfavorable effect on the result of operation. 
 
 With reference to the contents of the sac, omentum alone was found 
 ^^y times — in 17 inguinal and 20 femoral hernias. A loop of small intes- 
 
tine was found in 126 oases; several loops were found in 7 cases: Meckel's 
 diverticulum, twice: small intestine and omentum in 5 cases; large intes- 
 tine, once; large and small intestine, six times; large intestine and omen- 
 tum, twice; large and small intestine and omentum, once. Appendices 
 epiploic^ caused strangulation in four cases. The vermiform process had 
 become incarcerated in 12 cases. In nine of the latter the patients were 
 over 57 years of age, and in all of these hernia had been acquired late in 
 life. In 175 cases the patients made an uninterrupted recovery; in 32 
 complications arising from the respiratory organs were noted, with 5 
 deaths. Peritonitis was the cause of death in but i of 23 fatal cases. 
 In the majority of the cases death occurred not as the result of the opera- 
 tion, but in consequence of concomitant and unavoidable bodily conditions. 
 
 Regarding the contents of the hernial sac in the gangrenous cases, 
 the small intestine alone was found in 52 cases ; small intestine and omen- 
 tum in 15 ; omentum and large intestine, omentum, large intestine and 
 small intestine, small intestine and bladder in i case each. The vermiform 
 process was found 3 times. 
 
 Fuchsig and Haim {Deutsche Zeitschr. f. Chir., Vol. Ixix, No. 5 and 
 6) report 175 cases of strangulated hernia observed during ten years. Of 
 these 97 were inguinal ; 62 femoral ; 14 umbilical and i each obturator and 
 ventral. The presence of a congenital hernial sac could be proven in 17 
 cases of inguinal hernia. Of the inguinal hernias, 97 occurred in males and 
 7 in women ; femoral, 62 in women and 5 in men ; umbilical, 14 in women 
 and onlv i in a male subject. Incarceration was noticed on the right side 
 in 63 per cent, each of the inguinal and femoral hernias. In the great 
 majority of the cases the strangulation was primary, although in 20 in- 
 guinal, 7 femoral and 4 umbilical, repeated incarcerations had preceded 
 admission to the hospital. In only two (umbilical) had a radical operation 
 been performed previously. Thirty-seven cases w^ere cured by taxis. In 
 135 cases operation was performed, and in the majority of the inguinal 
 hernias Bassini's method was employed. Primary resection was done 14 
 times with a mortality of 54 per cent. (17 cases). Peritonitis was the 
 cause of death in all the fatal cases of resection. The total m.ortality was 
 20 per cent. — 35 deaths in 170 cases. Of these 135 were operated on, with 
 32 deaths — 23.7 per cent. Of the 37 cases in which taxis was employed i 
 died. Three patients refused operation. There were 70 cases of inguinal 
 hernia with 12 deaths (17.1 per cent.) ; 51 crural hernias, with 12 deaths 
 (23.5 per cent.) ; 13 umbilical hernias, with 7 deaths (53 per cent.) : one 
 case of obturator hernia with one death. 
 
 O. Pott {Deutsche Zeitschr. f. Chir., Nov., 1903) shows that the mor- 
 tality of all radical operations for hernia thus far performed is nearly i 
 per cent., 0.9 per cent., being the greatest in ventral hernia, w'hile in 
 inguinal hernia it is about the same as is the general mortalitv. The total 
 mortality for the last seven or eight years is far more favorable, being 
 but one-half of one per cent. ; the operations for femoral hernia showing 
 the greatest number of deaths. For inguinal hernia the mortality is two- 
 
PLATE XXXV. 
 
 Fowler's Operation for Inguinal Hernia. 
 
 Cord placed in peritoneal cavity and gap sutured. 
 
RESULTS OF OPERATIONS FOR STRANGULATED HERNIA 213 
 
 thirds of one per cent., instead of almost two per cent., as it was ni tlie 
 first two decades of modern surgery. 
 
 As regards the permanent results, that is, sound at least two years 
 after operation. Pott shows 82 per cent, for inguinal hernia, 70.5 per cent. 
 for femoral hernia, and 55 per cent, for ventral hernia. The results in 
 children (up to 14 years), including all varieties of hernia, were 560 per- 
 manent cures, 84 relapses, 4 doubtful — 96.4 per cent. In individuals over 
 fifty years of age, there were 259 permanent cures, 173 recurrences, to 
 doubtful — 58.6 per cent. 
 
 As to the best method of operatmg, Pott shows Kocher's transplanta- 
 tion method and the Bassini method to be about equally efficient. In 
 femoral hernia, ligature and extirpation of the sac and suture of the mouth 
 of the hernial ring have given the best results — 76.5 per cent. 
 
 AV. Thorburn {British Medical Journal, April 25, 1903) analyzed no 
 operations for strangulated hernia, in which the mortality was 24.54 per 
 cent. 
 
 Kennedy (B. M. J., Oct. i, 1904) gives the results of operation in 
 103 cases operated on more than a year ago; 96 of the patients v:ere males, 
 7 females. The youngest patient (for strangulation) was six months of 
 age, the oldest 74 years. Twenty operations were done in patients from 
 six months to three years of age. In 45.6 per cent, the sac was of the con- 
 genital type. Six cases were cecal hernias and one case was a hernia of 
 the ovary. There was only one death, occurring six weeks after operation 
 from tuberculous meningitis. 
 
 The older cases, 20 in number, were operated on after Macewen's 
 method; 11 were traced, w^ith two relapses. Seventy cases were operated 
 on by Kenedy's method ; 54 were traced from one to five years, with only 
 I relapse. 
 
 The late Dr. T. H. Alanley {Phna. Med. Jour., March 16, and 2t,, 1901) 
 reviews the literature of strangulated and gangrenous hernia. Heuser, of 
 Paris, recorded (1861-1865) 227 patients operated on, with 172 deaths, 
 a mortality of 75.08 per cent. Tschering, in 1888, reported 524 cases with 
 a mortality of 29 per cent. McCready collected the cases operated from 
 1869 to 1888, showing that the mortality was 36 per cent. 
 
 Hennegeler, in 1896, reported 296 kelotomies with 23.02 per cent, 
 mortality. Bouchard, in 1896, reported 86 kelotomies with 17.97 per cent, 
 mortality. Hagedorn collected 170 cases, from 1883 to 1890, with 14 per 
 cent, mortality. Gibson collected 226 cases of primary enterorrhaphies with 
 58 deaths, a mortality of 26 per cent. 
 
 Croft, in 1896, performed 13 colostomies, none of the patients dying. 
 Czerny and Hahn found the mortality of primary resection to be 47 per 
 cent. ; ^Mikulicz, 2)^ per cent. ; Bouchard, 36 per cent. Ziedler gives re- 
 section 49 per cent, and colostomy 74 per cent, mortality. Frank gives the 
 mortality of resection as 48 per cent., and of colostoni}- as 80 per cent. 
 Maydl gives 22 per cent, for resection, and \\^allace gives 25 per. cent., and 
 90 per cent for colostomy. The mortalitv for resection is given as 38 per 
 cent, by Makins, 37 per cent, by Bouilly. Korte found the mortality of 
 
214 RESULTS OF OPERATIONS FOR STRANGULATEb HERNIA 
 
 colostomy 57 per cent. ; Friederichshain, '](> per cent. ; Poulsen, 86 per 
 cent., and Lockwood, 88 per cent. 
 
 In 1894 the combined statistics of Czerny, Reidel, Kocher, Hagedorn, 
 and Hahn gave 64 cases of primary resection with 32 deaths, a mortahty 
 of 50 per cent. ]\IiknHcz had 94 cases of colostomy with 72 deaths, 76.6 
 per cent, mortality. Hofmeister had 167 cases, Avith loi deaths, 60.5 per 
 cent, mortality. ^Mikulicz had 68 cases of resection, with 32 deaths, 47.1 
 per cent, mortality; Hofmeister had 214 cases of resection with 99 deaths, 
 46 per cent, mortality. 
 
 In 280 herniotomies done by Czerm- from 1877 to 1900, the mortality 
 was 18.5 per cent. Arranged according to procedure, the mortality was, 
 reposition of intestine intact, 216 cases, with 2'j deaths, or 11 per cent.; 
 colostomy, 22 cases, with 15 deaths, 67 per cent.; primary resection, 28 
 cases, with 9 deaths, 33 per cent. Adding to this list 2 cases of double 
 resection with fatal termination, there are 52 gangrenous hernias with 2K> 
 deaths, a mortality of 50 per cent. 
 
 B. M. Ricketts {American Medicine^ ]^\Iay 4, 1901) states that in in- 
 guinal hernia the average of recurrence for 34 operators will be 5.58 per 
 cent, in 6,027 cases. He states that the preferred operations arc the Marcy- 
 Bassini, ]\Iacewen, Halsted, Ferguson, Andrews, Phelps and Blake. 
 
CHAPTER XX, 
 
 RESILTS FROM FERGISON METHOD. 
 
 PERSONAL EESTJLTS. 
 
 In twenty-four years (1892-1906) I have operated for the cure of 
 hernia in twenty different hospitals by ten differenc methods and eight 
 modifications of these methods. The evolution of my method — the typic or 
 anatomic operation — for the cure of oblique inguinal hernia is based on an 
 experience derived from the clinical study of 654 cases of hernia, 489 of 
 which were of the inguinal variety. In these 489 cases I did 543 operations. 
 There were 23 cases of direct inguinal hernia, and 466 cases of oblique 
 inguinal hernia. These 489 cases can be further subdivided as follows : 
 
 (i) Congenital and acquired, 31S cases. 
 
 (2) Infantile, 2 cases. 
 
 (3) Interstitial, (a) preinguinal, 2 cases; (bj inguino-interstitial 
 (Goyrand's hernia), 2 cases. 
 
 (4) Inguino-crural (ITolthouse's hernia), i case. 
 
 (5) Traumatic, 2 cases. 
 
 (6) Post-operative (vasectomy for tuberculosis of the vas), i case. 
 
 (7) Sliding (a) sigmoid, one case; (bj cecum, 4 cases; (c) cecum 
 and appendix, 2 cases. 
 
 (8) Incarcerated, 6 cases. 
 
 (9) Strangulated, 28 cases. 
 
 In this last series of cases there were five deaths; (a) suppurating at 
 time of operation, i case; (b) gangrenous, colostomy done, 2 cases; (c) 
 resection (double hernia), 2 cases, one patient operated on by the open 
 method, and the other by AIcBurney's method. 
 
 (10) Twelve unclassified cases of inguinal hernia (early work, rec- 
 ords not complete). 
 
 (11) Double inguinal, 46 cases (92 operations). 
 
 (12) 3>Iultiple hernias, 20 cases; (a) oblique inguinal and femoral, 
 8 cases; (b) oblique inguinal and umbilical, 2 cases; (c) oblique inguinal 
 and ventral, 3 cases; (d) oblique inguinal, femoral and obturator, i case; 
 (e) oblique and direct inguinal, 2 cases; (f) double direct, 2 cases; (g) 
 6 hernias in one patient; (h) ten hernias in one patient. 
 
 There were 44 cases of femoral hernia not including those in which 
 both a femoral and an inguinal hernia existed. These cases Avere divided 
 as follows : 
 
 (i) Saphenous, 26 cases. 
 
 (2) Anterior (Velpeau's), 2 cases. 
 
 (3) Ascending subcutaneous, 3 cases. 
 
2l6 RESULTS FROM FERGUSON METHOD 
 
 (4) Strangulated, 10 cases. 
 
 (5) Double femoral (6 operations), 3 cases. 
 
 There were 6 cases of epigastric hernia, 4 congenital and 2 acquired. 
 Fifty-two cases of umbilical hernia were divided as follows : 
 (i) Omphalocele, 42 cases. 
 {2} Funicular hernia, i case. 
 
 (3) Interstitial hernia; (aj subcutaneous, 4 cases; (b) subperitoneal, 
 I case. 
 
 (4) Strangulated, 4 cases with two deaths. 
 
 There were 60 instances of ventral hernia, as follows : 
 (i) Hernia in the Hnea alba, 48 cases; (a) congenital, 1 case; (b) 
 acquired, 2 cases; (c) post-operative, 45 cases. 
 
 (2) Hernia in the linea semilunaris; (a) acquired, i case; (b) post- 
 operative, 3 cases. 
 
 (3) Hernia through the rectus muscle, traumatic, i case; post-opera- 
 tive, 7 cases; (a) following cholecystectomy, i case; (b) following appen- 
 dectomy, 4 cases; (c) following salpingotomy, 2 cases. 
 
 There were only two cases of lumbar hernia and one case of obturator 
 hernia in which there was also a femoral and an inguinal hernia. The 
 obturator hernia was not discovered until after it had become strangulated. 
 
 There was one case each of the following varieties of hernia : Left 
 duodenal hernia; hernia through the transverse meso-colon into the lesser 
 cavity of the peritoneum ; vesico-rectal hernia ; vesico-inguinal hernia ; 
 diaphragmatic hernia, and one instance (referred to me by Dr. Albert 
 Peacock) of hernia into Douglas' pouch. 
 
 In this whole series of cases there were 21 recurrences, (a) After the 
 typic (author's) operation, new direct hernias, 4 cases; (b) after Bassini's 
 operation and its modifications, 11 cases; after McBurney's operation, i 
 case ; after Kocher's operation, 2 cases ; after other methods, 3 cases. 
 
 I have performed my own operation 356 times, with only one death, 
 from nephritis. The patient, a male, 24 years of age, was feeble-minded 
 and physically undeveloped. He had two enormous congenital inguinal 
 hernias, both of which were operated at one sitting. He took the anesthetic 
 very badly (first chloroform, then ether). Fie had suppression of urine 
 immediately following the operation. There was no clinical evidence, nor 
 anything in his personal history, that pointed to kidney disease. He never 
 fully regained consciousness after the operation, and died on the fourth 
 day. 
 
 In his case I found on the right side a very singular arrangement of 
 the internal oblique muscle. Its fibers were directed obliquely upward 
 and inward toward the umbilicus. There was a normal origin at Poupart'.-' 
 ligament, but its insertion at the border of the rectus muscle was at least 
 two inches higher than the level of the internal abdominal ring. After 
 ablating the sac and tightening up the slack in the transversalis fascia, so 
 as to form a new ring, I sutured the free border of the internal oblique 
 muscle to the edge of the rectus muscle, and then closed the wound as 
 usual. 
 
PLATE XXXVI. 
 Fowler's Operation for Inguinal Hernia. 
 Showing position of cord. Annals of Surgery — Year Book — Gould, 1899. 
 
 Fig. 30. Page 326. 
 I. Transversalis fascia. 2. Peritoneum. 3. Cord. 4. External oblique 
 muscle. 5. Internal oblique muscle. 6. Transversalis muscle 7. Conjoined 
 tendon. 8. Poupart's ligament. 
 
RESULTS FROAI FERGUSON METHOD 219 
 
 It is a source of much satisfaction to be able to state that in the 356 
 typic operations performed by me there is no known recurrence after more 
 than two years in 225 cases that I have been able to trace. Four patients 
 returned claiming that the hernia had recurred, but on examination I found 
 that there was not a return of the oblique inguinal hernia, for which the 
 operation was done, but that there was in each case a hernial protrusion 
 in Hesselbach's triangle — a direct hernia. To cure this condition I oper- 
 ated according to Bloodgood's method. If I had detected at the time of the 
 original operation that the conjoined tendon in these cases was deficient, 
 and had combined Bloodgood's method with my own, I am convinced that 
 the direct hernia would not have occurred. When there is a weakness in 
 the lower inguinal region, there is also a bulging of the internal inguinal 
 fossa, either external or internal to the obliterated hypogastric artery — 
 the two sites at which a direct hernia may form. 
 
 A weakness in this fossa is best detected by passing the index linger 
 through . the internal ring into the abdominal cavity and down into the 
 fossa in the triangle of Hesselbach, and creating a forward pressure in 
 the suspected weak place. The finger or fingers (I use two fingers for 
 this exploration) will detect a laxness of the peritoneum and the trans- 
 versalis fascia in this region when the conjoined tendon is deficient. This 
 is reason enough for the surgeon to take some steps in his operative pro- 
 cedure to protect the lower as well as the upper angle of the wound. 
 
 The statistics of W. B. Coley, of New York, do not bear on this point 
 at all, because children never have direct hernias. His statistics are based 
 principally on operations done on children under fourteen years of age. 
 And so far as relapses at the internal ring are concerned, it is rare indeed 
 to have a recurrence after herniotomy in children, because of the muscular 
 development. It is futile and unwise to give any consideration v/hatever 
 to statistics, however honestly and faithfully compiled, based on one line 
 of work on children in the determination of the most useful method of 
 curing inguinal hernia by operation. 
 
 The method which is most applicable in the case of hernia in children 
 is not always the most suitable one in the case of hernia occurring in the 
 adult. At the same time, however, any method that is applicable for the 
 cure of an oblique inguinal hernia in the adult will produce even better 
 results in the case of children. 
 
 There are three methods by means of which the triangle of Hesselbach 
 may be protected from becoming the seat of a direct hernia, either external 
 or internal. 
 
 (i) By making use of the rectus muscle according to the procedure 
 devised by W. S. Halsted, or that devised by John Bloodgood. The credit 
 for suggesting this method is due Halsted. I prefer using the rectus mus- 
 cle itself instead of its sheath. 
 
 (2) Anterior transplantation of the cord, either according to Eassini's 
 or Halsted's method. It is immaterial, however, whether the cord is 
 brought out above or below the aponeurosis of the external oblic|ue mus- 
 
220 RESULTS FROM FERGUSON METHOD 
 
 cle. Either method is to be condemned. I have shown that anterior trans- 
 plantation of the cord should never be performed. 
 
 (3) Posterior transplantation of the cord, either according to Fowler's 
 method, where the cord is placed intra-peritoneally, or according to the 
 author's method, in which the cord is placed between the peritoneum and 
 transversalis fascia. In the case of either method the deep epigastric ves- 
 sels must be cut and ligated with catgut ligatures. Either method is suit- 
 able when an oblique and a direct hernia exists, or when the hernia is com- 
 plicated by a non-descended testis. 
 
 If the surgeon bases his technic of operation for the cure of inguinal 
 hernia on the transplantation of the cord, it is well for him to transplant it 
 backward instead of forward, thus savmg himself the conviction of being 
 the cause of at least six per cent, of recurrences at the upper angle of the 
 wound. 
 
 COMPLICATIONS. 
 
 I have had three cases in w^hicli atrophy of the testicle occurred and 
 one case of gangrene of the testicle. In one case the atrophy followed as 
 the result of suppuration of the cord. Among the 356 operations done, 
 there were only six cases of stitch-hole abscess and two cases of deep sup- 
 puration. There were two cases of hematoma and six of secondary wound 
 secretion. In two instances it was necessary to remove the testes at the 
 time of operation. These were cases of strangulated hernia. In three cases 
 of strangulated inguinal hernia general peritonitis followed, and also in 
 two cases of femoral hernia. These five patients died. 
 
 RESULTS OF AUTHOR'S OPERATION DONE BY OTHERS. 
 
 W. J. and C. H. Mayo have operated on 1,244 cases of inguinal hernia 
 by the author's method. Of this number, 34 were strangulated and 3 
 deaths occurred. Of 125 femoral hernias, 10 were strangulated, and no 
 deaths occurred. Of 82 ventral hernias and 114 umbilical, 7 were stran- 
 gulated. They also operated on 12 sliding hernias, usually of the sigmoid 
 or cecum, and 6 hernias containing appendix, ovary and tube, etc. In all 
 cases of direct hernias they transplant the cord, doing a Bassini operation. 
 
 F. W. McRae, of Atlanta, Ga., since 1902, has operated on 30 cases 
 of hernia, with only one return, in the case of a double hernia, at about 
 the sixth month. The patient was very poorly developed physicalh'. 
 
 J. Y. Brown, of St. Louis, operated on 350 cases, with only one return. 
 
 F. G. Connell, Oshkosh, Wis., operated on 50 cases, with no return, 
 but a direct hernia developed in one case which he ascribes to faulty 
 technic. 
 
 A recurrence took place in two other cases, but one of these was com- 
 plicated by an undescended testis, and the other had been operated on for 
 a recurrence after a Bassini operation. 
 
 A. J. Ochsner, of Chicago, has informed me that during the past four 
 years he has done all his herniotomies according to the Ferguson method. 
 For some time prior to that he performed the Bassini on one side and the 
 
PLATE XXXVII. 
 Parks' Autoplastic Suture. 
 I. Sac dissected out. 2. Suture applied. (Courtesy of Lea Bros. & Co.) 
 
RESULTS FROM FERGUSON METHOD 223 
 
 Ferguson on the other in cases of double inguinal hernia, but finally he 
 discarded the Bassini operation entirely. 
 
 Of 710 cases of hernia of all varieties, operated on by Ochsner in his 
 service at the Augustana Hospital for the radical cure of oblique inguinal 
 hernia, all the patients lived. There were few complications and very few 
 recurrences. Ochsner had 740 cases of non-strangulated oblique inguinal 
 hernia, and 33 cases of strangulated hernia. In 283 cases of oblique in- 
 guinal hernia operated on according to my method, no deaths occurred and 
 only three recurrences. These recurrences were probably due to the pres- 
 ence of a deficient conjoined tendon. Nevertheless, there were in this series 
 1.06 per cent, of recurrences. 
 
 In Ochsner 's series there were 51 cases of umbilical hernia, in 3 of 
 which strangulation had occurred; 81 femoral hernias, 17 of which were 
 strangulated; 62 post-operative ventral hernias, and 13 cases of hernia of the 
 linea alba. Ochsner mentioned only those cases seen by him in his service in 
 the Augustana Hospital. Making a general estimate of the total number 
 of operations performed by him, it may be said that three or four hun- 
 dred other cases may be added to this list, inasmuch as he has a verv large 
 surgical clinic at the College of Physicians and Surgeons, another at St. 
 Mary's Hospital, and others elsewhere. If we include in this number the 
 herniotomies performed by E. H. Ochsner, the number of operations done 
 would be still greater. E. H. Ochsner's results compare very favorably 
 with those of his brother. 
 
 Inasmuch as I am not in possession of complete information as to 
 the number of patients operated on according to my method by other opera- 
 tors than those mentioned, it is impossible to present a complete report. 
 But the results quoted above will serve for comparison with those obtained 
 by other methods. 
 
PART II. 
 
 CHAPTER 1. 
 
 OPERATIONS FOR INGUINAL HERNIA. 
 
 In taking up the various operations that have been devised for the 
 cure of hernia, it is not my intention to make any extended remarks in the 
 way of comment. I merely propose to mention those procedures that can 
 be designated as definite individual operations, and to describe briefly such 
 of the modifications of these original procedures as have met with the favor 
 of operators of experience. It will be noted that the list of operations is 
 a long one, and if I have failed to mention any procedure, it is only because 
 it was overlooked and not because of any intention on my part to slight 
 the work done by anyone. 
 
 Many operations so-called are really merely modifications, some 
 slight and some more extensive, of older operative procedures ; but in 
 some instances the modifications possess the merit that the original proced- 
 ure lacks. I have not attempted to place these operations in any order, 
 either as to value or precedence, but mention them as they have occurred 
 to me. Whenever possible, I have elucidated the text with illustrations, 
 which will be of considerable interest to the reader, inasmuch as they are re- 
 productions of the originals given us by the authors. 
 
 MACEWEN'S OPERATION. 
 
 The method employed by Macewen for the radical cure of oblique 
 inguinal hernia aims at leaving the structures in their normal position 
 after the operation, the sac of the hernia being utilized to form a boss at 
 the internal ring. The primary incision is made directly over the internal 
 ring, commencing an inch or two above the ring, and extending downward 
 over the hernia for three or four inches. This incision passes through 
 the two layers of superficial fascia and the fat betwefen them. The inguinal 
 canal is then opened by cutting through the external ring, and separating 
 the fibers of the aponeurosis of the external oblique, to a point above the 
 internal ring. If the sac can be dealt v/ith without making this latter in- 
 cision, well and good. It can be dispensed with under such circumstances. 
 Any rolls of fat that may be found around the cord or along the sac must 
 be removed. 
 
 The sac itself is now dissected out carefully and is separated at its 
 neck from the transversalis fascia, the finger being used, for the space of 
 about an inch around the internal ring. If there is any question in the 
 
226 OPERATIONS FOR INGUINAL HERNIA 
 
 mind of the operator as to the existence of omental adhesions, the sac is 
 opened and inspected. If the sac is very large and redundant, a portion 
 of its fundus is cut off. The sac is now ready to be folded on itself into a 
 boss. j\Iedium-sized chromic catgut is fastened firmly into the fundus or 
 cut end of the sac. as the case may be, and with a non-cutting needle it is 
 passed through the sac from fundus to neck in a zigzag fashion, the last 
 two stitches being taken on a level with the peritoneal cavity. The finger 
 is then passed between the transversalis fascia and the peritoneum under 
 the upper border of the internal ring. Using the finger as a guide, the 
 needle is passed in, is made to pierce the transversalis fascia, and the 
 transversalis, internal and external oblique muscles, emerging subcuta- 
 neously at the upper angle of the wound. Traction being made on this 
 puckering or folding stitch, the sac is drawn upward and inward so as to 
 fold on itself until it comes to occupy the internal aspect of the internal 
 ring. The puckering stitch is secured subcutaneously and tied. 
 
 The next step in the operation is to overlap Poupart's ligament onto 
 the conjoined tendon, thus restoring the natural valve-like condition of 
 these structures, leaving the cord in its bed. 
 
 Macewen uses a special needle for this purpose, but any needle with- 
 out a cutting edge will do. The needle is passed through the conjoined 
 tendon from without inward immediately above the pubic bone, and then 
 is passed along the tendon posteriorly, emerging just short of gripping the 
 deep epigastric vessels from within outward (Fig. 25). The free ends of 
 this stitch (very stout chromic catgut) are then passed through Poupart's 
 ligament, one opposite the internal ring, and the other an inch and a half 
 or so below it, pulled tightly and tied. In this way Poupart's ligament is 
 made to overlap onto the conjoined tendon. If there is any tendency 
 of the sac to protrude, one or two stitches of finer catgut are inserted in 
 the same manner, gripping the lower border of the internal oblique muscle 
 and Poupart's ligament respectively; or, again, if there seems to l3e more 
 space below the great mattress suture than appears proper, one or two 
 stitches are inserted there for additional security. 
 
 The aponeurosis of the external oblique muscle is dealt wdth either by 
 a simple continuous suture, or by overlapping the cut edges. In chronic 
 cases overlapping is the preferable procedure, as revived by Andrews in 
 bis imbrication method. 
 
 The edges of the skin wound are brought together either by con- 
 tinuous or interrupted sutures. The wound is dressed and the patient is 
 kept in bed for from four to six weeks. The dressing is changed as often 
 as is required. 
 
 Macewen's operation v^as the first rational procedure presented to the 
 profession for the radical cure of oblique inguinal hernia. It served me 
 very usefully, because from it I worked out my present method, the typic 
 operation for the cure of obhque inguinal hernia. While I have discarded 
 utilizing the sac as a boss in the vast majority of cases, I still occasionally 
 make use of it after the method of Macewen. I have performed the Mac- 
 ewen operation fifty-two times without a recurrence, so far as I know. 
 
PLATE XXX\7II. 
 
 Bassini's Operation for Inguinal Hernia with Imbrication of Structures, as 
 recommended bv E. W'vllvs Andrews. 
 
OPERATIOXS FOR IXGUIXAL HERXIA 229 
 
 There is very little danger of the sac dying- and coming away as a slough, 
 if care is taken not to injure its neck and not to pass a ligature around it 
 at the internal ring, as has been done by some operators. 
 
 Macewen recognized that two conditions had to be rectified: (a) The 
 anatomical infundibuliform process at the internal ring, and (b) the ac- 
 quired funnel-shaped depression described by Sir Astley Cooper. Macewen 
 aimed to do this by using the sac as a plug or boss. 
 
 It was my privilege some years ago (1889) to examine an anatomical 
 preparation in the possession of Sir AVilliam Macewen which had been 
 removed from a patient whom he had cured by his operation. The man 
 had done heavy work for years afterward, although he did not wear a 
 truss. The cause of his death was aortic aneurism. The specimen showed 
 the inguinal canal closed tightly, and at the abdominal aspect of the in- 
 ternal ring the sac was folded on itself forming a cushion which abso- 
 lutely prevented the possibility of a recurrence of the hernia. Alacewen 
 told me that the hernia had been one of long standing, and that the sac was 
 a. very large one, composed principally of mature fibrous tissue. 
 
 If the rupture be a recent one, and if the sac is composed of deli- 
 cate elastic peritoneum, then I can readily understand the correctness of 
 Bassini's observation that at an autopsy made ninety-five days after an 
 operation somewhat like Alacewen's, no trace of the tampon could be dif- 
 ferentiated. That the tampon "must of necessity leave a hard, painful 
 svv^elling, slow to disappear", as stated by Marcy, of Boston, has not been 
 my observation in a single instance. 
 
 BASSINI'S OPERATION. 
 
 The Bassini operation is very dissimilar to that of ]\Iacewen. Bassini 
 does not make any use of the sac, merely passing a ligature around the 
 neck of the sac and cutting it off. The cord is raised completely out of 
 its bed and is carried to the upper and outer angle of the wound, which 
 displaces it about half an inch. Then the lower border of the internal 
 oblique muscle and the conjoined tendon are sutured beneath the cord to 
 the inner aspect of Poupart's ligament, care being taken to fit the cord 
 at the internal ring as closely as is compatible with its safety (Fig. 26). 
 
 A number of operators have found it necessary to place one or two 
 stitches above the cord between the internal oblique muscle and Poupart's 
 ligament, experience having shown them that about six per cent, of the 
 recurrences take place at this angle. 
 
 The aponeurosis of the external oblique muscle is then sutured care- 
 fully over the cord and the superficial skin v/oimd is closed in the usual 
 manner. 
 
 On account of the large number of rela.pses and complications occur- 
 ring after this operation, seen by me and also by others, I set myself the 
 task of devising an improvement. The returns of the hernia after Bas- 
 sini's operation, and after modifications of i)t. in my experience were be- 
 tween six and seven per cent, in a series of 165 cases. (Eleven recur- 
 rences, all at the upper angle of the woiuid.) 
 
230 OPERATIONS FUR INGUINAL HERNIA 
 
 KOCHEE'S OPERATION. 
 
 Kocher makes use of the sac subcataiieously on the outside of the 
 aponeurosis of the external obhque muscle instead of subperitoneally, as 
 is the case in Macewen's operation. The external ring and the aponeurosis 
 of the external oblique muscle in front of the inguinal canal are left intact 
 by Kocher. A small transverse incision is made opposite the internal ring, 
 passing through the aponeurosis of the external oblique muscle. The sac 
 is dissected out very carefully and freed up to its neck, and after having 
 made sure that its contents have been returned to the abdominal cavity, 
 the sac is dragged through the small slit (Fig. 27), twisted vigorously 
 on itself, and sutured in front of the inguinal canal in such a manner as to 
 press on it. 
 
 In a second operation devised by Kocher, which is really a modifica- 
 tion of the first, he ablates the sac after fastening it to the external aspect 
 of the aponeurosis of the external oblique muscle (Fig. 28). This modi- 
 lication was devised because of the sloughing of the sac in the old opera- 
 tion. Kocher urges the use of his operation (i) on account of its safety m 
 old subjects; (2) suppuration will destroy Bassini's results, but not his. 
 Among 126 patients operated on by this method, there were only foiu' re- 
 lapses, about 3 per cent., while the former procedure was followed by a 
 relapse in about 20 per cent, of the cases. 
 
 HALSTED'S OPERATION. 
 
 In 1893 W. S. Halsted devised an operation for the radical cure of 
 hernia. Experience showed, however, that the operation was not as satis- 
 factory as Halsted at first thought it would be. and therefore a new opera- 
 tion has been substituted for it. The cord is no longer raised from its bed 
 and transplanted, nor are the abdominal muscles incised above the in- 
 ternal ring. This modification, which is very similar to my operation, was 
 not published until three years after I produced my method. 
 
 The steps of this operation are so well shown in the illustrations made 
 by Brodel, and reproduced by Miss Cleaveland, that a description is almost 
 superfluous for those who consult the plates. The aponeurosis of the ex- 
 ternal oblique muscle is divided and the two flaps are reflected as in the 
 Bassini-Halsted operation. The cremaster muscle and fascia are split, 
 not directly over the center of the cord, but a little above it. The internal 
 oblique muscle is dissected free as much as is possible. A little artefaction 
 is often necessary. If the muscle cannot be drawn down to Poupart's liga- 
 ment, without exerting too much tension thereon, it is advisable to make 
 one or two incisions in the anterior sheath of the rectus muscle under the 
 aponeurosis of the external oblique. This sheath serving, in part, as the 
 aponeurosis of the internal oblique muscle, it can be seen quite readily 
 that incisions into it, if properly made, will be of service. It is advisable, 
 however, to postpone the making of these incisions until the suturing of 
 the internal oblique muscle to Poupart's ligament is begun. Then the de- 
 gree of tension present can be gauged, and the number, length and pre- 
 cise position of the incisions determined. A second reason for postponing 
 
PLATE XXXIX. 
 McArthur's Autoplastic Suture used in Bassini's Operation. 
 
OPERATIONS FOR INGUINAL HERNIA 233 
 
 these relaxation incisions, as they are termed, is that sometimes this por- 
 tion of the rectus sheath is used for the purpose of closing the lower part 
 of the inguinal canal (Fig. 33). 
 
 When the veins are very large, Halsted states they should be excised, 
 but with very great care, so as to avoid even the slightest extravasation of 
 blood into the tissues. The vas deferens should not be raised from its bed 
 or even handled lest thrombosis of its veins occur. 
 
 The veins should be ligated as high up in the abdomen as possible. 
 They are pulled down quite firmly just before the ligature ( in a needle 
 with a blunt end) is passed between them. In order to obviate slipping, 
 two ligatures of fine silk are applied, one to the abdominal stump and the 
 other to the proximal stump of the veins. The farther from the testicle 
 these veins are divided, the better; provided, of course, that the stump 
 is external to the external abdominal ring. 
 
 Ligation of the sac by transfixion or by purse-string suture at the 
 highest possible point. Both ends of this suture, after tying, are threaded 
 on long curved needles, then carried far out under the internal oblique 
 muscle from behind forward, and, passing through muscle, about 5 mm. 
 apart, are tied. The idea was suggested to the author by Kocher's opera- 
 tion, the principle being essentially the same. 
 
 The lower flap of the cremaster muscle and its fascia is drawn up 
 under the mobilized internal oblique muscle and held in this position by 
 very fine silk stitches, which, having engaged firmly a few bundles of the 
 cremaster, perforate the internal oblique, preferably where it is becoming 
 aponeurotic, and are tied on the external surface of the latter (Fig. 29). 
 
 The internal oblique muscle, mobilized, and possibly further released 
 by incising the anterior sheath of the rectus muscle, is stitched (the con- 
 joined tendon also) to Poupart's ligament in the Bassini-Halsted man- 
 ner (Fig. 30). Catgut is usually employed for this suture. The aponeu- 
 rosis of the external oblique muscle is overlapped, as in Andrew's method 
 (Figs. 31 and 32). 
 
 The skin is closed with a buried continuous silver suture and the 
 incision covered with five or six layers of silver foil. It is unnecessary to 
 dress or examine a wound closed in this manner for two weeks, when the 
 wire may be withdrawn. Patients are kept in bed from eighteen to twenty- 
 one days. 
 
 Halsted says, "We hope to be able to publish very soon the results 
 of the first 1,000 operations performed for the cure of inguinal hernia at 
 the Johns Hopkins Hospital. Certainly more than two-thirds of the opera- 
 tions have been performed by my associates, Drs. Finney, Bloodgood, 
 Cushing, Mitchell and Follis, for we are all much interested in the sub- 
 ject. Each operator has been at perfect liberty and is encouraged to per- 
 form the operation according to his best judgment. This fortunately 
 furnished a little variety, but of late the operation has, in almost every de- 
 tail, been performed just as the writer has described it." 
 
234 OPERATIONS FOR INGUINAL HERNIA 
 
 FOWLER'S OPERATION. 
 
 The late George Ryerson Fowler, of Brooklyn, N. Y., described an 
 operation for the radical cure of inguinal hernia which he termed an intra- 
 peritoneal transplacement of the spermatic cord with typical obliteration of 
 the internal ring- and the inguinal canal. In this operation the skin incis- 
 ion is curved and follows the course of Poupart's ligament. The sac and 
 cord are exposed in the usual way, the sac is cut away, and the cord is 
 raised from its bed. The deep epigastric vessels are tied twice, and then 
 severed between the ligatures. The posterior wall of the canal is opened 
 freely, the cord is transplanted within the abdominal cavity, and the wound 
 is then closed. 
 
 The patient is placed in the Trendelenburg position, in order that the 
 intestines may not embarrass the operator, subsequent to the opening 
 and emptying of the hernial sac. The incision commences at the spine of 
 the pubis, is carried parallel with the os pubis for about an inch, and then 
 curved obliquely outward and upward on the line which marks the gen- 
 eral direction of Poupart's ligament,_ until a point is reached corresponding 
 to the level of the internal ring. 
 
 Skin, fat and fascia to the aponeurosis of the external oblique are in- 
 cluded in the incision. The flap thus marked out is reflected when the 
 entire region involved in inguinal hernia, including the inguinal or sper- 
 matic canal, as well as the site of Plesselbach's triangle, is exposed to view. 
 The a:nterior wall of the canal is now split up to the site of the internal 
 ring. 
 
 The cord and sac are first isolated together, the isolation commencing 
 at the pubic bone, where the cord is usually easily identified and separated, 
 these structures are now separated from each other, each being traced to 
 the internal ring and thoroughly isolated froin all structures in the neigh- 
 borhood. The hernial sac is now opened, its contents reduced, if reduc- 
 tion has not already occurred, and the sac cut away to the level of the 
 muscular layer of the abdominal wall. Its incised edges are grasped 
 by forceps to prevent them from slipping away. The cord being held out 
 of the way, the place of crossing the deep epigastric artery on the trans- 
 versalis fascia is sought, and both the artery and vein are isolated and 
 ligated in two places and divided between the ligatures. 
 
 The index finger is now introduced into the peritoneal cavity through 
 the neck of the sac and the posterior wall of the canal, as well as the 
 site of Hesselbach's triangle, lifted up on the palmar surface of the finger. 
 With the latter as a guide, the entire intervening structures are divided, 
 including, from without mward, the- transversalis fascia, subperitoneal 
 connective tissue, and the peritoneum (Fig. 34). The spermatic cord is 
 now placed in the peritoneal cavity ; the gap in the incised posterior wall in 
 the inguinal canal is held apart by grasping the incised peritoneal edges 
 with forceps. In those instances in which the internal ring is greatly 
 enlarged in all directions and a large neck to the hernial sac exists, a slit 
 may be made in the edge of the latter toward Poupart's ligament, in order 
 to lead the cord easily into the peritoneal cavity. The edges of the open- 
 
PLATE XL. 
 McxA-rthur's Autoplastic Suture used in Bassini's Operation. 
 
OPERATIOXS FOR IXGUIXAL HERI. \. ' 237 
 
 ing are now drawn forward so that a broad approximation of their serous 
 surfaces is obtained. While held in this position, through-and-through 
 sutures are passed from side to side (Fig. 35). By this maneuver any ex- 
 isting relaxed condition of this portion of the transversalis fascia is cor- 
 rected. The suture is first passed above the site of the internal ring, and 
 includes the transversalis fascia which is drawn downward and forward 
 for that purpose. This serves to cover the point where the cord passes 
 into the peritoneal cavity at the site of the internal ring, thereby obliter- 
 ating the latter, the cord itself filling the small opening in the peritoneum. 
 The position of the cord on the peritoneal surface of the abdominal wall 
 is such as to act as a "shunt" carrying any intestine in the neighborhood 
 away from rather than toward the original weak point. 
 
 The suturing is continued until the lower angle of the gap in the 
 posterior wall of the original inguinal canal is almost reached. This angle 
 should be made low enough to compel the cord to curve slightly upward 
 and forward as it leaves its place of exit from the peritoneal cavity at the 
 newly formed external ring. The cord should rest easily in the angle, 
 and the suturing stop short of constricting it therein. 
 
 The inguinal canal, including the gap in the aponeurosis of the ex- 
 ternal oblique which represents the external ring, and the skin wound are 
 now to be closed. The canal sutures include the conjoined tendon and the 
 aponeurosis of the external oblique on the inner margin, and Poupart's 
 ligament on the outer. The two sutures should include the outer edge 
 of the pyramidalis, if this is present, and if not, the rectus muscle. The 
 effect of this is to displace a portion of the muscular tissue to a situation to 
 guard the point of exit of the spermatic cord (Fig. 36). A continuous 
 suture is now applied in order to secure a more accurate coaptation of the 
 margins of the aponeurosis of the external oblique muscle, the turns of 
 suture passing in the space between the interrupted sutures. The skin 
 wound is closed by a subcuticular or other appropriate suture, and proper 
 sterile dressings are applied. 
 
 I have performed this operation, or a modification of it, forty-five 
 times, usually in cases where the hernia was complicated by a non-de- 
 scended testis. The operation gives the vas deferens a shorter route be- 
 tween the testes and the base of the bladder. I have also used the method 
 in the treatment of both direct and indirect inguinal hernias, where the 
 hernia protruded considerably and where there was more or less bulging 
 of the posterior wall of the canal and the deep epigastric vessels. In cer- 
 tain conditions it is not necessary to cut the peritoneum, although the deep 
 epigastric vessels are severed. 
 
 LANPHEAR'S OPERATION. 
 
 Emory Lanphear, of St. Louis, in operating for inguinal hernia, forms 
 a flap and turn it down so as to expose the hernial sac and the inguinal 
 canal. The sac is then isolated, opened, and its contents reduced. The 
 opening in the abdomen is closed temporarily with a gauze pad, and the 
 cord and testes are elevated out of their new position and wrapped in 
 
238 OPERATIONS FOR INGUINAL HERNIA 
 
 iodoform gauze. From the hernial sac an artificial vaginal tunic is made 
 into which the cord and testes are passed, the tunic being sutured in such 
 a manner that not too much pressure is made on the cord. This mass 
 of tissue is pushed into the abdominal cavity and anchored by catgut su- 
 tures. Next, he closes the incision in the peritoneum and then the open- 
 ing in the scrotum. The abdominal wall is sutured in layers so as to 
 obliterate the inguinal canal. 
 
 The objection to the operation is that in case there occurs suppura- 
 tion of the testes or an epididymitis, it would be necessary to open the 
 abdomen in order to give operative relief. 
 
 GIRAKD'S OPERATION. 
 
 Girard splits the skin and the aponeurosis of the external oblique 
 muscle somewhat after the fashion of Bassini's operation, but he pre- 
 serves a strip of the muscle, about the width of a finger, at its attachment 
 to Poupart's ligament. A purse-string suture being passed through the 
 neck of the sac, the sac, of course, having been cut off, it is dropped back 
 into the abdominal cavity. The internal oblique and transversalis muscles 
 are sutured to the underside of Poupart's ligament, a running catgut stitch 
 being used. The external oblique muscle is then likewise sutured to the 
 underside of Poupart's ligament and then the strip of muscle is passed 
 in under the ligament and sutured to the aponeurosis of the external 
 oblique muscle, so that for a certain distance this aponeurosis is doubled, 
 an opening is left at the lower angle of the exit of the cord. The skin is 
 closed with a continuous suture. 
 
 PARK'S ATJTO-SUTTJRE (SAC) OPERATION. 
 
 Roswell Park recently devised a new method of utilizing the sac. 
 The sac having been exposed and isolated, is emptied of its contents and 
 freed of all superficial fat. It is separated from^ the cord and made to 
 appear as a distinct separate structure up to the level of the internal ring. 
 The abdominal aponeurosis is penetrated with forceps at a point opposite 
 the internal ring, and the forceps introduced through this opening is made 
 to appear lower down in the inguinal canal, the sac is seized, and is with- 
 drawn together with the forceps, thus bringing it out at the punctured 
 point. 
 
 Instead of cutting ofif the sac outside the point where it is fastened. 
 Park utilizes it as a band of suture material with which a coarse strong 
 suture is made binding together the lateral margins of the inguinal canal 
 (Fig. 37). Of course, much depends on the thickness and length of the 
 sac. Old and large sacs are far too cumbersome for this purpose, and 
 short sacs cannot be made to serve as sutures when twisted into a cord. 
 These difificulties are overcome easily either by reducing the sac, cutting 
 out a strip which can be made to serve as a suture, or by lengthening 
 the strip by division, so that a suture five or six inches long can be ob- 
 tained from a short sac. 
 
 The sac having been prepared, it may be used in one of two or three 
 
PLATE XLI. 
 M. L. Harris' aluminum bronze wire suture used in Ferguson's operation. 
 
OPERATIONS FOR INGUINAL HERNIA 24I 
 
 ways. A very large needle may be threaded with the suture or a Cleveland 
 ligature carrier may be used, passing it through the tissues on either side as 
 if it were an ordinary needle, then grasping the end of the sac and pulling 
 it back through the openings thus made as the instrument is withdrawn. 
 Sometimes Park passes into the end of the sac a silk suture, threading it 
 into a larger needle, and making it serve as a means of traction, the pro- 
 cedure varying a little with the density and strength of the sac wall. 
 
 In certain cases the portion of sac used may be divided into halves, 
 making two tapes which can be used in the form of a shoelace suture of 
 the pillars of the ring by either of the expedients mentioned. The ends 
 are drawn down at the lower end of the ring, where they are tied and fas- 
 tened with a suture. 
 
 The method is not applicable to all cases, nor is it likely to displace 
 other procedures. It should not be employed unless the operation can be 
 performed deliberately and only in the absence of infection. 
 
 WULLSTEIN'S OPERATION. 
 
 Quite recently Wullstein (Centralbl. f. Chirurgie, No. 38, 1906) pro- 
 posed a new method for the cure of inguinal hernia. The incision starts 
 at the pubic spine and makes a bow-shaped curve upward and outward, 
 running from one to two finger-breadths above Poupart's ligament and 
 extending to the neighborhood of the internal inguinal ring. The skiri 
 liap is reflected downward to Poupart's ligament. The sac is isolated in 
 the usual way and the aponeurosis of the external oblique muscle is split 
 as far as the internal ring. The sac is then tied off at the neck and cut 
 away. The cremaster fibers are separated from the cord, but are allowed 
 to remain in connection with the external oblique muscle and Poupart's 
 ligament. The transversalis fascia is split almost to the internal pillar 
 of the external ring, and the cord is dislocated backward so as to lie be- 
 tween the transversalis fascia and the preperitoneal fat. The external 
 oblique, internal oblique and transversalis m.uscles and the transversalis 
 fascia are united to the posterior surface of Poupart's ligament by inter- 
 rupted sutures as far as the external inguinal ring. In order to restore nor- 
 mal tension, -the sutures are placed a little nearer the middle line in Poupart's 
 ligament than in the abdominal wall. 
 
 A plastic flap is then constructed. The skin is pulled inward in order 
 to expose the rectus muscle. The outer two-thirds of the anterior rectus 
 sheath is cut transversely across immediately above the level of the 
 symphysis, thus exposing both the rectus and the pyramidalis fibers. The 
 cut is continued upward and outward until it ends opposite the pubic spine, 
 hut about four centimeters above it. This gives a tongue-shaped flap 
 which is freed from the muscle and reflected outward to the outer edge 
 of the rectus muscle. The fibers forming the inner pillar of the external 
 ring prevent a complete reflection of the flap, and these fibers are now cut 
 across close to Poupart's ligament. The remainder of the hernial opening 
 is closed by suturing the abdominal muscles to Poupart's ligament. 
 
 The purpose of the flap is to be placed behind the rectus muscle. The 
 
242 
 
 OPERATIONS FOR INGUINAL HERNIA 
 
 three sutures used to transpose the flap also serve to fix and carry the 
 cord into its new bed. The sutures are of the mattress type, the low- 
 est being placed horizontally, and the upper two vertically. They all pierce 
 the rectus muscle and enter the fascial flap some distance away from its 
 free edge. When the sutures are tied the aponeurotic flap is pulled be- 
 hind the rectus muscle, the cord assuming a course running well behind 
 this muscle, and then curving outward and downward to reach the scro- 
 tum. It is surrounded on all sides, except below, by rectus muscle, which 
 is also sewn to Poupart's ligament. The gap in the rectus sheath is re- 
 paired simply by stitching the two edges together. The cord thus is made 
 to lie in a new canal behind the rectus muscle, so that straining or cough- 
 ing merely presses aponeurotic flap to muscle. 
 
 Wullstein has used this method with perfect results in 19 cases of 
 direct and indirect, reducible and irreducible hernia. 
 
 NICHOLL'S OPERATION. 
 
 Nichoirs operation (Annals of Surgery, Jan., 1906) is really a modi- 
 fication of other operations. The hernial sac is treated as before, but it is 
 lodged over the internal aspect of the internal inguinal ring as a pad, resting 
 between the parietal peritoneum on the one hand and the fascia transversaHs 
 on the other. With blunt retractors the round ligament, or the cord, is 
 pulled upward, and Poupart's ligament downward. An incision is carried 
 along the superior aspect of the pubic ramus. Its limits are the pubic 
 spine and the femoral sheath. This divides the iliac fascia, the origin of 
 the pectineus and the periosteum. "Slightly detach both margins of the 
 periosteal wound, and drill the bone near its upper margin, as before, some- 
 where between the pubic spine and the femoral sheath, the position of the 
 holes varying with the shape and size of the hernial aperture. Pass a stout 
 absorbable ligature in the form, of a large mattress suture through the 
 internal pillar of the hernial aperture; pass the ends of the suture out 
 through the holes drilled in the bone and either in front of or behind the 
 spermatic cord as seems best to secure firm closure of the canal without 
 undue compression of the cord. Tie the ends of the two loops of the 
 ligature separately. The tightening of the knots brings the internal pillar 
 down into the periosteal incision and lodges it firmly against the bone. 
 The knots may be placed either above or below Poupart's ligament." 
 
 The operation is completed by lifting Poupart's ligament to the an- 
 terior surface of the internal pillar and fixing it there by interrupted sutures 
 of stout catgut or other absorbable material which should penetrate, at 
 least, the external and internal oblique muscles. 
 
 BECK'S OPERATION. 
 
 Carl Beck, of New York, makes an incision down to the internal 
 surface of Poupart's ligament and alongside the rectus muscle. The lower 
 third of this muscle is exposed down to the shelf of Poupart's ligament. 
 The sac is isolated, ligated and cut off within the internal ring. The cord 
 is held away, and the divided aponeuroses are dissected back. 
 
PLATE XLII. 
 Davison's Removable Silkworm Gut Suture. 
 
OPERATIONS FOR INGUINAL HERNIA 245 
 
 An oblique incision is made which divides the lateral fibres of the rec- 
 t'ds transversely, somewhat below the lower third of the muscle and for 
 about one-third of its width. The incised fibres are cut from the remaind- 
 er of the mus.cle so that when the upper portion is turned downward 
 it will reach Poupart's ligament. The muscular flap is then sutured on 
 one side to the conjoined tendon and on the other side to Poupart's liga- 
 ment. Formalin catgut is employed for this purpose. The sutures are 
 tied after the cord has been placed on the transplanted muscle flap. The 
 gap caused by transplanting this flap is closed by suturing the outer margin 
 of the rectus to the broad abdominal muscles. The divided aponeuroses are 
 sutured above the cord by a continuous suture. 
 
 In my opinion, the severing of the fibers of the rectus muscle is un- 
 called for in an operation for the cure of hernia. Without doubt, the 
 transplanted flap strengthens the inguinal region considerably, but why 
 resort to such a complex procedure when a more simple one will meet all 
 the indications? 
 
 STINSON'S OPERATION. 
 
 J. C. Stinson makes an incision parallel with and one-half inch above 
 Poupart's ligament, extending from the external ring to half an inch above 
 the upper angle of the dilated internal ring. The skin, subcutaneous tis- 
 sues, and the aponeurosis of the external oblique muscle are divided by 
 this incision. The aponeurosis is elevated and freed from the structures 
 beneath until the outer border of the rectus muscle and the shelving edges 
 of Poupart's ligament appear in the field. 
 
 The sac is isolated, opened, and its contents cleared out, all the altered 
 omentum being removed. All adhesions are separated. The sac is cut 
 off as high as possible and the cut edges of the serosa are closed with con- 
 tinuous sutures. The rings and canal are cleared out. The dilated internal 
 ring is sutured, commencing at the upper angle. 
 
 The inner and outer borders of the transversalis fascia are brought 
 accurately together with continuous sutures, leaving only sufficient room at 
 the lower angle, close to the pubic bone, for the cord. The internal ring is 
 re-enforced and the canal closed by uniting with continuous sutures, the 
 internal obhque and the transversalis muscles and their conjoined tendon 
 to the shelving edge of Poupart's ligament, leaving' only room enough 
 next to the pubic bone for the cord. The cut edges of the external oblique 
 and the pillars of the external ring are sutured and made to embrace the 
 cord. The skin is closed without drainage. Sterilized gauze is held firmly 
 in place by long strips of adhesive plaster, then a layer of cotton and over 
 all a firm spica bandage. 
 
 HERRING'S OPERATION. 
 
 E. K. Herring advocates the following procedure for curing hernias 
 in children: The operation is said to be a very simple one and can be 
 performed in a few minutes. The sac is cut down on and into in the usual 
 manner, and having dealt with its contents it is pulled down, that is, out 
 
246 . OPERATIONS FOR INGUINAL BERNIA 
 
 from the abdomen, sufficiently to insure subsequent retraction. The in- 
 cision is extended in the sac up to the margin of the ring, and then the 
 upper portion of the sac is turned inside out through the incision, so as 
 to expose the peritoneal surface. Then, with a knife or- a pair of scis- 
 sors, the peritoneum is cut across transversely. The proximal cut edge 
 retracts into the abdomen and it should be caught here and there with 
 catch forceps as the peritoneum is cut. These catch forceps are ar- 
 ranged so as to draw the cut edge of the peritoneum into a straight line, 
 and the two edges are stitched together by a catgut suture. The forceps 
 are then removed, and the tissue immediately retracts. . The opening is 
 closed with a subcuticular or other stitch and is then sealed. 
 
 Nothing further is absolutely necessary. When there is a large lax 
 abdominal ring, or when the little patient has a cough, it may be advisable 
 to put one or two stitches through the pillars as a temporary support. The 
 contents of the inguinal canal are practically not disturbed. The sac is 
 left in the canal to shrivel up ; the cord has not been touched nor pinched ; 
 the testicle has not been dragged out and exposed; no vessels have been 
 cut, so no ligatures are left behind, and the chances of sepsis are very 
 slight. 
 
 BENJAMIN'S OPERATION. 
 
 In 1903, Benjamin described an operation for the radical cure of ob- 
 lique inguinal hernia which possessed several distinguishing features. An or- 
 dinary incision was made, as in the Bassini operation, and then the aponeuro- 
 sis of the external oblique muscle was slit up to a pomt opposite the inter- 
 nal ring. The fibers of the internal oblicjue and the transversalis m.uscles 
 were divided carefully by blunt dissection, thus opening the inguinal canal. 
 The aponeurosis of the external oblique was carefully and thoroughly 
 removed from the internal oblique. The lower portion Avas dissected down 
 to Poupart's ligament, and the transversalis muscle separated from the 
 peritoneum. 
 
 The cord is now raised and silkworm gut sutures are introduced to the 
 outer side of the incision, passing through the skin, Poupart's ligament, 
 the internal oblique and the transversalis muscles, on the inner side of 
 which the loop is made. The needle, re-entering the transversalis and inter- 
 nal oblique muscles, passes through Poupart's ligament and comes out 
 through the skin to the outer and lower side of the cut near the point of 
 entrance. From three to five sutures are similarly introduced. These 
 sutures pull the internal oblique and the transversalis muscles below the 
 shelving edge of Poupart's ligament, thus creating a firm' barrier against 
 any internal force. 
 
 The sutures are then tied over rolls of sterilized gauze. The cord 
 then rests on the internal oblique, the external oblique being closed over 
 the cord. Interrupted figure-of-eight sutures aie introduced, bringing the 
 external oblique muscle in apposition with Poupart's ligament. The}- also 
 approximate the skin and are tied over a gauze roll. 
 
 This operation, according to Benjamin, completely closes the breech 
 
PLATE XLIII. 
 
 Showing Deficiency of Internal Oblique at Poupart's Ligament. 
 I. Usual deficiency. 2. Normal for male. 3. Normal for female. 
 
OPERATIONS FOR INGUINAL HERNIA 249 
 
 and makes a firm wall. There are no sutures for the tissues to absorb; 
 no buried, non-absorbable sutures left to irritate the tissues and cause 
 further trouble ; no necrosis from tight sutures ; therefore, few, if any, 
 stitch-abscesses. All sutures, after serving their purpose, are removed, 
 leaving only the natural supports, while the gauze rolls act as elastic 
 cushions which prevent scars from the sutures. 
 
 SCHWARTZ'S OPERATION. 
 
 When Schwartz first described his method for the radical treatment 
 of hernia, he called it hernial myoplasty. It was applicable both to inguinal 
 and to femoral hernias. The incision is a vertical rather than an oblique 
 one. After having exposed the hernia, the sac is isolated, and having tied 
 it as usual the sheath of the rectus muscle is opened by a longitudinal 
 incision six to eight centimeters in length. The aponeurotic folds are 
 held back by a fine Kocher's forceps. A muscular flap with the pedicle 
 below is separated, using especially the channeled sound ; the muscle 
 above is seized en masse and tied with catgut and cut. The flap is about 
 four to five centimeters long, after retraction, and about a centimeter to 
 a centimeter and a half wide. All this can be done without causing any 
 hemorrhage, and generally without tying a single ligature. 
 
 Lifting the internal pillar with a Kocher's forceps, the sheath of the 
 rectus muscle is opened below the pillar with a bistoury passed f^at and 
 the flap is looked for as it is made to pass through the opening as low as 
 possible. The incision in the sheath of the rectus muscle is closed with a 
 few sutures. When this has been done, the muscular flap is drawn into the 
 hernial region and sutured above to the lower border of the inferior 
 oblique and transversaHs muscles, and below to the crural arch. The 
 hernial pillars are sutured above it, and the operation is completed as usual. 
 In this way the inguinal orifice, or, rather, the hernial opening, and all 
 the region surrounding it, is closed by a solid flap of muscle which con- 
 stitutes a natural barrier. 
 
 WOELFLER'S OPERATION. 
 
 The principle of this method is the closure of the hernial opening by 
 suturing the internal oblique and transversalic muscles to Poupart's liga- 
 ment. Woelfier also removes the rectus muscle from its sheath and sutures 
 it to Poupart's ligament. At one time he made use of a method of trans- 
 posing the cord, which did not, however, prove very satisfactory. It 
 consisted in removing the testes from the scrotum by severing the guberna- 
 culum of Hunter. He then severed the transversaHs fascia at the outer 
 border of the rectus muscle and separated the subserous fascia from the 
 recti muscles. The testis is then pushed in through this opening, anvi out 
 between the two recti muscles. It is brought down in front of these mus- 
 cles and transferred to the scrotum, where it is again sutured to the guber- 
 naculum. 
 
 Naturally, serious complications often followed this method of trans- 
 position, because the cord was very likely to be compressed by the con- 
 
250 OPERATIONS FOR INGUINAL HERNIA 
 
 tracting recti muscles or the formation of scar tissue, and the result was 
 atrophy of the testis. Gangrene might also ensue. The method was prac- 
 tised but little b}- Woelfler himself, and rarely by any other operator. 
 
 BALL'S OPERATION. 
 
 Charles Ball operates on reducible inguinal hernia as follows : An 
 incision one inch in length is made over the neck of the hernia. The 
 sac is exposed and opened, and the finger is introduced to detect adherent^ 
 omentum. The sac is then separated. If the hernia is congenital the sac 
 must be divided circumferentially, leaving the lower portion, but peeling 
 off the upper portion from the cord. The sac is cleared up to the external 
 ring and is twisted with forceps. A curved needle threaded with stout 
 silk is carried up one inch into the subperitoneal space along the guiding 
 finger, and then directed forward through the muscles and skin of the 
 abdominal wall. The other end of the same piece of silk is passed to the 
 other side of the twisted sac and brought out through the abdominal wall. 
 The ends are tied together over a lead plate. 
 
 The sac now lies in the inguinal canal and along with the spermatic 
 cord is pressed with the finger backward toward the abdominal cavity, 
 while deep sutures are passed which take hold of the lateral structures of 
 the canal and also back up the twisted sac. If the sac is large a portion :if 
 its fundus should be excised. The skin wound is closed by continuous 
 sutures. 
 
 LEVINGS' OPERATION. 
 
 A. H, Levings (American Journal of Surgery and Gynecology, Feb- 
 ruary, 1905) employs an operation for the cure of congenital hernia in 
 the canal of Nuck, which is practically the same as the operation recom- 
 mended by me. The incision is made parallel to the inguinal canal, ex- 
 tending one-half an inch internal to the external ring, and passing along 
 the course of the canal to the region of the external ring. The aponeurosis 
 of the external oblique muscle is divided to the upper border of the internal 
 ring. When practicable, the peritoneal process should be separated from 
 the cord up to the internal border of the internal ring, where it is ligated 
 and cut away. 
 
 If it is found difficult to separate the peritoneal sac from the tissues 
 of the round ligament, all of these structures may be dissected up to the 
 internal ring, where they are ligated and cut away. In these cases a stout 
 catgut suture should be carried through the pillars of the internal ring and 
 the stump of the cut cord and sac so as to fix the cord in this position 
 and give anterior support to the uterus. Three or four heavy sutures of 
 catgut should be passed through the shelving portion of Poupart's liga- 
 ment and made to pick up the internal oblique and transversalis muscles 
 in the form of mattress sutures, thus bringing down the internal oblique 
 and transversalis muscles and closing the internal oblique and inguinal 
 canals. In closing the incision in the aponeurosis of the external oblique, 
 the sutures should take up at the same time a portion of the internal 
 oblique muscle, so as to make of all three layers one solid mass of tissue. 
 
PLATE XLIV. 
 
 Ferguson's Operation for Inguinal Hernia. 
 T. F. Transversalis fascia. I. R. Internal ring. P. L. Poupart's liga- 
 ment. I. O. Internal oblique muscle. A. Aponeurosis of external oblique. 
 C. Cremaster muscle. C. T. Conjoined tendon. 
 
OPERATIOXS FOR IXGUIXAL HERNIA 253 
 
 POULLET'S OPERATION. 
 
 J. Poullet (Lyon Medicale, Xo. 24, 190 ij brought forward a method 
 for the radical cure of hernia, which does away with the necessity of 
 rest in bed. In this method the peritoneal cavity is not opened, nor is 
 there any dissection of the sac, a single cut of the bistoury being all that 
 is necessary to incise the skin. The rest of the operation is done v/ith the 
 fingers, a tubular needle, and a large metallic thread. This thread takes 
 the place of the subcutaneous truss. Poullet has operated over four hun- 
 dred times by this method. At first there were some recurrences, but 
 these have become more and more infrequent. In no case did the operation 
 aggravate the patient's condition. 
 
 Poullet operates without any assistance ; he has never ligated a 
 vessel, and as a rule the operation requires about fifteen minutes. The 
 wire he uses is steel, three-tenths millimeters in diameter, 39 inches .weigh 
 I gram, 7 or 8 inches are required for each case, and the same method is 
 used whether the hernia is inguinal, femoral or umbilical in type. 
 
 The skin incision having been Inade, the neck of the sac is isolated with 
 the fingers, and a long forceps is placed on the sac to prevent its descent. 
 A fine tubular needle is passed through the neck of the sac five or six 
 times, below the forceps, the metallic suture is placed through the needle, 
 not including the vas deferens or the vessels and nerves, to the cord. In 
 the second stage of the operation the two ends of the suture are made to 
 traverse the whole abdominal wall, except the skin, from within out to 
 about fifteen millimeters from the upper border of the external ring. To 
 do this, the left index finger is introduced deeply into the inguinal canal 
 and the needle passed between it and the abdominal wall which it per- 
 forates from within, thus implanting the two ends of the suture an inch 
 apart. The third step is to close the canal by means of the two ends of 
 the same suture. The finger still remains in the canal to guide the curved 
 needle which perforates the abdominal vv'all from within out, or from 
 without in. This needle brings each suture successively through the two 
 fibro-muscular borders of the opening to be closed, each border is trav- 
 ersed three or four times, according to the size of the opening. Poullet 
 advises not to tighten the suture at the bottom until the last insertion has 
 been made below the ring in the fibro-periosteal tissue near the pubic spine. 
 
 The two ends of the suture are brought together, not pulling on the 
 suture, nor trying to bring the pillars in contact. They are brought closer, 
 but not in contact, the wire being the barrier. The tw^o ends are twisted to- 
 gether and a perforated shot is placed on the ends so that the tissues will not 
 be lacerated. 
 
 DTJPLAY AND COZIN'S METHOD. 
 
 Duplay and Cazin about ten years ago devised an operation for the 
 cure of hernia in which buried sutures were discarded entirely. They tied 
 the sac on itself, split its distal portion, tying a series of knots, or the 
 sac was divided primarily and one-half tied to the other. The wound was 
 closed with silver wire, which was removed after union had taken place. 
 
254 
 
 OPERATIONS FOR INGUINAL HERNIA 
 
 SYMONDS' OPERATION. 
 
 In the Lancet, Feb. 2, 1901, T. H. Wells describes an intra-peritoneal 
 method for the radical cure of inguinal liernia performed by Symonds. The 
 operation is divided into seven stages: (i) An incision two and a half inches 
 long in the linea semilunaris, ending over the external ring and passing 
 through the skin, fat. superficial and deep fascia; (2) deepen the upper one 
 and a half inches through the abdominal muscles, transversalis fascia and 
 subperitoneal fat, and having arrested all hemorrhage, open the peritoneal 
 cavity; (3) explore the sac with the finger and replace the intestine; (4) in- 
 sert forceps along the palmar surface of the finger, seize the apex of the sac 
 and invert it, bringing it out into the upper wound; (5) stitch the sac. after 
 giving it a couple of twists on itself to obliterate its cavity, through the peri- 
 toneum; (6) stitch up the external ring and, (7) close the wound by bring- 
 • ing the structures layer by layer into accurate apposition. 
 
 Symonds claims for this operation that it is expeditious; the neck of 
 the sac is obliterated high up ; the inverted sac aids in forming a firm scar ; 
 the sac and contents can be explored and, if necessary, the sac opened below 
 quickly and safely; the incision allows any method of closing the inguinal 
 canal and external ring. 
 
 TOREK'S OPERATION. 
 
 Franz Torek {Annals of Surgery, May, 1906) describes an operation 
 which he has employed- in cases where an appendectomy was necessary 
 at the same time that operation was done for the relief of a hernia. 
 
 An imaginarv line is drawn from the anterior superior spine of the 
 ileum to the umbilicus. A point on this line at a distance equal to one- 
 quarter of its length from the iliac spine marks the beginning of the in- 
 cision, which is carried down from here to the external inguinal ring. The 
 aponeurosis of the external oblique is exposed throughout the length of 
 the incision. This fascia is then incised in the direction of its fibers, as is 
 customary in the gridiron operation for appendicitis, exposing the internal 
 oblique muscle ; but the incision is prolonged downward so as to terminate 
 at the apex of the external inguinal ring. 
 
 The aponeurosis of the external oblique is pared off from the underlying- 
 parts in the usual manner, on the outer side exposing Poupart's ligament. 
 Then the hernia operation is proceeded with up to the point where the 
 sac is cut oft'. Here the hernia operation is intermitted and attention turned 
 to the appendix. 
 
 The fibers of the internal oblique and transversalis muscles are separated 
 bluntly in the usual manner, the peritoneum is opened, and the appendix 
 removed ; then the peritoneum, transversalis fascia and muscles are closed 
 again. The appendicitis operation is completed, except that the aponeurosis 
 of the external oblique is still left open. Next the internal oblique and 
 transversalis are sutured to Poupart's ligament, according to any of the 
 approved methods, and finally the aponeurosis of the external oblique is 
 sutured in the entire extent of its incision, so as to close both the appen- 
 dicitis and the hernia operation. Lastly the skin is sutured. 
 
PLATE XLV. 
 
 Ferguson's Operation for Inguinal Hernia. 
 A. Aponeurosis of external oblique. I. O. Internal oblique. C Cord. 
 C. T. Conjoined tendon. P. L. Poupart's ligament. 
 
OPERATIONS FOR IXGUIXAL HERNIA ' 25/ 
 
 Torek claims that the combined operation has decided advantages over 
 the performance of the two operations at separate sittings. It saves the 
 patient one operation and it takes only very little longer than the hernia 
 operation alone would require. Furthermore, there is greater firmness of 
 the abdominal wall, as it is certainly better to have one incision in the 
 aponeurosis than two. 
 
 I have frequently removed the appendix in the course of a herniotomy. 
 For some time past I have made it a practice to explore the abdominal 
 cavity by passing my hand and arin in through the hernial incision in 
 cases where disease of internal organs was suspected. Sufficient room to 
 accomplish this is obtained by separating the internal oblique and the trans- 
 versalis muscles from Poupart's ligament. When the patient is suffering 
 with chronic appendicitis and also has a hernia, I prefer to make a single 
 incision, that for the hernia, to deal with both conditions. 
 
CHAPTER II. 
 
 OPERATIONS FOR INGUINAL HERNIA. 
 (Continued.) 
 
 BUTLER'S OPEEATION. 
 
 C. A. Butler has devised a modification of the Halsted operation. A 
 skin incision is made parallel to Ponpart's ligament and three-fourths of 
 an inch internal to it, extending from a point slightly beyond the internal 
 abdominal ring to the spine of the pubes. The subcutaneous tissues are 
 divided in their turn the full length of the skin incision. The external 
 oblique is first incised parallel to the direction of its own fibers, then the 
 internal oblicjue and transversalis are cut, and finally the transversalis fascia 
 having been divided, the spermatic canal is fully exposed from the internal 
 to the external abdominal ring, thus bringing into view the cord. The vas 
 deferens is isolated and if there is any tendency to enlargement of its ac- 
 companying veins all but two or three are ligated, above and below, and 
 dissected out. - ■' 
 
 The subcutaneous incision is extended five-eighths of an inch or more 
 beyond the internal ring, in order to release the constriction and to get 
 firm, fresh tissue from which to build the new exit for the cord. Follow- 
 ing this the sac is opened, its contents carefully examined and replaced 
 within the abdomen. 
 
 A ligature of catgut is now passed around the neck of the sac close 
 to the internal ring and the sac is cut away. The ends of the ligature which 
 have been left long are threaded separately through long curved needles, 
 passed eye-end first through the abdominal opening alongside of the stump 
 of the sac and brought out a quarter of an inch apart through the internal 
 oblique muscle at a point one and one-half inches internal to the upper 
 angle of the incision, where gentle traction is made to draw the stump of 
 the sac away from the field of operation, when, by tying the ligature, 
 the stump is held in a permanently displaced position. Any cicatricial 
 mass or tissue of questionable vitality is dissected away from about the old 
 internal abdominal ring. Each muscular layer is sutured separately, allow- 
 ing the edges to overlap as much as the tension will allow, until the ex- 
 ternal oblique is reached. 
 
 Instead of suturing the aponeurosis of the external oblique in a direct 
 line, as in case of the other layers, a strip one-half inch wide and one 
 and one-half inches long is cut from the internal border of the external 
 oblique at a point directly opposite the site of the new ring, leaving the 
 upper end of the strip fast and passing the loose end under the cord and 
 suturing it to the superior surface of Poupart's ligament. This gives a 
 firm ring with the fibers running crosswise to the direction of greatest 
 
OPERATIONS FOR INGUINAL HERNIA 259 
 
 strain. The remainder of the aponeurosis is sutured below this loop in 
 the same manner as the underlying structures, using silk or fine silver 
 wire. Butler says that this portion of the method was employed by the 
 late W. V. Morgan, of Indianapolis, for two years prior to his death and 
 since that time by himself, together in more than fifty cases, with uniformly 
 good results. 
 
 The hernia now having been reduced, the stump of sac displaced away 
 from the operative field, the cord located on its new bed and the hernial 
 opening obliterated, all that remains to be done is to suture the skin with 
 kangaroo tendon and to apply a dry dressing. 
 
 TREVES' OPERATION. 
 
 Treves performs an operation which is a modification of Macewen's. 
 The sac is twisted on itself and a part of it is cut away and passed be- 
 neath the conjoined tendon. It is brought out through an opening made 
 near the median line, and is fixed by sutures. 
 
 BISHOP'S OPERATION. 
 
 In selected cases Bishop invaginates the sac and turns it into the 
 .abdominal cavity inside out, fixing it at the internal ring so as to form 
 a boss. 
 
 SMITH'S OPERATION. 
 
 A. C. Smith employ's the following method for the radical cure of 
 congenital inguinal hernia : After forming a tunic for the testis out of 
 the lower end of the sac, the remainder of the sac, except the strip which 
 lies immediately on the vas and its vessels and nerves, is trimmed away 
 close to the abdominal cavity. The simple wound of the peritoneum is 
 closed with a continuous suture, one extremity ending at the cord. The 
 transversalis fascia is sutured either with the peritoneum or separately, 
 and the operation is completed according to the Bassini method. The 
 strip which is left attached to the cord, consisting of peritoneal membrane, 
 does not interfere with the closure of the openings in the sac. 
 
 WHITE'S OPERATION. 
 
 J. W. White, believing that some of the failures following Bassini's 
 operation might be accounted for on the ground that union failed to occur 
 between two muscles or the edges of muscular tissue unless the edges are 
 freshened, suggested cutting out an inverted V-shaped piece of tissue in the 
 external oblique muscle, w^hich makes this muscle re-enforce the weak place 
 in the abdominal wall at the internal oblique muscle and Poupart's liga- 
 ment. He suggested a variety of methods to be used to close the hernial 
 openings with muscular tissue. 
 
 In cases in which the muscular walls have been stretched and are 
 very lax he suggests raising the edge of the internal oblique and exposing 
 the outer edge of the transversalis. An inverted V-shaped piece of this 
 muscle is excised, making a round opening for the cord to pass through ; a 
 
260 OPERATIONS FOR INGUINAL HERNIA 
 
 piece is also cut out of the transversalis. The cut edges are united with 
 sterile catgut. This will make tense the lower edge of the transversalis 
 muscle, drawing it down and closing the opening of the internal wound 
 with muscular tissue. The lower edge of the internal oblique is replaced 
 and the cord raised; the sutures are then inserted into the internal oblique 
 and Poupart's ligament, as in Bassini's operation, thus making a combined 
 operation. 
 
 DAVIS' OPERATION. 
 
 G. G. Davis (Annals of Surgery, Janviar_v, 1906) presented a modifi- 
 cation of the operation usually done for the cure of a direct inguinal hernia. 
 In cases of oblique hernia the cremaster fibers are sometimes quite abun- 
 dant, and may be utilized to close the canal, but in direct hernia these fibers 
 are apt to be too scanty to be of any service. When the hernia is an old 
 one, he divides the sac transversely and overlaps these tvv'o parts, suturing 
 the apex of the lower flap to the base of the upper, and then bringing 
 down the upper flap and suturing it in place, as is dene in the Ma,yo opera- 
 tion for umbilical hernia, but without dissecting off the peritoneum, which 
 is firmly blended with the other tissues and adds considerably to the 
 strength of the flap ; whereas alone it is too weak to be of much service. 
 \^''hen the peritoneum is not adherent to the conjoined tendon and inter- 
 columnar fascia in front, but has a layer of fat between, the fat may be 
 scraped away and the two laid together and treated as a single layer and 
 overlapped. 
 
 Davis believes that the overlapping plan has been found to work 
 satisfactorily in cases of oblique inguinal hernia and umbilical hernia and 
 that it also will be found of value in certain cases of direct inguinal hernia. 
 
 DENTIT'S OPERATION. 
 
 Dentu's method is very similar to Bassini's. The primary incision 
 is made exactly the same way. The aponeurosis of the external oblique is 
 carefully exposed, but not divided. The sac is separated from the cord 
 and other attachments as high up as the internal ring. A small opening 
 is then made in the aponeurosis at one side of the internal ring, and through 
 this is passed a long forcep which grasps the fundus of the sac and draws 
 the latter through the opening. The neck of the sac is then iigated and 
 returned to the abdomen and included in the mattress sutures which close 
 the opening in the aponeurosis. The redundant anterior wall of the canal 
 is folded on itself parallel to its long axis and secured in this position by 
 mattress sutures. 
 
 KENNEDY'S OPERATION. 
 
 In Kennedy's operation the sac is dealt with by Kocher"s latest method. 
 It is invaginated into the abdomen and brought out through the abdominal 
 wall. The ligature is then cut off and the internal oblique and transversalis 
 are stitched to the deep aspect of Poupart's ligament, but without cutting 
 the external oblique tendon. The cord is not transplanted. Among fifty- 
 
. PLATE XLVI. 
 
 Ferguson's Operation for Inguinal Hernia. 
 A. Aponeurosis of external oblique. P. L. Poupart's ligament. I. O. 
 Internal oblique. T. F. Transversalis fascia. C. Cremaster muscle. 
 
OPERATIONS FOR INGUINAL HERNIA 263 
 
 four patients operated on by Kennedy according to this method there was 
 only one case of relapse. 
 
 OWEN'S OPERATION. 
 
 The operation performed by Owen to cure inguinal hernia occurring 
 in boys is a good deal like that of Mitchell-Banks, except that Owen passes 
 the sutures deeply through Poupart's ligament, and the muscular inner 
 wall of the inguinal canal, so as to keep them in permanent contact. The 
 stitches cause the deposit of a large amount of plastic exudation, which 
 in the course of time is replaced by fibrous tissue which makes a splendid 
 barrier. 
 
 No doubt Owen, whose experience has been very extensive, is aware 
 of the fact that almost any operative procedure will cure a hernia occurring 
 in boys, provided the muscular development of the patient is normal. 
 
 BARNHILL'S OPERATION. 
 
 J. U. Barnhill has devised an improvement of the Bas?ini operation, 
 which, in my opinion, is as irrational in principle as is the operation which 
 it is intended to modify. In Barnhill's operation the skin and superficial 
 fascia are divided from the spine of the pubis to slightly beyond the inter- 
 nal abdominal ring. The external oblique aponeurosis is divided to about 
 the same point, leaving the lower flap of fairly good width. The sac is 
 then carefully separated from the cord, opened to free it of intestine, trans- 
 fixed, ligated high up, and excised, when it will retract through the internal 
 ring. If there are varicose veins in the spermatic cord the largest are 
 ligated and excised. The cord being held up out of the way, the transver- 
 salis fascia and internal oblique, including the conjoined tendon, are then 
 stitched to the shelving portion of Poupart's ligament, two stitches being 
 placed in the internal oblique muscle above the opening for the passage 
 of the cord to gather up the muscle and fascia, with a view of obliterating 
 the inguinal fossa, care being taken to bring the cord well down to the 
 lower border of the internal oblique, thus giving it considerable obliquity 
 in passing beneath these muscles. Mattress sutures are then passed 
 through the lower flap close to Poupart's ligament — that is, in the lower 
 portion of the outer flap — catching the margin of the internal oblique and 
 its fascia and the lower margin of the upper or internal flap. Three such- 
 mattress sutures are placed in the upper part of the incision over the muscle 
 and cord, the other four being passed beneath the cord. 
 
 A small incision, sufficient to niake an opening large enough for the 
 passage of the cord, is made in each flap ; in the upper one at a point an 
 half inch below that at which the cord passes out through the internal 
 oblique, and the one in the lower flap at the junction of its lower and 
 middle third. The mattress sutures are then tied and the cord passed 
 through the opening in the upper flap. The lower flap is then carried up- 
 ward over the cord and stitched to the upper flap above the cord, except 
 the lower third, which is passed beneath the cord and stitched in like man- 
 
264 OPERATIONS FOR INGUINAL HERNIA 
 
 ner. Both layers of the superficial fascia are then approximated and the 
 wound closed with a subcuticular silkworm-gut suture. 
 
 BEAVER'S OPERATION. 
 
 John B. Deaver, of Philadelphia, prefers to use a combination of the 
 Macewen and Bassini operations. The anterior wall of the inguinal canal, 
 excepting the lower fibers of the internal oblique muscle, is divided, the 
 sac freed, and replaced at the internal ring after the manner of the Macewen 
 operation. The canal is then closed as in the Bassini operation. 
 
CHAPTER III. 
 
 OPERATIONS FOR INGIINAL HERNIA. 
 (Continued.) 
 
 ANDREWS' IMBRICATION METHOD. 
 
 E. Wyllys Andrews, of Chicago, advocates overlapping the aponeuro- 
 sis of the external oblique muscle in the case of large hernias where' there 
 is a marked anatomical defect, and in cases of long-standing, where the 
 aponeurosis is redundant and where it is better to imbricate than to re- 
 move or plicate it. The internal lip of the cut aponeurosis is sutured to 
 Poupart's ligament under the cord, and the lower flap of the aponeurosis 
 is brought up over the cord and fastened to the anterior surface of the 
 aponeurosis along the inner border of the cord. Andrews overlaps these 
 structures (Fig. 38), no matter whether the Bassini operation or that of 
 the author is performed. The overlapping can be done in front of or 
 behind the cord, or the cord may be placed between the flaps. The imbri- 
 cation gives broad surfaces for union and by this means an opening of any 
 size can be covered with a stout fibrous layer. 
 
 While I fully agree with Andrews that imbrication of the aponeurosis 
 of the external oblique muscle is desirable to obtain additional strength in 
 the inguinal region, and I have always practised it in suitable cases ever 
 since I saw Macewen do it in 1889, still in a rational operation sight must 
 not be lost of (a) the slack of the transversalis fascia at the internal ring 
 and its correction; (b) the arched up and often deii-cient internal oblique 
 muscle and its restoration to its normal position; (c) the normal position 
 of the cord and that its removal from its bed invites a relapse of the her- 
 nia; and (d) we must not leave a weakened conjoined tendon unpro- 
 tected. It is not indicated to overlap the flaps of the aponeurosis when 
 undue tension is required to hold them in the imbricated position. 
 
 NOBLE'S OVERLAPPING OPERATION. 
 
 C. P. Noble has for some time made use of an operation in which 
 the peritoneum is first closed with a continuous suture of fine cumol catgut. 
 The fat is then dissected from the upper surface of the aponeurosis of the 
 transversus muscle on the left side of the wound over one-third to one-half 
 inch. The aponeurosis on the right side of the wound is then separated 
 for an equal distance from the rectus muscle. The muscle and fascia are 
 then sutured by means of a medium weight chromicized catgut suture. 
 
 The suturing is begun at the lower angle of the wound on the left 
 side, the suture being passed from above downward through the aponeu- 
 rosis and rectus muscle. Then the separated bundles of the rectus muscle 
 are united with a continuous suture until the upper angle of the wound 
 
266 OPERATIONS FOR INGUINAL HERNIA 
 
 is reached, when the suture is passed from below upward through the 
 aponeurosis on the left side of the wound. The suture is then passed from 
 below upward through the aponeurosis on the right side of the wound 
 and an additional suture is taken above this point to fix the suture and 
 to take the strain off that part v*diich has brought the muscle into apposi- 
 tion. The aponeurosis is then closed from above downward by catching 
 the aponeurosis over the left side of the wound after the manner of the 
 Lembert intestinal suture, and then passing the needle from below upward 
 through the aponeurosis on the right side of the w^ound. When this 
 suture is drawn taut, it slides the aponeurosis of the right side of the 
 wound on the aponeurosis of the left side. The process is repeated until 
 the upper angle is reached, when the two ends of the suture are tied. 
 
 In long wounds two or more mattress sutures are placed to take the 
 tension off the lines of continuous suture. The fat is closed wdth a con- 
 tinuous suture of fine cumol catgut. This is also used to close the skin 
 by means of the intra-cuticular method. In 1898 Noble abandoned silk- 
 worm gut sutures, and the continuous chromicized catgut suture for the 
 rectus muscle and for the aponeurosis was substituted. This method is 
 employed for celiotomies, herniotomies and the Alexander operation. 
 
 FREEMAN'S OPERATION. 
 
 The operation employed by L. Freeman is really a new method of 
 suturing. Before the operation is begun two or three needles are threaded 
 with long loops of silkworm gut or silver wire. Two pieces of stiff" silver 
 wire are taken, long enough to reach the entire length of the inguinal 
 canal. The internal ring is exposed ; the sac is ligated and cut off, and 
 the cord is held out of the way. One of the silkworm loops is passed from 
 without inward through the muscle tissue on the umbilical side of the ring, 
 wxll back from the margin, and tolerably close to the point of exit of the 
 cord. The loop is then carried through Poupart's ligament from within 
 outward. Another loop is inserted near the pubic end of the opening. 
 
 One of the pieces of prepared wire is run through the loops, which 
 are pulled tight enough to hold it in place. The other wire is laid along 
 Poupart's ligament between the free ends of the loops which are tied 
 firmly over it. The wires are thus approximated. To facilitate the removal 
 of the wires they are bent upward at their pubic extremities so as to pro- 
 trude through the external incision. The cord is dropped in place over 
 the line of union and the aponeurosis of the external oblique muscle is 
 united above it, the upturned ends of the wires passing through the ex- 
 ternal ring. This aponeurosis can be sutured either with removable suture 
 or with catgut because this structure is not subjected to tension. 
 
 In uniting the skin the free ends of the loops and the ends of the wires 
 are brought out through the incision between the stitches. In from ten 
 days to two weeks the wires are removed. This frees the loops, which are 
 likewise extracted. 
 
PLATE XLVTI. 
 
 Diagram of the position of the transplanted rectus muscle, demon- 
 strating the slight change in the direction of its fibers. — Bloodgood's opera- 
 tion. (Johns Hopkins Hospital Report. Vol. VH.) 
 
OPERATIONS FOR INGUINAL HERNIA 269 
 
 M'ARTHUR'S AUTOPLASTIC SUTURE. 
 
 L. L. McArthur, of Chicago, takes his suture material from the aponeu- 
 rosis of the external oblique muscle. He claims that the grafted suture 
 remains as fibrous tissue, or if it dies and becomes absorbed after a pri- 
 mary union has taken place, it accomplishes all that is accompHshed by 
 foreign suture material; whereas, if the suture lives, as his experiments 
 seemed to prove was the case, it remains to offer a permanent resistance to 
 future stretching (Figs. 39 and 40). 
 
 The skin and fat having been cut by the usual incision exposing the 
 external ring, the latter is prolonged upward in the usual manner, but to 
 its commencing muscular insertion. Special care is taken to parallel the 
 tendinous fibers. This divides the aponeurosis into an external and internal 
 flap, each of which can be readily separated from its contact with the 
 internal oblique. 
 
 The sac having been treated as the operator deems best, a bundle of 
 those white fibers which enter into the formation of the internal pillar of 
 the ring is then split off, from below upward, from the edge of the internal 
 flap of the aponeurosis of the external oblique, quite up to its termination 
 in the muscle belly. Above it is cut loose, but left attached to the pubic 
 spine below. This strip should vary in Avidth from one-eighth to three- 
 sixteenths of an inch, according to the development of the tendon. An 
 identically similar strip, beginning in the external pillar of the ring, is taken 
 from the outer flap of the external oblique. At this stage the suturing is 
 to be done. 
 
 The operation is completed, according to the choice of the operator, 
 bv the Bassini, an Andrews imbrication, or Girard method, using these 
 strips as suture material for a running stitch. As a convenient means 
 of handling, and for the purpose of avoiding infecting the graft suture, a 
 needle threaded with No. 3 silk is tied by a single knot to its free end, 
 and bv it the tendon graft is drawn through the tissues to be united. 
 Using the graft ending in the internal pillar for the first or deep suture, 
 the surgeon dra\vs the internal oblique and transversalis down to the 
 inner aspect of Poupart's ligament, as shown in the drawing, suiting his 
 convictions as to raising or not raising the cord. If he raises the cord 
 (Andrews), then no opening is left below for an external ring; if the 
 cord is not raised (Ferguson, Bassini), then the first stitch determines the 
 fit of the external ring around it. 
 
 The edges of the external oblique are then sutured with a running 
 stitch, using the graft made from an external pillar of the ring when a 
 Bassini is being done ; to the surface of the external oblique when an 
 Andrews or Girard is done. The ends of the suture strips can be fixed 
 by a simple knot in it, or by one or two stitches through and back, as a 
 tailor fixes his thread, or by a fine catgut stitch wnth the graft end caught 
 in its knot. 
 
 The deep suture penetrates the external oblique muscle for final fixation 
 after the new^ internal ring has been made. The skin and fat are approxi- 
 
270 OPERATIONS FOR INGUINAL HERNIA 
 
 mated according to the preference of the surgeon. A'lcArthur emphasizes 
 the importance of Hberating these strips of aponeurosis from below upward, 
 and not from above downward, because the fibers often curve outward 
 around the external ring', when followed in the latter manner. 
 
 HAEillS' WIRE SUTURE. 
 
 M. L. Harris, of Chicago, claims that wire suture can be employed 
 advantageously in all hernia operations (Fig. 41). The operation is per- 
 formed in the usual manner up to the stage of the ablation of the sac. 
 Harris claims that the advantages of the wire used by him, aluminum 
 bronze, Nos. 26 and 27, are its greater tensile strength, so that a smaller 
 wire can be used, and the fact that it does not kink so readily. The wire 
 can be easily, quickly and certainly sterilized by simply placing it in boil- 
 ing water with the instruments. In closing a median incision through 
 the abdominal wall, three wire sutures are used, one closing the peritoneum, 
 one in the sheath of the rectus muscle, and one in the skin. 
 
 The sutures are introduced in the following manner : A No. 27 
 aluminum bronze wire is threaded directly in a nearly full-curved round 
 needle with a specially constructed eye for carrying wire so that it will 
 not slip in the eye. The needle is made to enter the skin in the midline, 
 I to 3 cm. from the angle of the incision, and penetrates obliquely all the 
 tissues down to the peritoneum, where it should appear at the angle of the 
 peritoneal incision. The peritoneum is now taken up with the needle, 
 parallel with and quite near to its edge, first on one side and then on the 
 other, constantly in an advancing manner until the entire length of the 
 incision has been traversed. The grasp of the needle should not be more 
 than a centimeter in length, and the point of entrance of one grasp should 
 be opposite the point of exit of the last grasp. The suture is then brought 
 obliquely to the surface about the same distance from the cutaneous angle 
 as at its point of entrance. 
 
 The second suture, wire. No. 26, enters in the midline, but a little 
 nearer the angle of the incision. It penetrates as far as the sheath of the 
 rectus muscle, where the edges of this fascia are taken up longitudinally 
 in exactly the same manner as has just been described for the peritoneum. 
 No sutures are applied to the recti muscles. At no point in the midline 
 do the recti muscles lie in contact with one another ; hence, m closing a 
 median incision, it is unnecessary to suture together the recti muscles with 
 the expectation of obtaining union between them. The dense, thick, con- 
 joined fascia, of the linea alba in the upper part of the abdomen or 
 the firm anterior layer of the muscle sheath below Douglas" fold is the 
 all-important layer to be sutured. This is the layer m which the most 
 perfect apposition, edge to edge, should be secured. The third suture is 
 the usual subcutaneous or subcuticular suture. The wire enters and leaves 
 at the angles of the incision, running along in the corium, in and out, in 
 the same manner as has been described for the other two. It does not ap- 
 pear on the skin at any point, except where it enters and leaves. After 
 
PLATE XLVIII. 
 
 Ferguson's Operation for Inguinal Hernia. 
 {Ochsner's Clinical Surgery.) 
 
OrERATIONS FOR INGUINAL HERNIA 2.^2^ 
 
 the wires are introduced they are drawn back and forth until they are 
 perfectly straight and move easily through the tissues. 
 
 The wound may now be dressed in any manner one chooses. Thj 
 method Harris uses is to seal the line of union with silver foil, after th.j 
 method of Halsted. On this he places a compress of a few layers of plain 
 sterile gauze, over which are folded the ends of the wires, which should 
 be left long. On these is placed another similar compress, followed by 
 the usual dressing of plain sterile gauze and cotton. The wires are usually 
 allowed to remain two weeks. To remove the wires, they should be drawn 
 back and forth gently until loosened in the tissue, then one at a time cut 
 close to the skin and .withdrawn. They are easily removed with scarcely 
 any pain. Care should be taken not to break the wires by pulling sud- 
 denly before loosening them. In closing the muscle-splitting incision in 
 interval operations for appendicitis, one wire parallels the fibers of the 
 internal oblique and transversalis, entering and leaving the skin some 
 distance from the cutaneous incision, and crossing it almost at right angles. 
 Another wire parallels the fibers of the external oblique, and a third forms 
 the subcuticular suture. 
 
 In cases of inguinal hernia the suture is applied in the following man- 
 ner: 
 
 The needle enters the skin from one to tv/o centimeters from the 
 inner angle of the incision, passing directly down to and taking up a 
 "bite" of the beginning of the inner edge of Poupart's ligament. A "bite" 
 about one centimeter in length is then taken directly opposite, including the 
 external oblique and the internal oblique and transversalis, or so-called con- 
 joined tendon. Then a "bite" in Poupart's ligament, passing back and forth 
 until an opening only large enough to permit the passage of the cord 
 remains at the outer angle. Passing the wire beneath the cord, it is 
 brought out through the external oblique and skin about one or two centi- 
 meters from the outer angle of the incision. 
 
 The wire should be pulled back and forth until it is perfectly straight 
 and moves easily in the tissues. This wire is very easily introduced by 
 paying a little attention to a few points. Place a snap forceps on the free 
 end of the wire to keep it taut. Draw each stitch taut at once. Enter at a 
 point directly opposite the point of the last stitch. Take each "bite" 
 parallel with the edges to be brought together. Do not make an over-and- 
 over stitch, as it will not pull out. Do not allow the wire to kink. 
 
 After the wire is in, the cord is laid along its bed and the lower flap 
 of the aponeurosis of the external oblique covered over it and sutured by 
 wire introduced in the same manner as the first (Fig. 41), but passing 
 from the outer to the inner angle of the incision, leaving an opening at 
 the external abdominal ring just large enough to give exit to the cord. 
 The cutaneous edges are now brought together by a third wire on a cut- 
 ting-needle passed in the corium, a so-called subcuticular suture. The 
 incision is sealed with silver foil, a pad of several thicknesses of gauze 
 placed on the first one, and the whole held in place by a couple of strips 
 of adhesive plaster. The wires are removed at the end of two weeks. 
 
274 OPERATIONS FOR INGUINAL HERNIA 
 
 There is one criticism that I wish to make in regard to the manner 
 in which the first wire is used with the cord raised out of its bed, and 
 that is this: The danger of injuring the cord at the upper and also the 
 lower angle of the wound, where the wire hugs it closely. This danger is 
 obviated by not raising the cord out of its bed at all, and insures a radical 
 cure even better than the method of Bassini and its modifications. 
 
 REMOVABLE CONTINUOUS SUTURES. 
 
 L. Gratschoff employs a method of closing the inguinal canal which he 
 believes offers special advantages. He uses a piece of steel wire about 
 13 cm. long, terminating in a small perforated ball at each end. Two 
 small hooks to hold the silk thread are soldered to the wire, which is drawn 
 up into the shape of a bow after it has been introduced into the inguinal 
 canal. After the hernia has been taken care of, one end of the wire is 
 introduced through the incision and a stout silk thread is fastened to one 
 of the hooks and passed through the end of the wire bow and then around 
 the internal and then the external pillar, and again around them, until 
 enough stitches have been taken. The needle is then brought out through 
 the skin and the silk is drawn taut and fastened to the other end of the 
 wire bow. Both wire and sutures are rem.oved by the end of the week. He 
 has thus treated 44 patients with gratifying results. 
 
 WITHERBEE'g REMOVABLE SUTURE. 
 
 O. O. Witherbee inserts a figure-of-eight suture which he claims 
 cannot be adjusted with sufficient tension to stop the circulation if prop- 
 erly inserted. It has the additional advantage of being removable, and con- 
 sequently it does not overburden the power of absorption nor does it 
 tend to cause sloughing. To insure proper fixation and to relieve the skin 
 from undue pressure, a U-shaped plate is employed to the arms of which 
 are attached the sutures after they emerge from the skin. Witherbee 
 claims that four silkworm gut sutures thus introduced will effectually ap- 
 proximate both layers of Poupart's ligament with the external and in- 
 ternal oblique, the transversalis and the rectus muscles, if necessary, main- 
 taining their approximation for an indefinite period, or, at least, until 
 firm union has taken place. Witherbee also advises leaving the cord alone 
 and sparing the tissues all unnecessary manipulation. 
 
 REMOVABLE CONTINUOUS SUTURES. 
 
 Charles H. Davison, of Chicago, employs a suture for the closure of 
 all laparotomy wounds that are not drained, a removable, continuous, 
 longitudinal, silkworm gut suture, which approximates each layer. Al- 
 though the suture was not devised especially for the closure of hernial 
 wounds, yet it may be used for this purpose (Fig. 42). The suture in the 
 fascia of the abdominal wall is fastened by terminal bowknots on the upper 
 surface of the fascia, and the free ends of the suture are allowed to pro- 
 trude from the wound. The bowknots are untied by traction on the ex- 
 posed ends, and the suture removed at the completion of the process of 
 healing. 
 
PLATE XLIX. 
 
 Ferguson's Operation for Inguinal Hernia. 
 (Ochsner's Clinical Suro-ery.) 
 
OPERATIONS FOR INGUINAL HERNIA 2/7 
 
 The technic of the suture of the wound in a median laparotomy is as 
 follows: All hemorrhage in the wound in the abdominal wall is stopped 
 by spong-e pressure, by forcipressure or by torsion ; no catgut whatever is 
 used. The edges of the peritoneum are caught with forceps, and are held 
 up. away from the intestine, by an assistant, and the peritoneum is approx- 
 imated by a continuous ringbone suture. The suture is lightly shirred to 
 take up all the slack, and the ends are left hanging out of the angles of the 
 wound, temporarily held out of the way by snap forceps. In a median 
 laparotomy the linea alba is the strong layer of the abdominal wall, and if 
 this layer be fastened securely there can be no spreading- of the wound. 
 The edges must be accurately approximated. The fat must be cleaned 
 away, so that there shall be no interposition of tissue between the edges 
 of the fascia, as that would weaken the line of union and predispose to 
 ventral hernia. For this suture a perfect strand of silkworm gut, soft and 
 pliable from recent boiling, is selected. A small reverse bowknot is loosely 
 tied lo or 12 cm. from the end of the strand. The edges of the fascia are 
 caught with forceps and held by an assistant. The suture is introduced in 
 a firm place in the fascia back from the angle of the wound and drawn up 
 to the knot, and the fascia is approximated by a continuous herring-bone 
 suture. The needle perforations in the fascia are placed about ^ cm. 
 from the edge and i cm. apart. 
 
 At the last stitch the suture is shirred up tightly, grasped by a smooth 
 (serrations filed off) dissecting forceps at its exit from the fascia, held by 
 an assistant, and another reverse bowknot tied below the point of the for- 
 ceps. In tying the knot around the forceps the strand must pass under the 
 forceps, and the loop must pass up from below, or no knot will result. The 
 greatest care must be used not to crush or fray the silkworm gut with the 
 forceps at the knot, for such a defect might cause the stiand to break at 
 that point at the time of removal. As the bowknot is intended only to 
 form a body to obstruct the passage of the sutures through the fascia, it 
 should be tied loosely, to make a larger obstruction, and to facilitate its 
 untying at the time of removal. The ends of the tied suture must not be 
 held out of the way by snap forceps, as their weight might untie the knots. 
 The linea alba, being securely fastened, takes all the tension from the other 
 layers, and the unfastened sutures in the other layers do not tend to pull 
 loose. 
 
 The skin is closed by the Halsted subcutaneous stitch. If the patient 
 is very fat, an extra running suture can be placed to approximate the fat 
 and to avoid a dead space. If the wound is too long to close with a single 
 silkworm gut strand, it is closed in sections, by repeating each suture. 
 Lateral celiotomies are closed by suturing each layer of fascia with a tied 
 strand of silkworm gut, not allowing muscle or fat to be included in the 
 suture. 
 
 SINGLE TIER SUTURE. 
 
 J. R. Eastman (Annals of Surgery, Jan., 1906) describes a method 
 for closing all the layers with a single tier of easilv removable non-buried 
 
278 OPERATIONS FOR INGUINAL HERNIA 
 
 sutures which coapt all the layers either according to Bassini's method or 
 the method devised by the writer. In six cases operated according- to this 
 method Eastman used a heavy Pagenstecher celloidin linen. The incis- 
 ion is carried down to the aponeurosis of the internal oblique muscle, so 
 as to expose both the external and internal rings. The overlying super- 
 ficial tissues should be wiped with gauze, so that Poupart's ligament may 
 be exposed freely. After reduction of its contents the sac should be 
 twisted on itself as advocated by C. PL Mayo. The suture, bearing a 
 needle on each end, is first passed through Poupart's ligament from with- 
 out inward, one inch from its free margin. It is then passed through the 
 outer border of the internal oblique and transversalis muscles and brought 
 back through the ligament about one-third of an inch nearer its margin 
 than the first point of passage. The needle is then made to overlap the 
 free margin of Poupart's ligament and the aponeurosis of the external 
 oblique by carrying the linen through in the form of a simple running 
 mattress suture. 
 
 The needle is next passed through the superficial fascia, fat and skin 
 emerging about one-eighth of an inch from the skin wound margin on 
 the side opposite Poupart's ligament. The needle on the tail of the suture 
 is brought up through the subcutaneous fat and skin on the side of the 
 ligament when traction is made on the two ends of the suture. No kinks 
 or curls remain, and the suture is tied as a simple loop which may be drawn 
 out with the slightest traction. 
 
 The method is said to be applicable in practically every case of radical 
 operation for inguinal hernia in children. In small hernias in adults the 
 simple tier method is applicable, and in very large hernias, with a wide 
 separation of the conjoined tendon and Poupart's ligament, this suture is 
 not efficient. 
 
 SILVER WIRE m mGUINAL CANAL. 
 
 About seven years ago A. M. Phelps, of New York, conceived the 
 idea of introducing silver wire into the inguinal canal in cases where the 
 hernia was unusually large. He used a very fine wire that had been ster- 
 ilized carefully, then immersed in carbolic acid and passed through the 
 flame of an alcohol lamp just before using. He claimed that from twenty- 
 five to a hundred feet of wire could be inserted without causing any dis- 
 turbance, and in one case he introduced as much as three hundred feet 
 of the wire. It was not necessary to remove the wire subsequently. 
 
 ELECTRICITY IN HERNIA. 
 
 In August, 1899, H. Lane reported his results obtained from the use 
 of electricity for the cure of hernia. He introduced a needle into the 
 inguinal canal and passed a current of electricity of the strength of twenty 
 milliamperes for twenty minutes. A truss was then applied, which the 
 patient was instructed to wear for two months, at the end of which time 
 a cure is efifected. 
 
OPERATIONS FOR INGUINAL HERXIA 2/9 
 
 BICYCLING m HIENIA. 
 
 Some years ago Championniere stated that bicycling was of benefit 
 in the treatment of hernia because it tended to strengthen the abdominal 
 muscles and to improve the general health. The use of the bicycle should 
 be begun soon after the patient recovers from the operation. 
 
CHAPTER IV. 
 
 THE TYPIC OR ANATOMIC (FERGUSONj OPERATION. 
 
 This operation was devised by the author January, 1898, presented to 
 the profession in Ma}^, 1900, at a meeting of the American Medical Associa- 
 tion, at Columbus, Ohio, and published in the Journal of the Association, 
 July I St, of the same year. * - 
 
 On page 644, ''Haiidhuch der praktischen Chirurgie," by Bergmann, 
 Bruns and Mikulicz, III B. L T., appears a cut illustrating what is called 
 Girard's operation, in which the internal oblique muscle is sutured to Pou" 
 part's ligament. In this particular, and in that the spermatic cord is not dis- 
 lodged, the operation resembles the typic operation of the writer. The 
 Girard operation was first published in the October, 1900, number of the 
 Archives Provinciale de Chirurgie. It would not be necessary to refer to 
 what has been erroneously called Girard's operation, were it not that errors 
 of omission and commission on the part of certain American surgeons have 
 recently manifested themselves at discussions on the subject of hernia. 
 
 C. Hoffman {Centralhlatt f. Chirurgie, October, 1903) describes an op- 
 eration which embodies the principles governing the typic operation. In it 
 the sac, the transversalis fascia, the internal oblique muscle, and the aponeu- 
 rosis of the external oblique, are dealt with much the same as is done by the 
 writer, only differing in minor matters of technic. A. J. Ochsner (Central- 
 hkbtt f. Chirurgie, April 2, 1904) very kindly pointed out to the German 
 profession that this is Ferguson's operation, published four years previous 
 to Hoffman's article, which was no doubt inadvertently overlooked by him.. 
 
 While the anatomic principles on which the typic operation is founded 
 are as unassailable and as fixed as is the anatomy of the part itself, the tech- 
 nic, however, may vary materially according to the conditions encountered. 
 Since the presentation of this operation to the profession, the writer has not 
 found it necessary to make any material improvements or modifications. A 
 few new aids to its performance will be offered in the text, and the number 
 of illustrations for its demonstration is lessened. 
 
 The aim of the operative procedure is to imitate nature by fixing the 
 various structures in their proper relationship, one to the other. Even when 
 the anatomy is very defective (congenital or acquired), the surgeon who 
 possesses a practical knowledge of the normal parts in the inguinal region, 
 and who is an experienced operator, should have little difficulty in differen- 
 tiating one structure from another, and executing a rational procedure which 
 takes into consideration the function of each anatomic entity in this area. 
 
 It is admitted that over six per cent, of the recurrences in Bassini's op- 
 eration occur at the upper angle of the wound. Why? Because the cord is 
 
THE TYPIC OR ANATOMIC (fERGUSON) OPERATION 28I 
 
 transplanted there and the internal ring does not receive full protection. 
 This in itself is a sufficient reason for discarding that operation, especially 
 when another (the writer's) can be selected, which is easier of execution, 
 involves less manipulation of the structures, is anatomically and physiologi- 
 cally perfect, and, as far as its author knows, is without recurrences. Hal- 
 sted says : "It was well worthy of note that all of the cases treated in this 
 manner (cord undisturbed) remained cured." The writer, prior to 1898, 
 observed that recurrences at the upper end of the wound were frequent, and 
 in 1898 discovered a deficient attachment at Poupart's ligament of the in- 
 ternal oblique muscle. These observations led to the evolution of his typic 
 operation. 
 
 At the writer's request, his assistant, who was also teaching surgical 
 anatomy, made fifty dissections and some experiments on the cadaver. These 
 supported the author's claim regarding the congenital deficient origin of the 
 internal oblique muscle at Poupart's ligament. Inasmuch as every opera- 
 tion for the cure of hernia is a dissection on the living, accurate measure- 
 ments made while operating will verify the above, which has been done by 
 myself in almost every case for the last eight years. 
 
 Before proceeding with the description of the Ferguson operation, let 
 us consider briefly some points in the etiology of hernia that are essential 
 to a correct understanding of this operation. 
 
 Let the passive intra-abdominal pressure predisposing to rupture be 
 what it may — elongated mesentery, large omentum, or what not — we cannot 
 hope to lessen it to any great extent; but we can strengthen the abdominal 
 wall at the seat of rupture in such a manner as not only to withstand the 
 passive, but also resist the active pressure within the abdomen while strain- 
 ing, lifting etc. 
 
 The etiology of inguinal hernia is still a problem. While it is correct 
 to say that the congenital oblique inguinal hernia is usually due to the non- 
 closure of the funicular process at the internal ring, it does not explain why 
 this process remains patulous in some men and why it closes in others. 
 When we consider the physiologic process by which the testicle descends 
 from the abdominal cavity to the scrotum, it' is not surprising that oblique 
 inguinal hernia is five times more common in the male than in the female, 
 and that over three-fourths of all abdominal hernias are of this kind. Im- 
 perfect closure of the internal ring is common. It is occasionally open, and 
 no hernia protrudes ; then it must be that the bowels and omentum are well 
 suspended, and do not press unduly on the abdominal wall or valvular ar- 
 rangement of the structures at the internal ring and along the canal, which 
 is normal, and Cooper's fascia is strong and firm. In a perfect anatomic 
 subject the internal ring is so smoothly closed over that an infundibular 
 process of the peritoneum is very insignificant, or not at all perceptible ; the 
 valve formation of the internal ring and canal absolutely prevents a giving 
 way at the internal ring, for the more the intra-abdominal pressure increases, 
 the tighter the valve closes ; provided, however, that a normal muscular and 
 aponeurotic support is protecting it external to the transversalis fascia. 
 
 The two main structures that stand on guard to protect the internal 
 
282 
 
 THE TYPIC OR ANATOMIC (FERGUSON ) OPERATION 
 
 1, 
 
 1^ 
 
 ring- are the internal oblique muscle and the aponeurosis of the external 
 ' oblique, the former being the active agent ready to contract instantly, the 
 moment the ring is subjected to a sudden increase of intra-abdominal pres- 
 sure, as in running, jumping, lifting, etc. The fact is that in oblique hernia 
 the internal ring receives no substantial protection from the internal oblique 
 muscle, for the reason that it is not attached to the internal aspect of Pou- 
 part's ligament sufficiently low down, and as it passes downward and in- 
 ward from its deficient origin, it passes above the center of the internal 
 ring; or the lower border of the muscle which forms the cremaster is not 
 held down sufficiently to prevent a protrusion of the abdominal contents. 
 
 Indeed, the origin of this muscle may be entirely deficient at Poupart's 
 ligament, and this affords an opportunity for a sausage-shaped protrusion 
 of a hernial nature in the groin. Is it not probable that this congenital de- 
 fect of the internal oblique muscle is accountable for the non- closure of the 
 internal ring? If the internal ring is protected auring the descent of the tes- 
 ticle, one would suppose that the muscular tonicity v^^ould soon close the 
 course the testicle had taken behind the internal oblique muscle. 
 
 The key to the radical cure of oblique ingumal hernia is to suture the 
 1 internal oblique muscle and its tendon to the inner aspect of Poupart's liga- 
 ment, as low down as possible, without undue tension, after having ablated 
 the sac and strengthened the internal ring with a few stitches above the 
 'root of the cord. Any operation for the cure of hernia that diverts the 
 cord from its natural course favors return, endangers the testicle and is 
 empirical, and empiricism is the very thing that thinking men through all 
 the centuries have been trying to avoid. If all our work were done on the 
 plan of expediency, the search for the truth in the science of surgery would 
 lose its charm, and the art of imitating nature would lose its beauty. 
 
 In the anatomic or typic operation the sac is tied off. Why? To re- 
 store the rotundity of the peritoneum. The transversalis fascia is sutured 
 nicely around the root of the cord Why? In order to obliterate a patho- 
 logic infundibuliform process, and to make a new internal ring. 
 
 The internal oblique muscle is sutured to Poupart's ligament at least 
 two-thirds the way down, which is the usual attachment found in the female. 
 Why? That a congenital defect may be rectified, and the muscle may be 
 allowed an opportunity to protect the internal ring; and the aponeurosis of 
 the external muscle is then sutured and the skin coapted, for the reason that 
 the}' may occupy their normal place in this region. 
 
 It will be noted that no step is taken without a valid anatomic reason. 
 When the hernia is a direct one, or when the conjoined tendon is deficient 
 or absent, an additional procedure is required, and that is to split the sheath 
 of the rectus muscle, and sew it (rectus muscle) over to Poupart's ligament, 
 across the weak point. If, however, the entire inguinal area is deficient, 
 thinned out, atrophied, or degenerated, the writer has not hesitated to trans- 
 plant a portion of the sartorius muscle to this region as well. ^ <*■• 
 
 Operation. — After preparation begin the incision over Poupart's liga- 
 ment, one and a half inches below the anterior superior spinous process of 
 the ilium; extend it inward and downward in a curved (or straight) man- 
 
 7 
 
THE TYPIC or" anatomic (fERGL'SON) OPERATION 283 
 
 ner, circumventing the internal abdominal ring, and terminate it over the 
 conjoined tendon near the pubic bone. Cut carefully backward vi^ith a very 
 sharp knife and expose the vessels. Pick them up with forceps before sev- 
 ering them, thus preventing blood-staining of the tissues. Having passed 
 through the skin, two layers of superficial fascia, the fat between them and 
 the superficial epigastric vessels down to the aponeurosis of the external 
 oblique muscle, it will be noticed that it is not necessary to cut the super- 
 ficial circumflex iliac, nor the superficial pudic vessels. Take a pledget of 
 gauze, and with it turn the flap of skin, subjacent fat and fascia downward 
 and outward over the thigh. This procedure brings into view the aponeu- 
 rosis of the external oblique muscle, the external abdominal ring, with its 
 pillars and intercolumnar fascia, the hernial sac, if it has descended through 
 the external ring, the external surface of Poupart's ligament, the under 
 surface of the flap covered by the deep layer of superficial fascia, and the 
 superficial vessels. 
 
 Next cut through the external abdominal ring and the intercolumnar 
 fascia; separate the longitudinal fibers of the aponeurosis of the external 
 oblique muscle directly over the inguinal canal, beyond the internal ring, 
 over the surface of the internal abdominal oblique mmscle. Delicate trans- 
 verse fibers are encountered and severed. Retract the two flaps of the 
 aponeurosis of the external oblique muscle to eacli side, thus bringing into 
 view the deep structures, viz. : The contents of the inguinal canal, the whole 
 sac with its adhesions, the spermatic cord, ilio-inguinal nerve, internal ab-- 
 dominal ring usually enlarged, frequently an accumulation of subserous fat, 
 the cremasteric m.uscle, conjoined tendon, internal oblique muscle, and its 
 deficient origin at Poupart's ligament, transversalis fascia, and the internal 
 surface of Poupart's ligament. (Fig. 43.) 
 
 The author considers the congenitally deficient origin (Fig. 43) of the 
 internal oblique and transversalis muscles one of the niost frequent and im- 
 portant causes of oblique inguinal hernia. Inspect these structures carefulh,, 
 and determine whether the operation is to be typic or atyplc. When the 
 structures are well-defined and not too much weakened by pressure atrophy, 
 a typical operation can be proceeded with. 
 
 At this stage of the operation deal vvith the sac and its contents : The 
 cord, cremaster muscle, and subserous lipomata. 
 
 The sac is always opened (Fig. 44) preferably at its neck, at its junc- 
 tion w4th the general peritoneum, and then carefully dissected from the cord 
 and internal ring, from above downward, its contents inspected and dealt 
 with, and the sac is ligated high up, or sometimes sutured, or an internal purse- 
 string thrown around it. If the sac is of congenital origin, divide it in two, 
 the distal half to form a tunic for the testicle, and the proximal to be treated 
 as above mentioned. 
 
 When omentum is found within the sac and is adherent to it, it is with- 
 drawn, tied cii masse, cut off, the stump is covered with its own peritoneum, 
 or rolled beneath and within a fold of omentum, and there held by a stitch 
 or two of fine chromic catgut. 
 
 The writer has, very many times, employed Downes' electro-thermic- 
 
284 THE TYPIC OR ANATOAIIC (FERGUSON) OPERATION 
 
 hemostat clamps for the removal of omentum, and inclines to the belief that 
 they are safer than the ligature. When the omentum is redundant, or hyper- 
 trophied, its amputation decreases intra-abdominal pressure and lessens the 
 tendency to a return of the hernia. If the omentum is not adherent it is us- 
 ually not necessary to remove any portion of it. 
 
 When the sac is opened it is frequently found advantageous to place the 
 patient in jjie Trendelenburg position to prevent protrusion of and injury to 
 the intestines and omentum, and it also aids in the closure of the perito- 
 neum, whether by ligature or suture. 
 
 The transplantation of the stump of the sac high up underneath the deep 
 muscles, or twisting it and suturing it at the internal ring, has nothing special 
 to recommend it. It must be remembered that when a new internal ring is » 
 made the stump of the sac is buried beneath the transversalis fascia, which ';■ '^'''^/^ 
 must protrude it into the peritoneal cavity, and at its site a convexity is ob- 
 tained. 
 
 The appendix should always be brought out and inspected. If by ap- 
 pearance, or feel, or the history of the case, disease of it is at all suspected, 
 it had better be removed. When the patient is a female, the condition and 
 position of the uterus and ovaries may be palpated, and any surgical inter- 
 vention that may be deemed necessary can be carried out through an en- 
 larged hernial incision. 
 
 When the patient has also given evidence of stomach, gall bladder, in- 
 testina^l or other surgical intra-abdominal disease, the writer has not hesi- 
 tated to enlarge the opening, pass in the hand and carefully explore the ab- 
 dominal organs, with great satisfaction to himself and oftentimes with bene- 
 fit to the patient. Gallstones, carcinoma of the sigmoid, uterine displace- 
 ments, fibroids and ovarian cysts have been detected in this manner, and 
 been treated surgically there and then. 
 
 In order to adm.it the hand and forearm through this opening it is 
 necessary to make ample room by severing the attachment at Pottpart's 
 ligament, of the internal oblique and transversalis muscles, and extending 
 the opening in the sac upward through the fascia and peritoneum ; or when 
 the conjoined tendon is deficient there is an indication to open the sheath 
 of the rectus muscle in order to deal properly with the rupture, then it is 
 preferable to extend the opening in this direction, and on reaching the bor- 
 der of the rectus muscle, open its sheath and extend the opening to the 
 pubic bone ; then cut through the sheath of the rectus transversely to the 
 linea alba. The remaining structures, the peritoneum and muscular fibers 
 of the muscle, will stretch, while the transversalis fascia and sparse fibrous 
 covering on the posterior surface of the muscle yield to a little force. 
 
 While exploration of the abdomen through the groin is a subject some- 
 what irrelevant to this subject, still the writer feels that the value of the 
 procedure in connection with hernia patients may, in a measure, justify him 
 in deviating from the subject proper, craving the reader's indulgence. 
 
 The cord is not disturbed. The writer has never been satisfied with 
 the raising and transplantation of the cord. In more cases than have been 
 recorded the testicle has come to grief by this unnecessary procedure. Tear- 
 
PLATE L. 
 
 Ferguson's Operation for Femoral "Hernia. 
 I. Falciform process. 2. External oblique. 3. Poupart's lig. 4. Gim- 
 bernat's lig. 
 
THE TYPIC OR ANATOMIC ( FERGUSON) OPERATION 28/ 
 
 ing the cord out of its bed is without any anatomic reason to recommend it ; 
 any physiologic act to suggest it ; any etiologic factor in hernia, congenital 
 or acquired, to indicate it ; or brilliant surgical results to justify its continu- 
 ance. Let the cord alone, especially the vas deferens, for it is the sacred ^ -l 
 highway along which travel the vital elements indispensable to the per- r\/<-CCi^ ^ 
 petuity of our race. 
 
 The veins of the cord should not be disturbed. If a variocele compli- 
 cates the hernia, deal with it in the usual way, but do not ablate the veins in 
 the canal, for that endangers the testicle. When the veins were not ablated, 
 the writer has not seen a hydrocele or an epididymitis follow. 
 
 The cremaster muscle is allowed to hug the cord and is reattached to 
 the internal oblique muscle, for in this, its normal position, it is afforded an 
 opportunity to resume its double function of (a) holding down the muscle 
 from which it originally received its muscular fibers, and (b) by its con- 
 traction aid in emptying out the valveless veins in the cord. No part of 
 the muscle should be removed, but its redundancy is taken up with the 
 suturing of the transversalis fascia and internal oblique. 
 
 An abnormal quantity of subserous adipose tissue is sometimes depos- 
 ited around the sac and cord and along Poupart's ligament. This is an 
 etiologic factor in hernia, and if not removed tends to cause a return of the 
 hernia. A systematic search should be made for fatty aggregations and the 
 same removed. (See "Adipose Tissue an Etiologic Factor in Hernia," Ma}-, ^7/vjZ^<r4>^<A</ 
 1899, Illinois Medical Journal, by the author.) .._^.,..-' ^^^ / 
 
 The transve rsalis fascia forms the internal ring. /'In hernia its fibers *— ■■ 
 
 have become more or less stretched above and around the cord. The ring, I, / 
 
 in consequence, is abnormally large and the fascia bulges. To rectify this f ^ W^iVt '^ 
 condition take up the slack in the fascia and make an accurately fitting ring ^ tiky^ '^y^^^Ti 
 for the cord % means of a suture, interrupted or continuous. The writer t^(* \-~t^^^^ 
 usually takes up the slack .in this fascia with the same sutures that sew the "^'^ Hf/vwAC. <t,' 
 internal oblique muscle to Poupart's ligament. (Fig. 45.) Do not injure 
 the deep epigastric vessels, nor pass the needle too deeply in the direction 
 of the large iliac vessels. 
 
 Suture the internal oblic[ue and transversalis muscles (Fig. 46) to tne i 
 
 internal aspect of Poupart's ligament, and restore their normal origin. If i^i'^lh^i.^L 
 you choose, take up the slack of the transversalis fascia and the crema.stex^^^^^^^'^J^'f'-^^,^ 
 muscle with the same suture. (Fig. 48.) The suturing is extended fully /■« oJ^Ji~e-^ ^ 
 two-thirds down along Poupart's ligament, which is the normal origin of C^\^ / / 
 
 this muscle in the female. Take care not to split Poupart's ligament by 
 grasping the same longitudinal fibers with the needle each time. It is sur- 
 prising how easily these structures come together without the least dis- 
 cernible tension when the muscles are well liberated, and it is gratifying to J^ ALvvr^ 
 observe how perfectly they cover and protect the internal abdominal ring. ' ''^/^O^yy^-' 
 
 (Fig. 45-) ■ ■' ■ ^■■>H^^i' OH 
 
 If the conjoined tendon is deficient or absent, or if a direct hernia co- 
 exists, the sheath of the rectus muscle is opened freely down to the pubic 
 bone (Bloodgood, Fig. 47), and the muscle brought across the weak point 
 to Poupart's ligament. The writer has observed a few direct hernias occur 
 
288 THE TYPIC OR ANATOMIC (FERGUSON) OPERATION 
 
 after the cure, by operation, of an oblique inguinal hernia. In these cases 
 the conjoined tendon was deficient and the rectus muscle was not utilized at 
 the primary operation. 
 
 The external edges of the aponeurosis of the external oblique muscle 
 are brought together in lateral folds (Fig. 49) or by overlapping, thus re- 
 storing the external abdominal ring. (Fig. 45.) In bringing the skin 
 flap into normal position, be sure to coapt all its structure, like-to-like, espe- 
 cially the layers of the superficial fascia. 
 
 The different structures in the abdominal wall are placed in their nor- 
 mal relationship. The tying of the sac restores the normal rotundity of 
 the peritoneum. The suturing of the transversalis fascia, forming a new | 
 internal ring, at the same time obliterates the hernial infundibuliform pro- ' 
 cess. Sewing the internal oblique and transversalis muscle to Poupart's 
 ligament secures a normal origm for them, and they then form a perfect 
 protection of the internal ring, cord and canal. (Fig. 43.) The lateral or 
 overlapping suturing of the separated fibers of the aponeurosis of the ex- 
 ternal oblique protects the underlying muscles and cord, while the skin flaps 
 covers all. The lines of the sutures are not opposite each other, thus se- 
 curing an overlapping of the weak parts (line of repair) by normal tissues. 
 
 The curved incision has advantages for purposes of demonstration. The 
 hernial area is uncovered as in no other way, thus affording an accurate ob- 
 servation of structural relationship, etiologic factors and pathologic condi- 
 tions. There is less tendency of skin infection extending to the deeper 
 structures. 
 
 In cases of old scrotal hernias the large space from which the sac 
 was dissected is drained with several strands of silkworm gut until the first 
 dressing is changed. 
 
 We are gradually coming to the conclusion that after operation pa- 
 tients are usually kept in bed for too long a time, but the writer still en- 
 joins three weeks in the horizontal position after an operation for the radi- 
 cal cure of hernia. A bandage and pad are worn for three months there- 
 after, but no truss. 
 
 For ligatures and sutures, Nos. 00, o, and i of chromic catgut are used 
 throughout the operation ; No. i to tie off the sac, and the other sizes for 
 the coaptation of the remaining structures. The author believes that the 
 large-sized catgut used by other operators in miany instances is accountable 
 for suppuration and failure. The catgut should not be absorbed short of 
 about two or three weeks. 
 
 Of all the methods of operating the author has employed, the anatomic 
 is the simplest and easiest to execute. The results are all that could be 
 wished, there being no known return in 2,500 patients operated on by differ- 
 ent sursreons. 
 
CHAPTER V. 
 
 RADICAL CURE OF FEMORAL HERNIA. 
 
 The radical cure of femoral hernia has not engrossed the attention of 
 surgeons to the same extent as Has that of the inguinal variety. One rea- 
 son for this may be the comparative infrequency of femoral hernia, and an- 
 other may be found in the belief that the operation is more difficult to per- 
 form than is that for inguinal hernia. However, a number of operations 
 have been devised and some of them have been used extensively and with 
 excellent results. 
 
 Sir Astley Cooper dissected out the sac and closed the femoral ring se- 
 curely by means of sutures. Mitchell Banks placed a ligature around the 
 neck of the sac, and then cut it away, but made no attempt to close the canal. 
 
 Ball and Houston twisted the sac, ligated it at its neck, cut it off, and 
 closed the femoral canal with sutures. Barker removes the sac after having 
 ligated it at its neck. The stump of the sac is then pushed under the femoral 
 arch and the canal is closed with sutures which grasp the pubic portion of 
 the fascia lata and Poupart's ligament. 
 
 Marcy cuts oft' the s?.c below a ligature and closes the canal bv sutures 
 of kangaroo tendon. AIcBurney used the open method, the sac being li- 
 gated, cut away, and the wound packed with iodoform gauze. ^lacewen, of 
 Glasgow, employed the sac as a plug, much in the same manner as in his 
 operation for inguinal hernia, the plug forming a prominence on the in- 
 ternal aspect of the peritoneal cavity. He completed the operation by 
 stitching the falciform process to Gimbernat's ligament, thus restoring the 
 normal valve-like condition of these parts. Harvey Gushing closes the fem- 
 oral ring with a quilted suture, fastening the pubic portion of the fascia lata 
 covering the pectineus muscle to Poupart's ligament before closing the 
 saphenous opening according to Macewen's method. 
 
 In my operation I close the canal with three inversion sutures, seizing 
 hold of the fascia and pectineus muscle, close to the pubic bone, and then 
 grasping Poupart's ligament from above downward. (Fig. 50.) These 
 sutures, when tied, cause the falciform process to recede behind them into 
 the canal on a level with the deep crural arch. When the sac is small and 
 slender, and if Poupart's ligament and the falciform process cannot be 
 brought down sufficiently close to the pectineal fascia, to obliterate the fem- 
 oral canal effectually, there need be no hesitation in raising a flap from 
 the pectineus muscle, or from the periosteum of the pubic bone, and sewin^ 
 either with quilt sutures to the deep crural arch, fastening the falciform pro- 
 cess beneath it, as already described. 
 
 It is rather difficult to comprehend the reason for cutting off the sac, 
 which can be utilized as a plug to the best advantage. The sac consists of 
 
290 RADICAL CURE OF FEMORAL IIERXLA 
 
 fibrous tissue, whereas when a mass of muscle is raised to form a plug, it 
 means that this muscle must be converted into fibrous material. If the sac 
 is very small or the canal very large, I believe that Cheyne's flap would aid 
 materially in preventing a relapse. I have not seen this condition. 
 
 Josef Fabricius recommends ligating the sac and then cutting it ofif. He 
 exposes the crural canal freely by division of the superficial layer of deep 
 fascia and the removal of loose cellular tissue. The internal attachment of 
 Poupart's ligament is divided, thus relaxing it, and it is then sutured to the 
 pectineal fascia, the origin of the pectineus muscle, and to the periosteum 
 of the horizontal ramus of the pubic bone. (Figs. 51 and 52.) The first 
 stitch is applied next to the femoral vessels, being drawn by a blunt hook 
 toward the ilio-pectineal eminence. This stitch prevents these vessels from 
 returning to their normal position. Fabricius also recommends stitching 
 the superficial layer of the deep fascia to the pectineal fascia along the 
 femoral vein. 
 
 The objections to this operation are that it necessitates the division of 
 Poupart's ligament, and the fact that so extensive an operation is not at 
 all necessary to produce a radical cure of the hernia. 
 
 Bassini's method of operating on femoral hernia embraces the re- 
 moval of the sac and then putting m two rows of sutures, one fastening 
 Poupart's ligament to the pectineal fascia for the purpose of closing the 
 femoral canal, and the other suture securing the falciform ligament to 
 the pectineal fascia and muscle. 
 
 BALDWIN'S OPERATION. 
 
 For some years past Baldwin has made use of an operation which 
 in his hands has proven uniformly successful in about twenty cases. He 
 describes his method [Lancet, July 21, 1906) as follows: 
 
 "A curved incision about 1J2 or 2 inches long is made over the 
 saphenous opening. The sac is isolated and more or less cleared of fat. 
 If not already back, the hernia is reduced. A slightly curved hernia 
 director is now 'introduced up the crural canal in front of the sac and 
 when its point is behind Poupart's ligament it is moved laterally so as for 
 a short distance to strip off the peritoneum from the posterior surface of 
 the transversalis fascia. The point of the director is now pushed farther 
 upward and tilted forward so as to make the aponeurosis of the external 
 oblic[ue muscle project about half an inch above Poupart's ligament. A 
 small transverse incision is then made through the aponeurosis, parallel 
 to its fibers, on to the point of the director, which is now pushed up through 
 the opening. The latter is only just large enough to allow of this being 
 done. A sinus forceps, Spencer Wells forceps, or small nasal polypus for- 
 ceps — the last, being slightly curved, is more convenient — is now intro- 
 duced through the opening, passed behind Poupart's ligament, and made 
 to project from the saphenous opening; as this is done the director is 
 withdrawn ; in its descent it guides the forceps and prevents it from catch- 
 ing. The fundus of the sac is now seized by the forceps, which is com- 
 pletely withdrawn, dragging the sac out through the opening in the ex- 
 
PLATE LI. 
 Fabricius' Operation for Femoral Hernia. (Fowler). 
 
RADICAL CCRE OF FEMOR^XL HERNIA 293 
 
 ternal oblique aponeurosis. The sac is pulled out as much as possible 
 and ligated at the top of its neck. By this maneuver no pouch is left in 
 which recurrence may take place. A suture is then passed throug-h the 
 fundus of the sac, the suture is drawn through to its middle and then 
 tied, thus leaving two free ends of equal length, or this may be done be- 
 fore the sac is pulled up through the opening in Poupart's ligament, the 
 thread being seized by the forceps and used to pull up the sac. If the 
 sac is large, however, the thread may tear out and time be lost. One end 
 is threaded in a strong curved needle, one which will not rotate in the 
 forceps which grasps it. The needle is now passed backward and for- 
 ward through the sac several times, starting at the fundus and finishing at 
 the neck, as described by Macewen, for puckering the sac. The needle 
 is grasped in forceps, or a needle on a handle may be used, and its point 
 is passed through the hole above Poupart's ligament, through the neck of 
 the sac down to the transverse ramus of the pubes, then by a turn of the 
 wrist the point is made to slide forward across the pubic bone, as close 
 to it as possible, then to pierce the pectineus muscle and to appear through 
 the inner part of the saphenous opening. The needle is pulled through, 
 bringing its thread with it. By drawing on the thread and by tucking 
 the sac back again through the hole above Poupart's ligament by means of 
 a stout probe or similar blunt instrument, the sac disappears from view 
 and comes to rest in a puckered-up condition behind the transversalis fascia 
 and at the top of the crural canal, which it effectually roofs in. By this 
 time the other end of the thread is hanging out of the opening above Pou- 
 part's ligament. It is tied rather firmly, but not too tightly, to the thread 
 which projects from the saphenous opening; this fixes the sac in its place, 
 and fixes Poupart's ligament to the pectineus muscle, so obliterating the 
 crural canal. If necessary, a second suture may be put in for this pur- 
 pose, but nearer the pubic spine. A suture is put in to close the hole 
 above Poupart's ligament and the skin incision is closed. Thus there are 
 three distinct checks against the recurrence of the hernia: (i) The sac 
 is ligatured higher up than is possible by the ordinary method and leaves 
 no peritoneal pouch; (2), the sac is used as a buffer or roof above the 
 crural canal; and, (3), Poupart's ligament is approximated to the pectineus 
 muscle and obliterates the crural canal. It may be urged that the sac will 
 slough and cause trouble. This does not take place. It no doubt becomes 
 vascularized, converted into granulation tissue, and ultimately into fibrous 
 tissue. 
 
 In strangulated hernia, when it has seemed safe to leave the sac, and 
 when time was precious, the author has modified the operation by pushing 
 the sac up through the canal, after having made a little space for it as be- 
 fore, and then sutured Poupart's ligament to the pectineus muscle. 
 
 POLYA'S OPERATION. 
 
 The feature of Polya's operation is the obliteration of the femoral 
 canal by plugging it with the entire thickness of the sartorius muscle 
 (Ceutralbl. f. Chirurgie. Vol. XXXII, Xo. 18). 
 
294 RADICAL CURE OF FEMORAL HERNIA' 
 
 The incision is in the shape of a T or inverted L. The saphena is 
 hg-ated and severed, and the hernial sac tied and buried if possible. The 
 sheath of the sartorius is slit across below the level of the canal, and the 
 sartorius muscle is cut a trifle above this slit. The proximal stump of the 
 muscle is then worked through the saphenous opening above the large 
 vessels and sutured, after being pushed as far into the canal as it can be 
 made to go. Two or three stout catgut threads are passed through Pou- 
 part's ligament, the implanted sartorius and the sheath of the pectineus, 
 and the muscle is pulled deep into the femoral canal as the threads are 
 tied. A flap is made by cutting the fascia lata, and it is turned back and 
 sutured to Poupart's ligament, to the sheath of the pectineus and to the 
 sartorius below. 
 
 The operation has been performed a number of times with very satis- 
 factory results. One of the patients operated on succumbed not long after 
 to an intercurrent infectious disease, and the autopsy demonstrated the per- 
 fect anatomic results obtained by this technic. 
 
 MIKULICZ'S OPERATION. 
 
 C. Goebel (Bcitrlige s. Klin. Chir.. 1904) described a procedure em- 
 ployed by von Mikulicz, the principal feature of which is the utilization 
 of the periosteum of the os pubis for the formation of a double flap. The 
 technic consists, briefly, of the isolation, ligation, and submersion of the 
 hernial sac. An incision is made extending down to the bone, from the 
 tuberosity of the pubis to the vessels, in a frontal direction and slightly 
 anterior to the crest of the pubis. An upper and lower periosteal (perios- 
 teal-muscle-fascia) flap is then formed out of the os pubis, if necessary 
 with sagittal section across the bone at the outer and inner end of the 
 frontal incision. Suture of the upper (inner) periosteal flap to the outer 
 border of the ligament is the next step in the operation, and this is followed 
 by a subcutaneous suture of the rem.aining fascia, and suture of the skin. 
 
 The advantage of this method is said to be that the turned-up perios- 
 teum joined to Poupart's ligament causes an ideal closure of the crural 
 canal at its entrance at the very beginning of the femoral infundibulum. 
 In May, 1895 (Annals of Surgery) I published a method of raising the 
 periosteal flap. 
 
 KAMMEREE'S OPERATION. 
 
 F. Kammerer (AjuuiIs of Surgery. June, 1904) discusses the various 
 operations that have been devised for the cure of femoral hernia. He 
 employed Lotheisen"s method for a time and then abandoned it in favor 
 of Salzer's method, but Kammerer includes in the flap a laver of muscular 
 tissue taken from the pectineus muscle, which, in persons who have worn 
 a truss, is quite firm. Up to the time of writing he had performed this 
 operation ten times. In the only two cases that could be traced after the 
 operation, one, a woman, aged 34, operated on in 1902, for a right reducible 
 femoral hernia, and the other, a woman, aged 50, operated on also in 1902, 
 
I 
 
 PLATE LIL 
 Fabricius' Operation for Femoral Hernia (Fowler). 
 
RADICAL CCRE OF FEMORAL HER^'IA 297 
 
 for a double femoral hernia, neither patient has since worn a truss nor 
 has there been a recurrence of the hernia. 
 
 In 1903 he employed Lotheisen's method in a case of incarcerated 
 femoral hernia of very large size containing- adherent omentum and a 
 large knuckle of small intestine very much discolored. He divided Poupart's 
 ligament immediately over the neck of the sac, cutting from within out- 
 ward, as advised by Lotheisen. In five other cases of femoral hernia oper- 
 ated on the ligament was not divided. The result in all of these cases was 
 good. Kammerer says that dividing the constriction from within in an 
 outward direction is a procedure that should be relegated to the past. A 
 cross section of Poupart's ligament from without, cutting down on the 
 neck of the sac, is much more satisfactory when it starts from a previous 
 incision into the aponeurosis of the external oblique. In the case men- 
 tioned above, he fastened the cut ligament to the internal oblique muscle 
 after the latter had been sutured to Poupart's ligament. 
 
 NICOLL'S OPERATION. 
 
 The main feature of XicoU's operation {Annals of Surgery, January, 
 1906) are (a) the employment of the sac to form an intra-abdominal but- 
 tress over the internal aspect of the hernial opening or ring; (b) the use 
 of the pubic ramus as a point d'appui in the process of closure of the 
 hernial canal, and (c) the additional security of closure obtained by the 
 supraposition on the bone sutures of a plane of fascial sutures. A vertical 
 or transverse incision exposes the sac, which is opened longitudinally in 
 its middle line and emptied. The sac is separated from parts surrounding 
 its neck for one inch around the abdominal aspect of the ring, and bisected 
 longitudinally from fundus to neck. Make an aperture in one-half near 
 the neck and interlock the halves by putting one through this aper- 
 ture. Reduce the whole sac through the femoral ring into the extra- 
 perintoneal space previously cleared by detaching its neck from the ab- 
 dominal aspect of the ring. The sac thus lies bunched up within the ab- 
 domen betw^een the peritoneum and the transversalis and iliac fascia over 
 the hernial aperture of the femoral canal. 
 
 The femoral ring is closed as follows : Carry a bone-deep incision 
 from the femoral ring along the pubic ramus to the region of the pubic 
 spine, dividing the pubic portion of the fascia lata, the origin of the pec- 
 tineus and the periosteum. Detach the latter to a limited extent and re- 
 tract it. Drill the bone near its upper edge in two places, one-half to one 
 inch apart. Pass through one of the apertures a loop or stout catgut or 
 other absorbable ligature, and divide the loop of the ligature. Thread 
 one end in a large curved surgical needle and pass it as a mattress suture 
 through. Poupart's ligament. Repeat this procedure with the second end 
 of the ligature at a higher level, avoiding the deep epigastric artery to the 
 outer side, and, in male patients, the spermatic cord above. Withdraw 
 both ligatures through the second drill-hole in the bone ; tie the ends of 
 each loop separately over the front of the bone, thus bringing Poupart's 
 ligament down to the postero-superior surface of the bone, fastening it 
 
298 RADICAL CURE OF FEMORAL HERNIA 
 
 firmly in contact with that surface, constituting what is in fact an ex- 
 tension outward of Gimbernat's ligament and absolutely closing the 
 femoral ring to whatever extent may be desired. To make the closure 
 doubly secure the operation is completed by uniting by interrupted catgut 
 sutures the attached margin of the pectineal origin and the pubic portion 
 of the fascia lata to the anchored Poupart's ligament. 
 
 DE GARMO'S OPERATION. 
 
 The technic of the operation employed by W. B. De Garmo (Annals 
 of Surgery, August, 1905) is as follows: 
 
 The incision should be between two and three inches long, parallel 
 with and to the inner side of the femoral vessels. The upper angle of the 
 wound should be well up over Poupart's ligament and extend down over 
 the saphenous opening. When the skin and the superficial fascia are in- 
 cised, usually the sac and its subperitoneal fat will come into the wound 
 with the appearance of an encysted lipoma and, before separating the sac, 
 it is best that this entire mass should be lifted out of its bed by thumb for- 
 ceps and blunt dissection, so that its neck where it passes under Poupart's 
 ligament shall be entirely free from its surrounding. By traction on the 
 sac and its superimposed fat this neck may not only be freed, but it will 
 be materially lengthened, so that when it is finally ligated and cut off it 
 will retract within the abdominal cavity, leaving the femoral canal free of 
 foreign tissue. This is absolutely essential to a subsequent permanent 
 cure. The sac should be opened, and where the omentum is found adher- 
 ent it should be carefully ligated. cut away, and its stump reduced to the 
 abdominal cavity. Adherent intestine will rarely be found, but when it is 
 the adhesions must either be broken up or, if too firm, the adherent part 
 may be cut out of the sac and left attached to the bowel. When in doubt 
 the latter method is b}^ far the safer. Adherent omentum is frequently 
 found and should be cut away after careful ligation. The sac having 
 been entirely freed of its contents, is tied off as high as possible, while it 
 is being forcibly drawn down by an assistant. Great care must be used 
 to insure the perfect freedom of the neck of the sac from protruding 
 bowel or omentum while the ligature is being placed. After tying with 
 strong catgut (a double strand of No. 2 plain is preferred), pass the 
 needle, which has been previously threaded v/ith it, through the neck of 
 the sac and tie again. This gives a double hgature anchored by perfora- 
 tion between the two, and prevents slipping off. When the sac is cut away 
 the stump .should be examined to be sure that no bleeding vessels remain, 
 and not until then should the ends of the ligature be cut. When the liga- 
 ture is cut the stump usually retracts within the abdomen. If this is pre- 
 vented by connective tissue which has not been broken it should be care- 
 fully pushed back, leaving the femoral opening absolutely free. This open- 
 ing is closed by good-sized kangaroo tendon threaded in a strong, blunt 
 needle by pressing the end of the finger firmly into the femoral opening 
 under Poupart's ligament, and passing the needle throug"h the ligament 
 on the finger-point. This perforation should be well toward the outer 
 
RADICAL CURE OF FEMORAL HERXIA 299 
 
 side of the canal and close to the femoral vein. The operator should 
 assure himself, by pressure of the finger against the ramus of the pubes, 
 that the vessels are out of the way, and pass the point of the needle fully 
 down to the periosteum of the pubic bone, raking up all tissues over it. 
 This constitutes the first stitch, but should not be tied until the others are 
 in place. Others should then be placed in the same manner, every quar- 
 ter of an inch apart, until near the spine of the pubes. Usually three or 
 four will completely close the femoral opening. When tied down and 
 the ends cut moderately close, the fascia should be closed in by plain cat- 
 gut, to avoid a pocket in the tissues that otherwise may result, and the 
 skin may then be closed by buried sutures of plain catgut. The wound is 
 covered by collodion and a compress of sterilized gauze, held in place by 
 a figure-of-eight bandage. In ten days the dressings are changed and a 
 bandage for temporary support is applied. If healing has been complete, 
 the patient is allowed to sit up on the tenth day and to leave the house 
 on the fourteenth day after the operation. The bandage used after the 
 first dressing consists of a pelvic belt, of three thicknesses of canton flan- 
 nel, with a compress of gauze over the former site of the hernia, and a 
 perineal strap to prevent its slipping up. This is to be worn for four 
 weeks. No truss or other permanent support should be worn. 
 
 HEEZEIT'S OPERATION. 
 
 P. Herzen, after tying and removing the hernial sac, and reducing 
 the stump, detaches the femoral vein, draws it to one side, and Poupart's 
 ligament upward. He then dissects a flap of periosteum from the upper 
 aspect of the pubis about the width of the femoral canal, and about one 
 to 1.5 centimeters long, the base of the flap resting on the pectineus mus- 
 cle. This flap is then detached from the bone and turned back down- 
 ward. Two to four small holes are then drilled through the pubis in 
 such a way that the drill emerges always in the part exposed by the rais- 
 ing of the flap. The two ends of a bronze aluminum wire are then passed 
 from behind forward through Poupart's ligament and through two of 
 these holes. By pulling on the wire the ligament is brought into intimate 
 contact with the exposed part of the pubis. The flap of periosteum is 
 then replaced and fastened with a couple of stitches. By this means the 
 femoral ring is entirely closed, the ligament having taken its place and 
 being re-enforced by the periosteal flap. 
 
 OCHSNEE'S OPERATION. 
 
 For the past fourteen years A. J. Ochsner has used a method which 
 has not been followed by recurrence in any one of the thirty patients 
 that can be traced. The principle underlying the method is to change 
 the femoral canal into an unlined circular opening, which will close spon- 
 taneously. In order to effect this Ochsner dissects out the hernial sac 
 quite up into the peritoneal cavity beyond the inner surface of the femoral 
 ring, ligates it high up (Fig. 53), cuts it off, and permits the stump to 
 withdraw wdthin the peritoneal cavity. Removing all the fat contained 
 
300 RADICAL CURE OF FEMORAL HERNIA 
 
 in the femoral canal and simply closing the skin wound completes the 
 operation. Ochsner claims that this method is applicable to all simple 
 femoral hernias in which an actual femoral ring exists. The method is 
 not appHcable to cases of strangulated hernia in which the femoral ring 
 has to be cut to permit of reduction of the hernia. 
 
 SOCIN'S OPERATION. 
 
 In Socin's operation the skin incision is made a little below and 
 parallel with Poupart's ligament. The sac is then freed high up into the 
 abdominal cavity and all the fat and loose tissue removed. The sac. 
 after being pulled down by an assistant, is ligated and cut off high up, the 
 stump being allowed to slip back easily into the peritoneal cavity. The 
 skin incision is sutured according to the preference of the individual oper- 
 ator. 
 
 COLEY'S OPERATION. 
 
 W. B. Colev frees the sac well beyond its neck and then ligates ii 
 high up. A suture is then introduced through Poupart's ligament or the 
 inner portion of the canal or crural arch, thence passed downward into 
 the pectineus muscle or lioor of the canal, outward through the fascia 
 lata overlying the femoral vein, and upvv-ard through Poupart's ligament 
 or the roof of the canal, emerging about three-fourths of an inch from 
 the point of its introduction. On tying the suture the iioor of the canal 
 is brought in apposition with the roof of the canal and the femoral 
 opening is obliterated. The superficial fascia is brought together with 
 catgut or fine tendon, and the skin sutured with horsehair. 
 
 CURTIS' OPERATION. 
 
 Curtis closes the canal after the sac has been removed by introducing 
 three superimposed circular purse-string sutures of catgut, the first at the 
 internal femoral opening, the second One-third of an mch outside of this, 
 and the third at the external surface of the canal. The method is said not 
 to be suitable for large hernias. 
 
 LOTHEISSEN'S OPERATION. 
 
 In this method the external incision is made parallel to and a little 
 above Poupart's ligament so as to divide the fibers of the external oblique 
 and extend into the external inguinal ring. The neck of the sac is ex- 
 posed by entering between Poupart's ligament and the internal oblique 
 muscle. The sac is dislocated, if small, by pulling it into the opening 
 above Poupart's ligament. In large hernias the skin is dislocated at the 
 lower edge of the original incision so as to expose the external surface of 
 the sac. The sac is then incised and the stump dislocated in the same man- 
 ner as for small hernias. The edges of the transversalis and internal 
 oblique muscles are sutured to Cooper's ligament. The incisions in the 
 aponeurosis and the skin are sutured separately. 
 
PLATE LIII. 
 Ochsner's Operation for Femoral Hernia. 
 
RADICAL CURE OF FEMORAL HERNLV 3O3 
 
 HAMMESFAHR'S OPERATION. 
 
 After the femoral sac is resected and the stump reduced, three holes 
 are drilled in the upper margin of the pubic ramus from the slant upward 
 so that the inner opening is close beneath the edge of the crest. Strong 
 silk is then passed around Poupart's ligament and then through the holes, 
 and is tied firmly. 
 
 Salzer devised a method of closing the femoral canal which met with 
 considerable favor because of the permanency of the result obtained. He 
 employed a flap made from the fascia of the pectineus muscle. The flap 
 was formed by making a curved incision, with the convexity directed 
 downward, from the crista pectinea to Gimbernat's ligament. It was then 
 turned upward and sutured with strong catgut to the lower margin of the 
 inner third of Poupart's ligament. The sheath of the pectineus muscle 
 was restored by a few buried, absorbable sutures. 
 
 SPRENGEL'S METHOD. 
 
 At the last meeting of the German Congress of Surgery, Sprengel 
 proposed a new procedure for the treatment of certain femoral hernias 
 in women, consisting of the closure of the internal ring of the femoral 
 canal through the abdominal cavity. The operation consists of the fol- 
 lowing steps: I. Free exposure of the sac by linear incision, opening 
 and examination of the same, and clearing of the impacted contents. 2. 
 Transrectus laparotomy on the side of the hernia, damming back of the 
 intestines and the organs of the lesser pelvis. 3. Introduction of a Mik- 
 ulicz forceps through the fem^oral canal into the sac, and invagination of 
 the same into the abdominal cavity. 4. Firm rolling together of the sac 
 and suturing of it over to the internal ring, together with pulling forward 
 and suturing of the round ligament of the uterus lying in the immediate 
 neighborhood of the inguinal canal. 5. Closure of the abdominal incision 
 and the linear one over the femoral canal. 
 
 The method was tried in five cases, one being of ten months' duration, 
 and gave a perfectly satisfactory result. According to Sprengel, the 
 method is adapted particularly to old hernias of a large size and to re- 
 current cases. The method appears to he a very simple one, but it is im- 
 possible to judge of its value until a larger number of patients has been 
 operated and more time has elapsed after the operation. 
 
 SCHWARTZ'S OPERATION. 
 
 For the cure of a femoral hernia, Schwartz takes a flap from the 
 second or median adductor. It is raised, forced into the crural canal, 
 and fixed by sutures to the surrounding cellular tissue and to the lower 
 border of Poupart's ligament. This forms a true flap of muscle which 
 fills the crural infundibulum and reaches to the ring- itself. 
 
CHAPTER VI. 
 
 RADICAL CURE OF UMBILICAL HERNIA. 
 
 Women are usually the ones who suffer from this form of hernia 
 and as a rule they are obese, multiparas with very large hernial openings, 
 the recti muscles are widely separated, and from long-continued pressure 
 they become considerably atrophied. If an ordinary abdominal section is 
 done in these cases, difficulty will be encountered in attempting to close 
 the opening by bringing like structures in apposition, as is usually done, 
 unless transplantation of the recti muscles is resorted to. However, this 
 is neither necessary nor is it successful, except in the case of a small 
 hernia, and then it is the operation of choice. 
 
 W. J. MAYO'S OPEEATION. 
 
 In 1898 W. J. Mayo, of Rochester, Minnesota, called attention to the 
 impracticability of covering in the defect left by the excision of a large 
 umbilical hernia with muscle, and advocated the overlapping of the 
 aponeurotic structures which are already at hand, thus securing a wide 
 area of adhesions. Mayo described his operation (Fig. 54) as follows: 
 
 Transverse elliptical incisions are made including the umbilicus and 
 the hernia. The surfaces of the aponeurotic structures are cleared two 
 and a half to three inches in all directions from the neck of the sac. 'The 
 fibrous and peritoneal coverings of the hernia are divided in a circular man- 
 ner at the neck of the sac, thus exposing its contents. If intestinal viscera 
 are present, the adhesions are separated and restitution is made. The 
 omentum is ligated and removed with the sac of the hernia, without dis- 
 section of the adherent portion of the omentum. 
 
 An incision is made through the aponeurotic and peritoneal structures 
 of the ring extending one inch or less transversely to each side, and the 
 peritoneum is separated from the under surface of the upper of the two 
 flaps thus formed. 
 
 Beginning from two to two and one-half inches above the margin 
 of the upper flap, three to four mattress sutures of silk or other perma- 
 nent material are introduced, the loop firmly grasping the upper margin 
 of the lower flap; sufficient traction is made on these sutures to enable 
 peritoneal approximation with running or interrupted suture of catgut. 
 The mattress sutures are then drawn into position, sliding the entire lower 
 flap into the pocket previously formed between the aponeurosis and the 
 peritoneum above. 
 
 The free margin of the upper flap is fixed by catgut sutures to the 
 surface of the aponeurosis below, and the superficial incision closed in the 
 usual manner. In the larger hernias the incision throusrh the fibrous 
 
PLATE LIV. 
 Mayo's Operation for Umbilical Hernia, 
 
I 
 
 RADICAL CURE OF UMBILICAL HLRNIA 307 
 
 coverings of the sac may be made somewhat above the base, thereby in- 
 creasing the amount of tissue to be. used in the overlapping process ( Fig. 
 
 55)- 
 
 In the very large protrusions in which part of the hernial contents 
 
 is irreducible the patient should be kept in bed on a reduced diet and 
 directed to manipulate the hernia, with the intention of replacing as much 
 as possible. The irreducible portion must not be forced into the abdom- 
 inal cavity after losing the "right of habitation." If this consists of omentum 
 only, it is readily disposed of by excision ; if intestine, enough omentum 
 previously contained in the peritoneal cavity should be removed to allow of 
 reduction of the bowel without pressure. 
 
 The patients should be kept in bed three or four weeks after opera- 
 tion and after getting about should not apply a truss, although most of 
 them prefer to wear an abdominal supporter for a year. 
 
 Piccoli (Ccntralblatt filr klinische Chiriirgie, Jan. 13, 1900) reports 
 a case successfully operated on in August, 1899, after the lateral plan, and 
 refers to a case reported by Bonomo, operated on Dec. 9, 1899, with a 
 favorable result. 
 
 J. A. Blake (Medical Ass'n of Greater New York, J^n. 14, 1901) 
 reports several cases operated on by the lateral method during the year 
 1900, and refers to an article by Sapiejko (Rev. de Chir., 1900, No. 2, p. 
 240) in which a lateral operation is described. 
 
 The writer (Mayo) had described and operated by the lateral over- 
 lapping plan several years before the cases reported by these authors 
 and found the lateral a good operation, but it is not as good as the ver- 
 tical method, in which the retaining structures are given a bearing point 
 above the site of the umbilicus and intra-abdominal pressure thus acts 
 to prevent separation instead of aiding it. 
 
 BLAKE'S OPERATION. 
 
 J. H. Blake claims that the method which is particularly applicable 
 to the cases in which there is stretching of the linea alba with separa- 
 tion of the recti muscles is that of lapping the abdominal walls. This 
 method consists of the division of the linea alba above and below the sac 
 in the median line for the necessary distance, with or without excision 
 of the ring and a portion of the linea alba. The entire wall on one side 
 is then lapped in front of the other and there sutured, so that the ventral 
 surface of the one side is in contact with the dorsal surface of the other 
 (Fig. 56). Three patients were operated on after this method, with good 
 immediate results. The suture miaterial used was plain catgut for the 
 peritoneum. No. 2 chromicized catgut for the aponeurosis and muscles, 
 and silkworm gut and silk for the skin. Two points in the technic are 
 emphasized, the absolute cleansing of fat from the rectus sheath, 
 which is to be applied to the back of the opposite rectus, and the inser- 
 tion of the mattress sutures, so that they wall be in the course of the 
 muscle fibers, and not strangulate them. It has been found more conve- 
 nient to have the mattress sutures threaded on two needles. The sutures 
 
308 RADICAL CURE OF UMBILICAL IlERNIA 
 
 include about one-third of an inch of tissue, and are placed about five- 
 eighths of an inch apart. Some of the more apparent advantages of 
 the method are the doubling of the abdominal wall at the hernial site ; the 
 breaking of the lines of suture; a broad surface for union; the oblitera- 
 tion of the separation of the recti, and the reduction in the size of the 
 abdomen. 
 
 In applying the mattress sutures along the edge of the inner flap, 
 and to the peritoneum, care must be taken not to leave a raw edge on 
 the peritoneal aspect in order to prevent adhesions. If a little care is taken 
 to fit the flaps properly at the upper and lower corners, a uniform pres- 
 sure on the abdominal organs is obtained. In several cases I have liberated 
 the recti muscles ver}^ freely after sev/ing the peritoneum and the aponeu- 
 rotic structures, bringing the tv\^o recti muscles together in the mid-line 
 (Figs. 57, 58, 59, 60). 
 
 BOECKEL'S OPERATION. 
 
 Boeckel makes an elliptical incision, removing the umbilicus with 
 the sac. Chain sutures are inserted to close the peritoneum. The fibrous 
 edges are freshened even to the muscular structures of the recti, if nec- 
 essary. Kangaroo tendon or chromic catgut is employed to coapt the 
 fibro-muscular structures. 
 
 DATJRIAC'S OPERATION. 
 
 In this method both recti muscles are exposed through a median 
 incision, or the incision may be made elliptical. The sac is ablated and 
 then the peritoneum is closed. The next step in the operation is to cross 
 a portion of the right rectus muscle over to the left side, and a portion 
 of the left rectus muscle over to the right side, thus forming an X of 
 muscular tissue, the center of the X being placed over the center of the 
 spot occupied by the hernia. 
 
 This is done by dividing each muscle into two portions by two in- 
 cisions, a longitudinal incision and a transverse incision, the former be- 
 ing placed nearer to the inner than to the outer border of the muscle. 
 The transverse incision passes through the inner portions of the muscles 
 transversely at their upper ends, including the corresponding part of the 
 muscle sheath. In Greig Smith's operation the inner borders of the recti 
 muscles are liberated by a free separation of the margins of the ring and 
 they are sutured together with buried sutures. 
 
 Quenu recommends six layers of sutures coapting like structures, as 
 follows: (i) Peritoneum; (2) fascia; (3) posterior border of the rec- 
 tus muscle; (4) rectus muscle; (5) anterior border of the rectus muscle; 
 (6) subcutaneous soft structures; (7) skin. 
 
 DEAVER'S OPERATION. 
 
 Deaver's operation difTers slightly from the usual omphalectomy. The 
 sac is disposed of in the customary manner. The recti muscles are ex- 
 posed by incising the anterior walls of their sheaths near the linea alba on 
 each side of the wound, and thev are then brought together bv sutures 
 
RADICAL CURE OF UMBILICAL HERNIA 3O9 
 
 which are passed through them and the anterior walls of their sheaths, 
 from within outward. 
 
 Barker, Bennett, Keetlev, Ball, Macewen, and AIcGill laid great stress 
 on the importance of retaining the sac, twisting the stump and sewing 
 the other structures in front of it. 
 
 OMPHALECTOMY. 
 
 This is the ideal operation for the cure of an umbilical hernia of 
 moderate size, and in women with lax abdominal walls who have borne 
 children, hernias of considerable size can be dealt with successfully by 
 doing an omphalectomy, as was pointed out by Joseph Ransohoff, of Cin- 
 cinnati, who in 1897, reported three cases of this kind in which the opera- 
 tion was entirely successful. 
 
 In the para-umbilical, sub-umbilical and supra-umbilical varieties, the 
 conditions present must determine whether or not the umbilicus is to be 
 removed. If the hernia is a very small one, the umbilicus need not be re- 
 moved, but the rule is to ablate it. 
 
 WARREN'S OPERATION. 
 
 J. Collins Warren, of Boston, believes that in view of the fact that 
 the vertical diameter of the opening in these cases is always .shorter than 
 the transverse, better results will be obtained by bringing the lower and 
 upper margins of the ring together, rather than the lateral edges. He 
 uses silk for his buried sutures. In one case, the patient being 46 years 
 old, a case of recurrent hernia, the result was excellent ten years after 
 the operation. The patient had worn a belt since the operation. Of 
 eleven cases operated by this method, in only one was a recurrence reported 
 during periods of from one to thirteen years, about 9 per cent. 
 
 WINSLOW'S OPERATION. 
 
 K. Winslow (Annals of Surgery, Feb., 1904) states that the aponeu- 
 rotic coverings are the chief supporting structures of the abdominal walls 
 and that their approximation by overlapping in doubling the strength of 
 the aponeurotic layers doubles the strength of the abdominal incision. His 
 technic for the prevention of abdominal hernia by overlapping the aponeu- 
 rosis is described as follows : 
 
 The integument and subcutaneous tissue are incised down to the 
 aponeurosis. This is bared by reflecting back the skin and fat for the space 
 of an inch and a half on the side of the incision. The aponeurosis is 
 then incised in the same line and directly beneath the skin incision, and 
 the two flaps, one on each side of the incision, are raised from the under- 
 lying muscle by blunt dissection. One flap of aponeurosis is freed for 
 an inch or so from its cut margin and the other for about half that dis- 
 tance. The incision through the rest of the abdominal wall is completed 
 as usual. In closing the peritoneum is approximated by continuous suture. 
 In weak, fatty walls it is wise to introduce two or three retention sutures 
 placed well back from the margins of the wound and penetrating the layers 
 
3IO RADICAL CURE OF UMBILICAL HERNIA 
 
 above the peritoneum. The muscle, if well developed, is coaptated by 
 interrupted sutures, then the cut edge of the aponeurotic flap which was 
 but slightly freed is stitched to the base of the opposing flap by interrupted 
 or mattress sutures. The free margni of the opposing flap is lapped over 
 the other one and stitched down to the surface of the aponeurosis by in- 
 terrupted or continuous suture. A drain of gauze wrapped about with 
 rubber tissue, or a roll of rubber tissue alone, emerging from the lower 
 angle of the wound, should be inserted between the fat and aponeurotic 
 layer in cases where there has been much manipulation or where the 
 adipose tissue is thick. The skin may be coaptated with the Mitchell 
 clamp, buried silver wire or other suture. The retention sutures are of 
 silkworm gut. Medium catgut is used for the lower layers, plain in the 
 case of the peritoneum and chromicized for the muscle and aponeurosis. 
 The retention sutures, if used, are employed merely to support the wall 
 until the dangers of vomiting and meteorism are passed and union has 
 begun. 
 
 GRASER'S OPERATION. 
 
 Menge was very much opposed to cutting into the anterior sheath of 
 the recti muscles. He advised incision of the posterior sheath, so as to 
 effect the release and suture of these muscles as high and as low as pos- 
 sible. E. Graser performed this kind of operation four times in cases of 
 large umbilical and abdominal hernias, with most excellent results. How- 
 ever, the operation is a serious one; it is a tedious one, and the numerous 
 imbedded sutures favor the occurrence of sepsis. 
 
 The principal incision is made transversely over the highest point 
 of the abdominal tumor, its length varying from 35 to 50 centimeters. The 
 sac is opened, adhesions of the intestine are freed, and the trimmed part 
 of the sac is brought to the hernial ring. A separation of the sheaths of 
 the recti muscles into an anterior and a posterior flap is absolutely nec- 
 essary. The anterior sheath is divided transversely as far as the external 
 border of the rectus muscle, often widely displaced laterally, and then the 
 entire aponeurotic flap is lifted up. Where a separation is not possible, 
 the commissure of the rectus sheath is to be split along the inner border, 
 care being taken to avoid injuring the anterior la_ver. Above and below, 
 where the recti muscles approach each other but do not touch, a longi- 
 tudinal incision is made, near the linea alba, so that the fibrous structure 
 of this remains in contact as a stifle ligamentous layer. 
 
 The flap having been prepared, the peeling out of the rectus muscle 
 is effected, the loosening being- done very carefully both from the anterior 
 and the posterior sheaths, with preservation of the nerves. When the 
 loosening is completed, the suturing of the omentum is proceeded with, 
 and best simultaneously with closure of the posterior sheath of the rec- 
 tus. On account of the tension, stay sutures are generally necessary. 
 Above and below the union can only be made in vertical line on account 
 of the linear incision. Transverse seams may be added to diminish the 
 gaping. 
 
PLATE LV. 
 IVIayo's Operation for Umbilical Hernia. 
 
RADICAL CURE OF UMBILICAL HERNIA 3I3 
 
 Now follows, and likewise in vertical direction, the union of the 
 rectus muscles by interrupted sutures, some of which are passed deeper ; 
 others above these draw the edges somewhat over each other. The edges 
 of the anterior aponeurosis are trimmed and approximated by a right solid 
 row of interrupted iodized silk or catgut sutures. If the tissue is re- 
 dundant, one flap can be pushed under the other, thus doubling the line 
 of union. 
 
 C. A. Wheaton, of St. Paul, advises operation in all cases of umbilical 
 hernia, no matter what the size of the hernia, and also advises reducing 
 the body weight of fleshy patients by a systematic course of treatment 
 carried out for a few wrecks before the operation is done. 
 
 Terrier, Czerny, Reverdin, and others removed the hernial sac, re- 
 sected the omentum, reduced the contents of the sac, sutured the borders 
 of the hernial ring in layers, and closed the skin by a separate layer of 
 sutures. The results were not very satisfactory. 
 
 Condamin opened the abdominal wall at the periphery of the hernia 
 and continued the incision until the peritoneal cavity was reached. Thus 
 the sac, superfluous skin and umbilicus were removed in one portion. 
 Omphalectomy and closure of the wound in separate layers as in an or- 
 dinary laparotomy completed the operation. 
 
 Gersuny dissected free the edges of the recti muscles, uniting them 
 by suture. The skin wound was tamponnaded with gauze and allowed to 
 remain open for a few days, after which time it was closed by superficial 
 sutures. 
 
 Champonniere sutured the edges of the aponeurosis of the peritoneum, 
 placing a second and sometimes a third row of sutures in the aponeurosis, 
 — superposition of rows of sutures. 
 
 V. Pauchet recommended prolonged fasting before operating on large 
 hernias in obese subjects. He laid 'down the following regimen: Warm 
 or cold water is to be drunk at discretion at least four quarts during the 
 twenty-four hours, either pure or in the form of lemonade, or slightly 
 salted decoctions of herbs. If the patient is moderately active or con- 
 tinues at his work, an ungarnished salad at noon and an apple morning 
 and evening, or four or five oranges daily, may be taken. On this diet 
 the patient is reduced to his proper weight in six weeks or three months. 
 
 HERNIAS OPERATED ON BY LAPAROTOMY. 
 
 On ten occasions I operated on and cured femoral liernias b}' the 
 abdominal route, the primarj^ indication for the laparotomy being fibroids 
 of the uterus in tvv'o cases ; ovarian cysts ir two cases ; inguinal hernia in 
 three cases, and appendectomy in three cases. In each one of these cases 
 the sac was turned inside out and cut off. The interna) aspect of the crural 
 canal was exposed and the canal closed with two sutures of chromic catgut 
 passing through Pcupart's ligament and the periosteum of the pubic bone. 
 The peritoneum was then sutured in such a manner as to turn the raw edges 
 outward. 
 
 In treating femoral hernia bv the abdominal route, the technic of the 
 
314 R.\DICAL CURE OF UMBILICAL HERNIA 
 
 operalion is greath' facilitated by placing the patient in the Trendelenbi'irg 
 position. 
 
 V\"hen it becomes necessary to open the abdomen of an individual who 
 has a femoral hernia, there is no need for performing any of the special 
 operations for this condition. 
 
 A laparotomy is the only means of treating epigastric, certain umbilical, 
 ventral, vesical, lumbar, and urachal hernias, and also for those hernias, 
 either congenital or acquired, that occur through the rectus muscle, linea 
 alba, and linea semilunaris. 
 
 The special indication for laparotomy is the occurrence of the so-called 
 internal hernias, such as (i) diaphragmatic hernia; (2) hernia into the 
 duodeno-jejunal fossa (posterior internal hernia of Treitz) ; ('3) Winslowian 
 (a true internal hernia into the foramen of Winslow) ; (4) hernia into the 
 inter-sigmoid fossa; (5) into the mesocolic fossa; (6) omental and mesen- 
 teric hernia; (7) pelvic hernias — obturator, sciatic, vesico-rectal, perineal, 
 and hernia into Douglas' cul de sac. 
 
CHAPTER VII. 
 
 REPAIR OF LARGE DEFECTS IN ABDOMINAL WALL. 
 
 A number of operators have devised methods for repairing large de- 
 fects in the abdominal wall following operations for hernia and abdominal 
 sections done for various purposes. Xotable among these methods are 
 those devised b}^ Phelps, Meyer and Bartlett, in which a metal filigree is 
 employed. Witzel was the first to suggest the idea of embedding in the 
 wound a ready-made filigree. He drew the edges of the wound together 
 as much as possible with heavy silver sutures, which penetrated muscles 
 and fascia ; then, after these had been tied, he ran slender wares in every 
 direction across the opening which remained. 
 
 Willy ]Meyer, of New York, used a network consisting of wires 
 crossing at right angles and equidistant from one another, resembling 
 the ordinary mosquito netting. In the Annals of Surgery, November, 
 1902, he reports three cases in which a silver filigree was used with excel- 
 lent results. The first patient was a man, aged 55, who had previously 
 been operated for strangulated hernia. For several years the defect in 
 the abdominal wall was left unprotected until finally a large ventral hernia 
 developed, accompanied by severe pain. The opening was closed with sil- 
 ver wire netting, and although a fistula developed, which alternately closed 
 and opened, the man was perfectly able to atend to his heavy work. The 
 patient died two years after the operation from general peritonitis fol- 
 lowing the lifting of a heavy cake of ice and the production of a com- 
 plete intestinal obstruction at the site of an incomplete obstruction due to 
 manifold old-standing adhesions between coils of the small intestine. The 
 wire netting had no relation to the trouble. 
 
 The second patient, a woman of 43, following a laparotomy, devel- 
 oped a large, irreducible, omento-intestinal hernia, the aperture being 
 about midway between the symphysis and the umbilicus. Following a 
 first unsuccessful attempt at cure of the hernia, a second operation was 
 done with the help of the silver ware netting. It was successful. Sev- 
 eral months later a severe traum.a tore the continuous wire suture causing 
 one of the corners of the filigree pad to come loose. 
 
 The third patient, woman, aged 31, had what appeared to be an irre-. 
 ducible, inflamed umbilical omental hernia. It was finally reduced after 
 the inflammation had subsided and a radical operation was performed with 
 implantation of the silver filigree. 
 
 Willard Bartlett, of St. Louis, introduced a form -of filigree (Annals 
 of Surgery, July, 1903) vv^hich depends for its efficacy on the fact that 
 all but one of its wires run across the long axis of the scar and penetrate 
 for a distance of one or two inches betv/een the tissue lavers, where they 
 
3l6 REPAIR OF LARGE DEFECTS IN ABDOMINAL WALL 
 
 are firmly anchored, not by sutures, hut hy newly- formed scar tissue which 
 Bartlett says fills out the opening of each loop while the patient is in 
 bed after the operation. He purposely bends each of these cross wires into 
 the form of a loop in order that there shah be no sharp irritating ends 
 anywhere, and he lays great stress on the fact that each of these loops 
 should be entirely separated at the free end from its neighbor. Thus the 
 minimum of stiffening is imparted to the tissues by the single longitudinal 
 twist which binds the several loops together in the median line of the con- 
 trivance. The last-named wire strand appears necessary to prevent the 
 possibility of a hernia between two of the cross wires, which might easily 
 be forced slightly apart if they were not fastened together at all. 
 
 In cases that allow of no accurate determination beforehand, as 
 to the size of filigree desired, Bartlett uses a net which difi^ers slightly 
 in its construction from that just described. No median wire twist binds 
 the cross loops together ; however, Bartlett compensates for this by sewing 
 the filigree in place with a continuous suture of fine wire, being careful 
 to loop the suture around each point of crossing in the filigree. 
 
 J. Wiener, Jr. (Annals of Surgery, April, 1906) reports seven cases 
 in which he used Bartlett's filigree. The first patient, a man, aged 34, 
 had a ventral hernia. The gap was filled in with silver wire sutures 
 passed from side to side so as to m.ake a filigree. Sixteen months after 
 the operation there had been no recurrence and the patient was perfectly 
 comfortable. The second patient, a man, aged 30, had an oblique right 
 inguinal hernia for three years and a left sided hernia for one year. The 
 wide gap was bridged over by a continuous suture of silver wire so as to 
 make a sort of figure-of-eight filigree. The operation was successful. The 
 third patient, a man, aged 53, had a large right inguinal hernia which re- 
 curred after operation. A silver wire filigree was sutured over the inguinal 
 canal, and the superficial fascia and skin were brought together with in- 
 terrupted sutures. Death occurred on the sixth day and was undoubtedly 
 due to the fact that the abdominal cavity could not accommodate itself to 
 the large amount of intestines which had been in the sac. 
 
 The fourth patient was a man, aged t,/, who had a large ventral her- 
 nia in the left iliac fossa the result of a severe trauma. A silver wire 
 filigree, 2x 2J/2 inches, was placed between the peritoneum and the trans- 
 versalis muscle ; the external oblique was approximated with a running 
 suture of silver wire and the skin with silk. The man made a perfect 
 recovery. The fifth patient, a woman, aged 24, had a large ventral her- 
 nia following appendectomy. A hernioplasty was done with resection of 
 gut for gangrene and the abdomen was closed with silver wire. The pa- 
 tient recovered and has been doing arduous housework sini„e the operation. 
 
 The sixth patient, woman, aged 30, had a large umbilical hernia of 
 five years' standing which became irreducible. The sac was filled with 
 omentum and one loop of small intestine. The intestine was replaced and 
 the omentum resected. Sutures of silver wire almost completely obliter- 
 ated the diastasis at the neck of the sac. Three months later, during a 
 severe attack of bronchitis, the patient developed a small hernia below the 
 
REPAIR OF LARGE DEFECTS IN AEDO:SIIN.AL WALL 317 
 
 umbilicus. Meyer is convinced that if lie had put in a filigree in addition 
 to the wire sutures this recurrence would not have happened. 
 
 The last patient, a woman, aged 27, had a tumor of the rectus muscle 
 removed. A filigree was placed in the depth of the v/ound and a second 
 filigree through the oblique muscles. Recovery was uneventful. 
 
CHAPTER VIII. 
 
 DIAPHRAGMATIC HERNIA. 
 
 Having made the diagnosis of diaphragmaiic hernia, abdominal section 
 through the left upper half of the rectus muscle should be undertaken at 
 once, except when the hernia is of the congenital variety and occurs earl}' 
 in life. S^miptoms of intestinal strangulation are often the first indication 
 cf the existence of a diaphragmatic hernia, and the cause of these manifes- 
 tations often is not discovered until the abdomen has been opened or durmg 
 an autops3^ 
 
 As a matter of fact, the presence of a diaphragmatic hernia seldom is 
 discovered during life. In but seven of 266 cases reviewed by Lachner was 
 the diagnosis made ante-mortem. Maragliano also reported a case (1897) 
 in which the diagnosis was made during life. In this instance the hernia 
 developed suddenly during a fit of coughing. Air was pumped into the rec- 
 tum, and it was noticed that thereby the size of the left side of the chest 
 v/as increased and palpation elicited a tympanitic note. With each insuffla- 
 tion a sound was heard in the fifth intercostal space. Water was then in- 
 jected and it produced an area of dullness where there had been tympany 
 before. 
 
 The abdomen having been opened, a sandbag is placed beneath the 
 shoulder-blades so as to tilt the diaphragm. The intestines, stomach or 
 omentum, as the case may be, are drawn out from the thoracic cavity and 
 the opening in the diaphragm is sutured. Rochard, Schwartz, Perman, 
 Treves, and others advise attacking the hernia Lhrough the pleural cavity 
 by means of a resection of the costal arch of the ninth rib. If the hernia is 
 incarcerated, I believe that the thoracic route is the preferable one, but in 
 cases where the hernia is inflamed, ulcerated, strangulated, or gangrenous, 
 v/hen a resection of the bowel must be done, the thoracic route insures less 
 tendency to infect the peritoneal cavity. The bowel is clamped ofi^ readily 
 above the diaphragm, and the resection is done speedily. ;\n end-to-end 
 anastomosis completes the operation. The pleural cavity must be drained 
 freely. 
 
 Before undertaking the operation for the cure of a diaphragmatic hernia, 
 it is absolutely essential that the stomach be v/ashed out, because otherwise 
 there exists the possibility of the patient becoming drowned in his own 
 vomitus. This precaution should never be neglected in any case of intestinal 
 obstruction. 
 
 F. W. McRae (Trans. South. Sitrg. and Gyn. Assoc, 1894) reports the 
 case of a man who was stabbed in three places, in the back below the 
 scapula, and in the left side, four and one-half inches from the axillary 
 line between the fifth and sixth ribs, three and one-half inches from the 
 
PLATE LVI. 
 
 Large Umbilical and Post-operative Ventral Hernias. 
 (Author's Case.) 
 
DIAPHRAGMATIC HERNIA 32 1 
 
 nipple. The third wound passed through the tissues and entered the thoracic 
 cavity. The patient was unable to lie down on account of the pain in his 
 side. The wound was closed carefully. The patient recovered from the 
 injury, but the pain continued, and finally, eight months after the injury, 
 hiccough and stercoraceous vomiting set in. To the right of the wound there 
 was an enlargement about the size of a small hen's egg. The diagnosis 
 made was that of hernia or telescoping of the bowel. At the operation the 
 opening in the diaphragm was readily located, and the colon was found 
 completely strangulated. McRae found in the thoracic cavity the entire 
 stomach and greater omentum, about one foot of the small intestme, and 
 the whole of the transverse and a part of the descending colon. All these 
 structures were gangrenous. The wound was closed. The patient died' 
 about seven hours afterwards. The strangulation in the case had existed for 
 five days, and McRae is of the opinion that an early operation might have 
 served to prolong the life of the patient. 
 
 A second case seen b\ McRae was a woman, ^y years old, who was 
 taken sick suddenly with severe pain in the left lower quadrant of the 
 abdomen. The abdomen v,'as swollen and tender. The temperature was 
 elevated slightly. Repeated enemata were given, without results. On the 
 third day the patient vomited mucus and fecal matter. At the operation 
 part of the large intestine and a portion of the stomach were found pro- 
 truding through the hernial opening in the diaphragm on the left side. 
 Breathing became very poor, as soon as air was admitted into the thorax, 
 and mucus, mixed with a little fecal matter, began to run from the nose 
 and mouth. There was general peritonitis. During the closure of the abdo- 
 men the patient vomited a large quantity of matter, and "drowned." 
 
 Hale and Goodhart (Trans. Lon. Clin. Soc, 1892) report a case of 
 diaphragmatic hernia which was diagnosed as cancer of the stomach, and 
 in which death was caused by vomiting. The patient, a man, aged 49, the 
 subject of a double inguinal hernia, complained of bringing up raouthfuls of 
 a dark, clear mucus, and about every week or ten days he vomited enormous 
 quantities of fluid of a similar character. He had a sensation of heat and 
 pain at the ensiform cartilage. Bowels were obstinately confined. He had 
 been losing flesh for some time. A tympanitic resonance was found pos- 
 teriorly as high as the middle of the left scapula. There was retraction of 
 the abdomen. The post-mortem revealed a piece of the splenic flexure of 
 the colon entering the thorax through an aperture between the crura of 
 the diaphragm beneath the liver. A portion of the stomach and transverse 
 colon also entered through this opening. The stomach was enormously 
 dilated. A large portion of it was free in the bottom of the left pleura. The 
 sac contained two-thirds of the stomach, a large portion of the transverse 
 colon, the lesser omentum, and the greater part of the pancreas and the 
 duodenum. 
 
 In 1900, Funck-Brentano reported a case of congenital diaphragmatic 
 hernia which was discovered at the post-mortem. The patient died from 
 convulsions when fifty-five days old. There was a free communication be- 
 tween the thoracic and abdominal cavities. The left pleural cavity was oc- 
 
322 
 
 DIAPHRAGMATIC HERNIA 
 
 'cupied by the spleen, and a large part of both the large and small intestines. 
 The lung on that side was compressed to about the size of a bean, and the 
 heart was displaced to the right of the medium line. 
 
 I. A. Abt (Chicago Medical Recorder, August, 1900) also reports a 
 case of congenital diaphragmatic hernia, occurring in a child born dead. 
 The diaphragm on the left side was almost completely absent, the left 
 thoracic cavity being occupied in large part by the liver. The greater cur- 
 vature of the stomach occupied the space normally filled by the apex of the 
 luno- and a considerable portion of both the small and large intestines oc- 
 cupied the thoracic cavity. 
 
 Walker (Internat. Jour, of Surg., September, 1900) reports a case of 
 diaphragmatic hernia occurring in a man, aged 29, who was mjured by a 
 falling tree. There was severe pain in the left chest, which was aggravated 
 bv coughing and deep inspiration. Respirations were shallow and rapid; 
 pulse, 145 ; bowels could not be opened and fecal vomiting ensued. The 
 abdomen became distended. Examination of the left chest showed dimin- 
 ished expansion, amphoric breathing and a tympanitic note at the base of 
 the lung ; succussion sounds were heard when the patient was shaken. The 
 apex of the heart was displaced two inches to the right, and the seventh 
 and eighth ribs were fractured on the left side. At the operation a piece of 
 small intestine was found firmly held in a rent in the diaphragm. The bowel 
 was withdrawn and the opening partially closed. Patient recovered. 
 
 Klaggs (London Lancet, Aug. 6, 1904) collected 53 cases of diaphrag- 
 matic hernia of the stomach, including three of his own. Of the whole 
 number, 20 were congenital 21 were traumatic, and 12 were acquired. The 
 symptoms varied and were irregular. Usually there was disturbance of 
 respiration and digestion, wuth signs of obstruction and strangulation, and 
 especially tetanus. The physical signs were indefinite. 
 
 Stomach and intestinal murmurs w^ere heard in the thorax. The heart 
 was displaced. A murmur was often elicited by passing air into the stomach. 
 Other signs were interference with pulmonary murmur and resonance; 
 alteration in the shape of the thorax ; sanguine expectoration and inability 
 to lie on the right side. The lesions found at autopsy were adhesions, ulcer, 
 dilatation and strangulation of the stomach, and obstruction caused by vol- 
 vulus of stomach or torsion of lesser omentum. 
 
 H. B. G. Newham (Lond. Lancet, Dec. 24, 1904) saw a man soon after 
 a fall of thirty feet which had caused extensive bruising but no apparent 
 fracture. The stomach and part of the colon occupied the left half of the 
 thorax, displacing the heart to the right. The tear in the diaphragm was 
 supposed to have been produced by sudden anl violent muscular contraction. 
 The patient survived two days in spite of much precordial and abdominal 
 pain. 
 
 In dealing with this class of hernias, the operator must bear in mind 
 that over ninety per cent, of them have no sac. Grosser studied 433 cases, 
 only 40 of which had a sac. They are, therefore, either true or false, con- 
 genital or acquired. The whole left half of die diaphragm may be thinned 
 out and protrude upward, giving rise to symptoms and signs that simulate 
 
DIAPHRAGMATIC HERNIA ^2^ 
 
 a hernia of the diaphragm. This condition was designated by Cruveilhier 
 and Thoma diaphragmatic eventration. 
 
 In 1898, at the Chicago Post-Graduate Hospital, I was induced to ex- 
 pose the diaphragm of a young man for a supposed hernia of that muscle 
 on the left side. This young man had what has been termed the operation 
 habit. His appendix had been removed, his gall bladder had been explored, 
 the right kidney had been drained, and an exploratory laparotomy had been 
 done on him. I operated on him for a post-operative hernia following the 
 appendectomy. Nine months afterward he was referred to me again for 
 this supposed diaphragmatic hernia. Knowing of his habit, I observed him 
 for about three days, and then came to the conclusion that he did not have 
 a hernia. 
 
 Three days afterward he appeared at a medical meeting and the phy- 
 sician in charge made a positive diagnosis of a left-sided diaphragmatic 
 hernia. The patient was referred to me for operation. I explored the entire 
 lower surface of the diaphragm and demonstrated that no hernia existed, 
 but that the diaphragm was very much thinned and arched mucli higher 
 than normal. The patient left the hospital two weeks afterward in good 
 condition, having been relieved of many of his supposed symptoms. 
 
 I kept this young man under observation for a number of years. He 
 died in a neighboring city of general peritonitis following an operation 
 done for a supposed intestinal obstruction. I was informed that a long and 
 tedious operation failed to reveal any obstruction. 
 
 Early in my professional career I delivered a woman of a fully developed 
 boy. The next day the infant began to vomit, and became bloated. He died 
 on the fifth day, with symptoms of obstruction of the bowel. The post- 
 mortem revealed a loop of jejunum passing through the central tendon of 
 the diaphragm. 
 
 The surgeon should familiarize himself with the places in the diaphragm 
 where hernias have been found. Irrespective of gross congenital deficiencies, 
 and also apart from injuries of the diaphragm, hernial openings have been 
 demonstrated in the following places: (i) Central tendon (most frequent) ; 
 (2) muscular portion (posterior inferior); (3) sterno-costal fissures; (4) 
 esophageal opening; (5) lumbo-costal fissures ; {6) sympathetic trunk open- 
 ing; (7) aortic opening; (8) psoas muscle opening, and (9) the opening 
 through which the quadratus lumborum muscle passes. 
 
 A diaphragmatic enterocele is shown in Fig. 10, and an epiplocele 
 in the pericardium is shown in Fig. 9. 
 
 The results following operation for diaphragmatic hernia are not very 
 encouraging when strangulation has occurred. The mortality is about 95 
 per cent. It is said that cases have been operated on successfully by Hum- 
 bert, Leisrink, Postempski and Mikulicz. 
 
CHAPTER IX. 
 
 INTERNAL AND INFERIOR HERNIAS. 
 
 HERNIA INTO DTJODENO-JEJUNAL FOSSA. 
 
 Hernia into tlie fossa of Treitz (duodeno- jejunal) is an indication for 
 the performance of an abdominal section. There are two varieties of this 
 hernia: (a) Right, and (b) Left. In the former variety the superior mesen- 
 teric artery lies in front of the sac, and in the latter the superior mesenteric 
 vein is in front of the sac. The incision through the abdominal wall should 
 be made a little above and to the left of the umbilicus. 
 
 Although these hernias are always twisted, they are not difficult to 
 liberate, except when adhesions have formed or strangulation has occurred. 
 Then the edges of the ring may be nicked carefully and the opening dilated. 
 
 After withdrawing the intestines into the peritoneal cavity, a few- 
 stitches of silk or catgut should be inserted to obliterate the ring and pre- 
 vent a recurrence. The sac may be opened, if necessary, to facilitate the 
 reduction of the hernia. 
 
 This form of hernia is comparatively rare, but quite a number of in- 
 stances are recorded in the literature, and the following citations will serve 
 to explain the nature of these hernias, the method of treatment that is usually 
 adopted to correct them, and the results that may be obtained. It would 
 be useless to cite all the cases that have been reported. 
 
 Bingel (Archiv f. Pathologische Anatomic, No. i, 1902) reports a case 
 of hernia into the fossa duodeno-jejunalis occurring in a woman, aged 28 
 years, which proved fatal in twenty hours. At the autopsy the abdomen 
 contained a large quantity of blood-stained fluid and the coils of the intes- 
 tine on the right side were distended, infiltrated with blood and covered 
 with a thin, fibrous exudate. The left side of the abdomen was occupied 
 by a tumor reaching from the diaphragm to the pelvis. This tumor proved 
 to be a large peritoneal sac containing enormous coils of intestine and their 
 mesentery. Strangulation was brought about apparently by the escape of 
 a coil of intestine from, the sac. 
 
 L. L. McArthur (Surg., Gyn. and Obs., January, 1906) cites a case of 
 hernia in the fossa of Treitz consisting of an incarcerated loop of jejunum 
 of which an accurate diagnosis couM not be made before laparotomy, and 
 then only after a most exhaustive search through the abdom.en. After a 
 careful study of the history of the case it appeared probable that there 
 existed an acute intestinal obstruction, which might be due either to a 
 mechanical or to an infective inflammatory cause. In favor of the mechani- 
 cal nature of the obstruction was the somewhat gradual onset of the ob- 
 structive symptoms, without high fever, and with the appearance of blood 
 
PLATE LA'II. 
 
 Blake's Operation for Umbilical Hernia Completed. 
 (Author's Case.) 
 
INTERNAI. AND IXPF,RTOR HERM.'vS 32/ 
 
 and mucus in the stools ; the blood count, while elevated, not being high 
 enough to be convincing as to the presence of pus. Because of the tender- 
 ness over the whole abdomen, the sudden sharp exacerbation of the pains 
 on the second day, and some rise in temperature, attention was directed 
 to the appendix, but without other corroborative signs. Following the evis- 
 cerations in the endeavor to find the point of obstruction, almost the entire 
 small intestine was removed from. the abdomen before a small loop was 
 found which led to the discovery of the cause of the trouble. The patient 
 made an uneventful recovery. 
 
 Two cases of left duodenal hernia are reported by L. Freeman (Trans. 
 Am. Surg. Assn., 1903). 
 
 In the case of one of these hernias the sac contained the entire small 
 intestine, the cecum, and a portion of the colon, which was strangulated. 
 The patient, a man, aged 47, following an attack of diarrhea lasting three 
 weeks, developed a severe ileus, with the usual symptoms of acute intestinal 
 obstruction. On opening the abdomen, the cavity was occupied by an im- 
 mense tympanitic tumor, resembling an ovarian cyst. The small intestine 
 could not be seen, but the colon was felt below and to the right side. The 
 sac was opened, and then was found the entire small intestine, together 
 with the cecum and some six or eight inches of the adjacent colon. There 
 was also considerable foul and bloody serous fluid. In attempting to relieve 
 the condition, it was necessary to resect the cecum, which was gangrenous, 
 together with some six inches of the large intestine and a considerable por- 
 tion of the small bowel. 
 
 The patient's resisting powers were so poor and the operation was so 
 complicated and extended, that death resulted. The entire colon lay in folds 
 on the right side of the abdomen — a congenital condition. 
 
 The second case was seen at autopsy. The patient died of gangrene of 
 the small intestine, accompanied by a severe hemorrhage arising from 
 thrombosis of the mesenteric and portal veins. The patient had been subject 
 to indigestion and occasionally experienced slight pains and uneasiness in 
 the abdomen. The sac filled the entire left side of the abdominal cavity, 
 and was well over to the right of the median line. It contained all but six 
 inches of the small intestine, the transverse and descending colon being 
 spread out on its upper and left outer surface, lea'ving the cecum, colon and 
 sigmoid in their normal position. The mouth of the sac was round and 
 smooth, and easily admitted three fingers. From it emerged the lower end 
 of the ileum to join the cecum in the right iliac fossa. The opening was just 
 to the right of the vertebral column, on a level with the crest of the ileum 
 and toward the dorsal and inferior portion of the sac. There was no stran- 
 gulation of the bowel or mesentery. 
 
 In December, 1906, I had a similar case in private practice. The patient 
 had not been well for a number of years, but complained most of recurrent 
 attacks of pain over the region of the gall bladder. She said that she felt 
 as though something was slipping away behind the stomach. Inspection of 
 the abdomen was negative. Palpation elicited tenderness over the' gall 
 bladder and also over the appendix. The gall bladder was enlarged. On 
 
328 INTERNAL AND INFERIOR HERNIAS 
 
 the whole the physical examination did not furnish much evidence on which 
 a diagnosis could be based. 
 
 I made an incision through the right rectus muscle, exposing the region 
 of the gall bladder and the hepatic flexure of the colon. The gall bladder 
 was adherent to the right upper border of the great omentum, which in 
 turn was adherent to the lesser curvature of the stomach. To the right of 
 the bladder was a Riedel lobe, extending two and a half inches below the 
 gall bladder. On separating the adhesions between the stomach, gall blad- 
 der and omentum, a knuckle of bowel was felt to protrude above the lesser 
 curvature of the stomach. It could be pushed back behind the stomach, but 
 would return immediately. On passing two fingers through the foramen 
 of Winslow, it appeared to be blocked by a resilient mass, which I took to 
 be a hernia. I withdrew the great omentum and transverse bowel out of 
 the wound, disclosing a loop of the upper portion of the jejunum, extending 
 behind the stomach above the duodenum into the lesser cavity of the peri- 
 toneum. The bowel was not strangxilated, which accounted for the feeling 
 described by the patient of something slipping away from behind the stom- 
 ach. The sac of the hernia consisted of the posterior layer of the transverse 
 meso-colon. The mouth of the sac easily admitted two fingers. 
 
 I pulled the sac out and inserted a circular suture in such a manner as 
 to pucker up the sac on itself, thus obliterating the cavity of the sac, as 
 well as its mouth. 
 
 A short time ago Dr. H. W. Gentles referred a case of this kind to me 
 for operation. On opening the abdomen I found a perforation of an ulcer 
 of the stomach near the pylorus on its anterior surface, and a hard mass 
 near the pylorus which was thought to be a carcinoma. (Evidently not the 
 case according to later history.) On attempting to do a gastro-enterostom}^ 
 the bowel was found to be congested and I also discovered a left complete 
 hernia of the small intestine through the jejunal fossa. The hernia was re- 
 duced and the opening in the stomach was closed by a circular suture and 
 strengthened b_v sewing the falciform ligament as a flap over the seat of 
 perforation. The patient's condition did not warrant performing a gastro- 
 enterostomy. He made an uneventful recovery. 
 
 WmSLOWIAN HERNIA. 
 
 In this form of hernia the bowel passes through the foramen of Wins- 
 low into the lesser sac of the peritoneum. The hernia may be composed of 
 small bowel (Treitz), transverse colon (Majoli), cecum, or the entire 
 ascending colon and a part of the transverse colon (Treves). My own ex- 
 perience with this class of hernias being iiii, I cannot do better than extract 
 from a recent article by Faure {Bulletin ct Mem. de la Soc. dc Chir. de 
 Paris, No. 12, 1906) who, in a report on a case of intestinal strangulation 
 at the foramen of Winslow, communicated by Jcanbrau and Riche, gives 
 an instructive review of the diagnostic and therapeutic aspects of this rare 
 form O'f internal hernia. In three-fourths of the recorded cases the stran- 
 gulated mass consisted of small intestine ; and in the remaining fourth of 
 transverse colon which, it has been found, mav drae with the ascendiuir 
 
INTERNAL AND INFKRIOR ITERNIAS 329 
 
 colon and even the cecum, which extension, however, is hardly possible, 
 except in connexion with certain arrests of development, and with per- 
 sistence of a mesentery common to both small and large intestine. In two 
 cases the great omentum formed part of the herniated mass. The clinical 
 phenomena are those of intestinal obstruction with epigastric or umbilical 
 pain. The sole really important sA-mptom in regard to the diagnosis of the 
 localization of the obstruction is the presence of a swelling in these re- 
 gions. Hitherto, Faure points out, a precise diagnosis has never been made 
 before the performance of laparotomy, and, it is added, it has often been 
 found difficult even after exposure of the abdominal contents. 
 
 Attention is directed to the anatomical researches of Jeanbrau and Riche, 
 made with the view of devising some effectual method of relieving, by in- 
 cision of the margin of the foramen of Winslow, the intestinal constriction. 
 It has hitherto been assumed that the numerous difficulties in affording such 
 direct relief are insuperable, as incision of the margin of the foramen is ren- 
 dered impracticable by the contiguity of the vena cava behind, of the portal 
 vein in front and on the left, of the common bile duct in front and on the 
 right, and the Spigelian lobe above. Jeanbrau and Riche have suggested a 
 method of dilating the foramen by attacking its lower boundary in the inter- 
 space betw^een the vena cava and the portal vein. Faure, regarding the pro- 
 cedure of these surgeons as complicated, dangerous, and ineffectual, suggests 
 one which, though simple in theory, is not unlikely in its practical application 
 to be found very difficult. He proposes to incise the peritoneum along the 
 descending portion of the duodenum to the level where the membrane passes 
 from the posterior abdominal wall to the second portion of this intestine. 
 By means of the finger introduced through this incision the vena cava can 
 be separated from the duodenum, the head of the pancreas, and the portal 
 vein, and the inferior margin of the foramen of Winslow be thus relaxed. 
 If in a supposed case of strangulated hernia through the foramen of Wins- 
 low, and, indeed, in other varieties of internal strangulation, the patient 
 be in an alarming condition, and the intestine much distended, Faure would 
 abstain from prolonged exploration and free handling of the abdominal 
 viscera, and would establish a false anus above and as close as possible to 
 the umbilicus. If the patient recovered, a second operation, should such 
 be required, could be performed under much more favorable conditions for 
 the removal of the obstacle and the reduction of the herniated intestine. 
 Such procedure, though less brilliant, would, it is argued, be more success- 
 ful than that proposed by Jeanbrau and Riche of making an incision in the 
 wall of the distended intestine for the discharge of its contents, and then 
 proceeding to explore and, if possible, to dilate, tlie seat of the constriction. 
 
 {Rev. de Chir., XXVI, No. 5) contributes an article based on personal 
 clinical experience in one instance, and eighteen cases found m the litera- 
 ture. 
 
 When the patient is examined soon after the occurrence of the hernia, 
 a round, circumscribed tumor is noticed in the epigastrium or at the um- 
 bilicus, but it soon blends into the increasing general distension of the entire 
 abdomen. This early tumefaction is important for the diagnosis. It may 
 
330 INTERNAL AND INFERIOR HERNIAS 
 
 be directly in the center or more toward the right, and its center may co- 
 incide with the umbihcus or lie considerably above it, but always below the 
 costal arch. In none of the cases on record was the trouble correctly diag- 
 nosed. In some it was overlooked even at the laparotomy. The small in- 
 testine is generally involved. The stomach is forced forward and the af- 
 ferent loops of intestine are distended and held immovable under the liver, 
 high up to the right. No hernial sac is visible except in the rare cases in 
 which the intestine has slipped between the two sheets of the great omen- 
 tum. When the finger is able to trace the course of the incarcerated in- 
 testine, the pulsations of the large hepatic artery can be perceived. In the 
 II cases in which an operation was undertaken it proved to be too late to 
 save the patient in all but four instances. An incision into the intestine 
 should be made to evacuate it, after which reduction of the hernia is easy. 
 There is a sheet of loose cellular tissue, between the vena "cava and the 
 duodenum, through which it is easy to expose the lower part of the fora- 
 men of Winslow after incising the anterior sheet of the lesser omentum 
 over the upper duodenum, parallel to its longitudinal axis. 
 
 Delkeskamp (Beitr. z. Klin. Chir., XLVII, No. 2) relates the par- 
 ticulars of a case of intra-abdominal hernia through the foramen of Wins- 
 low. Immediately after a normal child-birth in a woman, aged 22, signs of 
 intestinal obstruction developed, the symptoms growing progressively worse. 
 The abdomen was opened on the seventh day after delivery, and the hernia 
 was reduced without much difficulty. 
 
 INTERSIGMOID HEENIA (POSTERIOR). 
 
 The intersigmoid fossa is not present always. Treves found it in 52 
 per cent, of 100 bodies examined. The fossa is located over the bifurcation 
 of the left iliac vessels, and the sigmoid artery lies above and to the right 
 side of it. The fossa extends upward along the left ureter. 
 
 According to Treves, only 4 cases of hernia into the intersigmoid fossa 
 were reported up to 1899. Three of these were strangulated and proved 
 fatal. The only treatment to be adopted is abdominal section, and this, too, 
 affords the only means of making a diagnosis of this condition. 
 
 Fowler, in his Textbook on Surgery, quotes Jonnesco as saying that 
 a hernia in this situation has been observed only twice. This statement does 
 not agree with that made by Treves. 
 
 MESOCOnC HERNIA. 
 
 A sharp line of differentiation must be drawn between intra-abdominal 
 protrusions of the intestines and internal hernias. A loop of bowel pro- 
 truding through a slit in the mesentery or omentum cannot be considered 
 a hernia unless there is a sac. An exploratory laparotomy must be done 
 in order to make a diagnosis, and also to carry out proper treatment. 
 
 Peacock, of London, England, reported two cases of mesocolic hernia, 
 one occurring in a woman of thirty who died on die ninth day of an attack 
 of illness which terminated by effusion on the brain. There were no symp- 
 toms referable to the abdomen. At the autops}' the whole of the small in- 
 
PLATE LVIII. 
 
 Ferguson's Modification of Blake's Operation in Suitable Cases. 
 (Author's Case.) 
 
INTERNAL AND INFERIOR HERNIAS 333 
 
 testine was found in a hernial sac, situated between the folds of the meso- 
 colon. The left half of the transverse colon was found deflected in a longi- 
 tudinal direction down to the middle line as far as the brim^ of the pelvis. 
 The patient had had a large tumor which projected on each side of^il. The 
 jejunum entered the sac at the upper and posterior part, while the ileum 
 passed out below, and on the right side, at a point about two inches above 
 the termination of that intestine in the cecum. There was no appearance of 
 an_v constriction having been exercised on the intestine. 
 
 In a second case, a man, aged 27, death resulted from strangulation 
 of the intestines. The man had pain in the abdomen and vomited fecal 
 matter. He died about forty-one hours after the onset of his symptoms,. 
 The descending colon was found on the left side of the cecum and the 
 small intestines were contained in the sac formed between the two layers 
 of the left meso-colon and situated on the left side of the descending colon. 
 The ileum passed out of the sac about two inches above the cecum, and at 
 that point the canal of the intestine was contracted, its coats thickened, in- 
 flamed, and gangrenous. 
 
 ILEO -COLIC HERNIA. 
 
 In the neighborhood of the appendix, cecum and termination of the 
 ileum are fossse which may be the seat of occurrence of a posterior hernia. 
 Hernia into the ileo-colic fossa is so rare that Treves felt himself impelled 
 to say that the ileo-colic fossa takes no part in the production of pericecal 
 hernias. 
 
 E. R. Secord,of Brantford, Canada (Annals of Surgery, Nov., 1906) 
 reports a case of ileo-colic hernia, the first to be placed on record. It may 
 not be amiss at this time to report the case, rather fully. 
 
 The patient, a white male, aged 40, complamed of recurring abdominal 
 pain, obstinate constipation, retching and some vomiting. The pain was 
 spasmodic in character, recurrent, and becoming progressively more severe. 
 The abdomen was slightl}^ distended, especially on the right side. There 
 was no board-like rigidity, but a feeling of resistance over the right rectus 
 muscle, and general tenderness over the whole right lower quadrant. On 
 observing the abdomen for a few moments, it was noted that with the onset 
 of the pain an elevation or tumor, of about the size of an orange, became 
 evident below and to the right of the umbilicus, which was doughy, tender, 
 tympanitic, and localized in the one position. 
 
 The abdomen was opened by an oblique mcision over the appendix 
 region. What appeared to be the distended and markedly-congested cecum 
 and colon appeared in the wound, vv^hich, however, on closer examination 
 showed themselves to be covered by an additional layer of peritoneum ; the 
 parietal peritoneum had of course already been well opened.. This addi- 
 tional layer of peritoneum was quite thin, fairly transparent, and easily 
 movable over the subjacent bowel. External to this mass was another loop 
 of what appeared to be colon. Following this latter loop upward it ap- 
 peared to be continuous with the ascending colon, but on followmg it down- 
 ward to the appendix region no caput coli or appendix could be discovered ; 
 
334 INTERNAL AND INFERIOR HERNIAS 
 
 and on searching more inwardly a taut band was iound running in an oblique 
 direction downward and outward from the root of the mesentery, roughly, 
 in a direction toward the anterior superior spine. The colon bulging out 
 from beneath this band was without the additional layer of peritoneum 
 noticed above and on slight traction being made on this loop of colon it 
 slipped out from beneath the band, followed by the cecum with the appendix, 
 and the terminal four inches of the ileum. These portions of the bowel were 
 all distended and markedly congested, and in one area on the outer surface 
 of the cecum the bowel-wall was ecchymotic, and in the center of this a 
 small whitish slough was situated. This slough was looked for and found, 
 since on withdrawing the bowel from under the above mentioned band, a 
 fecal odor had immediately become noticeable. 
 
 The pouch of peritoneum left by the withdrawal of its contained in- 
 testines was shaped much like a rubber tobacco-pouch, with its mouth about 
 an inch and a-half across, pointing in a downward and inward direction. 
 When filled the size of the pouch would be sonievvdiat greater than that 
 of the folded fist. 
 
 The mouth of the pouch was closed by a single row of catgut, attach- 
 ing the taut anterior fold to the anterior layer of the mesentery of the lower 
 end of the ileum. 
 
 The patient recovered. 
 
 ILEO-CECAL HERNIA. 
 
 Aschoff (Berliner Klinik, Heft loo, Oct., 1896) reports one case of 
 ileo-cecal hernia in which operation was successful. The patient was seized 
 suddenly with pain in the right side of the abdomen. For twenty-one days 
 symptoms of chronic intestinal obstruction manifested themselves, leading 
 to a diagnosis of cancer. The abdomen was opened for the purpose of 
 doing a right inguinal colotomy, when the ileo-cecal hernia of the small 
 intestine was discovered. The hernia was reduced and the patient made a 
 good recovery. 
 
 In 1846 {London Medical Gazette, page 125), John Snow described a 
 case of this variety of hernia occurring in a young woman who died on 
 the fourth day with symptoms of acute intestinal obstruction. A sac was 
 found at the site of the ileo-cecal fossa, which admitted the finger for about 
 two inches. Nasse and Riese have reported similar cases. 
 
 SUBCECAL HERNIA. 
 
 Jonnesco collected 11 cases of subcecal hernia, 7 of which were stran- 
 gulated, the remaining 4 being reduced with ease. The treatment is early 
 abdominal section with reduction of the hernia. 
 
 HERNIA OF PELVIC FLOOR. 
 
 After two attempts to correct a complete hernia of the pelvic floor, 
 Crile finally succeeded by performing an operation which he describes 
 {Cleveland Medical Journal, July, 1906) as follows: 
 
 With the patient in the Trendelenburg posture, a median incision of 
 
INTEKNAI- AND INFF.RIOR HERNIAS 335 
 
 good length was made; approximately one-fourlh of the entire abdominal 
 j^ contents were withdrawn from the hernial sac, the pelvic floor steadied and 
 
 f the hernia reduced. The bladder was found well down in this cavity and 
 
 totally prolapsed. An anteroposterior incision was made across the middle 
 of the floor of the pelvis, dividing the vagina into two lateral halves. The 
 vaginal mucous membrane of the part to be brought through the abdominal 
 incision was removed. The bladder was separated from the vagina for 
 some distance downward. It was then found that the vagina and the floor 
 of the pelvis had been so stretched that they coUld easily be brought out 
 through the abdominal wound beyond the surface of the skin. After makin^ 
 an incision through the abdominal fascia 4 cm. from the median line on 
 each side, the fibers of the recti were separated and the peritoneum per- 
 forated. Each half of the split vagina with the attached uterosacral and 
 uteropelvic ligaments and all the other structures of the floor of the pelvis, 
 together with the round and broad ligaments, were drawn out through these 
 openings on each side of the median incision. 
 
 While the parts were well up in place so that the top of the incised 
 vagina presented closely against the under surface of the peritoneum, the 
 latter was sutured in this position with plain catgut.' 
 
 The original peritoneal incision, the muscle and the external fascia 
 were then closed, the latter by continuous sutures of chromicized gut, after 
 which the freed ends of the vagina and pelvic floor, which had been drawn 
 up through the lateral openings in the peritoneum, recti and fascia, were 
 united in the middle line by means of chromicized gut. The skin was then 
 dosed. The patient made a good recovery from the operation and was 
 discharged in three and one-half weeks. 
 
 For some time after the operation the patient felt a sensation of 
 dragging on the wound and experienced some pain. This passed away after 
 several months. She has been doing her usual work, and at the present 
 time, more than three years after the operation, there has been no recur- 
 rence of the hernia. Crile says the indication for this operation exists only 
 in the cases of complete hernia (procidentia). ]n the minor degrees of 
 prolapse it would be quite impossible to carry out this technic for want of 
 sufficient length of ligaments and of vagina to reach to the external fascia. 
 
CHAPTER X. 
 
 STRANGULATED HERNIA. 
 
 Strangulation of a hernia is by no means an uncommon occurrence, 
 and it is not because of its frequency that a special chapter is being devoted 
 to it. But every now and then the strangulation produces a condition which 
 of itself is of sufficient interest as well as importance to the patient to war- 
 rant making special mention of it. 
 
 In looking over the literature I found a number of instances which it 
 seemed to me could be cited with profit in this connection. For instance, 
 Makins (Lon. Clin. Soc. Trans., Vol. 36) reports two cases of strangula- 
 tion which led to gangrene. One patient,, aged 87, had had. an irreducible 
 right inguinal hernia for sixteen years. It became strangulated. Six inches 
 of intestine were very much inflamed, and there was one gangrenous spot 
 with a small perforation in its center. On account of the condition of the 
 patient, four Lembert stitches were inserted in such a manner as to invert 
 the gangrenous area. The bowel was washed. The patient made an un- 
 eventful recovery. 
 
 The second patient was 9 years old. He had a scrotal hernia. There 
 was no vomiting and no constipation. On opennig the sac a foul-smelling, 
 bloody fluid escaped.. The bowel and omentum were found in the sac. The 
 strangulated area, about three-fourths of an inch in diameter, was found 
 to be gangrenous. This patch was invaginated by means of four Lembert 
 stitches, and complete recovery followed. . 
 
 A case of partial enterocele reported by C. T. Dent (Trans. Lon. Clin. 
 Soc, Vol. 15, 1881) is unique, because the patient was a male. The symp- 
 toms corresponded with those described by Littre. The sac on being ex- 
 posed was thick and inflamed, with a very slight stricture at its neck, which 
 was divided. With very slight pressure the hernia was reduced. A few 
 days after the operation persistent diarrhea sei in and the patient died on 
 the sixth day. The intestine, seven feet below the pylorus, showed a dark, 
 semi-gangrenous ring, which had evidently corresponded to the neck of 
 the sac and had been constricted by it. A portion of the intestinal wall 
 only, corresponding to the centrally more healthy part included in the ring, 
 had formed the hernia. A diverticulum sprang from the intestinal wall, 
 remote from the attachment of the mesentery. Some four feet below this 
 point there was evidence of an intense enteritis over a considerable extent 
 and wholly unconnected with the hernia. 
 
 J. Hutchinson, Jr., (Lon. Clin. Soc. Trans., A'ol. 33) reports two suc- 
 cessful cases of primary resection of a gangrenous small intestine during 
 a herniotomy. The first patient, a woman, aged 40, had for two years had a 
 hernia of about the size of a hen's egg, situated m the left groin, just below 
 
PLATE LTX. 
 i'erguson's Modification of Blake's Operation in Suitable Cases. 
 (Author's Case.) 
 
STRANGULATED HERMIA 339 
 
 Poupart's ligament, and external to the spine of ti^e pubes. The tumor was 
 irreducible. On opening the sac it was found to contain 6 or 8 drams of 
 a reddish serum and a knuckle of small intestine. Owing to the condition 
 of the bowel, the abdomen was opened, and five mches of gut were excised. 
 The ends were united by a double row of sutures. The patient miade an 
 uneventful recovery. After six years there was a return of the femoral 
 hernia, but it was controlled easily by a combination of plate and truss. 
 
 The second patient, a man, aged 29, had a strangulated right inguinal 
 hernia. The intestine was black and in a state of beginning gangrene for 
 about eight inches of its length. Ten inches of bowel were resected bv 
 Maunsell's method. Three years afterward the patient suffered from in- 
 flammation of the colon and died. The resected portion of gut did not 
 show the slightest trace of a narrowing of its lumen. There were no ad- 
 hesions. 
 
 McGavin {Trans. Lon. Clin. Soc, Vol. 36) reports a case of strangu- 
 lated inguinal hernia in which reduction en masse >vas eftected by taxis, but 
 the patient died. For nine years the man had a right inguinal hernia, which 
 had always been reducible and never caused strangulation. The rupture 
 suddenly came down and he was unable to get it back. A physician reduced 
 it, whereupon he felt great pain in the abdomen and vomited immediately. 
 On the following day the vomiting became stercoraceous. For six days 
 neither flatus nor motion was passed. The patient died from general peri- 
 tonitis. The post-mortem revealed the reduction eii masse and the continua- 
 tion of the strangulation. 
 
 In the NortheTH Lancet of November, 18S9, I reported a case of 
 strangulated hernia occurring in a man who had worn a truss for a number 
 of years. The hernia became strangulated as the result of severe exertion. 
 Efforts to reduce it by taxis proved unavailing. In addition to two or three 
 ounces of bloody fluid, the sac contained a loop of bowel about ten or twelve 
 inches long, very much congested and ecchymosed, but not gangrenous. The 
 patient made a good recovery. It is particularly interesting to note in this 
 case that the operation was not done until twenty-four hours after strangu- 
 lation had taken place, the patient meanwhile driving thirty miles over a 
 rough country road seeking relief. 
 
 Among twenty-five cases of strangulated hernia, reported by G. T. 
 Vaughan {Medical News, Dec. 24, 1904) there were two of the properi- 
 toneal or interstitial variety. 
 
 J. C. Da Costa {Annals of Surgery, Feb., 1899) reports two very in- 
 teresting cases. In one instance purulent clots were found in the accessory 
 veins of the cord. A microscopic examination of these clots showed that 
 they contained staphylococcus pyogenes albus. In the other case, that of a 
 man who suffered from prolapse of the rectal mucous membrane, and who 
 also had a reducible hernia on the left side, operation failed to effect a 
 cure. The prolapse was finally excised and the mucous membrane sutured. 
 On the evening of the third day while having a violent attack of coughing 
 he was seized with pain in the abdomen and he then found that the rupture 
 had com.e down. It was painful and irreducible. While attempting its re- 
 
340 STRANGULATED HERNIA 
 
 duction there was audible a crackling sound as though air was diffused 
 through the tissue. The crackling could be traced from the left to the right 
 side, apparently along the. course of the colon. 
 
 An incision was made, the hernia exposed and the sac opened. The 
 hernia was found to consist of the large bowel, and within the meso-colon 
 was a collection of air which crackled when pressed on. The ascending, 
 transverse and descending meso-coli were in the same condition. The w^ound 
 was closed. On examination of the rectum there was found above the line 
 of stitches an ulceration which had apparently Icllowed the cauterization. 
 When the bowel was pressed on air escaped from the ulcer in distinct bub- 
 bles. A tube was introduced through the opening and carried into the 
 subserosa so .as to permit of the escape of the emphysematous material, 
 which occurred in about five days. The patient recovered. 
 
 The coils were evacuated by three separate incisions, and the incisions 
 were closed by Lembert sutures. The sac was not removed because of the 
 condition of the patient, but the peritoneal cavity was shut off from the 
 external wound by means of a strong silk ligature, which was passed around 
 the neck of the sac in the subperitoneal tissue in such a way that when it 
 was drawn taut it closed the opening as the string of a bag closes its open- 
 ing. The patient recovered. 
 
 Knaggs (Annals of Surgery^ April, 1900) reports two cases of hernia 
 in which strangulation was caused by volvulus. 
 
 C. A. Porter (Boston \Medical and Surgical Journal, Oct. 10, 1901) 
 reported a case of strangulated inguinal hernia which had been converted 
 into a properitoneal or interstitial hernia by attempts made by the attending 
 physician to reduce it. The sac and a portion of its contents w^ere found 
 between the parietal pertoneum and the transveisalis fascia, having no re- 
 lation to the inguinal canal. 
 
 A case of strangulated hernia complicated oy volvulus is reported by 
 Parker (Trans. Lond. Clin. Soc, Vol. 17). The bowel was liberated and 
 pulled down in making an artificial anus. The patient continued to retch 
 and vomit after the operation, and no fecal matter passed through the colos- 
 tomy wound, nor per vias naturales. A median incision revealed a volvulus 
 involving six or eight inches of the bowel situated near the internal orifice 
 of the femoral ring. The patient died. 
 
 A very unusual case is reported by Marsh (St. Bartholoniczv's Hospital 
 Reports, Vol. 10, 1874). A boy, aged five months, had a strangulated in- 
 guinal hernia and was operated on, but died on the twelfth day from ery- 
 sipelas of the scrotum and the abdominal wall. The strangulation occurred 
 at the external abdominal ring, but when this was divided the bow"el was 
 returned easily without opening the sac. Everything went well until the 
 erysipelas set in. 
 
 Marsh (Trans. Lond. Clin. Soc., Vol. 30) reports another case, one 
 of left-sided strangulated hernia, in which there was no fluid in the sac, 
 but the included coils of small intestine were densely distended with a blood- 
 stained serum, mucus and a small amount of fecal matter. The sac con- 
 tained about two feet of small intestine. 
 
STRANGULATED HERNIA 34I 
 
 That strangulation may occur as the result of trauma is shown by the 
 case reported by T. M. Jones (Central States Medical Monitor, Aug. 15, 
 1906). His patient had a strangulated right inguinal hernia which extended 
 half way into the scrotum. It had existed for about two years but never 
 caused any trouble. The patient wore a truss. While playing polo, he was 
 struck by a ball in the right iliac region. Two w eeks later he began to feel 
 a dull pain in the lower abdomen and on attempting to reduce the hernia he 
 was unable to do so. The strangulation was relieved by operation but the 
 condition of the patient did not improve. Shock continued and death en- 
 sued twelve hours after the operation. Autopsy showed complete strangu- 
 lation of the small intestine in half a dozen places in the ileum and the 
 jejunum by bands of fibrous tissue which closed the lumen of the bowel a> 
 completely as if it had been ligated. The adhesions doubtless were the re- 
 sult of the trauma of two weeks previously. 
 
 Clogg (British Medical Journal, (October 20, 1906) collected 53 cases 
 fromi the literature of strangulation of the appendix in a hernial sac. In 
 the majority of these cases the appendix was the sole content of the sac. 
 Only three cases occurred in males. I agree fuliy with the statement of 
 Clogg that a correct diagnosis rarely is miade in these cases, and that they 
 are usually taken to be cases of ordinary strangulated hernia. As a rule, 
 these hernias are of small size, and are easily reducible when the attempt at 
 reduction is made early. Only rarely does the entire appendix lie in the 
 hernial sac, the apex being usually the miost advanced point. Adhesions are 
 not common. 
 
 A case of displaced strangulated femoral hernia is reported by Bryant 
 (Trans. Lond. Clin. Soc, Vol. 35). The sac with its contents was displaced 
 downward and inward, through an opening at the lower end of the femoral 
 sheath, and in front of the adductor muscles on tne inner side of Scarpa's 
 triangle. The tumor was tender on pressure and the patient manifested 
 symptoms of obstruction of the bowel. Although the patient was moribund, 
 an operation was done, but proved fatal. It was found that the hernia was 
 displaced into the fatty connective tissue of the nmer side of the thigh, the 
 seat of strangulation being an inch and a half below the femoral ring. 
 
 I. J. Buchanan (Medical Record, October 8. 1904) reports a case of 
 umbilical hernia in which strangulation occurred that is interesting, not 
 because of this fact, but because of the sequence of events and the final 
 outcome of the case. The patient, female, aged 48, had had a large umbili- 
 cal hernia for about seven years. For about one }"ear it had been irreducible, 
 and then suddenly became strangulated. In opening the hernial sac a small 
 incision was made into the gangrenous bowel, and most of its contents were 
 removed by exoression. The cpening was viicn temporal"! ly cio-cd vvitli a 
 ligature. The entire mass of intestine which ^vas so large as to simulate 
 the bulk of the gastro-intestinal tract, was in a state of complete gangrene. 
 The hernial ring was divided, traction was made on the gangrenous con- 
 tents in an efifort to deliver the adjoining portions of bowel, but without 
 avail. The peritoneal cavity was protected by a large quantity of iodoform 
 
342 STRANGULATED HERNIA 
 
 gauze packed around the base of the mass. The surface was covered with a 
 gauze dressing. The patient improved at once. 
 
 At the end of a week the gangrenous mass, though collapsed, was still 
 attached. A few days later the bulk of the mass was cut away. Examina- 
 tion showed that the mesenteric portion of a part of the bowel remained, 
 due to the fact that the meso-cecum and the meso-colon of the splenic flexure 
 were too short to permit the passage of the entire cecum and splenic flexure 
 through the ring, and that the line of mortification had passed through the 
 wall of these parts of the bowel longitudinally, leaving the distal part alive, 
 and its mucous membrane forming the surface of the mass protruding from 
 the ring. The destroyed intestine was the free surface of the cecum, the 
 ascending and transverse colon, with the distal border of the splenic flexure. 
 At a subsequent operation the ileum was implanted intp the sigmoid bv 
 simple continuous suture. The patient made a normal recovery. 
 
 P. Leech {Lancet, June 6, 1903) reports a case of strangulated left 
 duodenal hernia in which the symptoms of strangulation developed slowly. 
 No cause could be found for the obstruction. Other treatment failing to 
 give relief, a laparotom}' was done. When the abdomen was opened the 
 small intestine was seen to be under the mesentery and a diagnosis of re- 
 troperitoneal hernia was made. The sac looked obliquely upward and to 
 the right. The anterior lower margin was thickened and rigid. The finger 
 could be passed into the sac and about a foot of intestine was withdrawn. 
 The abdomen was closed and the patient made a good recovery. 
 
 A case of strangulated obturator hernia is reported by J. Mason {St. 
 Bartholomezv's Hospital Reports, Vol. 27, 1891). The patient did not come 
 to his notice until some months after the strangulation had occurred. For 
 fifteen years she had noticed two swellings in the right groin which occa- 
 sionally became very painful, and at these times she suffered considerably 
 from vomiting and general indisposition. The symptoms usually began with 
 bearing-down pains in the groin and dowm the thigh. On some occasions 
 relief was obtained by enemata, on others without any treatment but rest. 
 Suddenly s}Tnptoms of acute obstruction supervened. Under symptomatic 
 treatment, such as the use of enemata and gentle taxis, followed by the 
 application of a properly constructed truss, the patient made a complete 
 recovery. Reduction was best effected with the limb very slightly flexed 
 and everted, the outer side of the knee still resting lightly on the bed. 
 
CHAPTER XI. 
 
 HERNIA IN INFANTS. 
 
 Quite a number of instances are recorded in the literature of operation 
 ior hernia done on very young infants. Audion (Presse Medicale, Dec. 
 30, 1889) reports a successful operation for umbilical hernia done on an 
 infant one hour after birth. The hernia was reduced and three layers of 
 sutures were inserted. Stolypinski also reports such a case. Benedict oper- 
 ated on an infant three hours old, and Hinkson operated ten hours after 
 birth. Barton did a radical operation, which was successful, on an infant 
 thirt3'--three hours old. All of these operations were done for umbilical 
 hernias. C. MacLaurin (Lancet, May 5, 1900) reports a successful opera- 
 tion for strangulated hernia on an infant, fourteen days old, and E. D. Fen- 
 ner {New Orleans Medical and Surgical Journal, September, 1899) and D. 
 Power {Lancet, Sept. 30, 1899) each report a case c f successful operation 
 for strangulated inguinal hernia done on patients five months and three 
 months of age respectively. J. O'Connor {Lancet, August 26, 1899) re- 
 ports 150 cases of radical cure of acquired oblique inguinal hernia in in- 
 fants, with one death and two recurrences. Fraenkel {Centralbl. f. Chir., 
 No. 47, 1900) cites the histories of 68 children, 16 of whom were nurslings, 
 operated on to effect a radical cure of inguinal hernia. In order to prevenr 
 inflammation of the wound, he wraps the lower part of the body in a fixed 
 bandage, and covers the wound with impermeable dressings until it has 
 healed. 
 
 J. E. Briscoe {Lancet, Sept. 10, 1898) reports a successful operation 
 for strangulated hernia done on an infant twenty-one days old. It is inter- 
 esting to note in this case that the bowel was invested tightly by the peri- 
 toneal tube throughout the entire inguinal canal. The sac appeared to 
 tenninate abruptly at the inner ring, thus causing the physical signs to re- 
 semble those of an inflamed hydrocele. 
 
 Lilienthal {Medical Record, March 2, 1901) reports a case of strangu- 
 lated inguinal hernia occurring in an infant eight days old. The contents 
 of the sac consisted of sigmoid, ascending colon and appendix, together 
 with a large part of the small intestine. The child was operated on success- 
 fully. 
 
 Kellock {Lancet, July 5, 1902) records a case of bilateral strangulated 
 hernia occurring in an infant ten weeks of age. He operated, but two days 
 later there developed an inguinal hernia on the opposite side. It was re- 
 duced easily. Fifteen days later, however, it became strangulated and an 
 operation had to be done. 
 
 Reid {Nezv York State Journal of Medicine, 1903) operated success- 
 fully on a case of strangulated hernia in an infant twenty-seven days old. 
 
344- HERNIA IX INFANTS 
 
 W. B. Coley has operated on ii patients under two years of age, with 
 only one death. Six were under one year of age. 
 
 Corner {Lancet, Aug. 20, 1904) beHeves in the curabihty of hernia in 
 young children by means of a truss, except in cases of large, uncontrollable 
 hernias, in irreducible or difficultly reducible or incarcerated hernias, and 
 in strangulated hernias, when there is a congenital sac. Corner is not alone 
 in this belief, which is held by many operators of large experience. 
 
 H. J- Stiles {British Medical Journal, Oct. i, 1904) records 360 con- 
 secutive operations, 26 per cent, of which were done on infants under one 
 year of age. Unlike Corner, Stiles does not believe in mechanical treat- 
 ment. He says that in cases in which the hernia was supposed to have 
 been cured by wearing a truss during childhood, strangulation is likely to 
 occur in adult life as the result of a strain. Stiles had five deaths in his 
 series. In 24 of his cases the cecum was found in the sac, and in 5 of the 
 36 cases of inguinal hernia occurring in girls, the sac contained the ovarv 
 and tube. 
 
 The operation employed by Stiles was practically the one devised by 
 Banks, isolation and ligation of the sac at the neck on a level with the in- 
 ternal ring without splitting the aponeurosis of the external oblique muscle. 
 To close the canal he says all that is necessary in the majority of the cases 
 is to introduce a single catgut suture through the outer pillar of the ring 
 close to Poupart's ligament across the canal, superficial to the cord, and then 
 introducing it from within outward through the conjoined tendon and the 
 inner pillar of the ring. 
 
 Schenk {Prager Med. Woch., No. i, 1900) reports a case of congenital 
 lateral ventral hernia occurring in an infant. The hernia was about the 
 size of a walnut, and was situated on the right side betw^een the ribs and 
 iliac crest. The abdominal wall at this point was weak, and the knee, when 
 strongly flexed on the abdomen, fitted into the gap in the muscles. 
 
CHAPTER XII. 
 
 UNUSUAL FORMS OF HERNIA. 
 
 Many unusual forms of hernia have been recorded in the literature 
 by various observers. As a rule the diagnosis was not made until at the 
 time of cutting down on the tumor. A number of these instances have 
 been mentioned already in the first chapter of Part I, in connection with 
 the contents of the hernial sac, and I will now cite from the literature a 
 few cases that are of more than passing interest, not only because of. the 
 infrequency of their occurrence, but also because they are quite likely to 
 be mistaken for some condition other than hernia. The old saying that 
 "there is nothing new under the sun" often is exemplified in surgery, espe- 
 cially in the dislocation of a viscus. 
 
 Greenhow (Trans. Lond. Clin. Soc, 1880) reported a case of intes- 
 tinal obstruction caused by a hernia through the mesentery of a Meckel's 
 diverticulum, which had retained its attachment to the umbilicus. The pa- 
 tient, male, 7 years of age, presented symptoms that pointed both to in- 
 tussusception and to appendicitis. There was no evidence of the exist- 
 ence of a peritonitis until the day of death. Intestinal peristalsis was sus- 
 pended, but there was not complete obstruction. The ileum was very much 
 distended. Attached to the abdominal wall opposite the umbilicus was a 
 fibro-fatty cord half an inch in length, which passed on to the extremity of 
 a well-developed Meckel's diverticulum, which was nearly equal in calibre 
 to the ileum from v/hich it sprang. Except for its attachment at the umbil- 
 icus, this diverticulum was free for about two inches, but the remaining 
 one and one-half inch, together with several coils of collapsed ileum, ap- 
 peared to be included within the ring-like opening situated in the diver- 
 ticular mesentery. The ring was formed by a loop-like, fibro-fatty cord 
 passing from the diverticulum above to the general mesentery across the 
 ileum, nine and a half inches of which had passed through the ring. Be- 
 sides the diverticulum a knuckle of bowel had been forced through the 
 ring, thus completing the strangulation. 
 
 One case of rupture of Douglas' cul de sac, with protrusion of the 
 uterine appendages through the vulvar orifice is reported as having oc- 
 curred in a woman, 50 years of age. I have also seen one such case, which 
 I have reported elsewhere. 
 
 A. R. Moulton {Philadelphia Med. .Tour., March 16, 1906) reports a 
 case of rupture of the rectum which was followed by hernia of the small 
 intestine. 
 
 A rare case of strangulated recto-cecal hernia was reported by Ma- 
 rion {Gas. heb. de. Med. et Chir., April 11, 1901). The patient, a woman, 
 had signs of intestinal obstruction, but on opening the abdomen the in- 
 
346 UNUSUAL FORMS OF HERNIA 
 
 testine was found engaged between the cecum and the ihac fossa. It was 
 freed and the patient recovered. 
 
 An instance of a right cecal hernia comphcated by hydrocele and 
 suppurative appendicitis is reported by R. C. Turck {Jour. A. M. A., April 
 26, 1902). The patient had had a right inguinal hernia for over sixty 
 years, and a small hernia on the left side about twenty years. The ap- 
 pendix, testicle, hydrocele and hernial sac being agglutinated together, 
 were removed en masse. The patient recovered. 
 
 The fourth case on record of extraperitoneal crural cystocele is re- 
 corded by S. Mercade {Gaz. des Hop., July 3, 1902). The patient, female, 
 aged 53, had a small femoral hernia on the right side. A diagnosis of 
 epiplocele ' was made, and at the operation a slightly pyriform body was 
 found next to the omentum. On cutting into it a gush of urine showed it 
 to be the bladder. 
 
 Two very rare forms of hernia, obturator hernia of the bladder and 
 of the Fallopian tube, were noted by R. J. Gladstone {Annals of Surgery, 
 December, 1901). On the right side a U-shaped loop of the Fallopian tube 
 was found lying, together with a portion of the mesosalpinx, within a 
 small peritoneal sac. On the left side a corner of the bladder wall an- 
 terior to the line of reflection of the peritoneum was found firml}^ fixed 
 to the beginning of the obturator canal. 
 
 F. Flaherty {American Medicine, June 21, 1902) reports a case of 
 traumatic hernia of the diaphragm following a wound of the thorax. The 
 patient fell on a hay-knife, which penetrated between the seventh and 
 eighth ribs, on the left side, at the anterior axillary line and emerged be- 
 tween the tenth and eleventh ribs close to the spine. He presented symp- 
 toms of obstruction of the bowel. Necropsy showed the stomach filled 
 with gas, and filling the left chest except a small part above where the 
 collapsed lung was found. The opening in the diaphragm was three 
 inches in length, and in its passage through it the stomach carried along 
 part of the great omentum. 
 
 C. E. Black {Illinois Medical Journal, Jan., 1904) reports a very re- 
 markable case of hernia of the ovary, appendix and Meckel's diverticulum 
 into an inguinal sac. The appendix was gangrenous and had ruptured, 
 and six inches of bowel had to be resected, together with the appendix, 
 cube and ovary. 
 
 W. A. Dennis {St. Paid Medical Journal, Oct., 1905) records a suc- 
 cessful operation for traumatic diaphragmatic hernia following a severe 
 contusion of the left thorax from the end of a buggy pole. The blow was 
 received just behind the eighth chondro-cdstal junction, and while not 
 penetrating was of sufficient force to confine the patient to bed for three 
 months. The symptoms which led to the operative intervention did not 
 manifest themselves until eighteen months after the reception of the in- 
 jury. The hernia consisted of omentum, transverse colon and the greater 
 part of the stomach. 
 
 M. Metzenbaum {Journal A. M. A., Oct. 28, 1905) records a case of 
 umbilical hernia perforating the abdominal wall. The hernia was never 
 
/ 
 
 \ / 
 
 7 
 
 PLATE LX. 
 
 Final Result of Operation for Umbilical Hernia. 
 (Author's Case.) 
 
 y 
 
L-^NUSUAL FORMS OF HERNIA 349 
 
 reducible. At the operation it was found that nearly all of the small in- 
 testine, together with cecum and appendix and a large portion of the 
 omentum, comprised the hernia. Loops of intestine were grown together 
 with masses of the abdominal fat and omentum, and in many places were 
 firmly adherent to the abdominal wall itself. It was for these reasons that 
 the hernia was never reducible. 
 
 Another case of umbilical hernia containing a diverticulum of con- 
 genital origin is reported by A. J. Landman (Lancet, Nov. Ii, 1905), as 
 occurring in a child one day old. The tumor was of about the size of an 
 orange, and its coverings consisted of the constituent elements of the 
 umbilical cord. The sac contained small intestine, one part of which 
 consisted of a blind diverticulum, and this was the part adherent to the 
 sac wall. 
 
 Although Richter's hernia is believed to be of rather rare occurrence, 
 V. W. Low {Lancet, Jan. 28, 1905) reports four cases under his care 
 inside of a year. The patients were women who had right-sided femoral 
 hernias, 
 
 Oliver (Annals of Siirgery, May, 1901) cites three cases of properi- 
 toneal hernia. The first two cases belong to that group in which the her- 
 nia lies in the subperitoneal layer. The third case belongs to the group 
 in which the hernia lies between the internal and external oblique muscles. 
 One of the cases was not discovered until the necropsy. 
 
 L. J. Mitchell (American Journal of Medical Sciences, Nov., 1903) 
 describes two cases of retroperitoneal hernia. Both occurred into the 
 paraduodenal fossa. 
 
 C. T. Andrews (Lancet, Jan. 24, 1903) discovered one case on the 
 post-mortem table. 
 
 A. E. Halsted (Annals of Surgery, May, 1906) reports a case of 
 strangulated inguino-properitoneal hernia occurring in a man fifty-two 
 years old, who had had a right inguinal hernia for six years. It finally 
 became as large as two fists. A truss was worn with satisfaction. During 
 a severe strain the hernia slipped from under the truss and attempts at re- 
 duction failed. Hot applications were made, and after an hour the hernia 
 was reduced, but the swelling did not disappear, as on former occasions. 
 The pain was lessened, but did not subside entirely. The large tumor 
 had disappeared, but there v.^as present in the inguinal region a small mass 
 which was exceedingly sensitive to touch. The inguinal canal was empty. 
 With the finger in the canal, a tum.or could be felt above and to the inner 
 side of the external abdominal ring, in the abdominal wall. After expos- 
 ing the external abdominal ring, a sac was found extending from the ring 
 down into the scrotum. The inguinal sac contained a small quantity of 
 bloody serum. On pulling down on the inguinal sac the neck of the sec- 
 ond sac was brought into view. It contained a small knuckle of intes- 
 tine and a piece of omentum, dark in color and edematous. It was freed 
 from the skin, drawn out beyond the point of constriction, ligated and 
 cut off. The stump was pushed back into the abdomen. With the re- 
 
350 UNUSUAL FORMS OF HFRNIA 
 
 placement of the omentum the knuckle of gut was freed and dropped 
 back into the abdominal caviry. 
 
 The second sac was found to occupy a cavity between the peritoneum 
 and the transversalis fascia. The cavity containing it was above and to 
 the inner side of the inguinal canal. The sac opened by a common orifice 
 with the first sac into the abdominal cavity. This sac was not as large 
 as the first. The common neck of the two sacs was incised beyond the 
 abdominal orifice, and the resulting opening in the peritoneum closed by 
 suture. Recovery with cure of the hernia resulted. 
 
 The second case was one of left inguino-interstitial hernia, occur- 
 ring in a man, aged 65, who had had a large inguinal hernia for about 
 thirty years. A truss retained the hernia for part of this time. At the 
 operation the hernial sac was found to extend from the external ring down 
 into the scrotum. It was empty. The aponeurosis of the external oblique 
 was incised from the external to the internal ring, exposmg the neck of 
 the second sac. This sac was about three and a half inches long, and com- 
 municated with the first or inguinal sac. Both sacs opened mto the abdom- 
 inal cavity by a common orifice, which admitted two fingers. The second 
 sac lay beneath the aponeurosis of the external oblique, resting on the 
 internal oblique. It contained a loop of intestine about six inches in 
 length, which was not adherent and which was readily replaced into the 
 abdomen. A purse-string suture was passed around the common neck 
 of the two sacs, and these were removed. The abdominal cavity was 
 closed by tightening the purse-string suture. The hernia was cured. 
 
 Other instances of interstitial hernia have been reported by Auvray, 
 Mueller, Fredet, Bruno, and others. 
 
 F. T. Stewart {Phila. Med. Joiir., Feb. 9, 1901) reports a case of 
 enormous ventral hernia occurring in a woman 40 years of age. The con- 
 tents of the sac consisted of the lower half of the stomach, of all the trans- 
 verse colon, the. omentum and most of the small intestine. The sac was 
 emptied under great difficulty, but the patient made a speedy recovery. 
 
 English {Trans. Lon. Clin. Soc, Vol. 17, p. 270) reports a case of a 
 man, aged 62, who presented himself for the relief of a very large abdom- 
 inal hernia at the right semi-lunar line. It measured 16 inches in the 
 vertical diameter and 13 inches in the transverse. It had existed twelve 
 years. 
 
 In my own practice I had a case of hernia following vasectomy in a 
 patient twenty-two years of age, from whom I removed the right epididy- 
 mis, vas deferens, and seminal vesicles. On account of the persistent hem- 
 orrhage the cavity was packed very firmly from the internal abdominal 
 ring down to the base of the bladder. The packing was removed at the 
 end of a week and renewed. Within six months the patient returned with 
 a hernia of that region. I operated after my method, and the man Ijas re- 
 mained cured for more than four years. 
 
 Two years ago I saw in consultation with Dr. Albert Peacock, of 
 Chicago, a woman who was pregnant about three months. She com- 
 plained of a vague pain in the pelvis, which I found was due to a knuckle 
 
PLATE LXI. 
 Hernia Into Ileo-colic Fossa. (Secord's Case.) 
 A. Hernial sac. B, Mouth of sac. 
 
UNUSUAL FORMS OF HERNIA ^C\ 
 
 of bowel descending behind the cervix through Douglas' pouch. It was 
 covered on the vaginal side by a very thin membrane. It was deemed 
 advisable to treat the patient on the expectant plan; therefore tampons 
 of gauze were inserted so as to keep the bowel reduced until after parturi- 
 tion. The patient went on to the termination of her pregnancy without 
 any further trouble. The hernia has not been noticed since, and the 
 woman has not applied for any relief. 
 
 I have had two cases of right oblique inguinal hernia following a 
 direct trauma. One of the patients, a voung man, 28 years of age, was 
 pitching sheaves when his hand slipped and the end of the pitchfork 
 struck him in the right inguinal region, tearing the internal oblique muscle 
 from its attachment to Poupart's ligament. The pain was so intense that 
 the young man went to bed. On examination I felt a distinct deficiency in 
 the inguinal region, and at the time of the operation, which was done im- 
 mediately, I found that the internal oblique muscle had been torn away 
 from Poupart's ligament, and that the internal ring had been enlarged to 
 the size of the end of the pitchfork handle. I restored the parts to their 
 normal position by suturing the redundant transversalis fascia over the 
 slackened peritoneum, without opening the peritoneal cavity, and the in- 
 ternal oblique muscle to Poupart's ligament, closing the wound in the 
 usual manner. The patient made a perfect recovery. 
 
 The other patient was walking around the barn in the dark and fell 
 down, his inguinal region striking the sharp corner of a board. He re- 
 mained in bed for about a week, when he felt sufficiently recovered to re- 
 turn to his work. Three months afterward he applied to me for rehef from 
 a hernia into the scrotum which he could not retain with a truss. I 
 operated and found that the internal oblique muscle had bee'h torn from 
 Poupart's ligament almost up to the anterior superior spine. The internal 
 abdominal ring was very much enlarged. The typic operation was done 
 and a cure was effected. 
 
 Another case of traumatic hernia through the left rectus muscle 
 occurred in a very strong man who was doing some work on the highway 
 with a scraper. The implement inflicted a very severe wound opposite 
 the umbilicus at about the center of the left rectus abdominis muscle, the 
 force of the impact being sufficient to lift him bodilv and throw him at 
 the horse's feet. Although he complained of some tenderness in that re- 
 gion, the hernia did not develop sufficiently to be diagnosticated until six 
 years afterward. At that time I opened his abdomen and found a hernial 
 protrusion of the bowel through the left rectus muscle, at the site of the 
 original injury. A cure was affected by laparotomy. 
 
 Another very curious case was that of a man who acquired an epi- 
 gastric hernia as the result of carrying a flag, the end of the staff resting 
 on his abdomen belov^^ the ensiform. cartilage. 
 
 Another man developed an epigastric hernia from the use of a spoke- 
 shave, which he had employed for making shingles and ax handles for 
 about twelve years. He attributed the injury to the fact that while making 
 an ax handle the end of it was placed against the abdomen just above the 
 
 x 
 
354 UNUSl'AL FORMS OF HERXIA 
 
 umbilicus, and the spoke-shave was drawn toward him. Both these cases 
 were operated with satisfactory results. 
 
 I had one patient who suffered from six hernias (Fig. i), two epi- 
 gastric, one direct and one indirect inguinal hernia, one femoral, and one 
 interstitial, subcutaneous hernia. The banner case is that of a woman 
 who presented ten very distinct hernias, two femoral, two oblique inguinal, 
 a large ventral hernia through the scar of an old hysterectomy wound, 
 one ventral hernia following a nephrectomy, three forms of umbilical 
 hernia external and visible, and one interstitial umbilical hernia extending 
 between the transversalis fascia and the rectus muscle. This last-named 
 hernia became partially strangulated, and gave the indication for the oper- 
 ation. I operated on all these hernias at one sitting, and the patient made 
 an uneventful recovery. 
 
 The umbilical hernia had been operated on by the late John B. Hamil- 
 ton some years previously, and when it returned, and several of the other 
 hernia^- had developed, the woman went to him for advice. He refused 
 to operate because she was syphilitic. 
 
 The hernias, wdth one exception, were comparatively small. The oper- 
 ation was done inside of two hours, and for two years at least she remained 
 cured. Since then I have lost track of her. 
 
 Some time ago I saw a man who had been operated elsewhere for 
 a double oblique inguinal hernia by the Bassini method. Both hernias re- 
 curred and there also developed two direct inguinal hernias. I performed 
 the typic operation for the oblique inguinal hernias, and the lower angle 
 of the wound was protected after the method of Bloodgood, transplanting 
 the right rectus muscle. 
 
 I encountered a very unusual form of vesico-rectal hernia in a man, 
 27 years of age, who, while working in the field, allowed his bladder to 
 become over-distended. He fell from a sheaf of wheat, striking the pubic 
 region very severely. He had a verj- severe pain in the pelvis, and although 
 he felt the desire to urinate, he was unable to do so. I saw him twenty- 
 four hours afterward, and immediately catheterized, but failed to get any 
 urine. I examined him per rectum, and found a large mass protruding 
 into the bowel and filling the true pelvis. Suspecting this mass to be the 
 bladder, I passed a silver catheter and removed more than a quart of 
 urine. As the urine w^as being withdrawn, the tumor in the pelvis gradu- 
 ally diminished in size, until it completely disappeared. 
 
 With two fingers in the rectum, I pressed the sac back into the blad- 
 der and then inserted a self -retention catheter, asking the patient to leave 
 it in place for three days, which he did. I saw him again on the fourth 
 day, and found that he was able to retain and void his urine at will. 
 
 Eight years ago, at the request of Dr. Donald 3.1acrea, Sr., of Council 
 Bluffs, Iowa, I operated on a child, one week old, for a funicular hernia of 
 the small intestine. The distended cord, which formed the sac, became 
 gangrenous and ulcerated. The coils of intestine were agglutinated. I re- 
 moved the entire umbilicus, released the agglutinated intestines, and re- 
 turned them into the abdominal cavity. After flushing the peritoneal cavity 
 
PLATE LXII. 
 
 A. Loop of jejunum into lesser cavity of omentum. B. Great omentum. 
 
 C. Transverse colon. 
 (Author's Case.) 
 
UNUSUAL FORMS OF PIERXIA 
 
 357 
 
 with normal salt solution, the wound in the abdominal %vall was closed 
 with interrupted stitches of silkworm gut. Unfortunately, the child died 
 of exhaustion about five days afterward. There was no evidence of peri- 
 tonitis or of infection elsewhere. 
 
CHAPTER XIII. 
 
 LOCAL ANESTHESIA IN HERNIA OPERATIONS. 
 
 Although I do not approve of the use of local anesthesia in opera- 
 tions for the cure of hernia, it is of more than passing interest to review 
 in this connection the work that has been done by J. A. Bodine (Medical 
 Record, October 21, 1905). Bodine has operated on 284 patients, with 
 300 hernias, under local anesthesia, without a death or suppurating wound. 
 By means of Schleich's infiltration method the amount of cocain is re- 
 duced to a minimum and limited to a small area, producing acute local 
 anemia, effectually retaining the fluid in one spot. Cocainization of a sen- 
 sory nerve trunk, abolishing pain sensation in the region supplied by it, 
 renders it possible to operate for hernia by its use. The operative area 
 is superficial, and the region restricted by the anatomy of the parts. In 
 strangulated hernia, local anesthesia does not increase the shock, while 
 general anesthesia is often too great a load to be borne. The local anes- 
 thetic permits of the application of hot towels to a possibly gangrenous 
 intestine for some time, in order to determine whether it will react. The 
 operation does not give rise to the danger of injury to the nerve fibers. The 
 danger to a line of deep sutures from vomiting is done away with. There 
 is no danger of cocain poisoning with the small dose necessary — that is, 
 one-half grain injected intermittently throughout an hou-r. Morphin 
 given after the operation would act as an antidote were poisoning possible. 
 The operation is more thorough because of the absence of haste and the 
 lack of need to save the patient pain. There are no evidences of pain 
 during the operation. The cocain solution should be made fresh. The 
 solution is 0.2 per cent, for infiltration of the skin and nerve trunks, and 
 for subdermic infiltration half this strength is used. The line of skin 
 incision should be infiltrated throughout its extent sufficiently tightly to 
 maintain the local anesthesia for an hour. The aponeurosis of the external 
 oblique requires no infiltration. It should be incised over the situa- 
 tion of the underlying ring ; the ilioinguinal nerve will be exposed by re- 
 tracting the flaps, and its trunk is then cocainized by a few drops of the 
 solution. The incision may be carried painlessly into the external ring, 
 and the flaps reflected to expose Poupart's ligament and the conjoined ten- 
 don. The iliohypogastric, if found, may be cocainized. The margins of 
 the internal ring are infiltrated. A line of infiltration along the long axis 
 of hernial protrusion permits a clear cut through the hernial sac and cov- 
 erings. The neck of the sac is infiltrated, dissected away from the under- 
 lying cord, ligated, and amputated. The genitocrural nerve is cocainized. 
 The sac is dissected awav from the cord, and the operation is completed. 
 
LOCAL ANESTHESLV IN HERNL\ OPEK-VTIONS 35Q 
 
 Operation on the female is easier than on the male, because the round hga-' 
 ment is less sensitive than the cord. 
 
 J. H. Bloodgood has also made use of local anesthesia in hernia opera- 
 tions. He believes that it is especially indicated in cases of strangulated 
 hernia, and in cases where the hernia is very large. 
 
 From 1897 to 1899, a period of two years, 49 herniotomies were per- 
 formed at the Johns Hopkins Hospital under cocaine anesthesia. In the 
 majority of these cases the administration of a general anesthetic v/as either 
 deemed unnecessary or it was contraindicated. 
 
 In 1902 Frank Martin reported 4 herniotomies done under subarachnoid 
 anesthesia. One of the patients was 68 years of age, a confirmed alcoholic, 
 with marked cardio-vascular changes, chronic bronchitis, and nephritis. No 
 ili-efTects followed the operation. 
 
 Alexander Lyle did fifteen herniotomies under cocaine anesthesia, with 
 most excellent results. 
 
INDEX. 
 
 Page. 
 
 Abdominal cavit\', exploration of . . . 69 
 
 wall, repair of large defects in . . . 315 
 
 wall, weak points of 9 
 
 Abscess of scrotum 197 
 
 prevention of stitch-hole 143 
 
 Actinomj'cosis, following herniotomy . 193 
 
 Adhesions, separation of 43 
 
 Age, influence of on herniotom}- 33 
 
 Alcohol as an antiseptic no 
 
 Alcoholism and herniotomy 34 
 
 Andrews' imbrication operation for in- 
 guinal hernia 267 
 
 Anesthesia, local, in herniotomy .... 358 
 
 Antiseptics 109 
 
 Appendectomy after herniotomy 172 
 
 Appendix, in hernial sac 19, 20, 21, 22 
 
 retention cyst of in sac 21 
 
 • strangulation of in hernial sac . . 341 
 
 Arms, disinfection of 119 
 
 Auto-intoxication 89 
 
 B 
 
 Bacilli, varieties of 85 
 
 Bacteria, biologic division of 85 
 
 classification of 84 
 
 pyogenic 86 
 
 where found in body 90 
 
 Bacteriology, surgical 83 
 
 Baldwin's operation for femoral hernia290 
 Ball's operation for femoral hernia... 289 
 operation for inguinal hernia .... 250 
 Banks' operation for femoral hernia . . 289 
 Barker's operation for femoral hernia. 289 
 Barnhill's operation for inguinal hernia 263 
 
 Bartlett's filigree 315, 316 
 
 Bassini's operation for femoral hernia 290 
 
 operation for inguinal hernia 229 
 
 operation, results from 
 
 202, 293, 204, 207, 208 
 
 Beck's operation for inguinal hernia . . 242 
 Benjamin's operation for inguinal her- 
 nia 246 
 
 Bic3^cling in hernia 279 
 
 Bishop's operation for inguinal hernia 259 
 Bladder, diseases of following herniot- 
 omy 167 
 
 diverticulum of in sac 19 
 
 hernia of into rectum 66 
 
 hernia of through pelvic outlet .... 19 
 
 injury of during herniotomy 168 
 
 in sac 19 
 
 Blake's operation for umbilical hernia 307 
 
 Bloodgood's method, results from . . . 203 
 
 Blood pressure," observations on 150 
 
 Boeckel's operation for umbilical hernia 308 
 
 Boric acid : 115 
 
 saturated solutions of 54 
 
 Bowel, perforation of 198 
 
 resection of 198 
 
 Bronchitis, post-operative 191 
 
 Butler's operation for inguinal hernia 258 
 
 C 
 
 Canal of Nuck, hydrocele of 198 
 
 Carbolic acid 109 
 
 acid solutions, preparation of. .53, 54 
 
 Castration, following herniotomy 168 
 
 Catgut, Abbott's chromic 127 
 
 Abbott's chromic iodized 127 
 
 Abbott's iodized 127 
 
 as a source of infection 94 
 
 Bartlett's 128 
 
 cumolized 127 
 
 Esmarch's 124 
 
 Ferguson's 129 
 
 formalin 129 
 
 formalin chromic 129 
 
 iodized 128 
 
 Lockwood's 124 
 
 Ochsner's 128 
 
 preparation of 45, 46 
 
 sterilization of 123, 124, 127, 128 
 
 von Bergmann's 124 
 
 Cecum, hernia of 19, 2.2 
 
 Cellulitis of round ligament 198 
 
 Champonniere's operation for umbilical 
 
 hernia - 313 
 
 Chicago Hospital operating room 
 
 technic 52 
 
 Chlorine 116 
 
 Chloroform poisoning, resuscitation in 150 
 Colej^'s operation for femoral hernia. . 300 
 
 Colostomy, results from 213 
 
 Condamin's operation for umbilical 
 
 hernia 313 
 
 Constitutional diseases and herniotomx- t,j 
 Cooper's operation for femoral hernia 289 
 
 Copper sulphate 105 
 
 Coprostasis complicating hernia 193 
 
 Cord, anterior transplantation of .... 219 
 
 injuries of 169 
 
 posterior transplantation of 203 
 
 transplantation of 203 
 
 Corrosive sublimate no 
 
362 
 
 INDEX 
 
 Cr3'ptorchidism and herniotomy 6^ 
 
 Curtis' operation for femoral hernia. . . 300 
 Cushing's operation for femoral hernia 289 
 
 Cystitis, post-operative 168 
 
 Cystocele, diagnosis of difficult 19 
 
 extraperitoneal crural 346 
 
 Czerny-Banks method, results from 203, 204 
 Czerny's method, results from 204 
 
 operation for umbilical hernia .... 313 
 
 D 
 
 Dauriac's operation for umbilical hernia 308 
 
 Davis' operation for inguinal hernia . . 260 
 
 Deaver's operation for inguinal hernia 264 
 
 operation for umbilical hernia .... 308 
 De Garmo's operation for femoral her- 
 nia 298 
 
 Dentu's operation for inguinal hernia. 260 
 
 Diaphragm, hernial openings in 323 
 
 Disinfectants, chemical 102 
 
 Drainage 137 
 
 Dressing, removal of primary 142 
 
 Dressings, after herniotomy 13S 
 
 after herniotomy on children 141 
 
 Duplay and Cozin's operation for ingui- 
 nal hernia 253 
 
 E 
 
 Electricity in hernia 278 
 
 Enterocele -. 20 
 
 partial, in a male 336 
 
 Enterostomy for tympanites 163 
 
 Eserine salicylate in peritonitis 1S4 
 
 Exudates, traumatic 173 
 
 F 
 
 Fabricius' operation for femoral hernia 290 
 Fallopian tube and ovary, hernia of ... . 25 
 
 hernia of 25, 26 
 
 Fasting, prolonged, before herniotomy 313 
 Ferguson's anatomic operation in in- 
 guinal hernia 280' 
 
 method, complications following . . 220 
 
 method, results from 215 
 
 operation for femoral hernia .... 289 
 
 Fever, primary 187 
 
 secondary 187 
 
 Filigree, Bartlett's 315, 316 
 
 for closing wound 315 
 
 Meyer's 315 
 
 Phelps' 315 
 
 fecal 192 
 
 Fistula, urinary 192 
 
 Formaldehyde 105 
 
 Fowler's operation for inguinal hernia 234 
 Freeman's operation for inguinal hernia 268 
 Frey's method, results from 203, 204 
 
 Q 
 
 Gauze, sterilized, preparation of 54 
 
 Gersuny's operation for umbilical her- 
 nia 313 
 
 Girard's operation for inguinal hernia 238 
 
 Gloves, rubber 121 
 
 rubber, when should be worn 122 
 
 Glycosuria, temporary, in hernia 193 
 
 eraser's operation for umbiHcal hernia 310 
 Gratschoff's operation for inguinal her- 
 nia 27.^ 
 
 H 
 
 Halsted's method, results from 207 
 
 operation for inguinal hernia .... 230 
 
 Hammesfahr's operation for femoral 
 hernia 303 
 
 Hands, care of 119 
 
 chlorinated lime in disinfection of 121 
 
 disinfection of ■ •57- 116 
 
 disinfection of by permanganate of 
 
 potash and oxalic acid 121 
 
 Fiirbinger's method of disinfecting 121 
 Kocher's method of disinfecting . . . 12a 
 Pearson's method of disinfecting . 120 
 
 Harrington's solution 105. 
 
 solution, preparation of 54 
 
 Harris' wire suture operation in ingui- 
 nal hernia 270 
 
 Heat, sterilization by 100 
 
 Hematemesis 159 
 
 Hemophilia and herniotomy 32- 
 
 Hemorrhage, capillary 154 
 
 capillary control of 157 
 
 control of 40, 134 
 
 from vessels of cord 154 
 
 primary 154 
 
 secondary 157 
 
 treatment of persistent from loop 
 of bowel 157 
 
 Hernia, absence of internal ring in... 196- 
 
 anterior 14 
 
 cecal, complicated by hydrocele and 
 
 appendicitis 346 
 
 classification of abdominal 13 
 
 classification of femoral 14 
 
 classification of inguinal 14 
 
 clinical varieties of 16 
 
 condition of sac in 15. 
 
 congenital diaphragmatic .321, 322, 323 
 
 congenital lateral ventral 344 
 
 contents of sac of 15 
 
 diaphragmatic 318, 322 
 
 diaphragmatic, indications for oper- 
 ation 66 
 
 diaphragmatic, results following 
 
 operation on 323. 
 
 diaphragmatic, traumatic 346 
 
 direct inguinal, indications for op- 
 eration 64: 
 
 displaced strangulated femoral .... 341 
 
 en bissac 9, 196 
 
 enormous ventral 350 
 
 epigastric, indications for operation 65 
 femoral, indications for operation . 65 
 femoral, radical cure of 289 
 
INDEX 
 
 Z^2> 
 
 femoral, results of operation for. 
 
 202, 208 
 
 following vasectomy 350 
 
 frequency of occurrence in sexes. . 10 
 
 funicular, of small intestine 354 
 
 ileo-cecal 334 
 
 ileo-colic ^iZi 
 
 indications for operation 32 
 
 inferior 15 
 
 influence of intra-abdominal pres- 
 sure in 10 
 
 inguinal, following trauma 353 
 
 inguinal, of ovary, appendix and 
 
 Meckel's diverticulum 346 
 
 inguinal, recurrence after operation 214 
 inguinal, results of operation for 
 
 202, 208 
 
 inguinal, without sac 22 
 
 inguino-interstitial 350 
 
 inguino-properitoneal 349 
 
 in infants 343 
 
 internal 15 
 
 intersigmoid 330 
 
 interstitial 339, 340 
 
 into duodeno-jejunal fossa 324 
 
 into paraduodenal fossa 349 
 
 lateral 15 
 
 Littre's, of cecum 21 
 
 meso-colic 330 
 
 mortality of radical operations . . . 
 
 210, 213, 214 
 
 oblique inguinal, indications for op- 
 eration 58 
 
 of bladder and oviduct 346 
 
 of cecum 22 
 
 of Fallopian tube 26 
 
 of female pelvic organs 25 
 
 of Meckel's diverticulum 22 
 
 of non-gravid uterus 25 
 
 of ovary 26 
 
 of ovary and tube 25 
 
 of ovary without tube 25 
 
 of pancreas 22, 25 
 
 of pelvic floor 335 
 
 of pregnant uterus 25 
 
 of seminal vesicles 25 
 
 of tube without ovary 25 
 
 of uterus 29 
 
 of vagina 29 
 
 peritonitis complicating 174 
 
 posterior 14 
 
 prevalence of 10 
 
 properitoneal 339, 340, 349 
 
 retroperitoneal 349 
 
 Richter's 349 
 
 strangulated 336 
 
 strangulated duodenal 342 
 
 strangulated obturator 342 
 
 strangulated rectocecal 345 
 
 strangulated, results of operation 
 for 209, 210 
 
 strangulation caused by volvulus . 340 
 strangulation of as indication for 
 
 operation 33 
 
 suppuration in wound as cause of 
 
 relapse : 32 
 
 strangulation of umbilical 341 
 
 subcecal 334 
 
 superior 15 
 
 through Douglas' cul de sac . .345, 353 
 through foramen of Winslow . . . 328 
 through mesentery of Meckel's di- 
 verticulum 345 
 
 through rupture of rectum 345 
 
 traumatic 9 
 
 traumatic epigastric 353 
 
 umbilical, containing congenital di- 
 verticulum 349 
 
 umbilical, indications for operation 64 
 umbilical, perforating abdominal 
 
 wall 346 
 
 unique case of femoral 22 
 
 unusual forms of 345 
 
 ventral, indications for operation . .. 65 
 ventral, results of operation for. . 208 
 vesical, indications for operation . . 66 
 
 vesico-rectal 354 
 
 Hernias, 'eponymic 16 
 
 following appendectomy 65 
 
 inferior, indications for operation 66 
 
 internal and inferior 324 
 
 internal, indications for operation 66 
 
 multiple 354 
 
 operated on by laparotomy 313 
 
 Herniotomy and alcohohsm 34 
 
 and appendectomy combined .... 254 
 
 and constitutional diseases 2>7 
 
 and cryptorchidism 63 
 
 and mental conditions 2>7 
 
 and obesity 60 
 
 and occupation 59 
 
 and syphilis 37 
 
 and tuberculosis 34 
 
 bicycling after 279 
 
 cutaneous compHcations following. 164 
 
 electricity for cure of 278 
 
 femoral, Baldwin's method 290 
 
 femoral, Ball's method 289 
 
 femoral, Banks' method 289 
 
 femoral, Barker's method 289 
 
 femoral, Bassini's method 290 
 
 femoral, Coley's method 300 
 
 femoral. Cooper's method 289 
 
 femoral, Curtis' method 300 
 
 femoral, Cushing's method 289 
 
 femoral, De Garmo's method .... 298 
 
 femoral, Fabricius' method 290 
 
 femoral, Ferguson's method 289 
 
 femoral, Hammesfahr's method . . : 303 
 
 femoral, Herzen's method 299 
 
 femoral, Houston's method 289 
 
 femoral, Kammerer's method .... 294 
 
36^ 
 
 I ?s" DEX 
 
 femoral, Lotheissen's method 300 
 
 femoral, Macewen's method 289 
 
 femoral, jNIarcy's method 289 
 
 femoral, McBurne3''s method 289 
 
 femoral, Mikulicz's method 294 
 
 femoral, Nicoll's method 297 
 
 femoral, Ochsner's method 299 
 
 femoral, Poh'a's method 293 
 
 femoral, Schwartz's method 303 
 
 femoral, Socin's method 300 
 
 femoral, Sprengel's method 303 
 
 indications for 58 
 
 indications for immediate 63 
 
 influence of age on ^t, 
 
 influence of habits and disease on. 34 
 
 influence of sex on 34 
 
 inguinal, Andrews" imbrication 
 
 method 267 
 
 inguinal. Ball's method 250 
 
 inguinal, Barnhill's method 263 
 
 inguinal, Bassini's method 229 
 
 inguinal. Beck's method 242 
 
 inguinal, Benjamin's method 246 
 
 inguinal, Bishop's method 259 
 
 inguinal, Butler's method ■. 258 
 
 inguinal, Davis' method 260 
 
 inguinal, Deaver's method 264 
 
 inguinal, Dentu's method 260 
 
 inguinal, Duplay and Cozin's meth- 
 od 253 
 
 inguinal, Ferguson's anatomic 
 
 method 280 
 
 inguinal. Fowler's method 234 
 
 inguinal. Freeman's method 268 
 
 inguinal, Girard's method 238 
 
 inguinal, Gratschoff's method .... 274 
 
 inguinal, Halsted's method 230 
 
 inguinal, Harris' wire suture meth- 
 od 270 
 
 inguinal. Herring's metho-d 245 
 
 inguinal. Hoffman's method 280 
 
 inguinal, Kennedy's method 260 
 
 inguinal, Kocher's method 230 
 
 inguinal, Lanphear's method 237 
 
 inguinal, Leving's method 250 
 
 inguinal, ]\Iacewen's method 225 
 
 inguinal, McArthur's autoplastic 
 
 suture in 269 
 
 inguinal, Nicholl's method 242 
 
 inguinal, Noble's overlapping meth- 
 od 267 
 
 inguinal, Owen's method 263 
 
 inguinal. Park's auto-suture meth- 
 od 23S 
 
 inguinal, Phelps' silver wire meth- 
 od 278 
 
 inguinal, Poullet's method 253 
 
 inguinal, Schwartz's method .... 249 
 
 inguinal. Smith's method 259 
 
 inguinal, Stinson's method 245 
 
 inguinal, Symonds' method 254 
 
 inguinal, Torek's method 254 
 
 inguinal, Treves' method 259 
 
 inguinal, White's method 259 
 
 inguinal, Woelfler's method 249 
 
 inguinal, Wullstein's method .... 241 
 
 in hospital 80 
 
 intestinal complications following. 166 
 
 in the home 79 
 
 intraperitoneal 254 
 
 local anesthesia in 358 
 
 materials used by author 45 
 
 permanent results of 213 
 
 preparation of patient for 38 
 
 pulmonary complications of 191 
 
 radical, general discussion of .... 282 
 
 renal complications of 191 
 
 results of 202 
 
 shock following 49 
 
 special instruments for 44 
 
 umbilical, Blake's method 307 
 
 umbilical, Boeckel's method 308 
 
 umbilical, Champonniere's method 313 
 umbilical, Condamin's method .... 313 
 
 umbilical, Czerny's method 313 
 
 umbilical, Dauriac's method 308 
 
 umbilical, Deaver's method 30S 
 
 umbilical, Gersuny's method 313 
 
 umbilical, Graser's method 310 
 
 umbilical, Mayo's method 304 
 
 umbilical, radical cure of 304 
 
 umbilical, Ransohoff's method . . . 309 
 
 umbilical, Reverdin's method 313 
 
 umbilical, Terrier's method 3^3 
 
 umbilical, Warren's method 309 
 
 umbilical, Winslow's method 309 
 
 vesical complications in 167 
 
 vomiting during 158 
 
 when should not be performed. . .3^, 34 
 Herring's operation for inguinal her- 
 nia ■ ■ • 245 
 
 Herzen's operation for femoral hernia. 299 
 Hesselbach, triangle of, methods of pro- 
 tecting 219 
 
 Hoffman's operation for inguinal her- 
 nia 280 
 
 Horsehair, preparation of . . ., 50 
 
 Hospital, service staff in 57 
 
 Houston's operation for femoral hernia 289 
 
 Hydrocele following herniotomy 171 
 
 of canal of Nuck 198 
 
 Hydrogen peroxide ' 1 16 
 
 I 
 
 Ileus 166 
 
 due to tympanites 173 
 
 Immunity 98 
 
 Incision for herniotomy 132 
 
 how to make 133 
 
 Infection 89 
 
 following herniotomy 84, 171 
 
 mixed 89 
 
INDEX 
 
 36 = 
 
 obscure sources of 97 
 
 predisposition to 98 
 
 terminal 89 
 
 Instruments, disinfection of 102 
 
 special for herniotomy 44 
 
 sterilization by heat 102 
 
 used in hernia operations 39 
 
 Intestine, agglutination of 173 
 
 pathologic conditions of following 
 
 herniotomy 166 
 
 rejection of gangrenous during her- 
 niotomy 336 
 
 strangulation of following peritoni- 
 tis 183 
 
 stricture of in strangulated hernia. 197 
 
 Intoxication, septic 187 
 
 Iodine as a disinfectant iTj. 
 
 Iodoform 115 
 
 emulsion, preparation of 53 
 
 gauze, preparation of 53 
 
 K 
 
 Kammerer's operation for femoral her- 
 nia 294 
 
 Kennedy's operation for inguinal her- 
 nia 260 
 
 Koch's law 90 
 
 Kocher's method, results from.... 204, 208 
 operation for inguinal hernia .... 230 
 
 L 
 
 Lanphear's operation for inguinal her- 
 nia 237 
 
 Laparotomy, indications for 314 
 
 Lavage, gastric, for vomiting 159 
 
 Leving's operation for inguinal hernia 250 
 Liver, congenital hernia of into umbili- 
 cal cord 22 
 
 Lotheissen's operation for femoral her- 
 nia 300 
 
 Lysol 109 
 
 M 
 
 rvlacewen's operation for femoral hernia 2S9 
 operation for inguinal hernia .... 225 
 Marcy's operation for femoral hernia. . 2S9 
 Maj^o's' operation for umbilical hernia 304 
 McArthur's autoplastic suture opera- 
 tion in inguinal hernia 269 
 
 McBurney's operation for femoral her- 
 nia 289 
 
 Meckel's diverticulum, hernia of ... . 22 
 Mental conditions and herniotomy .... '^'j 
 
 Mercury, biniodide 114 
 
 INIercuric chloride as an antiseptic .... 113 
 
 [Meyer's filigree 315 
 
 [Micrococci, varieties of 84 
 
 [Mikulicz's operation for femoral her- 
 nia 294 
 
 N 
 [Nephritis, post-operative igi 
 
 Nicholl's operation for inguinal hernia 242 
 
 Xicoll's operation for femoral hernia. 297 
 Noble's overlapping operation for ingui- 
 nal hernia 267 
 
 Nurses, duties of 52 
 
 O 
 
 Obesity and herniotomy 60 
 
 Occupation and herniotomy 59 
 
 Ochsner's operation for femoral hernia 299 
 
 Omentum, amputation of 43 
 
 pathologic <:onditions <if 166 
 
 suppurating mistaken for hernia . . 198 
 
 Operating room, at home 79 
 
 care of ^z 
 
 in hospital 80 
 
 Operating sets 54 
 
 Operation, indications for 58 
 
 Operator, the TJ 
 
 Ovary and tube, hernia of 25 
 
 hernia of 25, 26 
 
 Owen's operation for inguinal hernia . . 263 
 
 Oxalic acid for hand disinfection .... 121 
 
 P 
 
 Pagenstecher's thread as suture mate- 
 rial 51 
 
 Pain as an indication for herniotomy 72 
 differentiation of causes of ....70, 71 
 
 in hernia 69. 70, 71, "]! 
 
 in peritonitis 177 
 
 post-orerative 163 
 
 treatment of post-operative 164 
 
 Pancreas, hernia of 22, 25 
 
 Park's auto-suture operation for ingui- 
 nal hernia 238 
 
 Patient, physical condition of before 
 
 operating 32 
 
 Patient, preparation of for herniotomy "^i 
 
 Peritoneum, injurj- of 43 
 
 Peritonitis, immunizing injections to 
 
 prevent - 183 
 
 in hernia 174 
 
 pneumococcus 184 
 
 post-operative 172- 
 
 symptoms of 177 
 
 symptoms of pneumococcic 184 
 
 traumatic 173 
 
 treatment of post-operative 179 
 
 treatment of traumatic 174 
 
 Phagocytosis 98 
 
 Phelps' filigree 315 
 
 silver wire operation, in inguinal 
 
 hernia 278 
 
 Pleurisy, post-operative 191 
 
 Pneumonia, post-operative 191 
 
 Polya's operation for femoral hernia. . 293 
 
 Potassiurn permanganate 115 
 
 Poullet's operation for inguinal hernia 253 
 
 Pregnane}', tubal, within hernial sac. . 25 
 
 Pulse in peritonitis 178 
 
 Pvemia 188 
 
366 
 
 TNDEX 
 
 Pyoktannin IIS 
 
 Pj'rexia, post-operative 187 
 
 R 
 
 Ransohoff's operation for umbilical her- 
 nia 309 
 
 Resection, results from 213 
 
 Respiration, artificial, in treatrrient of 
 shock 150 
 
 Reverdin's operation for umbilical her- 
 nia 313 
 
 Richter's hernia 349 
 
 S 
 
 Sac, contents of 10 
 
 pathologic conditions of 166 
 
 removal of in radical cure 204 
 
 varieties of hernial 9 
 
 Sal-alembroth 114 
 
 Sapremia 89, 188 
 
 Schwartz's operation for femoral hernia 303 
 operation for inguinal hernia .... 249 
 
 Scrotum, abscess of 197 
 
 Septicemia 187, 188 
 
 treatment of 188 
 
 Service stafif in hospital . . . . , 57 
 
 Shock, complicating herniotomj^ 149 
 
 in peritonitis 17S 
 
 latent or delayed 153 
 
 treatment of 153 
 
 Silk, as suture material 51 
 
 Silkworm gut, preparation of 50 
 
 Silver nitrate 115 
 
 Skin, diseases of following herniotomy. 164 
 Smith's operation for inguinal hernia. . 259 
 Socin's operation for femoral hernia. . 300 
 
 Spirilla, varieties of 85 
 
 Sponges, use of 54 
 
 Sprengel's operation for femoral hernia. 303 
 
 Steam, sterilization b\^ loi 
 
 Sterilization, methods of 100 
 
 Stinson's operation for inguinal hernia. 245 
 
 Suppuration and bacteria 86 
 
 in wound following herniotomj^ ... s^ 
 
 Surgerj^, aseptic 83 
 
 Suture, Davison's removable continu- 
 ous 274 
 
 Eastman's single tier 277 
 
 Gratschoff's removable continuous 277 
 
 Harris wire 270 
 
 material, varieties and preparation 
 
 of 45 
 
 McArthur's autoplastic 269 
 
 Park's autoplastic 238 
 
 removal of 142 
 
 Witherbee's removable 274 
 
 Symonds' operation for inguinal hernia 254 
 
 Seminal vesicles, hernia of 25 
 
 Sex, influence of on herniotomy 34 
 
 Syphilis and herniotomy t,/ 
 
 T 
 
 Temperature, changes in during herni- 
 otomy 158 
 
 in peritonitis 178 
 
 Tendon, obliteration of conjoined 197 
 
 Tendons, preparation of 49 
 
 Terrier's operation for umbilical hernia 313 
 
 Testes, atrophy of 197, 198 
 
 atrophy of following herniotomy.. 171 
 
 sarcoma of 197 
 
 undescended in hernia 197 
 
 Thread, celluloid, as suture material. . 51 
 
 linen, as suture material 51 
 
 Thrombophlebitis of accessory veins of 
 
 cord complicating hernia 339 
 
 Torek's operation for inguinal hernia. 254 
 Treves' operation for inguinal hernia. . 259 
 
 Tuberculosis and herniotomy 34 
 
 Tj-mpanites, death from 160 
 
 enterostomy for 163 
 
 post-operative 160 
 
 treatment of 163 
 
 Tympany in peritonitis 178 
 
 U 
 
 Uterus, hernia of 2Q 
 
 hernia of non-gravid 25 
 
 hernia of pregnant 25 
 
 subperitoneal fibroma of causing 
 
 hernia of bladder 19 
 
 V 
 
 Vaginocele 29 
 
 Vomiting, complicating herniotomy. . . . 158 
 
 gastric lavage for 159 
 
 in peritonitis . '. 178 
 
 treatment of post-operative 159 
 
 W 
 
 Warren's operation for umbilical hernia 309 
 Weight, reduction of before herniotomy 313 
 White's operation for inguinal hernia. 259 
 Winslow's operation for umbilical her- 
 nia 309 
 
 Wire, as suture material 49 
 
 silver, in inguinal canal 278 
 
 Woelfler's method, results from 202 
 
 operation for inguinal hernia .... 249 
 
 Wound, emphysema of 197 
 
 protection of from injury ..• 141 
 
 Wounds, closure of 134 
 
 healing of aseptic . 146 
 
 infection of 90, 147 
 
 secondary- secretion in 146 
 
 sources of infection of 90 
 
 treatment of 146 
 
 treatment of infected 147 
 
 Wullstein's operation for inguinal her- 
 nia 241 
 
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 The technic of modern operations 
 
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