COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00036285 ;Hmii'!!'.iiiiHMmiiim«mi i.ilfll nuuimim mil. 1 1 1 J'^-^ QQIIirfpi/^ !!MiurpQ|yY HEAL I H SCiL.NCES LIBRARY "^ ALFRED M-HELLMKN JCA^-J^. .'^^<^^. ^ut^t- TT- -t^^*' ^^'-t-<^^^iC'^-r>^ ^ ABDOMINAL HERNIA ITS DIAGNOSIS and TREATMENT BY W. B. De GARMO, M.D., NEW YORK. Professor Special Surgery (Hernia), New York Post-Graduate Medical School and Hospital; Fellow New York Academy of Medicine j Member American Medical Associ- ation, New York State and County Medical Societies, Honorary Member of the Medical Society of Virginia. PHILADELPHIA a^ LONDON J. B. LIPPINCOTT COMPANY K U Copyright, 1907 By J. B. LippiNcoTT Company Electrotyped a7id Printed by J. B. Lippincott Company The Washingiofi Square Press, Philadelphia, U. S. A. DEDICATION TO the many practitioners of medicine and surgery who, during the past twenty years at the New York Post-Graduate Medical School and Hospital, have patiently followed the Author's attempts to simplify the teaching of hernia, this work is dedicated. Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/abdominalherniaiOOdega PREFACE. The first appeal for aid by those afflicted with hernia, is usually made to the family physician. While the surgeon has plenty of literature to guide him in his part of the work, the physician, upon whom many times the full responsibility of the case must rest, finds little practical aid from that source in any language. It is t(j the physician that this book is especially addressed, and if it fails to furnish him useful suggestions regarding the diagnosis and treatment of adominal hernia, then certainly it will have fallen far short of its intent. The author's severest critic will scarcely accuse him either of writing a book too early in his professional career, or of compiling one from the experience of others. Many authors have been consulted, and quoted with credit, but the funda- mental part of the work is based upon personal experience, and the illustrations are largely from photographs of patients under treatment. The author realizes his liability to criticism for omitting mention of other forms of operation, popular, perhaps, in the country of their origin; but he justifies himself in the fact that they have not shown the success, that has followed the use of those here given. Furthermore he has tried to make clear the principles involved in curative measures rather than to suggest any special method. Acknowdedgment of obligations to many friends is freely given, especially the following who wdllingly granted the use of original drawings which are a valuable addition to the text : Dr. W. S. Halsted, Baltimore; Dr. W. J. Mayo. Rochester, Minn. ; Dr. William S. Bainbridge, New York ; Dr. Charles N. Dowd, New York; Dr. A. E. Halstead, Chicago; Dr. 6 PREFACE. W. Jay Seaver, New Haven; Dr. Samuel W. Kelly, of Cleve- land, and to Professor Julius A. Becker for special dissections from which Mr. K. K. Bosse has drawn some of the anatom- ical plates, and to Dr. Alfred M. Hellman for compiling the index. Manufacturers of appliances for the relief of hernia have allowed the publishers to draw freely upon them for electro- types, with which to illustrate different forms of trusses, and the author wishes to thank in this public manner, Wm. H. Horn & Bro., The J. Ell wood Lee Co., Chesterman & Streeter, and his brother Mr. G. J. De Garmo. CONTENTS CHAPTER PAGE I. Surgical Anatomy of the Inguinal Region 17 II. Descent of the Testicle 34 III. Cause of Inguinal Hernia 44 IV. Types and Conditions of Inguinal Hernia 54 V. The Hernial Sac 71 VI. Symptoms and Diagnosis of Inguinal Hernia .... 82 VII. Mechanical Treatment of Inguinal Hernia .... 114 VIII. Truss Fitting 152 IX. Mechanical Treatment of Inguinal Hernia in In- fancy and Childhood 189 X. Treatment of Inguinal Hernia by Gymnastics . . . 204 XL Surgical Cure of Inguinal Hernia 214 XII. Complications in the Surgical Cure of Inguinal Hernia , . 239 XIII. Sigmoid, C^cal and Bladder Hernia 277 XIV. Surgical Cure of Inguinal Hernia in the Female . 292 XV. Femoral Hernia 297 XVI. Mechanical Treatment of Femoral Hernia 317 XVII. Surgical Cure of Femoral Hernia 331 XVIII. Umbilical Hernia 344 XIX. Mechanical Treatment of Umbilical Hernia ... 355 XX. Surgical Cure of Umbilical Hernia 372 XXI. Ventral Hernia . 383 XXII. Rare Forms of Hernia 39S XXIII. Contra-Indications to the Surgical Cure of Abdom- inal Hernia 409 XXIV. Strangulated Inguinal Hernia 413 XXV. Medical Treatment of Strangulated Hernia .... 427 XXVI. Surgical Treatment of Strangulated Inguinal Hernia 432 XXVII. Strangulated Femoral Hernia 439 XXVIII. Strangulated Umbilical Hernia 443 ILLUSTRATIONS FIGURR PAGE 4- 5- 6. 7- 8. 9- 10. II. 12. 13- 14. IS- 16. 17- 18. 19. 20. 21. 22. 22- 24. 25- 26. 27. 28. 29. 30. 31- 32. 33- Original drawing.) Showing position of superficial vessels.. 21 Original drawing.) Aponeurosis of external oblique muscle and external ring 22 Original drawing.) Aponeurosis opened to show deep part of canal 24 Cooper.) Anatomy of inguinal and femoral region 25 Original drawing.) Proximity of deep epigastric and iliac arteries to inguinal canal 30 Leidy.) The greater omentum 32 GoDARD from Eccles.) Partial descent of testicle 35 GoDARD from Eccles.) Partial descent of testicle 2>^ Eccles.) Testicle in Scarpa's triangle 27 Original photo.) Right testicle in canal, left at internal ring. . 38 Original drawing.) Multiple cysts of cord 40 Original photo.) Hydrocele of cord simulating irreducible hernia 41 Macready.) Side view of abdomen of old man 46 Macready.) Early inguinal hernia 48 Original drawing.) A form of physical culture that produces hernia 52 Macready.) Double oblique and direct hernise 55 Eccles.) Incomplete inguinal and direct hernise 56 Original photo.) Right complete inguinal and enormous left scrotal hernias 57 Original photo.) Scrotal hernia of enormous size 58 Original photo.) Labial hernia in woman 59 Macready.) Double direct hernia 60 Original photo.) Sigmoid hernia 61 Original photo.) Right direct and left sigmoid hernije 62 Original photo.) Left interstitial hernia, right testicle in canal. 63 Eccles.) Right interstitial hernia with retained testicle 64 Eccles.) Right testis in cruro-scrotal pouch with hernia 65 Macready.) Right interstitial hernia with retained testis.... 66 Macready.) Left interstitial hernia simulating femoral hernia. 67 Original drawing.) Showing formation of interstitial sac... 68 Original drawing.) Three fibrous rings in acquired sac 72 Original drawing.) Two fibrous rings with strangulation in upper one 72 Original drawing.) Omentum incarcerated in ring in Con- genital sac 74 Macready.) Hernia in funicular portion of tunica vaginalis.. 75 9 10 ILLUSTRATIONS. FIGURE PAGE 34. (Original drawing.) Hernia into funicular portion of tunica vaginalis with cyst below "^6 35. (Original drawing.) Infantile sac with closed tunica vaginalis below "jy 36. (Original drawing.) Sac of peculiar shape 78 2,7. (Original drawing.) Interstitial sac 79 38. (Original drawing.) Relative thickness of tissues covering sac. 80 39. (Original photo.) Irreducible omental scrotal hernia 83 40. (Original photo.) Large reducible scrotal hernia 84 41. (Original drawing.) Improper method of examining for hernia 87 42. (Original photo.) Enormous irreducible left scrotal hernia.... 89 43. (Original photo.) Large scrotal hernia with true peritoneal sac 90 44. (Original photo.) Typical congenital hernia in adult 92 45. (Original photo.) Double congenital hernia in boy 93 46. (Original photo.) Double congenital hernia mistaken for h}-dro- cele 93 47. (Original photo.) Double congenital hernia retained by truss. 94 48. (Original photo.) Double congenital hernia two years after operation 95 49. (Original photo.) Tj-pical scrotal hernia of acquired type 96 50. (Original photo.) Right labial hernia 97 51. (Original photo.) Right labial hernia, four weeks after opera- tion 98 52. (Original photo.) Sigmoid hernia 99 53. (Original photo.) Caecal hernia lOO 54. (Original photo.) Sigmoid and Caecal hernia in same patient. . loi 55. (Original photo.) Csecal hernia in woman loi 56. (EccLES.) Left varicocele and femoral varix 103 57. (Original photo.) Varicocele mistaken for hernia 105 58. (Le Progre's Med., redrawn.) Statuette showing truss. 900 B. C. 115 59. (Original drawing.) Showing shape of pelvis 122 60. (Original photo.) Illustration of bad truss-fitting 127 61. Original photo.) Properly applied truss 128 62. (Original photo.) Usual manner of applying German truss.... 129 63. (Original drawing.) Position in which a truss spring should be applied 130 64. (Original photo.) De Garmo-Hood truss applied 140 65. (Original photo.) De Garmo-Hood truss applied, back view. . 141 66. Group of variously shaped pads (thirteen figures) 149 (yj. A standard of sizes for truss pads (four figures) 150 68. (Macready.) Measuring for inguinal truss I53 69. (Original drawing.) Methods of taking diagram with lead tape 154 70. (Original drawing.) Method of taking diagram, second position 155 71. (Original drawing.) Pelvic diagrams contrasting shape 156 ILLUSTRATIONS. 1 1 72. (Original drawing.) Pelvic diagrams contrasting shape 157 73. Shaping truss springs (seven figures) 159-160 74. (Horn.) Hard-rubber cross-body truss applied 161 75. (Original photo.) Large labial hernia 162 y6. (Original photo.) Labial hernia retained by cross-l)ody truss.. 163 77. (Horn.) Hard-rubber Hood truss applied 164 78. (Original photo.) Recurrent hernia in woman 164 79. (Original photo.) De Garmo-Hood truss applied to recurrent hernia 165 80. (Original photo.) Large double hernia 166 81. (Original photo.) Large double hernia retained l)y Hood truss. 167 82. (Horn.) Combination of radical-cure truss with ordinary dou- ble truss 168 83. (Macready.) English " Rat-tail " truss, applied 170 84. (EccLES.) English double truss, applied 171 85. (Horn.) Hard-rubber French truss, applied 172 86. (Original photo.) Double retained testes and hernia; truss applied 1 78 87. (Original photo.) Double retained testes and hernia 179 88. (Macready.) Truss for reducible interstitial hernia 181 89. (Original photo.) Large irreducible scrotal hernia 184 90. (Macready.) Hinged-cup truss for irreducible hernia 185 91. (Original photo.) Enormous irreducible left scrotal hernia.... i85 92. (Original drawing.) Method of supporting large inreducible hernia 187 93. (Original drawing.) Five-weeks-old boy with cross-body truss applied 191 94. (Original drawing.) Hood's truss applied to girl six months old 192 95. (Original photo.) Cross-body hard-rubber truss 193 96. (EccLES.) Hank of worsted truss 194 97. (Original photo.) Cross-body hard-rubber truss with perineal strap 195 98. (Original photo.) De Garmo-Hood truss on girl 196 99. (Original photo.) De Garmo-Hood truss on boy 197 100. (Original photo.) German scrotal hernia truss on boy 198 lOi. (Seaver.) Gymnastic exercise no. i 205 102. (Seaver.) Gymnastic exercise no. 2 206 103. (Seaver.) Gymnastic exercise no. 3 206 104. (Seaver.) Gymnastic exercise no. 4 207 105. (Seaver.) Gymnastic exercise no. 5 208 106. (Seaver.) Gymnastic exercise no. 6 208 107. (Seaver.) Gymnastic exercise no. 7 209 108. (Seaver.) Gymnastic exercise no. 8 210 109. (Original drawing.) Sac separated from cord and anatomy of inguinal region 221 no. (Original drawing.) Curved blunt needle 223 12 ILLUSTRATIONS. FIGU III. 112. 113- 114. 115- 116. 117. 118. 119. 120. 121. 122. 123. 124. 125- 126. 127. 128. 129. 130. 131- 132. 133- 134- 135- 136. 137- 138. 139- 140. 141. 142. 143- 144. 145- 146. 147- 148. RE PAGE (Original drawing.) Internal oblique stitched to Poupart's ligament 224 Original drawing.) Aponeurosis closed by continuous suture. 225 Halsted.) Relative position of sac, cord and vas deferens... 229 Halsted.) Cremaster fastened under internal oblique 230 Halsted.) Internal oblique fastened to Poupart's ligament... 231 Halsted.) Overlapping of aponeurosis (first step) 232 Halsted.) Overlapping of aponeurosis (second step) 233 Halsted.) Sectional view of fascial layers 234 WullsteiNj redrawn.) Transplanting of cord (first step).... 235 Wullstein, redrawn.) Transplanting of cord (second step).. 236 Halsted.) Halsted's method of utilizing split sheath of rectus 237 Origina Origina Origina Origina Origina tion Origina Origina Origina Origina Origina Origina Origina them Origina Origina tion Origina be a Origina Origina Origina sac . Origina sac . Origina Origina Origina Origina Origina Origina Origina Origina drawing.) Right retained testicle in boy of 10 years. 240 photo.) Right retained testicle in boy of 9 years.... 241 photo.) Double retained testes in boy of 13 years. . 241 drawing.) Delayed testicle surrounded by sac 242 photo.) Double retained testes two years after opera- 243 photo.) Retained left testicle and interstitial hernia. 244 photo.) Sac of interstitial hernia before opening... 245 photo.) Sac with testicle inside 246 drawing.) drawing.) drawing.) drawing.) Retained testicle, sac opened 247 Purse-string suture in sac 247 Sac tied by purse-string suture 248 Lifting muscles to place testicle beneath 249 photo.) Interstitial hernia and retained testicle 250 photo.) Interstitial hernia three weeks after opera- 251 photo.) Double hernia in child of 7 years supposed to jirl 252 photo.) Same as preceding, with hernia reduced.... 253 photo.) Same as preceding 255 drawing.) Appendix adherent to anterior wall of 257 drawing.) Appendix adherent to posterior wall of 259 drawing.) Appendix incarcerated in fibrous ring.... 260 photo, photo, photo, photo, photo, photo, photo. Sac and omentum removed together 262 Omentum spread out for ligating 263 Omentum irreducible from shape 264 Omentum, hypertrophied 265 Omentum and sac 266 Scrotal hernia to within two inches of knee. . 268 Side view of preceding case 269 ILLUSTRATIONS. l.'J FIGURE PAGE 149. (Original photo.) Preceding cape seven weeks after operation. 270 150. (Original photo. j Large scrotal hernia containing bladder.... 2~\ Original photo.) Preceding case six weeks after operation.. 272 Original photo.) Preceding case five years later with hernia on opposite side 273 Original photo.) Enormous scrotal hernia in man of 70 years 274 Original photo.) Irreducible scrotal hernia, intestine only.... 275 Original drawing.) Peculiar mesentery found in preceding case 276 Original drawing.) Hernial sac containing free caecum and loops of intestine 278 Original drawing.) Hernial sac in front of cjecum 279 Original drawing.) Form of purse-string suture for sigmoid sac 281 Original drawing.) Lifting internal oblique to bury stump of sac 282 Original drawing.) Protrusion consisting of hernial sac and bladder 287 Original drawing.) Hernial sac and bladder protruding sep- arately 289 Original drawing.) Closure of canal in female by single suture 294 Original drawing.) Anatomy of femoral region 298 Original drawing.) Transverse section of femoral region.... 299 Redrawn from Gray.) Showing relative position of femoral hernia and large vessels 301 Original photo.) Double femoral hernia in man of 50 years. . 302 Original photo.) Reducible femoral hernia of enormous size. 303 Original photo.) Irreducible femoral hernia 305 Original photo.) Double femoral hernia in woman 306 Original drawing.) Cystic femoral sac 307 Original photo.) Femoral hernia of peculiar shape, in woman. 308 EccLES.) Left varicose saphena vein 312 Original photo.) Femoral and labial varix in pregnant woman of 35 years 313 Original photo.) Lipoma simulating femoral hernia 315 Original photo.) Femoral hernia in woman, cross-body truss applied 2^2 Original drawing from photo.) Cross-body hard-rubber truss for femoral hernia 323 Redrawn.) German femoral truss applied 325 Redrawn from M.a.cready.) English femoral truss applied... 326 Original drawing from photo.) Adjustable truss applied to femoral hernia 327 180. (Original drawing from photo.) De Garmo femoral truss ap- plied 328 U ILLUSTRATIONS. FIGURE PAGE i8i. (Original photo.) Inguinal and femoral hernia in woman., truss applied 329 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193- 194. 195- 196. 197. 198. 199. 200. 201. 202. 203. 204. 205. 206. 207. 208. 209. 210. 211. 212. 213. 214. 215- 216. 217. 218. 219. 220. Original drawing.) Location of incision for femoral hernia... 334 Original drawing.) Showing femoral protrusion under Pou- part's ligament 335 Original drawing.) Femoral operation; sac drawn down.... 336 Original drawing.) Femoral hernia operation, sutures in place 337 Original drawing.) Femoral hernia operation sutures tied.. 338 Original drawing.) Femoral hernia operation; blunt needle.. 339 Original photo.) Double reducible femoral hernia, woman of 60 j-ears 339 Original photo.) Same case, side view 340 Original photo.) Same case six weeks after operation 341 Original photo.) Femoral hernia of unusual type 342 Original photo.) Umbilical hernia in child of 3 years 347 Original photo.) Enormous irreducible umbilical hernia 348 Original photo.) Same case, side view 349 Original photo.) Enormous umbilical hernia; man of 45 years 350 Original photo.) Reducible umbilical hernia in 200-pound woman 350 Original photo.) Irreducible umbilical hernia in woman 351 Original photo.) Irreducible umbilical hernia in man 351 Bainbridge.) Multiple hernije 352 Bainbridge.) Same case showing 5 hernise in median line.... 353 Dr. S. W. Kelly.) Plate and plaster for umbilical hernia.... 356 Dr. S. W. Kelly.) Plate and plaster applied 357 Original photo.) Truss applied for umbilical hernia, child of 3 years 359 Horn.) Outlines of umbilical plates 366 Continued.), Size of umbilical plates 367 EccLES.) An English umbilical truss 368 Horn.) Diagram for abdominal belt measure 369 EccLES.) English rim-plate concave umbilical truss 370 Original drawing.) Vertical overlapping of abdominal wall. . 376 Mayo.) Transverse elliptical incision 37S Mayo.) Transverse overlapping sutures in place 379 M.\YO.) Transverse overlapping, complete 380 Original photo.) Post-operative ventral hernia 387 Original photo.) Deposit of fat simulating ventral hernia.... 388 Original photo.) Ventral hernia following gun-shot wound. . 389 Original photo.) Same, front view 390 Original photo.) Bilateral post-operative ventral hernia 391 Original photo.) Ventral hernia after appendix operation.... 393 Macready.) Spontaneous double lumbar hernia 399 Macready.) Truss for right lumbar hernia 400 DowD. ) Congenital lumbar hernia 401 ILLUSTRATIONS. 1.5 FIGURE PAGE 221. (DovvD.) Anatomy of congenital lumbar hernia 402 222. (DovvD.) Operation for lumbar hernia sutures placed 40,3 223. (DowD. ) Operation for lumbar hernia sutures tied 404 224. (Original photo.) Exstrophy of bladder and vaginal hernia.. 406 225. (Original photo.) Same case with appliance 407 226. (Horn.) Appliance for perineal hernia 408 Classification of Trusses by Groups. Group of: Springless trusses (seven figures) 119-120 French, German and English trusses (eight figures) 125-126 Cross-body type of trusses (eight figures) 131-132 Chase type of trusses (eight figures) 133-134 Hood type of trusses (Twelve figures) ,. . . 137-13Q Unclassified trusses (four figures) 143-144 Double trusses (ten figures) 145-146 Trusses for femoral hernia (sixteen figures) 318-321 Infant umbilical trusses (nine figures) 358 Adult umbilical trusses (eighteen figures) 361-365 Trusses for ventral hernia (six figures 394-395 Diagrams (original drawing) showing formation of femoral hernia, extra-peritoneal fat and lipoma 300 ABDOMINAL HERNIA ITS DIAGNOSIS AND TREATMENT. CHAPTER I. INTRODUCTION. Definition. — Hernia is the protrusion from a cavity, of any of its natural contents ; as hernia of the brain from the cranial cavity, or hernia of the lung from the cavity of the chest. Abdominal hernia is, therefore, the protrusion through the retaining wall of any of the enclosed viscera. This gen- erally occurs at some point in the muscular wall that is weak- ened by the transmission of nerves and blood vessels, at points congenitally defective, or through muscular parts that have been previously lacerated or incised. The word " Rupture^' so commonly used to denote a con- dition of hernia, will be, as far as possible, avoided in this work, as it leads to an erroneous impression of what actually occurs. In the early ages this term was applied under the supposition that there was actual rupture of the peri- toneum. It is now well known that there is rarely laceration of tissue. Hernia results, in almost every instance, from the gradual stretching of tissue and escape of the abdominal con- tents, either into a preformed (congenital) sac, or by the formation of a sac (acquired) from the peritoneal lining of the abdomen. Abdominal herni?e derive their names from the part of the abdominal wall through which they pass. The terms mgumal, femoral, or umbilical, denote at once their place of 2 17 18 ABDOMINAL HERNIA. escape, the exception to this being ventral hernia, which may- occur at any point in the anterior abdominal wah other than in the regions named. As ventral hernia occurs at points in the muscular wall so strong as ordinarily to resist hernial protru- sion, it follows that when it does occur, it is either due to some congenital defect or is the result of some injury, such as a stab wound or a cutting operation. Extreme distension of the abdomen may also result in such separation of its aponeurotic fibres as to allow of protrusion. A little more than 73 per cent, of all hernias are of the inguinal type. Next in frequency is femoral hernia, with 18 per cent., and third, umbilical hernia with about 8^ per cent. This leaves. about i per cent, for all of the rarer forms. The individual may have a single hernia or multiple hernise. It is not uncommon to find inguinal and umbilical, or inguinal and femoral hernise in the same subject. The type, or form, of hernia is notably influenced by sex, as shown by the following comparison : Male: Inguinal, 96.33 per cent.; femoral, 2.53 per cent.; umbilical, 1,14 per cent. Female: Inguinal, 50 per cent.; femoral, 33.15 per cent.; umbilical, 15.9 per cent. That age has a decided influence on the occurrence of hernia is shown by the exhaustive studies of Paul Berger. His tables show 19.6 cases to 1,000 individuals in the first year of life, and drops to 4.2 per 1,000 in the second year; then there is a gradual decline up to the twentieth year when only 0.88 is found. From this time on to the seventy-fifth year the in- crease of proportion is constant, reaching at this age its highest point, 24.20 per 1,000 individuals. Hernia consists of the sac and its contents; the sac being formed from peritoneum, the lining membrane of the ab- dominal cavity. It may be formed at the time of the first pro- trusion and is then termed an acquired sac. As will be demon- strated later, a congenital sac may have existed long before the protrusion of the hernia, by the persistence of a pouch of INTRODUCTION. 19 peritoneum {Tunica Vaginalis) which normally should have been obliterated at, or shortly after, birth. The sac consists of its body, or the expanded portion, which contains the bulk of the protrusion ; the neck, which is the constricted part running through the muscular wall ; and its mouth, the aperture of communication with the peritpneal cavity. The acquired sac on first protruding, may be free from adhesions, and reducible, but readily becomes attached to sur- rounding tissues and from that time is irreducible. It then fur- nishes a permanent, moist, serous lining to the canal through which it protrudes. Hernia of the bladder, of the caecum and sigmoid flexure, may occur without a true hernial sac. The anterior bladder wall is not covered by peritoneum, and it may form the actual protrusion in inguinal hernia. If the protrusion is of fairly large size, it will also drag that part of the organ into the canal that is covered by peritoneum, when both bladder and ab- dominal contents will be found. This same condition exists in sigmoid and csecal hernia, except that in these the peritoneum covers the anterior wall of the gut and the posterior wall is dragged down without this covering. Following previous operations where the peritoneum has for some reason failed to unite, there may be protrusion imme- diately beneath the skin without sac formation. This is most frequently met with in ventral hernia following laparotomy, but I have found in one instance this condition existing in a recurrent inguinal hernia. It was qtiite evident that the previous operator had either failed to ligate the neck of the sac properly, or what is more likely, the ligature had slipped ofif, and both omentum and intestine were in contact with scrotal tissue. The contents of a sac may be either omentum, intestine, or in fact any of the movable contents of the abdomen. In some rare cases even those organs that are not ordinarily considered movable, as the kidney or a part of the liver, have been 20 ABDOMINAL HERNIA. found in the hernial sac. The contents of a sac may be freely reducible, or its reduction may be prevented by the great size of the mass and the smallness of the neck of the sac, or from adhesions of the protruding mass to the inner sides of the sac; also by the formation of fibrous bands which transverse the sac in different directions. Omentum and small intestine are most frequently found in the hernial sac ; next in frequency, in about the order named, will be found the sigmoid flexure, csecum and transverse colon. The bladder may also protrude into an inguinal hernia sac, but is more frequently found without peritoneal covering. The term enterocele refers to hernia, the contents of which is exclusively intestine, epiplocele to one containing omentum, and the use of the words combined, as entero-epiplocele, to one containing both intestine and omentum. While these are in some instances convenient terms, they will be avoided in this work on the ground that multiplicity of names adds to the con- fusion of the subject. SURGICAL ANATOMY OF THE INGUINAL REGION. The lower lateral third of the abdominal wall, known as the inguinal region, is an irregularly shaped triangle. Roughly, its outer boundary is Poupart's ligament, its inner boundary the median line of the body, and its upper boundary an im- aginary transverse line from the crest of the ilium to the median line. The anatomy of this triangle, although the region is comparatively small and easy of access, has proven one of the most difficult to comprehend and teach of any con- nected with the muscular system. The author assumes that his reader has already acquired an anatomical education from works upon the subject and from practical demonstration upon the cadaver, therefore, the anatomy here given is merely to refresh his mental picture of the parts. If the picture is presented from a different view to SURGICAL ANATOMY. 21 that which he is accustomed, and minus some of its technical details, it may be even clearer in outline, in which case the object sought will have been fully accomplished. Immediately beneath the skin of this region we come upon the two layers of superficial fascia. These layers contain a deposit of fat of variable thickness according to the condition Fig. Showing position of superficial vessels (size exaggerated), i, Superficial branch of ex- ternal pudic artery. 2, Superficial epigastric artery. Both are in deep layer of superficial fascia and are divided in hernia operations. 3, Circumflex iliac artery. Not usually divided. of the patient. In operating it will happen many times that the dividing line between the two layers is not discovered, but occasionally it is so well defined as to mislead the operator into the belief that he has already reached the aponeurosis of the external oblique muscle. The only surgical importance connected with this fascia is that the deep layer contains two sets of vessels that are usually cut in the first incision in hernia operations (fig. i). 22 ABDOMINAL HERNIA. These arteries both come from the femoral space and are first, the superficial epigastric, crossing Poupart's Hgament at its middle third and passing on upwards over the internal ring towards the umbilicus. Second, a superficial branch of the external pudic, leaving the femoral space and passing up di- rectly over the external abdominal ring, and arching over to Fig. 2. Aponeurosis of external oblique muscle, in which is shown the external ring covered by the intercolumnar fascia. the root of the penis. These vessels are not important in size but may require ligation at time of operation. Beneath this fascia we find the aponeurosis of the external oblique muscle which is easily distinguished by 'its glistening surface and from the fact that its fibres run obliquely down- ward towards the public bone (fig. 2). In operations for hernia the fleshy part of the external oblique muscle is seldom SURGICAL ANATOMY. 23 seen. The fibres of the aponeurosis are bound together by the overlying intercolumnar fascia, which is tendonous in char- acter and furnishes strong protection to the upper angle of the external abdominal ring, by arching across from one pillar to another. In opening down to the external abdominal ring, it frequently obscures the upper angle of that aperture and pre- vents the easy passage of the director under the aponeurosis, until it has been scraped away with some blunt instrument. The cord receives this fascia as its last covering as it comes out between the pillars of the external ring. The aponeurosis of the external oblique muscle is a thin, but very tough, inelastic tendon, which splits easily in the direction of the fibres, especially after the intercolumnar fascia is cut, but furnishes one of the most important parts of the retaining wall of the abdomen. At its lower border it is re- flected back under the abdominal wall forming Poiiparfs liga- ment. This lower portion of the aponeurosis is attached to the anterior superior iliac spine above, and to the spine of the pubes below. Just above the pubic attachment there is a split in the fibres for the transmission of the spermatic cord in the male and round ligament in the female. This aperture is called the external abdominal ring. The term " ring," an unfortunate one, conveys the idea of a circular opening, wdien in reality it is triangular in shape. This name, however, has from long use become so firmly fixed in the medical mind that it would probably result in even more confusion to adopt any other. The base of this triangular opening is formed by the crest of the pubic bone, and its upper angle is prevented from splitting still higher in the aponeurosis by the intercolumnar fascia. The sides of the triangle are formed by the free split borders of the aponeurosis and are called the pillars of the ring. The ex- ternal, lower pillar, curves around in sucli a manner as to form a groove upon which the cord rests. Tlie infernal, superior pillar, passes over the cord to the crest of the pubic bone, to interlace in the median line with its fellow of the opposite side. On account of the cord being larger than the round liga- 24 ABDOMINAL HERNIA ment, and to the fact that the testicle passes down through this opening, the external abdominal ring is considerably larger in the male than in the female. Poupart's ligament, extending from the iliac spine to the spine of the pubes, is also attached to the pubic bone at the pectineal line for about one inch, forming Gimbernat's liga- FlG. 3. Aponeurosis opened to internal ring, showing lower border of internal oblique muscle; transversalis fascia in deep wall of canal. , ment. The crural arch, beneath which emerges the femoral ves- sels, is formed by Poupart's ligament, internal oblique and transversalis muscles (figs. 3 and 4). All works on anatomy show these muscles, as shown in the accompanying cuts, nicely dissected one from the other. No such picture is presented on the operating table and for this reason the two muscles will be vSpoken of together. The lower border of the internal oblique SURGICAL ANATOMY. 2.3 is attached to the outer half of Poupart's ligament, and the transversahs is attached to the same Hgament immediately beneath it, but (july to the outer third. The filjres of both muscles are fleshy in character and arch up over the cord, the Fig. 4. A, Symphysis pubis. B. Anterior superior spinous process of crest of ilium. C, Muscular part of external oblique muscle. D, Linea alba. .F, J^, External abdominal rings. /, /, Poupart's ligament. .V, Aponeurosis of external oblique muscle cut open to show deeper parts. O, Internal oblique muscle. This is turned up at lower edge to show iP) Transversalis muscle. (In operative work these muscles are seen as one.) i^, Trans- versalis fascia. R, Internal abdominal ring. S, Epigastric artery, i, i, t. Spermatic cord. Oblique inguinal hernia leaves the abdomen at /?, (Internal ring), and follows the cord to F (External ring). Direct hernia protrudes directly through the wall at F. Femoral hernia protrudes at IV. (From Sir Astley Cooper on Hernia.) transversalis even higher than the internal oblicjue, and then the two muscles becoming blended into an aponeurotic structure, the conjoined tendon, pass down back of the cord and find insertion in the pectineal line of the os pubis. Here conjoined 26 ABDOMINAL HERNIA. tendon is exactly back of the external abdominal ring, and should furnish the most important barrier against the occur- rence of direct inguinal hernia. Some of the fibres pass towards the median line where it joins its fellow of the opposite side. The lower edges of these muscles are indistinguishable on the operating table, and are treated as one structure. Normally, the fibres of these muscles start from Poupart's ligament in front of the cord, and arching over close to it, descend back of the cord to the pubic bone. In many people this arch is abnormally high, and the insertion of the conjoined tendon is well towards the median line, leaving the muscular wall back of the cord very deficient throughout the whole length of the inguinal canal. At the time of descent of the testicle, through the canal, there is a covering taken from the lower edge of the internal oblique muscle w4iich develops some muscular fibres, and is afterwards known as the crciuastcr muscle. This fascia, or muscle, frequently forms one of the coverings of a hernial sac. The muscle receives its blood supply from the cremasteric artery, a branch of the epigastric, and its nerve supply from the genital branch of the genito-crural nerve. Neither of these are ordinarily seen in operations for hernia. When the aponeurosis of the external oblique muscle is first split and retracted, so that the canal is freely exposed, the ilio-inguinal nerve will usually be seen following closely the lower border of the internal oblique muscle. The ilio-hypo- gastric nerve will also frequently be seen a little higher on the surface of the same muscle. The rectus muscle should, perhaps, be mentioned here on account of its relation to the aponeuroses of the muscles just considered. The aponeuroses of all of the abdominal muscles below the umbilicus pass in front of the recti, leaving the posterior surface of the latter in contact with the transversalis fascia. The muscle is attached below to the pubic crest as far out as the pubic spine and doubtless affords some protection to the external abdominal ringf. SURGICAL ANATOMY. 27 TRANSVERSALIS FASCIA OR EXTRA PERITONEAL SHEATH. This is immediately beneath the transversaHs muscle and while in the upper part of the abdomen it is thin, in the inguinal region it is thicker and stronger. It gives the cord its first covering, the infundihuliform fascia. It also forms one of the coverings of oblique inguinal hernia. In the transversalis fascia is situated the internal ab- dominal ring. This is a purely arbitrary term given to the beginning of the inguinal canal, as there is neither a ring nor an opening into the abdominal cavity proper. Immediately beneath this sheath, or fascia, crossing the canal at right angles just below the internal abdominal ring, is the deep epigastric artery. In operations for hernia this important vessel is fre- quently hidden by the transversalis fascia and its location must be kept constantly in mind in order to avoid injury to it. This vessel and its accompanying two veins are embedded in the sub- peritoneal areolar tissue. This sheet of fat, between the trans- versalis fascia and the peritoneum, is of variable thickness in different individuals, and in the same individual at different times. It is very abundant in the vicinity of the cord, and is frequently an important factor in the production of hernia : ( i ) In its liability to the formation of lipomatous tumors which descend through the canal, dragging a process of peritoneum after them. (2) During violent muscular effort this fat may be forced into the canal, the point of least resistance, where it acts as a dilating wedge, stretching the tissues so that hernial protrusion readily follows. Beneath this subperitoneal fat we have the peritoneum, the lining membrane of the cavitv of the abdomen. Further attention will be given this important structure when we have finished our consideration of the abdominal wall. Having reviewed briefly the structure of that part of the abdominal wall involved in iguinal hernia, let us clearly under- stand the ingui)wl canal through which most hernije of this region descend. \\'e have seen that the transversalis fascia 28 ABDOMINAL HERNIA. (or extra peritoneal sheath), where it envelops the cord as the infundibuliform fascia, is really the internal abdominal ring and the beginning of the canal. From this point, deep in the abdominal wall, the canal runs parallel with Poupart's ligament obliquely towards the surface, coming out beneath the skin through the split in the external oblique known as the external abdominal ring. At birth these two rings are almost directly opposite each other, but on reaching adult life they have become separated by a distance of about one inch and a half. This change takes place rapidly in the early life of the child. The exact boundaries of the canal are somewhat difficult to understand, as in some instances the same structures form its outer boundary high up, its roof lower down, and its posterior border still lower. This remark applies to the lower border of the internal oblique and transversalis muscles. Its boundaries are perhaps better understood by following the steps of the operator rather than by following the classical methods of the dissector, even though not quite as accurate. After division of the skin and superficial fascia, and split- ting the aponeurosis of the external oblique muscle over the whole length of the canal, we find that this tendon has served as the principal part of the anterior wall. Arching over the cord, in front of the internal ring, will be found muscular fibres belonging to the internal oblique and transversalis muscles. For a distance of about three-quarters of an inch, from the internal ring down, these fleshy fibres form the anterior wall of the canal, the remainder of the distance being formed by the aponeurosis of the external oblique. The roof of the canal is principally formed by the lower border of the internal oblique and transversalis muscles; its floor by Poupart's ligament. Its posterior boundary, in its upper two-thirds, is formed by transversalis fascia, and the lower third by the conjoined tendon. My personal experience is, that in by far the greater number of cases operated upon for hernia, nothing is found back of the cord but transversalis fascia throughout the entire SURGICAL ANATOMY. 29 length of the canal. Beuealli this is the sub-peritoneal fat and the peritoneum. Embedded in the sub-peritoneal fat are the epigastric vessels, crossmg the posteri(jr wall of the canal at right angles about half an inch below the internal ring. The inguinal canal is occupied, normally, by the spermatic cord in the male and the round ligament in the female. Tn addition to these we frequently find the ilio-inguinal nerve, either following the surface of the cord or along the lower border of the internal oblique muscle. The spermatic cord, as it passes through the inguinal canal, receives the following coverings : ( i ) The infundibuli- form from the transversalis fascia. (2) The cremasteric fascia (or muscle) from the internal oblique. (3) The inter- columnar fascia from the external oblique, as it passes between the pillars of the external abdominal ring. DEEP EPIGASTRIC ARTERY. The relation of the deep epigastric artery to the inguinal canal is important. By the present methods of operating the artery is frequently exposed to accident, even though not always seen. It lies immediately back of the spermatic cord between the transversalis fascia and the peritoneum, and crosses the cord at an oblique angle just at the inner and lower border of the internal abdominal ring. It passes from the external iliac, its origin, just inside of Poupart's ligament, obliquely upwards to the sheath of the rectus muscle. It is usually accompanied by two veins. The close relation of the external iliac artery to the parts under consideration must always be borne in mind (see fig. 5). Although it is within the abdominal cavity, it is frequently in contact witli the deep parts of the canal, and several accidents to this vessel during operations are knowm to me, and one has been pub- lished by an eminent operator. The other blood vessels of this region, outside of those forming the spermatic cord, are unim- portant from a surgical standpoint. 30 ABDOMINAL HERNIA. The nerje supply to this region is by the ilio-hypo gastric and ilio-ingiiinal from the upper hmibar nerves, and is purely- sensory in character. These nerves are frequently seen when operating, just below the aponeurosis of the external oblique. Fig. 5. To illustrate proximity of deep epigastric and iliac arteries to inguinal canal. and with a little care can be avoided, but their division is only attended by temporary loss of sensation over a small area of surface. Peritoneum. — We have constantly to deal with this struc- ture in hernia operations, as all hernial sacs are formed from SURGICAL ANATOMY. 31 It, and it rarely happens tliat abdominal hernia occurs without peritoneal covering which becomes its sac. This serous membrane not only completely lines the abdomen, but entirely or partially envelopes every hollow organ contained in this cavity. Its surface is normally moist and shiny. It wraps itself completely about the small intestine and passes backwards to the spine, where it is attached as the mesentery. The mesentery gives to the intestine at least partial support; in hernial protrusions, however, it may bec(jme not only enormously elongated, but so changed in character as seriously to interfere with operative procedures. The right segment of the mesentery is longer than the left, allowing of greater pressure from the intestine in the right hypogastric fossae. This may, in a measure, explain the greater number of hernise on the right side. The external inguinal fossa is at the outer side of the epigastric artery and immediately back of the internal ring. This is the deepest of the fossae, and that on the right is deeper than the one on the left, another reason for the more frequent occurrence of inguinal hernia on the right side. Hernias entering the external inguinal fossa and passing into the canal become oblique inguinal hernia. The fossa towards the median line from the epigastric artery, is the internal hypogastric fossa, and it is in this pocket that direct inguinal hernia originates. In the relation of the protrusion of hernia to the epigastric artery originated the terms, external and internal inguinal hernia, the protrusion into the external fossa (oblique) being termed external, and that into the internal fossa (direct) internal hernia. The author has for many years avoided using these terms in his teaching, as they are confusing and misleading. Internal herniie are be- lieved to be such as occur within the body, as hernia through the diaphragm into the chest cavity, or hernia through the foramen of Winslow. While any organ within the abdominal cavity may become involved in hernia, there is only one other structure that we shall consider in this part of the work, and that is the onienfuni. 32 ABDOMINAL HERNIA. This forms a ratlier constant factor in the diagnosis and treat- ment of hernia (fig. 6). The omentum hangs as a great, fatty apron between the abdominal contents and anterior muscular wall, doubtless form- ing an important means of protection tO' the bowels from sudden changes of temperature, and against injury from blows Fig. 6. The greater omentum as seen from the front. Upon the abdominal surface. To those suffering from hernia, it is the source of much trouble, and necessarily much will be said about it in the pages to follow. It hangs in two sheets, or la3^ers, each covered by peri- toneum, from the lower convex border of the stomach and from the transverse colon. Perhaps it would convey a clearer idea to say that it passes down to the pelvis from its attach- SURGICAL ANATOMY. S.'} ment to the stomach, is tohlcd upon itself, and returns hj the transverse colon. 1"hc space between is normally a shut sac, but frecjuenlly, owinji;- to the delicate structure of the omentum, opening's into it will be found. Intestinal obstruction is some- times due to constriction of a locjp oi bowel in such an opening. The two layers cannot always be distinguished ; in fact, they seldom are when dealing with its lower part, but it must be remembered that they exist, as it not only hap])cns that cysts may form between these layers, but intestine has slipped in between them, and in this position has been ligated with the omentum and actually cut away. The nerve supply to the omentum is poor, but its blo(jd vessels are large and numerous. These vessels have very deli- cate w'alls, and as they are not surrounded by muscular fibre, there is no tendency to contract. A bleeding vein that perhaps would be of no importance elsewhere, in this structure might easily cause fatal hccmorrhage. When omentum first protrudes in hernia it has all of its normal characteristics, but if allowed to protrude frequently, or remain in the hernial sac, it becomes hypertrophied, in- durated, nodular, and may then at times act as a foreign body if returned to the abdominal cavity. It no longer belongs within that cavity. Omentum allowed to lie in the hernial sac soon becomes adherent to its sides and forms the most com- mon type of irreducible hernia. CHAPTER II. DESCENT OF THE TESTICLE. A knowledge of the formation and descent of the testicle affords an insight into the cause and origin of many hernise, especially in those that occur in early life, and it has direct bearing upon some of the complications which may arise during treatment. It is important, therefore, that we give this process careful consideration. The genital mass which is primarily formed just below the kidney and behind the peritoneum, begins its transit towards the pelvis, before it can be definitely stated whether it is to become ovary or testis. In the male this transition is not complete until it has passed through the abdominal wall to its natural abiding place in the scrotum. In the female the descent of the genital body is normally to the pelvic cavity, where it remains as the ovary. The analogy between the sexes is sometimes carried farther by the persistent effort of an ovary to descend into the labium majora. It has occurred several times in my experience that the ovary in its descent has followed the ordinary course of the testicle, and has been found outside the external ring, in which position it is, in some instances, irreducible. Another notice- able fact is, that when the ovary has once entered the canal, it is almost as persistent in its effort to descend through it, as the testicle is under the same circumstances. Like the testicle, the ovary may become adherent, or, from other causes, lodge at any point in the canal and not pass entirely outside the abdominal wall. It may then lead to difificult and painful menstruation, to the formation of cysts, or, as found in one case, such degeneration of its structure as to require removal. In the elephant and some other animals, the testicles re- main permanently in the abdomen, while tlie stallion, in some instances, has them under voluntary control, so that they may 34 DESCENT OF THE TESTICLE. 35 be found either within the abdomen or in the scrotum. In some other animals, they descend at the " rutting " season only. Instances where they are wholly, or partially, retained within the abdomen in the human subject are not uncommon. Where, however, they descend late in life or at any time after birth, they are quite certain to leave the inguinal canal in such a weakened state, that hernial protrusions are liable to fol- low. The testicle, in passing through the muscular wall of the abdomen, carries with it the various layers of fascia which i^IG. 7. A left testis retained in the cruro-scrotal fold.— A, Testis. B, Fasciculus of gubernaculuin attached to scrotal tissue at C. {Godard, from Eccles' " Imperfectly Descended Testicle.'") form the sheath of the cord ; these fascial layers are only demonstrated by the most minute dissection, and are unim- portant in the present consideration of the subject. TJie gnbernaculum testis is a bundle of fascia containing muscular fibres, which are attached to the testicle at one end- and in the scrotum at the other. At its lower end a few fibres pass off towards the thigh and some go to the perineum. It is these fibres outside the scrotum that are believed to be active in guiding the testicle into abnormal positions in some instances. The action of the gnbernaculum testis is not perfecly under- 36 ABDOMINAL HERNIA. stood, and it is not well known whether it aids in the descent of the testicle by a contractile force, or merely serves as a guide in a process that is carried out by some other method of development. The accompanying illustrations (Eccles) clearly illus- trate two distinct types; one (fig. 7) showing the testicle just Fig, 8. A left testis lying in the perineum. — The testis was the size of an almond, and its compo- nent parts could be readily made out through the skin. The left half of the scrotum was undeveloped. The right testis was of normal size in the right half of the scrotum. (Godard from Eccles' " Imperfectly Descended Testicle.") outside of the abdominal wall with the overlying tissues turned back. It also graphically shows the action of the gubernac- ulum testis upon the scrotal wall. The other illustration (fig. 8) shows a small testicle lodged in the perineum, and the scrotum on the left side undeveloped. Dr. W, B. Coley has called the hernia that sometimes develops with this form of mal-descent "inguino-perineal hernia." Still another posi- DESCENT OF THE TESTICLE. 37 tion is shown in fig". 9, where the testicle has descended into the tissues gf the thigh, presenting in Scarpa's triang-le the appearance of femoral hernia. Fig-. 10 shows a testicle lodged just outside the external abdominal ring, with hernia in the inguinal canal. ^ Fig. 9. A left testis in Scarpa's triangle. Its cord could be traced through the superficial abdominal ring. {Eccles.) The descent of the testicle may be arrested at any point within the abdomen, or it may pass into the iliac fossa and remain there. It may lodge at any point in the inguinal canal between the internal and external rings, or it may pass on to a wholly abnormal position outside the scrotum and be found in the perineum, at the root of the penis, or into the subcutaneous ' Dr. Albert E. Halstead of Chicago reports a case where both testicles were found on oiie side of the scrotum. Ectopia Testis Transversa, Sur- gery Gynecology and Obstetrics, p. 129, February, 1907. 38 ABDOMINAL HERNIA. tissues of the upper part of the thigh. At times, it comes out of the external ring, but turns upwards upon the surface of the aponeurosis of the external oblique muscle towards the crest of the ilium. Its normal descent may be prevented by a deficiency in the attachment, or formation, of the gubernaculum testis, by adhesions, or by lack of development of the inguinal canal. The external abdominal ring may be too small to Fig. io. Right testicle in canal at external ring. Complete oblique inguinal hernia above it. Left testicle at internal ring. Scrotum rudimentary. allow it to pass, or the scrotum may be so undeveloped as to prevent its entrance. It may even be retarded and its descent prevented by a truss improperly applied for associated hernia. There is considerable difference of opinion as to whether a testicle which has been prevented from reaching its normal position, is functionless, and the preponderance of evidence would seem to indicate that in a large number of cases it is. This has led eminent authorities to advise their removal at the DESCENT OF THE TESTICLE. 39 time of operation. Recent studies prtjve beyond question, how- ever, that there is an internal secretion from these functionless testicles, which is markedly beneficial to the proper develop- ment of the individual, especially at the period of chani^e from youth to adult life. It is, therefore, very desirable that they should be preserxed in e\ery instance, unless their diseased condition should proxe a menace to the health of their pos- sessor. In view of the considerations just stated and the mental effects of castration, an operation will be detailed under its proper heading, which enables us to leave these testicles under the muscular wall of the abdomen, in cases where the cord is so short as to make it impossible to place them in the scrotum. TUNICA \-AGIXALIS. Previous to the descent of the testicle, and apparently not dependent upon the transit of that organ, a pouch of peri- toneum, subsequently known as the tunica vaginalis, descends into the scrotum. The neck of this pouch, which communi- cates with the cavity of the abdomen, should be obliterated at birth, leaving that part which is anterior to the testicle a closed sac, the cavity of the tunica vaginalis. Failure to complete the obliteration of the neck of communication between these cavities, leads to the formation of certain types of herniae, and produces several forms of complications. This process of peritoneum should be obliterated at birth, or in early infancy, but for unexplained reasons it sometimes continues patulous until adult life. It is the remaining open, or the dilating of the partially closed neck of this pouch, that alloW'S congenital hernia to pass down in front of the testicle, wdthout true peritoneal covering. The normal obliteration of the neck of this process begins by three points of closure. These, it is well to remember, have special bearing upon cvstic formations, which occur between them bef(^re complete oblitera- tion has taken place. They are at the deep abdominal open- 40 ABDOMINAL HERNIA. ing, at the sui^eriicial abdominal opening, and immediately above the testicle. That portion which lies immediately in front of the testicle forms the cavity of the tunica vaginalis, where hydrocele of this membrane may occur. The word '' congenital.'' as applied to that type of hernia which protrudes into this cavity, has been and is confusing. It places, by inference, the date of origin of the hernia at the birth of a child, whereas, as a matter of fact, congenital hernia may Fig. II. A, A, A, Cysts in front of cord. B, Cyst hanging within abdomen by pedicle three inches long. C, Cord. D, Testicle. occur at almost any period of life, in subjects where the process of obliteration of the neck of this cavity has never taken place. It is only in recent years that anatomists have ascertained that in many subjects, in whom hernia has never occurred, there remains a small opening between the cavity of the abdomen and the cavity of the tunica vaginalis throughout life. The term congenital, therefore, refers to a defect which was present at birth, and which predisposes to a certain type of hernia. DESCENT OF THE TESTICLE. 41 The drawing shown in fig. 1 1 has been made from one of a number of similar cases met with in operative work. It is intro(kiced to ilhistrate how cysts, forming in tlie partially obliterated tunica vaginalis, may prove confusing in diagnosis and troublesome during operation. A young man, of 24 Fig. 12. Hydrocele of cord simulating irreducible hernia. Dotted line shows tumor extending- to the internal ring. Notice separation between tumor and testicle, showing that tunica vaginalis proper is not involved. Entire cyst removed by operation. years, had experienced much trouble in wearing a truss, and upon examination it was decided that a part of his hernia was irreducible. Upon operating, a sac about three inches long was found, and back of this were three cysts, shown in the sketch, closely associated with the cord. Within the neck of the sac was noticed a cord-like attachment which, when drawn 42 ABDOMINAL HERNIA. upon, brought from the abdominal cavity a cyst the size and shape of a small pear, hanging in the abdomen by a pedicle fully ^hree inches long. There is little doubt that all of these cysts formed in imobliterated portions of the tunica vaginalis, and at the upper portion of the canal, had bulged forward into the forming hernial sac, and finally dropped back into the peritoneal cavity. This occurrence was undoubtedly aided by the truss which had been worn over the canal lower down. Fig. 12 shows a young man with hydrocele of the cord, extending from the top of the testicle to the internal ring. He was subsequently operated upon, the entire cyst removed, and the canal closed by the Bassini method. CANAL OF NUCK. The process of peritoneum under consideration, enters the canal of the female fetus the same as in the male, and while ordinarily obliterated at birth, it may persist, producing similar conditions and complications. Nuck, in the seventeenth century, recognized this condi- tion, and when present it bears his name. When it remains patulous, it allows of the occurrence of congenital hernia in the female, or of congenital (reducible) hydrocele. Its presence also accounts for encysted hydrocele in the canal of the female, not uncommonly met with in opera- tive W'ork. It may be coincident with hernia, or exist alone, and I have long felt that it accounts for some failures to cure the female infant by truss treatment. SPERMATIC CORD. The cord extends from the internal abdominal ring through the canal to the testicle, and is composed of the vas deferens, three arteries with their return veins, lymphatics, and nerves, lliese vessels are held together and the cord formed by its sheath, which is composed of three layers of fascia given DESCENT OF THE TESTICLE. 43 off from tlie edges of the abdominal muscles as the cord fcjliows the testicle in its descent. These are from the deepest towards the surface: (i) Infundibuliform fascia. (2) Cremasteric fascia. (3) Intercolumnar ( or spermatic ) fascia. The cre- masteric fascia, or muscle, as it is frecj[uently called, contains muscular fibre as well as fibrous tissue, and aids in the support of the testicle. In some children and young persons, this muscle acts so violently at times, as to draw the testicle against the external abdominal ring with such force as to cause consid- erable pain. This action will be referred to again in connection with diagnosis, as " Retraction of the Testicle." Except the cremaster these fasci?e are seldom demonstrable at the time of operation. The nerve supply to the cord is from the renal plexus and by the genital branch of the genito-crural. To the latter is due the " cremasteric reflex " noticeable in many boys on touching suddenly the inner surface of the thigh, that surface being sup- plied by another branch of the same nerve. The vas deferens, or excreton,- duct, lies at the inner side of the cord, especially at the upper part of the canal, and turns sharply at the internal ring to go to the base of the bladder, while the vessels continue on their course. This separation accounts for the fact, that in the protrusion of hernia the vas deferens may be on one side of the sac, while the vessels are on the other. In hernia the usual position of the cord is back of the sac, but it is frecjuently found in front of, or at either side of it. CHAPTER III. CAUSE OF INGUINAL HERNIA. Inguinal hernia forms about three-fourths of all herniae, and should therefore have most careful consideration. Its causes naturally arrange themselves into two groups ; those that are predisposing, and those that are immediate, or direct. PREDISPOSING CAUSES. The following list of predisposing causes of inguinal hernia has been compiled for use in this work : ( i ) Heredity ; (2) Age; (3) Sex; (4) Descent of processus vaginalis (male and female) ; (5) Descent of testicle; (6) Anatomical defects; (7) Fat, excess, or sudden increase of. I. Heredity. — The result of the study of inheritance as a predisposing cause of hernia has not been very satisfactory, as it has proven little; but it has been strongly urged by some authors and doubted by others. The subject is attended by too many uncertainties and too many statistics to receive extended consideration in this work. While in my own experience I have had some striking indications that the tendency to hernia is occasionally transmitted from one generation to another, I have arrived at no conclusion as to what that tendency may consist of. Sir Astley Cooper attempted over a century ago to show that it was due to the shape of the bony pelvis, and others have attributed it to an inherited laxness of muscle, which proves inefficient in the retention of the abdominal contents. The theory of an inherited weakness of the abdominal muscles ap- peals to me, and appears to be sustained by experience. In one family, the members of which have been under my care for twenty-five years, three different generations have been cared for, and the three principal forms of abdominal hernia (in- 44 CAUSE OF INGUINAL HERNIA. 45 guinal, femoral, and umbilical) have been represented in their ordinary proportion. The cases are largely among the female members of the family, who have every appearance of good health and strong muscles. No member of this family would consent to operation, so that opportunity has not been afforded to confirm the belief that muscular deficiency is the cause of the inheritance. 2. Age. — The extremes of life are undoubtedly more productive of hernia than the intervening period, and for dis- cernible reasons. In early infancy we have not only the short canal, the internal ring being directly back of the external ring at birth, but we have the defects due to mal-descent of the testicle and lack of obliteration of the tunica vaginalis. Lockw^ood ^ has also demonstrated that in early life the mesentery is longer than in the years of maturity, being one- fifth the length of the body. At forty years of age it is only one-ninth the length of the body. In old age we have the degeneration of tissue so common to advancing years, and the change in form well shown in fig. 13, ^vhen the- stooping for- ward and relaxation of the abdominal muscles places them at great disadvantage. It has been stated that this form of abdomen is the result of large hernise, but to my mind it is more frequently a cause of hernia. 3. Sex, — The influence of sex upon the incidence of in- guinal hernia, is clearly shown by the large preponderance of this type of hernia among males. This difference is probably due to the large size of the spermatic cord as compared with the round ligament in the female, to the descent of the testicle through the inguinal canal, and its lodgements and detentions. The descent of the tunica vaginalis also plays an important part in the increase of hernise among males. It is true that this same process occupies the canal of the female, and. as the canal of Nuck, aids in the production of hernia, but not to the same extent as in the male. ^ Pathology and Treatment of Hernia. C. B. Lockwood, F.R.C.S., London, 1889. 46 ABDOMINAL HERNIA. 4. Descent of Tunica Vaginalis. — The failure of complete obliteration of the connecting neck, between the cavity of the tunica vaginalis and the cavity of the abdomen, beyond doubt leads to the formation of many inguinal hernise. This open- ing may exist for years without the protrusion of hernia, but usually, where it is present, it only needs unusual strain to fill the already formed sac. Fig. 13. Side view of the abdomen of an old man with scrotal hernia. To show the flattening above the umbilicus. (Macready.) 5, Descent of the Testicle. — The formation and descent of the testicle, through the alidominal \vall, is l^elieved to have such an im])ortant place in the procUiction of inguinal hernia, in the male, that this transit has already been carefully considered in the chapter devoted to this subject. 6. Anatomical Defects. — There are certain anatomical de- fects in the muscular formation, about tlie inguinal canal, which CAUSE OF INGUINAL HERNIA. 47 unquestionably lead to a very large number of herniae, yet they have not attracted specific attention until recent years, when frequent operations ha\e demonstrated them to every extensive operator upon iiernia. The lower borders of the internal oblicjue and transversalis muscles, passing over the cord as the latter enters the canal at the internal ring, run parallel with it and find inserti(jn into the pubic bone. In front, the canal is protected by a dense, fibrous layer, the aponeurosis of the external oblique muscle, but back of the cord there is little protection against protrusion, except that afforded by the peritoneum and the fascia trans- versalis. This muscular defect allows of deep pocketing from the peritoneal surface into the hypogastric fossa, and consti- tutes a strong predisposing cause of hernia. In the older oper- ations this weakness was not considered, and all repair work was done at the external ring, leaving the original defect to invite a recurrence of hernia. Another anatomical defect which is a frequent cause of hernia, especial jy in early life, is the nonobliteration of the com- municating neck, between the cavity of the tunica vaginalis and the cavity of the abdomen. That portion of the pouch of peritoneum which descends in front of the testicle, be- coming the tunica vaginalis, should be closed off from the abdomen by the obliteration of its neck, which passes through the inguinal canal. This stage of development should have been reached at, or before, birth, but unfortunately it fails to occur in a large number of persons, and the peritoneal surface remains continuous down into this pouch in the scrotum, invit- ing a protrusion through the moist, tube-like opening. Probably numerous persons have this condition through- out life without developing hernia, but in many others it is an important predisposing cause. When a hernia occurs in this pouch, it is known as congenital hernia; the term not mean- ing that hernia was necessarily present at birth, but that the defect was, which led to its occurrence. \Ve see numerous cases of congenital hernia occurring at all ages up to adult life. 48 ABDOMINAL HERNIA. showing that this tubular neck of communication, between the two cavities, has persisted during all of the previous years that the patient has lived, and needed only some additional cause to produce the hernia. The two anatomical peculiarities named are considered by far the strongest predisposing causes, the first existing to a Fig. 14. Abdomen of a male, age 39, wilh early inguinal hernia. To show the lateral bulgings often present in hernial subjects. {Macready.) greater or lesser degree throughout life in nearly all people, and the second being particularly active before puberty. There is a form of abdomen which some authors think is strongly predisposed to hernia, which was first described by Malgaigne as " Triple Bulging," and by Velpeau it was classed as ventral hernia. It is fairly well illustrated in fig. 14. The median bulge is due apparently to the strong contraction of CAUSE OF INGUINAL HERNIA. 49 the recti muscles, (liniinisliing tlie antero-posterior diameter of the abdomen, and causing the inguinal region to bulge on either side. Some of these cases seem due to excessive strength in the recti, rather than to any special weakness in the side muscles of the abdomen. 1 have watched some of them for years, where the conditicjn was marked, without seeing hernia develop. 7. Fat. — That fat, either in excess, or suddenly acquired, is i)ro(luctive of inguinal hernia, is abundantly proven. It acts in several ways: (a) B}- increasing' intra-aljdominal ])ressure; {b) by slipping into the canal, the point of least resistance under violent muscular exertion; (c) by the formation of sub- peritoneal lipoma, whicli may descend through the canal, drag- ging with it a process of peritoneum which then becomes hernial sac; (d) fat acquired by excessive beer drinking, has been found particularly productive of hernia, by a two-fold action. First, in the accumulation of fat ; second, in causing fatty degeneration of muscular tissue. This condition makes these patients poor subjects for the curative operation, increas- ing the danger and diminishing the chances of permanent cure. rVbnormally weak and premature children are especially prone to the occurrence of hernia in the early months of life, and debility from old age, or other causes, frequently leads to it. Those suffering from pulmonary tuberculosis are particularly susceptible, as thev not only have the relaxation of tissue, but also have the cough as a direct cause. The theories suggested in the early studies (^f the causa- tion of hernia seem rather unimpt^rtant in \-iew of recent experience. Most writers ha\'e sided with either those who have assigned the predisposing cause of hernia to purely me- chanical reasons, or with those who claimed that it was due to pathological changes. Those holding to the mechanical causa- tion, adhere to the belief that relaxation of the abdominal muscles is the primapy^ cause, wdiile the '* pathologists " believe that in the abnormal lengthening of the mesentery we may find the first change which results in abdominal liernia. 4 50 ABDOMINAL HERNIA. Anatomists have given the normal length of the mesen- teiy, from its vertebral attachment to its intestinal border, as from six to nine inches. It is quite evident, therefore, that in many of the hernise of large size, the elongation of this attach- ment must be considerable. Experience during the past de- cade, with an operation that corrects a mechanical defect in the abdominal wall, and cures permanently a large percentage of these hernise. of enormous size with lengthened mesenteries, seems to prove conclusively that the primary cause it not in the length of the mesentery. The problem of curing the defect having been solved, it is not in accord with the purposes of this work to further consider theoretical causes. IMMEDIATE OR DIRECT CAUSES. The immediate causes of inguinal hernia are too numerous to allow of naming each one. Any violent muscular compres- sion of the abdominal contents may act as a direct cause of hernia. The following is a partial list and will, perhaps, be sug- gestive of many others not enumerated : (i) Constipation: (2) Vomiting; (3) Cough; (4) Lifting; (5) Shouting; (6) Posture; (7) Obstructions to urination; (8) Crj-ing in chil- dren; (9) Acites. 1. Constipation. — After many years of obser\ation I do not hesitate to place constipation at the head of the list. The history of an attack of obstinate constipation immediately pre- ceding the discovery of a swelling in the groin is surprisingly common, and at once suggests an important part of the subse- quent treatment of the case. In chronic constipation the cause is more effective in that there is longer continued repetition of the straining at stool and greater distention of the bowel. 2. Vomiting. — Straining during this act is frec|uentlv an immediate cause in an indi\Mdual otherwise predisposed to hernia. CAUSE OF INGUINAL HERNIA. 51 3. Cough. — Violent and persistent couching, as in whoop- ing cough, chronic bronchitis, and phthisis, are active catises, as may also be an elongated uvula with resultant violent cough. 4. Lifting. — This is a common direct cause (jf inguinal hernia, but no more so to the laborer than to the merchant or editor. The muscles of the working man are trained to their work and when he makes even a heavy lift, they protect him. It is when he is caught suddenly, unprepared, that harm comes. The merchant or clerk is unaccustomed to heavy work-, but upon occasion takes hold "with the boys " and his muscles not trained to withstand the strain, the effort frequently results in hernia. A former patient was in charge of the gymnasium in (jne of the larger colleges and was accustomed to lead in all of the exercises which he taught, and felt that he could exceed, in strength tests, any of the younger men. He gave this occupa- tion up to become the editor of a daily paper, and in this posi- tion was closely confined to his desk. It was a mystery to him why, after he had abandoned very active and extreme exercise, that he should develop hernia. The mystery was explained wdien it was discovered that he had in his hrjme a pair of extra heavy dumb-bells, his pets of former days, with which he exer- cised at rare intervals. 5. Shouting. — The vigorous calling out of wares in the open streets, as done by hucksters, pedlers, and street fakirs, is quite liable to bring on hernia, and it is very hard to treat them successfully by mechanical means or cure them by operation as long as they continue their occupation. 6. Posture. — There are certain positions of the body which favor the occurrence of hernia, i.e., any muscular effort, while the abdominal muscles are relaxed, as in stooping for- ward, or while the arms are extended o\er the head. Golf has furnished a fairly large number of herni?e in men past middle life. The schools that teach so-called " Physical Culture bv Correspondence " aid many middle-aged men in producing hernia. The reason that T name particularlv this class of 52 ABDOMINAL HERNIA. schools, is to point out the fact that the fauh Hes more in the over-ambition of the pupil, than in the lack of knowledge on the part of the teacher. I feel warranted in illustrating here an exercise that has brought under my notice from 6 to lo cases of hernia a year (fig. 15). This consists in throwing the body back as far as possible, with the hands above the head, Fig. 15. A form of " Physical Culture" that produces many lierniae in men past middle age. and then stooping forward until the finger tips rest upon the floor. This one exercise had apparently been the cause in these cases; at least this is the only one form that all had taken. I am not a disbeliever in physical exercise, even for those who ha^•e hernia as I shall demonstrate later, but I do think that those past the muscle building age should not resort to it excei)t under strict personal supervision of an instructor. CAUSE OF INGUINAL HERNIA. 53 7. Urinary Obstructions. — These urinary disturbances, either as stricture, calcuh, or prostatic enlargement, may easily lead to the development of hernia. Men who have prostatic trouble are especially liable tcj it, both on account of the strain- ing in attempted urination, and to the fact that this trouble usually occurs at a time of life when the tissues are not in condition to withstand this frequently repeated strain. 8. Crying. — In infancy and early childhood there is no doubt that crying has an important place. The infant is strongly predisposed to hernia by its short canal and develop- mental imperfections ; add to these constipation and crying, and we have two very active direct causes. One other cause that I do not see as frequently as in my earlier years of experience, is the belly-band that "grand- mother " said " must be very tight or the baby could not be expected to thrive." By having the belly-band tight the intes- tines are driven into the lower abdomen and extreme pressure made upon the delicate tissues, especially when the child cries. Crying may not only act as an immediate cause, but it is very sure tO' aid in increasing its size rapidly, when hernia is once formed. When the infant cries, and the bowel is forced into the canal, causing pain, this in turn causes the child to cry more. 9. Acites. — An effusion of fluid into the abdominal cavity is spmetimes the origin of inguinal hernia, but for obvious rea- sons such cases are not common. In addition to the above enumerated causes, phimosis has been mentioned by eminent writers as a direct cause of hernia, otherwise it would not be referred to here. If the foreskin is so long or the opening in it so small as to cause the child to strain when he urinates, then w^e have a reasonable cause of hernia, otherwise not. Very rarely has such a case been seen ; furthermore, in the Jewish orphan asylums where all of the male children have been circumcised in early infancy the usual proportion of hernia exists. CHAPTER IV. TYPES AND CONDITIONS OF INGUINAL HERNIA. In early writings upon the subject, and even in many of more recent date, the divisions and subdivisions of inguinal hernia have been so numerous and its nomenclature so prolific, that much unnecessary confusion has been added to an already complex subject. Accepting risk of criticism, I have en- deavored to simplify this division to the extreme limit, and to use only those temis, so far as possible, which carry with them their own meaning. The necessary divisions for the proper consideration of inguinal hernia are : Oblique, direct, sigmoid or ccccal, and interstitial hernia. Fig. i6 shows tAvo oblique and one direct hernia in the same patient. The oblique type may either be of the congenital, or of the acquired form. In degree of development the congenital is nearly always a scrotal (or labial) hernia, as when it passes the inguinal canal it drops into a preformed sac. Acquired hernia, on the contrary, may be, according to its degree of development, either incomplete, complete, ov scrotal (or labial) in character. Direct inguinal hernia seldom becomes scrotal in character even though it attains large proportions. Sigmoid or Csecal hernia belongs to the direct hernia type, but on account of its peculiar anatomical characteristics must be considered under a special heading. This statement holds equally true of interstitial hernia, except that it may belong either to the acquired or congenital type, but very rarely to direct hernia. Oblique inguinal hernia is so called because the pro- trusion enters the inguinal canal at the internal abdominal ring and passes obliquely through the abdominal wall. If it protrudes into the canal only, it is then called incomplete in- 54 TYPES OF INGUINAL HERNIA. 55 guinal hernia (see fig. 17). if, however, it passes out (jf the inguinal canal through the external abdominal ring, then it becomes coiitplclr ()1)lique inguinal hernia (see fig. 18, right side). If these small herni^e are neglected or unskillfully cared for, they become by progressive development scrotal hernia in the male (figs. 18 and 19), or labial hernia in the female Fig. 16. A male, age 79, having an oblique inguinal hernia in an early stage, and a direct hernia on the left side, and on the right side an oblique hernia more advanced than that on the left. (Macready.) (^fig. 20). The terms " scrotal " and '' labial " indicate a stage of growth and should not be used to designate types of hernia. Some truss manufacturers make what they call a " scrotal- hernia truss," which is based upon the idea that it is for a special type of hernia, and it is only mentioned here because the author knows that some misapprehension exists in the minds of many practitioners. 56 ABDOMINAL HERNIA. Oblique inguinal hernia may protrude into a preformed sac, present at birth (from lack of obliteration of the tunica vaginalis), in which case it forms a congenital hernia. This protrusion may occur after the person has reached adult life, even though the defect has existed during all of the preceding years, but by far the greater number of congenital hernide do occur in infancy or early childhood. When we speak of con- FiG. 17. Incomplete inguinal hernia on iett. Direct inguinal hernia on right, poorly shown. (Eccles.) genital hernia, therefore, it does not indicate at what age such hernia may have developed, but does clearly mean that the hernia has come down into a sac already formed. Acquired inguinal hernia refers to a condition wherein the protruding mass carries with it, as a sac covering, the peritoneal lining of the abdomen. This peritoneal pouch is known as the hernial sac and, in the course of time, loses some of its char- acteristics as peritoneum by becoming thickened and otherwise changed in structure. It continues, however, as a moist. TYPES OF INGUINAL HERNIA. 57 serous mebrane, and as such favors the protrusion of the abdominal contents. Direct inguinal hernia does not enter the upper part of the inguinal canal at the internal ring, but protrudes directly through the external abdominal ring and presents a tumor Fig. i8. Showing on the right side a complete oblique inguinal hernia. On the left an enormous oblique inguinal (scrotal) hernia. Circumference, 32 inches; within two inches of knee-joint. circular in fonn that, even though it is large, has little tendency to descend into the scrotum (fig. 21). A tumor as large as a cocoanut has been seen standing out from the body over the pubic bone. Tumors of this type should be approached bv the operator with care, as they are liable to contain the fundus of the bladder, or they may prove to be sigmoid hernia as shown 5H ABDOMINAL HERNIA. in fig. 22. The deep epigastric artery passes across the inguinal canal just below the internal abdominal ring, and oblique hernia passes over it in going down the canal. Direct inguinal hernia, on the contrary, passes through the abdominal wall inside of the artery, towards the median line. This is usually Fig. 19. Showing the enormous size which scrotal herniae may attain by neglect. Right oblique inguinal hernia (scrotal) in a man over 70 years of age. SO, but in some persons with abnormally short canals the artery runs lower down, and while actually the protrusion is oblique, it has e\'ery appearance of a direct hernia. It must be remembered therefore in operating, that the deep epigastric artery may be found at either side of the neck of the hernial sac. TYPES OF INGUliNAL HERNIA. 59 Hernire of the direct type are not met with as frequently in women as in men, and the reasons for this are shown in the recent studies of Marie Donati {Archiviu per Ic Slicnzc Mcdischc, No. 3, 1905; Al)stract Medical Record, July 8. 1905). He believes that "the smaller number of the direct inguinal type that we find in women, is due to the different formation of the inguinal canal in the two sexes, and to estab- FlG. 20. Showing oblique inguinal (labial) hernia in a woman of 45 years. lish this conclusion he has dissected 52 cada\'ers of b(~»th sexes. 31 women. 21 men, and has found marked differences in them. The aponeurosis of the insertion of the great oblique muscles has linear interstices, which are much larger in the male than in the female. The pillars of the internal oblique are stronger in front of the canal in women. The arciform fibres (inter-crural) are in women often mingled with cross fibres which strengthen the ring, which are absent in men. The 60 ABDOMINAL HERNIA. orifice of the external inguinal ring is generally smaller in females than in males. It is generally situated higher and a little more external in men than in women, contrary to what has been supposed to be the case. The aponeurosis of the large oblique, which forms the anterior wall of the canal, is much stronger in the female sex than in the male. The lower margin of the ring in women is more horizontal, that in the Fig. 21. Double direct hernia. (Macready.) male more oblique. Hence this point, which is often weak in the male, is in the female most resistant."' Sigmoid hernia, the beginning of which is usually that of a direct inguinal hernial protrusion, has certain peculiari- ties in its development which make it essential that it should have a distinctive classification, and none of the terms applied to it seems so descriptive as the one here used. It will be remembered that the peritoneum not only lines the cavity of the abdomen, but envelops most of the hollow TYPES OF INGUINAL HERNIA. 01 organs, fcjrniing- Ixick oi thcni the mesentery which gives them partial support. In the case of the sigmoid flexure, the caicum, and the l)ladder, this covering is only partial. The sigmoid flexure is covered in front and on the sides, hut a ])ortion of a back part of the bowel is in direct contact with the ])osterior wall of the pelvis (iliac fossa). When hernia occurs to this Fig. 22, Sigmoid hernia. Peritoneal covering in front of intestine, none at its back. Loops of small intestine protruding in front of sigmoid flexure. part of the large bowel it pushes through the abdominal wall, carrying the portion of peritoneum that is in front as a peri- toneal pocket into which other parts of intestine may protrude. The posterior intestinal wall, as it ])rotrudes, usually precedes the part covered by peritoneum, forming the most prominent part of the tumor, and is entirely devoid of peritoneal cover- ing. If the operator does not anticipate this condition, and opens low^ down on the tumor he will find that he has made an 62 ABDOMINAL HERNIA. incision directly into the large bowel. If, however, he be so fortunate as to open high up on its anterior surface, he will then haAe opened into the sac which is in communication with the peritoneal cavit}-. recognize the true condition, and thus prevent an embarrassing situation. Fig. 23. Direct inguinal hernia on the right; sigmoid hernia on the left. The illustration is typical of the peculiar shape of sigmoid protrusions. In treating of diagnosis, suggestions will be made that may aid in recognizing this condition before operation, but this can not always be done. It is fortunate that I am able to present the photograph of such a typical case as that show^i in fig 23. On the right side an ordinary direct inguinal hernia appears ; on the left side can be seen what proved at operation to be a hernia of the sigmoid flexure. Its size has pushed it down to the top of the scrotum, but it is not a true scrotal hernia. TYPES OF INGUINAL HERNIA. 63 Cascal (ingminalj hernia does not assume the importance of tlie sigmoid type, Ijoth on account of its i^reater rarity and from the fact tliat tlie conditions ])resented by it are not as h'able to lead to disastrous results. The free Ct'ecum and the ai)pendix \ermiformis are not uncommon occupants of a true hernial sac, but these are Ufjt termed CcCcal hernia. It is cmly Fig. 24. Left interstitial hernia caused by delayed descent of testicle. Right testicle is inside of external abdominal ring. when the colon slides down so that the portion not covered by peritoneum forms a part of the protrusion that it is gi\-en this title. Interstitial inguinal hernia. Included under this title will be considered all of those hernicT that ha\"e been variously termed " properitoneal," "interparietal," "bubonocele rara," " superficial inguinal,'' and " interstitial." Any hernia tliat 64 ABDOMINAL HERNIA. protrudes between the layers of muscle, or tissue, which con- stitute the abdominal wall at this point, will be termed inter- stitial hernia. Such hernise usually begin as oblique inguinal hernia and, in their passage clown the canal, meet with some obstruction which turns them to some point of less resistance. Ordinarily these diverticula of the hernial sac are small, but Fig. 25. A right interstitial hernia, associated with the right testis in the canal. {Eccles.) sometimes they reach proportions quite in excess of the size of the true sac. Interstitial hernia, in the male, is very frequently asso- ciated with the imperfect descent of the testicle as shown in fig. 24, but a similar condition is not infrequently met with in the female. I have seen two such herniie in the female that were associated with an ovary contained in the same sac, show- ing a probable formation identical wit1i the imperfectly descendefl testicle in the male. The ovarv had first entered the TYPES OF INGUINAL HERNIA. 65 canal followed by the hernia, which, being- obstructed in its downward course, crowded itself between the abdominal layers. These i)rotrusions may be between any of the layers of the abdominal wall, but will be found most frequently in the order named: (i) Beneath the aponeurosis of the external oblique, and between this structure and the internal oblique. Such a Fig. 26. The right testis in a cruro-scrotal pouch, accompanied by a hernia. {Eccles.) formation is shown in fig. 25, as well as in the one just referred to. (2) Into the subperitoneal fat between the peritoneum and the transversalis fascia. (3) Between the skin and ex- ternal oblicjue muscle, or into the tissues of the thigh as shown in fig. 26. In formation the first type most frequently develops towards the iliac crest. The form that passes under the fascia transversalis more frequently fomis a pocket towards the 5 66 ABDOMINAL HERNIA. median line, while that forming immediately beneath the skin may go in almost any direction. A hernia of the latter type is shown in fig. 27, which has dissected up the subcutaneous tissues of the thigh and simulates femoral hernia (fig. 28). Not only may these hernise develop, from obstructions within the canal, but some that I have operated upon have been the Fig. 27. Interstitial hernia. The right half of the scrotum is absent and the testis, which is very small, lies within the canal near the external ring. The external oblique is in front of the hernia. From a man, age 50. {Macready.) result of trusses improperly applied. The truss pad had ob- structed the passage of the hernia through the external abdominal ring, but had not kept it out of the canal. The sac had, therefore, enlarged laterally where there was less re- sistance. Interstitial hernia that forms between the peritoneum and transversalis fascia is believed to be the most dangerous type of TYPES OF INGUINAL HERNIA. 67 this class, owing to its greater liability to become strangulated and to the obscure location of the exact place of strangulation. This was strongly impressed upon me several years ago while operating upon a woman seventy-five years old, for a strangu- lated inguinal hernia. On opening into an ordinarv^ inguinal Fig. 28. Literstitial hernia, falling over the thigh and simulating femoral hernia; in a man, age 56. {Macready.) sac it was found to contain small intestine, in fairly normal condition, which was reduced without much difficulty. A tumor was then discovered nearer the median line, which was found to be an interstitial sac just outside of the peritoneum, and it was in the neck of this sac that strangulation existed. The form of the sac is roughly shown in the following illustra- tion (fig. 29). 68 ABDOMINAL HERNIA. Conditions. — The conditions in which inguinal hernia may be found, at the first examination, are as follows : Re- ducible, irreducible, incarcerated, inflamed, or strangulated. Reducible inguinal hernia is where, irrespective of its size, its contents are wholly reducible to the cavity of the abdomen. Such hernias are uncomplicated and can usually be retained within the abdomen by truss pressure. In infants this method of treatment may result in a permanent cure, but in adult life this fortunate result is rarely obtained. The truss ordi- FlG. 29. A, Abdominal cavity. B, Sac in inguinal canal. C, Interstitial sac. D, Neck of interstitial sac, where strangulation existed. narily guards against strangulated hernia, providing its design and fitting are suited to the requirements of the case. Irreducible hernia may occur from one of many causes. (a) A very large mass of the abdominal viscera, either intes- tine or omentum, may protrude gradually through a small neck into the sac, and, when attempts at reduction are made, give the case the appearance of an irreducible hernia. Such a case, by ])crfect rest in l)cd and repeated gentle taxis, would be readily conveited into a reducible hernia and could then be treated as such, (b) Omentum tliat is allowed to remain in a hernial sac, is under pressure at its neck, and this partial obstruction to TYPES OF INGUINAL HERNIA. 69 the return flow of blood may cause an enlargement or nyper- trophy of the omental mass. The omentum becomes hard and nodular and without undue violence it cannot be forced back through the small neck of the sac. Even when this can be done, it is attended by much danger, the hypertrophied omen- tum acting as a foreign body within the abdominal cavity. In my early experience with hernia, when operations were attended by more risk and the ultimate result far from satis- factory, while I had no actual mortality, I was more than once concerned regarding the welfare of my patient, upon whom I had succeeded in reducing what appeared to be an irreducible hernia. In the present day, work of this type is seldom justifi- able, as the skillful surgical care of the case is probably attended by much less risk and by an incomparably greater degree of success, (c) The reduction of hernia may be pre- vented by adhesions of the protruding parts to the sides of the hernial sac. These adhesions most commonly occur between omentum and the sac wall. Adhesions between protruding in- testine and the sac wall are more rare than those involving the omentum, because of the peristaltic action of the bowel. Intes- tine, even when, packed into a sac in large cjuantities, must con- tinue this action in order to carry forward its contents, and this constant motion undoubtedly frequently prevents adhe- sions. Bowel in this abnormal position, however, becomes constantly less active and is still further crippled by adhesion to the sac wall. If only a small area is adherent the bowel still' performs its function, but as a greater amount becomes disabled obstinate constipation is followed by intestinal obstruction, and then, even the art and science of surgery is powerless to afi^ord more than temporary relief. In such cases, when operation for strangulated hernia is resorted to, the patient for a few days may appear to have been rescued from death, but symptoms of intestinal obstruction gradually reappear and death follows. The operation releases the bowel from imprisonment, and at that time it may appear to be in fairly good condition, but its paralysis has been complete and there is no hope of recovery. 70 ABDOMINAL HERNIA. Incarcerated hernia is a form which, though ordinarily reducible, has for some cause become temporarily irreducible. There is no strangulation of tissue, however, and no symptoms of intestinal obstruction, hence the term as here used is not intended to convey the idea of strangulation. (These two con- ditions are frequently confused in the medical mind.) If the protruding contents of the sac are intestine, the bowel may have become twisted in such a manner that for the time being its return is prevented, but the pressure upon the bowel is not sufficient to produce stasis, either of its blood supply or its con- tents. When the protruding contents are mostly, or wholly, omentum, the cause of irreducibility may be identical with that just named. An incarcerated hernia is not a condition of im- mediate danger, but may become so in two different ways. If intestine is involved, acute intestinal obstruction may result at any moment, while if omentum forms the bulk of the tumor, it may become inflamed, adding to the danger. Inflamed hernia is a term that should be limited to those cases of omental protrusion where this structure has become inflamed, which condition is most frecjuently brought on by over-violent attempts, either by the patient or his medical at- tendant, to reduce a mass of protruding omentum. The bowel, if also protruding, usually comes down into the sac back of the omentum and returns to the abdominal cavity upon the patient assuming a recumbent position. If the bowel is prevented from returning, the case is quite sure to result in strangulated hernia. Strangulated hernia is a type in which the intestine is usually the part involved, although we may meet with cases where it is the omentum, or, as most commonly occurs, both intestine and omentum are present. As this accident v/ill be fully considered under a special heading", it will not be necessary to treat of it here further than to say that it usually presents a picture of acute intestinal obstruction with its accompanying intense physical suffering. CHAPTER V. THE HERNIAL SAC. Formation. — In order to comprehend more clearly the con- ditions in which we may find hernia, some consideration must be given to the formation and development of hernial sac. It usually begins by the bulging forward of the peritoneum into one of the hypogastric fossae. If the hernia is to be of the direct type, it is into the fossa between the epigastric artery and the median line; if oblique, into the external hypogastric fossa outside of the epigastric artery. This bulging may occur under some unusual strain, and the elasticity of the peritoneum is such that it will, perhaps many times, recover its normal smooth surface, but when this undue stretching is repeated too frequently, or too violently, a pocket is formed in the canal lined with peritoneum. From that moment the peritoneal lin- ing of this pocket becomes the hernial sac, and it is with its increase in size and change in character that we have to deal. It is highly probable that a sac in the early period of its formation may be reducible, as well as its contents, but as a matter of fact we do not find it so upon the operating table, even though the case be one of very recent origin. Doubtless very shortly after its protrusion, it forms firm adhesion to the surrounding tissues. Its subsequent development, dependent somewhat upon the treatment of the hernia, is one of growth both in size and thickness of the tissue of which it is composed. An old and large hernial sac has lost entirely the characteristics of peritoneum. The thickening of its structure may be uni- form or it may become thickened in some parts while it remains thin in others, but it is no longer peritoneum, nor is it neces- sary to treat it as such. Not only has it ceased to belong to the abdominal cavity, but it has become a foreign body in the canal, and a cure can seldom be effected until it is completely eradicated. 71 72 ABDOMINAL HERNIA. There are certain changes in structure that I have met with frequently in operating, that have been httle spoken of in works on hernia, and still they seem to me important because they frequently are the immediate cause of strangulated hernia, I refer to fibrous, tough, inelastic rings, that form not only in many old sacs, but in some of rather recent origin. These rings are fairly well shown in fig. 30 taken from a man of thirty-five years, who had a right scrotal hernia for ten years. Fig. 30. Three fibrous rings in acquired sac. When I first began to meet with these rings I supposed that they were confined to congenital sacs and represented the origi- nal points of closure, or obliteration, of the tunica vaginalis, but further observation has convinced me that they are more frequent in sacs of the acquired form. These rings are so tough that if a loop of bowel is forcibly driven into one of them, strangulation is quite sure to result. They usually sur- round the entire sac, but sometimes only a portion of it, the balance of the sac being thin. From one to four may be found in the same sac, located at any point from the vicinity of the THE HERNIAL SAC. 7S testicle to the internal ring. In some instances they have nar- rowed the sac to a complete closure as shown at the lower ring in fig. 31. In this case intestine and bowel were found strangu- lated in the upper ring while the pocket below the lower ring was filled with fluid. The sac was unquestionably of the acquired type and was removed entire from the scrotum. There was no communication between the upper and lower cavities. Fig. 31. Showing two fibrous rings in sac. Strangulation of intestine and omentum was present in upper one. Lower cavity contained fluid only. Fig. T,2 shows a similar ring, in a congenital sac, in which was incarcerated (not strangulated) an omental protrusion. This was in a boy, ten years of age, who had been under treatment for some time and who was wearing a truss. Considerable thickening was felt in the scrotum, but the neck of omentum, connecting with the abdomen, was small, and the true condi- tion was not recognized until the operation. In this work will be found an illustration of an appendix, the end of which was incarcerated in a rino- near the bottom of the scrotum. 74 ABDOMINAL HERNIA. Congenital Sac. — It has been already stated that the con- genital sac is present at birth because nature, for some unknown reason, has failed to carry to completion one of the processes of development. This applies as well to the inguinal canal of the female, but the condition with her is unquestionably more rare. It is not intended to repeat here what has been said in connection with the descent of the testicle and the formation of the tunica vaginalis, but to call attention to a form of sac where Fig. 32. Boy, 10 years of age, with omentum incarcerated by ring in congenital sac. the hernia is in the funicular portion of the unobliterated tunica vaginalis (fig. 33). In these cases is found what appears to be a true hernial sac, and beneath this may be found an empty serous-lined cavity, or a cyst filled with fluid as shown in fig. 34. This sketch was made from a case as found in a young' man, about twenty years okl, who gave a histoi"y of hernia existing only one or two years. The tunica vaginalis had completely closed, above the testicle, and probably had partially closed at the internal ring. When hernia occurred the upper closure was dilated and the hernia then dropped at once to the top of THE HERNIAL SAC. 75 the testicle. Shortly after this the cyst developed in front of the testicle. The closure of the tunica vaginalis may be com- plete at the internal ring-, but nowhere else, leaving a capacious, serous-lined sac in front of the cord and testicle. Behind this may descend a new sac forming what has been termed infantile hernia (fig. 35). Fig. 2,2. J Hernia in the funicular portion of tlif tunica vaginalis. {Afacready.) It is especially important to keep this complication in mind as, on opening the tunica vaginalis, it might easily be mis- taken for the hernial sac and the latter overlooked entirely. One should always assure himself that the serous sac, into which he has opened, has communication with the abdominal cavity. These serous-lined cavities are sometimes very perplexing, when found in unusual situations, and are not easily accounted for. In one of mv own cases, a man 40 years old. I found such a cavitv entirelv disconnected, with the cord or true hernial sac 76 ABDOMINAL HERNIA. at the inner side of the cord and above the pubic bone, in a position that at first led me to beheve I had opened the bladder wall. The most careful investigation failed to demonstrate communication with any other cavity. It was a serous-lined cavity capable of containing about one ounce of fluid, empty, and was removed from the subperitoneal fat in which it seemed imbedded. The testicle was in its normal position in the scrotum. It is quite possible that these cysts may sometimes Fig. 34. Hernia into the funicular portion of the tunica vaginalis, with cyst below. Age, 20 years. arise from a hernial sac that has become occluded at its neck from truss pressure or other causes. I have found similar con- ditions in at least two femoral herni?e. In the case shown in fig. 36 the shape of the sac resembled that of a large mitten, and the diverticula corresponding with the thumb was full of small intestine. A sac may vary in size from that of a hickory-nut to an enormous pouch, reaching to the knee-joint. I have removed a number of sacs large enough to have slipped completely over the patient's head. A sac may form in a lateral direction if its descent is obstructed, or, if THE HERNIAL SAC. 77 already formed and its contents are prevented from entering it freely, it may expand between the fascial layers of the abdominal wall, forming interstitial hernia (fig. 37). Several illustrations of this have been seen, where the condition was considered due to the wearing of strong truss pressure upon the pubic bone, instead of retaining the hernia within the internal rine. Fig. Infantile sac. A, Irue hernial sac. B, Tunica vaginalis, closed sac. C, Cord. D, Testicle. Coverings of the Sac. — .\ classical description of the formation and coverings might be as follows : First, the pocket- ing into the upper part of the canal of the peritoneum, which eventually becomes the sac ; second, as this pushes forward it is covered by the transversalis fascia ; third, as it passes down through the canal, the cremaster muscle; fourth, as it protrudes from the external aljdominal ring it takes with it the inter- columnar fascia; fifth, the superficial fascia ; and sixth, the skin. The minute description and enumeration of the coverings of the hernial sac have led to much timidity on the part of the occasional operator, or with the physician who is forced into 78 ABDOMINAL HERNIA. an operation as an urgent life-saving- measure. If he refers to his works on anatomy, his confusion becomes worse by the very exact and exhaustive accounts, properly given, of these unim- portant fascial layers. Again let us follow the operator's knife and see these tissues as we see them at the operating table. If the hernia is direct, or complete oblique, and we cut down upon the sac, we divide the skin and its underlying fatty tissue (superficial Fig. 36. Showing sac shaped like a large mitten. fascia), and at once see the sac bulging up into the wound. It is true that this sac is covered by a layer of fascia, containing more or less muscular fibre and loose cellular tissue, so blended together as to make individual identification impossible. It is easily cleared from the sac surface by blunt dissection. Fre- quently it is so thin as to allow the sac to show plainly through it. It is composed of the transversalis fascia and the cremaster muscle, and possibly the intercolumnar fascia. If we are deal- ing with an incomplete ol3lic[ue inguinal hernia, we will not see the sac until we have split the aponeurosis of the external THE HERNIiVL SAC. 79 oblique. In the accompanying diagrammatic sketch (fig. 38) I have attempted to show the relative thickness of the cov- erings of the hernial sac, and a glance at that will indicate at once what a small part these two or three layers of fascia form. In the shape, formation, and direction in which tlie hernia may develoj), these fasciae not infrequently play an important part, but I am now speaking from a purely operative stand- point and the exaggerated idea of their importance in the mind of the young man, and the medical man who at times must, in justice to his patient, do surgical work and do it promptly. Fig. 37. Formation of an interstitial sac. A, Peritoneal cavity. B, True hernial sac. C, Inter- stitial sac. Only those wdio have taught hernia work to the practitioner can fully realize how often competent men hesitate to do the right thing at the right moment, because of their confused ideas of the anatomy of the parts, and consequently their excessive dread of approaching them surgically. It is to such men that I am trying to make this subject more clear; not encouraging incompetent men to do surgical work; far from it, but trying to lighten the biu'den of the conscientious practitioner who is striving to do his best as a conservator of human life. Contents of Sac. — As this work is not historical it cannot enter very fully into an account of all the many unexpected things that have been found in the hernial sac. As has been 80 ABDOMINAL HERNIA. previously stated all of the movable organs of the interior of the abdomen are found in it. On account of its longer mesen- tery the small intestine is most frequently met with. Next in frequency, if not fully equalling it, is the omentum. The large intestine may have a long enough mesentery to allow it to freel)^ occupy the hernial sac. The appendix and crecum are many times found in right side hernije, and while it has not occurred in my own experience, my associate, Dr. George E. Doty, has found an appendix in a left-side inguinal hernia, showing the extreme lengthening of the mesentery in some Fig. 7.8. Skin. Subcutaneous fat. Three fascial layers: A, Intercolumnar fascia. B, Cremasteric fascia. C, Tran.sversalis fascia. Sac. Showing relative thickness of tissues covering complete inguinal sac. people. The ovary and tubes are often found, and the uterus, pregnant or otherwise, has been recorded as found in a number of cases. As early as i6iO, Trautmann did a Ccxsarean section upon an incarcerated uterus and succeeded in saving both the mother and child. The stomach, liver, gall-bladder, spleen, pancreas, and kidney, have all been reported as found in inguinal sacs, as well as concretions of various shapes and sizes. In the case shown in the photograph, fig. i8, I found at the time of the opera- tion a perfectly round ball the size of a ping-pong ball, free in the sac. It was white and had a smooth exterior. It could be THE HERNIAL SAC. 81 easily cut, ho\\e\'er, aiul doubtless originated from a piece of omentum which had been separated from the larger mass, or from a h}-pcrtropliie(l appendix cpiphjica, which had finally cast loose fr!- bo «5"^ "^ bo BO MECHANICAL TREATMENT. 123 greater value is demonstrated by the fact that some manu- facturers who supply such a large demand seldom use them, in their own fitting-rooms, when the truss-selection is left to their best judgment. Their extensive sale is due largely to the fact that they require no fitting. Those suffering from hernia can buckle them on without difficulty. Furthermore, they wear out much sooner than other forms, the wearer frequently being obliged to renew his truss two or three times a year instead of wearing it several years. Springless trusses are, however, very defective in action, and their use in many instances results in serious trouble. Few people wear them for any length of time without finding their hernise worse than when they began. This occurs because the pad is drawn down against the pubic bone by the perineal strap, leaving the upper part of the canal unprotected and consequently occupied most of the time by a part of the hernia. A hernia held at the external ring only, is poorly held and sure to increase. If the pelvis were as round as a barrel, the springless truss would be more effective, but as its transverse diameter exceeds by fully one-third its antero- posterior diameter, it is thoroughly unscientific (fig. 59). A flexible band surrounding the hips and drawn tightly, will produce far more pressure over each hip than over the inguinal region where it is needed. A band of this character will not maintain its position upon the body without the perineal strap, and this is, for reasons which will suggest them- selves, an abomination, as well as positively injurious. The importance of retaining hernia within the internal ring can- not be too strongly emphasized. In many instances injury results from placing the supporting pad over the pubic bone and external ring, allowing thereby the upper part of the canal to be constantly occupied by a loop of bowel or piece of omentum, and compressing the cord against the bone, pro- ducing atrophy of the testicle in some instances. Added to this is their lack of cleanliness, which alone is quite enoug'h to condemn them for general use. They have one valuable use and that is, as a night truss. Ordinarily this is not needed 124 ABDOMINAL HERNIA. by the adult, but if from the enormous size of the hernia or a persistent cough the protrusion takes place at this time, these springless trusses serve a good purpose. There is little doubt that most wearers would get a greater degree of improvement by the use of a night truss, but the one that is exactly suited for the day is entirely unsuited for the night, and the reverse holds equally true. French, German, and English Trusses. — In the second group is shown a type of truss that has been well known in this country, and in most foreign countries, for many years. There are an endless number of variations in the minor details of its construction, but the general type remains. Doubtless it represents the first form of metal spring, and it had its origin either in Italy or France, probably the latter. The first recorded use of metal for a truss spring was, accord- ing to Macready (A Treatise on Ruptures, Jonathan F. C. H. Macready, F. R. C. S.. p. 195), the iron-band truss recom- mended by Gordon in 1306. Steel was first used by Nicolas le Quin of Paris (" The Sign of the Golden Truss ") in 1628. It is possible to present onlv a few of the numerous descendants of this type. In this country they have been known to manu- facturers as the French (nos. 6, 7, and 8 of group) or German (nos. 3, 4, and 5 of group) truss, the only distinguishing feature between them being that the former are made lighter, and usually bear some decorations in tlie form of fancy stitch- ing or embossed flowers upon the leather forming the outer surface of the pad. This form of truss as made in England (nos. i and 2 of group) is superior in two important particulars to those made here, and whether their origin was the same is not known. In the French-German truss the spring passes around the back to a point three or four inches beyond the spine, terminating over the gluteal muscles. In the English form this spring continues far enough around to clasp the opposite hip, thereby holding itself securely in place. It also has the retaining pad placed in a line almost parallel with the spring instead of arching MECHANICAL TREATMENT. 12; Group of Trussp:s, Frknch, German, and Encilish Tvpks. I. Single English type. 2. Double English type. 3. Single German type. 126 ABDOMINAL HERNIA. Group of Trusses, French, German, and English Types {Continued). 4. German type (so-called " scrotal-hernia truss'"). 5. Double German truss. 6. French truss. Adjustable French truss. 8. Hard-rubber or celluloid Frencl' truss. MECHANICAL TREATMENT. 127 abruptly down over the pubic bone as in the French-German truss. These are two serious defects in most oi the trusses made in the United States and Germany. Fortunately some of the larger manufacturers are recognizing this defect and endeavoring to correct it. The centre of the truss pad should be very nearly on a line with the centre of the spring, in order to have it effective and comfortable. When the pad is thrown Fig. 6o. Typical illustration of bad truss fitting with a French-German truss, frequently seen. Note that the pad acts as a compress directly over the pubic bone, and that the hernia is in the canal above. down SO low that its lower edge rests upon the pubic bone it ceases to be a reliable support, acts as a compress over the bone, and may for a time keep the hernia out of the scrotum, but the canal is gradually being dilated to such an extent that the hernia eventuallv becomes almost, if not quite, uncontrollable. The accompanving illustrations (figs. 60, 61, and 62) show this serious defect in truss-making and truss-wearing. The first pictures the case of a young man who, under the use of this 128 ABDOMINAL HERNIA. type, had gradually grown worse until it was almost impos- sible to retain his hernia, it is not uncommon to see these trusses worn in this way. The second photograph shows him with a Hood truss holding his hernia in proper position. As he was weak upon the left side, a thin pad for moderate support was placed over that region. Perhaps the worst feature of this form of truss, as now made, is in the fact that even if the pad is properly placed over Fig. 6i. Same case as Fig. 60, with properly adjusted De (Jarnio-Hood truss retaining- hernia within abdomen and with thin pad for support of opposite side. the inguinal canal, it will in a short time drop down over the pubic bone. The reason for this is that the spring naturally seeks the spot around the hips where it is least inlluenced by muscular action. This neutral point is midway between the crest of the ilium and tlie trochanter major (fig. 63), above the active muscles of the thigh and lielow those of the abdomen. In this position the front end of the spring terminates over MECHANICAL TREATMENT. 129 the middle of the canal. If the retaining pad is two inches below the spring, it will be seen at once that it must rest upon the pubic bone when the spring rests in its normal position. This criticism applies, with equal force to all of that vast variety of trusses of the type shown in the group under consideration and by the Chase type, to be "spoken of shortly. The English Usual maimer of wearing the so-called German style of truss. The hernia; on both sides are protruding into the scrotum. The canals are entirely unprotected. type of this group is very good, and the farther away from this form the more imperfect is the truss of this pattern. While trusses of this group have an enormous sale few expert truss- fitters use the^n ; the German instrument and truss makers, however, use them almost to the exclusion of all others. Cross-Body Type. — Towards the close of the eighteenth century, Salmon & Ody, an English firm still in existence, made 9 130 ABDOMINAL HERNIA. an important change in the form of truss springs, establishing one of the most valuable types of truss that we now have for the treatment of single inguinal and femoral hernia, known as the cross-body truss (no. i of group). The spring, in- stead of surrounding the hip on the side of the hernia, passes from the canal directly across the lower abdomen and around Fig. 63. Position in which spring should rest about hip. Midway between crest of ilium and tro- chanter major, its end in front over internal ring. If it comes across abdomen it should termi- nate at the same point. the hip of the opposite side. As originally made this truss had a convex pad over the inguinal region, held to the spring by a ball-and-socket attachment. The spring after passing across the abdomen and around the hip opposite the hernia, terminated over the spine, where there was another circular pad held by the same method of attachment. lliis truss was later modified, in this counti'y, by putting MECHANICAL TREATMENT. 131 Group of Trusses of the Cross-Body Type. I. Cross-body truss, leather cover, ball-and-socket pad. 2. Hard-rubber cross-body truss. 3. Hard-rubber, cross-body truss, small back pad. Continuous-spring 4. Hard-rubber " radical-cure truss." 132 ABDOMINAL HERNL\. Group of Trusses of the Cross-body Type {Continued). 5. Radical-cure truss. Continuous-spring cross-body 6. Leather covered continuous-spring cross-body truss. 7. Radical-cure truss, large leather covered back pad. MECHANICAL TREATMENT. Group ok Trusses of the Chase Type. 133 I. Chase truss. 2. Foster ratchet modified Chase truss. 3. Adjustable pad Chase truss. 4. Adjustable ball-and-socket, with set screw. 134 ABDOMINAL HERNIA. Group of Trusses of the Chase Type {Continued). 5. Modified set screw Chase truss. 6. Modified hard-rubber Chase truss. 7. Curved neck, ratchet pad. Adjustable pad and set screw. MECHANICAL TREATMENT. 135 on an elongated back pad (nos. i, 2, and 4) that should press on either side of the spine, its centre being arched ; and by making the spring longer (nos. 3, 5, and 6) so that it would terminate over the gluteal region, directly back of the hernia, either in a circular pad or continuous with the strap that com- pletes the circumference. The special advantages of this spring are — that it surrounds fully three-fourths of the body and, when properly fitted will retain its position, even though no strap is used ; it furnishes a longer, and therefore a more elastic, spring. The direction of the pressure is from the front pad to the centre of the back, and as it crosses the back at a slight elevation over the front, it has a slight upward pressure. It is convenient to the dealer because it can be quickly converted from a right- to a left-side truss. There are many modifica- tions as to the form of retaining pad and its method of attach- ment to the spring, but, while convenient, they are not essential. In this form, with such modifications as can be made to suit individual peculiarities, we have one of the most valuable appliances for the treatment of hernia that has ever been devised. Chase Type. — This form began with the truss bearing the name of its inventor, Dr. Heber Chase, 1837. It was issued during the war of the Rebellion (1861-5) to soldiers who developed hernia in the service. It consisted of a spring of the French type to which was attached in front a soft, malleable iron neck, curved downwards, holding a polished cedar pad. The pad was held by screws, passing through a slot in the iron neck, so that it could be raised or low^ered and the neck easily bent into any desired position. The truss was considered quite an improvement on its prototype which undoubtedly was the French truss. It has many descendants, a few of which are shown in their group. To a lesser degree they are all open to the objections that have been offered to the French type. The pad-centre being considerably below the spring-centre is an objection already mentioned. Also, the springs like all those that go on from the 136 ABDOMINAL HERNIA. same side as the rupture, are dependent upon the strap for retention of position, and when this stretches, or is improperly adjusted, they are very hable to shift their position and allow the hernia to protrude. For perfect fitting, comfort, and security, they do not compare favorably with the cross-body or Hood type of truss. Hood Type. — This is apparently an original type, purely American, the invention of Dr. J. W. Hood of Kentucky. In its existence of nearly seventy years, this truss has passed through many hands and has been the subject of many im- provements, but its general type remains. Its spring is solid in front, surrounding both hips, and terminates within about two inches of the spine on either side. Usually it has circular pads attached to the spring ends in the back upon which the counter pressure is taken, but some makers put on instead a flat, oblong disk which broadens the spring at this point and distributes the pressure over a greater surface. The retention pads used in front are of various shapes and designs, and may be selected to suit individual requirements. The original Hood pad is, however, for general use, an excellent form. It is thick at its lower edge, thin at the top, and in action presents a moderately convex surface over the inguinal canal. The pubic portion of the Hood spring has, on either side, a slot which runs parallel with, and is directly over, the inguinal canal. Transversly to this slot is another in the pad, and between the two there is quite a wide range of movement for accurate adjustment. When the adjustment is complete the pad is solidly fixed to the spring by set screws, which prevents motion between them while in use. The action of this truss is peculiar in that it does not depend wholly upon compression or spring action. It has. in fact, been extensively and very successfully used in a metal that has scarcely any spring action. It acts as a resisting frame about the pelvis with the pad making firm pressure over the inguinal canal when the wearer is in an upright position. Should he cough or strain, the abdominal wall is thrown for- MECHANICAL TREATMENT. Group of Trusses of Hood Type. 137 138 ABDOMINAL HERNIA. Group of Trusses of Hood Type [Cojttinued). MECHANICAL TREATMENT. 139 Groui> of Trusses of Hood Tvi'K [Continued). T2. 140 ABDOMINAL HERNIA. ward, but firmly met and restrained by the pad fastened to the pelvic frame. If, however, he should lie down, the frame would not follow to any extent the receding surface of the abdominal wall. Many truss makers have not fully compre- hended this action of the Hood truss and have made the Fig. 64. De Garmo-Hood truss applied. Right complete inguinal hernia. Left incipient hernia retained by thin "dummy ' jiad. Springs too heavy and with too much action, this error being fostered by the necessity of strong spring action in other forms of truss. The fact that in this truss a larger amount of com- pression can be dispensed with, makes it a much easier form for the patient to wear. When completely at rest, the wearer is in a measure relieved of pressure, which is a great comfort, quite in contrast with the tireless and never ceasing pressure MECHANICAL TREATMENT. 141 from a spring, the ends of which are endeavoring to come together. The Hood spring should surround the pelvis very nearly in a straight line, and some manufacturers have ruined it by arching the sides too high. As soon as this is done it loses its pelvic-frame action, the pads drop down over the pubic bone, and the truss then has many of the objection- able features of the trusses which have the pad set on a Fig. 65. De Garmo-Hood truss applied. Back view. descending arm. The shapes which are best for general use are shown in Nos. 6, 7, and 9 of the Hood type group. The Hood spring also has the advantage of carrying one or two pads, but it is always best with two. The one over the side not ruptured may be very thin and is called in the trade, a "dummy" (figs. 64 and 65). A person with one hernia is quite liable to develop another on the other side, which is more likely to happen when a single truss is worn than when none is used, for the reason that 142 ABDOMINAL HERNIA. the pressure against one side of the abdomen throws the intra-abdominal pressure towards the other side. Again, where double hernia exists, this solid-front spring is desirable because there can be no change in the relative position of the pads, by the stretching of a strap as in other forms of double truss, or by error of adjustment by the wearer. Increased weight and consequent change of size, is also better provided for by the adjustment of the strap in the back than in front. A person may gain or lose several inches in size without any rela- tive change in the position of the two inguinal canals. When the wearer becomes tired and wishes to relax the constriction of a truss, it can be done if fastened in the back, without disturbing its position in front ; on the contrary, if the pads are held in position by a strap in front, the moment this is loosened they are out of adjustment and the wearer is liable to accident. The truss of this type that I have used for many* years, more than any other, is shown in no. 7 of group, or fig. 64 and 65, applied. It differs from the others principally in its lightness, simplicity of construction, and in the fact that the spring is made of hard-rolled German silver instead of steel. It is covered by hard rubber and the pads are attached by simple clasps that allow of adjustment. There are few expert truss fitters in this country who have not used extensively the Hood type of truss, while some have used it almost to the exclusion of all -other forms. It is easier to fit than almost any other, and certainly easier to wear. The special advantages of the Hood truss are believed to be : (i) It passes around the pelvis at the most immovable part. (2) Surrounding both hips gives it stability. (3) It retains with relatively less pressure. (4) It protects one or both canals. (5) Counter pressure is on the gluteal region where best tolerated. It has, however, the disadvantage of being somewhat more expensive to manufacture than other forms, and for this MECHANICAL TREATMENT. 143 Unclassified Group. I. Wire-Spring Truss. 2. Spring and elastic web combined 3. Spring and elastic web combined. 144 ABDOMINAL HERNIA. Double Truss Group. I. Double ball-and-socket truss. 2. Double hard-rubber truss. 3. Modified Chase Truss. MECHANICAL TREATMENT DouiiLE Truss Group {Cojiiinucd). 145 4. Modified radical-cure truss. 5 Radical-cure truss. 6. Adjustable set-screw truss. 146 ABDOMINAL HERNIA. Double Truss Group [Coniimced). 7. Elastic web and spring truss. 8. Adjustable French truss. 9. Double elastic truss. 10. Double German truss. MECHANICAL TREATMENT. 147 reason alone, many truss sellers have declined to carry them in stock. The physician should impress upon liis patient the truth, that to the ruptured man a good truss, well fitted, is more important to him than his clothes. Undue economy in this connection is poor policy. Unclassified Group. — There is also a group of trusses that cannot be classified with any of those already mentioned. It contains one upon which I have never looked w'ith much favor though I have known good truss fitters (no. i) unbiased by personal interest, who claim to have found it satisfactory. Large numbers have been sold to dealers throughout the country, and for that reason it seems best to mention it here. It has the ap- pearance of an original type of truss, and I believe the makers considered it such, but as a matter of fact Dr. Tod of Lon- don, England, patented (about 1858) a truss to which this is exactly similar except in details of construction, his being made of a steel spring occupying exactly the same position as this, held in place by a similar band, while this is made of spring brass, or other wire, so shaped that one piece forms not only the spring, but the frames for both the front and back pads. The advantages of this truss are in its extreme lightness and small cost of construction. Its disadvantages, as they present themselves to me, are its great liability to become displaced, lack of durability and general inefficiency. Its retention in place is absolutely dependent upon the web band which surrounds two- thirds of the hip. Furthermore, the lengih of the spring, from the crest of the ilium to the hernial pad in front, is such, that in bending forward the pad is forced down over the pubic bone. Wearers have complained to me in reference to this as a great inconvenience, and it is certain that any truss pad that is so liable to displacement, must be looked upon as very dangerous. Nos. 2 and 3 of this group represent a combination of a short steel spring with an elastic band. It is a modification of, and I should think something of an improvement upon, the elastic truss. 148 ABDOMINAL HERNIA. Double Truss Group. — This group merely presents the same type of trusses already illustrated, as arranged for double instead of single hernia. Retaining Pads. — Pads for the retention of the hernia are made of many shapes, and are usually interchangeable so that the fitter can make almost any combination of spring and pad that he may desire (fig. 66). In ordering pads it is only necessary to state the form of spring they are intended to be used on, and suitable screws for attachment will be placed on them. For general use the best form is a moderately convex, oblong pad such as shown in nos. 3 and 7 of the pads grouped on the accompanying plate. These oval pads are made in several sizes, as shown in the diagram of sizes (fig. 67) ; using an unnecessarily large pad is a mistake most frequently made. This is especially true in the treatment of large sized hernise. The larger the pad, the stronger the spring pressure must be. With the smaller pad the pressure is concentrated immediately upon the spot, while if that same pressure is dis- tributed over a large area, it ceases to be effective. A thin, flat pad answers well for a thin person, but upon a fat patient, a deeper pad, such as No. 8 of pad group, must be selected. The pads are made either of soft material, felt, hair, or of hard material, such as wood, hard rubber, or celluloid. A soft pad that has proven useful is known as the water pad. This is made in every conceivable size and shape, and consists of a rubber bag filled with water or glycerine, sealed. Over this is a layer of felt and then a covering of silk, kid, or chamois. In some special cases this is a valuable pad, but its lack of durability is a serious defect. If the wearer is cautioned about its tendency to flatten out and leave him unprotected, it may save serious trouble. This change is so gradual that unless attention is drawn to it, it may not be noticed. For general use there is no pad made that equals in durability, cleanliness, and reliability, those made of hard rubber or celluloid. The skin maintains a much healthier condition under the pressure of a highly ])ohshed, impervious surface, than any soft material MECIIANICAl. TREATMENT Fig. 66. 149 TOP Group of Variously Shaped Pads Fig. 67. 150 A Standard of Sizes for Truss Pads. {Horn.) MECHANICAL TREATMENT. 151 that is constantly accumulating" tlie cxcreti(jns of the skin. Ordinarily tlic hard pad is ccjualiy comfortable to wear, if i:)laced in proper position, and does not impinge upon the bone or other hard parts. The tissues back of the pad are soft and flexible, conforming readily to the shape of the pad, thus closing the upper part of the canal. Truss Coverings. — The material with which a truss spring is covered has little to do with its efficiency, but may make much difference in comfort, cleanliness, and durability. Clean- liness of both person and appliance is the first essential of comfortable truss wearing, and it is for this reason that hard rubber and celluloid make the most desirable materials with which to cover truss springs and make the pads. In using these materials retaining pads can be made hollow, and there- fore very light. The use of hard rubber in truss-making was the invention of Dr. J. W. Riggs of New York City, about 1865, and was one of the most valuable contributions ever made in the interest of the truss wearer. The names of Riggs, Chase, and Hood, all reputable physicians, should long be remembered in connec- tion with the great advance of this country over other nations in truss construction. Manufacturers are to be congratulated upon the excellence of their products, but we must still claim for the medical man the honor of having made the most valu- able suggestions. In individual cases, especially in aged, thin, and sensitive people, it may be very advisable to have trusses constructed of the softest possible material, but for the average wearer there is nothing equal to the hard rubber or celluloid, which insures cleanliness, as they will not absorb the excretions of the skin. They can be washed in water, or boiled if worn during contagious disease. Physicians frcc[ucntly make -the mistake of speaking of the " Hard-Rubber Truss " or " Cellu- loid Truss " as though they were some definite type of truss. This is an error, as these names merely refer to the materials used in construction and are applied by makers to every known type of truss. CHAPTER VIII. TRUSS-FITTING. The fitting of trusses is an art that is difficult for a person to acquire who has no mechanical tastes or ability. Such a man would seldom become an expert, but if persistent, would, with practice, do the work fairly well. It requires in addition to some mechanical skill, patience unlimited, persistence until the ideal is attained, and tact in managing the patient, especially if he is an old truss wearer and has "ideas" regarding his needs. Unfortunately every beginner has had to acquire skill by personal experience, and when he has obtained this it has been considered shrewd business policy, by the non-professional expert, to impart as little of his knowledge as possible to others. There is no valuable guide to truss-fitting and largely because those who have written on hernia have had surgical experience only, while those who have had experience in truss-fitting have " bottled it up," fearing that their rivals might be benefited by it. Truss-fitting consists of obtaining the measure and shape of the patient, selecting the truss suited to the case, shaping of the spring, and its application to the patient. The patient should also be instructed in the reduction of his own hernia, in the removal and readjustment of the truss, in the necessity of care and cleanliness of the skin, and last, but not least, in the importance of returning for refitting and inspection. Taking Measure and Shape. — Every person is differently formed, even though the circumference be exactly the same, so that it is equally as important to consider the shape as the meas- ure. Manufacturers can only follow one general shape for a certain size, therefore, if a patient buys a truss from stock that fits him, it is because he happens to fit the truss. Practically each truss should be shaped to the form of the person that is to wear it, and recognizing this fact, truss makers temper their 152 TRUSS-FITTING. 153 springs so that they can, with care, be bent to the required form with little risk of breaking-. for inguinal hernia The measure for a truss (fig. 68) should be the entire circumference of the pelvis, about level with the internal ring, passing midway between the crest of the ilium and the trochanter major, and with the tape a little higher in the back than in front, corresponding with the pelvic obliquity. Fig. 68. Showing; location in which measure should be made for inguinal truss. Tape should pass midway between trochanter major and crest of ilium. (Mactcady.) This measure should be recorded in number of inches, and fol- lows the line properly covered by the truss spring as shown in fig. 63. It is also well to record the measure from one inguinal canal to the other in double hernia in order to locate the pads at a proper distance apart, remembering that in direct hernia the pads must be nearer together than in the oblique form. 154 ABDOMINAL HERNL\. Diagram. — Placing a diagram, on paper, of the patient's pelvis will materially aid even an expert fitter, and it puts truss- iitting within the possibilities of the inexperienced. The Fig. 69. Showing methfifl of taking diagram wilh lead tape. " Lead-Tape Method " suggested by the author many years ago, has proven a very easy and valuable way of doing this, but has not been as extensively known as it should have been. This diagram is obtained by the use of a strip of sheet lead, half TRUSS-FITTING. 155 an inch wide, one-sixteenth of an inch thick, and for use on adults, about twenty inches long. It can be cut from the sheet by any plumber. The end of this lead tape is placed over Fio. 70. Showing method of taking diagram ; second position. the hernia (fig. 69). extending from this point across the front of the abdomen and around the hip on the opposite side, thence across the back (fig. 70). The lead is gently pressed to the form of the body, carefully removed and placed 156 ABDOMINAL HERNIA. edgewise upon a sheet of paper, or case book, of suitable size. A tracing is now made of its inner surface with a lead pencil. This will represent about two-thirds of the circumference of the pelvis and when transferred to paper the diagram may be com- pleted by turning the lead over and completing the tracing, or Fig Diagrams of two persons of 32-inch measure. if preferred by repeating the process for the other side. This diagram gives the shape of a section of the hips taken on a line covered by the truss spring. The shaping of a truss spring by this diagram is much easier than shaping it to the patient's body. Time is saved to the fitter, and the embarrassment to both the patient and the physician of repeated trials upon the body is saved. Usually if the spring is carefully shaped to the diagram, very few, if any. alterations will be required when it is put upon the person TRUSS-FITTING. 157 of the wearer. This method so far simphfies truss-fitting as to l)lace it within the reach of every practitioner who is wiUing to devote the time necessary. The patient should be, and usually is, willing to pay for this time in order to be relieved of a very dangerous condition. The two diagrams show-n (figs. 71, 72) are reproduced from those of two taken from my case book of Fig. 72. Diagrams of two persons whose circumference is identical. two persons of exactly the same measure, and illustrate at once how impossible it would be for one to wear with comfort a spring shaped for the other. Shaping. — In truss-fitting one should have a pair of strong pliers, a screw-driver, and a pair of good hands, the latter being the most important part of the outfit, as nearly all of the actual bending of the spring should be done by them. The bending into the required shape of a tempered spring must be done carefully and net by a sudden, jerky force. Grasp the 158 ABDOMINAL HERNLV. spring firmly in the hands as shown in no. 3, fig. 73, and by a steady, firm pressure gradually bend it to the point required. In shaping by the diagram, begin at the point over the hernia and shape first across the front of the abdomen, if a cross-body truss, and then around the hip and across the back. If the spring crosses the back it must not be allowed to press upon the spine, but the pressure should be taken up by the heavy side muscles. If the lower edge of the spring needs twist- ing farther in or farther out to change the bearing of the pad or improve the fitting of the truss, this should be done by the pliers. It must be remembered in fitting a spring to the diagram, that allowance must be made for pressure. The spring must be forcibly held out to the shape of the diagram. All springs covered with hard rubber must be thoroughly warmed before attempting to bend them, otherwise the rubber covering will crack, damaging seriously the durability of the truss. The warming is done by passing the spring rapidly through a gas flame (no. i, fig. 73), or through the flame of an ordinary spirit lamp. The latter method is the best, as the gas flame smokes it and unless constantly wiped will soil the hands or patient's body. The skill necessary for this warming process is quickly acquired, and all that is necessary to prevent burning, is to keep the spring constantly moving. An equally good way, when convenient, and one free from danger of burning, is to dip the spring in boiling water for about one minute. Celluloid springs do not need warming before bend- ing, except to see that they are not extremely cold. They must not, under any circumstances, be placed in a flame. They are readily distinguished from hard rubber, which is always black, by their being pink or white. Ordinarily this material is suf- ficiently flexible to stand any necessary shaping. It is only when the springs have been kept long in stock that they become somewhat brittle, and then the pouring upon them of boiling water will prevent cracking. Every time a truss spring is bent its pressure is somewhat reduced, and for this reason it is best to start with a spring that TRUSS-FITTING. Fig. 73. 159 Shapings truss springs. 160 ABDOMINxlL HERNIA. Shaping truss springs {Continued'). TRUSS-FITTING. 161 is somewhat stronger tlian needed. Its pressure can be reduced by taking it firmly in hand rmd stretching out (nos. 6 and 7, fig. 73), or bending it over the arm of a chair. Caution is necessary not to reduce its strength too much, as it is easier to decrease than increase it. Its pressure may Ije increased, how- ever, by adding to- its curves, by short, firm bends between tlie hands, or curHng up the spring as shown in nos. 4 and 5, fig. y^. If increase of pressure obtained this way is considerable, it will be to quite an extent transient, and it is usually better to exchange for a stronger spring. It is to be rememljered that all hard-rubber covered springs must be warmed before bend- ing, but that this is not necessary in shaping celluloid or leather covered springs. Fig. 74. Hard-rubber cross-body truss applied to complete oblique hernia. In sniiiU hernia the pad may be higher. SELECTING TRUSS. Oblique Inguinal Hernia. — An incomplete or a small com- plete oblique inguinal hernia is usually retained by a very moderate pressure and a small pad, which should be either directly over the internal ring or upon the canal immediately beneath that point. It is more difficult to select a truss exactly suited to the treatment of a small hernia, from the stock of the average dealer, than it is for a large hernia. This is because many dealers will have nothing to do with a light truss spring, believing that its virtue is dependent upon its strength. Of the 11 162 ABDOMINAL HERNIA. trusses carried in stock by the dealers, few will be found better for a small and recent hernia than a light spring cross-body, preferably with a hard-rubber or celluloid covering (nos. 2, 3, and 6, cross-body group). If the spring seems too strong, reduce its pressure in the manner already described, while shaping it to the diagram of the patient. When applied it should occupy the position shown in fig. 74, or still better, Fig. 75. Woman aged 40 years, with right labial hernia of seventeen years' duration. with the pad a little higher. The pad as there shown, com- presses the entire canal, while in a small oblique hernia it is only necessary to compress its upper part. The higher the pad, with retention of the hernia, the greater the comfort of the wearer, and the greater will be the improvement obtained from its use. Fig. 75 shows a large labial hernia retained, in fig. "^^^ by a hard-rubber, cross-body truss. The pad should be about no. 3 or 4 oval (fig. 67) and moderately convex. Some TRUSS-IITTING. 163 manufacturers make what they caH a narrow-spring cross-body, which is particularly well suited to light cases. The next choice in such a case would be a light Hood truss, and if very light, is to be preferred even to the cross- body (fig. 'J'J^. If the meager stock of the dealer makes it necessary to select a Chase type of truss, select a size smaller Fig. 76. Right labial hernia retained by hard-rubber cross-body truss. than called for by the measure, and straighten out its neck nearly parallel with the spring (no. 3, Chase group), and shape by diagram. The smaller size is suggested because in turning the neck nearly parallel with the spring, the latter is thereby lengthened. Tlie most objectionable feature of this t3^pe of truss is in the length of its neck, and low bearing of the pad. If driven to the necessity of putting on a truss of the French or elastic type, let it be for temporary use until a better form can 164 ABDOMINAL HERNIA. Fig. 77. • i"4/ Hard-rubber steel-spring- Hood truss with pad on spiral spring. For double or single hernia. This arrangement of pad is better suited to fat than to thin people and where strong pressure is required. Fig. 78. Complete oblique inguinal hernia. Recurrent after operation by MacEwen method. TRUSS-FITTING. 165 be obtained, for under the permanent use of an inferior truss, small hernia; are quite sure to grow worse. Fig. 78 shows an inguinal hernia in a woman of middle life that would require a cross-body spring of more pressure, or what was believed better in this case, a Hood truss, as shown in fig. 79. This is a very light form of the Hood truss and, in some cases, might Fig. 79. Same as Fig. 78, with De Garmo-Hood truss applied. Hernia is perfectly held within the abdomen. Bulging over pubic bone is from a thickened sac and loose skin. not be sufficiently strong to retain the hernia perfectly, and it would be well to use the regular Hood form with steel springs, as shown in fig. yy. As oblique inguinal hernia increases in size there is a cor- responding shortening of the canal, by the dragging down of the internal ring, until it is nearly opposite the external, thereby increasing the difficulties of treatment. Instead of having a canal an inch and a half long to act upon, we then have a large hole beneath the skin leading directly into the abdominal cavitv. 166 ABDOMINAL HERNIA. In addition to this direct opening, there is usually a thickened sac, in these neglected cases, that also prevents in a measure the efficient action of a truss. Then again the pad must rest nearer the pubic bone, and this, by pressing the cord or other tissues against the bone, adds seriously to the discomfort of the patient. Even in these extreme cases the Hood truss arranged with deep Fig. So. Large double hernia. Protrusion on the left not complete when photograph was taken. Size of patient's head when fully out. pads (fig. yy) is an excellent truss. Fig. 80 is a photograph of enormous double scrotal hernia, which was retained by a Hood truss of the ordinary type, as shown in fig. 81. In order to clearly comprehend proper and inferior forms of truss, it is advisable to compare this with what the Germans call a " Scrotal-Hemia Truss.' In the latter there is an enormous compress over the pubic bone held in place by a TRUSS-FITTING. 1G7 strap between the legs. The amount of pressure necessary to retain the hernia, by such a large surface, must necessarily be great. In these enormous hernice I have for many years held as a last resort, the truss known as the " Radical-Cure Truss " (nos. 4, 5, and 7 of cross-body group). This will many times retain a hernia upon which every other form of truss Fig. 81. Same as Fig. 80. Hernia retained by double steel-spring hard-rubber Hood truss. has failed, but it should be used only as an extreme measure, as it is most uncomfortable. Its peculiarity is in the construc- tion of the retaining pad, which has a small, hard, oblong centre, surrounded by a soft-rubber or kid-leather ring. In action the greater amount of pressure is concentrated upon the small central pad, and to this, and the fact that they are usually made with an especially strong spring, is to be attrilmted their greater retaining power. The name had its origin in the 168 ABDOMINAL HERNIA. fact that it was advertised for many years by its originator under this title. That it possessed any special virtues, implied by its name, is not believed, except that it retained hernia securely and was skillfully applied by its inventor. Fig. 82 shows half of one of the double Radical-Cure trusses applied in combination with half of an ordinary double hard-rubber truss. The single truss should always be of the cross-body type. Some makers have attached this pad to a French spring, but this combination is practically worthless. Fig. 82. Hard-rubber radical-cure truss on right side, combined with ordinary double hard-rubber truss on left. In fitting these large and neglected cases, it must be remembered that the canal is destroyed, and that the point of greatest pressure must be very nearly over the external ring and consequently nearer the centre of the abdomen than it would be applied in small oblique hernia. In many of these large hernise the use of the water pad, which can be combined with any form of spring, will be found to retain better than the smooth, hard pad. When the water pad is used, it should, if possible, be changed to the hard pad as soon as sufficient improvement warrants it, for, while valuable, they are not very durable and therefore need to be watched. Under proper TRUSS-FITTING. 16» treatment, that is, perfect retention and gradual reduction of pressure, large oblique herniee improve in almost every instance. Ill is improvement is sometimes so great, that if the patient allow^s a protrusion of the hernia, he may be unable to reduce it, and serious results ensue. Patients under treatment for large hernicC must be particularly cautioned regarding this danger, and advised never to stand without a truss on. In the Author's experience there have been very few reducible hernise, even of enormous proportions, that could not be cfjntrolled by a suitable truss properly adjusted, and he has relied largely upon either the Hood form or cross-body spring, with such variations of pad as seemed to be required by the peculiarities of the case. The retention of these herni^e must be undertaken seriously, and not considered as trifling cases to which a truss can be applied and the patient sent away. It has frequently happened that patients, coming from a distance, have been sent away unattended until such time as they could be given the uninterrupted attention necessary to successful treat- ment. This course might entail a delay of from five to ten days, or longer, with the patient in bed part of the time, if retention could only be accomplished in the recumbent posi- tion. Cases of this type that had previously met with repeated failure, managed in this way, have had the most gratifying results. It is true, now that the surgical treatment of these cases is so successful, that there is not the incentive to this persistent and hard work as in former years; still, there may be good reasons why an operation is not advisable, and they should under no circumstances be abandoned as hopeless. When these enormous hernise are reduced and retained, in the male sex, there remains a large mass of thickened sac and fascia as well as elongated cords and scrotum. It aids greatly in the retention of the hernia and adds much to the comfort of the patient, to adjust a firm and tight-fitting suspensory bandage. In people who have large, pendulous abdomens and flabby muscular walls, a light, but strong, abdominal belt will aid. Such belts are usually kept in stock by dealers, but it is 170 ABDOMINAL HERNIA. far better, when possible, to have them made to order, as they usually contain rubber, which material rapidly deteriorates when lying unused. A group of these belts, and directions for measuring, will be found in the chapter on the mechanical treat- ment of umbilical hernia. The English use, for cases of very large hernise, what they term the " Rat-Tail Truss" (fig. 83). It will be noted Fig. 83. English " Rat-tail " truss. {Macready.) that this truss is c|uite similar to the French type, except that it is vastly superior in that the direction of the pad is nearly continuous with the spring, bringing it directly over the canal, instead of over the pubic bone as in the German truss. The spring in this truss is also long enough to clasp the opposite hip, which greatly aids in holding it firmly in place. It is to be hoped that, eventually, our truss makers will abandon the pat- terns now used for making the French-German type and adopt those more nearly approaching the English design. The TRUSS-FITTING. 171 advantages of the Eng-lish truss arc well shown in fig. 84, as api)lie(l to (lonble inguinal hernia; we believe, however, that with accurate fitting of the spring, the understraps, which are always objectionable, could usually be abandoned, and we can speak in praise of the position of the pads only. In contrast to this, attention is called to a truss of the same type (fig. 85), Fig. 84. An English type of double truss, applied. {Eccles.) very extensively sold in this country, which, while excellent in construction, has the serious defect of having the centre of the pad too far below the spring. This truss, as shown applied, is in very good position, except that the spring is too high. When the wearer stoops, the abdomen strikes the upper edge of the spring, and forces the pad down over the pubic bone. 172 ABDO:\riXAL HERNLA.. Direct Inguinal Hernia. — The mechanical treatment of direct hernia is, in most respects, similar to that of the oblique variety, except that the difficulties are somewhat increased on account of its close proximit}^ to the pubic bone. The con- tents of a direct hernia may sometimes account for truss-wear- ing being m.ore painful. In direct hernia we may have the bladder, cjecum, or sigmoid flexure, forming part or all of the protrusion. In such a case pain is caused by direct truss- pressure upon the bladder or bowel. Several cases of sigmoid Fig. 85. Hard-rubber French type of truss applied. The strap may be buttoned on stud-head at end of spring or on another below centre of pad. The latter is preferred. The tendency of this truss is to slip down over the pubic bone. and cjecal hernia have been seen, that could not tolerate any form of truss pressure that was sufficient to retain the protru- sion. In direct hernia a pad that is nearly circular in shape is frequently better than the oblong form. The water pad is par- ticularly good, for, even if some pressure is made against the pubic lx)ne, it does not cause the pain that a hard pad would. \\'hatever pad is used it must be placed nearer the median line, and lower, than for oblique hernia. Little or no improvement must be expected in direct hernia from truss-wearing. If the case is prevented from increasing in size and the patient is made fairly comfortable, it must be looked upon as successful. TRUSS-FITTING. 173 COMPLICATIONS. There are certain complications met with in the mechanical treatment of hernia that require special consideration, and notably are the following : (i) Cysts, within, or just outside the canal. (2) Elongated sub-peritoneal fat. (3) Reducible hydrocele or other fluid in sac. (4) Varicocele. (5) Delayed descent of testicle. (6) Interstitial hernia. (7) Pregnancy. (8) Adhesions of hernial contents. Cysts. — It is not very uncommon, and may occur in either sex, that cysts form within the canal or in the vicinity of the external ring, where they interfere seriously with truss-wearing and lead to doubts as to diagnosis. Those that form lower down on the cord, or in front of the testicle, are not now under consideration, as they are sufficiently far away from the canal to escape truss pressure. These cysts most commonly form in that part of the tunica vaginalis which occupies the canal and which has not been completely obliterated. They may be closely associated with the cord (or round ligament), or hang by a pedicle, so as to slip out of the canal and have the appear- ance of being reducible to the abdominal cavity. It is the latter type that prove the most troublesome and misleading in the mechanical treatment of hernia. They may be associated with hernia, or occur alone and be mistaken for the latter condition. Their recognition is usually not difficult, if their possible occur- rence is kept in mind. If a round, somewhat elastic tumor repeatedly slips under the truss pad, it is in all probability either one of these cysts, a piece of hypertrophied omentum, or sub- peritoneal fat. While the cysts present a round, elastic surface, that of omentum or sub-peritoneal fat is usually nodular, and its connecting neck is larger than the pedicle of a cyst. Further- more, if the patient is lying down, omentum is fully reducible 174 ABDOMINAL HERNIA. to the abdomen, and the cysts wiU appear to be reduced, yet deep pressure over the canal AviH reveal their presence. The treatment of such cases must depend largely upon the position of the cysts. If in the way of the truss pad, it is best to draw the fluid off. Frequently this can be done by a hypodermic needle, but if they are large, an aspirating needle will be better. It has been my habit to make no further attempt to cure them on the first tapping, as this alone is sufficient in many instances. If they reform, they are. upon the occasion of the second tapping, injected, through the same needle that has been used for drawing off the fluid, with from five to ten drops of 95 per cent, pure phenol. On the day following this injection, there will be a recurrence of the fluid, almost, if not quite, equal to the original quantity. By the fifth day their absorption will be noticeable, and by the tenth to fourteenth day it will usually be complete, and the cure of the cysts perma- nent. If these cysts drop so far below the truss pad as to cause no discomfort, they may be entirely ignored, as they seldom acquire sufficient size to be inconvenient ; but if within the canal, they are, by their distention of the tissues, a positive injury, besides causing the patient a great amount of discomfort. Sub-peritoneal fat is often a forerunner of, or associated with, inguinal hernia. During muscular action it is pressed into the canal from in front of the peritoneum, and in this position it becomes elongated, so that it may protrude at the external ring. It is entirely outside of the hernial sac, if one exist, and to the average observer it cannot be distinguished from protruding omentum. Its action under truss-pressure is very similar to that of a fluid cyst ; it will persistently slip from under the truss-pad and lead the patient, and probably also the doctor, to believe that it is the hernia that protrudes. Its feel- ing and shape are quite different from that of a cyst. It remains in the canal when the patient is lying down, and careful examination will usually reveal this condition. It cannot ordinarily be differentiated from omentum adherent within the TRUSS-FITTING. 17.5 sac. The truss pad can be worn over it without harm, and in many instances this pressure will result in its absorption. If recognized, it is best to assure the patient that no harm will come from it, even though it does protrude from beneath the truss. It is, of course, better that it should be held within the canal in the hope that it will be destroyed, but this cannot always be accomplished. The absorption and disappearance of this fat, under truss pressure, would doubtless account for some of the apparently remarkable cures of hernia in the adult by truss- wearing. In such cases the fat is present, but there is no hernial sac. In other words, no hernia exists. Reducible Hydrocele or other fluid in the sac. The con- dition of reducible or congenital hydrocele is not a very common one, and, as mig"ht be expected, is seldom found except in children. Its recognition is the most important part, as \'ery little modification will be necessary in the mechanical treatment. Where free fluid exists in the hernial sac no amount of truss pressure will retain it within the cavity of the abdomen. For- tunately, this condition is usually temporary, and if the truss pressure is maintained in order to retain the hernia, it will usually right itself. It is cpiite inadvisable to resort to any method but that of an operation for the cure of existing hernia and the destruction of the secreting membrane. It is seldom advisable to tap the hydrocele, and, wdien this is done, it must be remembered that in reality the cavity of the abdomen is being entered, and every precaution as to asepsis should guard the patient against infection. Free fluid in the cavity of the abdomen (ascites) from heart, kidney, liver or other lesions, is a very troublesome com- plication in the mechanical treatment of inguinal hernia, and frequently causes the patient greater mental concern than the possibly fatal malady which is its cause. It is entirely futile to attempt the retention of such fluid by truss pressure. If it is not large, truss-wearing should be continued in order to prevent the protrusion of bowel or omentum, and the patient should be assured that no harm will come from the fluid in the 176 ABDOMINAL HERNIA. sac. If the abdominal distention is great, it is really unim- portant whether the patient wears a truss or not, as the bowel and omentum both float at the upper abdominal cavity on the fluid, and there is no tendency for either to protrude through the inguinal canal. A large and strong suspensory bag affords about the only approach "to comfort that can be afforded. Ascites, following scarlet fever or from other causes, should be managed in the same general way, except that it is more important, in these cases, to continue the use of the truss even though a large quantity of fluid is present. When this fluid is reabsorbed, it may require temporarily increased truss pressure on account of the damage done the abdominal wall by over- distention, but as the case improves the pressure should be again diminished. Varicocele. — The small or moderate size varicocele demands little attention in the mechanical treatment of inguinal hernia, except to keep in mind the fact that compression of the cord, against the pubic bone, will retard the return flow of venous blood from the testicle much more than it will obstruct the arterial supply, so that poor truss-fitting tends decidedly to increase the condition. A large varicocele, combined with hernia, requires the use of a snug-fitting suspensory in addition to the truss. It will also make necessary the resorting to stronger spring pressure, as the cord is almost always much larger than normal. Various special pads have been designed, so made as to press on either side of the canal and avoid extreme pressure on the cord, but they are of little real ser- vice. A small pad placed high on the canal will protect the cord better than any other way known to the Author. Delayed Descent of Testicle. — This condition complicates, perhaps, more frequently than any other, the mechanical treat- ment of hernia. It is not uncommon in children that the absence of the testicle, from the scrotum, remains undiscovered by parents until bulging in the inguinal region is noticed. This bulging indicates the attempts of the testicle to get into its normal position, and it is safe to state that it is always accom- TRUSS-FITTING. 177 panied by hernia, and, that the hernia occupies a congenital sac. In view of these facts, it is a condition worthy of the most careful attention at whatever period in hfe it is discovered. It is obviously the duty of the physician to so treat the case, if possible, as to aid the attempts of nature to place the testicle in the scrotum, and to this end the truss should be so adjusted as to retain the hernia without preventing the descent of the testicle. If the patient is very young, the bulging slight, and the testicle not outside the canal, it is considered good practice to keep the case under observation, but to apply no truss. As the hernia increases in size, both it and the testicle will protrude at the external ring, and they may then l^e separated ; the former retained by a small pad over the upper part of the canal, while the testicle is kept from re-entering the canal, from below, by the same pad. The preferred spring, for these cases, is of the cross-body type, (no. 3, cross-body group), as light as possible, and to this should be attached a small, prominent pad the size of no. 3 or 4 of the oval pad diagram (fig- 67). If a truss of this type can be worn with comfort, it is advisable to continue its use for tw^o or more years, in children under five years of age. If, however, it causes any amount of pain, especially colicky pain in the abdomen, this indicates that the intestine is not fully reducible and the use of the truss should be discontinued. Such cases are unsuitable for mechanical treatment and operation is advisable at the earliest date convenient. Even where reduction and retention are complete, cases of hernia, associated with delayed descent of the testicle, are very seldom cured by truss treatment, as the congenital sac in communication with the testicle persists, and it is believed that they are properly operative cases. The only reasonable excuse for delay is, perhaps, the early age or bad general condition of the patient. ^^^^ere the testicle is retained high in the canal, associated with troublesome hernia of good size, some relief and protec- tion against strangulation of the intestine may be obtained by 12 178 ABDOMINAL HERNIA. using, after reducing the protrusion, a soft water pad directly over the testicle. A concave pad and one made in horseshoe shape have been used with at least partial success. The wear- ing of any pad that presses directly upon the testicle is, however, attended by more or less discomfort and aids in the destruction of the already impaired organ. That it leads to Fig. 86. Double retained testes associated with double congenital hernia. cancer of the testicle, as stated by some writers, has not been borne out by the author's experience. A testicle may be permanently retained within the canal by truss pressure, but if there is sufficient length of cord to allow of it, slipping beneath the truss pad is pretty sure to occur, and at such times is liable to produce the most excruciating pain. In the case illustrated in fig. (S6 a young married man of twenty-eight years of age had enjoyed perfect health in every TRUSS-FITTING. 179 respect except the defect under consideration. Both testicles were retained within the canals. At times one or hoth wcnild slip outside the external rint^- and he would then suffer extreme torture until he was able to reduce them to the canal. On the other hand, if he abandoned truss-wearing-, he was subject to symptoms of strangulated hernia. Between these two Fig. 87. M Double retained testes. Same as Fig. S6 with truss removed. Showing effects of extreme pressure. dilemmas he found truss-wearing the safer, and the truss shown on him seemed to be the best for his use. Examination of the photograph, with the truss removed (fig. 87), shows the result of the extreme pressure necessary to retain the testicles within the canals. This case was suhse(|uently operated upon. De- layed testes may, in some few instances, be retained in the canal under truss pressure for years with comparatively little trouble, and then become so irritable as to necessitate the abandonment 180 ABDOMINAL HERNIA. of the support. One patient, sixty years of age, had through- out his hfe worn a truss that retained the testicle in the canal, but the organ finally persisted in slipping under the pad and eventually descended into the top of the scrotum at that late period in life. A small, deep truss pad was adjusted so as to compress the upper part of the canal, retaining the hernia and thereby securing safety and comfort. Descent of the ovary into or through the inguinal canal complicates, more rarely, the mechanical treatment of inguinal hernia. It carries with it the same form of congenital sac and the same difficulties of treatment. It forms a mass in the canal which is hard to diagnose from adherent omentum. If the ovary is present the mass will usually at each period of menstruation become larger and more sensitive to pressure. As regards pain, truss pressure is better tolerated in these cases than where the testicle is similarly placed, and in several instances a small truss pad has been worn over the upper part of the canal, retaining the hernia wdiile the ovary has been protrud- ing at the external ring. In two or three cases a concave pad has been used directly over the ovary, retaining the hernia without any amount ' of discomfort. One patient, under observation for twenty years, has been obliged to remove her truss at each menstrual period, but suffers no discomfort at other times, and has declined operative relief. An ovary that has once entered the canal is seldom again fully reducible to the abdomen, and it is quite likely to become diseased in this abnormal position, especially when under truss pressure, and for this reason it is considered best to look upon them as operative cases unless especially contra-indicated by some other more serious condition. Interstitial hernia instead of following the canal and descending into the scrotum or labium, forms a sac for itself between the layers of the abdomen, and while it usually pre- sents a tumor covering a large area, its contents, if reducible, are returned to the abdominal cavity through a comparatively small opening at the internal ring. Personal experience leads TllUSS-llTTING. 181 to the l)elief that ahiiost any of the trusses used for obH(|ue inguinal hernia will be ecjually successful in this condition. The English prefer in these cases a larger pad such as shown in fig. 88, but the water pad of medium si;^e on either the cross-body or Hood spring has been found less cumbersome, and is believed to be more effective. Owing to the peculiar formation of the sac in interstitial hernia there is greater Fig. 88. Truss for reducible interstitial hernia. {Macready.) liability to the occurrence of strangulation, and unless the retention by truss pressure is complete at all times, early opera- tion for cure should be strongly advised. Pregnancy presents complications in the mechanical treat- ment of hernia that should be considered. In the earlier months difficulty in retaining the henn'a is increased by intra-abdominal pressure, and it is frequently necessary to add spring pressure. Later, this pressure should be removed and the size of truss increased. 182 ABDOMINAL HERNIA. As pregnancy advances and the uterus rises up out of the pelvis, it carries the intestines and the omentum higher in the abdominal cavity and away from the inguinal region. It there- fore commonly happens that a woman could with safety abandon her truss entirely during the last six weeks of gestation without suffering any protrusion of her hernia. It is not con- sidered best that this should be done, as a very light truss can be worn with safety. The disappearance of the hernia during the last months of pregnancy has frequently led both the patient and the doctor to believe that it had been cured, and conse- quently into the mistake of allowing the woman to get out of bed during her convalescence without having her truss on. This is fraught with special danger at this time, when the muscles are weak and flabby from recent distention. The truss should be very carefully readjusted before the woman leaves the bed. Adhesions of Hernial Contents to Sac Wall. — These cases will be more fully considered under the heading of irreducible hernia, and reference here is to those cases only where the bulk of the protrusion is reducible, but a small part, usually omentum, is held in the hernial sac by adhesion. This condition is not always recognized by examining the hernia, but may be first suspected by the extreme difficulty experienced in retaining it by the truss applied. In most cases where a hernia of moderate size cannot be retained by means of a well-fitting truss, there probably is a small piece of adherent omentum within the canal that is not reducible. After the truss is applied this omentum acts as a guide or actually drags down the bulk of the hernia. If the adherent part is omentum, no harm will come of wearing strong pressure across it, and eventuallv this will destroy it and the hernia become easily manageable by a truss of ordinary pressure. It is best, there- fore, to start with as strong a pressure as can be tolerated, and the patient should be instructed to reduce the hernia as soon as he feels that it has protruded under the truss pad. The so-called " Radical-Cure Truss " has been found most frequently sue- TRUSS-FITTING. 183 cessful (cross-body group, fig. no. 4), and a night truss is desiralMe. For the latter purpose nothing has been found better than the elastic truss shown in the group of spring- less trusses. The day truss should be applied before the patient leaves the bed in the morning and after careful reduc- tion of the hernia. The change to the night truss should be after the patient is in bed. In using extreme truss pressure the skin must be thoroughly cleansed twice daily and kept dry with some good antiseptic or talcum toilet powder. If bowel is adherent to the sac wall it will be found that strong truss press- ure cannot be tolerated. Colicky pains will be experienced similar to those in threatened strangulation, more frequently in the vicinity of the navel than under the truss pad, and truss-wearing should be at once abandoned and operative relief afforded. MECHANICAL TREATMENT OF IRREDUCIBLE INGUINAL HERNIA. It is not necessary to devote much space to this branch of the subject, as the proper treatment of irreducible hernia is by surgical, instead of mechanical means. There are cases, how- ever, where from one cause or another operation is inadvisable and then the question of palliative treatment must be met. The older works on hernia taught that it was dangerous to wear a truss pad over protruding omentum. Experience has so often disproven the correctness of this statement that it can be flatly contradicted. The protruding contents of an irreducible inguinal hernia are almost always omentum and intestine ; the latter being reducible, and the former adherent to the sides or bottom of the hernial sac. Such a case is shown in the photo- graph, fig. 89. Where the intestine is reduced it can, in many instances, be retained by strong truss pressure across the neck of omentum, wdiere it passes through the canal. Such pressure may protect the patient against strangulated bowel. The inconvenience that he will suffer will usuallv be that attendant 184 ABDOMINAL HERNIA. upon the wearing of an unusually strong truss. It seldom happens that pressure upon the neck of omentum does any- serious harm, and in exceptional cases it has caused its absorp- tion. In rare instances an inflammatory action has been set up, necessitating confinement to bed and application of an ice- bag for twenty-four or forty-eight hours, but nothing more Fig. 89. Large irreducible scrotal hernia. Intestine wholly reducible and could be retained by truss pressure. Subsequently cured by operation ; large mass of hypertrophied omentum amputated. serious has been seen. The case is certain to grow worse, even though protected against the dangers of strangulated hernia. The protruding omentum becomesi hardened and takes on a condition of hypertrophy which may lead to its development to an enormous size. In selecting a truss for these cases a strong spring must be used, usually of the cross-body variety of the ordinary type, or, still better, the radical-cure form. The water pad, aside from TRUSS-IITTING. 185 the fact that it is not durable, is a very g-ood one. Many times, however, a deep hard-rubber pad, of good size, may be worn with equal comfort and prove far more serviceable. If the irreducibility of the hernia is caused by adherent omentum in the canal, that does not extend down to the scrotum and is small in quantity, then a concave pad will prove useful. In these smaller cases it is not uncommon for the adhesions to Fig. 90. The hinged-cup truss for irreducible hernia. (Macrcady. > yield under the pressure of the truss and the hernia to become a reducible one. In such a case, where a concave pad has been used, it should promptly be changed to a convex one, in order to secure more perfect retention. The convex pad should be applied in every case where the protrusion can be reduced into the canal and is of small size. Where a mass of omentum is adherent in the scrotum, and a truss pad has been applied across its neck, a good-fitting. 186 ABDOMINAL HERNIA. strong suspensory bandage should also be constantly worn. The English use what they term a " Hinged-Cup Truss " (fig. 90), which appears to combine the pressure of a regular truss pad with a concave cup over the protruding omentum. Macready says of it: Fig. qi. Enormous irreducible left scrotal inguinal hernia. Both intestine and omentum irreducible. " It is seen to consist of two parts, of which one occupies very nearly the position of the pad of an ordinary truss and is not concave, and the other forms a scrotal portion, which is united to the former by a transverse hinge. The scrotal part is a three-sided frame of metal, covered in with chamois leather, curved to adapt itself to the distended scrotum. The apex of the triangle is downwards towards the perineum, and to it are attached the understraps, which are fastened to the side of the TRUSS-FITTING. 187 truss just behind the shoulder, as usual. Every pull on the understrap presses the cup against the scrotum, whilst by means of the hinge, the movement is hindered from being conveyed to the pad." The author has had no personal experience with it. F:g 92. Showing method of supporting enormous irreducible scrotal hernia, when no form of truss can be worn. The weiglit is transferred to the shoulders by a pair of suspenders. Irreducible scrotal hernia of enormous proportions, such as is shown in fig. 91, in which truss-wearing is impossible, and when operation is inadvisable, should be protected by especially constructed supporting bags (fig. 92). The bag should be made from measures carefully taken, while the patient is recumbent and with the tumor at its smallest. There should be a strong band about the pelvis to which can be buttoned an 188 ABDOMINAL HERNU. ordinary pair of non-elastic suspenders passing over the shoul- ders. A support of this kind will, in a measure, prevent increase in size besides adding materially to the comfort of the sufferer. Such hernise are pretty sure to cause the death of the patient eventually, and their operative relief should be seriously and immediately considered. It is true that danger attends such operations, but it must also be taken into account that the patient may be incurring a greater danger by declining it, besides almost complete disability. CHAPTER IX. MECHANICAL TREATMENT OF INGUINAL HERNIA IN INFANCY AND CHILDHOOD. One-half of all abdominal hernias occur during the first five years of life, and therefore come within the consideration of this branch of the subject. It may also be said that as regards treatment they form the most important, but by no means the most difficult cases. Important, because it is during this period that the defect must be cured, if this is ever to be accomplished without an operation. It is also important in the interest of the infant's good health, as it unquestionably affects the health and strength of the infant to a much greater extent than it does an adult. The mechanical treatment of inguinal hernia is not diffi- cult, and there are very few, if any, surgical affections that should be so thoroughly under the control of the family physi- cian. Infants are easier to fit than the adult, and they will be brought to the physician with greater regularity ; there is free- dom from many complications which arise later in life, and they prove of more interest because they are cured if properly managed. Unfortunately, however, it is a fact that children are grow- ing up to manhood and womanhood, carrying with them the liernise of infancy because of lack of proper attention on the part of the family physician. The case has been brought to the doctor, and he has " prescribed " a truss, and recommended a druggist or instrument maker who deals in these articles. Having done this, he feels that he has discharged his whole duty to his patient, and gives the case no further thought. The dealer sells to the patient whatever truss he happens to be inter- ested in, or has in stock, the case itself having little or no influence in deciding what form of appliance is to be worn ; nor in the majority of instances is the instrument selected ever 189 190 ABDOMINAL HERNIA. shaped to the form of the infant who is to wear it. In fact, tlie baby is fitted to the truss and not the truss to the baby. The sale of the truss having been made, no one but the parents feel any further responsibihty in the case, and this rests hghtly with them in the behef that just the right thing has been done.' If, by the merest chance, the truss was approximately correct at the time applied, this does not hold true a few weeks later, as the child is rapidly changing in shape and size. The parents know nothing of the advisability of frequently refitting the truss, the dealer's interest and responsibility terminated with its sale, the doctor is out of the case altogether by having referred to the dealer, and the result is the child goes without a cure. This is all wrong, and the wrong begins with the family physician who first sees the case and passes it into unprofessional hands. He should become at once as responsible for its cure as he would for a fractured femur or a dislocated hip- joint. If he cannot bring to bear upon it better knowledge than his own, then it is his absolute duty to do the best he can himself. In a few of the larger cities truss makers have, by practice, acquired considerable skill in fitting, and when they have taken the trouble to familiarize themselves with the anatomy of the parts, and have no special hobby or patent of their own to exploit, they do good work ; but the physician, already possess- ing the knowledge of anatomy and methods of diagnosis, will soon obtain by experience the necessary mechanical skill, and carry out treatment in a far more scientific manner than pos- sible for an unprofessional man, no matter how honest the intentions of the latter may be. He would also find that not only would the parents fully appreciate his efforts in behalf of their child, but by the cures which he would surely obtain his reputation would be materially enhanced. Fully 95 per cent, of the inguinal herni?e of infancy can be cured by careful mechanical treatment, but this must not be construed to mean the application of a truss, no matter how skillfully done, and the discharge of the case. It means taking the case under care and observation for not less than one year, MECHANICAL TREATMENT : INFANCY. 191 or until a cure is effected. It is important to discover, when possible, the cause of the hernia in the infant. Of course, if due to congenital defect, time alone can remove it, but it will surprise a good many physicians to know how often the cause can be ascertained and removed. In this connection, I will again call attention to the frequency of hernia resulting from constipation, whooping-cough, tight belly-bands, and long- continued crying. Attention to, and, so far as possible, removal Five weeks old boy with right complete inguinal hernia and hydrocele of tunica vaginalis on the same side. Hard-rubber cross-body truss applied. of, these causes is the first essential of successful treatment. This branch of the subject has already been considered under the cause and diagnosis of hernia. The mechanical treatment of hernia in infancy is believed to be the better method, for the reason that many can carry it out who are not qualified to do a surgical operation, and that the final result is equally good. The general practitioner can. if willing to devote the necessary time, secure good results with- out the use of the knife. There are very few ruptured infants that cannot be cured by the family physician. State- 192 ABDOMINAL HERNIA. ments that operations are advisable on children because trusses cannot be worn, are born of absolute ignorance of the me- chanical treatment of hernia; as a matter of fact, infants tolerate truss pressure better, if that pressure is intelligently applied, than do adults. It is unfortunate that almost all infant trusses are made entirely too strong, and if applied as sent out Fig. 94. Hood truss applied to child six months old. from the factory, must cause pain, if not actual injury, to the delicate tissues. It is just here that the physician's knowledge and supervision is essential. Nor is it a fact that hernia cured by truss is more liable to recur tlian wlien the same result has been brought about by an operation. It has been a matter of surprise that so few of the many children who have been under personal care and cured during the past twenty-five years have MECHANICAL TREATMENT: INFANCY. 193 had a return of tlieir ruptures. The recurrences have been wholly due to some violence, as whooping-cough, bronchitis, or some other cause, which would have been quite as likely to have produced hernia in a child who had never had it. The age at which mechanical treatment may be begun is a question which many physicians are in doubt about, and one often asked in the lecture-room ; the answer being that an infant old enough to be the possessor of a hernia is quite old enough to have the hernia treated (figs. 93, 94, and 95). Fig. 95. Cross-body hard-rubber truss as usually applied without perineal uuder-strap. Trusses have repeatedly been put on babies ten days and two weeks old, and there has been no occasion to regret beginning treatment at this early date. It is an erroneous idea, and unfortunately a rather prevalent one, even with physicians, that a baby wall ** outgrow '' this defect, or that it is " better to delay treatment until the child is older." It being conceded that it is advisable to begin treatment as soon after the development of the hernia as possible, the next question is as to the manner of supporting the protruding viscera. There is no bandage or makeshift of any description that will take the place, either for 13 194 ABDOMINAL HERNIA. comfort, cleanliness, or efficiency, of a carefully applied truss containing a metallic spring, and covered by material impennous to moisture, such as hard rubber or celluloid. Elastic bands, so-called elastic trusses, and bandages such as a "hank" of worsted (fig. 96) have been recommended at various times ; but they are a delusion and a snare, and usually an abomination. There is no lack of good trusses in this country. The druggists of every town and hamlet in the United States are annually visited by representatives of manufacturers, whose Fig 96. Application of a skein-of-wool truss. (Eccles ) This is considered a very poor makeshift. products are not equalled in any other part of the world, and still the number that are really suited for use on infants is very small, owing either to defects in the original design of the truss, or because of their being entirely too strong, even where the form of the truss is correct. All infant trusses which are made to apply from the side of the rupture, all of those where the pad is placed upon a descending arm at a level lower than the pelvic spring, and all trusses cushioned or padded with soft material, are condemned. The so-called French and Ger- man style of trusses, which comprise tlie bulk of stock of many druggists, should have become obsolete a half-century ago. MECHANICAl. TREATMENT: INFANCY. 195 In truss selection the following points sIkjuUI Ijc remem- bered : ( I ) The spring- should be so tempered, if steel, that it may be readily bent to the shape of the child, and its pressure added to or diminished by increasing or removing the amount of curve which it possesses. (2) The entire truss should be water-proof, that it may be frequently w^ashed and not damaged by urine. Any material which absorbs, and holds in con- tact with the child's skin, its excretions, will cause scalding and Fig. 97. Left complete inguinal hernia in child S years old, retained by hard-rubber cross-body truss with perineal under-strap. The latter is seldom required. excoriation, besides being actually filthy. (3) The truss should be simple and durable. The more simple in design the better is the truss, as a rule. Pads with ball-and-socket self- adjusting action, so-called, or with complicated set screws for adjustment, are entirely unnecessary and soon become useless. For the treatment of single inguinal hernia, in the infant, the cross-body spring, which, from the pad, crosses the front of the abdomen, passes around the hip of the opposite side, and across the back, is one of the most valuable appliances that can be used (figs. 93, 97). This truss can be obtained of 196 ABDOMINAL HERNIA. almost every druggist in the country, the spring is covered either with hard rubber or cehuloid and known in the trade as the " cross-body " truss. A spring of this kind will sur- round about two-thirds of the pelvis, and while it is supplied with a strap to complete the circumference, it readily holds itself in place whether the strap is used or not. Its pressure can readily be adjusted to the requirements of the case by increasing or diminishing the curve of the spring. Those covered with celluloid have the advantage of being readily shaped to the Fig. q8. De Garmo-Hood truss, German silver spring, hard-rubber cover. Applied to small right oblique inguinal hernia. form without heating ( which is necessary in shaping the hard- rubber springs), but have the disadvantage of being not quite so durable as those with the hard-rubber covering. The " Hood " truss, covered by celluloid or hard rubber, is made in infant sizes and kept by most dealers, and forms an extremely desirable truss for children whose pelvic measure exceeds sixteen inches, but is not desirable in those of smaller size. The De Garmo-Hood truss (fig. 98, 99) differs from the others in having a spring of German silver instead of steel, the MECHANICAL TREATMENT: INFANCY. 197 covering being of hard rubber. This material for springs in this form of truss has proven very valuable, owing to its being readily shaped to form without liability of breaking, and because of its not having the action of compression found in the steel spring. This truss has been extensively used in my private work. Manufacturers have told me that they could not sell it to the dealers because it was considered too lig'ht, and this clearly indicates how little the dealers comprehend the recjuirements of a proper truss for infants. Fig. 99. Right complete oblique hernia in boy of S years. Retained by De Garmo-Hood truss. The measure for selecting the size of the truss should begin just above where the hernia is seen; that is, at the internal abdominal ring, passing around the hips midway between the crest of the ilium and the trochanter major. This, in number of inches, will indicate the size of the truss required. In the shaping of the spring, the diagram method, previously de- scribed, will be found of the greatest service. The diagram is used instead of the child. If a spring covered with hard rubber is used, it should be passed through the flame of a spirit lamp until it is quite warm, and it can then be bent to the exact shape 198 ABDOMINAL HERNIA, required. As before stated, and it cannot be repeated too often, most infant trusses, as sent out from the shops, are too strong in pressure, and this should be carefully guarded against. Only a light pressure is required if the location of the pad is at the right spot. A very common, almost universal, error, in applying trusses, especially to infants, is in putting the pad too low (fig. lOo). If the pad rests on the pubic bone its efficiency is at once destroyed and the discomfort of the child is assured. Fig. ioo. Boy of 12 years wearing the German type truss. Fitting on right side good, on left bad, owing to the use of what the truss makers call a scrotal hernia pad. In this case, omentum was adherent in scrotum. It should be borne in mind that the design of truss-wearing is to keep the bowel entirely within the abdomen, and in order to accomplish this perfectly, the supporting pressure must be very nearly over the internal ring. The descent of the hernia, stopped at the external ring, may in this way be kept out of sight, but still occupies the upper part of the canal, and a cure will never result. A truss pad that rests against the bone cannot thoroughly protect the upper part of the canal. It is held away from it, and the child is made uncomfortable. MECHANICAL TREATMENT: INFANCY. 199 When the truss is fitted high the parts Ijack of the pad are soft and yielding, and discomfort is not caused. Having fitted the truss, the care of the case has only just begun. The case must be kept under observation and the truss changed in shape and size as the child grows. This change and growth is very rapid, and the child should at first be seen at least once a week, and not allowed to pass entirely from care nntil it is cured. In case of whooping-cough or severe bronchitis supervening, it is advisable to increase the truss pressure temporarily, but otherwise, after the first three months, it is well, if the hernia does not protrude, to begin to reduce the pressure. One year is the shortest period that a truss should be worn, and it should never be removed by the mother except for purposes of cleanliness, and this should be while the child is in a quiet and recumbent position. Absolute cleanliness must be insisted upon, and if the skin is kept clean and dry, it will tolerate strong truss pressure without abrasion. The free use of a good talcum toilet-powder is quite essential to the comfort of the infant truss wearer. After the careful cleaning and drying of the parts, it should be freely applied to the skin before placing the pad. Several good powders are on the market, or the formula given under general instructions, which was devised for this purpose many years ago and which has stood the test of time, may be used. Where an abrasion has once occurred and is slow to heal, on account of constant wetting by urine and the irritation of the truss, I have found nothing better than balsam of Peru. As previously stated, the truss should be kept on for a period of one year; if, however, the case has been one of con- genital hernia, it is best to prolong the wearing for two years. The truss pressure should be gradually lightened, until, dur- ing the last six months, it serves merely as a protective sup- port against the recurrence of the hernia. If a strong truss were worn during the same length of time and then entirely removed, there would be a far greater liability of the return of the trouble. Attention to the child's general condition should 200 ABDOMINAL HERNIA. not be overlooked. Constipation must be prevented and the digestive apparatus looked after. It adds greatly to the diffi- culties of controlling hernia if the intra-abdominal pressure is mcreased by flatulent distention of the intestines. Among the complications mentioned, fluid in the tunica vaginalis is, perhaps, the most common and certainl}' the most perplexing. This fluid, which is usually reducible to the abdominal cavity through the neck of the tunica, may be present when the case first comes under observation, but more fre- quently forms during treatment. It occurs in many cases of congenital hernia, usually from one to two months after treatment has begun. The parent will bring the child back and tell you that the rupture is not as completely held by the truss as it formerly was, and that it is down almost all the time. The means of distinguishing this from the hernia have already been mentioned. As regards treatment, it is best to let the fluid alone except in some rare instances where its quantity is so great as to inconvenience the child. If it ceases to return to the abdomen, indicating that the communicating neck has been obliterated, forming true hydrocele, it is well enough to tap with a small trocar, and this is usually sufficient to produce a complete cure. If from any cause the child has an effusion of fluid within the abdominal cavity and hernia, the fluid will also fill the hernial sac. In cases of this character truss pressure should be con- tinued in order to protect the tissues about the canal. The fluid cannot be retained by any form of truss. Non-descent of the testicle, associated, as it usually is, with hernia, requires careful consideration. We should never fail to examine carefully the scrotum of the ruptured child. It is not uncommon to see boys of eight and ten years old in whom it has never been discovered that only one testicle was present in the scrotum. In infancy this defect is likely to be over- looked, or, what is worse, if the testicle lies just outside the external ring it is mistaken for hernia, reduced, and kept back bv a truss. When the testicle is in the canal, treatment will. MFXHANICAL TREATMENT: INFANCY. ;^01 in many instances, have to be delayed until it passes the external ring; then a small pad may be applied over the upper part of the canal. In giving mechanical means the first place in the treatment of hernia in infancy, I do not wish to Ije understood as disap- proving surgical measures. On the contrary, I believe that it is as justifiable to operate for the cure of hernia in a child as it is for the cure of clubfoot or other malformations. If by mechanical means we cannot correct either, it is our duty to operate. In clubfoot there are cases which an experienced orthopedic surgeon could confidently state would never be cured by mechanical appliances, but this is scarcely ever true of hernia, some of the most extreme cases in infancy yield- ing promptly and a permanent cure resulting without the use of the knife. Tliis being true, beyond all question it is our duty to try the mild means first. If this is faithfully carried out, it will be found that few cases remain requiring operation. CARE OF SKIN AND GENERAL INSTRUCTIONS TO TRUSS WEARER. It is a matter of the utmost importance that the truss- wearer be instructed how to care for the surface of the skin under the bearing of the truss pad, as it will save him much dis- comfort. He must also be taught how to put on and take off his truss and cautioned regarding the danger incurred by going about without it, even while in his own room. It is best that he should also know how to reduce his own hernia and how to act in case he finds this impossible. The fatality attending strangulated hernia is in many instances due to the ignorance of the patient regarding its dang'ers. The first essential to comfortable truss-wearing is that the skin pressed upon l^y the pads shall be kept strictly clean and dry. Not only must the skin be kept clean, but the truss itself must be frequently washed. Besides the keeping of the parts clean, it has been found desirable to bathe the skin frequently with equal parts of 202 ABDOMINAL HERNIA. alcohol and fluidextract of hamamelis leaves; following this, after drying, by the application of a good, mildly antiseptic powder. The author has found nothing superior in the way of a powder to that published by him many years ago, which was designed for this special use, and the formula of which is here given : R Amyli ^iv Cretse Gallicae (powdered French ghalk) §ii Alum, ust., Acidi boracic, aa 3 ii Acidi carbolic!, 01. limonis, aa ^ss M. Sig. — Powder very fine. It should be made into a very fine powder and used by dusting the parts freely beneath the truss pad. As a toilet powder, for general use on infants, this will also be found superior to those commonly on the market. If the skin has been broken, or suppuration has occurred beneath the truss pad, as it sometimes will, balsam of Peru has been found useful. In slight excoriations the use of ben- zoated oxide of zinc ointment heals the surface quickly. Its action is especially good, on infants, where the skin lesion is started by urine getting beneath the truss pad. If there is suppuration, the pus should be washed off thoroughly with a solution of hydrogen dioxide and the Peruvian balsam freely applied. Healing may frequently be accomplished in this way without confinement to bed or the discontinuance of the use of the truss. There should be no compromise with a patient who suffers from a well-developed hernia, on the necessity of continuous truss-wearing. If for any reason he is obliged to discontinue its use temporarily, safety demands that he should maintain the recumbent position until such time as he can resume his truss. The man who has retained his hernia by a truss, for a time, and then discontinues its use, is in greater danger of strangulated hernia than lie who lias never worn one. MECHANICAL TREATMENT: INFANCY. 203 Trusses worn by adults should be removed at night after the patient is in bed, being reapplied in the morning before getting up. If the patient has a persistent cough, or the hernia is so large that protrusion occurs while lying down, then a special night truss should be provided. The elastic truss is best suited for this use. He should understand that the truss suitable for night use is worthless, even dangerous, for day use, and that a truss suited for day is unfit for use at night. Also that, in a measure, he is disabled for life, or until cured, and that he must remain under the observation of his physi- cian. A properly selected and good-fitting truss restores him, for the time being, to normal condition. Owing, however, to changes in his shape, changes in the truss, or bad habits formed in the wearing of a good truss, he should, for safety, submit himself to frecjuent inspection. A convenient way to instruct my patients has been to hand them a printed slip containing the following : INSTRUCTIONS TO TRUSS-WEARERS. Apply your truss before rising in the morning. Before applying, be sure that none of the hernia is protruding. Remove the truss after getting in bed at night ; if correctly fitted, it will need no attending during the day. In extreme cases a night truss may be needed. The one provided for day wear is unfit for such use. Infants and young children should wear the truss both night and day. Never go about your room without truss on. In taking shower bath keep truss on. Wash the truss — water will not harm it. Extreme cleanliness will add to comfort. Bathing the skin at night with equal parts of alcohol and Pond's extract will reduce irritation. The free use of a good talcum powder in the morning is advised. It is not safe to wear the truss over your underwear. Any unusual abdominal pain or discomfort should lead you to examine your hernia. If protruding, it should be at once replaced and the truss readjusted. This should be done while lying down if possible. If replacement of hernia is impossible and pain is severe, apply an ice bag and send for physician. Delay is dangerous. CHAPTER X. TREATMENT OF INGUINAL HERNIA BY GYMNASTICS. Works relating to abdominal hernia seldom mention gymnastics as an aid to palliative or curative treatment. It is, however, deemed quite worthy of consideration, and there is evidence both for and against it. On one hand, a large number of patients have been seen who have developed hernia by misguided physical exercise or who, already having hernia, have forced it down to such an ex- tent that strangulation or incarceration has occurred. On the other hand, many cases have been seen who have received de- cided improvement from its use. I cannot say, however, that of my own personal knowledge I know of any hernise permanently cured. I do not wish to intimate that I doubt the statement of scientific and careful observers who make contrary state- ments. Naturally those cases only who have hernia apply for relief, and those who have been cured have no occasion to. There is no doubt that the development of the muscles of the lower abdomen aids materially in the retention of hernia, even to the extent of its complete retention for a time in some instances, and I have for many years advised parents to allow their sons to go into almost any physical sport that they choose football excepted, , provided they were wearing a truss that retained their herniae. In very early youth I am convinced that increased muscular tone aids in obtaining a cure without operation. Furthermore, we must not pass by without due considera- tion the experience of such an able scientific observer as Jay W. Seaver, A.M., M.D., who for many years has had charge of the physical education of the students at Yale College. He has tabulated the physical examinations of over 35,000 college 204 TREATMENT BY GYMNASTICS. 205 students. Among- this number he found nearly 3 per cent, of the young men had inguinal hernia (The Treatment of Inguinal Hernia in the Young, Yale Medical Journal, Feb., 1900, and Feb., 1904). Believing that those young men who had hernia, represented a type that especially needed physical development, he made it a rule not to excuse them from gym- nastic exercises, unless especially recjuested to do so by the family physician. He directs that a suitable truss be applied and after the patient has become accustomed to it, the following exercises be taken twice daily, the severity of the movements being gradually increased : Fig. ioi. "(i) Lying on the back with thin cushion under head, raise the right knee, drawing it as close to the chest as possible, making special effort in the last part of the movement. Then extend the leg and perform the same movement with the left. Repeat the movement five times with each leg, then raise both knees toward the chest, doubling far enough to raise the j^elvis from the floor, placing the hands, palms down, just under the hips ; repeat five to ten times. It will be found much easier to take these exercises lying on a rug than on a bed, as a solid support gives the necessary resistance for the movement (figs. IOI, 102). 206 ABDOMINAL HERNIA. " (2) Lying on back with thin pillow under head and hands under back of neck, draw feet up to buttocks, then raise Fig. 102 hips from floor as far as possible bearing- the weight on the feet and shoulders. Repeat this exercise ten times. This movement will tend to strengthen the muscles of the abdomen and loins, Fig. 103. and is not a specially severe movement. This movement will be of increased value if the person will inhale deeply while hold- TREATMENT BY GYMNASTICS. ^207 ing the pelvis from the floor and exhale as the body is lowered (% 103). ■* (3) From horizontal position on Ijack, raise right leg to perpendicular, keeping the knee as straight as possible, and keeping left leg straight on floor, and hands with palms down, just under the hips. Repeat five times. Take the same exer- cise with left leg; then raise both legs to the perpendicular position an equal number of times, remembering to keep the leg straight at the knee. The movement may also be taken with fingers back of neck, but is more difficult. This is a Fig. 104. strong movement and must not be repeated so many times as to produce serious soreness of the abdominal muscles. By increasing at the rate of one movement every second dav. a healthy person may expect to accomplish twenty repetitions without discomfort (fig. 104). " (4) Lying on back, spread the legs so that the feet are three feet apart, then roll on to left shoulder, touching the floor with the right fingers as far as possible beyond the left shoulder, keeping the hips squarely upon the floor during the entire movement. Repeat five times and then take the same exercise, twisting the trunk to the right (figs. 105 and 106). 208 ABDOMINAL HERNU. " (5) Lying horizontal on back, with fingers back of neck, raise right leg and touch on floor as near the left shoulder as Fig. 105. possible, keeping the shoulders scjuare upon the floor. Repeat five times and take the same exercise with the left leg. This Fig. 106. movement is of special value in strengthening the oblique muscles of the abdomen (fig. 107). TREATMENT BY GYMNASTICS. 209 " (6) Standing in erect position, with the head and hips well back, inhale deeply, and, at the same time, draw in the lower abdomen as much as possible. Then relax the abdominal wall and exhale. Repeat from five to ten times, always trying to contract the lower part of the abdomen and, so far as pos- sible, push out the upper part near the waist line. Then reverse this movement by contracting the waist line \'igorously and cause, as nearly as possible, the wave of contraction to pass down over the abdominal wall. Fig. 107. " (7) Standing in position, with weight on the balls of the feet, with head and hips well back, raise the arms forward and upward, keeping the fingers well extended and palms parallel until, at the perpendicular position, they are the same distance apart as the breadth of shoulders. Inhale as the arms move upward, and use at least ten seconds in this inhalation. Then allow the arms to sweep downward to the original position, and the air to escape by the nose. Repeat six to ten times. " (8) Standing erect, with head well back, raise the hands sideward and upward to the horizontal position. Then bend the arms at the elbows until the finger tips toucli those of the opposite hand on the back of the neck. Then inhale deeply. 14 210 ABDOMINAL HERNL\. pushing the elbows upward and backward as far as possible. keeping wrists firm, and then exhale as the elbows are lowered, move slightly forward, but retain the finger tips in position on the back of the neck, and the neck well back during both inspiration and expiration. Repeat five to ten times. The abdominal wall must be made to move freely in this exercise, and it will be found that no free movement of respiration can be accomplished in this position, except by a use of the diaphragm and general abdominal wall. Fig. ioS. (9) Lying in a horizontal position with the toes under a sofa or any suitable piece of furniture, raise to a sitting posture, keeping the neck well back during the entire move- ment. There will be a decided tendency while taking this exercise to throw the head forward and bow the back. This must not be done. This exercise ma}- be repeated from three to ten times according to the strength of the individual (fig. 108). (10) Lying on the stomach, extend the toes on the floor and the arms in the opposite direction so as to secure the great- est length possible from tip of toes to tip of fingers. Then. with feet raised as far from the floor as possible, inhale deeply TREATMENT BY GYMNASTICS. 211 for at least ten seconds. Then exhale slowly, using about one- half this time in returning- to the quiescent condition. Repeat from three to five times, keeping the muscles of the limbs tense as in stretching during inhalation." Dr. Seaver advocates the use of the flattest truss pad that will retain the hernia and the gradual removal of pressure as the case improves. He believes that 75 per cent, of herniae occurring in young" men under twenty-five years of age, could be cured by the means suggested, and concludes as follows : " First, I w^ould recommend a surgical operation as the quickest and more efficient treatment for severe or long-con- tinued cases of inguinal hernia, where the matter of expense need not be considered, and wdiere there is no serious mental antipathy to an operation. Second, I would recommend what may be properly called the g}annastic treatment of such cases as are recent in development, and where the inguinal ring is not unduly dilated, although the case may be of fairly long standing; also in all cases, however severe, where surgical operation is not possible. Third, I consider the mere applica- tion of a truss, however good it may 1d€ and whatever the price paid for it, as simply palliative treatment." Geo. H. Taylor, M.D., published a work in 1885 (John B. Alden, New York) on " Pelvic and Hernial Therapeutics," including " Process for Self-Cure." While this work contains many valuable suggestions, it has been productive of much harm in that it leaves the patient with the impression that he is fully qualified to carry out his own cure. I have, in speaking of the causes of hernia, already stated my experience with the " Correspondence Schools of Physical Culture," and must again condemn any form of gymnastic exercise, for ruptured people, that is not personally supervised by an experienced instructor who appreciates its dangers as well as its good parts. A small, but more recent work by Bernard AlacFadden ("Natu- ral Cure for Rupture," Physical Culture Publishing Co.. New York, 1902), gives a series of exercises which he terms first, second, and third system, showing a gradual but an extremely 212 ABDOMINAL HERNIA. trying exercise for the abdominal muscles, which should never be used except under personal supervision. It is believed, as claimed by Dr. Seaver, that, for young people, systematic and carefully supervised gymnastic exercise is an important aid in the non-operative cure of inguinal hernia, but it is also considered a dangerous method for people nearing, or past, middle life. CURE OF HERNIA BY INJECTION. This method of treatment would receive no mention in this work if it had not been so extensively brought before the profession and so strongly endorsed (principally by those hav- ing a monetar)" interest in it) as to deceive those not familiar with the subject. From the fact that its use is almost always temporarily beneficial, and that it is curative in a few (very few) cases, it is not surprising that many physicians should be misled into recommending it. The opinions here expressed are based not upon prejudice, but actual trial in private prac- tice and in a large clinic, with every facility for following the subsequent history of the cases. This trial was made before present successful surgical methods were known. It was then, perhaps, excusable to test a method which now seems so crude and unscientific, as we were seeking a cure for hernia. The ultimate history of the cases injected was, as a rule, that of recurrence, and the method has been entirely abandoned for several years. Its promoters recommend it as a per- fectly safe method. Two deaths are known to have occurred from its use within the past few years, and one case was oper- ated upon in order to save the life of a woman who had been treated by a notorious (advertising) advocate of the injection method. In this case, his needle had punctured the wall of the intestine which was in the canal. Inflammation and strangu- lation rapidly supervened, and the woman was in a condition of collapse when first seen. An immediate operation, with the administration of oxygen and stimulants, barely saved her life. TREATMENT BY GYMNASTICS. 213 It is fully fifty years since attempts were first made by Velpean of Paris, Pancoast of Philadelphia, and others, to cure hernia by the injection of an irritatini^ substance either into the sac or the tissues of the canal around the neck of the sac. Heaton of Boston, a few years later, devised a formula which he used secretly for thirty years and then published.^ The early experimenters used for injection tincture of iodine, tincture of cantharides, and the essential oils. Pleaton used a combination of the solid and fluid extracts of white-oak bark, which was probably better than the formulae more recently used, consisting- of chloride of zinc, carbolic acid, cocaine, etc. The Heaton method was deceptive, as a certain amount of improvement was noticeable in every case. A few appeared cured for from three to six months, but unfortunately with almost the entire number hernia eventually recurred. From our present point of view, the method cannot be too strongly condemned. ^ The Cure of Rupture, Geo. Heaton, M.D., Boston, 1877. CHAPTER XL SURGICAL CURE OF INGUINAL HERNIA. In the great advance made in surgical work during the past few years the special surgery relating to the treatment and cure of abdominal hernia has occupied a foremost place. Per- haps, aside from pelvic surgery, no other branch has made an equal advance. The " radical cure of hernia " has been spoken of for many years, but the methods were not radical and seldom cured. There were operations for the radical cure, trusses for the radical cure, and still the fact remained that very few hernias in the adult were ever cured, and many surgeons had given up hope of seeing this very common affliction placed on the list of curable diseases. There is little time in this age of rapid advancement to discuss past failures, except, perhaps, to ask why they failed. Recent, and very large, experience has answered the question in a perfectly satisfactory manner, so that now it seems strange that light did not come to us before. It is a repetition of the old story of Columbus and the egg — after he had shown them how, they could all make the egg stand on end. The Columbus in the present instance was unquestionably Bassini, of Padua, Italy. ^ At least two of our own countrymen had devised opera- tions which would eventually have led to success, but the fact that Bassini published an operation, complete in its technique, and supported by a first report of over 200 cases, some oper- ated on several years previously, makes it only fair that we should give to Italy an honor which we should have been only too glad to claim for America. In operating to cure hernia at the present day the proposi- tion is not " to restore the canal to its normal condition," which attempt failed through many centuries, but to construct a canal better than it ever was before. ^Arch. f. klin. Chirg. Vol. xl, 1890, p. 429. 214 SURGICAL CURE. 215 The great success of the present operation lies in the thoroughness with which all abnormal tissues are removed from the inguinal canal and the subsequent correction of an anatomical defect which exists in the larger part of the human family. The failure to do these very things, and the general incompleteness of all previous operations, are the very good reasons for their almost uniform failure to produce permanent cure. For many years the imperfect operations were persisted in, because of the ever-present fear of doing anything surgically that would approach or disturb the peritoneal mem- brane or cavity. Furthermore, it was long believed that the persistence of the hernial sac was the chief cause of the continu- ance of the hernia, and if this could be destroyed, without injury to the patient, a permanent cure would result. The attempts to cure hernia in the past have been made at or near the external ring, while now the corrections begin at the peri- toneal surface and continue with each layer until the skin is closed. This is truly a " radical " operation for the cure of inguinal hernia. The preparation of the patient for an operation for hernia should be made with the same care in every detail that would be exercised in any other abdominal operation. There is plenty of evidence at hand to indicate that discredit will be reflected upon the modern operation for the cure of hernia by those undertaking its performance who would not think of doing any other abdominal work. This is sure to reflect against the operation in two ways. It will cause a mortality that is entirely unjustifiable, and it will show a larger percent- age of failures than should be presented. In most instances the applicant for an operation for the cure of hernia is in fairly good general health, and long preparation is unnecessary. It is important that the condition of the heart, lungs, and kidneys should be ascertained in order to intelligently decide upon the form of anaesthesia best suited for the case under considera- tion, and this should be done before the patient is prepared for operation. 216 ABDOMINAL HERNL\. AVhen possible, the patient should be under the control of a trained nurse, or in the hospital for about twenty-four hours before the operation is performed, to insure careful preparation and to regulate the food supply. A cathartic should be given and the parts prepared the night before the operation. If the cathartic is not effective, an enema should follow in the morn- ing. The preparation of the field of operation on the preceding night consists of a complete shaving of the entire region, the cleansing and application of a liberal green-soap poultice, held in place by a suitable bandage, usually the Spica. In the morn- ing this dressing is removed, the parts thoroughly cleansed with sterilized water, followed by 90 per cent, alcohol. Gauze moistened in a one to 2,000 solution of bichloride of mercury is then applied under a bandage and left in place until the patient is on the operating table. Here the field of operation is again scrubbed with liquid soap and a sterilized brush, and washed off with sterilized water, followed by a one to 2,000 solution of bichloride of mercury. Sterilized towels should now be spread so as to cover the entire patient, except the immediate field of operation, and all chemical solutions thrown away. No fluids, except sterilized water, or normal saline solution, should be used during the operation. Every person connected with the operation in any way should prepare in the most careful manner. Many methods have been tried, but none has been found better than first scrub- bing the fingers, hands, and arms to the elbows with soap in water that has been boiled, then washing in alcohol, followed bv a thorough washing in a one to 2,000 solution of bichloride of mercury. The finger nails are doubtless the most frequent carriers of disease germs, and they should be given the utmost care. They should be cut and filed down as near the " quick " as possible, and then in cleansing should receive special care and scrubbing. Sterilized rubber gloves should be worn, but the use of these should be preceded by the same careful scrubbing and chemical sterilization as though they were not to be worn. SURGICAL CURE. 217 Bassini Operation. — In the surgical cure of inguinal hernia, the work of the leading operators has crystalHzed into the following essentials, and while the operation is done under various names, it appears to the author that Bassini was the hrst to demonstrate their importance. ( I ) The complete removal from the inguinal canal of all foreign tissue (sac, fat, abnormal vessels). (2) Utilizing the fascial layers about the canal to so fortify it as to prevent recurrence. (3) The execution of the work with extreme asepsis to ensure safety and prompt healing. Almost all operators select some form of suture material not quickly absorbed, but few in this country now follow Bassini in the use of silk. Every operator of experience will modify the operation to meet the special indications of the case in hand. Briefly, the Bassini operation is as follows : ( 1 ) An incision through the skin, fatty tissue, and aponeurosis of external oblique muscle, wdiich exposes the canal in its entire length. (2) The sac is opened, its contents reduced and, after double ligation of its neck flush with the peritoneum, it is cut away. Any other tissue foreign to the canal is removed. (3) The cord is held aside and the lower border of the internal oblique and transverse muscles attached to Poupart's ligament by interrupted sutures (silk according to Bassini, per- sonally a continuous suture of kangaroo tendon is preferred). (4) The cord is placed upon the muscular wall and the aponeurosis and skin closed over it in separate layers. To Dr. Henry O. Marcy of Boston, a pioneer in modern methods for the cure of hernia, we are under obligations for showing us the value of kangaroo tendon. It is an almost ideal suture material for the deep buried sutures of hernia operations. We believe also that he was the first to use the subcutaneous stitch for the closure of the skin ; two things which add materially to the success of this operation. Aly own modification of the Bassini operation has been principally in the use of the kangaroo tendon, and in using a continuous 218 ABDOMINAL HERNIA. instead of an interrupted suture. In individual cases, it would seem that I had made ahnost every possible modification to meet the exigencies of the case in hand. Details, of the opera- tion used in over 1,200 cases of inguinal hernia, follow. OPERATION. Oblique Inguinal Hernia. — In planning the incision, cer- tain anatomical landmarks must be observed, and the first of these is to locate accurately the external ring. In thin subjects this is not difficult, as it is readily felt through the skin and sub- cutaneous fat, but where there is a thick deposit of adipose tissue it is not such an easy matter. It has been found that in a majority of cases, with male patients, the most satisfactory way is to roll the spermatic cord between the fingers and the pubic bone, following it up to its point of entrance into the abdominal wall, this giving accurately the external ring. The same test answers equally well in the female in most instances, as the thickened sac and its covering of fascia have very much the feeling of the cord in the male. Locate Poupart's ligament by placing a finger upon the anterior superior crest of the ilium and another upon the spine of the pubes. An imaginary line slightly curved downwards between these two points represents the ligament. In the adult the incision should be parallel with and about one inch towards the median line from Poupart's ligament, and from three to four inches long, according to the patient. In very fat patients, a much longer incision will be required through which to do good work than in those who are thin. The operation has been done frequently on adults by the author through an incision one and a half inches long, but this should be attempted by those only who are thoroughly familiar with the work. The incision passes through the skin and the superficial and deep layers of fascia to the aponeurosis of the external oblique muscle. No attempt need be made to recognize the two layers of fascia, as in many instances they cannot be dis- tinguished. In others, however, the dividing line is so clearly SURGICAL CURE. 219 marked as to lead the operator to belie\e that he has ah'eady reached the aponeurosis. The latter should be recognized by its white, glistening surface and the direction of its fibres. The lower end of the incision should terminate at the upper edge of the pubic bone, and its upper end should be well above the internal ring. Even in very large scrotal hernicC, it is neither necessary nor is it advisable to extend the incision into the scrotal tissues, as the whole scrotal tumor and sac can be turned out through the inguinal incision. If this incision is of full length, both the superficial epigastric and superficial pubic ves- sels will be cut and require clamping. In many instances if the clamps remain on during the following steps of the opera- tion up to the closure of the skin, ligature of the vessels will not be required. If the patient is fat, the clamps will obstruct the operative field, and it is better to tie the vessels at once or close them by torsion. There should be no uncertainty as to their complete closure, as subsequent oozing would almost certainly preclude primary union. At this stage of the operation, the beginner frequently has trouble in locating the external ring, and this is because it is partially covered by the intercolumnar fascia. This fascia can readily be scraped away from above downwards by the handle of the scalpel or the grooved director. The director can then be slipped through the external ring up under the aponeurosis of the external oblique muscle, and the latter is split in the direction of its fibres to a point a little above the internal ring. The inner split edge is taken by a clamp and the aponeurosis is stripped away from the internal oblique muscle towards the median line by slipping the fingers between the two. The outer split edge is clamped and all fascia removed from inner surface down to Poupart's ligament. The clamps should be allowed to remain on the flaps as a guide. The whole extent of the canal is now wide open, and still, in many instances, the sac is not visible and the beginner is perplexed as to its whereabouts, doing actual harm in some instances by cutting muscular fibre that should never be divided. In fact, no muscular fibre should 220 ABDOMINAL HERNIA. be cut in this operation. ]\Iuscle may be split and it will reunite without harm to its function; but once cut across its fibre, it is doubtful whether it will ever return to its former useful- ness and strength. The ilio inguinal nerve will usually be seen passing down over the sac and should be lifted up and put out- side of one of the clamps holding the aponeurosis, in order to protect it from injur}^ In finding the sac, pick up with thumb forceps the tissue presenting most prominently at the lower deep part of the wound, and almost invariably it will lead to the sac. The sac and the cord should now be lifted out of the canal together. The sac is covered by fascia that it has picked up from the edge of the muscles in its progress down the canal, and this can be readily divided by any blunt instrument. The cord should now be separated from the sac, and this is often attended by diffi- culty. It should be done by blunt dissection, and better by the fingers than by instruments. It is accomplished by carefully stripping one from the other, and the first point of separation should be as near the internal ring as possible. Many have failed in this part of the operation by trying to separate them at a point lower down. This is especially true in congenital hernia. The separation, to be accomplished at all, must begin as near the peritoneal surface as possible. At this point it can be done in almost every case, and it is one important element in the success of the operation. Especial caution is necessary in separating the vessels of the cord from the sac not to tear them, and it has been found most convenient and satisfactory to do this by clearing all tissue from the sac at one point and then to roll the sac in one direc- tion over the finger end while all tissues and vessels are cleared off by and held in the fingers of the other hand. The vas deferens, next to the artery of supply, is the most important vessel of the cord and the most likely to be overlooked, as in color it is white like the sac. Its location can always be ascer- tained by rolling the tissues between the thumb and fingers under considerable pressure. Its hard, wiry feeling is char- SURGICAL CURE. 221 acteristic. Communicating vessels broken while stripping away the sac, if at all important and on the cord, should be tied at Fig. 109. Showing, A, sac separated from cord ; B, cord held up by blunt hook ; C, lower border of internal oblique and transversalis muscles ; D, epigastric vessels, crossing wound transversely beneath internal oblique; E, split aponeurosis of external oblique held back by clamps on either side, showing Poupart's ligament at extreme inner border. once, as, if lost to view, they are hard to find again. Bleeding vessels on the sac surface are unimportant, as the entire sac is to be removed after ligation (fig. 109). 222 ABDOMINAL HERNL4. The sac should in every instance be opened and, if found empty, its neck hgated after clearing it of all vessels and fat. Where the size of the sac will permit, it is considered best that the operator hold the finger of one hand well within its neck, while the assistant ties down on the end of the finger. As the pressure of the ligature is felt around the end of the finger, the latter is withdrawn. By this method there is little danger of including a loop of bowel or piece of omentum within the liga- ture. After the first ligature has been completed, the sac should be perforated just outside of it, surrounded and ligatured again b}-^ the same strong catgut. In this manner two complete ligatures with perforation between them prevent the slipping off of either. The sac should be cut away before cutting the ligature, as by the latter the stump can be controlled and it can be seen that there is no bleeding. Ordinarily there are no important vessels in the sac wall, but there are very important exceptions to this rule, and a case is known where a young operator cut the sac without tying, expecting to close it as in an ordinary cceliotomy. Hsemorrhage resulted, which could not be, or at least was not, found, and which proved fatal to the patient. Another case was seen in consultation where the operator had failed to find the bleeding vessel. While the sac is being ligated, traction should be made upon it so as to draw it well up into the wound. In this manner the ligature is placed flush with the peritoneal surface, and when the sac is cut away it leaves no pocketing of peritoneum from within — the intra-abdominal surface is left practically smooth at this point. An accident that must be guarded against, at this stage of the operation, is the looping up of the spermatic vessels on the neck of the sac and their subsequent ligation. As the sac is tied, the operator should make traction on it so as to draw its neck well up into the wound. When it is tied and cut, it will retract and the peritoneal surface will become smooth upon its inner surface at the site of the internal ring. The canal should be cleared of all loose fat or other abnormal tissue, and the SURGICAL CURE. 223 operator is then ready to begin its closure, and upon the thoroughness and care with which this is done will depend to a very great extent the permanence of the cure. With the canal wide open and freed from the sac, it will be seen that there is a triangular space back of the cord, which is entirely unprotected by muscular or tendinous structure. In fact, there is usually nothing but peritoneum and its overlying fascia. This triangle, with its apex directed towards the iliac crest, is formed above by the lower border of the internal oblique muscle, below by Poupart's ligament, and the pubic bone forms its base. This muscular defect is overcome (in this operation) by freeing the lower part of the internal oblique and trans- versalis muscles from their connections above and below, slipping them down and stitching their lower border to Poupart's ligament. Fig. iio. Blunt needle (actual size) used in placing kangaroo tendon sutures in the deep muscular tissue and the aponeurosis of external oblique. The connective tissue between the aponeurosis of the external oblique and the internal oblique has been separated in the earlier part of operation. The internal oblique and trans- versalis should now be freed from their deep connections by gently passing the finger along under their lower border. When the deep muscles are thus freed above and below, their lower border can be brought into contact with Poupart's liga- ment without undue tension. With a strong, blunt, curved needle (fig. no) threaded with heavy kangaroo tendon, the lower borders of the deep muscles are perforated well liack from their edges, and at a point over the internal ring. The cord is held up by a blunt hook, or by the finger of an assistant. 224 ABDOMINAL HERNIA. the needle passed beneath it and through Poupart's Hgament, high up. When the suture is tied, it will be found that the Fig. III. A, cord held up by blunt hook ; B, internal oblique stitched to Poupart's ligament by kan- garoo tendon : continuous suture made by passing suture over point of needle each time after puncture of tissue, and before tightening the thread; C, aponeurosis held by clamps on both sides. lower Ijorfler of the internal obli(jue surrounds the cord closely. The muscle is now stitched to the ligament throughout the SURGICAL CURE. 225 length of the canal from the internal ring to the pubic bone (fig. III). -\n interrupted suture can be used if preferred, but the continuous is believed better, as it does away with the Fig. 112. Aponeurosis of external oblique closed over cord by continuous suture of kangaroo tendon. numerous knots and can be put in more rapidly. An additional suture placed above the cord has been suggested by Dr. ^^^ B. Coley. I have occasionally used this extra suture above the cord, but have usually preferred to crowd the cord up into the 15 226 ABDOMINAL HERNIA. extreme upper angle of the wound, making the canal as long as possible. The cord is placed on this muscular wall, which has been constructed beneath it, and the split aponeurosis closed over it by kangaroo tendon with the same stitch (fig. 112). The split made in the aponeurosis is C[uite likely to extend up under the intercolumnar fascia, and its appearance is there- fore deceptive. The first suture should be taken an inch, if pos- sible, above the apparent split, otherwise a weak place is left, inviting recurrent hernia. It is neither necessary nor advisable that the aponeurosis be brought together edge to edge. It is better that the needle punctures be well back from the edge and not all in the same line. The closing of the skin by the sub- cutaneous (buried) suture and the sealing of the wound by collodion, complete the operation. A compress of folded, sterilized gauze, held in place by adhesive strips across the hips, with a liberal spica bandage, form the dressings. Drainage need not be used except in enormous scrotal herniae, where the stripping out of the sac is liable to leave con- siderable oozing. In these cases a rubber drainage tube is carried through the bottom of the scrotum and left in for twenty- four hours. During this time its outer end is care- fully protected by moist bichloride gauze. The upper wound is completely closed and sealed in the manner described. The bandage and dressings on the hernial wound are not removed for ten days unless the elevation of temperature or pain demands it. An elevation of temperature on the day following the operation is not considered as indicating the removal of the dressings, but when it occurs about the fifth day it is sus- picious, pointing to wound infection. Under proper aseptic work, deep infection is never seen, and that which does occur is superficial, coming largely from the skin. The skin in old truss wearers is frequently in particularly bad condition, and no amount of cleaning will, with certainty, sterilize it. When such infection does occur, the dressings should be removed and the wound cleansed daily with some good antiseptic. I have found nothing better than borolyptol for this purpose. Delayed SURGICAL CURE. 227 healing does not, as has been claimed, prevent a permanent cure of the case. It is certain!}^ undesiraljle, but not a serious coni- pHcation. There are certain pecuharities of sac formation that demand shght modification in the operation. In congenital hernia, it is not essential that the entire tunica vaginalis should be stripped away from the cord and front of the testicle. That portion which occupies the canal, from the peritoneal surface to nearly the top of the testicle, should be separated from the cord and excised with ligatures applied at both the upper and lower points. There are instances also where it may not be advisable to remove the fundus of a very large accpiired sac from the scrotum, and the communicating vessels are quite large enough to prevent its sloughing after the excision of the neck. This leaves cjuite a mass of thickened tissue in the scrotum and the possibility of hydrocele occurring within the sac, so that unless there is some good reason for not doing so it is better practice to remove it. In old and feeble men, it is much more im- portant to terminate the operation with the greatest possible speed, than it is to be certain that no particle of thickened tissue shall remain in the scrotum. It is the opinion of the author that the Bassini method as described, meets in an ideal manner the indications for the operative cure of ordinary cases of oblique inguinal hernia. It is desirable, however, that every operator should be familiar with certain important modifications that may be necessarv in. cases where closure is extremely difficult. In 1895, Dr. Edward Wyllys Andrews of Chicaga ("Imbrication or Lap-joint Method," "A Plastic Operation for Hernia," CJiicago Medical Recorder, Aug.. 1895) sug- gested that in certain cases where there was great deficiencv of the internal oblique and conjoined tendon, increased strength could be obtained by " Imbrication '' or overlapping of the fascial layers (see also Surgery, Gynecology, and Obsfe fries, vol. ii, p. 89, January, 1906). This he accomplished in the following manner : 228 ABDOMINAL HERNIA. The opening of the canal and treatment of the sac were m every particular similar to the Bassini operation. In closing, however, the split aponeurosis, and whatever of the deficient internal oblique could be obtained, were brought down together and stitched to Poupart's ligament under the cord. The cord was then laid upon this wall, and the remaining outer flap of the split aponeurosis brought over it and edges stitched down to aponeurosis. This method places back of the cord the aponeurosis of the external and internal oblique muscles, and in front of it the additional overlapping layer of the aponeurosis of the external oblique. This would seem to utilize to the fullest extent the defective material that we may sometimes have to work with and the method has been used by the author on several cases with good results. Dr. Andrews says in his first paper, •" I make use of it to supplement and reinforce existing methods without losing sight of their good qualities," but in his more recent article he declares that he has adopted it as a routine method. A somewhat similar operation has been elaborated at the Johns Hopkins Hospital by Dr. Halsted and Dr. Blood- good (" The Cure of the More Difficult as Well as the Simpler Inguinal Ruptures," W. S. Halsted, M.D., Johns Hopkins Hospital Bulletin, Aug., 1903). In presenting this operation, I certainly cannot do better than to give it in Dr. Halsted's own words, and by the repro- duction of the beautiful plates by Brodel: The Operation. "(i) The aponeurosis of the external muscle is divided and the two flaps reflected as in the Bassini-Halsted operation. " (2) The cremaster muscle and fascia are split, not di- rectly over the cord, iDut a little above it. " (3) The internal oblique muscle is made as free as pos- sible. A little arti faction is here often necessary. If the muscle cannot be drawn, without tension, down to Poupart's ligament, it helps, I think, to make a relaxation cut or two in SURGICAL CURE. 229 the anterior sheath of the rectus muscle under the aponeurosis of the external oblique muscle. This sheath being in part the aponeurosis of the internal oblique muscle, one can readily comprehend that incisions into it, if properly made, mig-ht be of service. It is well, however, to postpone making such incisions until the sewing- of the internal oblicjue muscle to Poupart's ligament is begun, for then the amount of tension can l)e nicely gauged and the number, length, and precise position of the Fig. I 13. Showing relalive position of sac, cord and vas deferens ; method of haiidHng. {Hahtfd ) relaxation cuts determined. A second reason for postponing relaxation incisions into the anterior sheath of the rectus muscle is that we sometimes use this portion of the rectus sheath to close the lower part of the inguinal canal, as already stated. " (4) When the veins are large, and this is usually the 230 ABDOMINAL HERNIA. case, they should be excised with very great care to avoid even the slightest extravasation of blood into the tissues about the smaller veins and about the vas deferens which they accom- pany. And the vas deferens, as first emphasized by Blood- good, should not be raised from its bed or handled or even touched, lest thrombosis of its veins occur (fig. 113). The Fig. 114. Showing the cremaster being fastened under the internal oblique muscle by fine silk sutures. {Halsied.) veins should be ligated as high up in the abdomen as pos- sible, being pulled down quite firmly just before the ligature (in a needle with blunt end first) is passed between them. As a precaution against slipping, we apply two ligatures of tine silk, both for the abdominal stump and for the testicle stump of the veins. The farther from the testicle the veins are divided, the better, provided, of course, that their stump is external to the external abdominal rine. SURGICAL CURE. 231 " (5) Ligation of the sac by transfixion or by purse-string suture at the highest possil)le point. Both ends of this suture, after tying, are threaded on long curved needles, then carried far out under the internal oblique muscles from behind for- wards, and, passing through the muscle, about 5 mm. apart. are tied. The idea was suggested to the author by Kocher's operation, the principle being essentially the same. Fig. 115. .1 1 1 / \li / / / I / / / 1 \^^l telS^^T' ^^jk -.^» ^"M Ws^ '^^^Tr'"' \.-'' ' / / pi 1 ^ t' iii i "^^^S iy • 'x%^SnH ^S^^^ """^^Bk KbSS^ ■ c ■ fmatter' ;gH fl l^ij'"' n ^g m ■ 1 1 Internal oblique sutured to Pouparl's ligament by catgut. {Halsted.) " (6) 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. 114). " (7) The internal oblique muscle, mobilized, and possibly further released by incising the anterior sheath of the rectus muscle, is stitched (the conjoined tendon also) to Poupart's 232 ABDOMINAL HERNIA. ligament in the Bassini-Halsted manner (fig. 115). Catgut is usually employed for this suture. The drawing was made from an unusually muscular subject and possibly exaggerated the size and extent of the internal oblique muscle, as well as of the cremaster, although the artist endeavored to record accu- rately what he saw. " (8) The aponeurosis of the external oblique muscle is overlapped, as shown in figs. 116 and 117. This is known as Andrews' method {The Chicago Medical Recorder, Aug., Fig. n6. Overlapping of the aponeurosis of the external oblique, first step. {Halsted.) 1895, vol. ix, p. 67), although devised independently by us.* " (9) 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. * April 13, 14, igo6, Dr. Bloodgood demon.strated before the Society of Clinical Surgery (Surgery-Gynecology and Obstetrics, June, 1906) his present rhethod of operating upon inguinal hernia without transplant- ing the Cord, using the internal oblique fascia instead of the rectus for closing large hernial openings. SURGICAL CURE. 233 Patients are kept in bed for a period of eighteen to twenty- one days." This operation differs from the Bassini method in the fol- lowing particulars. First, that the essential part of the cord, the vas deferens and its associated vessels, is not lifted from its normal position. Second, in the ligation of a part of the vessels of the cord in most instances ; and, third, in the closure of the fascial layers by overlapping. While I have great confi- FiG. 117. Overlapping of the aponeurosis of the external oijlique, beeond sit)). \Hahttd.) dence in this operation, and its use in the hands of its author and others has proven its value, it has not been adopted by me for the following reasons : In getting 99 per cent, permanent cures by the Bassini operation, I have felt that more could hardly be expected from any method. I have also been timid, perhaps unnecessarily so, about closing the canal without trans- fer of the cord, as it did not seem possible to me to get as strong a closure. Excision of the veins I have long used in excep- tional cases where the cord was uncommonly large. In many 234 ABDOMINAL HERNL\. of the cases a regular varicocele operation has been done through the inguinal incision. In the displacement of the cord several modifications of the Bassini method have been suggested, one of the most recent being by AA'ullstein of Halle (Cciitralblatt fur Chirurgic, no. 38, 1906, Beilage). His incision starts at the pubic spine and makes a bow-shaped curve upward and outward to the neigh- borhood of the internal ring, one or two finger-breadths above Poupart's ligament, and the skin flap is reflected downward to it. The aponeurosis is split as in the Bassini operation, and the sac removed. The cremaster fibres are separated Fig. tiS. Sectional view of fascial layers in completed operation. {Hoisted.) from the cord, but not otherwise disturbed. The transversalis fascia is now split, being careful not to injure the epigastric vessels, and the cord displaced backward upon the extra- peritoneal fat. The external and internal oblique muscles, transversalis muscle and fascia, are then all stitched to Pou- part's ligament throughout the canal to near the external ring, as shown in fig. 119. A flap is then made from the outer two-thirds of the anterior rectus sheath as shown in the cut, and the cord is transferred from the external ring to the upper angle of this incision. The fibres of the rectus muscle are then dissected and the end of the flap stitched beneath them and the cord as shown in fig. 120. AMien the sutures are tied the SURGICAL CURE. 235 aponeurotic flap is pulled l)ehiiKl the rectus muscle, and the cord assumes a course running well behind the same muscle, curving outward and downward to reach the scrotum. The gap in the rectus muscle is repaired by stitching its edges together. In a series of 1,500 children under fourteen years of age, operated upon at the Hospital for Ruptured and Crippled, New York, on 125 the cord was not transplanted, and there were 5 Fig. 119. ' i Cord placed next the peritoneum, tissues stitched over it to Poupart's ligament ; flap cut in aponeurosis, into upper angle of which cord is to be transferred. relapses, while in 1,076 Bassini operations there were only 6 recurrences ("Results of 1,500 Operations for the Radical Cure of Hernia in Children," Wm. T. Bull and Wm. B. Coley, N. Y. Med. Record, March 18, 1905). These results confirm my long established belief that the transfer of the cord adds to the permanence of the cure. Direct Inguinal Hernia. — It is in direct hernia that we find, in many instances, a deficiency of tissue with which to make a closure that will permanently cure the case. It has been my 236 ABDOMINAL HERNIA. custom in operating upon direct hernia to carry out the various steps of the Bassini operation the same as done in the obhque variety. The sac protrudes inside of the cord (i.e., towards the median Hne) and does not occupy the whole canal, but the latter has been opened in its entire length the same as in oblique hernia, the cord has been lifted from its groove, and the internal oblique closed beneath it. It has seemed to me that in Fig. I20. Cord transferred to upper angle of flap ; the latter passing beneath it is stitched to the rectus muscle. this way, especially if the internal oblique has been carefully freed from its attachments, a better closure may be made than possible without transfer of the cord. Cases are not uncom- monly met with, however, where the muscular structure of the internal oblique and the conjoined tendon are so deficient that it is not possible to make a strong barrier against the return of the hernia with them alone. We then have a choice of splitting its sheath and using the rectus muscle (suggested by Wofler in 1892, Beitriige z. Fest- SURGICAL CURE. 237 schrift f. Th. BiHrotli, and in 1898 in a better form by Blood- good), or what would usually seem better, using the sheath itself to close with as suggested by Halsted. In some instances it will be found that the muscle can be brought down without undue tension and the closure made strong. If any amount of tension exists, however, the sutures are sure to cut through its Fig. 121. Halsted's method of utilizing the split sheath of the rectus in closing the canal where there is deficiency of conjoined tendon. fibres and the muscle will resume its normal position. On the other hand, by cutting a flap from the sheath of the rectus it can be turned over and the weak triangle permanently fortified. This is beautifully illustrated by the plate made by Brodel and reproduced from Halsted's article already quoted (fig. 121). I have resorted to its use with success where I am confident failure would have resulted from the ordinary opera- tion. This has been done in addition to bringing down all of 238 ABDO]\nNAL HERNIA. the internal oblique that could be obtained. This method of interlapping of the fascial layers is one that has probably been utilized by almost every extensive operator for hernia, both before and since the publication of Dr. Halsted's article, but the details probably have not been as carefully elaborated any- where as they ha\e at the Johns Hopkins Hospital. The sac of a direct hernia is almost always broad at its base or neck, and usually cannot be tied off with a circular ligature, but must be closed as a laparotomy wound is, by stitching its edges together. In these cases it must be con- stantly borne in mind that the work is being done in the imme- diate proximity of important blood vessels and of the bladder. Two unpublished deaths are known to the author, resulting from haemorrhage into the abdominal cavity from vessels injured by a needle used in making this form of closure. The parts had in both instances been closed, and there was no external evidence of the haemorrhage. Another case, seen in consultation, where fortunately the haemorrhage was external, the patient was saved by reopening the wound at once and tying the deep epigastric arter}' which had been perforated. The bladder has also been punctured in the same manner, lead- ing to subsequent extravasation of urine. In uncomplicated cases of inguinal hernia, if primary union has been obtained, the patient is allowed to sit up on the tenth day, and leave the hospital on the fourteenth day after operation ; the bandage is continued for four weeks longer and then all support abandoned. CHAPTER XII. COMPLICATIONS IN THE SURGICAL CURE OF INGUINAL HERNIA. Oblique. — In the canal may 1)e found fat, abnormal ves- sels, delayed testes, ovaiy, appendix, adhesions, caecum, sigmoid flexure, and bladder. In operating for the cure of inguinal hernia there are complications that cannot be anticipated, but there are others frequently seen where the operator should l^e prepared to instantly modify the operation to meet the demands of the case. The disposition of surplus fat in the canal has already been spoken of. No loose fat should be allowed to remain, either in or near the canal, and safety is always on the side of ligating it before removal, care being taken not to make such traction upon that layer of fat just outside of the peritoneum, as to draw that membrane or a fold of the bladder within the ligature. Remember that fat protruding into the canal, near the pubic bone, may be that covering the anterior bladder wall, of which more will be said later. Enlarged or varicose veins will be found not only in the canal of the male, but (rarely) in the canal of the female, and these should be carefully ligated and excised. In the male it has been pretty well established that a fairly large number of the vessels of the cord can be cut away without harming the testicle, several writers claiming that if the vas deferens is pro- tected and everything else divided, the testicle will still main- tain its vitality and function. I must confess that I have not complete faith in the power of the very small vessels, that ac- company the vas, to perform the full work of the testicle. This feeling remains, even though in the one instance where I cut away the entire cord except the vas and its closely associated vessels, no atrophy occurred. Delayed Testes. — The imperfect descent of the testicle forms one of the rather common complications in the surgical 239 240 ABDOMINAL HERNIA. cure of hernia. In 1,205 operations for the cure of inguinal hernia, I found ^2 cases where this condition was associated. These patients have been largely boys between eight and sixteen years of age (figs. 122, 123, and 124), the youngest patient being five and the oldest thirty-five years old. The operation has not been encouraged in very young children who were having no trouble from the condition, under the belief that Fig. 122. Right retained testicle and complete inguinal hernia in a boy lo years old. about the tenth year was the most favorable time. It is con- sidered perfectly justifiable, however, and to be advised any time after the seventh or eighth year, or any time earlier when demanded by the discomfort of, or danger to, the patient. In 65 of the y2 cases it has been possible to place the testicle outside of the abdominal wall, and usually well down in the scrotum. Not in a single instance has there been retraction of the testicle into the canal subsequent to operation, so frequently com- plained of by the earlier writers. This fact is considered due COMPLICATIONS IN SURGICAL CURE. 241 to the extreme thoroui^lmess exercised in freeing- the cord from all tissues that would restrict its descent. Not in anv instance Fig. 123. Boy 9 years old. Right testicle retained at external ring. has the testicle been anchored to the scrotum or other tissue. Care has been taken to close the external abdominal ring so Fig. 124. Double retained testes; age, 13 years. Right at internal ring, left at e.xternal ring. Subsequent operation put both in top of scrotum. closely around the cord that the testicle could not slip back into the canal. In 7 of these cases (all adults) the cord was found 16 242 ABDOMINAL HERNIA. permanently so shortened as to preclude the placing of the testicle in a comfortable position outside of the canal. That is, if placed outside of the external ring, it would have been so tightly held against the pubic bone as to cause discomfort and danger of injury. In delayed descent of the testes, even though hernia is not actually protruding, there is usually an accompanying sac suit- FlG. 125. Showing sac around delayed testicle, the latter appearing to be inside of it. Sac held open by clamps. able for its reception. The interior of such a sac is illustrated in fig. 125, and, as there shown, the testicle has the appearance of being inside the peritoneum. This in reality is not true in any case. The testicle may be completely enveloped by peri- toneum and hang free in the abdomen, the peritoneum actually forming a mesentery by which it is supported and which, on the other hand, prevents its being placed in its normal receptacle. By careful manipulation the sac can usually be separated from COMPLICATIONS IN SURGICAL CURE. 243 the cord at a point near the internal ring, and when it and all fascia have been cut through, the vessels of the cord can be further stripped away from their attachment outside of the peritoneum, and thereby considerably elongated. Freeing the cord of everything but its essential elements is absolutely neces- sary to insure success. The neck of the sac should Ije closed either by ligature completely surrounding it, or by a purse- string suture applied from its inside. The cord should be free Fig. 126. Double retained testicles, two years after operation, placing them under muscular wall and obliterating inguinal canals. For photographs of this case before operation, see figs. 86 and 87. from every form of adhesion, so that its vessels can be straight- ened out to their greatest length. When this is done, it will almost always be found that the testicle can be placed in the scrotum. Before this can be done, however, a suitable pocket for its reception must be formed by running the finger down into the scrotum and forcibly dilating it. When this has been accom- plished, the testicle should be placed in this pocket and the operation may be completed by the Bassini method. I have 244 ABDOMINAL HERNIA. found no child in which this procedure could not be carried out, but in the adult the problem is quite a different one. In 7 of my adult cases there appeared to be no way of sufficiently lengthening the cord so that the testicle could be placed in its normal receptacle. Some writers glibly tell us to remove these testicles, that they are worthless and liable to cancerous or Fig. 127. Retained left testicle and irreducible inguinal (interstitial) hernia ; age, 24 years. A large, deep-seated tumor (shown in fig. 12S), in left inguinal region, does not show. tubercular affections. Recent studies, however, show conclu- sively, it would seem, tliat the testicle has a function aside from its procreative power, and that this function is beneficial to the growing child or young man. The well known mental effect following their removal is also to be taken into account before sacrificing one or both of these organs. Furthermore, it is yet to be proven that testicles lodged in the abdominal wall are any COMPLICATIONS IN SURGICAL CURE. 245 more liable to malignant disease than when in their normal position. The necessity of having some form of operation that would provide for the saving of these testicles, where the cord is too short to allow of their being put in the scrotum, was forcibly brought home to me in the case shown in fig. 126, two years after operation. This y(^ung man demanded that unless I could otherwise afifdrd him relief, that both testicles should be Fig. 128. Case of retained testicle shown in fig. 127. Whole sac and contents before opening. removed. He was 25 years old, had been happily married for two or three years, and was thoroughly competent to discharge his matrimonial obligations. He had suffered extremely, both from the slipping of the testicles under the truss pads, and from attacks of strangulated hernia whenever the truss was left ofif. The amount of constriction by the truss, which was found necessary in order to retain both the hernia? and the testicles, is shown in the photograph (fig. Sy) which was taken upon the removal of the truss. In entering upon 246 ABDOMINAL HERNIA. this operation, I had no very definite idea just what I should do, and when I had finished thought that I had devised a new operation for just such cases, but found shortly after- wards that my friend, Prof. Dawbarn, had recommended practically the same procedure. His operation had not espe- cially contemplated the relief of cases of delayed testes, but the cure of ordinary inguinal hernia.^ F"iG. 129. Sac with testicle inside, shown by dotted line. The location of the cord is not so distinct as here indicated. Just how much I may have been influenced by this article, or whether I had even read it, is now impossible for me to say, but of this I am quite certain that I did not have it in mind at the time the operation was performed. The procedure is as follows : The incision is made in every respect as in the Bassini operation, the aponeurosis of the external oblique being split to, or above, the internal ring. The sac is taken out completely (as shown in figs. 128, 129), before opening. In some cases it has ^Transplanting Testicles for the Cure of Hernia, Robert H. M. Dawbarn, M.D., Wood's Reference Handbook, Vol. ix, p. 415. COMPLICATIONS IN SURGICAL CURE. 247 also been possible to separate the vessels of the cord and vas from the neck of the sac high up before opening, and this, when Fig. 130. Retained testicle, figs. 127 and 128 ; sac opened. Omentum in right hand, testicle within sac in left hand. it can be accomplished, is desirable. ( In the case shown in figs. 127 and 128, the sac was full of omentum, which was ampu- tated and the stump reduced, leaving the testicle showing from F'iG. 131. Sac cut away from testicle, ready to tie with purse-string suture. Should be closer to peritoneal surface than here shown. the inside of the sac as seen in fig. 130.) The neck of sac (really the tunica vaginalis) must be gradually worked away 248 ABDOMINAL HERNIA. from the cord just where the vessels leave it to dip down into the pelvic cavity, and a ligature is either passed around it, or a purse-string suture is placed from its inside, and it is cut away from the cord and testicle (figs. 131, 132). If it is now decided that the cord is too short to allow of the testicle being placed in the top of the scrotum, the fingers should be run under the internal oblique and transversalis muscles towards the median line, forming a pocket between these structures and the peri- toneum (fig. 133). In this pocket the testicle is then placed and the canal entirely obliterated by closing it according to Fig. 132. Sac tied by purse-string suture. the Bassini method, except that there is no cord to provide for. The closure can be completed, as it is in most cases, in the female. In the 7 cases where I have placed the testicle in this posi- tion, the patients have, in every instance, experienced the most complete comfort. In one doubtful case on the left side, I found that the testicle would come well outside of abdominal wall, Init not fully into the scrotum, and I made the mis- take of leaving it in this position instead of placing it under the muscles as on the otlier side. It has since been a source of more or less discomfort to the patient. In young chil- dren, the subsequent and further descent of the testicle can COMPLICATIONS IN SURGICAL CURE. 249 Testicle Lifting up internal oblique and transversalis muscles, to slip testicle into preformed pocket in front of peritoueum. 250 ABDOMINAL HERNIA. be counted on, but not so in the adult. A photograph of the first case that I operated upon by this method, two years after- wards, is shown in fig. 126. This operation was done ten years since, and the rehef and satisfaction of the patient has been most gratifying. This is equally true with every patient upon wdiom the method has been used. Fig. 134. Interstitial hernia and retained testicle on right side in a man of 25 years. Right side of scrotum rudimentary. Hernial sac found beneath external oblique muscle. Testicle inside of external ring. I wish it clearly understood that I have not done, nor found it necessary to do, this operation of placing the testicle between the peritoneum and the muscular wall of the abdomen, on any young child, but I am convinced that it is far better than castration, in adult cases. If the testicle can be brought down as low as in the case shown in figs. 134 and 135, it is COMPLICATIONS IN SURGICAL CURE. 251 better to put them in the scrotum. It is beheved that any time after the patient has passed eight or ten years of age, these cases of delayed testes should be looked upon as belonging to the surgeon. They always carry with them an element of danger in the ever-present sac which frequently communicates with the abdomen by a narrow neck, making strangulation Fig. 135. Same as preceding, three weeks after operation. Testicle in top of scrotum. especially liable and dangerous. These sacs may exist for years without actual protrusion of intestine, and when it does occur, a small knuckle of gut, strangulated beneath the thick muscular covering, is quite liable to be overlooked upon exam- ination. The many individual peculiarities that have been met with in connection with this class of cases, indicate their excep- tional danger in case of strangulation : as adherent omentum, 252 ABDOMINAL HERNIA. adherent intestine, and, in one case, an adherent vermiform appendix. Various other operations have been suggested for the rehef of this condition, as suture of the testicle to the bottom of the scrotum, or carrying the suture through the bottom of the scrotum and fastening it to a wire frame, of attaching the Fig. 136 Sylvia L., aged 7 years. Double inguinal hernia. Supposed to be a girl and was so dressed. Operation demonstrated double retained testes. testicle to a flap from the tissues of the thigh, or even attaching it to its fellow of the opposite side. None" of these methods are given in 'detail, as they have not proven successful, but the one described has. One of my cases of this type is worthy of mention somewhat in detail, as showing how analogous the physical indications of sex may become by certain tricks of development. COMPLICATIONS IN SURGICAL CURE. 253 Sylvia L., aged seven years, was apparently (without any- thing in a general way to indicate that she was not just what she was named and dressed for) a girl, of rather large size for the age. Until recently the mother had never doubted the sex of her child, but on consulting a physician, he found the large swelling shown in the photograph (fig. 136), and detected two small bodies within these swellings that he believed to be testicles. When the hernize were reduced (fig. Fig. 137. Sylvia L. Herniae reduced. 137), the external parts presented what appeared to be the normal vulva of a female child, except that the labia were some- what larger than usual. Upon separating the labia (fig. 138) the parts seemed to indicate an abnormally large clitoris and the entrance to the vagina. I operated upon this child at the Post-Graduate Hospital, curing its hernia, and at the same time carefully examined the pelvic cavitv, but, as expected, no trace of uterine appendages were found. The urethra opened just below the penis and the latter, when liberated, would have been nearly of normal size. 254 ABDOMINAL HERNIA. It had been intended that considerable should be done in restoring him to the sex that nature had intended him to repre- sent, by various plastic operations, and with this in view, the testicles were left down in what was afterwards to become the scrotum. The penis was to have been liberated and the urethra brought out through it, and then the divided scrotum was to have been united. The child had Potts' disease of the spine, and upon his recovery from the hernia operations, it was deemed advisable to delay further surgery for at least one year, but before this time arrived, he developed pulmonary tubercu- losis and died. In 1,411 hernia operations done by the author, 1,205 h^ve been of inguinal type, and the testicle has acted as a complica- tion as follows : Removed for disease : sarcoma 2, degeneration i 3 Removed to save time in operating 2 Not found I Found within abdomen (brought out i, left in i) 2 Delayed descent, right side (put in scrotum) 39 Delayed descent, left side (put in scrotum) 33. 72 (8 were both sides) Buried beneath abdominal muscles (3 sing., 2 dble.) 7 87 Ovary in Canal. — It is not very uncommon, in operating for inguinal hernia on the female, to find an ovary in the canal. As stated elsewhere, when the ovary drops into this posi- tion it is usually difficult to reduce without operation, and it is as persistent in attempts to slip under the truss pad, if one is being worn, as would be a delayed testicle in the same position. In operating, an ovary found in the canal, if not diseased, should be returned to the cavity of the abdomen after it has been entirely freed of adhesions. In two instances I have been obliged to remove them on account of disease. No case of double descent of the ovaries has come under my personal observation, but a number have been recorded by COMPLICATIONS IN SURGICAL CURE. 255 other operators. One such, that is of special interest on account of family history, is reported by Dr. William P. Matthews of Richmond, Va. {"' Hernia of the Ovary Inguinal," A'. Y. Medical Record, Nov. 30, 1901). A girl of seventeen, who had double inguinal hernia present since birth, had never menstruated. Upon operation the ovaries were found in the canals, and it was ascertained that she had no uterus. Her great grandmother, twice married, bore children Fig. 138. Sylvia L. Supposed labia held apart, showing what was thought to be the clitoris but which was really a small penis. The urethra was immediately beneath the penis, forming what appeared to be the vagina. by each union. Eight female descendants of the first marriage were never unwell; one of the two daughters by the second marriage was never unwell. Two aunts of the patient have never menstruated and one has double reducible inguinal hernia. Five first cousins have never menstruated and two have double hernia. The patient's sister has never menstruated and has double hernia. I had a woman of superb physique under my care for many years, for double inguinal hernia, who had never menstruated and whose uterus and ovaries were undiscoverable and prob- 256 ABDOMINAL HERNIA. ably absent. She was twice married, but never bore children. Dr. R. Ferguson of London, Ontario (" Inguinal Hernia of an Imperfectly Developed Uterus and Appendages," American Medicine, Sept. 26, 1903), found upon operation an incom- pletely developed uterus and both ovaries in a left inguinal hernia in a woman thirty-two years old. He ligated and removed them completely, dropping the stump back into the abdomen, and closed the canal by the Bassini method. Recov- er}^ was prompt and relief complete. Dr. Frank T. Andrews of Chicago (" Hernia of the Tube Without the Ovary," Journal of American Medical Associa- tion, Nov. 25, 1905), has in an exhaustive study of recorded cases of the involvement of the female pelvic organs with hernia, given the following division of cases. He has tabu- lated 366 cases, which are divided as indicated in the fol- lowing table : " Hernia of Tube without Ovary , 46 cases. Hernia of Ovary and Tube 80 " Hernia of Ovary without Tube 167 " Hernia of Non-Gravid Uterus . . . 43 " Hernia of Pregnant Uterus 30 " ." Appendix Vermiformis in Canal. — In many instances the appendix is held in a position so remote as to cause no compli- cation no matter how large the hernia may be, l3ut in others it seems ever ready to drop into the canal and become adherent or otherwise involved. The question of the removal of the appendix when found with other reducible parts of the hernia must be decided by the operator, but it has been the author's rule to remove them if unusually long; if nodular masses could be felt in its lumen ; if it showed the least indication of former inflammatory conditions. In a case recently operated upon there were found adhe- sions of the omentum, in the vicinity of the internal ring, of an inflammatory character, that could hardly be accounted for by the presence of the iiernia. Fxploration through the internal COMPLICATIONS IN SURGICAL CURE. 2.57 ring with the finger brought to the surface a very much inflamed appendix, which clearly showed a beginning (jr a sub- siding appendicitis. It is quite probable that it was the pain of Fig. 139. Appendix adherent to posterior wall of hernial sac, the latter held open by clamps. this, which was attributed by the patient to his hernia, that brought the case to the operating table, and still it might easily have been overlooked. In a number of cases, where there has 17 258 ABDOMINAL HERNIA. been a history of a previous attack of appendicitis, the appendix has been brought out and removed through the same incision while operating for hernia. This opening is, of course, not as convenient as one made especially for the purpose, but I have failed only once to get it out through the internal ring when it was wanted, and, in this instance, it was obtained by splitting the internal oblique muscle in the direction of its fibre, just above and to the inner side of the internal ring. The method of removing the appendix will usually be governed by the education and preference of the operator, as several excellent methods are taught. The author has for several years followed the one of ligating and burying the stump. The steps of the proceeding are : (i) Ligating the vessels of the mesentery. (2) Division of peritoneal covering only, usually by scissors. (3) Tying in groove thus formed, with chromic gut. (4) Placing the burying suture of fine silk with round needle through peritoneal coat of bowel, an inch away from and around insertion of appendix into caecum. (5) Cutting off appendix and touching end of stump with pure carbolic acid ( wipe afterwards with alcohol on Sponge ). (6) Depression of stump and tying of burying suture. The drawing shown in fig. 139 represents the condition found in a woman thirty-two years of age. She had noticed a swelling for the past year on the right side, and it was found that considerable thickening remained after the reduction of the bulk of the tumor. At the first examination she was advised to have an operation, as it was believed that either the tube or ovary was involved. This conclusion was reached because of the fact that at each menstrual period she had increased pain. A truss was tried but proved uncomfortable, and operative relief was sought. On opening the sac the condition shown in the drawing was found. That is, the appendix was found lying along and firmly adherent to the posterior wall of the hernial sac, and the head of the csecum was firmly held in the internal abdominal ring, the vessels of the mesentery lying COMPLICATIONS IN SURGICAL CURE. 259 between the appendix and the sac surface. Little trouble was experienced in ligating them, freeing the head of the caecum, Fig. 140. ■ '/-.: A<...?'Vj,„„i^--4,'^.,7,j'-i'i;'|V|iil>,V'i-g.^-, .y^;-'.^-.'j-;'rj .'-<■■ 1 Appendix adherent to anterior wall of hernial sac, holding caecum in intern;il riii.a; Truss worn over appendix for many years. and reducing it to the cavity of the abdomen after tying off the appendix. The neck of the sac was then ligated and cut away. 260 ABDOMINAL HERNIA. Another quite similar case is shown in fig. 140. This man had been under my care for many years, and while he was obliged to wear an unusually strong truss, he suffered little inconvenience and was only brought to the operation through the influence of friends who had been cured of hernia. He not only followed his profession as a lawyer, but was an all around athlete and a long distance bicycle rider. It was therefore quite a surprise to find, on operating, an appendix Fig. 141. Top of appendix incarcerated in fibrous ring in sac. adherent to the anterior wall of the hernial sac in such a posi- tion that his truss pad pressed directly across it near its junction with the caecum, and still it showed no evidence of inflammation or disturbance. The adhesions were of a char- acter to clearly indicate that they had been there for many years. Earlier in this work reference has been made to the white, fibrous rings that form in hernial sacs and the liability of strangulation to take place in them. A peculiar illustration of this is given in the case portrayed in fig. 141. This Avas a COMrLlCATlONS IN SURGICAL CURE. 261 boy about eight years old, nnder care at the cHnic for the treat- ment of hernia at the New York Post-Graduate Medical Scliool and Hospital, but who had not done very well under truss treatment, and as ciu'e was not anticipated by this means, he was placed in the hospital for operative cure. The end of the appendix was so firmly held within one of the rings above spoken of, that it could not be withdrawn, and still actual strangulation did not exist. It had the appearance, however, of having been there for a long time. It was an uncommonly long appendix, probably fully seven inches; the tip was down as low as the bottom of the "testicle, and the Ccccuni was in the upper part of the canal. The Ccccum was elongated and merged so gradually into the appendix that it was difficult to decide just where the latter Ijegan. It is not within my own experience, but my associate, Dr. George E. Doty, as well as several other operators, have found the appendix in left in- guinal hernia. Adhesions Within the Sac are most commonly of omentum at its sides or bottom, but it occasionally happens that the intestine is adherent, and it then requires considerable care and skill tO' avoid serious injury. Attempts to tear such adhesions apart, unless they are of the most trifling character, should never be made. A large patch of the sac may, however, be cut out and left adhering to the bowel without fear of harm resulting. Torn surfaces upon the bowel, even though they may not endanger its integrity, cause great delay and incon- venience from the liability of free oozing of blood. Adhesion of omentum, if small in area, can usually be easily broken up, but it is better to tie them by catgut rather than run anv risk of subsequent bleeding'. Amputation of Omentum is worthy of especial discussion, both on account of its frefpiently being required, and on account of the dangers attending its removal if not carefully done. It is much better to remove large masses of omentum that have been outside the abdomen for some time, than to attempt its replace- ment, for two reasons : 262 ABDOMINAL HERNIA. ( I ) It has become shaped to the canal and to the sac that contains it, and if crowded back into the abdominal cavity, Fig. 142. Omentum irreducible because of adhesions. A, Omentum. B, Neck of sac. C, Sac cut open D, Fundus of sac with omentum firmly adherent. remains in a large mass at the internal ring ready to again dilate the canal and cause recurrence of the hernia. COMPLICATIONS IN SURGICAL CURE. 203 (2) Omentum long resident outside of the abdomen becomes hypertrophied and so chang-ed in character that it may act as a foreign body when returned witliin the jjeritoneal cavity. Formerly it was considered good surgery to take a mass of omentum, such as shown protruding through the neck of the Fig. 143. Omcuium spread out before ligating to isolate vessles and prevent risk of injuring intestine. sac in fig. 142, pass a ligature around it and cut it off. Work of this type was followed by fatal accidents from secondary haemorrhage, and in more than one instance, from injury to bowel that was lying unseen within the omentum. Many years since I advocated a method of ligation that has become almost universally used by careful surgeons. It 264 ABDOMINAL HERNIA. consists in drawing down the protruding mass until normal omentum is brought outside of the canal, being careful not to make undue traction. It is then spread out by the hands (fig. Fig. 144. Mass of omentum irreducible from quantity and shape. Narrow part at top was in the canal. 143) so that every blood vessel of any considerable size can be easily seen. Ligation then begins at one side of this sheet of omentum and progresses carefully across to the other. Fat COMPLICATIONS IN SURGICAL CURE. 265 with very small xessels is tied in fairly good quantity, but each large vessel is carefully cleared of its surrounding fat and tied off separately. No. 2 chromic catgut has been mcjst frequently used as suture material. As many as 25 ligatures ha\e been applied in removing a piece of omentum. After the ligatures are in place and the omentum is cut away, the stump, which is usually left about half an inch long beyond the ligature, is examined for any l^leeding- points, and these are also carefully tied. Fig. 145. Omentum. Sac which contained it shown at left. The freshly cut stump of omentum is dusted with aristol and returned to the abdomen. The use of the aristol may be entirely unnecessary, but it is believed to prevent adhesion of intestine to the cut surface and it has been used by the author for many years. Herniae of Unusual Size. — The large size of hernia does not in itself preclude its surgical cure. Unfortunately these extreme cases occur most frequently in the aged and infirm, and for these reasons operation may be quite inadvisable. If the general condition of the patient will allow of it. the surgeon 266 ABDOMINAL HERNIA. should feel it his duty to give these sufferers not only relief, but freedom from the danger that is constantly with them of acute strangulated hernia; or what is even more fatal, a gradual paralysis of the protruding bowel and eventual intestinal obstruction. Fig. 146. Omentum. At lower part is the sac which coniained it. It has l)een in my experience a noticeable fact, that many very large hernise are particularly easy to operate upon, and, as a rule, the difficulties that will be encountered can be fairly well estimated in advance, if the following points are carefully considered. COMPLICATIONS IN SURGICAL CURE. 2G7 (i) Is the patient's condition such as to stand an anesthetic and an operation of some magnitude? (2) Is the hernia reducible and is tlie cavity of the abdomen large enough to receive it ? (3) If not reducible, is it omentum or intestine that cannot be reduced? The patient's actual age is not nearly as important as his condition; in fact, people of advanced age usually stand the operation well. If any large portion is reducible, it is well to keep the patient in bed for some days before the operation, and keep as much of the hernia as possible within the abdomen. There is little doubt that some of these cases have had a fatal termination, due to extreme intra-abdominal pressure resulting from the return of enormous masses of intestine and omentum that have long been outside of the abdominal cavity. For this reason it is also advisable to remove as much of the protruding omentum as possible rather than to replace it. I have on several occasions removed what appeared to be nearly the entire omentum with no ill effects following. If, however, upon examination it is decided that the greater part of a large irreducible tumor is intestine, and this can usually be ascer- tained by percussion and general feeling of the contents, then great caution should be observed in advising the operation. If the intestine is extensively adherent, the handling necessarv to free it and return it to the abdomen may, in itself, cause col- lapse of the patient. Patients who have become completely disabled bv such enormous herni?e are sometimes willing to assume unusual risks with the hope of obtaining relief. Such a case is shown in figs. 147 and 148. This man was seventy-four years old, had a pulse rate never exceeding 50, and had albumen in his urine. He was told that the risk of not surviving operation was believed to be fully one out of five, and he at once assured me that he had decided to have the operation if I thought he had even chances of living or dying. The operation was done and he completely recovered, and lived four years more in complete 268 ABDOMINAL HERNIA. comfort, so far as his hernia was concerned. Fig. 149 shows him seven weeks after the operation, after which time he wore no bandage or other support. One pecuHar circumstance con- FiG. 147. S. L. B. Age, 74 years. Operated upon Oct. 12, 1899. Duration of hernia, 20 years. No truss ever worn. No recurrence to 1903, when he died of an affection of heart, present when operated upon. No support worn. Note that the testicle is clearly outlined at bottom of scrotum. nected with this case was that the pulse, which we had been unable to find above 50 for two weeks ]:)revious to the operation, was 70 on the following morning, and did not drop materially COMPLICATIONS IN SURGICAL CURE. 269 below this during- the subsequent eight or ten weeks that he was under observation. In this case, in order to aid in rapid work, the testicle and sac were removed together after hgating the cord separately Fig. 148. S. L. B. Side view of case sliown in fig. 147. at the neck of the sac. The sac was removed through the inguinal incision, the scrotal tissues not being touched. Nor was drainage of any kind used, the wound being closed com- pletely and primary union obtained. If, however, there is con- siderable oozing following the stripping out of such an 270 ABDOMINAL HERNIA. enormous sac, it is then advisable to put a good-sized drainage tube, preferably rubber with numerous fenestra cut out, down through the bottom of the scrotum. The protruding end of this tube should be very carefully guarded, by gauze moistened in 1/2000 corrosive mercuric chloride, and the tube should be Fig. 149. S. L. B, seven weeks after operation. removed in twenty-four, or, at the outside, thirty-six hours. It is only by extreme care that infection can be avoided where a drainage tube is left in, and it has usually been my preference to take the risks of a good-sized hematoma rather than to subject the patient to the liability of infection. The blood clot will, as a rule, be absorbed in the course of three weeks and does no harm. In onlv one instance have I seen such a clot COMPLICATIONS IN SURGICAL CURE. 271 become infected and require evacuation, and this case was unattended by symptoms of any importance. The enormous hernise now under consideration do not seem so hable to recurrence as would naturally be expected. The case shown in figs. 150, 151, and 152 is an illustration of Fig. 150. T. S., 50 years old. Riglit inguinal (scrotal) hernia for 20 years; never retained. Measures. A to B, 14 inches; circumference, C to D, 2 feet, 2 inches. Operation Dec. 4, 1895; no recur- rence to 1906. No truss worn. Contents, large and small intestines, omentum, bladder inside of sac, and free fluid. Note right testicle at B, left at Z>. See figs. 151, 152. this fact. The man there shown was operated upon for an enormous uncontrollable scrotal hernia and made prompt recovery, healing by primary union. At that time there was no hernia on the left side. Five years later swelling was noticed on the left side (fig. 152), and I found him with com- plete oblique hernia the size of a hen's egg, which was operated 272 ABDOMINAL HERNIA. upon and cured. Many experiences of this kind convince me that in these very large hernise there is httle trouble in effecting a permanent cure. In the case shown in fig. 153 the man was over seventy years of age and had a hernia reaching nearly to his knee, of many years' duration, and wholly uncontrollable. The hernia, F1G.151. T. S., six weeks after operation for enormous right scrotal hernia. See figs. 150, and 152. which proved upon operation to contain mostly intestine, both large and small, could be reduced to the abdomen. He was kept in bed for fully one week before operating, and the hernia was kept reduced most of that time to accustom the abdominal cavity to its presence. The operation was not particularly difficult, and plenty of good muscle was found with which to close the very large opening. COIVirLICATIONS IN SURGICAL CURE. 273 Fig. 154 is a case of very different type and one, if recog- nized, where an operation should not Ije attempted. In this case it was easily ascertained that a large amount of intestine was present, a small amount of it reducible, and it was believed that a large mass of hypertrophied omentum was also in the sac. This unfortunately did not prove true. The man had Fig. 152. T. S. Recent left inguinal hernia ; operation upon enormous right scrotal hernia five years previously. See figs. 150 and 151. suffered several attacks of partial intestinal obstruction unac- companied by very acute symptoms of strangulation, but increasing in frequency, and the case had every indica- tion that surgical relief was rec}uired. The condition observed upon operating was apparently a most unusual one. 18 274 ABDOMINAL HERNIA. On opening the sac no omentum was found, on the con- trary, it was packed with convolutions of bowel held on a mesentery of very unusual character (fig. 155). This mesen- tery was a fan-shaped, board-like mass, fully an inch thick. Fig. 153. Enormous right scrotal hernia in a man over 70 years old. Wholly reducible but not re- tainable by any truss that could be tolerated. Contents, large and small intestine and small amount of omentum. having a feeling somewhat like that of a dense, broad tendon. At the point where it entered the abdomen, it was bunched together into a mass as large as an adult forearm, just below the elbow, and apparently almost as inflexible. COMPLICATIONS IN SURGICAL CURE. 275 Those who have operated upon large hernicC will fully realize the almost insurmountable difficulties of the situation. The entire mass was finally returned to the abdominal cax'ity and the wound closed, but the patient did not long survive the operation. The feeling of the tumor, which led to the belief that it contained a large mass of omentum, was really produced Fig. 154. M. G., 40 years of age. Irreducible left scrotal hernia packed with intestine on peculiar hypertrophied mesentery. Duration, 20 years. Never retained. by this peculiar hypertrophied (if it may be so called) mesen- tery. The ultimate termination of this case, if it had not been operated upon, would in all probability have been by intestinal obstruction produced by gradual loss of peristalsis in the pro- truding bowel. I have seen only one other case at all similar, nor do I recall having seen mention of any like it by other operators. 276 ABDOMINAL HERNIA. ]\Iy other case was in a woman with enormous femoral hernia shown in the photograph, fig. 169, and even this did not Fig. 155. Intestine which was irreducible on account of hypertrophy and hardening of its mesentery. present the extreme difficulties met with in the case under consideration. CHAPTER XIII. SIGMOID, C^CAL, AND BLADDER HERNIA. Hernise of the sigmoid, caecum, and bladder, belong to the direct type of inguinal hernia and are classed together because of similar anatomical peculiarities. In the accidents which may occur during the operation for their cure they are also similar. In the chapter on diagnosis will be found suggestions which may, in some instances at least, lead to the recognition of sigmoid and csecal hernia before the operation; in many others, how^ever, there are no distinguishing signs previous to the opening of the parts, and even then serious mistakes may be made. It is perhaps wise to look upon all direct herni^e as extra-hazardous and to use extraordinary care in operating upon them. Petit (Rechcrches siir les causes des hernies) has truly said that hernial sacs are full of deception. My own experience leads me to feel that sigmoid and csecal hernia can usually be recognized, or at least suspected, before operation by their peculiar form (see photographs of cases), their slowness of reduction, especially of the last part of the tumor, and by the fact that not only are they frequently uncontrollable by truss pressure, but the wearing of any mechanical support is intolerable because of the pain produced. The difficulties in operating upon hernise of the direct type, especially the three forms now under consideration, are largely due to the distribution of the peritoneum. The pro- trusion takes place at a point where the peritoneum leaves the abdominal wall and is reflected over the pelvic organs, \\nien it is carried through the abdominal wall it drags, by its at- tachments to them, one of these organs with it. This is espe- cially true of the large bowel on either side and the bladder, on account of their being freely movable and conveniently 277 278 ABDOMINAL HERNIA. placed. While the peritoneum completely surrounds the small and in some parts the large intestine it covers only the anterior surface of both the sigmoid flexure and caecum. It is for this reason that a portion of the large bowel on either side may protrude without a hernial sac, and if not recognized by the operator may be opened by mistake. Tuffier (Etude siir le ccncimi et les hernies, Arch Gen. de Med., 7th ser., vol. xix, p. 642) found in the examination of 100 bodies that 9 per cent, had the posterior surface of the cscum uncovered by peri- FiG. 156. Sac wall Hernial sac containing: fiee caecum and loops of small intestine. toneum. The bladder is covered by peritoneum upon its summit and a small portion of its posterior wall, but not its anterior wall. \\'hen this distribution of peritoneum is considered it will be readily understood how any one of these organs may pro- trude in either one of three conditions : ( i ) It may become a part of the hernial contents, in a preformed sac — intra-peri- toneal (fig. 156). (2) It may protrude independently, with- out any serous covering — extra-peritoneal (fig. 157). (3) It may be dragged down in the formation of the hernial sac and SIGMOID: CiECAL: BLADDER. 279 have a partial peritoneal covering, and become both intra- and extra-peritoneal. As previously stated, protrusions into a preformed sac ha^'e not been considered by the author to constitute either sigmoid, czccal, or bladder hernia, because they are easily reduced with the other hernial contents, quickly recogiiized, and not liable to accidental injury. Sigmoid and Cascal Hernia. — In these hernise the bowel may be dragged down by a sac of peritoneum previously Fig. 157. Sac wall Hernial sac in front of caecum. No peritoneal covering on posterior wall of bowel. formed and containing other folds of the large, or many loops of small intestine and omentum. The posterior sac wall is then the normal peritoneal covering of the anterior surface of either the caecum or sigmoid, as the case may be. If the operator, fortunately, opens into the sac high up, near the internal ring, he will usually discover the true state of affairs and avoid injury to the bowel, either by tying off a portion of it with his sac ligature, or bv rudely tearing it away from its deep attach- ments and perhaps lacerating the intestinal wall in a manner that would be difficult to repair. If, on the contrary, he opens 280 ABDOMINAL HERNIA. into the fundus or lower portion of such a protrusion he may discover too late that he has opened directly into the bowel. In operating upon these extremely difficult cases unusual caution is necessary throughout the entire operation : ( i ) In the opening of the sac. (2) In separating the fleshy attach- ments of the bowel from the deep parts. (3) In the closure of the sac. (4) In the closure of the enonnously large open- ing which is left in the muscular wall of the abdomen after the reduction of the bowel. In opening down upon any sac of the direct type, with broad base, it should be the invariable rule to separate the extra-peritoneal fascia well up towards the internal ring, pick up the peritoneum where it is thin and free, and open it care- fully between anatomical forceps. If this one precaution were strictly adhered to it would prevent most of the accidental openings of the bladder and large bowel. Had I adhered to this point, which I have carefully taught my classes at the New York Post-Graduate Medical School and Hospital for many years, I would have avoided my only, but nevertheless mortify- ing, mistake of opening into the bladder. In this case I was so certain that I was dealing with a true hernial sac that I opened it even while speaking of the liability of bladder acci- dents in hernia operations. When the peritoneal cavity has been entered near the internal ring, the finger can be passed down into the fundus of the sac, if present, or it can be ascertained that the protrusion is actually extra-peritoneal, and it can be dealt with accord- ingly. If the sac cannot be readily lifted from its posterior attachments it should be suspected at once that it is either sigmoid, caecal, or bladder hernia. When the finger is within the peritoneum, the anterior sac wall may then be carefully cut upon it with l)lunt scissors, care being exercised to avoid intestinal adhesions that may be present, and remembering the immediate proximity of the epigastric artery. The contents of the sac may then be freely examined and so far as possible reduced. SIGMOID: C/ECAL: BLADDER. 281 The second step in the operation is to separate the posterior wall of the bowel from its attachment. This may be (lone bv gently pushing- the fingers upwards between the bowel and the deeper parts, exerting as little force upon the intestine as possible, and watching closely for broken vessels, which should be tied at once even though small. The point of separa- FlG. 158. Form of purse-string suture for sigmoid sac. tion between the structures should be carried well up into the abdomen so that the bowel can be reduced wdth perfect free- dom. It is necessary to exercise caution in pushing the bowel back not to telescope it into itself, thereby producing an intus- susception. Closure of the Sac ('fig. 158). — It is quite obvious that a sac of this type cannot be closed by an ordinarv ligature, as its posterior wall is formed of bowel. It is best done bv a 282 ABDOMINAL HERNLi. purse-string suture applied from the inside of the sac, going well up to the internal ring, or peritoneal surface on its anterior wall, and approaching with caution that part attached to the bowel. AMien this suture (usually no. 2 plain catgut used double) is tied, the sac is perforated, and any surplus of sac wall that exists is drawn up and ligated outside the purse- string suture and cut away. The ends of the sac ligature with Fig. 159. Lifting internal oblique muscle to burj- stump of sac beneath it. needle attached are used to anchor the stump of the sac, with attached bowel, in the following manner : The internal oblique and transversalis muscles are sepa- rated from the peritoneum by slipping the ends of the fingers between them and the peritoneum, above the internal ring and towards the median line (fig. 159). The needle on the sac stump ligature is passed through these muscles from within outwards, and then back at another point, ^^'hen it is tied SIGMOID: C^CAL: BLADDER. 283 with the free end of the stump ligature it will invert the sac stump and carry the attached bowel well away from the inguinal canal. I am convinced that the anchoring of this elongated loop of bowel well away from the internal ring is a great aid in the prevention of recurrence. The details of the closure of these large openings in the abdominal wall must depend upon the condition of the sur- rounding muscular tissue and the preference of the operator. The first essential of success is thorough and careful work whatever technique is adopted. If there is an abundance of good muscular tissue it has been my habit to close exactly as in oblique inguinal hernia. Even though the neck of the sac is at the external ring and the upper canal unoccupied, it is important that the cord should be displaced at its junction with the peritoneum, the lower edges of the internal oblique and transversalis muscles wrapped closely around it, and stitched to Poupart's ligament throughout the length of the canal. The continuous suture of the peculiar type already shown (figs. Ill, 112), is believed to make a more accurate closure than is possible with the interrupted. Especial care is taken in these cases to see that the closure is made as per- fect as possible in the aponeurotic, as well as in the muscular structures. In some of these cases the method of overlapping, already mentioned, has been used with advantage, and in one the rectus was split and turned out in order to get sufficient tissue to make a firm closure. Even where ever}- precaution is taken there is little doubt that sigmoid and cjecal hernia will furnish a larger percentage of recurrences than herni?e of the oblique inguinal type. In view of this fact it is advisable to keep them under closer scrutiny after operation, and, if anv sign of weakness of the abdominal wall is discovered, to place a support upon them before actual protrusion occurs. At this time a good abdominal belt, that gives support over the whole lower part of the abdomen, is usually better than a regular truss, and should be worn with less discomfort. 284 ABDOMINAL HERNIA. Bladder Hernia. — Like tlie hernias just discussed, the bladder may protrude through the abdominal wall, either inside of a true hernial sac without any peritoneal covering, or with both conditions present. Little attention has been given to those cases where the bladder protrudes within the sac covered by peritoneum, as there is no liability of accidental injury, and it is easily reduced with the rest of the hernial contents. In 1895 Dr. B. Farquhar Curtis made a most valuable contribution to this subject (''Wounds of the Bladder in Operations for Hernia," Aiinols of Surgery, June, 1895). In this study of the subject he collected 41 cases in which the bladder was wounded during operation, and 1 7 in which it was recognized and returned without injury. Only two years later Dr. C. L. Gibson (" Personal Experience in Hernia of the Bladder," Med. Record, March 20, 1897) collected and added 45 cases to the list of Curtis, making a total of 103 cases. The report of Curtis's 58 cases covered the dates from 1575 to 1895 (300 years), while Gibson's 45 cases, with three excep- tions, included onty those reported during the two subsequent years. In those two years there had been nearly as many reported as had appeared in all previous literature. In the combined cases of Curtis and Gibson there were 76 males and 23 females; 70 males and 7 females had inguinal hernia; 16 males and 16 females had femoral hernia. ]\Iore than half of the cases (52) were over fifty years of age, the voungest being two and one-half years. The bladder was intra-peritoneal in 7, and extra-peritoneal in yT) instances; 18 were both intra- and extra-peritoneal. , Undoubtedly the most dangerous and deceptive, as well as the most common, variety is tlie extra-peritoneal, which comes through the abdominal wall uncovered by peritoneum. Frequently it constitutes the entire hernia and the surgeon is verA- apt to mistake it for the hernial sac. These bladder pro- trusions may vary in size from that of the end of one's finger to the entire bladder. The entire bladder and prostate gland have been found in a hernial protrusion of this type. The SIGMOID: CiECAL: BLADDER. 28.5 bladder protruding in this position has been mistaken for hernial sac, lipoma, properitoneal fat, omentum, cyst, thickened patch in hernial sac, hydrocele of the cord, sacculation of the colon, or a second hernial sac. Plummer thinks that it would be particularly liable to be found in recurrent herni^e, as the first operation would be apt to draw it toward this point. Bladder w^ounds accidentally inflicted, during operations for the relief of hernia, have become too common to be longer considered surgical curiosities. This fact does not indicate increasing carelessness on the part of the surgeon, nor does it lessen the importance of the subject. It is unquestionably due to the greatly increased number of hernia operations being per- formed, and to the apparent impossibility of always being able to distinguish between the hernial sac and the bladder wall. It is to be hoped, and it is probable, that, as many operators are led to study it more closely, valuable knowledge will accumulate which will afford greater protection against this accident. The diagnosis of bladder hernia is seldom made before operation, but as more attention is given to the subject there will be more cases that will be at least considered suspicious. In fact, the only safe method is to consider all cases of direct hernia, or hernia in very fat patients, as being a possible bladder hernia ; if on guard the operator will usually recognize the condition, if present. The indications may be divided into those to be looked for before, and those met with during, operation. Before Operation. — The history of any bladder symptom that can be obtained from the patient should be considered suspicious. In the case shown in the photographs (figs. 150 and 151 ) the patient informed me that while urinating he was usually obliged tO' compress the scrotal protrusion with both hands. At the operation a large protrusion of bladder wall was found (intra-peritoneal) protruding into the hernial sac. This was reduced as easily as the omentum and intestine that also occupied the sac in large quantities. After the operation, however, he was unable to void his urine, and it was then dis- 286 ABDOMINAL HERNIA. covered that it was impossible to pass a catlieter. Perineal section became necessary two days later. He obtained primary union in the hernia wound and made a rapid recover3^ Pressure upon the tumor may in some cases cause a desire to urinate. This was strikingly demonstrated in one of my cases where the bladder was found involved at the time of operation. Dr. J. F. Baldwin (" Hernia of the Bladder," Complete Inguinal Extra-peritoneal. Recovery. Am. Med. J our., May i8, 1901) reports a case, of eight years' duration, in a man of fifty-one years, where the bladder was protruding to the size of two fists. Ordinarily this swelling was reducible, but for forty-eight hours before operation it could not be reduced. The previous history showed that the patient was obliged to lift the tumor every time he urinated, and the pro- trusion had been uncontrollable by a truss. The slowness of the reduction of these tumors, and in some its apparent incompleteness, should lead us to suspect that we have either large bowel or bla.dder to deal with. It has been suggested that there may also^ be felt a rush of fluid when quick and firm pressure is made. This, however, seems to the author a somewhat misleading suggestion, as many large hernial sacs contain fluid in appreciable quantities when no bladder protrusion is present. Furthermore, it is not in hernise of enomous size that we are liable to mistake, but rather in small or medium-sized hernise of the direct type with no suspicious symptoms. Dr. S. C. Plummer ("Inguinal Hernia of the Bladder," Jour. A. M. A., July 22, 1905) suggests that a test be made of having the patient retain his urine for a long time to see if it influences the tumor. The passing of a sound has, in some instances, verified the suspicion of bladder hernia, but in others it has failed. At the time of operation this has proved of great service to me, and has in several cases enabled me to decide that I was dealing witli the l:)ladder wall. Indications at Operation. — On opening into the canal a sac found protruding at the inner side of the cord, close to the SIGMOID: C^CAL: BLADDER. 287 pubic bone, should cause us to proceed with caution. This is especially true where it seems deeply imbedded in fat from which it is hard to separate it, and where it has a broad base. Fig. i6o. Showing a protrusion, the upoer half of which was peritoneal sac containing intestine, the lower half, bladder. The dividing line has been intentionally exaggerated. In the patient it did not show so clearly. One would think that the bladder wall could be recognized by its muscular covering, but this, in my experience, cannot 288 ABDOMINAL HERNIA. be relied upon. This difficulty is well illustrated by the case reported by Dr. Rudolph Winsboro (" Direct Inguinal Hernia," Injury to Bladder, Virginia Medical Scmi-Monthly, Feb. lo, 1904). He says : " To the inner side of the sac was a mass separated with great difficulty . . . about the cord was a translucent area which evidently contained fluid." Think- ing it an encysted hydrocele, he incised it and at once recog- nized urine by its odor. McLachlan states {Applied Anatomy, vol. ii, p. 469) that " in sacculated bladder the walls of the sacculi contain no muscular fibres. The mucus membrane is forced through the bundles of muscular fibres, forming sac- culi." When, on pulling up an inguinal sac, there appears in its neck a mass of fat covered by peritoneum, it is highly im- portant that it be neither ligated with the sac nor punctured with a needle, as it is in all probability bladder. This is most likely to occur in direct hernia, but I have also seen it in the oblique variety. When two sacs are present in the canal it is safe to conclude that one is bladder. It has been stated that bladder wall is difficult to separate from the surrounding fat, and this, it is believed, is true. In my own case, w^hen I committed the error of opening into the bladder, it was very readily lifted from the mass of fat which surrounded \i and there was no true hernial sac. In the case shown in fig. 160, where the upper half of the tumor was hernial sac and its lower half bladder, the latter came out of the canal as easily as the former. The first appearance of the bladder part of the tumor was of loose fat in the canal. When this fat was lifted out, the bulging above, which proved to be the true sac, was brought to view. From the opening made in the latter it was easily demonstrated that the lower part was bladder. The sac was closed by purse-string suture, the l^ladder protrusion was inverted into itself and the muscular wall care- fully closed. In the case shown in fig. 161 the liability to mis- take is in supposing that the lower protrusion is of an ordinary direct hernia. It is entirely possible to have oblique and direct SIGMOID: CECAL: BLADDER. 289 hernia on the same side, and their true character can be quickly ascertained by opening the upper sac and exploring the lower one through this opening. Fig. ]6i. Hernial sac above, and bladder iirotrusion (extraperitoneal) below, in man 60 years of age. In bladder as well as in sigmoid and c?ecal hernia many uncertainties in diagnosis, and a great many operative diffi- culties, are avoided by opening into the sac or peritoneal cavity 19 290 ABDOMINAL HERNIA. well up toward the internal ring. The bladder, the caecum and the sigmoid are thus avoided, as well as the confusion that sometimes comes to an inexperienced operator by opening into an unobliterated tunica vaginalis. It must be borne in mind that in double hernia the bladder may protrude on both sides. Gibson reports such a case and I have had one recently in a young man under thirty, ^^'hen the bladder has been recog- nized before opening, it has been gently separated from its abdominal adhesions and pushed back into place, and the muscular' wall very accurately closed over it. In one instance I turned the sacculated part into the bladder by inversion, get- ting it entirelv away from the canal. Repair of Bladder Wounds. — An accident that has hap- pened so many times and to so many dift'erent operators will certainly happen again and it is advisable, therefore, that those who contemplate doing the operation for the cure of hernia should have definite ideas as to what they will do when con- fronted by a bladder accidentally opened. On certain points in the repair of bladder wounds there are no differences of opinion, but on others, operators of experi- ence difi'er widely. The merest tyro in medicine under- stands — for it is one of the earliest teachings in surgery — that in closing a bladder wound its walls must not be stitched through and through. Able operators also agree that such wounds are best closed by layers of sutures, some advising two, others three overlying rows. Some advise that the mucous membrane lining the bladder shall be first closed by small, plain catgut, and then the muscular and serous coats brought together above this by two more rows of silk or catgut ; others prefer to put no sutures in the mucous membrane, relying entirelv upon the muscular closure to prevent leakage. It seems rational that tlie use of small-size plain catgut to close accurately the mucosa adds materially to the protection against leakage, and, owing to its early absorption, subjects the patient to little risk of having concretions form upon it within the bladder. It is certain that silk should never be used for this laver. SIGMOID: CiECAL: BLADDER. 201 The tendency of late writers upon the subject is in favor of catgut throughout the operation. Curtis says on this point : " Whether silk or fine catgut is employed seems tO' be a matter of indifference, but the sutures should ncjt penetrate the mucfjus membrane; they should be placed very close together, ten or twelve to the inch, and there should be at least two layers, and by preference three." Dr. Orville Horwitz (Annals of Sur- gery, December, 1905) expresses the following positive opin- ion on this subject : " It is generally conceded that the wound is best closed with fine silk, as the catgut sutures cannot be depended upon to endure for a sufficient length of time. Sev- eral cases have been reported in which this latter material was employed where a leakage occurred, owing to a too rapid absorption of the suture, death resulting from peritonitis." Horwitz recommends two layers of sutures, first, interrupted Lembert, second, mattress. Personally I feel "that in silk there is greater safety, and still, in view of the fact that in my own case a part of the silk was afterwards extruded into the bladder, became encrusted and had to be removed, I should hesitate to use it in an exactly similar case. If the wound is extra-peritoneal and there has been no opening into the peritoneal cavity, then one can take greater risks of leakage with little increase of danger. The questions as to leaving provision for drainage in the wound and a permanent catheter in the bladder must be regu- lated by the judgment of the operator. If the operator has confidence in the security of his closure it is far better to pro- ceed with the operation for the cure of the hernia, as otherwise it will necessitate subjecting his patient to a second operation. The use of a catheter retained in the bladder four or {\ye davs would certainly seem indicated, but recent writers rather favor reliance upon either catheterization or voluntary urination every two hours. Again I say, if there is a possibility of leakage, into the abdominal cavity the catheter should be retained for constant drainage: but if the danger is only of an extra-peri- toneal vesical fistula I might rely upon frequent catheterization. CHAPTER XIV. SURGICAL CURE OF INGUINAL HERNIA IN THE FEMALE. The operations described in the preceding pages are ideal when apphed to the inguinal canal of the female, where we have no cord to deal with. In many operations the round liga- ment has not been seen and the canal has been obliterated with- out any regard to its whereabouts. In a few cases, however, it will be found as large as a moderate-sized spermatic cord and should be treated exactly the same; that is, it should be lifted out of its bed and the internal oblique muscle closed beneath it, after the sac is tied off and cut away. In some cases of congenital hernia in the female, where the process of peritoneum corresponding with the tunica vaginalis in the male was unobliterated, and so intimately blended with the round ligament as to make separation impos- sible, the entire mass was ligated and cut away. In these cases a purse-string suture is put around the inside of the sac first and then the ligature passed around ligament and sac. The stump has then been firmly stitched to Poupart's ligament and the internal oblique near the internal ring. In former times the Alexander operation for shortening the round ligaments resulted in a large percentage of hernias, owing to the fact that the work was all done at the external ring. Gyne- cologists of the present day usually open the entire canal and close it by the Bassini method. Dr. Charles P. Noble of Philadelphia, who has had a large experience, says (Reprint, Lackawanna Co. Medical Society, March 28, 1905): "If the ligament is pulled out through the external ring the process of peritoneum may be pulled down and a hernia invited." Traction upon the ligament will always bring a peritoneal pouch into the upper part of the 292 SURGICAL CLRE: FEAL\LE. 293 canal, and if this is left unobliterated it forms a convenient pocket into which intestine or omentum is almost sure to drop, eventually forming a good sized hernia. A\'hen the canal is open it is easy to push back and strip away this peritoneum before anchoring the ligament and closing the canal. In this connection S. Goldner has made a valuable study (" Does the Injury to the Round Ligament in Herniotomy Cause Retrode- viation of the Uterus?" — Zcntralblatt fur Gyndkologie, August I, 1903. Li 50 women who underwent Bassini's radical operation he examined 28 in from three to six years after the operation. In 13 cases the operation was bilateral and in 15 unilateral. These patients belonged to the working class and went back to their labors undisturbed and free from pain. Of especial interest was the condition of 12 in whom the round ligament, on account of adhesions, was cut through and the stump of the hernial sac ligated with the round ligament ; in 6 cases this was done on one side and in 3 cases on both sides, and in none of them was there any change in the position of the uterus. This condition led him to conclude that the sever- ing of the round ligaments in the inguinal canal caused no dis- advantageous results, and that the fact that even in those cases in which both ligaments were severed no retroflexion occurred, justified the use of the radical operation of Bassini. My own experience has been that in 1,300 hernia opera- tions, 306 were in the female; of these there were 156 inguinal hernise, 25 being double. Five had inguinal hernia on one side and femoral on the other ; i had inguinal on one side and double femoral ; 2 had inguinal and femoral hernia on the same side ; i had double inguinal and umbilical ; i had inguinal and umbilical. When more than one hernia existed all were oper- ated upon at a single auccsthesia. Incidentally other surgical work was frequently done upon the patient where needed, as curetting, cervical, and perineal operations, for hremorrhoids. or the removal of small tumors. In none of these cases was there any untoward result, nor has there been a single recur- rence so far as known. One of these women had experienced 5 294 ABDOMINAL HERNIA. previous failures to cure a small inguinal hernia, and. I removed 5 or 6 large silver wire sutures that had been left in the canal. This case was particularly instructive in the fact that apparently in none of the previous operations had any attempt been made to bring the internal oblique muscle down to Poupart's ligament. Fig. 162. Continuous suture in muscular and aponeurotic layers as used in the female. In the case of the double femoral hernia the woman was forty-three years of age, and the operation was for left strangulated femoral hernia caused by the incarceration of an epiploica appendix, which held a portion of the lumen of the intestine in the femoral ring. In the inguinal canal on the same side was found, firmly adlierent, the tul)e and ovary. The sac, inchiding ovary and tulDC, was tied off and cut away. The patient was out of bed on the tenth day and left the sanitarium SURGICAL CURE: FEMALE. 295 on the fourteenth cured of her three hernise and of much obscure abdominal pain from which she had suffered for many years. The operation for cure is done in the female in every respect as in the male except that the canal is wholly obliter- ated. I have found it very convenient and effective to close the canal in the female by a single suture for both the deep muscles and the aponeurosis of the external oblique (fig. 162). The suture begins at the internal ring, bringing the lower edge of the internal oblique and transversalis in contact with Poupart's ligament all of the way down to the pubic bone. The blunt needle used, is then made to perforate the aponeurosis near its insertion into the pubic bone to the inner side, and then through the external pillar of the ring externally. When this is tightened it practically obliterates the external ring. The remainder of the continuous suture can be rapidly placed, the second and last knot being tied just above the upper angle of the split aponeurosis. The time required to operate on the female is less than on the male and the results are even more satisfactory, yielding in my own experience 100 per cent, permanent cures. The question of operating for the cure of hernia upon women who are pregnant is one that will come to most operators. In three instances I have operated upon women who were in the early months of pregnancy. In e\'ery instance they were less than four months advanced and. as would be expected, no unpleasant symptoms followed. It is inadvisable to do surgical work upon a pregnant woman unless especially called for, as in these cases. I have recently been called upon to decide between two physicians as to whether or not an abortion was justifiable upon a woman three and a half months advanced in pregnancy because of her having an uncontrollalDle femoral heniia. It was not an unreasonable question in view of the fact that the woman had once required an operation for the strangulation of this same hernia. My decision was, as it probably would be in 296 ABDOMINAL HERNIA. every other similar case, that such an act was entirely unjusti- fiable in view of the fact that women, even though suffering from extremely bad hernise, seldom have any trouble with them during pregnancy or confinement. This is more especially true of inguinal or femoral hernia for the reason that as soon as the uterus begins to occupy the pelvis and lower abdomen, the intestines and omentum are lifted up and away from the hernial openings. It not uncommonly happens that in the last months of pregnancy a large hernia will disappear and not protrude even if no truss is worn. Women frequently are deceived by this into the belief that they are cured and make the mistake of getting up after confinement without applying a truss. CHAPTER XV. FEMORAL HERNIA. Eight per cent, of all hernise are of the femoral type, and it occurs more frequently in the female than in the male, as shown by the fact that of all women suffering from hernia, 38 per cent, have this variety. According to Macready (Treatise on Ruptures) women during the child-bearing period have inguinal and femoral about equally, but after fifty years of age femoral hernia is slightly in excess. In men between twenty-one and sixty-five years of age, 3.9 per cent, have femoral hernia, but among bakers, as a separate class, it exists to the extent of 8.7 per cent. It is the most dangerous of all hernise, not only on account of its greater liability to strangu- lation, but owing to the fact that when strangulation does occur the destructive process is much more rapid than in any other form. This latter fact is undoubtedly due, first, to the inelastic structures which surround the femoral canal, and second, to the knife-like edges against which the intestine or other protruding abdominal viscera are violently pressed. This variety of hernia is seldom encountered before early youth, and most frequently occurs in later life. The youngest case met with in the author's experience was in a boy four years of age who had double femoral hernia of nearly one year's duration. Another boy of eight years had right femoral, and the youngest girl, also eight years old, had right side hernia. That it seldom or never occurs in infancy is due to the anatomical fact that in early childhood the calibre of the femoral opening is very small, enlarging as adult life approaches. This form of hernia may be single or double, and may be associated with inguinal hernia on either the opposite side or the same side. The author has seen one case of double inguinal 297 298 ABDOMINAL HERNIA. and double femoral hernia in the same person. It may be reducible, irreducible, or strangulated. It is seldom irreducible without producing symptoms of strangulation, and in this it differs markedly from either inguinal or umbilical hernia, where we may find large masses of omentum or even intestine which do not produce any great amount of discomfort. Fig. 163. Femoral region. A, Poupart's ligament. B, Anterior crural nerve. C, Crural branch of genilo-crural nerve. D, Femoral artery. E, Gimbeniat's ligament. F, Femoral vein. G, Fascia lata cut away to show head of pectineus muscle. ANATOMY. Poupart's ligament is a strong, fibrous band extending from the anterior-superior spine of the crest of the ilium, to the spine of the pubes separating the abdomen from the thigh (fig. 163). Beneath this structure (between it and the pubic bone) are the parts most concerned in the formation of femoral hernia. The transverse section of these parts is shown in the FEMORAL HERNIA. 299 accompanying illustration, and a brief study of this will give a clearer idea of the relative position of the parts than can be given by mere description (fig. 164). Gimbernat's Ligament (fig. 163) is attached to the ileo- pectineal line from the spine of the pubes outwards, and fills the triangle between this line and Poupart's ligament, its base being directed toward the femoral vein. Its total length is Poupart's ligament Gimbernat's ligament Anterior crural Crural b'h gen-crural Psoas m. Femoral artery Sheath of vessels Femoral vein Femoral ring Transverse section showing relation of vessels and nerves to femoral canal. from two-thirds to three- fourths of an inch. Immediately back of it is the conjoined tendon. The Femoral Ring lies to the outside of the base of Gim- bernat's ligament between that and the femoral vein, and is bounded above by Poupart's ligament and below by the ramus of the pubes. Hesselbach has given its measurement as 10 mm. in the female and 5 mm. in the male. The femoral ring is ordinarily filled with subperitoneal fat and sometimes a small gland. When standing it is nearly horizontal. 300 ABDOMINAL HERNIA. Diagram Showing Formation and Covering of Femoral Hernia ; Protusion of Extra Peritoneal Fat and Lipoma. Diagram showing parts involved in femoral hernia. The arrow shows line of descent. A, Subcutaneous fat. I, Mus- cular wall. B, Fascia lata. C, Cribriform fascia. E, Femoral sheath (transversalis fascia near its junction with iliac fascia"). F, Peritoneum. G, Extra-peritoneal fat. H, Pubic bone. Femoral hernia. A, Subcutaneous fat. B, Fascia lata. C, Cribriform fascia. D, Hernial sac. E, Femoral sheath (trans- versalis fascia). F, Peritoneum. G, Extra- peritoneal fat. H, Pubic bone. Fatty hernia through femoral canal. D, Extra-peritoneal fat. J, Fatty tumor. Not fixed below, but freely movable in subcutaneous tissue. FEMORAL HERNIA. 301 Femoral Sheath. — The transversalis fascia, covering the anterior wall of the abdominal cavity, passes clown under Poupart's ligament and forms the anterior layer of the femoral sheath, while the iliac fascia forms its posterior layer and is Fig. 165. (Redrawn from Gray.) A, Showing small pocket by side of femoral vessels, where hernia usually protrudes, breaking down Gimbernat's ligament and forming an elongated, triangular opening. The top of this triangle is Poupart's ligament ; the floor, the tissues covering the ramus of the pubes ; its base, the femoral vessels ; and its point, the spine of the pubes. B, Femoral artery. C, Femoral vein. D, Saphenous vein. continuous with that on the pectineus muscle. The meeting and blending of these layers of fascia form a funnel-shaped space termed the femoral canal, which is about half an inch in length. Hernia protruding through this opening carries before 302 ABDOMINAL HERNIA. it this fascia and subperitoneal fat. The fascia is sometimes so dense as to lead the operator to suppose that he is dealing with the hernial sac. At other times the tissues covering a femoral sac are so thin that it is only by extreme care that they can be incised without opening into the sac. The most common point of protrusion of femoral hernia is within this sheath between the femoral vessels and the outer Fig. 1 66. Double femoral hernia, in a man of 50 years. Typical illustration of fairly large femoral hernia. On the left the tumor has turned up partially over the external ring, but its centre is below the crease formed by the junction of the thigh and abdomen. edge of Gimbernat's ligament. Below the sheath is the pectineus, and at the outer side the psoas muscle. To the outer side of the femoral sheath close to Poupart's ligament is the crural branch of the genito-crural nerve. Femoral protrusions leave the abdominal cavity by escap- ing beneath Poupart's ligament, and passing to the inner side of the femoral vessels (fig. 165). Gimbernat's ligament is crowded towards the median line. It is this thin tendon which ordinarilv produces the knife-edge cutting of the bowel that is FEMORAL HERNIA. 303 so destructive in strangulated hernia of this type. These pro- trusions escape from beneath the fascia lata at the saphenous opening, penetrating or carrying before them the cribriform fascia, and form a tumor on the anterior and inner aspect of the thigh three-cjuarters of an inch to the outer side of, and the same distance below, the spine of the pubes. The long diameter of the femoral opening, after hernia has distended it, is trans- FlG. 167. Side view. Front view. Reducible femoral hernia of enormous size. This hernia was reducible and could be retained by a truss. verse, or parallel with the ramus of the pubes, and is triangular in shape, the term " Ring " being a misnomer. Considering the parts from within, we have first, the peri- toneum; second, the extra-peritoneal fat; third, the transver- salis fascia, which forms the sheath of the femoral vessels; fourth, subcutaneous tissue ; and fifth, skin. The vessels of the region are important and should be clearly fixed in mind, but their proximity need cause no timidity on the part of the 304 ABDOMINAL HERNIA. careful operator. The saphenous vein passes over the falci- form edge of the fascia lata to join the femoral vein, and here also are given off from the femoral artery the external pubic, the external epigastric and the circumflex iliac arteries. Formation. — Femoral hernia usually develops by a slow process, frecjuently attended by some pain or a dull aching in that region and extending down the leg. This is often described as a burning sensation. In many instances, as in inguinal hernia, a swelling in the femoral space is the first indication of anything wrong observed by the patient. There is little doubt that the subperitoneal fat frecjuently acts as the entering wedge and is the forerunner of the hernia. Under some violent strain it is forced into the femoral sheath, and, slipping under Poupart's ligament, presents a small tumor at the saphenous opening. Shortly following this the peri- toneum, dragged down by the attached fat, and pressed upon from within by the abdominal contents, is sure to be found protruding, and the hernia well established. Ordinarily femoral hernia does not attain a very great size, but pre- sents a small, round tumor varying in size from a hickory- nut to that of a good-sized hen's e.gg (fig. i66). As a rule femoral hernia remains small; as in other forms of hernia, however, there may be great variation in its size and shape. The enormous proportions that they may assume when neglected is well shown in the cases here illustrated. Fig. 167 shows the case of a man 50 years of age, in good general health, who was being supported by a Hebrew chari- table institution for complete disability. The hernia was considerably larger than the patient's head. Notwithstanding total lack of treatment for man}^ years, the hernia could be completely reduced to the abdominal cavity and comfortably retained bv truss pressure. The man was doing perfectly well under truss treatment until it occurred to him that he was losing his only possible claim upon the institution, after which nothing could be done willi liim. nor would he consent to operative cure, which Could most certainly have been afforded FEMORAL HERNIA. 305 him. The photograph shown in fig. i68 is of a woman fifty-five years of age, who had an enormous irreducible femoral hernia. The full size of this hernia is not shown in the photograph, as it had not only formed down on the thigh, but had dissected up the skin from the fascia around toward the back part of the leg. Fig. 1 68. Woman 55 years of age. Irreducible femoral hernia. Extent of tumor not shown here, as it extended well around to back of thigh. Contents, intestine with a large mass of adherent omentum. Cured by operation. Hernise of this size are pretty sure to be made up largely of omentum, as in this case, but the author has seen one case fully as large where the protruding content was entirely intes- tine and irreducible. The case referred to is shown in fig. 169. This photograph fails to show the full proportions of the tumor, or another femoral hernia that existed on the opposite side. This tumor also extended around to the inner side of 20 306 ABDOMINAL HERNIA. the thigh. Upon operating, the right-side hernia was found to consist of intestine held upon a mesentery so thick and inflex- ible that reduction appeared, at first, impossible. No adhe- sions existed, and no omentum was found protruding. Reduc- tion was finally accomplished and the greatly distended femoral opening closed. The opposite side was also operated upon. The patient, more fortunate than my one other instance of Fig. 169. Double femoral hernia in woman aged 48 years. Right side only shown and not in its full size. Irreducible. Contents, intestine held down by hypertrophied mesentery. No adhe- sions. No omentum. Both herniae cured by operation on the same day. mesentery of this peculiar type, made a prompt recovery and remains sound four years later. No truss has been worn. The dangers of acute strangulaton are not quite as great in herni?e of such large size as in the smaller ones, inasmuch as they protrude through such enormously distended rings ; they are cjuite likely, however, to eventually reach a fatal termina- tion where the bowel forms a large part of the protruding contents and is irreducible. This comes, first, with obstinate constipation, gradually increasing to intestinal obstruction and death. Tt is due to the fact that the bowel, in its abnormal position, under pressure at the abdominal orifice, gradually FEMORAL HERNIA. 307 loses its peristaltic action and when obstruction occurs, an operation returns bowel which, while it may be otherwise in good condition, is paralyzed beyond recovery. The sacs of femoral, like those of inguinal hernia, may also be modified in shape by bands of connective tissue form- These bands become fibrous in character ing in the interior. Fig. 170. Cyst of old hernial sac. A, Cyst. B, Point of closure. C, Interior of sac. D, Femoral ring. and add materially to the risk of strangulation. The neck of the femoral sac, where it passes under Poupart's ligament, is usually very small and this in itself becomes a source of danger to the protruding parts. The sac becomes tough and thick- ened at this point, and in some rare instances where a truss has been constantly worn, is closed off entirely. This closure is temporary in character and does not result in a cure. A sac 308 ABDOMINAL HERNIA. that has been closed off in this manner is quite hkely to take on a conchtion of hydrocele, and, as it occupies the exact site of the former hernia, is very likely to be mistaken for irreducible femoral hernia. Such a case is illustrated in a drawing (fig. 170), made from a sac removed from a patient supposed to have irreducible hernia. The hernia proper was in the upper 13art of the sac and easily reduced. Fig. 171- Irreducible femoral hernia of peculiar shape in a woman of 38 years, due to resisting bands of fascia. Adherent intestine in sac. Cured by operation. The shape of the sac, and even the exterior surface of the hernia, may be modified by resisting vessels or fascia as it descends through the short canal or as it lifts up the cribriform fascia at the saphenous opening. A case with a lobulated sac from the latter cause is shown in fig. 171. The patient was a woman thirty-eight years old and had the hernia for eight or ten vears. Trusses tried in this case could not be tolerated FEMORAL HERNIA. 309 because, as was found on the operating table, she had bowel adherent in the sac. Both bowel and omentum were found, the latter being ligated and removed. It is due to these resist- ing bands that occasionally a femoral sac, instead of forming below the opening through which it protrudes, turns upwards over Poupart's ligament and simulates inguinal hernia. Macready {Treatise on Ruptures, p. 60) gives an illustra- tion of a case where three femoral sacs were found upon the same side in one patient, and it is mentioned here to show the possibility of a sac protruding at unusual places. In Macready's case one protrusion was through Gimbernat's liga- ment close to the spine of the pubes, one at its usual place, and the third just to the outer side of the femoral vessels. The condition was not recognized during life. The contents of a femoral sac may be almost any of the movable organs of the pelvic or abdominal cavity. Intestine is most commonly found, omentum next in frequency, but there are many recorded cases of tubes and ovaries, the appen- dix and the bladder, being found. The subject of appendicular femoral hernia has been care- fully stuched by Dr. Alfred C. Wood of Philadelphia {Annals of Surgery, May, 1906, p. 668). He has collected 100 cases, from that of Garangeot, 1 731, to his own 2 cases. He has col- lected only those cases where the appendix occupied exclusively the sac of a femoral hernia. Those where other portions of the intestine were present have been excluded. " Of the 100. cases of appendicular femoral hernia, 81 were women, 7 men, 12 sex not given. Youngest 19 years, oldest 87. More than half were over 50 years, and over 85 per cent, were past 40. Diagnosis previous to operation quite unusual." DIAGNOSIS OF FEMORAL HERNIA. In many instances it is more difficult to make a diagnosis of femoral hernia than of the inguinal variety, and not infrecjuently distinction between the two is attended by great uncertainty. The author has seen 2 patients who had been 310 ABDOMINAL HERNIA. operated upon for inguinal hernia where the femoral type existed, and, of course, as soon as the patients were on their feet, the herniae protruded again. These occurred in the prac- tice of men well known in connection with abdominal surgery. In one case the operator told of failing to find any sac, and later, when the femoral hernia appeared, it dawned upon him why he had failed. In both cases the patients refused to allow the original operator to operate again and were suspicious as to the true reason of failure. Colicky abdominal pains are very likely to be present dur- ing the formation of femoral hernia if the intestine forms a portion of the protruding contents, but if it contains omentum alone, this may not cause the patient sufficient annoyance to attract attention. In a case recently seen of strangulated omentum in a left side femoral hernia, the patient complained of a dragging in the lower part of the abdomen on the right side. Even where the intestine is strangulated, the pain is far more likely to be abdominal than local. If femoral hernia forms a small, round, typical reducible swelling in Scarpa's triangle, then the case is very clear, and the diagnosis easy; but in the descent it may come in contact with resisting tissues that turn it up over Poupart's ligament directly over the inguinal canal. In reducing such a tumor it must be followed in the line of least resistance, and then it will be traced to its true origin. If it is not reducible, by lifting it up and away from the abdominal wall, its neck may be sur- rounded and its point of exit located. The anatomical points that must be constantly borne in mind in deciding between femoral and inguinal hernia are the anterior-superior spine of the crest of the ilium and the spine of the pubes ; an imaginary line drawn between the two with a slight downward curve representing Poupart's ligament. This line is roughly represented by the crease between the thigh and the abdomen, and is clearly shown in most people. The top of a femoral hernia just touches this crease, and an inguinal protrusion is above it. Furthermore, an inguinal hernia FEMORAL HERNIA. 311 usually travels up the canal as reduced, while in femoral hernia reduction is directly back towards the thigh as it passes into the saphenous opening and slips under Poupart's ligament. In direct inguinal hernia the differential points may be more obscure, owing to its very close j)roximity to the femoral open- ing and to the fact that it reduces directly backwards. Here the spine of the pubes must be the guide, remembering that the femoral opening is three-cjuarters of an inch to the outer side and about the same distance below that point, and that the direct inguinal protrusion is almost immediately above the spine. Another point of difference is that usually the inguinal variety can be easily reduced with the patient standing, by making pressure with the hand, while in femoral hernia it is almost always impossible to reduce the tumor until the patient has been placed in the recumbent posture, and even then reduc- tion takes place very slowly. It is well to look with extreme suspicion upon any tumor in the femoral space that is easily reduced while the patient is standing. In the male much valuable information may be obtained by invaginating the thin tissues of the scrotum upon the finger, following the cord up to the external ring" and carefully examining the condition of the external ring as well as locating the relative position of the tumor. With the tip of the finger in the external ring it can usually be decided whether the protrusion is to its inside, — direct hernia, — or to its outer side and a little lower, — femoral hernia. Here the author would again caution the examiner against passing the finger iip the canal. Such method of examining the canal is reprehensible and may lead to hernia where none exists. There is one small round tumor forming in the femoral space that is easily reducible, that has the typical shape of femoral hernia, and that is frequently mistaken by the examiner, viz., a varicose condition of some of the vessels of this vicinity. Varix of some of the larger vessels of this region may prove very perplexing to those of moderate experience (fig. 312 ABDOMINAL HERNIA. 172). The points of differential diagnosis are first, and most important, great ease of reduction in varix ; second, the fluid feel of the contents and peculiar impulse upon coughing. Fig. 172. A left varicose saphena vein. {Eccles.) Femoral hernia, as previously stated, is slow and rather difficult of reduction, and it is almost always a necessity that the patient should be recumbent before it can be accomplished. Varix, on the contrary, is soft and readily compressible with the patient in the standing position. By pressure over it with the hand it quickly disappears and as quickly returns when the FEMORAL HERNIA. 313 pressure is removed. Furthermore, there is a strong impulse in the varix when the patient coughs which does not exist in femoral hernia. The impulse gives the sensation of " thrill " rather than of expansion. It is the impulse of fluid, and has that characteristic feel under the fingers. A single varix of this type may exist without other vessels of the region, or on Fig. 173. Femoral and labial varix in a woman of 35 years, 6 months pregnant. the lower leg, being affected. Usually in suspected cases, however, an examination of the leg will reveal varicose bunches about the ankle, calf, or popliteal space. During pregnancy some women are very liable to a con- dition of varix that is mainly limited to the labia and femoral region (see fig. 173). In these cases the suspicious appearance of the tumor and a consideration of the general condition usually lead to a correct diagnosis. Varix occurs most fre- SU ABDOMINAL HERNIA. quently in women of middle age, but I had in my clinic during the past year a young girl of eighteen years where the con- dition was marked and perplexing. The case was afterward taken into another hospital as one of femoral hernia. The patient's family physician, who was present at the operation, informed me that no hernia was found, but the varix was tied off. I had advised against this operation as not necessary and as attended by considerable danger. The following indi- cates the possible danger. Dr. William J. Taylor {Annals of Surgery J July, 1905, p. 127) reports a case of a woman thirty years of age who had been wearing a truss for a supposed femoral hernia. Upon operation he found a varicose condition of the saphenous vein. He ligated the vein below the enlarge- ment and then ligated it again three-quarters of an inch from the femoral vein. Seven days later she went into collapse and died the ninth day after operation. Post-mortem showed heart clot. Haberern reports (Deutsche Medizinische Wochen- schrift, Dec. 20, 1906) cutting down on what he believed to be incarcerated femoral hernia and a gush of blood poured out. The saphenous vein was tied off together with the plexus of inflamed varicosities. Patient recovered. He believes that the difficulties of diagnosis between incarcerated femoral hernia and varicosites of this type to be considerable. A violent inflammation of the superficial glands of the femoral region is seldom mistaken for hernia because of local pain, heat, and usually discoloration of the skin. In the case of glandular trouble it has a feeling of closeness to the surface that is seldom present in hernia. Incarcerated omentum in a femoral sac, from which it is most difficult to distinguish ade- nitis, is usually accompanied by at least some abdominal discom- fort, even though actual pain is not present. Tlie author recently o|>erated upon a case where the diagnosis was very uncertain, as there had been considerable local pain and there was fluctu- ation. The tumor had a history of two weeks' duration and gradual increase in size. Nine years previously he had oper- FEMORAL HERNIA. 315 ated for femoral hernia upon the opposite side in the same patient and obtained a permanent cure. The present operation revealed a dark-colored femoral sac filled with a coffee-colored fluid, the result of strangulation of a small piece of omentum. Fig. 174. Lipoma simulating femoral hernia. In this case the lipoma is in the subcutaneous fat and does not protrude through the femoral ring. The woman had suffered no abdominal symptoms, and had discomfort, rather than pain, locally. Hydrocele of a sac, the neck of which has been obliterated by truss pressure, may present symptoms almost identical with those just narrated, but without the local discomfort. Its elasticity and the smoothness of the surface of the tumor are the usual guides. Between fluid tumors resulting from hydro- 316 ABDOMINAL HERNIA. cele of the sac, or from strangulated omentum, it may be impossible to make an exact diagnosis previous to operation, as in the case just cited. The author has seen two cases of lympho-sarcoma that were at first examination quite perplex- ing, but fortunately these are of rare occurrence. Psoas abscess is very rarely mistaken for femoral hernia, as it occurs most frequently in young persons suffering from Pott's disease of the spine, and is therefore easily recognized. Subperitoneal fat, or lipoma (fig. 174), not only fre- quently precedes femoral hernia, but is easily mistaken for it. As its treatment should be the same as for hernia the obscurity surrounding the diagnosis is of no serious importance. If it can be reduced through the femoral opening it may be retained by a truss, and if irreducible it should be removed by operation. Irreducibility. — Femoral hernia becomes irreducible more than ten times as often as inguinal, and the contents are most frequently omentum. Owing to the smallness of the neck of the sac and the inelasticity of its surroundings, it is improbable that bowel would be irreducible without being attended with the usual violent symptoms of strangulated hernia. Very rarely, however, in extremely large and old herniae this may occur. J^W CHAPTER XVL MECHANICAL TREATMENT OF FEMORAL HERNIA. In no form of abdominal hernia is prompt and efficient treatment more important than in that variety known as femoral, nor is there any form where more diffitulty is ex- perienced in carrying treatment into effect. This refers more especially to its palliative or truss treatment, and is due to the extreme difficulty of producing sufficient pressure over the deep-seated femoral opening to prevent a protrusion through it without making intolerable pressure on adjoining important nerves and blood vessels. Furthermore, even if the exact compression of the canal has been obtained, nothing but the most careful and accurate fitting of the truss spring wih main- tain the location of the pad. It is easily displaced by the motions of the leg, upon the muscles of which its lower edge necessarily rests, or by the folding over of the abdominal wall against its top. For these reasons, and for the additional reason that femoral hernia is never cured by truss-wearing, no matter how young the patient nor how recent and small the hernia, this form should always have the benefit of present-day surgery and be cured, unless there is some other physical condition which is contraindicative. This statement is not intended to convey the impression that there are not hundreds who go through life and escape accident, but it means that they are much more liable to accident and experience greater incon- venience from truss-w^earing than those who are afflicted with inguinal hernia. What has been said of truss-fitting in general, the taking of a diagram of the pelvis, which is especially important in these cases, and the shaping of truss springs need not be repeated here. 317 318 ABDOMINAL HERNIA. Group of Trusses for Femoral Hernia. I. Chase femoral-hernia truss, hard rubber. 2. Chase femoral-hernia truss, cedar pad, leather cover. 3. Double, hard-rubber, extension-neck truss. 4. Hard-rubber cross-body truss. MECHANICAL TREATMENT: FEMORAL. 319 Group of Trusses for Femoral Hernia {Con(imied). 5. Cross-body truss applied for femoral hernia. 6. Chase hard-rubber truss. 7. French truss with perineal strap. 8. Foster ratchet truss, hard rubber. 320 ABDOMINAL HERNIA. Group of Trusses for Femoral Hernia ( Continued'), 9. Hood truss modified for femoral hernia on left side. 10. Double hard-rubber truss. Made for inguinal hernia ; good form for femoral. II. French truss, leather and hard rubber. 12. Extension neck hard-rubber cross-body truss. MECHANICAL TREATMENT : FEMORAL. 321 Group of Trusses for Femoral Hernia {Continued). 13. Turn-pad hard-rubber truss. 14. Chase hard-rubber femoral truss. 15. Adjustable French truss, hard rubber. 21 16. Elastic truss. 322 ADOMINAL HERNIA. One of the most important points in selecting a truss for femoral hernia is that its retaining pad shall be small enough to tit into the deep femoral space without impinging upon the spine of the pubes at the inner side or upon the femoral vessels at the outer side of the hernial opening. The pad should be Fig. 175. Cross-body bard-rubber truss witb writer pad. Ajiplied to right femoral hernia. narrow, not too long, and deep enough to sink well into the femoral space immediately beneath Poupart's ligament; having a pressure backwards towards the thigh, and slightly upwards. The pad shown in no. 4, well answers this purpose, in a thin ])crsnn, and has been much used on them b_v the autlior. If, however, the jjatient is at all fat it is not sufficiently deep. MECHANICAL TREATMENT: FEMORAL. 323 A small-sized, but prominent, water pad (fig. 175) is very comfortable in these cases, but should be used only on those who can be relied upon to report for inspection with regularity, Fig. 176. ,^Xii£:^iZj:*ti Cross-body hard-rubber truss with deep pad, for femoral hernia. owing to its perishable character. These pads are liable to flatten out in two or three months' wear and must be renewed. This change of shape is particularly dangerous in femoral hernia, as the pressure then comes upon Poupart's ligament or 324 ABDOMINAL HERNIA. the spine of the pubes and is held away from the hernial opening". Fig. 1/5 shows applied, a form of truss known in the trade as a hard-rubber cross-body spring, with water pad, and the combination forms a most excellent truss for femoral hernia. The small hard-rubber pad is usually preferred. This truss, when properly fitted, can be worn without the perineal strap always so objectionable. This is especially referred to as it is kept in stock by nearly all truss dealers and is therefore readily within the reach of most practitioners. As found in the market, it is designed and shaped for use in cases of inguinal hernia, but the modifications necessary to transform it into a femoral hernia truss are easily made. In selecting a spring, secure one wath the lightest obtainable pressure, as femoral hernia never requires as strong pressure for its reten- tion as inguinal. Then select the smaller pad, as the one ordinarily used on the spring is too large. Such a pad will usually be found in the stock of the dealer on the youth's size of inguinal truss, and can be easily transferred to the spring selected. The essential changes now to be made are as follows : ( 1 ) Changing the uniform curve across the front of the spring so that the pad will rest flat against the femoral space. In making this change warm thoroughly the rubber that covers the spring by passing- it through the flame of a spirit lamp, or by putting in boiling water, and then bend the spring with the hands or pliers, being careful not to bend it too near the screw hole. (2) In the shaping of the spring it must be lengthened in front so that it reaches over against the thigh. In the gen- eral fitting, the method of making a diagram described under the article on inguinal hernia must be followed closely, as in this wav, better than any other, can accurate adjustment be secured. The cross-lxxly spring ]:)asses around tlie hi]) op]:)osite the affected side (as shown in fig. 176), just above the trochanter MECHANICAL TREATMENT: FEMORAL. 325 major, in very nearly the position occupied by the inguinal hernia truss ; the pad is placed about one inch lower, its lower edge resting upon the top of the thigh. The spring must be about half an inch longer in front than when used for inguinal hernia. Some of the trusses known as the French (no. 7 of group) or German style (fig. 177) are very good for femoral hernia. The two styles named are alike except that the " French " are lisfhter in construction and therefore better Fig. 177. German femoral truss applied. Noie that direction of pressure of the pad is towards the spine of the pubes instead of into the femoral space and towards the thigh. Good illustra- tion of poor truss-fitting. adapted for femoral hernia. If this truss is carefully shaped by the diagram method it can usually be successfully worn without the perineal strap, but if it fails to maintain an exact position, it must be worn even though irksome. The spring in this truss does not pass across the abdomen, but goes around the hip of the affected side. The English form of this type is even better on account of its having a smaller pad (fig. 178). Springs that go on from the side of the hernia, like the German, French, and English type, are better suited to femoral 326 ABDOMINAL HERNIA. than to inguinal hernia, as the curve of the spring brings the direction of pressure toward the thigh. The truss known as the " Chase " is of this type and is very good. Some inguinal ti-usses with adjustable pads known as " Common Sense " and " Excelsior " trusses, — very similar in design, — are also good for femoral hernia if the spring pressure is sufficiently dimin- ished. One is shown in fig. 179. Fig. 178. Light form of femoral truss, English form. {Macready.) Illustration of good-fitting truss. Several manufacturers have modified the " Hood " truss for use in femoral hernia, but in my own hands it has not proven as satisfactcjry as those of the cross-body type. A truss of the latter type, designed by me many years ago, is shown in fig. 180. This has a light cross-body spring, the pad being supported on an arm, which is in turn attached to the spring by a ratchet. There was also a slot in the face- MECHANICAL TREATMENT: FEMORAL. 327 plate of the pad that allowed of adjustment. Between the ratchet and the slot very accurate adjustment of the pad could be obtamed. Fig. 179. Adjustable truss made for inguinal, also suitable for femoral hernia. The Elastic Truss is strongly advised against as being both unreliable and uncomfortable. The author has seen cases which have become strangulated, and many others w^hich have increased in severity under its use. Nor has the author ever 328 ABDOMINAL HERNIA. seen any form of bandage that he considered in the least degree safe. While waiting for a suitable truss, if one is not at hand, a tight bandage with a moderately hard compress in the Fig. i8o. De Garnio femoral truss. femoral space is somewhat protective and should be used only until something better can be done. In double femoral hernia the choice of truss should be between the " Double French " and the doul)le hard-rubber MECHANICAL TREATMENT: FEMORAL. 329 truss shown in no. lo of group, the latter with small pads being very much preferred. This truss is made for inguinal hernia and the curve at the end of the spring must be modified in order to have the pads rest fiat upon the thigh. It seldom requires the thigh strap to keep it in position. Fig. i8i shows a truss of this type applied to an inguinal hernia on the left side and femoral on the right. This combination has proven thor- FiG. i8i. Woman of 45 years with right femoral and left inguinal hernia retained by double hard- rubber truss and water pads. The latter are for temporary use only, the hard-rubber pads being better. oughly satisfactory in many cases. A smaller pad than the one shown in this photograph was put on later. Irreducible femoral hernia should rarely be treated mechanically, as tlie only safety in these cases is in operation; in some cases, however, the attending circumstances are such that operative means cannot be carried out and some substitute must be used. If the hernia is small a concave pad may be used, preferably on the cross-body spring. Usually in such cases the perineal or thigh strap is necessary to keep the 330 ABDOMINAL HERNIA. pad in place. The contents of irreducible femoral hernia is almost uniformly omentum, and in a few instances the author has seen its absorption occur under the pressure of a concave pad. and has then changed to the convex pad generally used in femoral hernia. The idea advanced in some of the older works upon this subject that it is dangerous to make truss pressure upon irreducible omentum has been too often dis- proven in the experience of the author to allow of anything but the most emphatic denial. CHAPTER XVII. SURGICAL CURE OF FEMORAL HERNIA. The history of the operative cure of femoral hernia is pecuHar, in that works upon the subject have repeatedly stated that owing to the formation of the so-called " ring " its cure is uncertain and improbable. At the same time the experience of the individual operator has constantly shown, in this coun- try at least, that if he be careful to clear the femoral opening of sac and all foreign tissue and to close it by almost any method, a cure is more than likely to result. The truth, it would then seem, is that the objections to its surgical cure have been theoretical rather than practical, yet this has led to the suggestion of many different methods by many different operators. So far as to him known, the report of the author before the Surgical Section of the New York Academy of Medicine (Annals of Surgery, August, 1905, p. 209) of no cases oper- ated upon by one method and by the same operator, is the largest that has been made. This method is given in this work to the exclusion of others, not because it was original with the author, but because of its simplicity, ease of execu- tion, and the permanence of its results. It was first done by him, on March 4, 1890, and has been taught' to his classes at the New York Post-Graduate Medical School and Hospital since that date. The cases recorded in the report referred to were met with in operating upon a series of 1,250 abdominal herni?e. The no femoral hernise were in 99 patients, 83 of whom were females and 16 males. Eighty-eight patients had single and 1 1 had double femoral hernia. Of the single hernias, 59 were on the right side and 29 on the left. One patient had double femoral hernia and left inguinal. Three had double inguinal 331 332 ABDOMINAL HERNIA. and single femoral hernia. Two had single femoral and inguinal hernia on the same side, making 5 cases who had femoral and inguinal hernia on the same side. Six had femoral hernia on one and inguinal on the opposite side. In 28 patients, strangulation of the hernia existed at the time of the operation, and 82 were operated upon for the cure of the hernia. The ages were, 4 under ten years; 6 between ten and twent}^ years; 18 between twenty and thirty years; 34 between thirty and forty years; 15 between forty and fifty years; 11 between fifty and sixty years; 5 between sixty and seventy years ; 5 between seventy and eighty years ; I over eighty years. The youngest patient was eight years of age and the oldest eighty-one years. The latter was operated upon in a private house, in the middle of the night, for femoral hernia of enormous size that had existed for thirty years and which had been strangulated for six hours. She lived nine years after the operation, during which time she wore no truss and had no recurrence. Mortality. — In the entire number only one death has occurred, and that was an old woman of seventy years, who had suffered from strangulated hernia for three days, during which time she had been subjected to the most violent attempts at reduction. Perforation of the bowel was found, and, owing to the moribund condition of the patient, the intestine was fastened in the wound and freely opened. She died of exhaus- tion twenty-four hours later. Recurrences. — In one case there was recurrence three weeks after the operation from violent vomiting due to acute indigestion. This case was re-operated upon eight months afterwards, and has remained cured three years. One patient, a man, who had double inguinal and right femoral hernia, was supposed to have a recurrence of the femoral hernia. Upon re-operating, the protrusion wa*5 found to be subperitoneal fat that had slipped through under Poupart's ligament, but no hernial sac had formed. In one other case, believed to be identical with the one just narrated, a woman of thirty-five SURGICAL CURE: FEMORAL. 333 years had a small swelling in the femoral region nine months after operation. A light truss was applied and worn one year, and she has now been five years without support and no pro- trusion. It is believed that this also was a small protrusion of subperitoneal fat, and absorption was produced by truss press- ure. I have never seen a femoral hernia cured by truss pressure, no matter how young the patient nor how small the protrusion. One woman of seventy-five years of age had a recurrence within eight months of the operation, and, so far as I know, this is the only actual recurrence. By far the greater number of these cases have been traced and the permanence of the cure ascertained. Three cases operated upon were recurrent follow- ing some previous operation, the character of which is unknown. All of these recurrent cases have remained cured for more than four years. Two cases had by mistake been operated upon for inguinal hernia, when, in reality, femoral hernia existed, and it is a rather remarkable fact that both were done by operators noted in other lines of surgical work. Contents. — Contents of the hernise were in most instances intestine or omentum, or both. In one instance a small and unhealthy ovary was found in the sac. In two cases of strangulation with quite acute symptoms, appendices epiploicae were found strangulated. In these cases the bowel itself was held firmly against the femoral opening, but the lumen of the intestine was not constricted. Cysts in or around the sac were found in 4 cases. In one case, the daughter of a well-known physician, strangulation was coincident with the first protrusion of the hernia. In stepping from a railroad-car, the step being much higher than she had estimated, a hernia was forced through the femoral canal, and urgent symptoms at once presented. The safety and comfort of the patient demand that every case of femoral hernia, whether reducible or irreducible, shall be cured unless there is something in the condition of the patient that positively contraindicates an operation. Its peculiar 334 ABDOMINAL HERNIA. anatomical surroundings make femoral hernia an unsually dan- gerous condition, and render its successful treatment by mechanical means uncertain as well as attended by discomfort. On the other hand, viewed from the surgical side it is consid- ered the safest of all hernise for operative cure ; the operation is easier of execution and it is fully as permanent in its results as that done on any other form of hernia. The danger in the Fig. 182. Showing location and direction of incision for femoral hernia operation. hands idridg-e.) 23 354 ABDOMINAL HERNIA. large umbilical hernia seem especially liable to localized inflam- mation; this extending to the contents results in a matting together and soon causes the hernia to become irreducible. Symptoms. — There is little trouble in making a diagnosis of umbilical hernia. In the infant a reducible tumor in the umbilical region may be accepted as an umbilical hernia. An error that is sometimes made is in mistaking an unusually long and prominent navel for an umbilical hernia. Several instances of this kind have been seen by the author; one in a girl of fourteen, brought to him from a distant state. She had worn a truss since one year old for supposed umbilical hernia. No hernia was found, and from the history elicited it was confi- dently believed that none had ever been present. The navel, about the size of an adult little finger, projected fully three- quarters of an inch from the abdominal surface. There was no protrusion inside of this loose skin. Several similar cases have been seen in the hernia clinic at the Post-Graduate Hospital. Aside from the tumor there are few symptoms attending an umbilical hernia in infancy or early childhood. In the adult, however, it is frequently accompanied by considerable local pain, and gastro-intestinal symptoms are marked. Nausea and even vomiting may be produced when there is no strangulation, and this is believed to be due to traction upon the stomach. In the larger hernias obstinate constipation, eventually ter- minating in intestinal obstruction and death, results from the crip'pled condition of the bowel. Common types of this form of hernia as seen in the adult are shown in figs. 196, 197 and 198. The case of Bainbridge {The Posf-Gradiiatc, February, 1905) is of special interest in showing the defective closure throughout the median line of the abdominal wall. In this case there existed five hernic-e in the median line besides a femoral hernia (figs. 199 and 200). CHAPTER XIX. • MECHANICAL TREATMENT OF UMBILICAL HERNIA. The discussion of the treatment of umbiHcal hernia naturally divides itself into a consideration of methods which are palliative or mechanical, and methods which are curative or surgical; this again divides the cases into those occurring in infancy and very early childhood, which are readily cured by palliative means, and those occurring in adult life, when a cure is never obtained except by surgery. Treatment of Umbilical Hernia in Infancy, — The cure of small umbilical protrusions in early infancy is, in some instances, accomplished independently of the family doctor. The grandmother has, on discovering the condition, made a compress of a half dollar, if particularly wealthy, but more frequently of a button-mold, and has held it in place by a belly- band for two or three months, and the hernia has been cured v/ithout the doctor ever having known that it existed. This illustrates by what simple methods umbilical hernia may be cured in the new-born child, and makes it seem strange that in the adult its cure can never be obtained, except by a surgical operation. It has been my habit for many years, both in my clinical and private work, to put no trusses on babies under one year of age, or, in other words, before they begin to walk. They have, with rare exceptions, been treated by a compress over the navel, held in place by one or more strips of zinc oxide plaster. The compress has sometimes, and preferably, been a hard-rubber umbilical pad, such as is found on infant trusses; sometimes it has been a wooden button-mold, and many times a roll of gauze wrapped about by plaster with the sticky side out so that it would stay just where placed. Fine cork with its edges 355 356 ABDOMINAL HERNIA. beveled forms an excellent compress. The hernia should be reduced, the compress placed over the navel, and inch-v\^ide strips of zinc oxide plaster placed across it at different angles, the ends extending about two-thirds of the distance around the body. Two strips are usually sufficient and many times one will answer every purpose. It is not M^ell to have the plaster meet in the back, as there is then no allowance for abdominal distension. I have seen a child who had inguinal hernia pro- duced by plaster applied in this manner and the consequent Fig. 20I. Dr. S. W. Kelley's combination of hard-rubber plate and plaster, i. Hard- rubber plate. 2. Plate with plaster attached. 3. Plaster unbuttoned and plate turned back. forcing of the abdominal contents into the lower abdomen. This dressing should be removed once a week and renewed after the parts have been bathed. The suggestion of Dr. Samuel W. Kelley is an excellent one {Ohio State Medical Jour., November i8, 1905) of having a hard-rubber pad with buttons on it, folding the front ends of the plaster back upon itself and cutting a button-hole in the plaster (figs. 201 and 202). The mother can remove the umbil- ical plate evei"y day for the purpose of washing the skin without disturbing the plaster, and she can easily renew any part of the plaster that may become loosened. In Germany the method MECHANICAL TREATMENT: UMBILICAL. 357 of using the skin and subcutaneous tissues in the vicinity of the navel as a compress has been adopted and seems to have met with success. The skin and loose tissue on either side of the umbilicus are grasped with thumb and fingers and infolded, the plaster being then placed over. When I first read of the method it impressed me as being particularly good, and I at once adopted it in my clinic ; but we found that there was great liability to ulceration of the skin surfaces that were folded together, and soon went back to the use of the compress and plaster, as already described. Fig. 202. Dr. S. W. Kelley's method of combining plaster with hard-rubber plate. Plaster is folded back upon itself, and has button holes cut in it. The length of time required to cure an infant of umbilical hernia seems to depend somewhat upon its age. At three months of age it can ordinarily be cured in three months, but at six months of age it will frequently require six months, while a full year of mechanical support is usually required after the child walks. When it is a year old I seldom resort to the plaster and compress, experience having proven that a light spring controls the hernia with greater certainty. In the group of umbilical trusses for infants will be seen several good forms. My preference with very small children is for the single-spring trusses covered Avith either hard rubber or celluloid so that they can be kept perfectly clean and worn in the bath. In children 358 ABDOMINAL HERNIA. Group of Infant Umbilical Trusses. I. Infant's hard-rubbersingle-spring umbilical 2. Infant's hard-rubber single-spring umbili- truss. Sizes, 10 to 21 inches. cal truss. (Youth's sizes, 22 to 29 inches.) 3. Youth's double-spring hard-rubber umbilical truss. 4. Bow spring (leather covered ) cedar pad umbilical truss. * 5. Fine French kid or cedar pad. umbilical truss. 7. Umbilical belt truss, sateen band, elastic sides to lace in back. Kid or hard- rubber pad. 6. Double band elastic hard-rubber plate umbilical truss. S. Elastic umbilical truss, hard-rubber cedar, or kid pad. 9. Soft-rubber belt with inflated air pad. MECHANICAL TREATMENT: UMBILICAL. 359 of three years and over I am quite partial to light double springs with the fastening in the back, as shown in fig. 203. The selection of the pad or button that presses into the umbilicus is a matter of importance. If the child is very fat the centre projection on the umbilical pad must be quite prom- inent, in order to reach down to the abdominal wall; if very thin such a prominent centre would do actual harm by wedging Fig. 203. Umbilical hernia (in a child 3 years old) retained fay a hard-rubber truss, the spring going around the body on both sides. itself into the umbilical ring and preventing closure. Some- times in very thin children the use of a perfectly flat surface is attended by better results. As in inguinal hernia, these cases must be kept under the frequent observation of the physician in order to obtain good results. The children are growing rapidly, and this growth must be provided for. Here, also, as in inguinal hernia, infants are good truss wearers if the skin is kept perfectly clean and dry. 360 ABDOMINAL HERNIA. Children under five years of age are almost always cured by tlie means suggested if they are kept under care; the curability of umbilical hernia by mechanical support, however, diminishes rapidly after passing the third year, and, while in recent cases a few cures may be obtained, even in children ten or twelve years old, this fortunate result has been very rare in my experience. It has been my practice to recommend operative cure in all children who have passed the tenth year, and in some much earlier, where there appeared little prospect of curing by means of the truss. Where springs are used their accurate adjustment will be greatly enhanced by resort to the lead-tape diagram method, which has been described under the mechan- ical treatment of inguinal hernia. Mechanical Treatment of Umbilical Hernia in the Adult. — In the adult umbilical hernia is unquestionably the most difificult of all herniae to treat either mechanically or surgically, and for this reason its occurrence should always be looked upon as a serious matter even though the hernia be insignificant in size and giving no immediate discomfort. In fact, the most prompt and persistent treatment should be insisted upon from its very inception in order to protect the patient against the many ills and dangers that are sure to follow its neglect. While there is not such a large variety of trusses made for this form of hernia, there are several good ones from which to select in order to meet the special indications of the case. In small hernia upon a person of medium weight, the single spring trusses are lighter, more convenient and consequently better. Little dependence can be placed upon trusses made of elastic 1)ands. and caution in their use is therefore advised. In those cases where it seems advisable to use a truss at night they answer the purpose admirably, but under their use during the day most cases grow worse. In selecting springs preference should always be given to those covered by hard rubber or celluloid. In shaping them it must be borne in mind that those covered with hard rubber must be warmed before bendincf. What has been said about MECHANICAL TREATMENT: UMBILICAL. 361 Group of Adult Umbilical Trusses. I. Celluloid single-spring umbilical truss. 2. Double-spring hard-rubber umbilical truss. 3. Chase umbilical truss. Leather cover, cedar pad. 362 ABDOMINAL HERNIA. Group of Adult Umbilical Trusses ( Conimued). 4. Single-spring hard-rubber umbilical truss. 5. Elliptic double-spring hard-rubber umbilical truss. 6. Bow-spring hard-rubber umbilical truss. MECHANICAL TREATMENT: UMBILICAL. 363 Group of Adult Umbilical Trusses {Contiftued). 7. Elastic umbilical truss. 8. Narrow band elastic umbilical truss. 9. Bo\v-spring leather umbilical truss'. 10. Elastic umbilical truss, celluloid plate. Concave hard-rubber pads. 26i ABDOMINAL HERNIA. Group of Adult Umbilical Trusses {Contitmcd). Concave hard-rubber pads for use inside of abdominal belts in irreducible umbilical hernia. II. Combinatioa belt and umbilical pad. 12. Combination belt and umbilical pad with springs outside of belt. MECHANICAL TREATMENT: UMBILICAL. 365 Group of Adult Umbilical Trusses {Cotttimied) , 13. Extra hard-rubber pad, elliptic spring, and band to be used in combination with abdominal belt. ^:ittate»«w.Mt«i^' 14. Hard-rubber elliptic-spring umbilical truss applied. 15. Belt for general abdominal support, to which may be added umbilical pad and extra retaining band. Woven silk or cotton-covered thread. 366 ABDOMINAL HERNIA. Oi'TLiNES OF Umbilical Plates and Centres. Showing Actual Sizes. Fig. 204. Solid cedar pad, 5j; V ■ /C"%. /o "a Diagram for abdominal belt and umbilical truss measure. — i. Umbilical hernia : Circumference on line with navel and shape by lead tape (see Truss-fitting, Inguinal hernia) on same line. 2. Abdominal belts: Circumference at K, L, M; length from 6 to 8. If' an umbilical plate is to be added, give distance from 6 to navel. 3. Ventral hernia belts: Cir- cumference M, L, K, 6 to 8. Distance of top of pad from navel to 9, of bottom of pad, 10 to II. admirable combination for corpulent people suffering from large reducible or irreducible umbilical hernia. The belt not only gives valuable general support, but prevents the truss 24 370 ABDOMINAL HERNIA. springs becoming imbedded in the fat. The umbiHcal plate, being inside the beh, is also held more securely in place. Where a belt is ordered as a part of the support, careful meas- ures of the abdomen should be forwarded to the manufacturer. The diagram shown in fig. 206 will aid the physician in taking these measures, and the letters w4iich designate the points of circumference are understood by all reputable manufacturers. Hernije containing large omental protrusions are very liable to inflammatory conditions, which may be mistaken for true strangulation. This inflammation is ordinarily due to pro- FiG. 207. English rim-plate concave-pad truss for irreducible umbilical hernia. {Eccles.) trusion of a new mass of omentum and its constriction at the hernial aperture. If allowed to follow their own course, sloughing is liable to occur. Long continued hot applications I feel sure favors this result. I have found the use of ice more satisfactory, and have kept it on for several days at a time, with the most happy results. Let it be distinctly understood that I do not approve of any such delay if there is the least indication of intestinal obstruction. By the application of ice and daily gentle manipulations, the hernia can frequently be restored to its former condition. Irreducible Umbilical Hernia. — This leads to the mechan- ical treatment of those cases which are only partially reducible. MECHANICAL TREATMENT: UMBILICAL. 371 A few of these can, by confinement to bed and repeated gentle taxis, be converted into reducible hernise. At least an attempt should be made to reduce all that is possible; then a concave pad, fitting exactly the remaining protrusion, and attached to one of the springs already described, should be applied. In large people, the combination of belt and spring with concave pad of suitable size, is especially desirable. After wearing one of these concave pads over an irreducible hernia, the protrusion may so diminish in size that a smaller pad will be required. The English use a form of truss shown in fig. 207, which, it would seem, might be useful in the cases under consideration. The treatment of irreducible umbilical hernia by mechanical means is not attended by an amount of success that is encouraging. In fact the history of such cases is one of con- stant increase in size, discomfort, and danger. Unless there is some special contra-indication it will be best to advise such patients to submit to surgical treatment. CHAPTER XX. SURGICAL CURE OF UMBILICAL HERNIA. Those having little practical experience will find the litera- ture of this subject confusing, and in many instances mislead- ing, inasmuch as authors differ so widely in their statements. We are assured by some, who should speak with authority, that the operations for the cure of umbilical hernia are par- ticularly dangerous and usually followed by failure to obtain a cure. Then again men of such ripe experience as Dr. George Ben Johnson of Richmond tells us (Medical Register, August 15, 1897) that most authors are too conservative. Dr. John- son says, " I am astonished at the cautious manner in which some of our best authors advise the procedure." Those of us who know his work know that Dr. Johnson is himself a con- servative man ; we also know that some of these umbilical cases are particularly dangerous cases for operative treatment. The truth is that we cannot speak positively upon the subject as a whole; we must attempt to separate and recognize those cases that are safe for operation, and when we are forced to operate upon those that are dangerous we should do so with a full understanding of the responsibilities involved. As previously stated, most umbilical hernise of early life need never come to the operating table, if given proper mechanical support for a suitable length of time. In some instances, however, the muscular defect is too great to be over- come and the question will arise as to the advisability of operative relief. These cases may all be classed as safe for operation, and a permanent cure is quite certain to follow. I have no knowledge of a fatality or a failure following an operation on young patients. Operations upon adults of middle and advanced life must be considered more carefully, and examination of Dr. Johnson's 372 SURGICAL CURE: UMBILICAL. 373 " excluded " list will at once show the reason of his positive and favorable opinion. Here are those who, according to his opin- ion, should not be operated upon : " The old and feeble, where there is extensive separation of the recti muscles below the umbilicus, where there is so much hypertrophied omentum that its removal would prove dangerous to life, where there is extreme atrophy of the surrounding muscles." To this I would add the excessively fat, who are liable to degeneration of the heart as well as other muscular structures. We at once recognize the fact that a large percentage of umbilical hernije as seen in the adult come within the limits of this excluded list, and should therefore be considered as extra-hazardous as regards danger to life and the permanence of cure. My personal views have changed materially within the past ten years. Formerly I was inclined to avoid the surgical treatment of umbilical hernia in adults. I have, however, had the mortification of seeing some of those same cases, through neglect of the patient or my own inability to so adjust support as to control the hernia, grow gradually but surely worse. When first seen they might have been operated upon with a small amount of danger, but later that risk has increased many times. For this reason I have come to feel that all cases of umbilical hernia should, if possible, be operated upon while the protrusion is small. The larger these herni?e become the greater are the dangers attending their cure, and the poorer are the structures which are used in effecting closure of the hernial ring. Operation. — The preparation of the patient should be made with all the extreme care that would be exercised in any other laparotomy. Even greater attention must be given to the sterilization of the skin, which is frequently in bad condi- tion either from ulceration due to over-distention, or from the effects of truss-wearing. Many authors direct that a vertical incision shall be made over the most prominent part of the tumor. This, I am con- vinced, is fraught with great danger. The incision should 374 ABDOMINAL HERNIA. rarel}^ if ever, be made in the median line, as at this point the skin and sac are usually so intimately united as to make their separate division impossible ; furthermore, the intestine may be adherent to the interior of the sac and opened at the first sweep of the knife. The incision should be elliptical in form, beginning well above and spreading out on each side of the na\-el so as to avoid to a great extent the risk of opening into the sac. The dissection of the subcutaneous fat can be rapidly carried down to the aponeurosis and then carefully . upon this surface towards the neck of the sac. When the neck of sac thus approached is freed on all sides it can be lifted up and an opening made through it to examine its contents, all reducible parts having been previously returned to the abdomen. If the sac is free it can at once be cut away at its neck, leaving the adherent fundus attached to the removed ellipse of skin. If on opening the side of the sac a mass of adherent omentum is found, it is best to draw it out through this opening, ligate it by multiple ligatures, cut it away and reduce the stump. Then cut away the sac, which will be removed with attached omen- tum, skin, and umbilicus. This method saves much valuable time that is lost when opening directly into the top of the sac; If it is found that intestine is adherent then it is better to care- fully extend the side incision into the sac, laying it wide open. Patches of sac firmly adherent to the bowel should be cut out and left upon the intestinal surface rather than incur risk of serious laceration by attempting to strip them loose. In cutting away the sac it should be far enough from the abdominal sur- face to leave plenty of material for closure of the peritoneum. The method of closing the umbilical ring should depend largely upon the conditions found. If the surrounding struc- tures are of normal thickness, the stripping away of the peri- toneum from the edges of the ring, its closure by plain catgut, and then the splitting of the aponeurotic structures into two layers and their separate closure, preferably by kangaroo ten- don, and finally the closure of the skin, will result in an effective repair of the distended ring. SURGICAL CURE: UMBILICAL. 375 If the case is one where intra-abdominal pressure will be great and liable to tear the sutures through the tissues, put in before closing the tendinous layers, three or four relaxation sutures of silkworm gut. These are put in by a long needle between the layers, if the wall has been split, or just outside of the peritoneum if not, and extended well back from the wound on either side. They are not tied until the other steps in the operation are complete. The wound is now closed in the following manner : Peri- toneum by continuous suture of catgut. Each layer of abdominal wall separately, by heavy strands of chromicized kangaroo tendon, and skin by subcutaneous catgut. The relaxation sutures are then drawn tight and tied. These are cut and removed about the tenth or twelfth day. The usual dressings under a firm binder are applied. This is not dis- turbed for ten days, unless there is pain or elevation of temperature. Overlapping of Abdominal Wall. — At the meeting of the Medical Society of the State of New York at Albany, February I, 1899, in a paper on the treatment of umbilical hernia, I made the following statement ( Transactions Med. Soc, State of New York, 1899) : " In several cases where the abdominal wall was thin, and intra-abdominal pressure not great, I have suc- ceeded in overlapping the cut edges, so 'that, when complete, it gave two layers of tendinous structure in the median line. I am quite partial to this method, but in some cases it cannot be used on account of the extent to which the abdominal cavity is thereby diminished." I had previous to 1899 operated upon 6 cases by this method, my first having been on March 9, 1896, at the New- York Post-Graduate Hospital. This statement is made definitely because of the fact that American writers have recently been accused (P. T. Diaknow, M.D., Annals of Sur- gery, July, 1906) of not giving credit to Russian authors whose first writings were according to Dr. Diaknow, by him- self in 1898, and Dr. Sapiejhko {Annals of Russian Surgery) 376 ABDOMINAL HERNIA. in 1900. The truth is that eveiy operator of good surgical common sense would be very likely sooner or later to see his opportunity of making a closure of this type, and without feel- ing that he had made an}- great discovery. Dr. Joseph A. Blake of New York was perhaps the first to demonstrate the method properly by drawings showing its technique (Medical Fig. 208. Vertical overlapping of abdominal wall in umbilical and veiitxal hernia. (Size of incision exaggerated.) Record, May 25, 1901). His claims for it were as follows: "(i) The doubling of the abdominal wall at the hernial site. (2) The breaking of the lines of suture. (3) The broad sur- faces for union. (4) The obliteration of the separation of the recti, and the reduction in the size of the abdomen." After several years' experience with this operation I feel that the claims made for it are fully justified. The method is SURGICAL CURE: UMBILICAL. 377 executed as follows : After the removal of the sac, the linea alba, with the peritoneum, is divided for one and a half or two inches above and below the umbilical ring. The peritoneum is separated from the abdominal wall on both sides to whatever distance the overlapping can be done, and it is then closed in the median line by a running suture of catgut. The denuded aponeurosis of the right side is slipped under that of the left and fastened there by interrupted sutures. Kangaroo tendon is preferred for this purpose. The other edge of the flap is now united to the right side by a running suture of the same material (fig. 208). Blake used the interrupted suture for the closure of both lines. The skin is closed in the usual way. This gives a broad surface of union and has proven protective in cases that seemed almost hopeless so far as permanence of cure was concerned. In some instances the intra-abdominal pressure is so great as to make it almost impos- sible to get the material w^ith which to do this overlapping. These cases should, if possible, be recognized before they come to the table and the pressure relieved by light diet for some days before the operation, and the complete freeing of the intestinal tract by , cathartics. Dr. William J. Mayo of Rochester, Minn., prefers to do the overlapping in a transverse direction and his operation has been largely followed in the West. My own experience with it would not lead me to adopt it as a routine method. He gives the steps of his operation of transverse overlapping of the abdominal wall as follows {Jour. A.M. A., July 25, 1903) : "(i) Transverse elliptical incisions are made surrounding the umbilicus and hernia ; this is deepened to the base of the hernial protrusion. (2) The surfaces of the aponeurotic structures are care- fully cleared two and a half to three inches in all directions from the neck of the sac (fig. 209). (3) The fibrous and peritoneal coverings of the hernia are divided in a circular manner at the neck, exposing its contents. If intestinal viscera are present, the adhesions are separated 378 ABDOMINAL HERNIA. and restitution made. The contained omentum is ligated and removed with the entire sac of the hernia, and without tedious dissection of the adherent omentum. (4) An incision is made through the aponeurotic and peritoneal structures of the ring, extending one inch or less Fig . 209. Transverse elliptic incision to aponeurosis, and circular division of sac neck. (Afayo.) transversely to each side, and the peritoneum is separated from the under surface of the upper of the two flaps thus formed. (5) Beginning from two to two and one-half inches from the margin of the upper flap, three to four mattress sutures of silk or other permanent 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 SURGICAL CURE: UMBILICAL. 379 with running suture of catgut. The mattress sutures are then drawn into position, shding the entire lower flap into the pocket previously formed between the aponeurosis and the peritoneum above (fig. 210). Fig. 210. Lower flap slipped into pocket between peritoneum and aponeurosis. Mattress sutures ready to tie. (Mayo.) (6) The free margin of the upper flap is fixed by catgut sutures to the surface of the aponeurosis below, and the super- ficial incision closed in the usual manner. In the larger hernise the incisions through the fibrous coverings of the sac may be made somewhat above the base, thereby increasing the amount of tissue available for use In the overlapping process " (fig. 211). 380 ABDOMINAL HERNIA. As to whether the overlapping shall be in a vertical or transverse line must, it seems to me, be decided by the oper- ator after the parts are open and it can be seen in which direction there is the least resistance. In making this a basis upon which the incision rests it has appeared to me that in the Fig. 211. I'pper flap closed over lower and stitched to aponeurosis. (Mayo.) greater number of cases it would be easier to overlap the aponeurotic structures vertically than transversely. Further- more, this, to my mind, more nearly restores the normal relative position of the recti muscles, which are so widely separated in the large hernire in which one or the other of these operations seems so well calculated to cure. The excision of the umbilicus, which I have for years fol- SURGICAL CURE: UMBILICAL. 381 lowed in nearly every case, is also believed to be an important step toward a permanent cure. The umbilical ring is a weak spot in the abdominal wall because of its surrounding a mass of tissue that is never completely obliterated. When operating, by removing entirely this mass, we materially aid in the abso- lute closure of that ring. The suggestion that the sheath of the recti be cut and their fibres united in the median line is not in many cases practicable, especially in large hernise where there is special difficulty in obtaining a cure, because these muscles are so widely separated and so thin that it is not possible to bring them together. The after treatment of cases operated upon for umbilical hernia should differ somewhat from that given in the inguinal and femoral types. The patient should be confined to bed for at least two weeks and in very large hernise even longer. A good snug binder with a compress over the former site of the hernia should be worn for from two to three months. If the hernia has been large and the structures poor it is far better to have a good woven elastic belt worn for a year or even permanently than to take the risk of losing the benefits of the operation. It is believed the best policy to tell patients who have been operated upon for this form of hernia that the risk of recurrence is much greater than in other forms, and that much depends upon them and the care they take of themselves. CONGENITAL UMBILICAL HERNIA. It scarcely comes within the intent of this work to speak of congenital umbilical hernia, which in reality is not hernia, but rather a malformation or lack of development. It is not a pro- trusion of abdominal contents through the umbilical ring, but a portion of the viscera which has never been closed within the abdominal cavity. The umbilical ring has really never formed, and, as in spina bifida, the lateral halves of the body wall have failed to unite. The subject is briefly discussed here, however, to correct a rather common error among physicians that most umbilical hernise in infancy are of the congenital type. 382 ABDOMINAL HERNIA. This condition is found at the birth of the child, the abdominal wall having failed completely to enclose its normal contents. There is an unclosed cleft in the wall and the pro- truding viscera are covered only by the attenuated coverings of the umbilical cord. Lindfors (Centralblatt filr Gyndk, p. 255, 1884) gives the number of cases of this malformation in 21,000 confinements, at the Munich Lying-in Hospital, as i in every 5,184 births. In size it may be anywhere from that of a walnut to complete eventration containing in addition to the intestinal tract the stomach, liver, spleen, and even the heart. ^ Diagnosis. — The sac is translucent, and its contents are usually intestine, but may be a part or the whole of any of the abdominal viscera. Diagnosis should not be difficult, but doubt may be caused by possible confusion with hydrocele of the umbilical cord. The treatment of these cases is far from satis- factory, but all authors agree that in immediate operation there is greater safety. Dr. Willis Macdonald {Am. Jour. Ahst., p. 7, 1890) gives a history of 12 cases treated by compress and bandage, of which 9 died, while of 19 others subjected to early laparotomy only 2 died. The tumor may be partially or fully reduced, and retained by dry aseptic gauze dressings held in place by strips of zinc oxide plaster. The tumor must be handled with extreme caution and this dressing merely employed while preparing for an operation. The operation consists in closure of abdominal wall over the stump of the sac, after that has been tied off and cut away, A belly-band with compress should be worn for several months afterwards. ^ Those who wish to follow the subject more fully are advised to consult the very valuable article upon the subject by Dr. Charles Green Cumston, of Boston {Medical Record, September 23, 1905). CHAPTER XXI. VENTRAL HERNIA. A protrusion of the abdominal contents at any part of the abdominal wall other than the umbilical, inguinal, or femoral region may be correctly termed a ventral hernia. In order to constitute a hernia the tumor must have a neck and a lining of peritoneum. Those cases of deficiency at birth of the muscular wall, with consequent bulging of one side or a part of one side of the abdomen, are looked upon as congenital malformations rather than ventral hernise. The two principal causes of ventral hernia are defective points in the tendinous closure of the abdominal wall, and traumatism. The latter in itself forms an important division of the subject. Eccles {Hernia, p. 190) uses the terms " spon- taneous " and " traumatic " ventral hernia. As these terms are concise and expressive they will be used in discussion. Spontaneous Ventral Hernia. — Macready, in collecting statistics on this subject, found that this form was nearly four times more frequent in the male than in the female, and that it occurred most frequently in middle life, although it may be found at any age. In 21,812 hernicC examined, 38 ventral hernise, or i in every 574 cases, were found. Its relation to other herniee is shown by the following table from his work: Sex. Inguinal. Femoral. Umbilical. Vent in Linea Alba. Ventral + Inguinal. Male 17,538 1,803 461 1,197 209 566 15 6 15 2 Female Spontaneous ventral hernia never protrudes through muscular tissue, but always through some of the tendinous structure of the abdominal wall. It is therefore most fre- quently found in the median line coming through some 383 384 ABDOMINAL HERNIA. defective spot in the linea alba, but it may come through at eitlier edge of the recti muscles, the linea transversa, or linea semilunaris. Various names have been applied to it according to the location of the hernia (as, epigastric ventral hernia to all of those protruding above the navel), but here, as in other parts of this work, multiplicity of names will be avoided as leading only to confusion. The linea alba being weaker in structure above than below the navel, we find, as might be expected, a greater number of ventral protrusions above this point. Protrusions of subperi- toneal fat (commonly called lipoma) through these openings may simulate ventral hernia so closely as to defy diagnosis before operation. This, however, is unimportant, as they are not only frequently the forerunners of true hernia, but by traction upon the peritoneum they are equally painful. Some authors have called these tumors fatty hernise, but it is hardly necessary to give them any title other than ventral hernia, diag- nosis seldom being made before operation. These remarks do not apply to true lipomata that form in the cellular tissue out- side of the abdominal wall and which can usually be readily lifted up from the muscular surface. In the latter cases there is ordinarily no pain or discomfort and the patient is concerned in the growth merely as something abnormal. Spontaneous ventral hernia is usually found as a small round tumor varying in size from the end of the little finger to that of an English walnut. Cases have, rarely, been recorded where the tumor has become large and pendulous, but such have not come within my own experience. The con- tents of these hernise are most frequently omentum, but may be intestine or both. The sac is frequently small and at the base of the subperitoneal fat which has protruded first, drag- ging the peritoneum through the aperture after it. These small tumors may, in many instances, be demonstrated by having the patient lie prone on a hard surface and then attempt to raise his head and slioulders. In other cases they are better found by having the patient stoop forward and cough while standing. VENTRAL HERNIA. 385 Symptoms. — The amount of pain and discomfort that frequently attend this form of hernia is entirely out of propor- tion to the size of the swelling. The diagnosis of obscure abdominal trouble would many times be made clear by the discovery of this apparently insignificant " lump." The patient may know that it is there and still not associate his abdominal trouble with it. I have seen several cases where the overlook- ing of a small ventral hernia has led to the patient's great dis- comfort and unnecessary expense. One man upon whom I operated had been treated by various physicians for " dys- pepsia," " renal colic," " gall-stones," " ulcer of the stomach," and was finally told that his distress was due to some malignant growth. He had called the attention of one or two to this little swelling about two and a half inches above the navel and a little to the left of the median line, but was told that it was of no account. In this case, as in some others I have seen, there was no local pain. These little protrusions may cause dragging abdominal pains and gastro-intestinal disturbances quite remote from the seat of the trouble. " Cramps " and vomiting were both present in the case above referred to, and yet at operation nothing was found in the sac but a very small piece of adherent omentum. The cure was absolute both as to the distressing symptoms and the hernial protrusion. Not- withstanding these symptoms actual strangulation seldom occurs in this form of hernia. Lockwood {" Hunterian Lec- tures on the Morbid Anatomy, Pathology, and Treatment of Hernia," p. 137) found one of the appendices epiploicse of the colon protruding through a small hole in the linea semilunaris at the level of the anterior superior spine of the ilium and incarcerated. It can be readily seen what an amount of disturb- ance would result from such a condition without producing symptoms of intestinal obstruction. Treatment. — The treatment of spontaneous ventral hernia by mechanical means is not usually attended by any great degree of success. They are seldom fully reducible on account of the pro-truding fat outside of the sac, and they are at points 25 386 - ABDOMINAL HERNIA. on the body where the accurate adjustment of a truss is extremely difficult. I have usually had greater success with a light double-spring umbilical truss than any other. The pad may be much smaller than that used in umbilical hernia and its inner surface nearly flat. The plates ordinarily used on the youth's umbilical trusses answer this purpose very well. If the protrusion is near or below the navel the plate may be held in place by an elastic belt. Operative Treatment, — If there is considerable pain — and these cases seldom seek relief unless there is — it is believed that they should at once submit to the operative cure of the condition. They are unquestionably the most satis- factory of all hernise under surgical treatment. The opera- tion consists in an incision just large enough to enucleate the tumor which is almost always present, freeing its neck so that fresh peritoneum is drawn into the hernial opening, then open- ing the sac and liberating whatever is found. The neck of the sac is ligated with plain catgut, and if it has previously been freed from the edges of the aperture its stump will drop back into the abdominal cavity, and the opening, which is usually very small, can be readily closed by kangaroo tendon or chromic gut. Oskar Witzel {Saminl. Klin. Vortr. Volkmann, 1890, No. 10, p. 45), noticing that these openings in the linea alba were usually wider from side to side, advised their closure in a transverse line. The direction of closure should be in the line of least resistance and the edges should be overlapped if pos- sible. " The abdomen should be entered in every case in order to free adhesions that may exist." Personally I have not found that necessary, but certainly would not hesitate to do so if in the least doubt aJ^out having fully liberated any adhesions present. Traumatic Ventral Hernia. — When we speak of traumatic ventral hernia we have reference to hernia following some form of injury to the abdominal wall. The injury may have been in the form of an abscess or a blow, but it comes far more fre- VENTRAL HERNIA. 387 quently from some incisive wound which has divided the muscular fibre. In the author's early experience, shortly after the Civil War, several cases of this type were seen which resulted from stab wounds usually inflicted by the bayonet. These cases were, so far as seen, all small protrusions which were easily controlled by simple mechanical supports. The experience of Fig. 212. Post-operative ventral hernia, after six operations for cure. Woman 34 years old. Original operation was ovariotomy. recent years, however, has been with ventral hernice of quite a different type, enormous in size and extremely difficult to con- trol. They have followed the line of the surgeon's knife in incisions of the abdominal wall. A very common form of this hernia is shown in fig. 212. The woman there shown was at the time of this photograph only thirty-four years old. Her orig- inal operation was for an ovariotomy, the reason for which could never be ascertained. Following apparent recovery an abdominal abscess formed and required evacuation. On recov- 388 ABDOMINAL HERNIA. er^' from this the woman became enormously fat and the hernia, which had been present from the first, increased to a size equal to that of her head. Four successive attempts to cure the hernia failed owing to lack of material with which to close the enormous opening present. Unfortunately hernia due to stretching of an abdominal cicatrix is quite common, its frequency, as a rule, depending on Fig. 213. Irregular deposit of fat over right inguinal region, but no hernia. Case operated upon five years previously for ventral hernia, size of large cocoa-nut. the manner in which the wound of a laparotomy is closed and want of care in providing the patient with a proper and well- fitting abdominal bandage either for a time or constantly, as the case may demand. Even in these days of asepsis, from lack of care at times, suppuration does take place with the resulting granulation instead of primary union. Diagnosis usually is easily made, but in some instances deposit of fat may be mis- leading as shown in fig. 213. VENTRAL HERNIA. 389 A very common type of traumatic ventral hernia are those following operations for appendicitis. Traumatic ventral hernije following all abdominal operations are fortunately much less frequent than they were ten years ago from the fact that surgeons fully appreciate its serious liability and are using every possible precaution to prevent its occurrence. Fig. 214, Post-operative ventral hernia. Perforating g:un-shot wound. Entrance of ball gluteal, exit inguinal region. Hernia the result of operative attempts to close suppurating sinus. A few years ago the operation for the removal of the appendix, even where no abscess existed, involved the cutting directly across, with consequent destruction of, the internal oblique muscle, and all the nerves and blood vessels with which this region is so richly endowed. Complete restoration of the parts was practically impossible and hernia resulted in a large proportion of cases. This in some abscess cases may, even 390 ABDOMINAL HERNIA. now, be a necessity as a life-saving measure, but most surgeons, in this country at least, have learned that quite extensive work can be done in this region by splitting each muscle in the direc- tion of its fibres and holding them apart by retractors. Where the abdomen is entered by this method and deep drainage is not required ventral hernia very seldom results. The case shown Fig. 215. Front view of previous case. in fig. 214 and 215 is of rather unusual form, and resulted from the indiscriminate cutting away of the muscles of the lower abdomen in an attempt to cure a sinus following a gunshot wound. The sinus was of very little importance when it is considered in connection with the hernia that was the direct result of the operative work, which also failed in its original purpose. ' VENTRAL HERNIA. 391 Traumatic ventral hernise are as varied in size and shape as the patients are numerous. When the protrusion once starts it increases rapidly unless checked by suitable and prompt treat- ment. In its passage through the wall there are usually some fibrous bands which retard a portion of the tumor and cause it to become irregular in shape ; it may come out on both sides Fig. 2 1 6. Bilateral post-operative ventral hernia, in woman aged 44 years. Hysterectomy and ovario- tomy seven years previously. of the median line, as shown in fig. 216, or it may protrude at several different places along the line of incision. The contents of the hernise under consideration may be any of the abdominal or pelvic viscera, as in other forms of hernia. (Dr. Howard Kelly (Gynecology, vol. ii, p. 466) shows a photograph of a woman upon whom previous celiotomy had been done, with pregnant uterus protruding ^ through a traumatic ventral hernia. She had a normal labor at term and 392 ABDOMINAL HERNIA was delivered of a living child.) Omentum is usually the first to protrude and as the opening enlarges intestine soon follows. Adhesions quickly form between the omentum and sides of the sac and not uncommonly between one of these and the intestine. In its earliest stage it is freely reducible, but if allowed to go untreated it very shortly becomes only partially so. It is usually not very painful at first, but as it increases in size is not only more painful but is accompanied by a sense of weak- ness that borders closely upon prostration. Strangulation of these large traumatic ventral herni?e is rarely reported, as the neck of the tumor is usually so large as to allow free circula- tion through the bowel. Gradual loss of peristaltic action in the bowel, eventually terminating in intestinal obstruction, is far more likely to occur. MECHANICAL TREATMENT OF TRAUMATIC VENTRAL HERNIA. Many cases of traumatic ventral hernia seen early will show very satisfactory results under mechanical treatment. They must be carefully watched, for, like cases of umbilical hernia, there is in them a strong tendency to grow worse if not kept under perfect control. Contrary to the rule in umbil- ical hernia, however, they not infrequently improve very materially under the use of mechanical support, and I have seen a few that have been cured without surgical interference. If the surgeon doubts the stability of his abdominal closure he should give the parts support either by a truss spring to which has been adjusted a suitable pad, or with a general abdominal belt with a special compress arranged over the line of incision. The spring is always best where the wound has been on either side of the median line and, in fact, usually preferable in cases of median incision. The effect of the belt is especially good in some cases wlicre there is great tendency to rapid increase of fat. as it undoubtedly in a measure checks this. Good, firm support must, however, be afforded by a surface that is not so conical in shape as to force itself directly into the cicatrix. VENTRAL HERNIA. 393 The hard-rubber cross-body spring made for the treatment of inguinal hernia has frequentl}^ been used with satisfaction. It is shaped by the lead tape diagram method suggested in the chapter on the mechanical treatment of inguinal hernia. Such a truss is shown in fig. 217, applied to a woman sixty- five years old, following an operation for an abscess case of Fig. 217. Woman 65 years old, with ventral hernia following operation for appendicitis, retained by hard-rubber cross-body truss, with ordinary inguinal pad. appendicitis, where drainage was necessary for many weeks. Inguinal springs used for this purpose should be reduced in pressure considerably, as the amount required is much less than for other forms of hernia. In a large number of patients the pad used in inguinal hernia can also be used here, as shown. In fact, where the patient is rather fat it is better than the perfectly flat pads made by most truss-makers. The large fiat pad rests upon the skin and subcutaneous fat, but does not 394 ABDOMINAL HERNIA. Group of Trusses for Ventral Hernia. I. Elastic ventral hernia truss. Soft- or hard-rubber pad. Hard-rubber cross-body spring with perforated pad for ventral hernia. ^^ B D p E 3. A variety of pads for ventral hernia. VENTRAL HERNIA. 395 Group of Trusses for Ventral Hernia {Continued). Hard rubber 4. Laparotomy belt, with hard-rubber or soft compress. 5. Hood truss. Modified for ventral hernia on right side, and inguinal on left. 6. Cross-body hard-rubber ventral hernia truss to which any desired form of pad may be attached. 396 ABDOMINAL HERNIA. reach down to the muscular wall where the difficulty exists. In young and thin subjects the flat pads are admirably well adapted for the purpose. In enormous protrusions, such as shown in the accom- panying illustrations, nothing short of a well-made and accurately-fitted, strong canvas belt will give the general abdominal support that is demanded. In these extreme cases it amounts to the supplying of an artificial wall, and one who has not had experience cannot fully appreciate the difficulties involved. Patience, perseverance, and many refittings will, however, accomplish a great deal, and when we consider that it is in just this class of cases that surgical relief is almost hope- less, the importance of the service of a good belt maker will be more fully realized. A belt used after an abdominal operation should be of stout, unstretching material — not elastic, although this is often inserted to save trouble in fitting. It is to be worn next the skin and straps should not be needed under the thighs to hold it down or make it comfortable. This will ensure the patient using it as directed. SURGICAL TREATMENT OF TRAUMATIC VENTRAL HERNIA. No hard and fast rules for operating upon traumatic ventral hernia can be formulated, nor can we speak of its sur- gical cure with the same degree of certainty that is justifiable to use in connection with other forms of hernia. Many small protrusions, where the muscles, vessels, and nerves have not been ruthlessly cut, can be permanently cured by a secondary operation. Cases following operations for appendicitis are, as a rule, quite amenable to successful treatment, especially if the incision has been pretty well out toward the crest of the ilium. When the internal r)bHf|ue muscle has been divided, its outer stump retracts toward Poupart's ligament and rapidly atrophies so that a few months later it has become worthless to use in closing the hernial opening. In this condition the only hope of making an efficient closure is in getting out freely that part VENTRAL HERNIA. 397 of the muscle which Hes toward the median Hue. This usually retains a fairly normal condition and if freely stripped away from the aponeurosis of the external oblique can be brought over against Poupart's ligament and sutured there somewhat as is done in the Bassini operation for the cure of inguinal hernia. If this is done and the aponeurosis of the external oblique is closed tightly over it a cure will almost certainly result. The success of these operations depends upon freeing the muscular and tendinous layers of the abdominal wall from adhesions, and then, after excising as much as possible of the cicatrical tissue, bringing them together in their normal rela- tions. Every layer should be sutured independently. The suture material used by the author has been no. 2 plain catgut for the peritoneum, kangaroo tendon for muscular and tendi- nous structures, and where possible the skin has been closed subcutaneously by the same material as is used for the peri- toneum. The overlapping of the fascial layers may sometimes be used to advantage in these cases. The bringing together of the opening edge to edge is of little use, and sutures that require considerable tension to tie will soon cut through. Dr. Carl Beck of New York {Medical Nezvs, October 27, 1900) reports a case that seemed hopeless by ordinary means, where he obtained a cure by turning out a flap cut from the rectus muscle to fill in the gap that could not otherwise have been closed. CHAPTER XXII. RARE FORMS OF HERNIA. Lumbar Hernia. — There has been considerable discussion as to the exact point at which lumbar hernia leaves the abdomen, but this is unimportant. It is at best a rare con- dition, and it is not in accord with the intent of this work to enter into the discussion of fine points that are of no practical value to the general practitioner. Whether it most frequently protrudes at Petit's triangle or Braun's space is immaterial to its proper mechanical or surgical treatment. Its occurrence is very rare, only 4 cases having been seen at the London Truss Society up to 1893, the total number of reported cases up to that date being 26, according to Macready. Lumbar hernia forms a tumor in the lumbar region which may vary in size from a walnut to that of a child's head, and presents all of the peculiar characteristics of abdominal hernia in other locations. It is usually reducible, and if con- taining intestine is resonant on percussion with the peculiar gurgling sound found elsewhere. It may be spontaneous or traumatic, but Borchardt {Berliner klinische Wochenschrift, December 9, 1901) divides these hernise into four groups according to the etiologic factors causing them ; those of trau- matic origin, those following abscesses, those arising spon- taneousl}^ without any known cause, and the congenital lumbar hernia. Out of 43 lumbar hernise, he has collected 19 follow- ing injuries. The number following psoas or pelvic abscesses which break in this region is comparatively small, and no doubt the pointing of the abscess is in some part caused by the natural weakness of the abdominal wall. The form which is com- monly spoken of as spontaneous also tends to occur in the region known as Petit's triangle. Symptoms of strangulation 398 RARE FORMS OF HERNIA. 399 are of comparatively frequent occurrence. Ten cases of this kind have been reported. In 5 of these the strangulation was of a transient character. The case shown in fig. 218 was due to congenital defect and the protrusion occurred on both sides, the right being much the larger. The treatment mechanically of lumbar hernia is attended by considerable trouble on account of its peculiar location Fig. 2i5 Spontaneous double lumbar hernia due to defective muscular structure. (Macready.) and the difficulty in securing counter-pressure for the truss- spring. Abdominal belts with a compress over the hernia may be useful, but a spring designed by Mr. Kingdon of the London Truss Society is the best appliance so far noted in any publication (figs. 218 and 219). The base of action is in the cushioned, covered plate, held in position, mid- way between the trochanter and the crest of the ilium, by a perineal strap. The spring attached to the front of this plate, by ball and socket, passes obliquely across the front of 400 ABDOMINAL HERNIA. the abdomen around tlie right side, and holds the retaining pad also by ball-and-socket attachment. From this point a strap passes to the back of the curved plate upon which it buttons. Lumbar hernise, as a rule, show considerable improvement under ef^cient mechanical support, and some cases have so far improved as to allow of the abandonment of the appliance. The operative treatment of lumbar hernia should be carried out upon the same general principles that govern the Fig. 219. Truss lor riyht lumbar hernia designed by Mr. Kingdon. {Maci-eady.) surgical treatment of ventral hernia in other locations. This consists in the enucleation and opening of the sac, the reduc- tion of its contents, the ligation of the neck, and finally the closure of the hernial aperture. The overlapping of the struct- ures to secure union by a broader surface will usually be found feasible and effective in this region. Dr. Chas. N. Dowd of New York has recently elaborated an operation {Annals of Surgery, February, 1907, p. 245) for RARE FORMS OF HERNIA. 401 this form of hernia that seems commendable, and with his per- mission I reproduce his cuts which ilhistrate his method more clearly than words could. The child shown in photograph fig. 220 was three and a half years old and had worn a belt without improvement for Fig. 220. Congenital lumbar hernia, presenting through an enlarged triangle of Petit. {Dowd.) two years. The protrusion was the size of a goose ^%%, and at operation was found to come through the triangle of Petit. The hernial sac was distinct but without a narrow neck. At the lower end of the protrusion the appendix vermiformis was found and removed : "A portion of the sac was exsected, and the tissues were then brought together from the sides; the 26 402 ABDOMINAL HERNIA. margins of the external oblique and the latissimus dorsi being drawn together as far as possible. After this was done, there was, however, a triangular defect above the crest of the illium. An effort was made to close this in with an aponeurotic flap turned up from below. The fascia lata and the aponeurotic Fig. 221. Congenital lumbar hernia (i?owrf.) ^, transversalis fascia; .ff, external obliqus muscle; C, latissimus dorsi muscle; Z*, crest of ilium; £, gluteus maximus muscle; /-", gluteus medius muscle. tissue about the insertion of the gluteus maximus and medius formed a filjrous layer which could be used as a flap, and which was turned up, having the attachment at the crest for the illium as a hinge. This was stitched in place with chromic gut, some sutures passing through the previously mentioned trans- verse band, some through the edge of the latissimus dorsi, and RARE FORMS OF HERNIA. 403 others through the edge of the external obHque muscle. There was, however, still a triangular defect above the flap, and this, together with the repaired area, was covered by turning for- ward a flap cut from the aponeurosis of the latissimus dorsi. This was stitched to the external oblique " (see figs. 221, 222, and 223). Fig. 222. Operation for the cure of cong-ential lumbar hernia {Bowd) .—Flap composed of fascia lata and aponeurotic part of gluteus maximus and medius. Stitches placed for suturing this flap to the lumbar-fascia, to the external oblique muscle and to the latissimus dorsi muscle and for drawing the upper parts of the latissimus dorsi and external oblique together. Obturator Hernia. — Obturator hernia presents as an obscure, deep-seated swelling upon the thigh, below Scarpa's triangle. It is rarely recognized until strangulation has occurred or until after death has taken place. Berger, in 404 ABDOMINAL HERNIA. examining- 10,000 cases of hernia at the Paris Central Bureau, found one case of obturator hernia. It leaves the pelvis through the obturator canal with the nerve and vessels of the same name. It most commonly occurs in women who have passed the middle age of life, and it may be double. The contents of the sac are most frequently intestine, but Fig. 223. Stitches tied, leaving a triangular defect above the Hap. (Dowd.) the Ijladder and uterine appendages have also been found in it. Franz Schopf (U^iciicr Kliiiischc U'ochcnsclirift, Feb- ruar}^ 19, 1903) reported, including his own case, 5 cases of protrusion of the tube and ovary in obturator hernia. In one the uterus was included. The same writer states that during twenty years in a Vienna hospital in 393 cases of strangulated hernia 3 were for ol)turator hernia. RARE FORMS OF HERNIA. 405 Diagnosis is seldom made until strangulation occurs or after an autopsy is made. The tumor is more easily felt than seen. Macready thinks it is very liable to be overlooked on account of faulty methods of examination. He says, " It is most easily approached from the inner side of the thigh. The thigh must be flexed, rotated outwards, and carried inwards to relax the adductor muscle, and the finger placed against the descending ramus of pubes behind the adductor longus. The finger may also explore the inner opening of the obturator canal from the vagina or rectum." The treatment of this form of hernia has not been attended by success and 84.4 per cent, of those operated upon for strangulation have died. If recognized it is not probable that any form of appliance could be so adjusted as to give the patient any degree of comfort and safety. It is beyond question that the safer plan for the patient to adopt would be an attempt to effect a cure by operative means and the approach to the hernia should be through the abdomen. Sciatic Hernia. — This form of hernia is so extremely rare that it is mentioned only to call attention to its possible occurrence. Its name indicates its location. It comes through the great sacro-sciatic foramen and its contents may be omen- tum, intestine, ovary, or bladder. Regarding treatment there has been little suggested that would be of real service to the average surgeon. Perineal, ischio-rectal, and vaginal hernize all pass down through the pelvic outlet in protruding and require only brief consideration here. All hernise that protrude through the pel- vic floor properly are perineal hernise, but they have been given different names according to their coverings. If they push the vaginal wall down between the labia, or if the rectal wall is carried down, they are accordingly called vaginal or ischio- rectal. If they descend in the wall between the bladder and the rectum, pushing the skin before them, they are called perineal hernia. 406 ABDOMINAL HERNIA. These hernire have their origin in Douglas's cul-de-sac and may be caused by defective development of the muscular structure of the pelvic floor, or by accidental injury; rarely where no such cause is ascertainable, they have been called congenital. They occur most frequently in the female. In Macready's collection of 40 cases only 6 were in the male. The contents may be those found in hernia elsewhere, but are be- FlG. 224, Woman aged 30 years. Exstrophy of bladder and vaginal hernia. lieved to be most frequently small intestine. The sigmoid flex- ure, the bladder, and the ovary have been found. In the female the hernia may come down at the side of the vagina and enter the labia, but more frequently the vaginal wall is carried down as its external covering, and is liable to be mistaken for cysto- cele or labial abscess. They may also protrude either at the posterior or anterior part of the vaginal entrance, and in some instances become enormous in size if left unattended. RARE FORMS OF HERNIA. 407 The case shown in the photograph (fig. 224) came to me as a private patient many years ago. In addition to the enormous protrusion there shown, which contained the uterus, ovaries, and a large mass of intestine, the woman suffered from extrophy of the bladder, the anterior wall of that organ being entirely absent. The appliance designed for her relief is shown, applied, in fig. 225. It consisted of a steel frame Fig. 225. Same case, with supporting appliances on. arching over each hip and resting firmly upon the crest of the ilium of either side. This frame held a large hard-rubber plate so shaped as to pass over the pubic bone and support the entire perineum. This served the double purpose of retaining, per- fectly and comfortably, the pelvic and abdominal contents as well as protecting the patient against the constant wetting with urine that dribbled from the ureters. The urine was carried off through a flexible tube, from the bottom of the plate to a 408 ABDOMINAL HERNIA. rubber bag strapped to the leg. She wore this apphance at night, as well as during the day, and assured me that for the tirst time in her life she had been enabled to sleep without being wet from her neck to her feet. As shown by the foregoing case, perineal hernia, even of enormous proportions, can be controlled by properly designed supports. Ordinarily the one shower in fig. 226 answers the purpose very well. This consists of a metal base held in place over the sacrum by a leather belt about two inches wide. To this base is attached, by means of a screw, two light hard- FlG. 226. Appliance for perineal ischio-rectal, or vaginal hernia. The spring comes from the back and may have attached a pad of any desired size or shape. rubber covered steel springs. The inner one of these springs has a short curve and should terminate at about the centre of the intended field of support. To this spring any form of pad desired may be attached. The outer and longer spring passes down over the inner one, and curving forward has attached to it the perineal straps that come up in front and are buckled to the belt. By this combination of the tw^o springs the amount of pressure to be used can be very accurately adjusted. A few cases of vaginal hernia, if detected early, may be controlled by the introduction of a suitable pessary, but such relief is very likely to be only temporary. Little of value has been written upon the surgical treatment of vaginal hernia. CHAPTER XXIII. CONTRA-INDICATIONS TO THE SURGICAL CURE OF ABDOMINAL HERNIA. There are certain indications which should cause us to hesitate in advising the operative cure of hernia; the added danger in the individual case may be greater than is incurred by the continuance of the disease. Excessive fat is one of the most common contra-indica- tions in people of middle life. It is particularly bad if its accumulation has been aided by heavy beer drinking, which not only leads to the production of excessive fat, but causes a corresponding degeneration of muscular tissue. This degen- erative change is quite noticeable in the abdominal wall and is equally present in the heart muscle. When such conditions exist operative treatment is considered dangerous and there is more liability to a recurrence of the hernia. Still it may be advisable that they should be operated upon, owing to rapidly approaching complete disability and the increasing- dangers of their condition ; either they or their friends should be told of the danger of operation and the probable necessity of wearing good support for a year or longer. Ascites. — In no case, except as a life-saving measure, should an attempt be made to cure hernia by operation in any patient who has an excess of fluid in the abdominal cavity, no matter whether this be temporary and trifling or serious and permanent. Such patients should be assured that no danger attends the presence of the fluid in the hernial sac and that no operation is advisable while it exists. Enormous hernia with intestinal adhesions are especially dangerous for operation, owing to the amount of handling of the bowel and the intra-abdominal pressure to which it is sub- jected after the reduction in large quantities. Usually these 409 410 ABDOMINAL HERNIA. cases can be recognized before operation by percussion, after all that is reducible has been returned to the abdomen. If the resonant note usually found over the bowel is obtained it will be known that adherent intestine must be dealt with. Tubercular patients, unless in an advanced stage, stand the operation perfectly well, and it has, in the author's experi- ence, in several instances seemed advisable to operate upon them, and he has had no occasion to regret having done so. Age. — The condition of the patient has been found more important as a contra-indication than advanced age. Old people, if organic lesions are not actually present, stand the operation well and are not particularly liable to recurrence. In all of these cases that would, in insurance phraseology, be termed extra-hazardous, much can be done to diminish the danger by having every preparation complete for doing the work as rapidly as possible. Assistants and nurses should be selected and coached so that they will thoroughly understand and perform their various duties promptly. The anaesthetist should always, in such a case, be a person of admitted judg- ment and experience. ACCIDENTS FOLLOWING OPERATIVE CURE OF HERNIA. Thrombosis of Femoral Vein. — This, fortunately, is an accident that very rarely follows operation for the cure of abdominal hernia, yet it must be considered as one of the possible accidents. Goldner, reporting the results in 800 Bas- sini operations in Prof. Albert's clinic, Vienna (Arch, filr Klinische Chinirgie, Bond Ixviii, Heft i, 1902), states that 3 patients died, one during narcosis and 2 from embolism. " Both of the latter had large varices on the legs and this condition should impose caution in doing a radical operation." In my own experience, in 1,400 operations for abdominal hernia, I have had 3 cases of thrombosis of the femoral vein, one terminating fatally by pulmonary embolism. The latter, a man about forty, having the appearance of being poorly CONTRA-INDICATIONS TO SURGICAL CURE. 411 fed and overworked but otherwise apparently in good health, was operated on for an ordinary complete inguinal hernia on the left side. The time required was about twenty-five minutes, and nothing occurred to which the subsequent trouble could be traced. Everything appeared favorable up to the seventh day, at which time he began, to complain of extreme pain in the left leg, and evidence of thrombosis was plainly visible. Five days later pulmonary symptoms developed. The healing of the wound was primary and there was no' varicose condition in his case. The two other cases were women of about thirty-five years. One a frail woman upon whom an operation for right femoral hernia had been done about six days before, developed unmis- takable evidence of thrombus in the left leg. The operation (on the opposite side) had been a very simple one and the wound healed completely by first intention. The patient was lame for three months and then recovered perfect use of the limb. The third case was a large, healthy woman, operated on for supposed irreducible inguinal hernia, which proved to be a lipoma protruding from the canal. This was removed without difficulty and the parts healed by the tenth day without infec- tion. About the sixth day pain developed suddenly and the left leg. began to swell. Troublesome lameness continued for several months. It is not possible to discuss the cause of these accidents here as in reality it is unknown. They are liable to occur in all abdominal and pelvic operations. If the reader wishes to pursue the subject he is advised to consult the excellent article on Embolism by Eugene Boise (Surgery, Gyn. and Ohstr., July, 1906), who believes that it never occurs in a normal con- dition of the blood. Secondary Hemorrhage is an accident seldom known in these days of careful ligation of vessels. Its most serious occurrence is in connection with the ligation of omentum. These vessels have no surrounding muscular tissue to aid in their contraction, and if the ligature is inefficient, or slips off, 412 ABDOMINAL HERNIA. the bleeding will be continuous and probably fatal. All liability to such accident can be guarded against by careful ligation of indi\idual vessels unaccompanied by fat. Peritonitis is, with aseptic surgery, practically unknown in operations for the cure of abdominal hernia. Undue trau- matism should most certainly be carefully avoided. Sepsis. — General sepsis resulting from operations for the cure of hernia is now extremely rare, but the occasional operator should realize that its danger is always present, and that for its occurrence he is personally responsible. INTERNAL HERNIA. It is not within the intent of this work to consider so-called internal herni?e, such as diaphragmatic, hernia of the foramen of AVinslow, of the duodeno-jejunal recess, of the inter-sigmoid recess, or retro-vesical hernia While in one sense these belong to the subject of abdominal hernia, in another they belong to that of intestinal surgery. The diagnosis of these conditions is very rarely made before operation, frequently not until the autopsv. If they reach the surgeon they come as cases of intestinal obstruction, with little evidence that the bowel may be incarcerated at one of the points named. CHAPTER XXIV. STRANGULATED INGUINAL HERNIA. Few things in the practice of medicine are more alarming, not only to the patient and his family but to the family physi- cian, than the occurrence of strangulated hernia. A tumor which was formerly reducible is suddenly found hard, tender, painful, and irreducible. If the strangulation is acute and the obstruc- tion complete, the agony of the patient is beyond description. That which was a few minutes before considered the threaten- ings of a mild colic, has rapidly advanced to a degree of suf- fering toO' great for human endurance. A strong man will cry out like a child in the intensity of his suffering. Shortly vomit- ing intervenes to add to his distress, he breaks out into a cold sweat, and if aid is not promptly afforded he goes into a collapse and death is a welcome relief. Cause. — Volumes have been written discussing various theories as to the cause of strangulation, and those who wish to pursue their investigation along theoretical lines should consult such writings, since this work deals, as far as possible, with facts. Theory is of little interest to the man who suddenly finds himself violently sick, nor does it aid the attending physi- cian in this emergency. The patient, as a rule, has had a hernia for several years and has known how to replace it, but now finds this impossible. The hernia has probably become impacted at the smallest part of the neck, and under the pressure of this impaction the normal action of the bowel has been checked. Furthermore, we know^ full well that while the circulation in the bowel wall may not have been completely shut off this will promptly take place, with consequent destruc- tion of all tissues under constriction. In cases where the symptoms gradually reach the most distressing stage, it is probable that enough of the protruding 413 414 ABDOMINAL HERNIA. contents is forced into the most constricted portion of the sac to impede venous circulation. The arteries, whose resistance is greater, continue to pump blood down into the tumor, but the return of venous blood is prevented by the constriction. Swell- ing and effusion of fluid then take place, increasing the pressure until finally the whole mass is as completely shut off from the cavity of the abdomen as it would be by strong ligature. Location of Stricture. — Many times it cannot be told before operating where the constriction will be found, nor is this extremely important. In hernia of the congenital variety it will in many instances be found due to fibrous rings. These rings are, perhaps, the remains of nature's attempts to carry out her original design of obliterating this tubular neck between the cavity of the abdomen and cavity of the tunica vaginalis. Wliatever may have been their origin, they are tough, inelastic, and usually situated in the neck of the sac which they completely surround. Sometimes, however, they are just above the tes- ticle and may at this point be the cause of constriction. In the greater number of cases of strangulated inguinal hernia, the constriction is at or near the external ring and is caused by the dense and strong tissues outside of the sac at this point, but it occasionally happens that the cause of strangu- lation is within the sac and from some band of connective tissue. This is usual in cases of old hernise of large size. Rarely, it will have its origin in the twisting of the bowel upon itself within the sac, or more frequently, from slipping through a hole in the omentum which forms a part of the hernia. Irreducibility is in itself no evidence of strangulated hernia, as it many times happens that those who have large hernise cannot for the time reduce them, either from the quan- tity that has protruded or from the position in which the contents have come down ; temporary incarceration results, but no accompanying symptoms of strangulation. No immediate concern need be felt about such cases, but they must be watched with strictest care, as they are on the borderland of strangu- lated hernia, and may become such at any moment. STRANGULATED INGUINAL HERNIA. 415 Such tumors are, in many instances, not tense or hard, and the handHng of them is unattended by pain. As soon as they begin to get hard or tender, they should be subjected to immediate operation. It is very seldom that a hernia becomes irreducible from its outset and it rarely happens that strangula- tion takes place in one just formed. The author has seen several exceptions to this, notably one just operated upon. A young woman, in stepping from a car "where the step was much higher than she had anticipated, felt an immediate pain in the left groin. Shortly afterward, acute abdominal pain and vomiting came on, and it was discovered that she was suffering from a femoral hernia in a state of strangulation. Physical Signs. — One of the physical signs of inguinal hernia, recently strangulated, is a tumor of variable size any- where in the inguinal region or the scrotum. It feels hard, especially toward the point where its neck enters the abdomen. If the symptoms are acute it may have the elastic feel of fluid, as effusion rapidly occurs under tight constriction. Discolora- tion of the surface seldom takes place until very late, and is then more frequently the result of violent handling than from other causes. It must be borne in mind that the appearance of the surface is no indication whatever of the condition of the parts within. There is likely to be heat after the strangulation has lasted for some hours, but not in the earlier stages. It should also be remembered that an inflamed hydrocele, either in the scrotum or encysted in the inguinal canal, may be deceptive, but neither will be accompanied by general symptoms of strangulation. (This also applies to inflamed hydrocele in the canal of Nuck in the female. The latter is more likely to be confusing since many physicians are not aware that hydrocele occurs in the female.) A case was seen by the author in con- sultation, wdiere all the physical signs of strangulated hernia were present — that is, a small tumor in the inguinal region, extremely sensitive, and wnth a history of hernia and truss- wearing. To add to the obscurity of the case the patient had 416 ABDOMINAL HERNIA. felt that he might vomit at any moment, although he had not clone so. He was sick only when the tumor was handled. It proved to be a case of orchitis in a testicle which had never reached its destination in the scrotum. SYMPTOMS. Pain, — It almost invariably happens that the very first pain experienced from strangulated inguinal hernia is not, as w^ould be expected, at the point of stricture, nor even in the region of hernia, but in the vicinity of the umbilicus — an ill-defined, colicky pain that is likely to lead the patient to believe that he has eaten something which is disagreeing with him. This may increase to an extreme pain without local symptoms to lead the patient to examine his hernia, but in most instances there occurs more or less discomfort in the inguinal region, and the true condition of the swelling is discovered. The pain increases in intensity with more or less rapidity, according to the acuteness of stricture, and it is paroxysmal, appearing at times to have left the patient entirely and then returning with renewed force. This undoubtedly corresponds with the peristaltic action of the bowel which makes endeavors with increasing violence to free itself. If at this point the physician steps in and relieves the pain by a hypodermic injection of morphine, the patient's mind is also entirely relieved, but the pathological changes go on uninterruptedly and the man is rapidly advancing to his death. The pain is described by the patient as a most terrible distress rather than a pain, and it usually extends over the entire, abdomen. The following cases illustrate in a striking manner how little dependence can be placed upon the location of pain in strangulated hernia. A woman, seventy-five years of age, with valvular lieart trouble and otlierwise not in good general condi- tion, developed extreme abdominal distress, which was soon followed bv vomiting and comjjlete intestinal obstruction. The familv i)livsician saw the case on the first day and discovered that she had small hernine in both the umbilical and femoral STRANGULATED INGUINAL HERNIA. 417 regions, but the patient assured him that there was no notice- able change in these swelhngs. Both had existed for several years and neither had been reducible for a long time. Local symptoms were entirely lacking. Hypodermics made a doubt- ful case still more obscure, as temporarily they relieved the pain. On the third day the case was seen by the author in consultation. It was at once decided that one of the hernias was in trouble, and an immediate operation was strongly urged. There was no guide as to wdiich hernia should be operated upon, except that femoral hernia is more liable to strangulation than the umbilical variety. Ether was given and a loop of small bowel was found caught under Poupart's liga- ment in the femoral canal. The bowel was in bad condition, but after applying hot cloths for half an hour, it was returned to the abdomen. The patient made a perfectly good recovery. In hernise that have been long strangulated, the bowel after a time becomes paralyzed or gangrenous and the pain in a measure subsides. Distention ensues and the patient is very likely to die, even if an operation is performed. This remark must not be taken as intimating that the operation should not be done even in the most desperate case. Death is absolutely certain without it, and cases apparently moribund are not infre- quently saved by it. Vomiting. — The vomiting in strangulated hernia is doubt- less reflex in character and may begin within a few moments of the strangulation or may be delayed for several hours. It is perhaps the most important symptom. If a portion of the bowel high up in the intestinal tract is involved, it is very likely to come on early, but this also depends somewhat upon the tightness of the constriction. It is quite certain that in cases involving the large bowel vomiting is very likely to be delayed. The contents of the stomach are first vomited and later the contents of the small intestine, when the characteristic fecal odor is presented. In former years it was considered good practice not to operate for strangulated hernia until stercora- ceous or fecal vomiting had occurred. It is not surprising 27 418 ABDOMINAL HERNIA. that few recovered after operation, and to-day such waiting would be plainly criminal. Pain and vomiting- usually indicate the severity of the case and the urgent need of haste. If the symptoms are violent prompt relief must be afforded or the patient will die. It hap- pens rarely that complete destruction of the bowel coats have taken place without vomiting having been present. The cessa- tion of vomiting in a given case, after having existed for some time, is a most grave symptom, and usually denotes complete collapse, or paralysis of the bowel, either of which is pretty cer- tain to lead to a fatal termination. Constipation is usually complete. In a fairly good pro- portion of the cases there will be one movement of the bowels after strangulation has taken place, the lower bowel merely emptying itself. There may be tenesmus and frequent desire and the feeling that a movement is about to occur. Cathartics, by increasing peristalsis and vomiting, merely add to the suf- ferings of the patient, and should never be given. Eructa- tions and hiccough are frequently early and persistent symptoms. There is one exception to constipation as a symptom, and that is in a case of partial enterocoele, which will be referred to a little later. Thirst is intense, and if indulged the fluid is at once rejected by the stomach. The Pulse is many times an important aid in deciding as to the severity of a given case of strangulated hernia, and impending collapse is first indicated by changes in it. The grave character of a case may be indicated by it where other symptoms are not very prominent. Temperature. — It is surprising how many physicians make the mistake of supposing that so long as there has been no elevation of temperature the case is not in great danger. The truth is that there is more frequently subnormal temperature than elevation. A neglected case which has developed general peritonitis may have elevation of temperature, but more die in STRANGULATED INGUINAL HERNIA. 419 collapse without ever reaching that stage. Ordinarily there is little change of temperature throughout the case, and it is important only when subnormal, which indicates the need for haste in the preparations for relief. Respiration is almost always hurried, until the patient is passing into a condition of stupor, when it may become slow and stertorous. Collapse may come on almost immediately after strangu- lation has taken place, or may be delayel for several hours. It is at any time a very grave symptom, and has been considered by some inevitably fatal. That it is not universally fatal, the author has had several illustrations. In one case, that of a man nearly eighty year.s of age, who was apparently in complete collapse and about to die, with strangulation for about three days, the operation was done without an anaesthetic, as he was in a stupor. The bowel was found in bad condition, but, under the application of hot towels, showed evidence of recovery and was returned to the abdomen. The patient's condition improved before the opera- tion was completed, and he made a slow but complete recovery. . It has been noticed in several instances that the pulse, respira- tion, and general condition begin to improve shortly after the constriction is cut. It is also believed that the hot-water appli- cations which have been sO' frequently used in these severe cases, acts as a stimulant to the patient. In one patient recently operated upon, collapse came on again after there had been general improvement during the operation, and the woman came very near dying on the table. An otherwise healthy woman, sixty-eight years of age, suf- fering from an inguinal hernia on the right side, placed herself in the hands of one of the quack firms that promised to cure hernia by hypodermic injection. The first two injections, an interval of one week between, were fairly painful, but were tolerated w^ithout much complaint ; the third, however, pro- duced the most excruciating pain and prevented her leaving the bed on the following day. She grew rapidly worse and 420 ABDOMINAL HERNIA. began to vomit, and her family physician came in and admin- istered opiates. On the morning of the second day consuha- tion was cahed, and the case pronounced strangulated hernia, and was sent to the author for operation. When she arrived at the private hospital she was in partial collapse, with the whole body bathed in cold perspiration, and suffering from the most agonizing pain. Preparations were cjuickly made and the operation begun. Her daughter was informed that death might occur before the operation w^as completed. Upon opening the parts, it was found that the injection for the so-called " cure '' of hernia had been through the neck of the sac into the coat of the bowel, and the violent inflammation following had resulted in a complete stricture of the bowel. The bowel was adherent in the canal, but it could not be decided positively whether this adhesion was due to the injection, or had previously existed. After the constriction had been cut and hot applications made to the bowel, the patient's condition improved rapidly, but just as she was about to be transferred to the bed it was discovered that she had again gone into a state of collapse so complete that at one time she was thought to be dead. After an hour's work with the use of oxygen, stimulants, and hot saline solutions under the skin and per rectum, she was restored and made a complete and rapid recovery. This case has been given somewhat at length, as contain- ing several illustrative points. 1st. — That the injection of irritants about the canal may cause death. 2nd. — That strangulation maj^ be secondary to an earlier inflam- mation. 3rd. — That patients may suffer and even die, from the recurrence of the symptoms of collapse. 4th. — That it is not best to abandon too early efforts at restora- tion of a patient in collapse. Collapse may come on so early and violently in cases of strangulated hernia, as to cause the death of the patient before STRANGULATED INGUINAL HERNIA. 421 it is possible to afford relief. The amount of injury to the bowel cannot be estimated by the degree of collapse in which the patient is found. In some cases, when death has occurred early, the bowel has not been found badly damaged. Collapse and death must, in these cases, come wholly from reflex action. In cases long neglected, where fecal vomiting has existed for some time, poisoning may occur from this source and death result either before or after the operation. It is in cases of just this character that general anaesthesia should^ if possible, be avoided, as it adds to the depression which already exists, and there is also liability of the patient drawing into the lungs, by inhalation, the poisonous fluids which are being constantly vomited. Convulsions are not uncommon as an early symptom in young children, and they may occur, though very rarely, in the adult. Peritonitis, Local and General. — In almost every instance of strangulated hernia, some indications of localized peritonitis will be found, even though the case may have been of only a few hours' duration. This may consist merely of the exudation of a little plastic lymph, which glues the protruding contents to the side of the sac, or a quite active peritoneal inflammation, extending in every direction from the point of the constriction. It is believed that death more frequently results from shock due to pressure on constricted bowel than from general perito- nitis. The latter, however, does occur, and when it is present the prognosis must be of the gravest character. Again, it will be urged, however, never to abandon a case no matter how hopeless it may appear. Better give the patient his only chance of life, even though he die on the table. General peritonitis may develop from the point of constric- tion, following the peritoneal surface, or it may be communi- cated from the bowel, which is enormously distended above this point. From the latter cause it may become general, either before, or after the operation. Perforation of the bowel into the peritoneal cavity is usually followed by immediate collapse and early death. 422 ABDOMINAL HERNIA. Where there is extreme abdominal distention, the prog- nosis is always bad, as it frequently indicates complete paralysis of the bowel above the point of constriction. In such patients one or more normal evacuations may occur after the operation, and then the symptoms of intestinal obstruction are again pre- sented and the patient dies. The operator is quite liable under such conditions to think that he has failed to remove all con- strictions of the bowel at the time of the operation, when in reality, the cause of death has been complete paralysis of the over-distended bowel. Partial Enterocele. — This form of hernia is where one coat of the bowel has been caught and strangulated, but the entire lumen has not been occluded. The fibrous rings which •frequently form in hernial sacs have been previously alluded to, and into a ring of this character such a hernia may protrude and become strangulated. This form of hernia has frequently been referred to as Lavaters, Littres, and Richter's hernia. Diagnosis is obscure, from the fact that a very small tumor, if any, can be found, and also that there is not complete obstruc- tion of the bowel. It not infrequently occurs that there is a tendency to diarrhoea. The pain is, however, characteristic and similar to that found in other forms of strangulated hernia ; that is, coming in paroxysms with intervals of relief. The dis- tention found in other cases is not usually present, and the stools are occasionally bloody. It is seldom that such cases can be relieved except by operation, and the following case indicates their deceptive char- acter: A man, twenty- four years of age, had left inguinal hernia since early childhood, and had never worn a truss. Symptoms of strangulation occurred five days before he was seen by the author, vomiting beginning on the second day. An operation was done on that day by the attending ])hysician, who opened down to the external ring, incising a distended sac of the congenital variety. From this consider- able dark-colored fluid escaped, but otherwise it appeared empty. As the finger could ht passed freely in either direction. STRANGULATED INGUINAL HERNIA. 423 he assumed that the hernia had been reduced under ether, and closed the parts. As later, symptoms increased in severity, the author was called to see the case three days after the operation. Marked evidence of intestinal strangulation was present. Extreme pain was masked somewhat by the free hypodermic use of morphia. The man had a dusky skin, was becoming stupid, had a distended abdomen, and a weak heart. The wound was re-opened and the canal split to the internal ring. A knuckle of _ small intestine was found imprisoned just at the upper end of the canal, and as the stricture was divided, the gut dropped back into the abdomen. By enlarging the opening somewhat, and making gentle press- ure upon the abdominal wall above, it was obtained again and brought outside for inspection. The anterior wall of the bowel had been under sharp constriction, but its mesenteric attach- ments had not been under pressure, so that the circulation of the posterior surface had been maintained. The bowel was dark and edematous, but under the application of hot water a change of color was noticeable, and it was returned to the abdomen. The man made a prompt recovery. Where we have acute symptoms, showing us that the intestine is involved, it is desirable that we should see the bowel in order to decide whether or not is is safe to return it to the abdominal cavity. Inflamed Glands, occurring in those who have been known to have suffered from hernia, may cause considerable obscurity in the diagnosis. It will at once be seen, by lack of general abdominal symptoms, that the intestine is not involved, but it is not so- easy to decide that a tumor may not be a mass of inflamed omentum. We almost invariably, however, have a few abdominal symptoms where the incarceration involves omentum exclusively. Orchitis in Retained Testicle or Torsion of Cord may cause some confusion in diagnosis with physicians who do not see many cases of this character. The table of Eccles (" Imperfectly Descended Testis," W. McAdam Eccles, M.S., 424 ABDOMINAL HERNIA. F.R.C.S., Wm, Wood & Co., 1903) is so sug-gestive that it is thought best to introduce it here. Differential Diagnoses of Torsion of Spermatic Cord, Strangu- lated Hernia and Acute Lymphadenitis. 1 Torsion of Cord. Strangulated Hernia. Lymphadenitis. History Position of testis Shock Probable of strain. Often imperfectly de- scended. Moderate. Slight and not persist- ent. May be present. Is'ot marked. May be expansible if hernia be present. May be felt twisted. Often of strain. Usually fully de- scended. Often severe. Severe and persistent. Is absolute. Marked. No expansible impulse Obscured. Of infection. Usually fully de- scended. Induration or fluctua- Impulse on cough . . . Condition of cord . . . tion. No expansible impulse. Normal. The lodgment of a testicle in the inguinal canal is quite liable to be mistaken for strangulated hernia. Reference has already been made to such a case seen in consultation, where two physicians had failed to recognize the true condition. The error is quite excusable on account of nausea and vomiting frequently present in this condition. Intestinal obstruction is not present, however, and the character of the pain is quite different from that present when the bowel is strangulated. In the latter condition the pain is intermittent, corresponding with the violent peristalsis, while in orchitis there is an intense, dull, sickening pain which is constant. The onset of the pain is usually quite different, that of strangulated bowel being sudden and rather violent in character from the first ; in orchitis there is usually a history of traumatism with gradual increase of the symptoms. The absence of the testicle from the scrotum should also cause suspicion as to the true cause of the trouble. Scrotal Hernia of Enormous Size. — In these cases symp- toms of strangulation are seldom of tlie acute variety. Usually they contain large masses of omentum, and the protrusion of the bowel inside is somewhat protected from extreme pressure even though it may be strangulated. If the contents of these larger herni?e should be exclusively omentum, the symptoms STRANGULATED INGUINAL HERNIA. 425 will then be more of an inflammatory character, and under rest and cold applications may subside without operation. On the contrary, however, if the constriction is very tight, slough- ing of the omental mass may occur, seriously complicating the case. A case of this character which had been five weeks under treatment was brought to the author from a distant city. Dur- ing most of this time the man had been in bed and applications of hot olive oil had been made to the tumor. Upon operation it was not only found that the omentum in the scrotum was about to slough, but that the entire omentum, above as well as below the point of constriction, was involved. This omen- tum was inflamed, thickened, and attached to the peritoneal surface, so that it was necessary to leave it in about the condition found, although that portion in the scrotum was removed and the abdomen closed. The wound closed by primary union, but it was found at the end of the second week after the operation that general abdominal trouble was increasing. A hard tumor had formed nearly on a level with the umbilicus and about three inches to the outer side. An incision was made into this, and for nearly three weeks slough- ing omentum was discharged, but the man eventually made a good recovery. Strangulation, occurring in hernije of enormous size, is frequently preceded by a long term of obstinate constipation, finally terminating in complete intestinal obstruction. Such cases, unless operated on very early, are quite sure to prove fatal, as they have their origin in the paralysis of the loop, or loops, of bowel which have formed the contents of the hernia. The bowel, being held by adhesions, has gradually lost its peristaltic power, and when paralysis has resulted symptoms of intestinal obstruction are presented. Such cases do well for a few days after the operation, when intestinal obstruction again comes on and the patient dies. In these large herniae, strangulation may occur by bands of connective tissue which hold the bowel at an acute angle. At the time of the operation. 426 ABDOMINAL HERNIA. such bowel will be found in perfectly normal condition, but doubled upon itself, in such a manner that its lumen is occluded. Children. — As a general rule, the symptoms of strangula- tion in young children are not quite so violent and acute as in older persons, nor is the occurrence of strangulation attended by quite the same amount of danger. Many cases of tem- porary incarceration have been seen in children under treat- ment by mechanical means, with little indication of pain or intestinal obstruction, yet the hernia was hard and irreducible. Such cases, of course, require close watching, but an early operation is not necessarily indicated. The author has, in a number of instances, sent the mother home with the child in this condition, with instructions to make gentle pressure over the tumor when the child was asleep ; in almost every instance this has proven sufficient to cause its reduction. With careful and proper manipulation cases demanding immediate relief can generally be reduced while the child is under chloroform. The author has never seen a case of strangulated hernia in infancy that he could not reduce under chloroform by care- ful manipulation, but he freely admits that such cases may occur. Even more care must be observed than in handling the adult, owing to the greater delicacy of the structures. Force that would be allowable in the adult would be violence if used on an infant. After such hernise have been reduced it is not uncommon for the child to have one or more bloody stools. CHAPTER XXV. MEDICAL TREATMENT OF STRANGULATED HERNIA. Perhaps the very best way to discuss this branch of the subject is to state at once that there is no medical side to the treatment of strangulated hernia, leaving the subject there. To many this would doubtless appear dogmatic ; on the other hand, there is reason to treat of the medical side in order to show its dangers. Certain it is that medication is time-consuming, and therefore dangerous, and should be avoided in almost every case. The literature of the subject is not lacking in the number of remedies which have been recommended in these cases. Large doses of atropine, opiates, and other drugs, as well as strong decoctions of coffee, have been recommended. Atropine and morphine have been given by physicians, having in mind the theory that strangulation comes from a spasm of muscular tissue, and that when this spasmodic action is overcome reduc- tion of the hernia can be accomplished. It is believed that all operators of large experience will bear out the statement that no such condition is found to exist at the time of operation. Perhaps no drug has been the cause oi more deaths in strangu- lated hernia than opium and its products. The hypodermic injection of morphine, which has been such a blessed relief to the patient, has misled JDoth him and the attendant into the belief that the conditions were improved, while in reality the pathological changes which take place in strangulated intestine have been rapidly advancing, and when the physician has dis- covered his error it is too late to save the patient. This means of relief to the suffering may and should be given while preparations for a more rational and radical form of relief are being made. 427 428 ABDOMINAL HERNIA. The use of coffee or cathartics is thoroughly irrational, although they have, in some instances, hastened relief by caus- ing violent peristaltic action of the bowel and thereby aiding in its withdrawal from the point of constriction. This, no doubt, is the only action which strong decoctions of coffee have. The coffee has one advantage over cathartics in that it is a powerful stimulant and delays the period of collapse. The cathartic is sure to leave the patient in much worse condition than before it was taken, and only in the rarest instances does it accomplish the desired result. Safety is on the side of limiting medication tO' the hypo- dermic use of morphine (preferably combined with atropine), and the application of cold to the tumor, to afford the patient partial relief while preparations for the operation are being made; these should be advanced with all possible haste, even though the opiates have temporarily placed the patient in a perfectly comfortable condition. Taxis. — By the word " taxis," a very indefinite idea is conveyed to the mind of the average physician regarding a certain form of manipulation, which may be more or less violent, according to the peculiarities of the manipulator, and the works on surgery, even of the later day, contain very little precise information regarding its technique. Taxis comes midway between the medical and the surgical treatment of strangulated hernia, but properly belongs to the surgical side, and the operator should bear in mind that it is a delicate surgical procedure to attempt to reduce strangulated intestine by means of manipulation. He should realize the fact that not only is he liable to fail to accomplish the desired result, but he is apt to add materially to the risks which his patient has already incurred. The length of time this method should be used can scarcely be stated, as one man will do more harm to the parts than another. There are perhaps few things in surgery where more actual skill is required and can be displayed than in the reduc- tion of strangulated bowel by manipulation, or so-called taxis. MEDICAL TREATMENT: STRANGULATED. 429 The author has, for many years, avoided the use of this word ahiiost entirely, and has taught the reduction of hernia by what he has called traction and compression, which is accomplished in the following manner : Try at once to assure your patient that you are not going to add to his torture, and confirm this in his mind by handling the tumor with the greatest gentleness. By this you will secure his co-operation instead of unconscious resistance. Place him on a table with the hips well elevated, instead of working over a soft and yielding bed. An ordinary kitchen table, with the legs at one end elevated six or seven inches, answers every purpose, and is obtainable in almost every house. When the patient is in position, first gently crowd the entire abdominal contents away from lower abdomen toward the chest, then work the fingers of one hand around the neck of the tumor where it issues from the abdomen, holding its bulk in the palm of the hand if pos- sible, and, instead of trying to push the tumor back into the abdomen, try to draw it farther down. Now, with the other hand, grasp the canal with its contents (if inguinal hernia) gently but firmly between the thumb and fingers, and, while making traction, and compression with the hand that is holding the tumor, manipulate the canal with a kneading motion. This can be done without adding to any extent to the patient's pain, and will succeed when more rude handling fails. When you push upwards on strangulated hernia, usually you carry it up over the ring upon the abdominal wall, and accomplish nothing more. In the method suggested, by trac- tion you lengthen out the mass that is blockading the canal, favoring the effect which you afterwards produce by compres- sion, i.e., the partial emptying of engorged blood vessels, and the displacement of gases and fluids. This is further aided by the action of the fingers upon the canal, working the bowel free at the point of constriction. This work should be done only while the patient is conscious, as his endurance of pain should clearly indicate the amount of force that it is desirable to use and beyond which it is never safe to go. 430 ABDOMINAL HERNIA. The amount of time which should be expended upon these cases depend somewhat upon their character. If the hernia is an extremely large one, and its contents chiefly omentum, considerable time may be allowed in this manipulation, carefully executed, without fear of doing harm to the patient. If, on the other hand, the hernia is small, with acute symp- toms of strangulated intestine, not more than fifteen minutes should be expended in attempts at reduction. If it cannot be reduced in this time, nothing but harm can come of pro- longed handling. So far as possible, not more than one physi- cian should ever attempt to reduce a hernia by manipulation. The second one called will do well to take none of the responsi- bility of handling the tumor, but should proceed at once to the operation. It should be borne in mind that rude and violent handling of a strangulated bow^el is far more dangerous than an operation, even though the latter be done by a man who does not consider himself an expert. External Applications. — The literature on this branch of the subject is full of delusions and snares. Every sort of poultice, hot and cold, that could possibly come to the imagina- tion of man, has been applied to strangulated hernia. There is only one external application which should be applied, and only in the earliest stages of the difficulty, and that is cold. Sulphuric ether, allowed to drip slowly over the tumor, has been very strongly recommended, and no doubt has scored some successes. Ethel chloride spray has also been suggested. The only effect that such an application has is the cold produced by rapid evaporation, and if it can be obtained more conveniently in this way than by the application of ice, it is all right. Per- sonally ice is preferred. If delay is necessary in preparing for the operation in a given case, two things should always be resorted to in a pallative way — the liypodermic injection of morphine to relieve pain, and the immediate application of ice upon the tumor. Ac^ain it must be urged tliat this application must be only in the earlier stages before pathological changes have taken place. MEDICAL TREATMENT: STRANGULATED. 431 Hernije of the large type, containing large masses of omentum, and where the symptoms are not very acute, may frequently be reduced after the application of an ice-bag for twenty-four hours or less. This amount of delay must cer- tainly not be tolerated in cases where there is extreme pain and vomiting. Aspiration in order to draw off the fluids of the tumor and thereby aid in its reduction formerly had strong advocates. Not only is there serious risk of injuring the already damaged bowel, but it is believed by the author that the fluid is both a protection to the gut and an aid in its reduction. Anaesthesia for the Reduction of Hernia. — The opinion of the author on this point has been indicated by the statement made before, that taxis should be used only on conscious patients. It is believed that it seldom happens that a judicious amount of force is used where the patient is under the effects of anaesthetics, and that this force applied to strangulated intestine is more dangerous than operation for its relief. An anaes- thetic should seldom be given until all preparations for the operation have been completed. This rule does not hold good with Infants, in whom reduction is so frequently accomplished. In some instances, where the patient Is very much alarmed regarding the operative part of the work. It Is a comfort to him to be assured that an attempt will be made to reduce the hernia after the anaesthetic has been given, and that only In case this fails will the operation be done : manipulation should be even more gently executed than were the attempts at reduc- tion while the patient was conscious. CHAPTER XXVI. SURGICAL TREATMENT OF STRANGULATED INGUINAL HERNIA. As previously intimated, the treatment of strangulated hernia, from first to last, belongs strictl}^ within the domain of surgery. The cases are, however, usually first seen by the practitioner of medicine, who, perhaps, ordinarily does nothing but minor surgery and who has been taught tO' look upon an operation for this affliction as belonging to the major opera- tions. Unfortunately, also, a surgeon may not be within easy call and hence the liability to delay means death to the patient. In an emergency of this character it is far better that the practitioner subject his patient to the risk attendant upon an unskilful operation rather than to those involved in delay. The life-saving element in this operation is not difficult to carry out if done early in the case before complications, due to dis- ease, have set in. It is purely a mechanical problem and rec[uires no such anatomical knowledge as is usually supposed. An unyielding band of some sort surrounds the intestine and must be cut. There are two operations that every physician should be prepared to perform at the very shortest notice; viz., Tracheotomy and Herniotomy. The difficulties of both have been exaggerated by the too careful anatomical consideration of the parts. I do not mean by this to discourage minute and exact anatomical knowledge; but it is not possible that ever\^ physician should remain throughout life a perfect anatomist, nor should he be discouraged from executing these life-saving measures because he has forgotten the number and distribution of the vessels and nerves of the parts. The preparations and instruments may, if necessary, be of the simplest character. The author has operated with nothing 4.32 SURGICAL TREATMENT: STRANGULATED. 433 but a knife, clamp, scissors, and needle from a borrowed pocket case, and silk from the work-basket of the patient's wife. It is beyond c[uestion that the patient's life was saved in this instance by the immediate release of the imprisoned gut. Where time allows, it is uncjuestionably better that every preparation be made that usually attends any other abdominal surgery. In any case the parts must be thoroughly cleaned, the water, instruments, and towels used about the wound boiled, and the greatest source of danger, the operator's hands, must be made aseptic by much scrubbing, closely trimmed nails, and such anti- septics as may be at command. If fecal vomiting has already occurred, it is advisable to wash out the stomach before giving an anaesthetic. The pres- ence of this poisonous matter in the stomach certainly leads to toxemia and adds to existing shock and prostration. Further- more, vomiting, which is quite sure to occur during anaesthesia, may result in carrying this matter into the lungs by inspiration, thus causing pneumonia. The question as to the advisability of giving a general anaesthetic, or resorting to local anaesthesia, must be seriously considered. If the case has already existed for some time, with shock and fecal vomiting present, sensation is considerably blunted, and by the aid of local anaesthesia the operation may be done without unbearable pain. The local anaesthetic recommended is cocaine by the Schleick method, always being careful not to exceed the physiological dose of the drug. The Incision. — If the hernia is large, this should be a little longer than that made in the operation for the radical cure, but on the same lines. It should extend from above the internal ring to a point over the upper part of the pubic bone, following the direction of the cord in the male, and opening up the entire canal. In making this incision the superficial pubic vessels will be cut at the lower angle of the wound and the superficial epigas- tric vessels at its upper angle. Both are between the skin and the external oblique muscle, and, while they will probably 28 434 ABDOMINAL HERNIA. require clamping, are unimportant. If they are large and bleed freely it is better to tie them at once with small-sized catgut; if small, merely allow the clamps to remain on while other work is being done ; they will then frequently be found permanently closed. It is essential, however, that no oozing points remain when the parts are closed. The opening of the canal should now be accomplished by splitting the aponeurosis of the external oblique from a little above the internal ring to the external ring. Where the external ring is sufficiently free to allow of it, this is best done by slipping in a grooved director and cutting upon it, but in strangu- lated hernia it is seldom possible owing to the constricting bands about the ring. In this case a small opening may be made in the aponeurosis directly over the internal ring and the cutting done by knife or blunt pointed scissors, following down in the direction of its fibres to the external ring. In many instances when the canal has been freely opened and the con- stricting bands at the external ring cut, the cause of the strangu- lation will have been removed and the hernia can be reduced; it is highly important, however, that this should not be done until the contents of the sac have been carefully examined. On the contrary, it may be that the constriction is in the neck of the sac, or by transverse bands within the sac itself, or a loop of bowel may be strangulated through a hole in the omentum. In any case the sac must be opened. The sac, having now been well exposed, should be carefully stripped loose from its adhesions and lifted, with the cord still attached, out of the canal. This loosening of the sac is done by gently pressing the fingers around it in every direction, and it is easier while the sac is full than when it is emptied. Even when very large and in the scrotum, it may, in this way, be delivered through the high incision. The cord may sometimes be easily separated before opening the sac, but unless the fatal band of constriction has already been cut, veiy little time should be lost in this work, but proceed at once to the opening of the sac. SURGICAL TREATMENT: STRANGULATED. 435 The discussion as to whether or not the sac should be opened belongs to a past age; it should always be opened. Much care must be exercised at this stage of the opera- tion, as it not uncommonly happens that the bowel has become adherent to the sac, and to cut carelessly one would be quite certain to open into the intestine. In almost every instance of strangulated bowel there is rapid effusion of fluid, and the opening into the sac should be at a point where this is felt to be present. Usually this will be at or near the bottom of the sac. This fluid may be a clear, colorless serum, or it may be of dark coffee color and of the most offensive odor. If of the latter variety it is full of septic matter and indicates a very grave state of affairs. The sac having been freely opened, the constriction should be searched for and cut. The bowel should now be drawn down so that the part which has been subjected to the greatest pressure can be inspected. This usually is the point of greatest danger. The bowel may present any degree of injury, from a mere congestion of its surface vessels to gangrene and perforation, according to the length of time strangulation has existed, the tightness of the stricture, and the amount of rough handling it has been subjected to by those trying to reduce it. It is not uncommon to find it a dark claret color, and if there are no gangrenous spots, it may recover fully from this degree of injury under proper treatment. When the bowel has been drawn well down and all constriction removed, it is believed that there is nothing so beneficial as the application of towels wrung out of hot sterilized water. It is perfectly justifiable to spend half an hour or more, if necessary, in restoring the bowel in this way. If a change in color to a lighter shade is effected, it may be assumed that the bowel will live. If, how- ever, there are spots of a dull, ashen-gray color, which have lost the lustre natural to the bowel, it may be known that these are liable to perforation if returned to the abdomen. If not too large, they may be folded in and the healthy edges of the bowel united by Lembert sutures of fine silk. 436 ABDOMINAL HERNIA. If perforation has actually occurred, and the bowel is so far damaged as to preclude its repair by the turning in of its torn edges, then resection, or the formation of an artificial anus, should be considered. In this desperate condition, unless the operator is quite familiar with intestinal surgery, it will be a life-saving measure to anchor the bowel in the wound by a few stitches, covering it by moist, warm dressings, to be frecjuently changed. Should the patient survive, resection may be done as a secondar}^ operation under more favorable conditions. Gib- son in a valuable article on " Gangrenous Hernia " {Annals of Surgery, vol. xxxii, p. 486) gives the mortality in these cases, in the three most common forms of hernia, as follows: Inguinal, 26 per cent. ; femoral, 37 per cent. ; umbilical, 67 per cent. If the operator has at hand the ]\Iurphy button, primary resection may be quickly done, but even the handling of the bowel necessary for that method adds to the profound shock from which the patient usually suffers in the extreme cases under consideration. Strangulated omentum found within the sac should always be removed, as returning it to the abdomen adds materially to the patient's danger. Omentum which has been under press- ure and is inflamed may slough if returned to the abdominal cavity. Its ligation should be carefully done, as accidents from secondary hemorrhages have occurred, even in the hands of noted operators. It is well understood now, however, that accidents come from ligating large masses of omentum together and the subsequent slipping of the ligature. The omentum should be spread out thin and every vessel that can be seen tied, with as little fat as possible included. The fat should then be tied separately. This subject has been fully dealt with under the surgical cure of hernia. An ovary or testicle in the canal must be treated accord- ing to its condition. If unhealthy, it is very easy to remove it; if normal, it should be restored to its natural position. A normal testicle with a cord so short that it will not reach the scrotum should be treated in the manner described under the SURGICAL TREATMENT: STRANGULATED. 437 heading-, " Complications in the Operative Cure of Inguinal Hernia." The reader is also referred to this section for details regarding the closure of the wound, as it should, with rare exceptions, be so closed as to effect a permanent cure of the trouble which has proven such a serious menace to the life of the patient. The after-treatment of the case should be conducted upon general principles to meet conditions present. Shock should be as promptly overcome as possible by hypodermic and rectal stimulation, and by surrounding the body with artificial heat. One of our most valuable means of combating shock is trans- fusion, the introduction of normal saline solution into the circulation. A strong decoction of coffee for rectal enema has proven efficacious. It is not deemed good practice to give cathartics early after strangulated hernia, especially if the bowel has been badly compressed. Pressure paralysis is liable to result, even though the coats of the gut have suffered little visible damage. It is better to give the bowel complete rest for a few days unless there are other symptoms contra- indicating this course. It is also better to empty the lower bowel thoroughly by enema before giving laxatives. It must be remembered that perforation has occurred as late as the tenth day after doubtful bowel has been returned to the abdomen. Fluid food should therefore be continued for this length of time in suspicious cases. Hemorrhage from the bowel, of greater or lesser degree, may occur after the return of the damaged gut, coming on from the first to the third day after the operation. Children are especially liable to this, and it has been seen where strangula- tion existed for only a few hours, and where the hernia had been carefully reduced without operation. In no instance has a fatal or very serious result been seen by the author. If this hemorrhage is accompanied by persistent diarrhoea it becomes a more serious matter, and repeated small doses of opium are recommended. The Subgallate of Bismuth, in doses of from 5 to lo grains every hour, has, in the experience of the author, 438 • ABDOMINAL HERNIA. acted very nicely and saved the giving of opium, which is usually contra-indicated by the condition of the patient. A few loose movements produced by cathartics, unwisely given before the operation, must not be mistaken for the condition here named. In almost every instance of strangulated hernia evidence is found of localized peritonitis, which, in a few cases, becomes general after the operation and must be treated accordingly. First among- remedies is believed to be the ice coil, but this must not be applied while the patient is still in a condition of shock from the effects of strangulation. All of these complications result from delay, and will not be seen where prompt operative relief has been afforded. The operation itself is not one of danger. CHAPTER XXVII. STRANGULATED FEMORAL HERNIA. Symptoms. — The symptoms of strangulated femoral hernia do not differ materially from those attending strangula- tion at other points, except that the attack is likely to be more violent, the prostration (shock) is more profound, and dis- astrous results more quickly supervene if relief is not promptly afforded. The reasons for this especial violence in femoral hernia have been entered into in the anatomical considerations of the subject and need not be repeated here; but the urgent necessity for the earliest action possible cannot too often be impressed upon the physician, nor must he allow the temporary relief afforded by opiates to mislead or delay him for a moment. From the beginning of an attack to an early fatal issue the destructive pathological changes advance rapidly. When the intestine forms the contents of the hernia there may be some premonitory abdominal discomfort, but it is more common for the pains to become severe at once, followed rapidly by all of the grave symptoms of acute intestinal obstruc- tion; general abdominal pain, vomiting, prostration, and col- lapse. Old and feeble people may die from this collapse or shock within a very brief period of time, and before patho- logical changes have taken place to a sufficient degree to cause death. Absence of local pain has undoubtedly misled the physician in very many instances, and hastened a fatal issue. It is not uncommon that the abdominal distress is so great that the patient's attention is not called to the site of the hernia at all ; he may not even know that hernia exists. Contrary tO' experi- ence in inguinal hernia, the author has seen several cases of femoral where it was quite evident that strangulation had taken place with the very first protrusion. Where decided abdominal 439 440 ABDOMINAL HERNIA. disturbances exist all locations where hernia commonly occurs should be carefully examined and any abnormal condition found should be looked upon with decided suspicion. In the femoral region, especially, a small kernel no larger than the end of the little finger, the existence of which is wholly unknown to the patient, may be an imprisoned knuckle of bowel which will certainly result in death if not recognized and relieved. Where omentum only is strangulated, the symptoms may be of the mildest type, amounting to discomfort rather than pain in the abdomen, with a burning, or dragging sensation, the latter usually in the umbilical region. While these cases demand early surgical attention, there is not the urgent need for haste as when the bowel is imprisoned. In fact, this acci- dent occurs many times without the true condition being realized by either the physician or the patient. When the tem- porary congestion' of the strangulated omentum subsides or its fat is entirely destroyed by cutting off its circulation, it leaves the patient with a permanently irreducible hernia. These hernise are very likely to increase in size, they are more dan- gerous to the patient than the reducible type, and should therefore be cured by operative means at the earliest conveni- ent moment. Reduction by Taxis. — All that has been said regarding the reduction of inguinal hernia by so-called " Taxis," or manipulation, applies here, with two exceptions: (i) The length of time that taxis is used, and the degree of force employed, should be decidedly modified. The tightness and knife-edge character of the constriction in strangulated femoral hernia make the chances of damaging the bowel by handling much greater and the probabilities of success less. Therefore, the greatest caution and gentleness in handling should be exer- cised. (2) The direction of pressure should be downward and toward the centre of the thigh. Any pressure upward only draws the intestine up over Poupart's ligament and does not aid in the least in its reduction. STRANGULATED FEMORAL HERNIA. 441 Medical Treatment. — Properly there is no medical treat- ment for strangulated femoral hernia. If the hernia is large and the symptoms not very acute, indicating that the mass may contain considerable omentum, the ice bag should be applied while preparing for operation. This is not advisable if the attack has been of long enough duration to allow of destructive pathological changes, and if shock is present. It will not be of much service if the hernia is small and its contents exclusively intestine. Morphine combined with atropine should be used for the immediate relief of the patient while preparations are being made to operate, but with no other idea than that of temporary comfort. Do not be delayed one moment in prompt action, by the great relief that it affords. OPERATION FOR STRANGULATED FEMORAL HERNIA. All preparations for the operation for strangulated femoral hernia should be attended by the same strict regard for asepsis that is carried out in every important surgical pro- cedure. The incision is the same as in the operation for the cure of femoral hernia. The sac should be loosened from its bed and brought out through the skin incision and its neck fully freed in the canal before opening. The constriction in femoral hernia is almost invariably beneath Poupart's ligament, and may be either in the neck of the sac itself or by its surrounding ligamentous structures. After raising the sac and its contents out of its bed, and the neck has been well freed, it is then care- fully opened. It may be split up to and through its neck with little danger of injury to the bowel. This almost uniformly divides the constricting band. In cutting the stricture in strangulated femoral hernia, keep constantly in view the fact that the parts are to be so closed afterwards as to protect the patient against recurrence of the trouble. This cannot be done if Poupart's ligament is divided. On opening the sac it is very common to find it filled with a coffee-colored fluid which is a product of strangulation and does not necessarily indicate that the case is particularly 442 ABDOMINAL HERNIA. serious. If this fluid has a strong fecal odor, every precaution should be used to protect the wound, as it is quite sure to con- tain septic matter. The adhesions ordinarily found between bowel and sac are of recent origin and are usually easily separated. If, however, they are so firm as to endanger the tearing of the intestine, it is better surgery to cut out this adherent patch of sac and leave it attached to the bowel. No harm will result from this method of procedure. All omentum that has been under constriction should be ligated and cut away in the manner described in the chapter on inguinal hernia. Intestine that has been constricted must be carefully examined for damaged places and especially must it be drawn down until normal bowel is seen on both ends of the loop in order to inspect the line that has formed at the point of greatest pressure. Hot towels, as already suggested (see Inguinal Hernia), will obviate the necessity for resection in many instances. The completion of the operation should be in accordance with the suggestions for operative cure. It seldom happens that the case is so extreme that the proper closure of the parts to secure a permanent cure cannot be carried out without additional risk to the patient. CHAPTER XXVIII. STRANGULATED UMBILICAL HERNIA. In no cases of strangulated hernia is the prognosis more grave than in those occurring at the umbihcus. This is for the two-fold reason that strangulation usually occurs in herniae of enormous size, where adhesions are numerous, and in very fat patients whose resistance is poor. It can seldom be reduced by taxis, as the abdominal wall is so flexible as tO' furnisli very little resistance, and, when the hernia is pushed upon, the whole wall is carried back and nothing is accomplished. The symp- toms are in every respect similar to those of intestinal strangu- lation elsewhere. The use of the ice-bag here has, in the author's experience, been attended with good results, owing, doubtless, to the fact that in many instances umbilical hernia contains a large amount of omentum. The operation must be conducted on the same general principles which govern that for other cases of umbilical hernia. Great caution is necessary in making the initial incision, as dis- tended bowel may lie in such close contact with the inner surface of the sac that the cutting of one is pretty sure to accidentally open into the other. Here, as in other cases of strangulated hernia, fluid is quite sure to collect in some part of the sac, and usually it can be safely opened by taking up a small piece of the latter between anatomical forceps. In many cases the knuckle of bowel that is in trouble may be inside of a layer of omentum, and on opening the sac it is a great error to try to reduce the whole mass without examination. The bowel that is pinched must be found and its condition carefully con- sidered. That which has been previously said regarding the treatment of strangulated intestine applies here as well. In one of my own cases, on opening a large sac a mass of omentum and a loop of intestine were found, both apparently normal, except 443 444 ABDOMINAL HERNIA. that the former was hypertrophied and adherent in several places. The intestine was easily reduced through a perfectly patent umbihcal ring, whereupon it was discovered that the strangulation of the bowel was through a hole in the omentum just within the abdominal wall. In another case the bowel was found incarcerated under a tough fibrous band, the remains of the obliterated umbilical vessels; it was flexed upon itself at such an acute angle as to entirely close the lumen of the bowel. Umbilical sacs of large size are much more liable to have connecting fibrous bands running across them in various ways than large sacs in other forms of hernia, and in these bands intestine is quite liable to become entangled. In these, as in all other large hernise, all parts of the bowel that are reducible should be returned to the cavity of the abdomen as quickly as possible and with the smallest amount of handling. Such parts as cannot be immediately replaced should be covered with moist, hot, sterile towels, changed sufficiently often to maintain a temperature of about lOO degrees. The treatment of strangulation in the rarer forms, ventral, lumbar, obturator, and perineal hernia, needs no special con- sideration. When there is intestinal obstruction and hernia exists at any point, time will usually be saved by operating first at the site of this hernia, wherever located, even though there are no local symptoms. SUMMARY OF 1,411 PERSONAL OPERATIONS FOR ABDOMINAL HERNIA. {Tabulated January, 1902.) Males, 757. Females, 274. Patients, 1,031. Ages under 10 years (27 under 5 years; youngest 5 months) . . 166 137 " 10 to 20 " 20 " 30 " " 30 " 40 " " 40 " 50 ' " 50 '• 60 ' " 60 " 70 " " 70 " 80 " " over 80 " 221 198 140 93 47 27 2 103 1 Under 14 years, 239. Over 14 years, 792. Inguinal Hernia: Right, 713. Left, 524. (Double, 253).... 1237 (1205 were operated upon by Bassini method) Femoral Hernia: Right, 75. Left, 44. (Double, 12) 119 (119 operated upon by De Garmo method) Umbilical Hernia 35 Ventral Hernia 20 1411 5 had Inguinal Hernia on one side and Femoral on the other. 6 " Double Inguinal and Femoral. 2 " Inguinal and Femoral on same side. I " Double Inguinal and Umbilical. I " Inguinal and Umbilical. I " Femoral and Umbilical. Triple operations were done upon the same patient in 7 instances. The Bladder was recognized but not opened 17 The Bladder not recognized and opened for sac i (All in inguinal hernia) Ovary in canal 5 (Youngest In girl of 7 years) Fallopian tube adherent outside Umbilical ring i The Appendix was found involved and removed through inguinal incision 19 Retained Testes: Right, 39. Left, 2)2>- (Double, 8) 72 445 446 SUMMARY. Varicocele sufficient to require operation 32 (Operation through inguinal incision in 31) Hydrocele 31 Hernia irreducible 208 Omentum removed 230 Hernia strangulated (Inguinal 21, Femoral 16, Umbilical 8).. 45 Recurrences, 19. Reoperated upon, 9 lO Mortality. 43 Operations for Strangulated Hernia : deaths 9 1257 " " Cure of Hernia: deaths 8 The operations for cure of hernia were not all operations of choice. While some were considered " extra hazardous," it was believed safer to operate than to leave the patient to the risks of his condition. My — 1st death (Case No. 429) in the latter class was a man of 75 years, completely disabled by the size of his hernia. He stood the operation perfectly, and his condition was good until on the third night, when he got out of bed and went to the toilet. He was missed from bed on return to ward of the night nurse and was found in the toilet room in a state of collapse, from which he never recovered. 2d death (Case No. 467). Boy 8 years old. Syphilitic menin- gitis 4 days after operation. Autopsy by Professor Brooks, Pathologist of Post-Graduate Hospital, showed wound and abdominal cavity in normal condition. One brother of this boy had died of meningitis after a four hours' illness, and another brother has partial paralysis. These facts were not known to author before operating. 3d death (Case No. 583). Man 48 years old. On 7th day Sepsis. 4th death (Case No. 628). Man 49 years old, very fat. On 6th day Volvulus, following operation for sigmoid hernia. 5th death (Case No. 731). Man 55 years. Left Complete In- guinal Hernia, nth day Pulmonary Embolism follow- ing thrombus of left femoral vein. 6th death (Case No. 965). Man 42, enormously fat. Hyper- trophied mesentery. Inoperable case. Shock. 7th death (Case No. 1280). Man 56. Weight 300 lbs. Very large right Scrotal hernia. Infection through drainage tube in scrotum. Sepsis on 5th day. 8th death (Case No 1.364). Man 43. Double inguinal hernia of small size. No unfavorable symptoms. Death on 3rd day. Apoplexy or pulmonary embolism. INDEX A PAGE Abnormalities of descent of testicle 36 Abscess differentiated from, femoral hernia 316 inguinal hernia 107, 1 10 Accidents of hernia operation 410 Acquired hernia 17 definition 17 inguinal 56 time of appearance 18 Adhesions of contents to sac in inguinal hernia as complication, to operating 261 to truss wearing 182 Age, as contra-indication to hernia operation 410 as predisposing cause of hernia 45 for applying truss 193 Albert, Professor 410 Amputation of omentum 261 Ansesthesia for reduction of strangulated hernia 431 Anatomical defects as predisposing cause of hernia 46 Anatomy of, femoral hernia 298 inguinal hernia 20 umbilical hernia 345 Andrews, Dr. Edward Wyllys 227 Andrews, Dr. Frank T 256 Appendix, complicating femoral hernia 309 inguinal hernia 256 removal through inguinal hernia incision 258 Ascites as complication of truss fitting 175 as direct cause of hernia 53 Author's operation for femoral hernia 445 inguinal hernia 218 umbilical hernia 375 powder for truss wearers 202 summary of his operations for abdominal hernia 445 B Baldwin, Dr. J. F 286 Bassini operation 214 Halsted operation 228 modified by author 218 Beck, Dr. Carl on 7 Bladder hernia 19, 227, 279, 283 before operation 285 frequency of 284 indications at operation 286 repair of accidental wounds . . . 290 Blake, Dr. Joseph 376 operation for umbilical hernia 376 Bloodgood, Dr ; 228, 237 Body of hernia ig Boise, Eugene 411 447 448 INDEX. PAGE Borchardt 398 Braun's space 398 Brodel Max 228 Bubonocele rara 63 Bull, Dr. Wm. T 235 C Caecal hernia 19, 63, 277, 279 closure of sac in 281 closure of wound in 283 differentiated from other inguinal hernia 98 Canal of Nuck 42 Care of skin under truss 201 Causes of, difficulty in operating direct hernia 227 femoral hernia 304 inguinal hernia 44 direct 50 predisposing 44 strangulated inguinal hernia 413 traumatic ventral hernia 386 umbilical hernia 345 ventral hernia 383 Cavity of tunica vaginalis 39 Chase, Dr. Heber 135 truss for femoral hernia 326 inguinal hernia 129, 135 Children with strangulated ingtiinal hernia 426 Classification of trusses 118 Closure, of sac in caecal hernia 281 in direct hernia 238 in femoral hernia 33 5 in sigmoid hernia 281 wound in caecal hernia 283 in femoral hernia 338 in inguinal hernia 223 in sigmoid hernia 283 points of tunica vaginalis 39 Coley, Dr. Wm. B 36, 225, 235 Combination of hernias 18 Common sense truss for femoral hernia 326 Complete hernia .• • • 55 Complications and their treatment in operation for inguinal hernia. . 239 to truss fitting ^73 ComDression and traction in reducing hernia 429 Condition of umbilical hernia 349 Congenital hernia S6 definition ^^ female inguinal 4^ male inguinal 4° differentiated from acquired inguinal hernia 92 time of appearance ■ ^° umbilical hernia 3°^ diagnosis and treatment 3°^ Conjoined tendon ^ ^5 Constipation as direct cause of hernia 5° Constituents of hernia ^°' ^9 Construction of trusses ^'^^ INDEX. 449 PAGE Contents of hernia 19, 20 femoral hernia 309, 333 inguinal hernia 79 umbilical hernia 345, 349 Continuous truss wearing 202 Contra-indications to surgical cure of abdominal hernia 409 Cooper, Sir Astley 44 Cough as direct cause of hernia 51 Coverings of inguinal hernia. 77 umbilical hernia 348 Cremasteric fascia 42 muscle 216 Cross body truss : 129, 169 Crural arch 23 Crying in children as direct cause of hernia 53 Curative treatment of inguinal hernia 113 Andrew's operation for 227 author's operation for 218 Bassini's operation for 216 Curtis, Dr. B. Farquhar 284, 291 Cysts as complication to truss fitting 173 differentiated from inguinal hernia no of tunica vaginalis 40 D Dangers of closure of sac in direct hernia 238 femoral hernia 297, 306 Dawbarn, Robert H. M., M.D 246 Deep epigastric vessels 27,29 Definition of hernia 17 acquired hernia 17 congenital hernia 17, 18 femoral hernia 17 inguinal hernia 17 umbilical hernia 17, 344 ventral hernia 18, 383 De Garmo-Hood truss 196 Delayed testicle 37 as complication of inguinal hernia 176 complication of inguinal hernia operation 239 predisposing cause of inguinal hernia 46 causes for 38 differentiated from inguinal hernia 107, 109 function of 38 Descent of ovary as complication to truss fitting 180 testicle 34 abnormalities of 35 as predisposing cause of inguinal hernia 46 tunica vaginalis as predisposing cause of inguinal hernia. . . 46 Diagnosis of congenital umbilical hernia 32 femoral hernia 309 inguinal hernia 82 oblique inguinal hernia from other conditions 102 traumatic ventral hernia 388 umbilical hernia : 354 Diagram for truss fitting 1^4 Diaknow, P. T., M.D 375 450 INDEX. PAGE Diaphragmatic hernia 412 Differential diagnosis, between femoral and inguinal hernia iii femoral hernia 310 strangulated inguinal hernia 423 types of inguinal hernia gi Difficulties of mechanical treatment of femoral hernia 317 Direct inguinal hernia 57 differentiated from other inguinal hernia 97 Divisions of umbilical hernia 344 Donati, Marie 59 Dot}^ Dr. George E 80, 261 Double truss 147 Double French truss in femoral hernia 328 Dowd, Dr. Chas. N 400 Drainage after hernia operations 226 Dressings after hernia operations 226 Dummy pad on truss 141 Duodeno-jejunal recess 412 E Eccles, W. McAdam, M.S 35, 36, 383, 423 Elastic truss in femoral hernia 327 inguinal hernia 121 English truss 121 for femoral hernia 325 for inguinal hernia 124 for umbilical hernia 369 Enlarged veins as complication to operation for inguinal hernia 239 Enterocele 20 Entero-epiplocele 20 Epiplocele 20 Excelsior truss for femoral hernia 326 External abdominal ring 23 iliac artery 29 inguinal ring 31 oblique muscle 22 pudic vessels 22 F Fat as, complication of operation for oblique ingtiinal hernia 239 contra-indication of operation of abdominal hernia 409 predisposing cause of hernia 49 Femoral hernia 297 age relation to 18 anatomy of 298 combined with inguinal hernia 340 contents of 309, 333 danger of 297, 306 definition of 17 diagnosis of 309 differentiated from inguinal hernia iii, 316 fitting truss for 324 formation of 304 irreduci1)le 316 truss for 329 mechanical treatment 317 percentage of 18 INDEX. 451 PAGE Femoral hernia, post-operative treatment of 340 sex relation to 18 shape of sac of 308 strangulated 439 medical treatment of 440 operation for 444 symptoms of 439 taxis in 44° surgical treatment 331 history of 331 prognosis of 333 technique of 334 symptoms 309 time of occurrence 297 Femoral ring 299 sheath 301 Ferguson, Dr. R 256 Finding hernial sac 220 Fitting trusses for femoral hernia 324 inguinal hernia 152 complication in 173 Foramen of Winslow hernia 412 Formation of femoral hernia 304 French trusses 124 Function of delayed testicle 39 G Garangeot 309 Genital mass, primary location of 34 transition of 34 Genito-crural nerve 26, 43 German trusses for femoral hernia 325 inguinal hernia 124 umbilical hernia 356 Gibson, Dr. C. L 284, 290, 436 Gimbernat's ligament 23, 299 Goldner 29, 410 Gordon 124 Gubernaculum testis 35 Gymnastic treatment of inguinal hernia 204 Seaver's views on 206 H Haberen 314 Halsted, Dr. W. vS 228, 237, 238 Heaton, Geo. M.D 213 Heredity as a predisposing cause of hernia 44 Hernial dyspepsia 345 Zabe on 345 Hinged Cup truss 186 History of trusses 116 Hood, Dr. J. W., trusses 136 for femoral hernia 326 inguinal hernia 128, 136 their advantages 142 Horwitz, Dr. Orville 291 452 INDEX. PAGE Hydrocele differentiated from, femoral hernia 315 inguinal hernia. 108 congenital differentiated from inguinal hernia 104 Hypogastric f ossas 31 I Ilio-hypogastric nerve 26, 30 Ilio-inguinal nerve 26, 30 Impulse of inguinal hernia 85 Incarcerated inguinal hernia 70 Incision for combined inguinal and femoral hernia 340 Incomplete hernia 54 Infantile hernia 75 Infant umbilical hernia treatment 355 Inflamed inguinal hernia 70 Inflamed glands differentiated from strangulated inguinal hernia. . . 423 Infundibuiiform fascia 27, 42 Inguinal adenitis differentiated from oblique inguinal hernia no Inguinal canal 27 Inguinal hernia, age relation to 18 anatomy of 20 Andrews' operation for ' 227 author's operation for 218 Bassini's operation for 216 combined with femoral hernia 340 curative treatment for 113 definition 17 diagnosis of 82 differential 102 differentiated from femoral hernia in percentage of 18 sac of 71 sex relation to 18 strangulated 413 differential diagnosis of 423 taxis ; 428 treatment of 427, 432 gymnastic 204 mechanical 114 surgical 214 types of 54 Inguino-perineal hernia 36 Injection of hernia 212 Instructions to truss wearers 201 Intercolumnar fascia 23, 43 Internal aV)dominal ring 27 hernia 412 inguinal hernia 31 oblique muscle 24 secretion of testicle. . 39 Interparietal hernia 63 Intersigmoid recess 412 Interstitial hernia 63 complicating truss fitting 180 Invagination of scrotal tissue in diagnosis of inguinal hernia 86 Irreducible hernia 19, 20 femoral 316 INDEX. 453 PAGE Irreducible femoral hernia, truss for 329 inguinal 68 strangulated 414 umbilical 370 tumor differentiated from oblique inguinal hernia 108 J Johnson, Dr. George Ben., views on operation for umbilical hernia. . 372 K Kangaroo tendon 217 Kelley, Dr. Samuel W 356 Kelly, Dr. Howard 391 Kingdon, Mr 399 Kocher 231 L Labial hernia 55 varix differentiated from oblique inguinal hernia 105 Lavater's hernia 422 Lead tape method of measuring for truss 154 Lifting as direct cause of hernia 51 Ligation of blood vessels in inguinal hernia 219 hernial sac 222 Lindf ors 381 Lipoma differentiated from femoral hernia 312 oblique inguinal hernia 109 Littres hernia 422 Location of spontaneous ventral hernia 384 stricture in strangulated inguinal hernia 414 Lockwood, C. B 45, 385 Lumbar hernia 398 M Macdonald, Dr. Willis 382 Macfadden, Bernard ' . . . 211 Macready, Jonathan, F. C. H .. . 124, 186, 297, 309, 383, 398, 405, 406 McLachlan 288 Marcy, Dr. Henry 217 Mathews, Dr. Wm. P 255 Mayo, Dr. Wm. J., operations for umbilical hernia 377 Measuring for truss 152 Mechanical treatment for, femoral hernia 317 inguinal hernia 114 in infancy 189 when irreducible 183 lumbar hernia 399 umbilical hernia 355 in adults 360 in fat subjects 368 ventral hernia 392 Medical treatment for strangulated hernia 427 Mesentery 31 length of 50 Method of examination for inguinal hernia 84 454 INDEX. PAGE Moc-Main truss 121 Mortality from operation for femoral hernia 332 Mouth of hernia 19 N Neck of hernia 19 Needle for femoral hernia 342 Night trusses 124 Noble, Dr. Charles P 292 Nuck, Dr 42 O Oblique inguinal hernia 54 acquired differentiated from other types of inguinal hernia 94 Obturator hernia 403 Occurrence of abdominal hernia 17 Ody, Salmon and 129 Omentum 31 Opening of hernial sac 222 Operations for, bladder hernia 286 csecal hernia 280 delayed testicle with inguinal hernia 247 femoral hernia 331, 334 combined with inguinal hernia 340 inguinal hernia 228, 237 sigmoid hernia 280 umbilical hernia 373 Orchitis differentiated from strangulated inguinal hernia 423 Overlapping abdominal wall in umbilical hernia 375 P Pads, truss 148 Palliative treatment of inguinal hernia 113 Pancoast 213 Partial enterocele 422 Percentage of various forms of hernia 18 Peritoneum 30 Peritonitis as complication to hernia operation 412 Petit's triangle 277, 398 Phimosis as direct cause of hernia 53 Physical signs of strangulated inguinal hernia 415 Pillars of external abdominal ring 23 Plastic operation for femoral hernia 343 Plummcr, Dr. S. C 286 Post-operative treatment for femoral hernia 340 umbilical hernia 381 Post-operative hernia 19 Posture as direct cause of hernia 51 Poupart's ligament 23, 298 Powder for truss wearers 202 Pregnancy as complication to operation 295 to truss fitting 181 Preparation for operation 215 Prognosis of femoral hernia 333 inguinal hernia 114 obturator hernia 405 INDEX. 455 PAGE Prognosis of strangulated 421 femoral 439 inguinal 425, 438 umbilical 443 umbilical hernia 368 in infants 357, 372 ventral hernia 396 Properitoneal hernia 63 Q Quin, Nicola C 124 R Radical cure truss 167 Rare hernia, lumbar 398 obturator 403 sciatic 405 strangulation of 445 vaginal 408 Rat-tail truss 170 Rectus muscle 26 Recurrences after operation for femoral hernia 332 Reducible hydrocele as complication to fitting truss 175 Reducibility of non-strangulated inguinal hernia 68, 82 Repair of bladder wounds 290 Results of operations for inguinal hernia 235 failure of obliteration of tunica vaginalis 39 Retaining pads 148 Retraction of testicle 43 Retro-vesical hernia 412 Richter's hernia 422 Rigg's, Dr. J. W 151 Round ligament in female inguinal hernia 293 Rupture 17 S Salmon and Ody 129 Sapiejhko, Dr 375 Sciatic hernia 405 Scrotal hernia 55 truss 166 Seaver, Jay W., A.M., M.D 204 Secondary hemorrhage as complication to hernia operation 411 Selection of truss • 161 for infants 194 direct inguinal hernia 172 oblique inguinal hernia i6r Separation of hernial sac 222 Sepsis as complication to operation for abdominal hernia 412 Sex as predisposing cause of hernia 45 relation to various forms of hernia 18 Shape of sac of femoral hernia 308 Shaping truss for femoral hernia 317 inguinal hernia 152, 157 Shouting as direct cause of hernia 51 Sigmoid hernia 60, 277, 279 456 INDEX. PAGE Sigmoid hernia diflferentiated from other inguinal hernia 98 operation for 280 Silk as suture materia] 217 Situation of umbilical hernia 344 Size as complication to operation for inguinal hernia 265 contra-indication to operation for abdominal hernia 409 of umbilical hernia. 346 Spermatic cord 29 constituents of 42 Spontaneous ventral hernia ^8^ Strangulated hernia 427 femoral hernia 439 inguinal hernia 70, 413 rarer hernia 444 umbilical hernia 443 Sub-peritoneal areolar tissue 27 fat as complication to truss fitting 174 Summary of author's operations for abdominal hernia 445 Superficial epigastric vessels 22 fascia 21 vessels of 22 Stirgical anatomy of inguinal region 20 Svu-gical treatment of, femoral hernia 331 inguinal hernia 214 Andrews' operation for 227 author's operation for 218 Bassini's operation for 216 Halsted's operation for 228 in female 292 lumbar hernia 400 strangulated hernia 432 iimbilical hernia 372 author's operation for 373 Blake's operation for 375 Dr. Johnson's views on 372 Mayo's operation for 377 ventral hernia 396 Symptoms of bladder hernia 285 femoral hernia 309 inguinal hernia 82 spontaneous ventral hernia 384 strangulated hernia 416 umbilical hernia 354 T Taylor, Dr. Geo. H 211 Dr. William J i 3^4 Taxis 428 on umbilical hernia 444 Testicle 34 Theory of operation for inguinal hernia 214 Thrornbosis of femoral vein as accident to hernia operations 410 Time of occitrrence of femoral hernia 297 Time of oVjliteration of tunica vaginalis 39 Tod. Dr 147 Traction in reduction of hernia 429 Transversalis fascia 27 INDEX. 457 PAGE Transversalis muscle in inguinal hernia 25 Traumatic ventral hernia 386 Trautmann 80 Treatment of femoral hernia 317 inguinal hernia 113 lumbar hernia 399 umbilical hernia 355 congenital 382 traumatic ventral hernia 392 Trusses, classification of 116 construction of 116 coverings of 151 fitting of 152 for bladder hernia 277 for caecal hernia 277 for femoral hernia 317 for infants 194 for inguinal hernia 116 for sigmoid hernia 277 for umbilical hernia 358 for ventral hernia 393 instructions to wearers of 201 varieties of 121 Tuberculosis as contra-indication to operating abdominal hernia. ... 410 Tuffier 278 Tumors differentiated from femoral hernia 316 Tunica vaginalis 39 cysts of 40 Types of hernia '54 U Umbilical hernia 344 age relation to 18 anatomy of 345 contents of 349 definition of 17 irreducible 370 percentage of 18 sex relation to 18 strangulation of 443 symptoms of 354 taxis on 444 treatment of 355 infant. 355 mechanical 355 surgical 372 Unclassified trusses 147 Undescended ovary differentiated from oblique inguinal hernia no Undescended testicle, see delayed testicle 37 Urinary obstruction as direct cause of hernia 52 V Vaginal hernia 408 Varicocele as complication to operation for inguinal hernia 239 complication to truss fitting 176 differentiated from femoral hernia 311 inguinal hernia 104 458 INDEX. PAGE Vas deferens 43 Velpean 213 Ventral hernia 383 causes of 383 definition of 18, 383 percentage of 18 spontaneous 383 symptoms of 384 treatment of 385 traumatic 386 symptoms of 388 treatment of 392 Vomiting as direct cause of hernia 50 W Winsboro, Dr. Rudolph 288 Witzel, Oscar 386 Wofler 236 Wood, Dr. Alfred C 309 WuUstein 234 Z Zabe, Dr., Hernial dyspepsia 345 RD 621036 1907 P """"*""" "la- Its cliannn ■iiiiii 2002098296