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 THE CURE OF THE MQRE DIFFICULT AS 
 
 WELL AS THE SIMPLER INGUINAL 
 
 RUPTURES 
 
 W. S. HALSTED, M. D. 
 
 Surgeon in-^hief to the Johns Hopkins Hospital, Professor of Surgery in the 
 Johns Hopkins University 
 
 Reprinted from The Johns Hopkins Hospital Bulletin, No. 149, August, 1903 
 
 ZU ^oxi> Q0afttinovc (preee 
 
 THE I'KIEUICNWALU COMPANY 
 ISALTIMOKE, MU. 
 
 1903 
 
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[From The Johns Hopkins Hospital, Bulletin, Vol. XIV, No. 149, 
 August, 1903.] 
 
 THE CURE OF THE MORE DIFFICULT AS WELL AS 
 THE SIMPLER INGUINAL RUPTURES. 
 
 By W. S. Halsted, M.D., 
 Surgeon-in-Chief, The Johns Hopkins Hospital. 
 
 This communication will, I hope, be of interest to friends [2081 
 who have asked for precise information as to the modifications 
 which our operation for hernia has undergone in the process 
 of development during the past thirteen years, and of service 
 to operators who seek to obtain in each instance a result as 
 perfect as possible and who recognize that not infrequently 
 there occur cases of hernia requiring for their cure extraor- 
 dinary operative procedures. The present operation has been 
 evolved by degrees and stands for the experience of 14 years 
 derived from more than 1000 operations for the cure of in- 
 guinal hernia ; features of the old where they seemed unneces- 
 sary have been dropped and new ones, as they seemed to be 
 indicated, added. To record even the cruder general results 
 of so many operations (upon adults with few exceptions)* for 
 the cure of inguinal hernia are required special training, some 
 
 1 The value of an operation for the cure of inguinal hernia can hardly 
 be determined upon children for the surgeon is greatly assisted by nature 
 as the child develops, and he is not confronted with the more difficult 
 problems arising from an undeveloped or an acquired atrophy of the 
 conjoined tendon, or from fatty degeneration and atrophy of the inter- 
 nal oblique muscle. Furthermore, the recurrences have almost invari- 
 ably followed operations for the cure of very large and old ruptures, 
 such as are impossible in children. And to quote from Bloodgood, 
 "As we have had no recurrences" in children " whether the veins have 
 been excised or not, it does not seem to make much diflerence what 
 is done with the very small cord." 
 
 (1) 
 
[308] zeal and a particular honesty of purpose ; and for the recogni- 
 tion and interpretation of the nicer facts, keen perception and 
 fine tactile sense are indispensable. A few drops or even a 
 dram of fluid in the tunica vaginalis might readily escape de- 
 tection, and to determine slight swelling or induration here 
 and there in the epididymis and the relative size of the two 
 testicles may be difficult. A novice can usually discover a dis- 
 tinct recurrence and so can the patient, but I have known an 
 eminent surgeon to overlook a weakness in a scar of his own 
 making sufficient to constitute, without doubt, a recurrence. 
 The surgeon is fortunate and likely to be true to himself 
 whose observations are controlled by mature assistants with 
 large experience in the operative treatment of hernia and 
 who are as eager as he to ascertain and state the exact truth. 
 If our operation for the radical cure of inguinal hernia has 
 improved, it is due in no small measure to the arduous labors 
 of Dr. Bloodgood, whose valuable contribution' should be 
 better known. He established several facts of prime import- 
 ance from his study of our first 300 cases of inguinal hernia. 
 The majority of inguinal ruptures are now easily and quite 
 well cured by a variety of procedures and by the average oper- 
 ator, hence it is difficult for the student and young practi- 
 tioner to comprehend that it is hardly more than a decade since 
 this variety of hernia completely baffled the efforts of the best 
 surgeons to cure it. That so simple an operation as Kocher's 
 can cure perhaps many of the milder ruptures, provided the 
 neck of the sac is not too wide, leads to the inquiry whether 
 the features, of these operations, upon which most stress has 
 been laid may not be relatively unimportant, since operations 
 of the magnitude of Bassini's and the author's are not in all 
 cases indispensable. If the transplantation of tlie neck of 
 the sac can cure so many cases, is it not possible that the trans- 
 plantation of the cord, which at first was deemed so essential 
 by Bassini and the author, may have owed its success in part 
 to the fact that it made possible this very high closure of the 
 sac's neck? Although for several years our operation, so far 
 as transplantation of the cord and high closure of the sac is 
 
 « Johns Hopkins Hospital Reports, vol. vii. 
 
 (2) 
 
concerned, was even more radical than Bassini's (the cord was [308] 
 transplanted into the substance of the divided internal oblique 
 muscle), we were tempted, at the very outset, to test the rela- 
 tive value of cord transplantation in some of the cases, and 
 permitted the entire cord to lie undislocated and altogether 
 undisturbed in its bed and to trust to the suture of the inter- 
 nal oblique muscle to Poupart's ligament, to the "lining of 
 the wound with muscle " to efEect a cure. It was well wor- 
 thy of note, as Bloodgood emphasizes in his article, that all of 
 the cases treated in this manner (cord undisturbed) remained 
 cured. Another fact which Bloodgood's painstaking study 
 established was that of one hundred and nine cases in which 
 the larger bundle of veins of the cord was excised and the heal- 
 ing was per primam, not one showed a recurrence or any weak- 
 ness at the site of the transplanted vas deferens, whereas in 
 6.4 per cent of the cases which healed by first intention and 
 in which the veins had not been excised, there was a recurrence 
 at the upper angle of the wound, at the site of the trans- 
 planted cord. And even in the wounds which suppurated, 
 there was not a recurrence in the nine cases of vein excision, 
 whereas, of eleven suppurating cases in which the cord-veins 
 were not excised, four (36.3 per cent) recurred. In 118 
 cases, therefore, in which the larger bundle of veins was ex- 
 cised there was no recurrence at the site of the transplanted 
 cord whether suppuration ' occurred or not. And, certainly. 
 
 3 Nine suppurations in 118 cases, and for most of wliich the author 
 was personally responsible, seems a large percentage (7.6^) even for 
 hernia cases ten years ago, but it was considered a good showing in 
 those days. Since every one, including the operator, has invariably 
 worn rubber gloves, suppurations even in the operations for hernia, has 
 occurred in probably less than 1^ of the cases. In 1890, all the assis- 
 tants at an operation, the nurses and physicians, systematically wore 
 gloves, bat the operator wore them only for special operations, such as 
 exploratory laparotomies, explorations for foreign bodies, loose carti- 
 lages, etc., in the joints, suture of the fractured patella, etc.— in other 
 words, when there was a possibility of doing serious harm and no cer- 
 tainty of doing great good. By degrees the operator wore gloves more 
 frequently, until Dr. Bloodgood as Resident Surgeon, and who had become 
 thoroughly accustomed to them as assistant, wore them invariably as 
 operator and demonstrated from our statistics the necessity of doing so. 
 It seems to be a fact that one who has been trained to operate always 
 
 (3) 
 
1.209] the eases in which the veins were excised, were not the simpler 
 ones. 
 
 One of xhe most important of the facts ascertained by 
 Bloodgood was the great variation in the width of the con- 
 joined tendon and the responsibility of the insufficient tendon 
 for the recurrences at the lower angle of the wound, through 
 the external ring, direct. The transplantation of the rectus 
 muscle recommended by Bloodgood * to close this defect seems 
 to accomplish Avhat its originator hoped it might, although, 
 a priori, one would fear that this powerful straight muscle 
 must eventuaJlly djraw away from Poupart's ligament to 
 which it had been sewed. Is it not conceivable, however, that 
 a, new encompassing fascia may develop about a transplanted 
 muscle and that this fascia may remain even after the muscle 
 has been pulled away? Experiments upon animals to deter- 
 mine this point would be interesting. M. Holl, now Professor 
 of Anatomy in Gratz, directed attention many years ago to the 
 part muscles probably play in the determination and develop- 
 ment of the fasciae. 
 
 Hence, so long ago as 1896 we recognized, thanks to Blood- 
 
 in rubber gloves finds it awkward to operate without them. I have 
 more than once heard my assistants, while performing some insignificant 
 operation without them, call for gloves because, as they said, they were 
 conscious of unnatural finger movements, of a certain clumsiness with- 
 out them. With gloves one probably acquires special methods of tying 
 knots, holding instruments, etc. In our clinic the heavier gloves are 
 exclusively used, although probably every member of the Staff has by 
 predisposition been in favor of the thinner gloves and had to convince 
 himself by trial of the thinner varieties that the thick ones, even with 
 seams on the fingers, were preferable. The thin gloves were too slip- 
 pery ; also too unsafe, chiefly because of the danger of minute unde- 
 tected holes. Cotton gloves, if changed very frequently, are undoubt- 
 edly better than no gloves at all. If the operator desires the physical 
 property of the cotton which enables him to hold more securely and 
 handle with more precision the intestines and viscera he might wear a 
 very delicate gauze-mesh glove over the rubber or over two or three 
 fingers of the rubber glove. Possibly a rubber glove might be manu- 
 factured with a wide gauze mesh permanently imbedded in its palmar 
 surface. 
 
 ■•Anton Wofler, Beitrage zur klinischen Chirurgie (Festschrift f. 
 Billroth), 1893. 
 
 (4) 
 
good, the value of the excision of the veins of the cord and the [209] 
 necessity for paying more attention to the neglected lower angle 
 of the wound. Naturally, it was primarily to the upper angle 
 that we had devoted our thoughts, for, as emphasized in one 
 of the author's articles on the subject, " the cord is the first 
 cause of the hernia and the ultimate obstacle to its cure."' 
 And this is true, notwithstanding the fact that recurrences at 
 the lower angle were at first not very rare ; for, our attention 
 having been called to these lower angle recurrences, methods 
 to cure them were soon found. 
 
 The success attending excision of the veins (one hundred 
 and eighteen cases without recurrence at the site of the trans- 
 planted vas deferens) seemed to justify a continuance of this 
 practice, provided it occasioned no undesirable results; but 
 excision of the veins with transplantation of the vas deferens 
 taught us that, not infrequently, a hydrocele, usually insig- 
 nificant in size, was to be expected, and that in about 10 per 
 cent of the cases atrophy of the testicle had occurred. x\tro- 
 phy of this organ, however, was observed only in cases com- 
 plicated by a very considerable swelling of the epididymis, 
 and this observation of Bloodgood's, made so many years 
 ago, has been verified by our study of more than one 
 thousand operations. Great care was exercised, therefore, 
 in excising the veins and, for a short time, a few months 
 perhaps, this procedure was not so invariably practiced by all 
 of us, being reserved for cases which seemed imperatively to 
 demand it. We formerly handled the cord as, I presume, 
 almost everyone still does; separated it, more or less roughly, 
 by tearing, from the sac and its enveloping membranes, and 
 raised it on a hook or strip of gauze preparatory to transplan- 
 tation and while the stitches were being applied. We now 
 treat the vas deferens with great deference, thanks again to 
 Bloodgood. (Vide description of operation below.) 
 
 It occurred to Bloodgood before the publication of his report 
 on hernia that it might be well to split the cord, transplanting 
 only the veins to the outer angle of the wound and permitting 
 the vas deferens to lie undisturbed. This method was finally 
 abandoned by Bloodgood and other members of the staff who 
 had practiced it, because the subtraction of the vas deferens 
 
 (5) 
 
[309] did not appreciably reduce the size of the cord; furthermore, 
 there were one or two recurrences at the site of the trans- 
 planted veins. This is a particularly good confirmation of 
 the author's belief that the veins are largely responsible for 
 the development of oblique inguinal hernia. The vas deferens 
 contributes, relatively, very little to the size of most adult 
 cords, but the veins, which at one moment make a bundle as 
 large as one's linger, may the next and when empty be reduced 
 to the size of a small quill. Is not this variation in the size 
 of the cord possibly a factor in the production of hernia? 
 When the hernia is first developing and the sac is, at opera- 
 tion, inside the internal abdominal ring, it can readily be 
 demonstrated by a little pull on the veins. The fat, too, 
 which is recognized as sometimes a probable factor in the pro- 
 duction of hernia, accompanies for a short distance the veins 
 rather than the vas deferens. This fat when present should 
 be excised with the veins. For several years, then, we have 
 been excising the veins in this careful manner, leaving the vas 
 deferens untransplanted, undisturbed, and the internal oblique 
 muscle undivided. In a few cases, however, without, that I 
 am aware of, ultimate damage to the testicle, we transplanted 
 the vas deferens to the outer angle of the wound. But we are 
 quite certain that, as a rule, the less the vas deferens is mani- 
 pulated and the more carefully the veins are excised, the less 
 is the subsequent congestion of the epididymis. It is instruc- 
 tive from day to day to study the stump of the veins, the 
 epididymis, the testicles, etc., after operations for hernia. 
 
 It is not the purpose of this communication to give the re- 
 sults in detail of these observations. 
 
 In a recent private case, urethritis Neisseri made its appear- 
 ance a few hours after the operation. We naturally watched 
 the epididymis on the operated side with some concern, fear- 
 ing that excision of the veins might lower the resistance of 
 this organ. On the twelfth day, without warning, a very slight 
 induration of the epididymis became evident. T attributed 
 
 [310] tliis to the fact that the patient carried out his irrigation- 
 treatment badly, for the proper"^ method of irrigation being 
 
 6 When the author's method of treating gonorrhoea can fail in his own 
 wards, because improperly understood, it is not strange that so admir- 
 
 (6) 
 
instituted, the swelling of the epididymis immediately sub- [2i0] 
 sided and the urethral discharge promptly ceased. 
 
 Four years ago the author used, for the first time, a part of 
 the aponeurosis covering the right rectus muscle to close the 
 lower part of the right inguinal canal. I felt compelled in 
 this case to resort to some such measure, for the internal ob- 
 lique was fatty and attenuated to a degree not very often seen 
 by us, and the rectus muscle did not seem to promise so much 
 as its fascia did. This patient was a college-mate of mine 
 and for this reason I wished, perhaps, more than ever, to be 
 very sure of the result. One year ago I examined this patient 
 very carefully and was gratified to find as solid a closure as 
 one could desire. I considered the result as perfect as any 
 that I had seen. Dr. Harvey Gushing, house surgeon at the 
 time, made a sketch of this act of the operation, which Brodel 
 has kindly elaborated (vide Fig. VII). This procedure may 
 have a wider application than I have proposed for it. The 
 
 able a surgeon as Dr. Orville Horwitz, apropos of Janet's work on the 
 abortive treatment of gonorrhoea by permanganate of potash, should 
 write : "In spite of the claim of quick cures and prevention of complica- 
 tions a length of time elapsed before it began to be generally adopted in 
 this country. The profession was skeptical as to the claims made for 
 its brilliant results. This was probably due to the disappointment 
 which had followed the employment of retroinjections of hot water sug- 
 gested by H. Holbrook Curtis, and of the continuous irrigation with a 
 hot solution of mercury bichloride, recommended by Dr. W. S. Halsted, 
 which at the outset seemed to offer more benefit to the patient than the 
 conservative methods then in vogue, but resulting after a fair trial by 
 a large number of observers in being found valueless and often danger- 
 ous ; the employment of these remedies having been found to be 
 attended with great discomfort to the patient and being frequently ac- 
 companied by severe complications, such as acute posterior urethritis, 
 seminal vesiculitis, prostatitis, and cystitis." This is not the proper 
 time to tell how one must use the bichloride solutions in order to obtain 
 the best results which have been claimed for it, but to judge from my 
 own experience with this method twenty years ago in private practice, 
 too much has hardly been said in its favor. The bad and indifferent 
 results probably come from mismanagement or misconception. I should 
 be glad at some future time to publish the treatment in detail, for it 
 happens that I have not heretofore described or, in print, claimed any- 
 thing for the method which rightly bears my name. I agree with Dr. 
 Horwitz that irrigation with hot water is not only useless but dangerous. 
 
 (7) 
 
[310] anterior sheath of the rectus muscle might be employed in 
 the way described whenever the conjoined tendon is insuffi- 
 cient, whether the cremaster muscle can be well used to rem- 
 edy the defect or not. And Berger' has recently suggested 
 using the rectus sheath in much the same way in operations 
 for the cure of inguino-interstitial hernia. 
 
 In the upper part of the canal we have strong tissues and 
 plenty with which to close, and hence it was perhaps natural 
 to transplant the cord to the upper angle, to bring it out 
 through thick muscle. But it is not perfectly certain that the 
 cord may not be a useful adjunct in the closing or filling in of 
 the lower angle in some cases, and it is a fact that with Bas- 
 sini's operation the percentage of recurrence at the position of 
 the transplanted cord in the case of adults has been quite large, 
 probably over 6 per cent. Wliatever the truth may be, we 
 have in the excision of the veins a distinct contraindication to 
 transplanting the vas deferens, and thus far we have had no 
 reason to believe that the results would have been better if the 
 vas deferens had been transplanted, as was our custom for sev- 
 eral years, to the outer angle of the canal. We may eventually 
 discover that the transplantation of the cord, which Bassini, 
 and at one time the author, considered not only so important, 
 but perhaps the principal feature of the operation, is harm- 
 ful rather than helpful. Briefly, we may find that not only 
 the vas deferens, but even the entire cord, would be more safely 
 transmitted at the lower angle of the deep wound than at the 
 upper. It would require a very large number of observations 
 to determine this point because the percentage of recurrences is 
 so small in these days; and it is unfair to compare the results 
 of various operations in the hands of various operators. Sur- 
 geons do not seem to be agreed even as to what shall constitute 
 a recurrence, or wound suppuration, and, if they were agreed, 
 the personal element would still count for much. 
 
 The Use of ihe Cremaster Muscle. — A device which we hit 
 upon in our efTorts to close more securely the lower part of the 
 
 ^P. Berger: La. Hernie ingiiino-interstielle et son traitement par la 
 Cure radicale. Revue de Chirurgie, Janvier, 1902. 
 
 (8) 
 
canal, but which we now make use of as often as feasible, [210] 
 probably in over 75 per cent of the cases, is the utilization of at 
 least a part of the cremaster muscle, which we formerly cut 
 away. This is a step of the operation to which one is irresist- 
 ibly drawn in some cases by the great strength of the cremas- 
 ter and the firmness and extent of its attachments to Poupart's 
 ligament. A natural insertion, such as this, of the cremaster 
 and its fascia into Poupart's ligament, has in each case a value 
 which can be demonstrated on the operating table and can be 
 counted upon definitely to contribute something, and occa- 
 sionally perhaps a great deal, to the strength of the abdominal 
 wall; whereas the artificial insertion of the internal oblique 
 into Poupart's ligament, although undoubtedly of the utmost 
 importance and always to be tried for, may occasionally and 
 perhaps often fail, from insufficient muscle, too great tension, 
 or gradual redressment, to close securely even the upper part 
 of the canal. The lower part of the canal, ordinarily pro- 
 tected by the conjoined tendon, can rarely be entirely safe- 
 guarded by the muscle fibres of the internal oblique when its 
 conjoined tendon is deficient. The cremaster, on the other 
 hand, seems in just these cases to serve a particularly good 
 purpose. The cremaster, unaided, has repeatedly made such a 
 complete and strong looking closure that we have felt the 
 hernia would be well cured if the operation were abandoned at 
 this stage. 
 
 I have today, June 10, 1903, examined a patient whose very 
 wide inguinal canals (the gap would have admitted the hand) 
 were closed eighteen months ago solely by the cremasters 
 stitched over instead of under the internal oblique muscle; 
 the result, in the opinion of those who examined the case, is 
 absolutely perfect, on both sides. My house surgeon. Dr. Fol- 
 lis, and one or two others examined the man'' with me. Even [sii] 
 
 ^The history is briefly this. Male, fet. 59 years; Surgical No. 12,905 ; 
 was operated upon January 15, 1902, for two very large scrotal ruptures, 
 eighteen and twenty-four inches long (from external ring to bottom of 
 scrotum). The conjoined tendons on both sides were almost obliterated. 
 The circumcentral rings easily admitted four fingers. The cremaster 
 muscles, very well developed, were used to close the entire dehiscence 
 because the internal oblique muscles could, only with great tension, be 
 
 (9) 
 
1211] had I known what the result in this case was to be, I would 
 have used, if possible, the internal oblique muscles in the old 
 way, and hence have stitched the cremaster under rather than 
 over the former. But the muscles were attenuated and not 
 close at hand. Stitching the cremaster over the internal ob- 
 lique muscle necessarily precludes the sewing of the latter to 
 Poupart's ligament. The closure with the cremaster seems 
 almost ideal in some cases ; it is a method so inviting during 
 the operation, and so true, when finished, to one of the great 
 principles of surgery; there is no tension. It is, in this 
 respect, as a plastic operation should be. What the ultimate 
 verdict will be it is too soon to predict. The cremaster fibres, 
 particularly the hypertrophied ones, will, in time, atrophy; 
 but when this occurs, the cremasteric fascia, perhaps stronger 
 than before, would probably remain, holding together the atro- 
 phied muscle bundles. There can, at least, no harm result 
 from this attempt to strengthen the wall, for the internal 
 oblique muscle has been used in the usual manner. The worst 
 that could happen would be a recurrence, in a certain class of 
 cases, at the lower angle, one that might, possibly, have been 
 avoided if the aponeurosis over the rectus muscle had been 
 employed instead of the cremaster as described by the author. 
 The future will decide these nicer points, and it would seem 
 that only the nicer points remain now to interest the operator. 
 
 Another feature of the present operation is to transplant 
 the neck of the sac as described below. It is merely an addi- 
 tional precaution warranted by the good results obtained by 
 Kocher and others with his operation. 
 
 And, finally, we overlap the aponeurosis of the external ob- 
 lique muscle to insure the union which a mere approximation 
 of the edges of the aponeurosis cannot do, and to close more 
 snugly the external ring. 
 
 We still examine with the same care, but no longer 
 with concern, the epididymis, testicle, stump of veins, etc., 
 chiefly to ascertain if there is congestion (induration) of 
 
 drawn down to Poupart'a ligament; the former was stitched in front of 
 instead of behind the latter muscles. We had never before and have 
 never since had occasion to use the cremasters in this way. Dr. Mitchell, 
 my house surgeon, operated upon one side, and the author upon the other. 
 
 (10) 
 
THE JOHNS HOPKINS hlOSPITAL BULLETIN, AUGUST, 1903. PLATE XIV. 
 
 Fig. I. 
 
 Fi<;. in. 
 
THE JOHNS HOPKINS HOSPITAL BULLETIN, AUGUST, 1903. PLATE XIV. 
 
 Fig. II. 
 
 [ yyi-3- 03 
 
 Fro. IV 
 
THE JOHNS HOPKINS HOSPITAL BULLETIN, AUGUST, 1903. PLATE XV. 
 
 1 n t er n a 1 ^^Sjj^^ 
 
 ni - 
 ^~~- U ApoTieurobis of 
 
 Cremaster--' 
 
 ^^^^^^^ 
 
 
 ■';!-^-;' "^ ^.,..u 
 
 Fig. V 
 
 Fio. vr. 
 
THE JOHNS HOPKINS HOSPITAL BULLETIN, AUGUST, 1903. PLATE XV. 
 
 Fig. VII. 
 
the epididymis or fluid in the tunica vaginalis. Often there [2ii] 
 is an appreciable, though very slight, induration of the epi- 
 didymis, particularly if the veins have been ligated through 
 the dense plexus very near the testicle; and often a few 
 drops or a drachm or two, or even more fluid is present in the 
 tunica vaginalis. This may become absorbed in a few weeks 
 or months and might, when present, usually not be noticed by 
 the patient except for the repeated careful examinations. Hy- 
 droceles containing several ounces have been recorded in our 
 histories; in two or three instances operation for the cure of 
 the hydrocele has been performed. What the proportion of 
 hydroceles is to the cases operated upon for the cure of hernia, 
 without vein excision, I cannot say for the reason that we ex- 
 cise the veins almost invariably nowadays, and in the days 
 when the veins were not excised we did not observe our cases 
 quite so keenly with reference to this point. One of the 
 larger hydroceles followed, as I have said, an operation in 
 which the veins were neither excised nor transplanted nor in 
 any way disturbed. The patient, a navy officer, had an indi- 
 rect rupture on each side. Both sides were operated upon at 
 the same time and on both, hydroceles developed in a few days, 
 although neither epididymis became more than just perceptibly 
 indurated ; but the larger hydrocele was on the side of the un- 
 disturbed veins and of the smaller hernia. Not a single atro- 
 phy of the testicle has been recorded since 1899, when Blood- 
 good-^ublished his report, and I believe that at that time it 
 was noted that not one had been observed for several years. 
 
 Possibly some of my readers will ask, " Why take so much 
 trouble, why make the operation so complicated when such 
 good results as are published may be obtained by simpler 
 methods ?" The operation is not complicated for the surgeon 
 competent to operate for the cure of hernia, nor are all its 
 details required for the simpler cases, and we do not know 
 just what the results obtained by simpler methods are. We 
 cannot ascertain definitely even our own results, although we 
 make a great effort and are admirably equipped to do so. This 
 can be said, however, that, since the publication of the author's 
 second paper, June, 1892, not a single recurrence has been 
 
 • (11) 
 
1211] charged to him. One of the world's most distinguished sur- 
 geons, the inventor of a clever hernia operation, made, with 
 reference to himself, some such remark to the author three or 
 four years ago, and the next morning two recurrences pre- 
 sented themselves. This surgeon permits his patients to get 
 out of bed in eight days because, as he said to me, "A man 
 can better afford to be operated upon three or four times for 
 recurrence by my method than once by a method like Mc- 
 Ewen's, which requires lying in bed for five or six weeks." In 
 my exj^erience a man would, after operation, prefer to spend 
 several additional weeks in bed than run the risk of a recur- 
 rence. It is only before, not after the operation that a patient 
 objects so vigorously to the time to be spent in bed. 
 
 The Operation. — The several steps of the operation are so 
 well depicted by the illustrations of Brodel that a verbal de- 
 scription is almost superfluous for those who have the plates. 
 
 (I) The aponeurosis of the external oblique muscle is di- 
 vided and the two flaps reflected as in the Bassini-Halsted op- 
 eration. 
 
 (II) The cremaster muscle and fascia is split, not directly 
 over the centre of the cord, but a little above it. 
 
 (III) The internal oblique muscle is made as free as pos- 
 sible. A little artef action is here often necessary. If the mus- 
 cle cannot be drawn, without tension, well down to Poupart's 
 ligament, it helps, I think, to make a relaxation cut or two in 
 the anterior sheath of the rectus muscle under the aponeurosis 
 of the external oblique muscle. This sheath being in part the 
 
 [212] aponeurosis of the internal oblique muscle, one can readily 
 comprehend that incisions into it, if properly made, might be 
 of service. It is M'ell, however, to postpone making such in- 
 cisions until the sewing of the internal oblique muscle to Pou- 
 part's ligament is begun, for then the amount of tension can be 
 nicely gauged and the number, length and precise position of 
 the relaxation cuts determined. A second reason for postpon- 
 ing the 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 port of the inguinal canal, as 
 already stated. 
 
 (13) 
 
(IV) When the veins arc large, and this is usually the case, [313] 
 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.' (Vide Fig. VI.) 
 The 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 the blunt end first) is passed between them. 
 As a precaution against slipping, we apply two ligatures of 
 fine 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 ring. 
 
 (V) Ligation of the sac by transfixion or by purse string 
 suture at the highest possible point. Both ends of this suture, 
 after tying, are threaded on long curved needles, then carried 
 far out under the internal oblique muscle from behind for- 
 wards, and, passing through this muscle, about 5 mm. apart, 
 are tied. The idea was suggested to the author by Kocher's 
 operation, the principle being essentially the same." 
 
 (VI) The lower fiap 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 ; vide Fig. I. 
 
 (VII) 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 
 
 ''The fact is that the vas deferens is frequently accidentally handled 
 or squeezed, but harm that we know of has never resulted since we have 
 recognized the necessity for exercising great care in the separation and 
 ligation of the veins. 
 
 3 I have read recently in the Centralblatt fiir Chirurgie a reference to 
 some other surgeon's account of this very procedure, but, unfortunately, 
 cannot recall the surgeon's name and have not the facilities at this 
 moment to hunt for it. 
 
 (13) 
 
[212] ligament in the Bassini-Halsted manner. (Vide Fig. 11.) 
 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 mus- 
 cle, as well as of the cremaster, although the artist endeavored 
 to record accurately what he saw. 
 
 (VIII) The aponeurosis of the external oblique muscle is 
 overlapped, as shown in Figs. Ill and IV. This is known as 
 Andrew's " method, although devised independently by us. 
 
 (IX) The skin is closed with a buried continuous silver 
 suture, and the incision covered with five or six layers of silver 
 foil. It is unnecessary to dress or examine a wound closed in 
 this manner for two weeks, when the wire may be withdrawn. 
 Patients are kept in bed from eighteen to twenty-one days. 
 
 We hope to be able to publish very soon the results of the 
 first 1000 operations performed for the cure of inguinal hernia 
 at the Johns Hopkins Hospital. Certainly more than two- 
 thirds of the operations have been performed by my associates, 
 Drs. Finney, Bloodgood, Cushing, Mitchell and Follis, for we 
 are all much interested in the subject. Each operator has been 
 at perfect liberty and is encouraged to perform the operation 
 according to his best judgment. This fortunately furnished 
 a little variety, but of late the operation has, in almost every 
 detail, been performed just as the writer has described it. 
 
 Inasmuch as only a limited number of surgeons see the 
 Johns Hopkins Hospital Eeports, in which Dr. Bloodgood 
 published his article, it may be well to publish one or two of 
 the Summaries which he prepared with such care and so great 
 labor. He intends quite soon to investigate the condition of all 
 those, so far as possible, who are included in these Summaries. 
 
 " Summary of the Ultimate Eesults. Complete to 
 June 1, 1899.'^ 
 
 " Eecent cases, less than 6 months, and cases lost track of 
 were not included. 
 
 10 The Chicago Medical Recorder, August, 1895, vol. ix, p. 67. 
 
 (14) 
 
All cases Group I to Y healing p. p.. 301 cases. 13 recur. 4.3^ [212] 
 All cases Group I suppurating 31 " 9 " 29^ 
 
 Total 332 " 22 " 6.6^ 
 
 Halsted's operation, Group I, healing 
 
 p. p 218 cases. 9 recur. 4.1^ 
 
 Halsted's operation, Group I, suppu- 
 rating 20 " 6 " 30^ 
 
 Total, Group 1 238 " 15 " 6.2^ 
 
 " Eecurrence in Wounds Healing Per Primam." 
 
 Cases. Recurrences. 
 
 (1) 'At the position of the transplanted 
 
 cord, veins excised 109 nil. 
 
 (2) At the position of the transplanted 
 
 cord, veins not excised 109 7 (6.4^) 
 
 (3) Upper angle of the wound, cord ex- 
 
 cised or not transplanted 83 1(1. 2^) 
 
 (4) Lower angle of the wound, con- [2i3i 
 
 joined tendon wide and firm, rec- 
 tus muscle not transplanted 264 nil. 
 
 (5) Lower angle of the wound, con- 
 
 joined tendon obliterated, rectus 
 
 muscle not transplanted 8 5(6 2^) 
 
 (6) Lower angle of the wound, con- 
 
 joined tendon obliterated, rectus 
 
 muscle transplanted 14 nil. 
 
 (7) Lower angle of the wound, con- 
 
 joined tendon wide and firm, rec- 
 tus muscle transplanted 16 nil. 
 
 " Eecurrence in Wounds Healing by Suppuration.''' 
 
 (1) At the position of the transplanted 
 
 cord, veins excised 9 nil. 
 
 (15) 
 
[313] 
 
 Cases. Recurrences. 
 
 (2) At the position of the transplanted 
 
 cord, veins not excised 11 4 (36.3^) 
 
 (3) Upper angle of the wound, cord ex- 
 
 cised or not transplanted 11 1(9^) 
 
 (4) Lower angle of the wound, con- 
 
 joined tendon wide and firm, rec- 
 tus muscle not transplanted 27 2 (7.4^) 
 
 (5) Lower angle of the wound, con- 
 
 joined tendon obliterated, rectus 
 
 muscle not transplanted 4 2 (50;^) 
 
 Dr, Bloodgood's " Conclusions as to the operation for in- 
 guinal hernia'' published in 1899 : 
 
 " Our observations prove that Halsted's operation with the 
 excision of the veins will give perfect results, except in those 
 few cases in which the conjoined tendon is obliterated; in 
 these cases our observations so far have demonstrated that the 
 transplantation of the rectus muscle will give perfect results." 
 
 " If the veins could be excised in every case of inguinal her- 
 nia and the remainder of the cord transplanted without any 
 risk of epididymitis and atrophy of the testicle, a perfect re- 
 sult would probably be accomplished in every case." 
 
 " The operation would then be : The ligation and excision 
 of the veins, the transplantation of the remaining portion of 
 the cord into the upper angle of the divided and transplanted 
 internal oblique muscle, and, in cases in which the conjoined 
 tendon is obliterated, the transplantation of the rectus m^uscle. 
 So far we have not observed a single recurrence when these 
 procedures have been adopted. The sole objection to this 
 method is the danger of atrophy of the testicle after excision 
 of the veins. Atrophy of the testicle has been observed only 
 after a very marked epididymitis. The probabilities of this 
 epididymitis are very much less when the veins are excised 
 without disturbing the vas deferens and its immediate vessels. 
 For this reason I. should advise that when the veins are ex- 
 cised the remainder of the cord, a very small affair, be left 
 undisturbed. I am very much inclined to believe that the 
 
 (16) 
 
cord, reduced to such a diminutive size by the excision of the [313] 
 veins, will be as little likely to be the cause of a recurrence in 
 the lower angle of the wound as in the upper angle when it is 
 transplanted/' 
 
 " Cases in which the Veins should not he Excised." 
 "When during the dissection of the sac the cord is torn 
 from its bed in the inguinal canal and subjected to trauma- 
 tism, and the testicle withdrawn from the scrotum, the veins 
 should not be excised, because the probabilities of epididymitis 
 and atrophy are too great. In such cases I would advise the 
 transplantation of the veins alone, so that the larger cord is 
 divided," and the wound is weakened less by the presence of a 
 very small cord in two places than by the presence of a larger 
 cord in one place, which from our results we know to have 
 been the cause of a recurrence in 6.4 per cent of the cases.'' 
 
 "Xote, June, 1899. In October, 1898, I performed for 
 the first time the splitting of the cord, transplanting the veins 
 only. Since this date the modification has been followed in 
 26 operations for inguinal hernia. In 12 the rectus muscle 
 was transplanted. The wounds in 25 cases healed per 
 primam. In 19 cases no swelling of the testicle followed op- 
 eration. In 7 cases there was slight but temporary swelling. 
 Thrombosis of the veins was not observed in any of the 26 
 cases. It is seven months since the first two operations. Both 
 are perfect results. The others are recent operations." 
 
 " When the bundle of veins is unusually large, and complete 
 excision is contra-indicated for reasons already given, I have 
 suggested that a portion should be ligated and excised and the 
 remainder transplanted. This has been done in a recent case 
 by Doctor Gushing." 
 
 "In children the veins should not be excised; the proba- 
 bility of atrophy is greater than in adults. As we have had no 
 recurrences whether veins have been excised or not, it does not 
 seem to make much difference what is done with the very small 
 cord." 
 
 "The splitting of the cord has been discontinued by its author. 
 
 (17) 
 
[313] " In the female the round ligament and its vessels is 
 such a small affair that it makes little difference what is done 
 with it." 
 
 "References to the transplantation of the rectus muscle by 
 Wofler: Wofler published his method of transplantation of 
 the rectus in 1892 in the Beitrage z. Festschrift f. Th. Bill- 
 roth. I did not see this publication until my colleague, Dr. 
 Clark, returned from Germaiiy, in June, 1898. My prelimi- 
 nary report had then just been published. For this reason no 
 mention was made of Wofler's work. In the Archiv fiir klin- 
 ische Chirurgie, June, 1898, Dr. Slajmer publishes 150 opera- 
 tions after the Wofler method. A careful reading of these 
 two articles has convinced me that this method of transplan- 
 tation of the rectus differs from mine. In the first place no 
 special reasons are given for the transplanting of the rectus 
 muscle, while in my publication the reason given for the 
 transplantation of the rectus is to strengthen the lower por- 
 
 [214] tion of the inguinal canal by the introduction of muscle which 
 is weakened by the obliteration of the conjoined tendon. The 
 description of the Wofler method and the illustration on page 
 912 of the second article show that the rectus muscle is not 
 transplanted in the best way to strengthen the lower portion 
 of the wound, because the sheath of the rectus is not divided 
 down to the symphysis pubis ; but the division of the sheath 
 ends at least 2 to 3 cm. above the pubic bone. For this rea- 
 son the transplanted rectus muscle is approximated chiefly 
 over the upper two-thirds of the wound. In addition, Wofler 
 divides the sheath of the rectus on the anterior surface above 
 the linea semilunaris. In my method the sheath of the rectus 
 is divided posteriorly and the belly of the muscle is brought 
 out behind the internal oblique. I believe that by this method 
 the muscle can better be transplanted so as to occupy the 
 lower two-thirds of the wound. Slajmer reports 6 recur- 
 rences, about 6 per cent. In three of these cases the wound 
 suppurated." 
 
 (18) 
 
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