Radical Cure of Hernia. 
BY 
C. M. THOMAS, M.D., 
PROFESSOR OF OPERATIVE AND CLINICAL SURGERY IN THE 
HAHNEMANNIAN MEDICAL COLLEGE OF 
PHILADELPHIA. 
[R EPRINT PROM PROCEEDINGS OF AMERICAN INSTITUTE 
of Homoeopathy for 1880.] 
PHILADELPHIA. 
18 80. THE RADICAL CURE OF HERNIA. 
By Charles M. Thomas, M.D., Philadelphia, Pa. 
In practically considering the question of operation for radical 
cure of hernia, it might be well to bear in mind that in all 
cases, most or all of the following conditions will be found to be 
present: 
1. A weakness and enlargement of the so-called rings or 
canals through which the rupture passes. 
In inguinal and umbilical hernia especially, this enlargement 
is at times very great, even sufficient to allow the introduction of 
several fingers. It must be remembered, however, that this is 
not a real opening or breach from a mechanical lesion, but a 
simple stretching or protrusion of a naturally weak spot in the 
abdominal walls, and is often found as a congenital defect. 
2. The formation of a covering or sac for the protruded vis- 
cera out of a stretched and displaced portion of the parietal peri- 
toneum. 
It is now conceded by most modern surgeons, that a hernia is 
very rarely caused by a sudden or violent straining or pressing 
of the abdominal contents through a simply weakened ring. On 
the contrary, it is more than probable that the defect is either 
congenital or of comparatively slow formation through a gradual 
local relaxation of the abdominal walls, and a correspondingly 
gradual stretching and pocketing of the peritoneum through the 
abdominal openings to form the hernial sac; the giving way of 
the rings being but a late manifestation of the lesion. Patients 
who suppose they have suddenly been ruptured are really de- 
ceived ; the rupture with its peritoneal covering has been form- 
ing for some time before, and only becomes apparent externally 
at the moment of some unusual exertion of the abdominal com- 
pressors, which forces the mass farther outward. 2 
THE RADICAL CURE OF HERNIA. 
3. An abnormal lengthening and, at times, hypertrophy of 
the protruded viscera, and an elongation of their mesenteric at- 
tachment or support, by which a constant tendency to recurrence 
of the protrusion is favored, even after the most careful reposi- 
tion. 
4. In large hernise, which have for a long time remained un- 
reduced, such a lessening in the capacity of the abdominal cavity 
that the herniated portions can with difficulty be accommodated. 
This condition I found very pronounced in operating on a 
large scrotal hernia which had been unreduced for many months; 
and a second time in a case of large congenital umbilical hernia, 
the child being but a few days old. Here, after having divided 
the strangulating bands, although there was no obstacle at the 
opening to the return of the intestine, the greatest difficulty was 
experienced in finding room for it within the abdomen. 
With these facts before us, it would seem that an open or weak 
ring, plays by no means, the most important part in the formation 
and continuance of a rupture. If, therefore, it be admitted that 
a rupture depends for a cause upon something more than a sud- 
den forcing of viscera through a weakened portion of the ab- 
dominal walls, it is fair to conclude that, in order to accomplish 
a thoroughly permanent cure, it must be necessary to remedy 
all of these organic changes just mentioned, and yet since with 
our present knowledge we are able to cope with none but the 
first (enlarged rings, etc.), it remains a question whether the 
operations commonly known as radical, really deserve the name, 
inasmuch as they neither affect the tendency to sac formation nor 
shorten the lengthened mesentery, etc., and only aim at overcom- 
ing the lesser—perhaps secondary—causes of the ruptures, viz., 
the enlarged abdominal canals or rings through the building up 
of mechanical external barriers of greater or less strength at 
these points. Under such circumstances it can hardly be a mat- 
ter of much surprise that these operations have not met with 
more success. 
In spite, however, of the almost insurmountable difficulties in 
the way of obtaining a really radical cure, cases will constantly 
arise in which an operation for the closure or narrowing of the 
hernial openings may be called for, and the only question then THE RADICAL CURE OF HERNIA. 
3 
is, to what length we may go in our admission of cases to this 
class. At the present time most surgeons agree that a radical 
operation can only be recommended when the rupture is very 
annoying, and either not reducible, or, if reducible, cannot be 
held by a truss; or finally, when the hernia, in spite of every 
care, tends to increase rapidly in size. 
It is for the future to decide whether these indications may or 
may not be increased through the employment of more effective 
methods than we now possess. 
The various ways in which cures have been attempted may be 
considered as follows: 
Posture—Natural Cures.—A very necessary factor in any 
radical cure is, that the abdominal contents shall not at any time 
enter the canals, and so long as the horizontal position and quiet 
is preserved, there is but little liability of this occurring. 
Cases have been reported where patients, obliged on account 
of other illness to lie quiet for a long period have, upon their 
recovery, found their ruptures entirely cured. 
Pressure.—In young people, and when the hernial passages 
are not large, a cure can occasionally be accomplished through 
the application of carefully adjusted pressure over the ring 
and sac by means of the hernia truss. The action of the truss 
upon the ring, is not to bring its edges together, but simply to 
prevent any prolapse of the viscera, for if the protrusion is but 
once allowed to occur, the treatment is entirely thwarted, and 
must be again started from the very beginning. Hence the ne- 
cessity, where a radical cure is expected, of insisting upon the 
wearing of the truss both by night and day. 
The further action of the truss is upon the sac, particularly 
at its neck, where, by the constant and firm pressure of its serous 
surfaces against each other, an adhesive inflammation is finally 
set up sufficient to cause closure of its cavity. 
In order that the pressure be effective, it is of course necessary 
that the truss pad be made of some hard though polished material, 
such as wood, ivory, or hard rubber, and that it be sufficiently 
large to overlap the edges of the hernial ring, for if it is smaller, 
the integuments will be pushed into the open ring, and, acting 4 
THE RADICAL CURE OF HERNIA. 
as a wedge, will tend rather to enlarge than contract the open- 
ing. 
With children under ten years, in whom the prospects of cure 
are far surer than at any other age, the truss should be worn for 
at least two years uninterruptedly, and for a third year leaving 
it off only at night or when lying. In adults a cure will some- 
times take place in this way, but only when the truss is worn 
continuously for many years, and when the rupture has been 
small. After the removal of the truss, when a cure has ap- 
parently taken place, the greatest precaution should be taken 
against abdominal straining or sudden exertions. 
Operations.—The object of all the more purely operative 
methods has been in a general way to obliterate by inflamma- 
tory action the hernial passages from the rings outward. Some, 
particularly the earlier operations, were directed mainly toward 
the obliteration of the hernial sac and the closure of its neck, 
while in the more modern procedures, the aim has been to include 
the hernial ring in the operation. 
The earliest accounts of the radical operation for hernia are 
found in the writings of Celsus, who advised that the tissues 
overlying the hernia be carefully cut through until the hernial 
sac was exposed, when, the ring being enlarged, the viscera were 
replaced and the wound allowed to heal by granulation. This 
would seem to have been simply our present operation for stran- 
gulation without opening the sac, as no mention is made of any 
interference with this, his object evidently being to produce a 
dense cicatrix, which was to act as a barrier to the recurrence of 
the prolapse. In others of his writings, however, he mentions 
the cutting into and removal of a portion of the sac, and at 
times overlying integuments, for the purpose of producing a 
cicatricial shortening of the soft parts. 
Heliodorus, in the time of Trajan, advised and practiced the 
extirpation of the sac at as high a point as possible. 
Leonides, of Alexandria, in the beginning of the third cen- 
tury, believed that the formation of a tough scar through the 
application of the hot iron was the most favorable operation. 
In the early part of the seventh century, Paul of iEgina, after 
laying bare the sac of a scrotal hernia, transfixed it near the neck THE RADICAL CURE OF HERNIA. 
5 
with a double ligature and tied it tightly in halves. The sac 
below the ligature was then cut through and removed, together 
with the testicle. In other cases the sac was invaginated by means 
of a probe, and stitched fast inside the inguinal ring, there to 
act as a sort of plug. This idea was again revived in the opera- 
tions of Gerdy, Wiirtzer, and others in more recent times. 
Following the teachings of Paul of iEgina, the method of cas- 
tration was practiced by numbers of irresponsible travelling oper- 
ators (so-called rupture cutters) from those early times, up to 
within less than a hundred years ago,and singular as it may seem, 
not only did large numbers of the victims survive this barbarous 
operation, but many were permanently cured. 
In one diocese in Germany there were found five hundred 
children and two hundred adults castrated. 
In the early part of the eighteenth century, Freytag, of Zurich, 
dissected down upon the sac, returned its contents, and tied the 
neck as high as possible. The ligature ends were brought out 
through the wound, and left till they came away by suppuration. 
Although this operation was said to be quite successful, and was 
practiced by a number of surgeons of that time, it soon fell into 
disuse, and was for some time replaced by crude endeavors to 
block the passages with an eschar formed by caustics or the hot 
iron. 
Petit condemned such operations, and advised that the sac, 
after having been freed of all adhesions, should be pushed 
through the hernial ring, as high in the abdomen as possible, the 
wound being left to heal by granulation. As, however, his 
results were not satisfactory, he finally discouraged even this, and 
advised his patients to be satisfied with a well-fitted truss. 
Ligation of the neck of the sac, as practiced at intervals from 
the seventh to the fifteenth century, was really tantamount to 
the castration operation of Paul of iEgina, inasmuch as the sperm- 
atic cord was included by the ligature. It was not until the six- 
teenth century that Ambrose Pare performed ligation without 
injury to the cord. Rousset, Petit, Abernethy, Langenbeck, and 
others, followed him in practicing the same operation until the 
early part of this century. The plan consisted in thoroughly 
freeing the neck of the sac, and after the reposition of its con- 6 
THE RADICAL CURE OF HERNIA. 
tents, tightly ligating it as high as possible. The sac below the 
ligature was then cut through, and the ligated stump replaced 
within the canal. 
About this same period Le Blanc, Sharp, and others, laid open 
the parts and stitched together the edges of the ring or canal, 
leaving the sutures till suppuration had set in. This operation 
has been in late years repeated, with slight modifications, in this 
country, by James Wood and S. D. Gross, with tolerable success. 
For more than a century past, attempts have been made by 
various operators, to obliterate the hernial sac by cutting into it, 
and introducing foreign bodies for the purpose of exciting profuse 
suppurative inflammation, but they have been found very unsat- 
isfactory. 
Thus Bonnet, in the early part of this century, passed needles 
through the sac in such a manner, that by means of corks, with 
which they were provided, a constantly increasing pressure could 
be made upon its walls. Later Belmas introduced pieces of 
dried gelatin, with a needle constructed for the purpose, and left 
them there, in the hope of causing sufficient inflammatory action 
to close the sac. 
Maesner passed threads through the neck of the sac and allowed 
them to remain for two or three weeks, and although he claimed 
this to be a radical operation, he nevertheless did not allow the 
patients so operated on to go about without a truss. The unusual 
number of fatal cases following this method, soon brought it into 
disrepute. 
Up to the present century, most of the operations, as has been 
shown, consisted in laying bare the sac by a dissection ; but since 
that time the subcutaneous methods have taken the preference, 
and instead of exciting suppurative action in the tissues, the set- 
ting up of a simple adhesive inflammation was attempted. 
Velpeau was the first to employ subcutaneous injection of irri- 
tants into the sac, the idea suggesting itself to him from the 
success he had obtained by this means in the radical cure of hy- 
drocele. The operation was done with a small trocar and canula, 
the latter having openings in the side. 
Guerin and others sought a similar result in subcutaneous 7 
THE RADICAL CURE OF HERNIA. 
scarification of the sac, and although the risks were slight, but 
few cases of cure were reported. 
The recurrence of the hernia after this and similar operations 
was so constant as to oblige surgeons to turn their attention to 
other methods offering surer results. As experience had already 
taught that the organic plugging of the canal with the inverted 
hernial sac, as practiced by Petit and others, was not only ineffect- 
ual, but, as it required the dissection of the overlying parts, was a 
more or less dangerous operation, the idea of invaginating all 
the soft parts for the plug, was suggested by Gerdy, and in 1835 
carried into effect by him. He describes the operation about as 
follows, it being of course applicable to inguinal hernia only. 
The viscera being carefully replaced, the scrotal tissues are caught 
upon the point of the index finger of the left hand and pushed as 
high as possible through the inguinal ring ; then a threaded fixed 
needle, with an eye in the point, is slipped along the finger until 
the point reaches the top of the invaginated tissues, when it is 
thrust through all the overlying parts and made to appear on 
the abdominal surface, and one end of the ligature is drawn 
out. The needle, without unthreading, is then drawn back till 
the point is again on the scrotal side, when, at a short distance 
from the first puncture, it is a second time thrust through to the 
abdominal surface. The other ligature end is then unthreaded 
and the needle withdrawn entirely. The ends of the loop so 
formed are then tightly fastened, while the inverted scrotum is 
thoroughly pushed up with the finger or a sound. A caustic 
application is now applied to the contiguous inverted scrotal 
integument, the object being to cause union of the raw surfaces, 
and so secure for the inguinal canal a firm organic plug. 
The original method of Gerdy has since been much 
both by himself and others, but the principle of invagination 
remains the same in all. In 1838 Wurtzer, of Bonn, Germany, 
considering that the simple adhesion of the invaginated scrotum 
to the neck of the sac was insufficient to hold the scrotum in place, 
endeavored to accomplish a complete obliteration of the invagi- 
nated* anterior wall of the sac. For this purpose he had con- 
structed a so-called invaginatorium, consisting of two plates, one 
of which being passed into the inguinal canal, instead of the 8 
THE RADICAL CURE OF HERNIA. 
finger, is held in place by a long needle passed through it and 
the abdominal walls into the second plate, which is made so to 
articulate with the first that it lies immediately over it upon the 
abdomen, and by means of a screw the soft parts held between 
the plates are gently compressed until the included sac-wall is 
obliterated. 
Max Langenbeck and Valette went still further than Wurtzer, 
and by means of a greater pressure of modified plates and the 
use of active caustics, produced an actual gangrene of the parts 
lying between them. 
Other operations of a similar character have, from time to time, 
been introduced, as, for instance, that of Wood, of London, and 
Agnew, of Philadelphia; but they are all only greater or less 
modifications of Gerdy’s method, and have been attended by but 
little, if any better result. We have no knowledge of the number 
of cases cured by Gerdy, but it is well known that there were four 
fatal cases out of sixty-two treated by him ; a mortality sufficient 
to cast it out from a place among recognized surgical procedures. 
Owing to the discouraging results of these late attempts, the 
radical operation for a number of years fell into marked disfavor 
with the majority of surgeons, and no new method was offered 
to the profession until 1876, when Dr. Dowel, of Texas, brought 
forward his plan of eircumclusion of the boundaries of the ingui- 
nal canal. After making sure that the hernia has been entirely 
reduced, he passes the index finger into the inguinal canal, car- 
rying ahead of it the tissues of the scrotum. The only instru- 
ment used is a semicircular needle, about three inches long, 
sharpened and eyed at either end, and carrying a heavy silk 
thread. This needle is entered about an inch and a half above 
the external ring, and passed behind the invaginating index finger 
across the canal, and brought out on the opposite side, near Pou- 
part’s ligament. Before the second point of the needle has left 
the tissues it is a again made to cross the canal backwards, as it 
were, but this time in front of the finger, and reappears at the 
first opening or point of entrance. The needle is then unthreaded 
and withdrawn, leaving the ligature loop entirely encircling the 
canal, and the cord hanging from a common opening. A silver 
wire is nowT fastened to the silk thread, and as the latter is with- THE RADICAL CURE OF HERNIA. 
9 
drawn the wire naturally follows and takes its place. After a 
number of such stitches have been introduced, they are each 
firmly tightened over a compress of lint. They are all removed 
on the eighth day, and the patient allowed to go about on the 
twelfth. I)r. Dowel reports a large per cent, of cures in this 
way, but a longer period of observation will be required before 
a correct judgment can be formed as to the value of this method. 
From the time of Velpeau to the present decade, the method 
by subcutaneous injection of an irritant or astringent fluid had 
been entirely without advocates, but a few years since, Schwalbe, 
of Germany, and Heaton, of Boston, revived the practice. 
The former injected into the ring and tissues about it, a small 
quantity of alcohol, at intervals of five to nine days, and claimed 
for the limited number of cases treated a uniformly good result. 
The Ileatonian method consists in the hypodermic application 
to the ring and contiguous tissues, of a few drops of the fluid ex- 
tract of Quercus alba, or white-oak bark. The operation was 
given to the profession by Dr. Warren, who was an assistant of 
Dr. Heaton. The latter, it is said, practiced this operation for a 
long time as a secret method. 
The instrument used by Dr. Heaton is the ordinary hypo- 
dermic syringe, the needle of which is provided with orifices on 
the sides, for the purpose of making a lateral distribution of the 
liquid. 
The instrument has been variously modified by Drs. Warren, 
of Boston, Janney, of Philadelphia, and Dr. Garmo, of New 
York. 
In performing the operation, the hernia must first be entirely 
reduced. A finger being then introduced into the inguinal ring, 
to act as a guide to the point of the syringe-needle, the latter is 
thrust into the abdominal walls until it lies in close relationship 
to the ring and canal, when by slowly screwing the piston home, 
about 10 minims of the extract is deposited in the tissues. A 
firm compress is now carefully bound over the parts, and the 
patient put to bed for a fortnight. 
Those who have practiced this procedure claim very good suc- 
cess from it. 
* The injection fluid is prepared as follows : Evaporate the fluid 10 
THE RADICAL CURE OF HERNIA. 
extract of white-oak bark to the consistency of glycerin. To this 
add an equal quantity of absolute alcohol, and to a half ounce 
of this mixture, add a half drachm of Sulphuric ether and two 
grains of Morphia sulphate. 
A new epoch appears to have been opened for the radical cure 
of hernia, by the general introduction of Lister’s antiseptic treat- 
ment, especially in England and Germany. The brilliant results 
attending its application to almost every department of surgery, 
has induced operators, particularly in the above-mentioned 
countries, to attempt to utilize it for the purpose of more safely 
reintroducing the old operation of Celsus and Heliodorus, which 
had been discarded more on account of the danger attending 
them, than because of doubt as to the correctness of the principles 
underlying them. 
To Steele, of England, belongs the credit of having first ap- 
plied the Lister method to this operation. In an article, pub- 
lished in 1874, in the British Medical Journal, he gives the 
details of an operation upon an eight-year-old boy, with a large 
congenital inguinal rupture, in which he freshened the columns 
of the ring, and drew them together with two catgut sutures 
without disturbing the sac. Recurrence took place six months 
after, when the operation was repeated. A year later there was 
no sign of return; the patient had, however, worn a truss since 
the last operation. 
Since Steele’s case, most of the reports of the Lister method 
have been from Germany. The operation has generally consisted 
in cutting down upon the sac, and where it can be emptied with 
certainty, it is ligated tightly at the neck with the catgut liga- 
ture or carbolized silk. The edges of the ring are then brought 
together with continuous or interrupted stitches, proper drainage 
is provided, and the wound of the integuments closed. The 
strictest antiseptic precautions are observed throughout, and the 
carbolized spray kept playing on the parts till the dressings are 
applied. In a number of cases the sac has been removed below 
the ligature at its neck, especially when it was found necessary 
to open it for the purpose of replacing its contents within the 
abdominal cavity. The time occupied in healing has varied from 
two weeks to two months ; the average being about twenty-eight THE RADICAL CURE OF HERNIA. 
11 
days. In many cases union took place without febrile reaction 
or other unfavorable symptoms, but in a few it has been compli- 
cated with abscess, sloughing of integuments, etc. 
Out of about seventy cases reported since 1876, by Annandale, 
Nussbaum, Czerny, Socin, and others, there have been but one 
death and six recurrences. Many of these operations, however, 
have been done so recently, as to render it impossible to judge as 
to the true proportion of recurrences. 
Within the past two years I have operated on three cases,—two 
of inguinal and one of femoral,—in this manner. In but one 
(inguinal) was the carbolized spray used. In each the sac was 
opened in order to replace viscera, and tied at the neck, but not 
removed. From three to five interrupted sutures were applied 
to the edges of the ring in each. Catgut ligatures were used in 
two cases; in the other carbolized silk. The temperature rose 
from two to three degrees in each, and suppuration took place in 
all. All recovered in three, six, and seven weeks respectively. 
My first case (inguinal) was done nearly two years ago, and re- 
currence took place five months later, but was easily held by a 
truss, which could not be done before the operation. The second 
and third have remained sound for five and seven months respec- 
tively, and without a truss. 
The following conclusions may be arrived at after a careful 
study of the cases operated by this method, up to the spring of 
1879: 
1. In strangulated hernia, both femoral and inguinal, after re- 
lieving the stricture and returning the bowel, the hernial sac 
should be ligated as high as possible, cut through below the liga- 
ture and removed entirely. As an additional precaution, the 
edges of the ring may be brought together with interrupted su- 
tures. Every antiseptic precaution must be observed. 
2. In irreducible hernia, and in the reducible variety when a 
truss will not properly hold it back, this operation for radical 
cure may be performed with but little risk to the life of the 
patient. 
3. In inguinal hernia, atruss should be worn as a precautionary 
measure after the operation, except perhaps in young individuals. 
In femoral cases this will seldom be required even in adults.