THE OPERATIVE TREATMENT 
OF 
HERNIA IN CHILDREN 
WITH A REPORT OF FIFTY-ONE CASES 
BY 
WILLIAM B. COLEY, M.D. 
ASSISTANT SURGEON TO HERNIA DEPARTMENT OF THE HOSPITAL FOR RUP- 
TURED AND CRIPPLED ; SURGEON TO THE NEW YORK CANCER HOSPITAL 
Reprinted from the Medical Record, July 1, 1893 
NEW YORK 
TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
1893 THE OPERATIVE TREATMENT 
OF 
HERNIA IN CHILDREN, 
WITH A REPORT OF FIFTY-ONE CASES. 
/ 
By WILLIAM B. COLEY, M.D., 
ASSISTANT SURGEON TO HERNIA DEPARTMENT OF THE HOSPITAL FOR RUPT- 
URED AND CRIPPLED ; SURGEON TO THE NEW YORK CANCER HOSPITAL. 
Reprinted from, the Medical Record, July i, 1893. 
During the past two years 2,174 new cases of hernia, oc- 
curring in children under the age of fourteen years, were 
treated at the Hospital for Ruptured and Crippled. In 
addition to these cases, a much larger number, recorded in 
preceding years, yet returning for further observation and 
treatment, were seen. As the great majority of these 
cases were treated by mechanical means, and hence have 
but an indirect bearing upon the subject of this paper, 
they will be referred to only in the briefest way. 
In looking back over the various operations devised 
for the cure of hernia during the last decade, we are 
struck with two main facts which go far toward ex- 
plaining the present attitude of many of the profession in 
regard to operative procedures. This attitude may be 
characterized as one of doubt, or at least of very limited 
faith, and the two facts that hive been referred to as ex- 
plaining it are, first, the too indiscriminate application of 
imperfect methods; second, the tendency to expect uni- 
formly perfect and lasting results, and falling short of these, 
to consider all such operations failures. There is really no 
reason why the operation for the cure or relief of hernia 
should be judged by a standard entirely different from 
that adopted in deciding the merits or defects of other 
operations. Few, if any, are so successful that failures do 
not sometimes occur, and it seems to me that operations 
for the cure of hernia should stand or fall according as 
they fulfil these two conditions of all operations (except 
emergency) : First, a mortality either nil, or not greater 
than that associated with the condition prior to operation. 
Second, a reasonable hope of success, either in the shape 
of cure or of relief. Furthermore, there is a tendency to 
estimate the value of the operation from the results of 2 
the older and less perfect methods, without recognizing 
the great advances made during the past four years. 
Time will not permit me to review or criticise the 
various methods that have been, and still are, employed to 
cure hernia by operation, and even if it did, the object ol 
this paper would be better accomplished by confining 
myself chiefly to personal and clinical observations. 
I shall assume that the majority of physicians and sur- 
geons admit, under certain conditions, the advisability of 
operating upon hernia in adults, however they may differ 
as to the extent and limitations of such conditions. 
The question of applying the same operative procedures 
to children cannot be disposed of so easily, for the reason 
that up to very recently we have had insufficient data for 
the drawing of any conclusions of value. 
Indications and Contra-indications for Operation.— 
The indications for operation may be classed as follows: 
1. Cases of adherent omentum. 
2. Cases complicated with reducible hydrocele. 
3. Cases irreducible and strangulated. 
4. Cases unable to obtain the care and attention req- 
uisite for successful mechanical treatment. 
5. Cases where mechanical treatment has been faith- 
fully tried for a number of years without benefit. 
These five classes seem to me to embrace all hernia in 
children to which operative measures should be extended. 
It now remains to look at these indications more closely, 
and then we shall examine the contra-indications in the 
light of clinical experience, in order that we may judge 
how far they obtain. 
Adherent Omentum—This condition, though much less 
frequent in children, is occasionally met with, and when 
present interferes materially with mechanical treatment. 
Reducible Hydrocele Associated with Hernia.—This is 
not a very rare complication, and after repeated and per- 
sistent attempts to treat such cases by means of a truss, I 
am convinced that operation is the only proper method 
of treatment. 
Irreducible and Strangulated Hernia.—In strangulated 
hernia nearly all will admit the advisability of operation, 
after taxis, under anaesthesia, has failed to give relief. 
The operation, if done early, is not dangerous, while the 
delay necessary to the carrying out of any other method of 
treatment is not infrequently responsible for the fatal results. 
Among the poorer classes seen at a dispensary clinic 
there are a number of cases without parents or anyone 
sufficiently interested or intelligent to give the necessary 
attention to a truss; and these cases I believe to be proper 
subjects for operation, mechanical treatment having been 
thoroughly tried. 3 
The supposed contra-indications are: 1. The general 
belief that all cases of hernia in children can be cured 
without operation, a belief that is not supported by facts, 
as shown by a careful analysis of 600 cases under the age of 
ten years treated at the Hospital for Ruptured and Crip- 
pled. 2. The belief that strangulated hernia almost never 
occurs in children, and hence the condition is not danger- 
ous. Strangulation, though infrequent, does occur, four 
cases having been seen at the hospital during the past 
year. The third and chief objection is that operation is 
attended with greater risk in children, and that the final 
results are less satisfactory. 
Karewski, of Berlin, has recently collected and tabu- 
lated 81 cases of operation for hernia in children under 
five years of age. Of these, 74 were reducible and 7 
strangulated. There were 5 deaths, of which 4 occurred 
in strangulated cases, and the fifth was the result of shock 
from prolonged operation, in a child two years of age. 
The mortality, then, in the 74 non strangulated cases was 
1.3 per cent. 
As to wound healing and final results, we find that 
39 cases were well and free from relapse one year and 
longer after operation, while 7 relapses were noted. 
Suppuration occurred in thirty-three per cent, of the cases; 
yet when we consider the number of different operators 
represented, together with the fact that the operations 
date back for a period of ten years or more, the wound- 
healing is seen to be quite as good as in adult cases un- 
der similar conditions. In fact, the results are better than 
those obtained in Billroth’s Klinik—136 cases, reported 
by Haidenhain 1 in 1890—in which suppuration occurred 
in fifty per cent, and relapse in thirty per cent. To 
these 81 cases collected by Karewski I have added 169 
new cases where operation has been performed under 
the age of fourteen, making a total of 250. 
Of these 250 cases— 
Cases. 
Relapses. 
Deaths. 
Bassini operated upon. .. 
36 
I 
O 
Poor (of New York) .... 
24 
I 
O 
Bayer 
O 
O 
Manley 
7 
I 
O 
Karewski (own cases) 
Karewski (collected cases 
9 
exclusive of 
0 
O 
Bassini’s) 
5° 
6 
I 
Championniere 
18 
0 
O 
Halstead 
2 
O 
Bull, W. T 
21 
8 
I 
Coley 
46 
2 
O 
— 
— 
— 
250 
21 
2 
1 Archiv. f. klin. Chirug., 1890. 4 
Thus we find in 250 non-strangulated cases but two deaths, 
or a mortality of T8ft of one per cent., or less than the 
lowest mortality ol any adult statistics. But nineteen re- 
lapses, or 8.6 per cent., were observed. The two deaths 
that occurred were both in cases under two years of age, 
and both were irreducible and complicated with exten- 
sive adhesions, necessitating a prolonged operation. 
Personal Observations.—During the past fifteen 
months at the Hospital for Ruptured and Crippled I 
have operated upon 46 cases of hernia in children, 42 of 
which were non-strangulated and between the ages of four 
and fourteen years. The 4 strangulated cases were aged 
eight weeks, eight months, seven and one-half months and 
one year, respectively. There has been no mortality in 
the non strangulated cases although many were difficult 
and complicated, and but a single death in the strangu- 
lated cases, that of a baby, eight weeks old. The hernia 
was of the caecal variety, and there had been acute strangu- 
lation with constant vomiting for upward of twelve hours, 
and the infant was practically in collapse when first seen. 
It revived after the operation and lived three days. 
Wound Healing.—Absolute primary union occurred in 
44 of the 46 cases, and the suppuration in the 2 remain- 
ing was due to the use of silk instead of animal suture. 
Nearly all of the cases were up and about the wards at 
the end of two and a half weeks. The eight months’ 
baby that was operated upon for strangulation left the 
hospital at the end of one week, union by first intention 
having occurred. 
Method of Operation.—The Czerny Risel method was 
employed in a few of the earlier cases, but the great ma- 
jority, thirty-two in number, were operated upon by the 
Bassini method, kangaroo tendon being used for the 
buried sutures. This method has given by far the most 
satisfactory results, and when once familiar with its tech- 
nique it is not difficult to perform. 
Upon the choice of suture material, next to the choice 
of method, depends, I believe, the success or failure of 
the operation. Silk is regarded by many as the best kind 
of suture, but the majority of surgeons, in spite of every 
precaution, have been unable to bury it in the hernial 
canal without causing subsequent trouble. In Billroth’s 
T36 cases (Czerny method) silk was used instead of cat- 
gut, and in 77 cases followed up 38, or fifty per cent., 
suppurated. It was repeatedly tried at the New York 
Hospital with the same results, and in the only 2 cases 
of suppuration which occurred in my 46 cases, the result 
was due to the silk suture. I do not deny that it can be 
used without producing sinuses and interfering with pri- 
mary wound-healing in some cases, but I believe that the 4 
Diagnosis. 
Sex 
• Age. 
Nature of hernia, anc 
history. 
Dura- 
tion. 
Truss 
Date of opera 
' tion. 
Operation. 
Operator. 
Results. 
1 Incarcerated omenta 
1 M. 
8 yrs. 
Right inguinal; size 
Congen 
Yes. 
Dec. 12, 1891 
Czerny operation. Hydrocel 
e W. B. Coley. 
Primary union, 3 weeks ; 
with effusion. 
esg- 
ital. 
I of cord in addition to her 
no recurrence, 6 
| niai sac ; small bit of incar 
cerated omentum ; no drain 
months. 
Large oblique ingui 
M. 
13 yrs. 
Size, orange ; right; no 
3 years 
Yes. 
Dec. 28, 1891 
age. 
Bassini operation. Silk sut 
J 
Suppuration; silk liga- 
k] nal hernia ; redu 
held by truss. 
ure ; no drainage. 
ture came away, 5 
j cible. 
weeks ; recurrence, 5 
weeks. 
Reducible; inguina 
M. 
6 yrs. 
jEgg ; portion not re 
- 2 years 
Yes. 
Jan., 1892... 
Czerny. Hydrocele of core 
“ 
Primary union ; no re- 
1 oblique. 
| ducible. 
| sac found alongside of trut 
hernial sac : no drainage. 
lapse, 1 year. 
Reducible ; inguina 
M. 
8 yrs. 
Small egg; not helc 
Congen- 
Yes. 
Jan., 1892... 
Czerny. Hydrocele of core 
W. T. Bull. 
Slight suppuration; no 
j oblique. 
Inguinal ; reducible 
with truss ; left. 
ital. 
J sac with true hernial sac 
[ drainage. 
recurrence, i year. 
i 
M. 
9 ys. 
j Small egg; not held 
i 4 years 
Yes. 
Jan., 1892 
Czerny. No drainage; sill 
W. B. Coley. 
Primarv union ; sinus 
oblique. 
right. 
sutures. 
soon formed, and silk 
sutures ; came away, 
3 months; truss could 
not be worn, and slight 
recurrence. 3 months ; 
Tnguinal; reducible 
[ oblique. 
Bassini’s operation ; 
well, r year later. 
6 
M. 
13 yrs. 
11 yrs. 
pro ba- 
Yes. 
Jan., 1892 
Czerny. No drainage ; chro 
micized catgut for canal 
Primary union ; no re- 
currence, 1 year. 
bly con- 
! old congenital sac and new 
genital. 
acquired sac found. 
7 
Inguinal ; reducible 
M. 
10 yrs. 
Small egg ; left: not 
Congen- 
Yes. 
Feb., 1892.... 
Czerny. Small sac of old hy- 
“ 
Primary union; no re- 
] oblique. 
held. 
ital. 
drocele of cord ; chromic 
, acid catgut ; no drainage. 
lapse, 1 year. 
8 
Irreducible; adhe- 
M. 
7 yrs. 
j Small egg; not held... 
3 years. 
Yes. 
March, 1892.. 
Bassini. Large mass of ad- 
Primary union ; sound, 
rent omental. 
April, 1892... 
herent omentum removed 
chromicized catgut; no 
drainage. 
i year. 
1 Very large double 
M. 
iX yrs. 
I.eft, orange ; right, 
4 years. 
Yes. 
Czerny. Both sides ; one op- 
“ 
Primary union; sound, 
-< inguinal ; redu- 
egg; not held. 
eration ; no drainage; 
11 months. 
1U 
f cible. 
chromicized catgut. 
ii 
j Left inguinal , 
M. 
7 yrs. 
Inguinal; cured by 
3 years. 
Yes. 
April, 1892.. . 
Bassini. Operation for ingui- 
Primary union, both 
12 
\ right femoral. 
truss; recurred; 
nal; purse-string suture to 
sides, 3X weeks; 
egg; femoral; 6 mos.; 
crural canal in femoral; 
sound, 1 month. 
not held ; almond. 
kangaroo tendon suture.* 
I3 
Large inguinal; re- 
M. 
13 vrs. 
Wore truss several 
11 years. 
Yes. 
Mav s, 1802.. 
Bassini operation. Very large 
W. B. Coley. 
Primary union ; sound, 
ducible; oblique. 
years; not held; 
goose egg. 
sac, admitting two fingers 
small bit of adherent omen- 
10 months. 
turn at neck of sac ; kanga- 
'4 
Large inguinal; irre- 
M. 
iX yrs. 
Right; small egg 
Several 
No. 
June 6, 1892.. 
Bassini operation. Kangaroo 
“ 
Primary union ; sound, 
ducible ; adherent 
years. 
tendon ; sac adherent 10 
i year. 
omental. 
testis ; tunica vaginalis 
opened; sutured with cat- 
gut; sac removed ; omen- 
tum excised. 
x5 
Inguinal ; reducible. 
M. 
4% yrs. 
Truss ; not effective.. . 
2 years. 
Yes. 
Tune 14. i8q2. 
Bassini operation. Kangaroo 
u 
Primary union ; well, 
Yes. 
tendon. 
1 year. 
16 
Right inguinal ; re 
M. 
4 yrs. 
Truss; painful 
3 mos. 
June 21, 1892. 
Bassini. Tendon suture 
Primary union; per- 
lapsed case (No. 5 
fectly firm 1 year af- 
of Czerny opera- 
tion). 
Congen- 
Yes. 
ter. 
17 
Right inguinal; 
M. 
8 mos. 
Strangulated 
July 8, 1892.. 
Czerny. Catgut suture 
“ 
Primary union ; well 9 
strangulated. 
ital. 
Yes. 
months after. 
18 
Right inguinal 
M. 
July, 1892.... 
Bassini. Kangaroo tendon.. 
Charles W. Wil- 
Primary union ; sound, 
9 months. 
Congen- 
Yes. 
son, House 
Surgeon. 
19 
Left inguinal 
M. 
14 yrs. 
Goose egg 
July, 26, 1802. 
Bassini. Kangaroo tendon ; 
W. B. Coley. 
Primary union ; sound, 
ital 
Congen- 
portion of sac left and sut- 
ured over testis. 
9 months. 
20 
Right inguinal 
M. 
10 yrs. 
Reducible ; size, fist... 
Yes. 
Tulv. 26, 1802. 
Bassini. Complicated with 
44 
Primary union ; sound, 
ital. 
reducible hydrocele ; h a 1 f 
pint fluid withdrawn from 
9 months. 
sac and abdomen. 
21 
Left oblique 
M. 
14 yrs. 
Reducible; egg 
iX year. 
Yes. 
Aug. 23,1892. 
Bassini. Kangaroo tendon.. 
Primary union ; sound, 
7 months. 
Primary union; sound, 
22 
Left oblique 
M. 
12 yrs. 
Reducible 
6 years. 
Congen- 
Yes. 
Yes. 
Aug., 1892... 
Bassini. Kangaroo tendon.. 
* 
7 months. 
Primary union; sound, 
23 
Large csecal 
M. 
4 yrs. 
Reducible ; uncontrol- 
Sept. 13, 1802. 
Sac sutured and deep kanga- 
44 
lable. 
ital. 
Yes. 
roo tendon suture to canal 
as in Bassini; cord not 
changed. 
6 months. 
24 
M. 
11 yrs. 
Sept., 1892.. . 
Primary union; sound, 
6 months. 
Congen- 
ital. 
25 
M. 
6 yrs. 
Reducible ; hydrocele; 
complicated. 
Oct., 1892.... 
Bassini. Kangaroo tendon.. 
Primary union ; sound, 
5 months. 
Primary union ; well, 4 
Yes. i 
26 
Right oblique ingui- 
M. 
14 yrs. 
Egg; congenital; cured 
Congen- 
Oct. 29, 1892.. 
Bassini. Kangaroo tendon ; 
44 
nal 
by truss; relapsed 6 
months ago. 
ital. 
Congen- 
no drainage. 
months. 
27 
Left oblique inguinal. 
M. 
12 yrs. 
Orange; ring admitted 
Yes. 
Nov. 1, 1892.. 
Bassini. Suture of sac; kan- 
“ 
Primary union; sound, 
two fingers. 
ital. 
garoo tendon ; omentum 
very troublesome; no 
drainage. 
4 months. 
28 
Right oblique 
M. 
4 yrs. 
Small hen’s egg ; not 
Congen- 
Yes. 
Nov. 4, 1892.. 
Bassini. Kangaroo tendon ; 
“ 
Primary union; well, 4 
held by truss. 
ital. 
(Congen- 
1 
lower portion of sac sutured 
over teslis ; no drainage. 
months. 
29 
Right oblique 
M. 
11 yrs. 
Egg; not held by truss. 
Yes. 
Nov. 29, 1892. 
Bassini. Kangaroo tendon; 
“ 
Primary union; sound, 
Right caecal 
M. 
ital. 
Yes. 
Dec. 26, 1892. 
no drainage. 
4 months. 
3° 
4 yrs. 
Orange ; not controlled 
2 years; 
Bassini. Kangaroo tendon; 
“ 
Primary union; sound, 
with truss; compli- 
acquir- 
no drainage. 
3 months. 
cated ; spinal disease 
and incontinence of 
ed. 
Right oblique 
M. 
urine. 
Congen- 
31 
8 yrs. 
Complicated with un- 
Yes. 
Jan. 13, 1893. 
Bassini. Kangaroo tendon; 
“ 
Primary union ; sound, 
M. 
descended testis. 
ital. 
Several 
Yes. 
testis anchored in scrotum ; 
no drainage. 
3 months. 
32 
Right oblique 
6 yrs. 
Size of hen’s egg; com- 
plicated with reduci- 
Jan. 20, 1893. 
Bassini. Kangaroo tendon; 
Primary union; sound, 
years. 
no drainage. 
2 months. 
Left oblique 
M. 
ble hydrocele. 
Size of hen’s egg 
Yes. 
Jan. 24, 1893. 
33 
9 yrs. 
4 years. 
Bassini. Kangaroo tendon; 
4* 
Primary union ; sound, 
Left oblique 
M. 
Yes. 
no drainage. 
2 months. 
34 
14 yrs. 
Size of hen’s egg 
2 years. 
Jan. 27, 1893. 
Bassini. Kangaroo tendon ; 
“ 
Primary union ; sound, 
M. 
Yes. 
Feb., 1893 ... 
Feb. 24, 1893. 
no drainage. 
2 months. 
35 
7 yrs. 
2 years. 
Bassini. Kangaroo tendon ; 
no drainage. 
Primary union; sound, 
2 months. 
M. 
No. 
36 
Left oblique; stran- 
i year. 
Size of goose egg 
t ew 
Bassini. Kangaroo tendon ; 
“ 
Primary union ; left hos- 
gulated; 24 hours. 
months. 
no drainage ; temperature 
pital end of 1 week ; 
107° F. next day; cold 
sound at present, 
Right oblique with 
undescended testis. 
M. 
Congen- 
ital. 
Yes. 
Feb. 28, 1893. 
baths treatment ; recovery. 
June, 1893. 
37 
13 yrs. 
Bassini. Kangaroo tendon • 
no drainage. 
4 4 
Primary union ; sound, 
April, 1893. 
Primary union. 
M. 
Yes. 
March 3,1893. 
38 
Right oblique with 
undescended testis. 
15 yrs. 
Congen- 
Bassini. Kangaroo tendon ; 
no drainage ; testis and epi- 
44 
ital. 
Congen- 
ital. 
didymis separated ; testis 
anchored in scrotum; wire 
frame. 
39 
F. 
10 yrs. 
Yes; 
March 6,1893. 
Bassini’s operation as far as 
possible in female; kanga- 
44 
Primary union. 
IO 
M. 
Since 3 
years. 
March 24, ’93. 
roo tendon ; no drainage. 
♦0 
Right oblique, caecal. 
10 yrs. 
Size, goose egg 
Yes; 
Bassini. Kangaroo tendon; 
“ 
Primary union. 
months 
IO 
no drainage; appendix in 
M. 
old. 
Since a 
years. 
sac and firmly adherent; 
adhesions separated and 
sac sutured. 
41 
Right oblique; ingui- 
nal. 
5 yrs. 
Yes. 
March 31, ’93. 
Bassini. Kangaroo tendon.. 
44 
Primary union. 
few 
months 
old. 
42 
Right femoral; incar- 
F. 
14 yrs. 
English walnut 
3 years. 
No. 
April 4, 1893.. 
Purse string suture of canal, 
Primary union. 
cerated. 
M. 
Yes. 
kangaroo tendon. 
43 
1 Double inguinal... 
13 yrs. 
Egg; double recurrence 
2X yrs. 
April 11, 1893. Bassini. Both sides ; kanga- 
44 
Primary union. 
44 
i 
M. 
from Czerny opera- 
tion, 1890. 
roo tendon. 
45 
Right inguinal 
6 yrs. 
7% mos. 
Egg...... 
3 yrs. 
Yes. 
April 18, 1893. Rassini 
Primary union. . 
Primary union. 
46 
Caecal and appendix 
M. 
Egg 
Congen- 
Yes. 
May 18, 1893 ; 
Bassini. Appendix removed. 
44 
strangulated twen- 
ty four hours. 
M. 
ital. 
47 
ii yrs. 
4 yrs. 
Yes. 
May, 1893. 
Ligature sac ; purse - string 
suture of canal. Bassini. 
44 
Primary union. 
M. 
48 
4X yrs. 
8 weeks. 
Congen- 
ital. 
Congen- 
ital. 
June 16, 1893. 
June 16, 1892. 
Bassini. 
Child nearly moribund at 
time of operation ; peritoni- 
4* 
Primary union. 
Died on third day'. 
49 
Caecal and appendix 
strangulated 
M. 
No. 
Right inguinal 
M. 
Congen- 
ital. 
Yes. 
June 23, 1893 
tis already present. 
50 
9 yrs. 
Bassini. Kangaroo tendon.. 
44 
* The kangaroo tendon in all cases was obtained from Dr. H. O. Marcy, of Boston, to whom great credit is due for bringing to notice the merits of this suture material. 
Operations for Hernia in Children, by IV. B. Coley. 5 
danger is a real one, and that since we have other and 
better suture material, silk should be discarded in hernia 
operations. 
The kangaroo tendon, or the ox-peritoneum, fulfils all 
the requirements for a buried suture in the hernial oper- 
ation. They have no tendency to produce slow-healing 
sinuses, as is the case with silk, and to a less degree with 
silkworm-gut, and yet they remain unabsorbed for a 
period of three months or more, as shown by the recent 
experiments of Ballance and Edmunds,1 a period suffi- 
ciently long to insure a thorough agglutination of the parts. 
It has been claimed by the followers of Macewen and 
others that it is immaterial whether or not the suture is 
absorbed after ten days or two weeks, since sufficient 
union will have taken place at the end of that time. 
Clinical experience will not bear out this statement. 
Macewen’s own brilliant results cannot be taken as evi- 
dence, since he used not only catgut of a large size but 
chromicized in addition, so that it probably remained 
unabsorbed for one or two months. Directly bearing on 
this point may be cited the recent experiments of Busse3 
on the suture of tendons in animals. His experiments 
prove that union of tendons seldom if ever occurs within 
ten weeks. The successful closure of the inguinal canal 
depends chiefly upon the more or less firm union secured 
between Poupart’s ligament—a tendinous structure—on 
the one hand, and the tissues of the internal oblique 
muscle and conjoined tendon on the other. There is no 
evidence to show that such union occurs in the short 
space of ten days. On the contrary, there is much to 
prove that it does not. 
Three years ago, at the Hospital for Ruptured and 
Crippled, sixteen children were operated upon with cat- 
gut sutures; six recurred within the first year, most of 
them shortly after the operation. I cannot but think 
that buried kangaroo sutures secure better approximation 
of several layers, and therefore a more permanent closure 
than the so called “ crossed suture ” advocated by Dr. G. 
R. Fowler, that has to be withdrawn at the end of five 
or six weeks. Another advantage is that the period 
required for the healing of the wound is shortened from 
three to four weeks, an important consideration with 
most patients. 
Wound Treatment.—No drainage has been employed 
in any of my cases, and I believe it to be unnecessary. 
In addition to the regular antiseptic dressings of iodo- 
form and bichloride gauze, a plaster of Paris casing ex- 
tending from the umbilicus to the foot is applied, and to 
1 Ballance and Edmunds : Ligature of Arteries in Continuity, 1892. 
2 O. Busse : Deutsche Zeit. f. Chir., 1891-92, 31. 6 
this fact is undoubtedly due, in a large measure, the uni- 
form success in obtaining primary healing. The dress- 
ing is left undisturbed for eight days, at the end of which 
time the plaster is removed and only an ordinary muslin 
spica applied. 
As fine catgut is used in closing the skin portion of 
the wound, the dressing does not have to be changed 
earlier to remove the stitches. 
Final Results.—The cases have all been operated upon 
during the past eighteen months, it is therefore too early 
to estimate the number of permanent cures. All the 
cases have been kept under observation, and most of 
them recently seen Two relapses have occurred, one 
following a Czerny operation, the other a Bassini. Both 
failures were early cases, and due to faulty technique and 
the use of silk suture, which caused suppuration. 
Both occurred within three months after operation. A 
Bassini operation was performed upon the case of relapse 
from the Czerny method, and the patient was recently 
seen, perfectly sound, one year later. 
The Bassini method was adopted because no other 
method has given such brilliant and permanent results. 
own cases, 251 in number, all but 4 of which 
were traced, showed but 7 relapses and no mortality; 108 
were free from recurrence from one to four and a half 
years afterward, while 47 had passed the two-year limit.1 
The results of Championniere, Macewen, and Kocher, 
although exceedingly good, are inferior to Bassini’s. 
Whatever method is adopted, I believe prompt pri- 
mary wound-healing essential to success, and that all varia- 
tions in technique that interfere with such healing should 
be abandoned. In proof of this, most of Halstead’s 6 re- 
lapses (in 58 cases) failed to heal primarily, and the same 
is true of nearly all of Kocher’s recurrences. 
In addition to the 32 cases in children, I have operated 
upon 16 adults by the Bassini method. Of these 48 
cases, but one relapse, already rt ferred to, has taken place, 
and I obtained perfect primary union in 46 successive 
cases. 
Limitations as to Age.—I believe that few cases other 
than strangulation require an operation under the age of 
four years. There are few under that age that cannot be 
controlled by a truss. 
My 46 cases have been arranged in tabular form, and I 
shall not give them in detail. Several of them, however, 
are of sufficient importance to deserve special notice. 
In 6 cases the hernia was of caecal variety. 
Two were the strangulated. Three occurred in children, 
1 A recent personal communication shows that Bassini has operated 
upon 560 cases, with no mortality and but 15 relapses. 7 
aged four years, and one in a child of ten. All were very 
large, and it was absolutely impossible to control them 
with a truss. One case was complicated with spinal dis- 
ease and incontinence of urine, yet primary union was 
obtained. In another, a long appendix was found adher- 
ent to the sac, almost to its tip. In one strangulated case 
the hernia was removed. In three cases adherent omen- 
tum, and in four reducible hydrocele of the sac existed. 
A form of hernia rarely found in children, viz., femoral, 
occurred in two cases, one in a boy, aged seven. He had 
an old inguinal hernia on the opposite side. Both were 
operated upon the same day. In the femoral the sac was 
ligated high up and the opening closed with a purse- 
string suture of kangaroo tendon. The boy was up and 
about at the end of two and a half weeks. The case of 
strangulated hernia in the child, one year old, was of ex- 
ceptional interest. The condition at the time of operation 
was very bad. The Bassini operation was quickly done 
under chloroform anaesthesia. The child reacted well, 
but the temperature steadily rose, and the following morn- 
ing recorded 107° F., with a pulse of 150 to 160, and res- 
piration 40 to 50. The abdomen was distended and 
tender, and the child was apparently nearly moribund. 
It was treated with half-hour tub-baths at a temperature 
of ioo° F., cooled down to 950 F., and repeated when 
the temperature rose above 104° F., or about every two or 
three hours, for two days. After two days the child be- 
gan to improve, and recovery was interrupted. In spite 
of the unfavorable conditions the wound healed by abso- 
lute primary union. 
In three cases the hernia was complicated with unde- 
scended testis. The testis was brought down and 
anchored in the scrotum. A wire frame was made use 
of in two cases, and in a third the epididymis was 
dissected from the testis, thus increasing the length by 
nearly one inch. The result was very satisfactory as 
regards the hernia, but in two cases the testis retracted 
to the external ring. 
The question of what is the best method of dealing 
with the undescended testis complicating hernia is still 
sub judice. There is some ground for believing that the 
majority of them are functionally of no value, and there- 
fore one is warranted in removing them. We know that 
this is generally true as regards domestic animals, espe- 
cially the horse, and Mr. Owens, of Glasgow, has 
demonstrated the same to be true in several cases in 
man. Championniere in his 275 cases of hernia, 
operated upon 10 with undescended testis. In 5 he 
removed the organ, and in 5 he anchored it in the scro- 
tum by Tuffier’s method. 8 
My object in presenting these cases has not been an 
attempt to prove the advisability of operating upon hernia 
in children in general, for I believe that most cases can 
be cured without operation, but rather an effort to show 
that there are certain cases in children that cannot be 
cured by mechanical means, and that the operation is 
practically devoid of risk, while at the same time it gives 
results superior to those in adults. 
It should be remembered that these 46 cases operated 
upon have been selected from upward of 4,000 cases of 
hernia in children, and hence represent less than one 
per cent, of the entire number treated. 
18 East Thirty-second Street.