The Radical Treatment of Hernia. 
BY 
JOHN B. DEAVER, M.D., 
OF PHILADELPHIA. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
June, 1895. Reprinted from The American Journal of the Medical Sciences, June, 1895. 
THE RADICAL TREATMENT OF HERNIA. 
By John B. Deaver, M.D.y 
OF PHILAffflLlt'HlA. f 
The total number of radical operations I have done up to date is one 
hundred, and include Macewen’s, Barker’s, McBurney’s, Bassini’s, 
Halsted’s, and my own modification, which is a combined Barker and 
Macewen, and was the one I most frequently performed until the 
introduction of the Bassini and Halsted operations. 
The indications for the radical cure of hernia are first hernias which 
are complete, and in which the external abdominal ring is so large as to 
make it difficult, if not impossible, to apply a truss that will hold the 
rupture; second, irreducible hernias, this being a form in which it is 
difficult to obtain a truss to fit accurately enough to prevent the escape 
of a new portion of the gut; and third, strangulated hernias, in which 
the bowel is not gangrenous, or if deeply injected, when it responds to 
the application of moist heat sufficiently to permit of its being re- 
turned. 
The Bassini and Halsted methods have given such satisfactory 
results, with so small a mortality, that I believe that simple reducible 
hernia should be included among the indications. Granted that a hernia 
so treated showed a tendency to relapse after either of these operative 
procedures, the adjustment of a light-fitting truss will eliminate the prob- 
abilities of subsequent strangulation. I have recently operated for 
obstruction of the bowels in a patient who was the subject of a reducible 
hernia. The obstruction was due to a band formed by the omentum, 
which had become rolled upon itself, and had become adherent to the 
sac of the hernia just beyond the internal abdominal ring. The fact 
that such a state of affairs can arise seems to me to offer itself as an indi- 
cation in considering the advisability of this operation in simple redu- 
cible hernias. 
It is hardly necessary to state here that patients the subjects of chronic 
coughs, and those who have large, flat and flabby belly-walls, especially 
in advanced age, are unfavorable cases. When the hernia is very old 
and large the abdominal cavity must necessarily have contracted more 
or less in accommodating itself to the absence of the viscera which occupy 
the hernial sac; therefore, it is questionable if, under these circura- 2 
DEAVER: RADICAL TREATMENT OF HERNIA. 
stances, it would be wise to perform a radical cure at all. In cases of 
this character the patient should be kept in bed for some days with the 
hernia reduced and retained before the operation is even attempted. 
The contraindications to operations in general are applicable to the 
radical treatment of hernia, except, of course, in the case of strangula- 
tion, where the operation becomes a life-saving measure. 
The choice of operation must necessarily depend upon the individual 
case. The Bassini, with or without the Halsted modification, is appli- 
cable in the great majority of uncomplicated hernias, and to all cases of 
simple reducible hernia. When strangulation has occurred it may be 
necessary to treat the wound after the method of McBurney. All, 
however, agree that the mortality is small. Of course, when we say a 
cure we must modify the statement as to time for a relapse. The chief 
etiological factors in the production of hernia are weakened abdominal 
wall and an elongated mesentery, either congenital or acquired, and so> 
while we can remove and cure a rupture, we cannot altogether remove 
these anatomical weaknesses, although in a large percentage we can and 
do add largely to the strength of the abdominal walls. 
Too much importance cannot be laid upon the after-treatment of the 
case, especially during the first six months. While in bed the ordinary 
dressing of the wound is quite sufficient; after the patieot is up and 
about a light-fitting truss may be worn constantly for a long period of 
time, but this I do not feel is necessary. Abdominal massage and 
electricity are of use as strengtheners of the abdominal walls. 
We are all so familiar with the modern methods for the radical cure 
of hernia that I will not attempt to go into a detailed account of their 
individual merits, but will give the results of my experience in favor of 
those which I believe have best fulfilled the indications in obtaining a 
cure. 
The strongest objection to the Macewen operation is that the sac is 
not opened. By this it seems to me wre take a great deal for granted in 
not inspecting the contents to determine the presence of adhesions. 
These, while they may not enter as a factor in the reduction of the rup- 
ture, may at some future time play an important role in an acute 
mechanical intestinal obstruction. The same objection can be urged 
against the Ball and Kocher operation. Another objection to these 
operations is that there is an attempt made to close the old canal. 
The objection to the McBurney operation is that the permanency of 
the cure is dependent upon the presence of a large amount of scar-tissue. 
It is a well-established fact that abdominal wounds that heal by primary 
union are less liable to be followed by hernia than those which heal by 
granulation. 
Bassini’s and Halsted’s operations are so logical, and based upon such 
firm anatomical aud physiological grounds, and have given such satis- DEAVER: RADICAL TREATMENT OF HERNIA. 
3 
factory results, that they have practically supplanted all other methods 
of operation. 
Between the Bassini and Halsted operation I give preference to the 
latter for the majority of cases. I agree with Halsted, that it is not 
always advisable to bring the cord out at the internal abdominal ring, 
but this should be determined by the condition of the muscles at this 
locality. By excising the superfluous veins of the cord the latter is 
reduced in size, and consequently its opening of exit is correspondingly 
smaller, thus offering greater resistance to the entering wedge of the 
subsequent hernia. 
Another feature of the Halsted operation is the position which the 
cord holds when the operation is completed. The fact that the cord 
overlies the aponeurosis of the external oblique makes the new canal 
more circuitous, and, therefore, less liable to be followed by a relapse 
than in the Bassini operation, where the cord lies below the aponeurosis. 
This further simplifies the operation by doing away with a second row 
of sutures. 
In the operation for the radical cure of hernia several points present 
themselves which are well worth discussion, namely, first, the propriety 
of enucleating the entire sac of an old and large scrotal hernia. This 
question must be decided according to the condition of the sac itself, 
and the answer must depend largely on the surgeon’s judgment. If the 
sac be tightly adherent to the tunica vaginalis and the lower portion of 
the cord, necessitating a prolonged dissection, particularly if the patient 
be advanced in years, I think it is better to content ourselves with the 
removal of that portion of the sac which occupies the inguinal canal. 
The presence of the remaining portion of the sac does not interfere 
with the reparative process following the operation. I have seen gan- 
grene of the testicle follow the determined efforts of the surgeon to free 
the fundus of such a sac. 
Second, when a mass of irreducible omentum is encountered it is best 
to ligate it and cut it away, including only a small portion in each 
ligature. Care must be exercised in tying the ligatures when the vessels 
are atheromatous. Under the latter condition it is better to use heavy 
ligatures, preferably catgut, as the larger ligatures are les3 liable to cut 
through the thin-walled vessels. 
A condition I have met with a few times, and to which Dr. William 
T. Bull has called attention, is that of inflammation of the stump of the 
omentum with localized peritonitis. One of these cases went on to sup- 
puration and opened spontaneously above Poupart’s ligament. While 
the risk of ligating and cutting away a portion of the omentum is 
slight, still it is not justifiable to expose our patient to this additional 
risk, and therefore when reducible it should be returned. 
A chronic irreducible omental hernia may undergo a variety of 4 
DEAVER: RADICAL TREATMENT OF HERNIA. 
changes, viz., calcareous, cystic, or fibrous degeneration. Where the 
fatty element of the omentum becomes absorbed and the peritoneal sur- 
faces crowded together, adhesion takes place, and the omentum is thus 
converted into a fibrous cord. Again the peritoneal surfaces may 
adhere and the serous fluid accumulating in the cavity thus formed, 
convert it into a cyst. Where the quantity of fluid contained is small 
and the hernia has been of long duration, these cysts at times resemble 
intestine or testicle. 
It is not very uncommon to meet with the vermiform appendix within 
and adherent to the sac. As it does not complicate the operation it 
should be removed. Although it is true that the spleen, the kidney, the 
ovary and the Fallopian tube, a Meckel’s diverticulum and the epiploic 
appendages, and even a dermoid cyst, have been found in the sac of an 
inguinal hernia, I have never met with any of these except an epiploic 
appendix. Certain loose bodies, generally derived from the epiploic 
appendices, are also met with. An elongated and thickened epiploic 
appendix may be mistaken for the vermiform appendix. 
In one of the cases of inguinal hernia which I operated upon for 
radical cure there was a prolapse of the extra-peritoneal portion of the 
bladder which I had the misfortune to open. In an acquired hernia of 
the inguinal variety it is not uncommon to meet with an undescended 
testicle occupying the lower part of the canal. This is a serious com- 
plication in the radical cure, as in the vast majority of cases it necessi- 
tates the removal of the organ. If the testicle, however, can be drawn 
down into the scrotum it should be made to occupy its normal position. 
The operation for the radical cure in congenital inguinal hernia dif- 
fers from that of the acquired variety from the fact that the tunica 
vaginalis most commonly constitutes the sac of the hernia, the contents 
of which are in contact with the testicle. The method of treating the 
sac in this variety, consists in dissecting out the tunica vaginalis entire 
with the testicle, or treating it after the manner of Macewen. The 
latter procedure is preferable, as it saves the testicle and permits the 
cord and inguinal canal being treated after the method of either Hal- 
sted or Bassini. When the testicle is removed with the tunica vagi- 
nalis it simply remains to close the canal. As we are not able to 
recognize this condition before operation, unless the testicle is diseased 
or very small, thus offering a potent reason for its removal, or are not 
able to bring it down into the scrotum, I should hesitate to do so without 
the patient’s consent. 
The encysted variety of congenital hernia is very rare, although I 
have met with it. The procedure to be carried out is to separate the 
hernial sac from the tunica vaginalis, which is patulous up to the inter- 
nal ring, to ligate it, and cut it away. The radical cure is completed as 
in ordinary cases. DEAVER: RADICAL TREATMENT OF HERNIA. 
5 
The difficulty in retaining a femoral hernia by mechanical appliances 
makes the radical cure particularly applicable to this variety. The 
contents of the sac are seldom entirely reduced, thus permitting strong 
adhesions to form. 
There is very little difference in the methods for the radical treatment 
of femoral hernia. I usually perform a modification of Barker’s oper- 
ation, as follows: 
After the sac has been exposed and opened and the contents reduced, 
the neck is tied off high up in the canal with a long silk ligature. The 
ends of the ligature are allowed to remain long. One end is threaded 
in the eye of a long-handled curved needle, which is passed up beneath 
Poupart’s ligament and brought out through the aponeurosis of the 
external oblique on a line with the upper border of the ligament. The 
needle is withdrawn and the other end of the ligature threaded and 
brought out one-quarter of an inch on the other side of the first. These 
are now drawn tight and tied down upon the aponeurosis, thus anchor- 
ing the stump of the sac in the orifice of the internal femoral ring. 
The operation is completed as described by Barker, namely, “ A long- 
handled needle threaded with silk is passed through the posterior layer 
of the femoral sheath and pubic portion of the fascia lata at a point 
about an inch below Poupart’s ligament, and a little internal to the 
femoral vein, which is protected by the little finger; it is then thrust 
upward nearly as far as the peritoneal ridge, and is then made to 
emerge across the crural opening, and pass through the lower border of 
Poupart’s ligament. The thread is now withdrawn from the eye of the 
needle, and the latter is removed and threaded afresh and made to 
traverse the same structures in a similar manner about a quarter of an 
inch internal to the first stitch. This is repeated until a sufficient 
number of threads have been introduced to draw the structures together 
and completely close the femoral canal. The stitches are tied and the 
skin wound closed.” 
The operation for the radical treatment of umbilical hernia consists 
in making two elliptical incisions carried down to the aponeurosis of the 
external oblique. The sac is freed from the margin of the hernial open- 
ing. The sac is now opened and its contents reduced, enlarging the 
hernial opening if necessary. The redundant portion of the sac and the 
overlying skin and subcutaneous tissues included between the elliptical 
incisions is cut away. The margin of the hernial opening is freshened. 
The edges of the wound are approximated with two rows of sutures; the 
deep set of kangaroo-tendon, including the aponeurosis and peritoneum, 
and the superficial of silkworm-gut, including the skin and subcutaneous 
tissues. 
Among the number of operations I have performed for the radical 
treatment of hernia my record shows 100 cases divided up as follows: 6 
deaver: radical treatment of hernia. 
Acquired inguinal 49 
Congenital inguinal 8 
Strangulated inguinal 18 
Femoral 7 
Strangulated femoral 11 
Umbilical 2 
Strangulated umbilical 3 
Ventral 2 
100 
In this number there were eight deaths, two following the radical 
treatment, and six the operation for the radical treatment where strangu- 
lation existed. The deaths occurring in the strangulated cases were five 
inguinal and one umbilical. Tfye Johrijal 
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