[Reprinted from The MEDICAL News, January 25, 1890.] 
RADICAL OPERATION FOR HERNIA. 
Abstract of a Clinical Lecture 
Delivered at the Harlem Hospital, New York. 
By THOMAS H. MANLEY, M.D., 
OF NEW YORK. 
The first case presented for operation was one of 
strangulated inguinal hernia. The patient, a strong man 
of twenty-four years, gave a history of having noticed a 
swelling, in the left side since he was six or seven years 
old. He had worn a truss almost continuously until 
two years ago, when he found that after having left it 
off the hernia did not reappear. 
The features in the clinical history to which Dr. Man- 
ley particularly directed attention were, first, the origin 
of the trouble. The patient thought that the hernia had 
not appeared before he was seven years old; but Dr. 
Manley was convinced that while the protrusion may 
not have been large enough to attract notice until that 
age, the lesion was congenital, as are the vast majority 
of all herniae. 
Secondly, the patient, supposing himself cured, had 
discarded the truss for two years ; and it was only after 
a severe strain that he found his rupture had returned. 
For the first time he found that after patient and perse- 
vering efforts he could not reduce the hernia. 
It descended at about three o'clock in the afternoon. 2 
MANLEY, 
Two hours later a local practitioner was summoned, 
but failed to reduce it. Constitutional symptoms having 
developed, the patient was advised to seek admission to 
hospital. 
The great pain at the seat of the protrusion, which was 
very large, and the constant vomiting and great ex- 
haustion, all pointed to strangulation. 
The operator said he approached the case with two 
objects in view. The first and most important was to 
relieve the obstruction by dividing the constricting band 
wherever it might be located; then to complete the 
operation with the object of a radical cure of the hernia. 
Here he referred to the defective structural develop- 
ment ; the deranged and confused anatomical position 
of the parts; which should be considered before decid- 
ing on the precise surgical measures which might prove 
most efficient in obtaining a cure. 
Important questions were: 
Did the foetal type still persist ? 
Was there an undescended testicle or one lying some- 
where in the inguinal canal, or, further, if the testicle 
had descended, was it adherent to the floating viscera of 
the abdomen, carrying a portion of them to the base of 
the scrotum ? 
Was the fault due to an excessive amount of omentum 
or an abnormally long mesenteric ligament ? 
The operation was begun by the long, free incision. 
On reaching the deeper structures it was at once mani- 
fest that the case was one of the congenital variety. 
There was no true sac. The immense mass of extruded 
omentum lay in apposition to the tunica albuginea of 
the testicle, but was not adherent to it. 
On finding this condition Dr. Manley stated that he 
would be unable to do the classic operation of Mc- 
Burney, which he had hitherto performed with most RADICAL OPERATION FOR HERNIA. 
3 
gratifying results in strangulated hernia. He would do 
a modified Macewen operation, or what might, perhaps, 
be designated a " McBurney-Macewen operation." He 
would ligate the sac off without sacrificing the testicle, 
and fill in and obliterate the greatly enlarged space 
between the pillars of the ring. 
In order to do this, after ligating and cutting away the 
superfluous omentum, the remaining stump was fixed in 
the canal with the quilted suture, after the plan of Mac- 
ewen, while the remainder of the operation was com- 
pleted after the McBurney method-the cutaneous mar- 
gins of the wound sewed down to the peritoneum-and 
the whole treated by the open method. 
The second case for operation was a boy of seven, who 
had had his hernia since birth. His father had taken him 
to travelling charlatans during the first few years of his 
life, but lately had consulted several well-known sur- 
geons. There was a great difference of opinion as to 
what the swelling really was, and as to the plan of 
treatment; some maintaining that it was a hydrocele or 
an encysted spermatocele, etc.; some recommended 
operation and others advised against it. 
There were a few points unmistakably clear in con- 
nection with this case. The first was, that there 
was a protrusion that increased in size with the boy's 
growth, and that could not be reduced. Again, its 
growth was rapid, and it became so prominent, under 
the trowsers, that it attracted notice, and hence brought 
down on the lad the jeers and banter of other boys, so 
that the little fellow himself was anxious to get rid of it. 
Thorough antisepsis being observed, the operation was 
commenced with the usual long, free incision over the 
line of the spermatic cord, from the internal ring down- 
ward. Here, as in the preceding case, there was no sac, 
but after freely opening the tunica vaginalis, which in- 4 
RADICAL OPERATION FOR HERNIA. 
vested the protruded mass, it could not be replaced in 
the abdomen with ordinary taxis. The enlargement 
consisted of nearly twelve inches of intestine. It was 
found, on careful examination, that the reason the gut 
failed to return was not resistance from above, but be- 
cause on its mesenteric border the vas deferens, the 
epididymis, and testicle were in one confused mass, all 
bound rigidly to the intestine by organized fibrous tissue, 
which had to be divided with the scissors. 
After having thoroughly freed the bowel, the atrophied 
testicle was removed high up, when the gut itself was 
returned and the peritoneal cavity closed, by ligating 
off the fascia propria on a line with the internal ring. 
The wound was treated by the open method. 
Dr. Manley next exhibited a man, seventy-three years 
of age, on whom he had operated successfully three 
months previously. 
The man had a large incarcerated hernia on each 
side, which, he said, had annoyed him for more than 
forty years. At first they were reducible, but owing to 
badly fitting trusses a localized peritonitis had developed, 
which ended in the firm adhesion of the sac to its con- 
tents; and had, in this instance, as is usually the case 
in all after a sufficient time, produced what is known as 
incarcerated hernia. 
Dr. Manley asked that the great difference in age be 
noticed in these two cases, and said that neither extreme 
constituted an obstacle to operative measures, if the 
patient was in sound health. On the other hand, in 
congenital hernia he would advise the operation at the 
earliest possible date; preferably before the infant was 
a month old. 
Note.-The two cases operated upon made excellent 
recoveries, and were dismissed from the hospital, cured, 
six weeks later.