vvV- W^fr ^K,:^^^1v,i■■■■•:'^''•^;••. W^V.^. ■;:••;;:•:; ■.v%s«v^'V'--'aV^!;;'^^,. ■;■.•■',■■■ •, »te'--'v.---:'-' ■.*•■■■=■■■ &*■■$$;>!>»• • •• £>#$■■>/ ' *-*Y".7 ,-*. j ■■.''■.. k''r»^Jf;'t.>.■•• i ', ■ •■ //i w•'-.'.••■ .;.■■•-. ,"■ (■''■Vf.Y'.-.V'Ji ■'*'•'.■''•■.' NATIONAL lIBRARv Of MEDICINE NLM OD13flaAl4 1 a*ra*r^^.^*^*f^^^ SURGEON GENERAL'S OFFICE Section, JVo. PRESENTED BY Shelf B3!»:^'sa;^T*,gT'»OT:*3;^j»,u*,*,>va,^33'aaaffl NLM001388849 wwm ^;*>\^t- ■'^i&^L*. ^ 'Tic Reprinted from The International Journal of Surgery, for February. 1895. THE ELEMENT OF ELIMINATION AND ASSIMILATION IN PUS-FORMATION. By Thomas H. Makley, M. D., New York. At the late annual meeting of the Erie Railway Surgeons at Niagara Falls, in the discussion on the treatment of pathological conditions of the periton- eum, Professor Roswell Park, of Buffalo, dwelt at considerable length on tbe importance of attending closelv to the organs of elimination in all cases, oper- ative and non-operative, of the abdomen, and stated that in not an inconsiderable number we might, by stimulating the emunctories into increased activity, dispense with radical surgical measures entirely. There can be no doubt in my mind now, after twenty years practice, but, that of late years, since the germ theory has taken such a hold on the profes- sion, and all the intricacies of disease are supposed to vanish under the objective glass of the microscope, this latent function of all the excreting organs in neu- tralizing and throwing off the lethal elements of dis- ease, has not received the attention which its import- ance merits. When one, accidentally or otherwise, swallows a poison, nature promptly commences the work of elimination by emeses, purging or diaphore- sis. The usual onset of all serious maladies is marked by similar phenomena. 2 Pathologists are not in accord on the question of elimination of pus by the absorbents ; some main- taining that suppuration can occur only through the intervention of germs, and hence its mechanical evacuation is, under all circumstances, imperative. Others, on the contrary, recognize pus as often a non- septic product, producible, by both mechanical and chemical agents; infection acting only in occasional instances, and, even under these circumstances, the chemistry of the economy may destroy it. This lat- ter view, no doubt, is the correct one, for the calcare- ous, or inspissated masses or foci, which we often find in the lungs, on autopsy, in unmistakable terms, proves its validity. There can indeed be no longer any question but that small isolated, purulent collec- tions may become rapidly encapsulated, disintegrated and obliterated by vital action alone. Professor Charles Heitzman, of New York, has re- peatedly demonstrated, that by the simple expedient of adding an alkali to purulent urine it is at once transformed into a ropy, myxomatous mass. This hint should not be lost sight of, under a thousand circum- stances, when we wish to transmute a localized puru- lent collection into a substance, at once, inert and readily taken up by the circulation, without detri- ment to health. In order, however, for us to fully dispose of a purulent collection, all the emunctories should be called into action. The temperature-wave will indicate when the work is done and all danger oi. toxaemia is past. But, in order for us to derive the greatest advantage through this provision of the economy, the glands must be fed with fresh, invigor- ating blood ; which means, that the functions of as- similation should not be overlooked, that our patient's general nutrition must be well supported, and that he must have tonic, reconstructive treatment. 3 In order to realize anything like satisfactory re- sults in the treatment of any description of severe in- juries or local affections, it is more important to di- rect our attention to the stomach than the lesion. My own experience induces me to place beef-tea in the very front rank as an aliment—the best tolerated and most strengthening. Next comes infant's food, milk, which has been greatly over-estimated as a per- manent aliment. Along with nutritious diet, stimu- lants, tonics and reconstructive remedies should be employed. Alcohol in certain forms may be utilized with advantage. Quinine, iron and other hsematic medicines should not be neglected. Of late, my experience in a considerable number of cases, in which I have used maltine with coca wine, has been most gratifying. It embodies the tonic ac- tion of coca, besides the digestive and food proper- ties of maltine. It goes without saying, that proper covering of the body, pure water, and proper venti- lation, with care, are all essential. Let us then give nature a chance and not be too ready to operate, when as much and more can often be accomplished by a rational, constitutional therapy. Malnutrition constitutes the pathological foundation of the greater number of diseased states, therefore, curationes mor- borum causam demonstrant. 115 W. 49th Street. / \ y^^^^L^l^<^Z^^^^ HERNIA: -ITS— PALLIATIVE AND RADICAL TREATMENT Adults, Children and Infants. / By THOMAS H. MANLEY, A.M., M.D. VISITING SURGEON TO HARLEM HOSPITAL, CONSULTING SURGEON TO FORDHAM HOSPITAL, MEMBER OF NEW YORK ACADEMY OF MEDICINE, AMERICAN MEDICAL ASSOCIATION, NEW YORK STATE AND COUNTY MEDICAL ASSOCIATIONS, INTERNATIONAL MEDICAL CONGRESS, PATH. SOCIETY, NATIONAL ASSOCIATION OF RAILWAY SURGEONS, ETC, ETC. PHILADELPHIA, PA. : THE MEDICAL PRESS CO., Limitbd, 1725 Arch Street, 1893. WI M27hysician for treatment of internal-obstruction of the bowels. I found her col- lapsed, cold, and almost pulseless. The house-surgeon informed me that there was no hernia, but my hand passing under the clothing came on to a firm mass the tumor Avas opened under / cocaine. An old, omental pro- trusion Avas found anteriorly, firmly adherent to the femoral vein, and behind it a fresh mass, which nipped a coil of the intes- tine as' it entered the crural canal. Fortunately, her recovery Avas uninterrupted. There is a large number of hernise Avhich are greatly benefited by the rest treatment, conjoined with manipu- lation, massage, or pressure and electricity. To this class, belong, the recently incarcerated, the incoercible, rapidly-groAving, and those presenting symptoms of approaching strangulation. We have seen, how the recumbent posture, favors the cure of hernia in the infant, by aiding nature in her process of evolution, and it is well to ascertain if, after the groAvth of the body, Ave cannot rely on this agency as a useful therapeutic factor. We will invariably observe, that when the general-health is seriously disturbed, when an organ or a limb is compromised by disease or accident, Nature immediately forces the body into a state of rest. It is not perhaps, as well known as it should be, that rest, is an adjuvant of incalculable value in a great variety of func- tional and organic ailments. If travel (recreation, change of air and exercise) is the "positive pole" in hygienic-therapeutics, rest is the " negative," and this is particularly true in hernia. 46 HERNIA. Certain varieties of adult-hernia may be cured by rest alone; physiological rest. Rest must be utilized in a relative, rather than its positive sense. The patient, to secure a cure, if following a laborious pur- suit, must discontinue it. If an athlete, he must discontinue feats of agility. If a performer on a wind-instrument, he must lay it aside. In other Avords, if he would give rest to his hernia, he must discard everything, Avhich exercises undue pressure on it, or which, perhaps, even caused it, It is said, if you Avould cure disease, first remove the cause. But there are many maladies, the cause of Avhich cannot, always be remoA^ed. This certainly is the case with many phases of hernia. Unhappily, too, there are not a feAv, among the poor, suf- fering from hernia, Avho cannot abandon a trade or occupation, on which, perhaps, a family depends for its sustenance. By a wise provision of Providence, hoAvever, most hernia1 are not encoun- tered among hard-working people, but rather among those best able to comply with a necessary hygiene. Many times it has been my good fortune, to see hernia! which had suddenly become painful and irreducible, by the aid of rest in bed, a soothing inunction, and a sleeping draught, quietly retract and disappear in one night. With others, of greater age, volume and sensitiveness, by the employment of massage, knead- ing, bathing and graduated pressure Avith a flannel bandage, after a varying period from a day to a Aveek or more, they too have re- turned ; and, if not, they have been greatly reduced. Dr. J. Collins Warren, of Boston, at a meeting of the American Medical Association, in NeAvport, R. I., reported several cases of unman- ageable, large, old hernise, Avhich Avere rendered quite coercible and comfortable under the truss, by treating them Avith rest on the back and intermittent pressure. With those rapidly-groAving in spite of supporting measures, Avhen the escaping mass threatens to attain great dimensions, we may often interfere in this way Avith the most salutary results. But, in order, to derive the greatest benefits, it may be necessary to confine our patient in the recumbent posture over a consider- able period of time; besides, methodically, directing treatment to the immediate seat of the hernia. HERNIA. 47 It is almost needless, to again speak of the marvelous power of rest in aiding the restoration of a strangulated intestine; for, it is Avell-knoAvn to hospital-surgeons that often, Avhen taxis has totally failed, by the use of a hvpodermic of morphine, elevation of the hips and a feAv hours undisturbed repose, the constriction at the neck will slacken and the hernia disappear of itself. Before leaving this part of the subject, it may be desirable that Ave have a correct knoAvledge of the therapy of rest, when applied to the treatment of hernia. Exclusive of the manner in which change of occupation and cessation of active muscular ex- ercise act, rest relieves and sometimes cures: 1st. By relieving the herniated area of the weight of the in- testines, which, in the erect posture, falls on a weak vent, on an opening in the over-strained, thinned, aponeurotic wall. 2dly. By clearing the dilated canal of the visceral plug, which tended to constantly widen it, an opportunity is given to the fibres of it, to contract, and hence, narrow the portal of escape. Although, it is assumed that aponeurotic, fibrous-tissues possess but slight, if any contractile poAver, it is not so, with the cremaster muscle in male, inguinal hernia. In this variety of the malady, Ave Avill invariably find the fibres of the cremaster-muscle enormously hypertrophied ; so that, it is but reasonable to sup- pose, that when once the viscera are returned, this will so contract, as to aid very materially, in closing the lumen of the sac. The dorsal decubitus favors the equalization of the circula- tion and relief of the congested state, Avhich previously con- tributed towards enlarging and fixing the hernia. In the hernia of females it is notorious, that the distress in standing just before menstruation is always very marked, while great comfort comes from rest on the back at frequent periods. When a hernia has been recent, and its sudden passage down- ward has started up a sharp inflammation over the entire surface of the sac, if it can be now returned and fixed without strain, until these plastic surfaces become glued together and obliterated, a cure may be affected. 3clly. In those massive hernia* we must commence our at- tack, by placing the body at rest, then by massage and gentle press- ure, continued until the rings through which this mass escaped, 48 HERNIA. relax and permit its return. They will very often severely test one's patience; but if we are gentle and persistent, we will often conquer them. An opening through which a hernia escapes, should permit its return ; and it generally will, except in certain strangulated, and in cases, attended with promiscuous and in- timate adhesions; though, Ave should always remember, that its escape was gradual, almost by imperceptible stages, and noAv its return must likeAvise be slow and cautious. Having re- duced it, it must be confined to the abdomen until the hernial orifice has had time to contract. A most aggravated case of this description, I have seen wholly disappear after three Aveeks treat- ment in bed; though as a prophylactic against its return, a truss was worn. Local bathing, douching, massage and galvanism. each serve a useful purpose, conjoined with rest in many cases in w7hich there is a vascular stasis of the cord and in the loose tissues enveloping the sac. In many, old hernias, no hope need be entertained of effecting the return of the serous envelopes or sacs; for their adhesions are firm and extensive; nevertheless, a prac- tical cure of them may be secured with the sac in situ. If Ave, in any manner secure the obliteration of its lumen, the end is at- tained, just as effectually as if the fascia propria itself Avere com- pletely enucleated. This closure of the lumen is brought about by contraction, by plastic inflammation, and by atrophy. Physio- logically, the contraction of the circular fibers q& the orifices of a hernial canal retain the viscera in their position, Avhile patho- logically this same contraction may induce interstitial changes in the escaping structures which it embraces, and they may even, by spasmodic action, induce serious symptoms through the vio- lent pressure Avhich they bring to bear on the imprisoned viscera in strangulation. CHAPTER VII. MECHANICAL TREATMENT OF VENTRAL PROTRUSIONS, IN ADULTS, MALE AND FEMALE. Iii this class are grouped: 1st, Umbilical hernia. 2d. Hernia in the upper abdomen, the umbilicus, central and lateral. 3d. Hernia through the abdominal Avails, below the umbili- cus, but above the inguinal zones. These might be further subdivided into those of a pathologi- cal and those of a traumatic origin. This group taken as a whole, in both sexes, after adult years are attained, is the most unmanageable and incurable of all hernise. UMBILICAL HERNIA. These are rarely met with in men, but in child-bearing women are not \rery uncommon. 4 49 50 HERNIA. Many of them though hopelessly incurable, are nevertheless borne without serious inconvenience, and comparatively rarely jeopardize life. Of late years, since neoplastic formations have become so common in women, and very many pathological conditions of the female, internal generative organs have been radically dealt Avith, through incisions in the abdominal walls, hernia has occasionally occurred through the incision cicatrix. These I have designated laparotomy hernise. These protrusions, commonly known as umbilical, strictly speaking should not be so designated ; for, but a very feAv of them emerge through the centre of the navel orifice or carry with them the urachus or round ligament of the liver. On the contrary, they usually emerge either immediately above or on either side of the umbilical scar. The accompanying (Fig. 8) is a photograph of a very aggra- vated case of umbilical hernia in a woman thirty-eight years old, which came under my care. She did not notice any umbilical de- formity till the birth of her first child, ten years previously. With each of her successive, four con- finements it increased in volume, till noAv, when unsupported, it hangs down on the pubes. It will be observed, that it protrudes through the median line, and is spherical in outline. The integu- ment which covers it is as thin as parchment. Its contents are intes- tinal, which are wholly irredu- cible. Slie carries it in a sling, and without much inconvenience, and performs the duties of a house- keeper. This anatomical arrangement is not of much consequence in prothetic treatment, but, as will be observed later, it has its im- portance when a surgical operation is undertaken. We seldom f j£?- Fig. 8. Mammoth Typical Umbilical Hernia in Female. HERNIA. 51 &fe*: see hernia through the muscular planes, above the umbilical hori- zontal line, except in the child-bearing. This area of the abdomi- nal enclosure is least exposed to pressure, or to the surgeon's scalpel in laparotomies. In certain child-bearing women, hoAvever, with loose, flabby fibre, in Avhom the foetus during pregnancy attains a rapid and considerable development, as the uterus mounts upward the float- ing viscera are confined within reduced limits. The same occurs in dropsy of the amnion. Should the patient in this condition make a sudden strain, or be subjected to vomiting or coughing, something is apt to give ; to rupture; and Ave Avill have a thinning and expansion of that Avedge-shaped plate of aponeurotic sub- stance, Avhich lies between the diverging ascending recti, or else a tear through its inner lamina, .<*■ to be succeeded by a genuine ^r*"",r?r ^mnvm**^ rupture, Avith a bagging forward OATer the umbilicus of the viscera. This may be of limited propor- tions, or of considerable extent. As a rule, after confinement, when the gravid uterus is emp- tied the umbilical viscera recede> backAvard, into their normal abode, all morbid pressure is re- moved ; Avhen, if moderate sup- port is provided over the weak- ened gap, all traces of the defor- mity disappear, until another pregnancy; when, it may return. In neglected cases with wo- © men bearing many children, this condition may remain, though it rarely gives much inconvenience. In my service at the Nine- ty-ninth Street Hospital, in the autumn of 1885, an elderly woman came under my care who had a large projecting mass extending from the ziphoid cartilage down- ward. Below the navel the abdomen Avas rather retracted and flat. Fig. 9. A Voluminous Exomphocele with its Invest- ments dissected away. 52 HERNIA. We could secure, but an imperfect history from the woman. The physical qualities of the fullness inclined me to regard it as a new growth. But at the autopsy it was discovered that it con- sisted of a hernial extrusion, which had split the inner fibers of the aponeurotic fascia; and, in this manner made its way outAvard. The sac contained the gastro-hepatic omentum, all of the transverse colon, and the greater part of the small-intestine, from the pylorus. IRREGULAR VENTR0-ABD0MINAL HERNIA OF CHILD-BEARING WOMEN. The inner surfaces of the abdominal recti, from the umbili- cus down to the pubes, lie flush to each other, nothing separating them except their sheaths in the male sex and in non-child-bearing women. On the contrary, however, Avith the mothers of one or more children, there may be a well-marked interval dividing these muscles, varying from one to several inches. Pregnancy in many women of modern life, over-fed and UDder-exercised, Avhose foetuses are large, fat and plump, puts the muscular planes of the abdomen on a great strain, often so much over-stretching them that they never quite recover their tonicity after labor, or the fibrous structures are so far over-stretched that a complete return to their former integrity is quite impossible. The mother then is left "pot-bellied." The belly hangs over the pubic brim. The recti muscles have so far diverged, as to permit the greater part of the abdominal contents to occupy this hiatus, caused by the want of muscular support. With women so burdened, if there be but little adipose tissue present, we may at times quite distinctly feel the vermicular movements of the intestine through the thinned integument. These bulging masses in the lower mesial plain, like those above, are not attended with any danger to life. They are not commonly classified as hernise, though serologically and pa- thologically they are quite identical. They derive their greatest interest from the deforming effects which they produce, and from the fact that many of the most ag- gravated cases of this description, if seen early in young women, may be averted or wholly cured by simple means. LAPAROTOMY-HERNIA. Laparotomy hernia constitutes a distinct type. It may de- velop in any region of the abdomen into which a blade has HERNIA. 53 entered. I have seen a hernia follow a stab wound, inflicted by the smallest blade of a penknife, in the left lumbar region. The Avound was a mere puncture, yet when the patient recovered and took his feet he had hernia. One case occurred in a boy who had a Avell defined perityphlitic abscess, which Avas opened directly down on end, and drained through a small opening. There is no manner by which they can be completely obviated, when the fascia pro- pria is penetrated. Many devices haATe been suggested to prevent them, such as cutting through muscular-tissue rather than apo- neurotic, AA'hen selection of site is permitted ; the homologous and independent approximation of tissue in closing in the incision ; but none of these expedients Avill always secure the patient against their development, though Avithout doubt, Avhen drainage can be dispensed Avith, the latter is the most reliable and efficient. They have a morbid-anatomy of their own. They are the most ungov- ernable of all hernia, and exhibit a persistent tendency to increase in size if the greatest vigilance is not exercised. As they possess no independent, serous investment they are not prone to strangulation. PALLIATIVE TREATMENT OF ADULT VENTR0-ABD0MINAL HERNIA. The treatment of ventral-hernia resolves itself into mechani- cal and preventive measures. Umbilical hernise of small size, as they commonly give no discomfort, require no special treatment. It is only Avhen they manifest a tendency to increase in size, or threaten strangulation, that they require a truss or support. A simple flannel or canvas broad belt, Avith a pad adjusted, is usually as efficient as any- thing. With those of great volume, all that an apparatus can do is to support them. Large, irregular protrusions, occurring above or below the um- bilicus, arising in consequence of the long-continued'intra-abdomi- nal pressure of pregnancy or parturition, require rather preventive than direct treatment, though the latter, in many, is efficient. If the abdominal girth is put on a great strain, by a distend- ing uterus, then an auxiliary, circular support, which will trans- mit the superincumbent weight from the muscles and aponeurosis to the strong, powerful column of the spine, should be applied, and its use continued till after confinement. 54 HERNIA. It has been seen, when the remedial-agencies of infantile- hernia were being considered, that the protracted rest on the back or side during lactation in the infant, was a potential element in cure. It is interesting to inquire, as to the utility of rest, after con- finement as a preventive against hernia or visceral displacement. We are told that among savage, non-civilized races, the mother is on her feet the day after the birth of her child. This is the common custom with North American Indians, living in their natural state. As the mother during encienteWie pursues her usual, active occupation, and is sustained on the non-stimulating, precarious diet of the prairie or forest, her muscular system preserves its firm fiber, and her offspring is born small, lanky and devoid of fat; its average weight being from tAvo and a half to four pounds. With many, too, of our own working Avomen, they rise after the second or third day. The conventional period is nine days. In average cases this probably is long enough. But with the easy classes and with those Avho have borne many or very large babies, no doubt by pro- longing the time and giving the abdominal muscles an opportu- nity to contract and recover their full tonicity, the tendency to median, aponeurotic expansion and bulging forward of the vis- cera would be largely overcome. Obstetricians are divided in their opinion on the necessity of the post-partum binder. The late Professor Charles A. Budd used to say, that he could never see that it served a useful purpose, but he advised its employment nevertheless, because it ahvays gave the patient comfort. Surgically, the binder is an artificial girth, which affords rest to the abdominal muscles, hoav thoroughly fatigued from lono*- continued violent muscular effort, It is essentially a bandage, fulfilling the same functions in this instance over a temporary traumatized region of the bodv, and to my mind ahvays serves an invaluable purpose in civilized communities. There can be scarcely a doubt but a considerable number of those large hernial pouches which appear along the median-plane, as well as in those attributable to a free lateral sagging of the oblique and transverse muscles, are in the greater number of cases HERNIA. 55 caused by improper adjustment, or too early discontinuance of the bandage or binder after confinement. Embonpoint is pronounced, the body fills out in normal preg- nancy after the fifth month. The intestinal-canal itself no doubt also shares in this hypertrophy. Constipation is common, and the intestine in order to overcome the impediment from uterine Aveight enlarges in its calibre and is much thicker in its muscular coat, so that there is an actual and positive increase in its volume. Labor ended under favorable conditions of hygiene, involution once more effects full restoration. Many of these cases here described may be remedied, and the normal symmetrical outlines be restored by treatment, The individual should be placed on a light, easily-digestible diet. The boAvels should be kept open, and plenty of exercise may be taken Avhen the flabby abdominal Avails are trussed up. Electrization of the muscular Avails, with small hypodermic injec- tions of strychnine into the muscles, massage and douching sedu- lously employed in selected cases, each and all contribute towards re-establishment of tonicity in the abdominal walls. In those obliged to do laborious work, or in Avomen considerably advanced in years, little can be done. TREATMENT OF LAPAROTOMY-HERNIA. For laparotomy-hernise Ave can accomplish little when they have attained a considerable size. As they are not reducible gen- erally, they cannot be confined by any adjustment. And having no independent fibro-serous investing wall or sac to limit them, after the viscera have left the cavity of the peritoneum, they wander in every direction under the integuments between the muscles and cellular tissues. When they first appear, if they consist of omentum only, should adhesive inflammation fix them in the opening which they have made, and all severe straining be avoided, they may not SAvell in volume or advance any further. But when they are large and sAving over the abdomen, the best we can do for them in the wray of prothetic support, is to substitute an arti- ficial for the peritoneal sac. There are aggravated types of this infirmity in young, healthy women or men, which may be successfully dealt Avith by operative measures, but to be effective they should be employed early. PART III. CHAPTER IX. THE RADICAL CURE OF REDUCIBLE AND IRREDUCIBLE HERNIA BY DIRECT SURGICAL INTERVENTION. ITS ORIGIN, PROGRESS AND PRESENT POSITION. We have already, in a general way, dwelt on what retarded and what accelerated many great scientific truths, and what has cleared the way for the pioneers in the healing-art, who, by their industry, toil and genius, have earned for themselves an imperish- able fame in teaching mankind the art of preserving health, over- coming deformities and prolonging life. An historical description of ancient methods, devised and practiced in the early times, though attractive and full of inter- est, would have but little practical value in this century. For in those days little was accurately knoAvn of structure or function, and the facilities of the nineteenth century were Avholly un- known. Yet, withal, as many are under an impression that the 56 HERNIA. 57 operative-field in hernia was a terra incognita until the very recent past, and as hernial-operations, with different objects in view, have at various epochs been performed on a large scale, a superficial perusal of the more ancient literature,* may not be without inter- est and some advantage. In reviewing this part of the subject, we discover that for cen- turies those afflicted Avith hernia Avere objects of scorn and con- tempt, The victims of the infirmity Avere degraded, and Avhat was the most lamentable of all, when a hernia became strangulated, if palliative means failed to overcome it, it Avas was left undis- turbed, and the patient alloAved to perish unrelieved, as it Avas only in the beginning of the sixteenth century that strangulation Avas treated by division of the tissues. Encouraged by the suc- cesses Avhich obtained by intervention Avith the scalpel, reducible and complicated hernise were promptly treated by sanguinary measures, Avhich caused a large mortality. In the seventeenth century the spring-truss Avas invented ; and noAv it Avas discovered that with several, simple support would efface many hernise. Operations became unpopular. In the beginning of the nineteenth century, in spite of the claims of the spring-truss, it was in many in- stances being cast aside, when Gerdy, Wood, and others intro- duced a cure by invagination. This method, however, was short- lhTed, and passed into oblivion with its authors. The history of the radical cure of hernia is contemporaneous with the time of Celsus. This famous surgeon Avas not an extreme partisan of surgical interference, although he operated many times Avith successful re- sults. The precepts Avhich he formulated eighteen centuries ago cannot be much improved on, even now. Not only did he pre- scribe the age most favorable to success, but he likeAvise indicated the modification of procedure in the varying types of the infirm- ity. He directs a few incisions, resects the sac, and jealously guards against doing injury to the elements of the cord or testis- The omentum was cut away, and the surface of the stub was charred with the hot iron. We do not gather that he operated on *I am indebted largely to M. Paul Segond's valuable treatise for many data on the histori- cal part of this subject. " Cure Radicates des Hernies," edition 1st. 58 HERNIA. exomphocele. We find no mention of crural hernia by him, or any other author until the eighteenth century. It Avould appear that he regarded all hernia as having a peri- toneal investment, though he clearly distinguishes two varieties, viz.: One, in Avhich the protrusion is caused through a slipping and stretching of the peritoneum ; and, another, by a rupture, or tearing of this membrane. Oribase appears in the fourth century. He makes no men- tion of operation for strangulation, nor does he speak of elastic pressure, which was a very ancient expedient; but confines himself to only the reducible, incarcerated, and adherent, AAThich he dealt with by means of a keen-edged instrument. His writ- ings, however, reveal a remarkable fertility of genius, and many of the features of his technique have been utilized by operators of our time. Like Ball, of Dublin, " he twisted the neck of the sac and resected the dependent part." His directions as to the manner in Avdiich we should proceed in complicated cases are very minute and precise. He made a counter-opening in the scro- tum. He does not say Iioav durable his cures were, but it appears his mortality was large; some dying from hemorrhage, others from peritonitis, and many more from pysemia. Oribase regarded a lively inflammation over the seat of operation, as indispensable to secure permanent results. ^Etius and Paul, of ^Egina, in the fifth century, recom- mended and practiced operations on reducible-hernia. They di- vided hernia into two grand varieties, to which they attached great importance, viz.: One, by rupture of the peritoneum with a brusque advent and violent symptoms; the other, occurring by an elon- gation and distension of the peritoneum, of a slow, imperceptible and painless development. Umbilical-hernia of every description they undertook to cure. Their steps in operation varied but slightly from the latest we are familiar Avith. In inguinal hernia, when the intestine came doAvn into the scrotum, they removed the testis <$ci that side, but when the omentum appeared this Avas exsected and the testis retained. In enterocele, after a long incision was made, and the testicle stripped, it was confided to an assistant, and the spermatic cord moderately drawn on, when a double threaded suture was passed HERNIA. 59 through the inner pillar of the ring and out above, in such a man- ner as to firmly close the canal and tightly compress the vessels of thfc cord. The cord Avas now divided and the incision closed. With bubonoceles a similar incision is made through the in- tegument; the omentum dniAvnwell down and cutoff; its vessels ligated and then returned. The divided sac is hoav closed, in- vaginated on a sound passed up the inguinal canal. After remain- ing in situ from three to six days the sound is AvithdraAvn and the opening closed by granulations. From the time of ^Eginus, AAThich Avitnessed the fall and de- struction of the Alexandrian school, the art of surgery passed from the hands of the Greeks to the Arabs and Europeans. With the latter until the sixteenth century, the time of the Reformation, medical science and religion Avere associated together. Departing or driven from Toledo, a number of physicians, mostly JeAvs, scat- tered through the south of Italy and founded the school of Salerno, Avhich gave to the world the celebrated Constantine, who enriched the treasures of surgical knoAvledge by the translations of Hippo- crates and Galen. Salerno became the most celebrated of the Italian schools, the recognized scion of its Arabian predecessor. It Avas this great centre which produced Roger of Palermo, Roland and the " Four Masters." But towards the end of the twelfth century Salerno had to encounter a formidable rival at another extremity of Italy, in Bologna. In Italy, in the time of Roger and Rowland, surgery had largely fallen into the hands of empirics. The greater part of those, says Brunus, w7ho practiced the healing art in those times were rustics, fools and imbeciles, the most depraved and the vile, presumptous Avomen, Avho feared nothing. At this time, the same state of affairs prevailed in Paris, Avhere nearly all the surgeons Avere clergymen; Avho regarded any sort of surgical operation as beneath their dignity, and every description of manual function as beneath them; leaving to the barbers, scarifying, leeching and bleeding. Lanfranc himself never opened the abdomen for ascites, never operated for hernia, nor cut for stone. A surgeon then had to prepare to deal with a reign of empir- ics, charlatans, and traveling operators; the " cutter for stone," Hernialists, those who "punctured for cataract," "bleeders," 60 HERNIA. " extractors of teeth," men and Avomen. They cut and slashed, mangled and mutilated the inhabitants of ancient cities and vil- lages. They promised to cure every sort of hernia, castrating every patient, and to such an extent that they threatened to strip the country of its most virile and useful citizens. Now those in authority interfered, and, by the severest edicts, the progress of those merciless mutilators Avas arrested. Nevertheless, in spite of imperial edicts, castration was in vogue for a long time. In Montpellier, Balesere de Tarante cas- trated lepers, and Peter of Borsia, castrated for simple hydrocele. Indeed, castration was practiced not only among charlatans, but by accredited surgeons, and Avas so Avell recognized as a cure for hernia, that in the eighteenth century kelotomy, literally speaking, was understood as synonymous with castration. Guy de Chauliac represented the surgery of the fourteenth century, and in him Avas incarnated Arabian science. Not only, had he given the precise methods for radical cure of hernia, but also clearly and fully set forth appropriate cases, Avith their im- mediate dangers and probable results. He divided hernia into two great classes: (1). Umbilical. (2). Inguinal. As his predecessors, he recognized hernia by stretching of the peritoneum, and by rupture of it. Though a frequent opera- tor for hernia, he had great faith in the efficacy of bandaging, plasters, topical applications and regimen. He is said to have cured patients of sixty and eighty with local medicaments alone. It is reported, hoAvever, that he resorted to methods which savored of quackery, for he claimed to possess a secret preparation, compounded by himself alone, which he administered in a peculiar fashion. His patient being placed on his back, Avith a metallic plate over the hernial tumor, which Avas firmly compressed by a bandage, he commenced to dose the patient with his favorite powders, which, he claimed, after their full therapeutic action was developed, would, by a violent attractive power which they possessed for the metal, draw the hernia upward into the abdomen. Theodorus, Crevez, Pierre and Lanfranc each, in various ways, resorted to caustics, chemical and thermal. Arsenic Avas the favorite ingredient applied directly over the ring when the hernia was reduced ; beginning on the surface its HERNIA. 61 erosive action, it ceased only Avhen it had divided the spermatic cord and penetrated deeply. The patient was confined a long time to bed, and when he survived the ordeal, he was required to wear a support for thirty days. Others ligated the sac, removed it and then freely cauterized the pedicle and adjacent tissues with the potential cautery. Franco, after having removed the sac, staunched the hemor- rhage and freely exposed the canal; lightly touched over the nude parts Avith caustics, in order that the succeeding inflamma- tion might be rich in plastic, cicatricial material, and therefore offer a more solid and resisting barrier against the re-descent of the hernia. The Point Dore was devised, it is said, by a Swiss named Metheus, in the eighteenth century. Master Metheus operated by pursuing similar steps to his predecessors, in exposing the canal, liberating the spermatic cord, and dividing the sac; but he employed a suture of gold, Avith Avhich he approximated and fixed the inguinal rings in such a manner as to seal the canal, yet preserve the cord. It is said that Ambrose Pare gave it a trial, but soon laid it aside and condemned it. At this time (the fifteenth century) two traveling charlatans Avent through England curing hernia. Their method was essen- tially the same as those of Metheus, employing a metallic suture to approximate the pillars of the ring. It is evident, that for a very long time the principle of pressure, as an auxiliary, to the cure of hernia Avas known ; hence, wre find Marcus of Pavia, Bartholomew of Padua, and others contemporaneous with them, employing a wooden-pad of a conical form, secured in an elastic-bandage to overcome the most refractory hernia. Ambrose Pare Avas a Avarm partisan of the massage-treatment in the hernia of young adults ; when they Avere recent, an emolli- ent aromatic ointment being ahvays employed in conjunction with it. In the more rebellious, he reduced the intestine by taxis, and then closed the breach en masse by carrying the suture from side to side, through and through, all the while guarding the vessels of the cord. 62 HERNIA. Pare also resorted to a species of inA^agination, for the cure of inguinal-hernia. He employed an ivory plaque with a strong curved needle, the eye being in its convexity. This Avas fixed in a firm holder. Having reduced the hernia, he seized the integument and adherent sac, pressing the cord aside, and introducing his ivory between the cord and the sac, carrying his needle around with heavy silk, behind this, through all the tissues. In this way the lumen of the sac was closed and the suture firmly tied, remaining in place fronten to twelve days. This simple method is said to have been introduced and first successfully practiced, on a large number, by Benditti, a Spanish empiric. In 1665 a Dane named Scullet, described a neAV procedure for hernial cure. This consisted in reducing the bowel, then, imbed- ding and fixing the testis in the canal. This was so successful as to receive the royal approval, and Avas regarded as an infallible measure. We are informed that he gathered in an immense fortune through its employment. Louis XIV, purchased at a high price, from Prior Cam- brieres, a remedy which he engaged to keep a solemn secret, until, the death of the prior, so that the secrecy of the remedy Avas sacredly guarded. The distribution of this " royal-remedy " Avas made Avith great pomp before Blegny, and the royal procurator. The famous rem- edy (?) consisted simply in nitrate of potash dissolved in spirits of Avine, Avhich was to be taken for twenty-four days; and, an astring- ent plaster was applied over the hernia. During the treatment, the patient might be about, on foot, but he must not ride horseback, or in a carriage, but ahvays Avalk or go in a boat, in the meantime, wearing a firm bandage. George I, of England, on discovering so many men in his army Avith hernia (1 in 8 soldiers), didn't hesitate to give £5,000 and a pension of £500 to a notorious empiric named " Little John," Avho claimed to possess a " sovereign remedy " against hernia. " Little John " after being idolized in England, crossed the straits with his remedy, to France. In this country, he met with bad results from the start. His method was a brutal and tortur- HERNIA. 63 ing one. He scarified over the sac, applied vitriol and pressure. He operated unsuccessfully on one patient three times, finishing by inducing a slough of the scrotum and loss of the testis. In the seventeenth century Nicholas Seguin introduced a truss, which he alleged would cure hernia so effectually that sanguineous-operations should no longer prevail. Saviard The- vinin, became engaged in a dispute about the priority right to a certain apparatus worn in hernia, Avith curative effects. Blegny was proceeded against as a charlatan, and under an injunction {line lettre de cachet) Avas for eight years confined in the Bastile. The ambulant operators for this infirmity, castrated so generally, at about the middle of the eighteenth century, in Holland, that the authorities ordered every-one, publicly lashed, Avho operated Avithout special permission for the cure of hernia ; or unneces- sarily castrated. At about the same time, in France, Robert de Housse Avas sentenced to three years servitude in the galleys, for ligating the spermatic cord in ten cases; in which, mortification of the testis folloAved. Mary Ann Presse, of Rheims, who had prac- ticed castration on four herniated infants, in each case followed by death, was publicly castigated and imprisoned for seven years. Hernial operations Avere again revived with great ardor in the middle of the eighteenth century, by Petit, Garengeot, Le Dran, Richter and Heister. The various symptoms of hernia, the anatomical mechanism and pathological changes Avere minutely and exhaustively studied by these eminent surgeons. Richter, in his famous treatise on hernia, lays it doAvn with great em- phasis, that bloody operations are out of the question in every de- scription of reducible, non-strangulated hernia. Jean Louis Petit denounced operative procedure for every species of hernia, except strangulated, and in those uncontrollable and painful. The views of his contemporaries, Gauthier, Maget, Bodenhan, La Condamine, and Bicetre, were in like respect conservative. Desault and Boyer operated on none, except those located in the umbilical region. They used the ligature in effac- ing the fibrous pouch, and required their patients to wear a sup- port for six months, after the parts had healed. Reneuline, Lagavanne, and Fabricius Hilandus, all had abiding faith in the efficacy of rest. The latter reported a man of 64 HERNIA. ninety, Avho had been cured of a large incoercible hernia, by re- pose alone ; he having been confined to bed continuously for six months. It may be said, that at the beginning of this century (nine- teenth), the radical cure of reducible hernia by sanguinary opera- tions had been definitely abandoned. It was the general opinion at the time that all the operations wrere dangerous to life, and that none of them were radically curative. Percival Pott would have every one hung who undertook a hernial operation, unless life was threatened. It wTould seem, hoAvever, from the Avritings of LaAvrence, Bichat, Scarpa, Beaumont, Schumacker, and others, at the begin- ning of the present century, that they had in certain rare cases resorted to hernial operations for reducible hernia. Operations sustained a crushing blow in the classic writings of Boyer, Avho explained in great detail the modus operandi of truss action, and of Astley Cooper, who operated in his lengthy career on nothing but strangulated hernia, and generally disapproved of all others. Very naturally, the inventors of trusses profited by the cessation of operations. " Medicated" trusses came into vogue, " possessing marvelous healing powers." A plant, possessing " won- derful properties," John Dubois had discovered. The tree grew in Cyprus. Dubois Avas a graduate in medicine, and Avrote a lengthy brochure on the subject. The book closed with testimonials of cure from many of the leading citizens of the realm. This is something like the Chinese system of curing hernia, as described by Mr. Duhalde, in the fourth volume of his travels in China. The Chinese commence by reducing the protrusion, washing the integuments and then applying the juice of ginseng and another plant named keon-ki. The patient is then restricted to a diet of rice, bread and water, wTith sheep's kidney. The patient is said to be radically cured in six days. In France the most singular claims were made for the cura- tive properties of various medicaments. Verdier, a hernial sur- geon, published in 1818 an article in which he claimed radical cures of hernia by pills of the muriate of mercury. Hernial operations, however, were again pressed on the notice of the profession in 1855, when there appeared the pro- HERNIA. 65 cedures of JVelpeau, Leroy D'Etoilles, Bonnet, Malgaigne, Mayor, Guerin and Thierry. These distinguished surgeons con- fined themselves to the inguinal variety mainly, although Boucha- court described a method for treating umbilical hernia. In Ger- many and England operations for reducible hernia failed to be- come popular at this time. When Gerdy died, the loss of his powerful advocacy and sup- port of intervention was felt, and in a short time again little was heard of surgical intervention in simple hernia. Wood, in England, in 1865 commenced to cure hernia by in- vagination. Heaton, of Boston, had attained to great notoriety in curing hernia in 1855, by subcutaneous injections into the in- guinal canal. In 1875 and later Schede, Nussbaum, Czerny, Reisel and Socin, taking advantage of anaesthetics and antiseptic protection, began to treat many cases of reducible hernia by sur- gical intervention. In France Championniere was the first to treat reducible hernia by operation on a large scale. The invagination operation was practiced on quite an extensive scale in England and Germany long after it had "become unpopular in the country in Avhich it originated. It possessed the merits of being a bloodless procedure, was not very dangerous to life, and Avhen it did not cure it generally left the hernia in a position by which it was more easily managed by a truss. But it Avas a painful and tedious method, and caused so much irritation in many that it could not be completely carried out. Wiitzer, of Bonn, "f^othmund, of Munich, Spencer Wells and Mr. Red fern Davies, of London, treated many by the invagination of the scrotum. Each had a peculiar mechanical device of his OAvn, yet all aimed at essentially the same object. The treatment lasted from seven to fourteen days, after which the patient must wear a light truss for three months, and abstain from all active exercise for a considerable time. THE MANAGEMENT OF THE SAC IN REDUCIBLE AND STRANGULATED HERNIA. Heister, in the eighteenth century, Avas the first who recom- mended and practiced the preservation of the sac. The theory on which this Avas introduced was, that as the cavity of the peritoneum 66 HERNIA. was not opened there was less tendency to shock or danger from consecutive peritonitis. There were many adherents of this plan who persevered in its practice until very recent times, but for reasons which will be later detailed it finally became unpopular. Birkett, in Holmes' System of Surgery, cites the views of Lawrence on the question of the radical cure of hernia, as viewed in the time of this distinguished surgical authority, who said: " The subject of a strangulated hernia submits to an operation in order to save his life, but he whose hernia is reducible endangers his life to get rid of an inconvenience, for which an operation affords no greater prospect of entire recovery than he had without it. For after he had undergone an operation at the hazard of his life the complaint may return, and the only protection against a relapse is to wTear a truss." Velpeau * tells us that Garangeot and Steffens dissected up the sac, folded it into a peleton (pad) and fixed it in the canal as a plug, in all operations for strangulated inguinal hernia. This is what Professor McEwen, of Glasgow, is doing in our time with reducible hernia of the same type. Kocher's operation is essen- tially the same. The only exception which Garangeot made Avas in epiploceles, when, instead of the sac he employed the omentum to block the passage. Their aim in more ancient times was, as is ours at present, to obliterate or plug the outlets with new tissue, Avith the omentum, testis, sac, or integument. The venerable Gross, in the seventh and last edition of his famous treatise on surgery, speaks thusAvise of radical cures of hernia: " Various methods besides the truss have been suggested for promoting the radical cure of hernia. Some date back to a very remote period of the profession, and partake largely of the rude nature which characterized the practice of the older surgeons. To this category belong excision of the sac at its neck ; its in- cision, Avith the application of irritants, for the purpose of inducing its obliteration; all of which resulted in much suffering, besides the loss of many lives. What surprises one is not that these oper- ations have been practiced in ancient times, but that they should -have been repeated at a comparatively recent period. In scrotal *Halad Chirurg., Vol. II, 3d Ed., p. 224, Arelpeau. HERNIA. 67 hernia the testes were often extirpated with the sac, and so com- mon had this practice become in the seventeenth century .that Dionis asserts that a certain itinerant operator Avas in the habit of feeding his dogs Avith the organs thus removed. Hardly less cruel and unscientific are some of the more modern devices for radical cure of this complaint, especially that of Belmont, Avhich consists in exposure of the neck of sac and introducing gold-beat- er's skin, Avith a vieAv of exciting adhesive inflammation." Bonnet recommended acupuncturation of the sac in reducible hernia, after the intestine had been returned into the abdomen. .After the needles had excited suppuration pressure Avas applied. This Avas in 1836. Of fourteen cases thus treated, eight failed, four Avere cured, and t\vo died. Pancoast, of Philadelphia, and Velpeau, of Paris, invented a method for radical cure, Avhich was based on the same principle as that employed in treating hydrocele. The intestine Avas reduced, and strong iodine tincture injected into the sac, after which firm pressure was maintained. Of these operations, Gross says, suc- cesses "were few and far between." About twenty years ago, Dr. Joseph H. Warren, of Boston, at- tempted to revive the operation of Heaton, though he injected the tincture of iodine, instead of extract of oak bark. By an ingeniously constructed syringe the liquid Avas sprayed either along the interior of the empty elongated neck, or into the wTalls of it, or just outside, into the interspace. Dr. Gay, of Boston, in 1870, gave this mode a thorough trial, operating on eighteen cases, with the following results: Five cures, eight benefited, and five failures. Dowall, of Texas, thought he had discovered a manner of operating Avhich would cure reducible hernia, and so enthusiastic was he at the beginning that he Avrote a lengthy monograph on its technique and results, but like many others of its predecessors it was ill-fated and short-lived. Dr. Jamison, of Baltimore, described a singular and unique method of treating hernia many years ago. He operated on a young lady, who had a large inguinal hernia, with an immense outlet. Stripping the sac, he returned it into the abdomen ; then he took a tongue-shaped flap of skin from the region of the Fal- 68 HERNIA. lopian ligament, and having pared the edges of the ring, he se- cured this with many sutures, in the breach, between the pillars. The graft became imbedded firmly in the hiatus, and this auto- plastic procedure is reported to have cured her infirmity. Although this venture can be regarded as little better than a barbarous mu- tilation, yet, so great an authority as Velpeau spoke in high terms of it. The late Professor Amsby, of Albany, employed setonsr passed through the sac. They were occasionally moved " to and fro," to excite adhesive inflammation. Karnochan employed this plan on six patients. It was shortly discontinued. MISCELLANEOUS METHODS EFFECTING OR FAVORING RADICAL CURE. Different authors mention various severe cases of reducible and incarcerated hernia, Avhich underwent permanent cure, while those who had them, were confined to bed, suffering from serious desease or injury. Many cures of reducible hernia have been reported through the "rest treatment" b}T Hilandus, LeDranr Pott, Hey, Earle, Cloquet, Bramsby and Astley Cooper, Heister, Schmucker and others. Dr. J. Collins Warren, in Boston, recommended for treatment of adult non-strangulated hernia, that the patient be placed on the back, the bed partly inverted, i. e., the head loAvered and the feet raised, a sort of Trendelenburg position, Avith constant elas- tic graduated pressure over the hernia. This same identical mode was first introduced) thirty-five years ago by Maisson- neuve, for large, recent inguinal or femoral hernia. This had been designated " Cure by Posture and Pressure." Mr. Kingdom, of the London Truss Co., and Dr. V. P. Gib- ney, of the Hospital for Ruptured and Crippled in New Yorkr both report a large number of cases, as coming under their notices for trusses, who had been reported as cured by operation. One of the most notorious and remarkable charlatans that ever posed before the American public, Avas Heaton, of Boston, Mass. For fifty years he was knoAvn far and near; and during that time plied his craft with such a large measure of success that the herniated, from all sections of the United States and Canada, of all castes and classes, flocked to him for succor and to be cured HERNIA. 69 so that iii a short space of time he reaped a large fortune. He claimed that hernia of every description was curable; and at least convinced the people that such was the case. Not finding the West a congenial atmosphere for his progress, he immigrated to Boston ; and on his arrival had the audacity to invite the repre- sentatives of the medical profession to see him perform his ope- rations. They did not accept his invitation, and he at once became a martyr. The public press espoused his cause, and he soon derived the benefit of being gratuitously advertised the world over. He made a triumphal tour through England ; Avas wined and dined in London, as one of the greatest benefactors of the age, and re- entered the " Hub," a more popular man than he ever was before. Little wonder that he was lionized, for those who came to him Avith large old incoercible hernia, for which the most eminent sur geons could offer nothing better than a stiff truss, left Heaton cured. Like Prince Mattei, of Bologna, he kept his method a pro- found secret. It certainly is inexplicable; this strange fascination of man- kind for the mysterious. In no instance in medical history was this more conspicuously demonstrated than in the case of Heaton. Dr. Heaton was a regularly qualified physician, and one wTould think, that inasmuch as certain types of hernia are by their very nature absolutely incurable, he would not have the unblush- ing effrontery to proclaim to the profession and public alike, that none were beyond his skill, when they applied early for relief. So deep-rooted and widespread was the faith, which even the medical profession had in this strange individual, that finally the American Medical Association was forced to take action. It was regarded as puerile folly, to expect men to close their eyes to the evidence of their own senses, and allow their preju- dices to stand in the way of the acquisition of knowledge. Heaton had the secret. " He might die without revealing it," Hence a committee of the American Medical Association was appointed to wait on Dr Heaton, request permission to see his operations and report their observations on their utility and value. 70 HEBNIA. This was in the year 1851. The committee was composed of Drs. Geo. Hey wood, J. Mason Warren and Samuel Parkman. Heaton declined to permit the committee to witness any of his operations, or give them his secret nostrum.* The committee, though they were unable from any inspec- tion made, either to admit or deny the efficacy of any of Heaton\s claims, reported at the next annual meeting, " that there is no surgical operation at present known, which can be relied on Avith confidence, to produce in all instances, or even a large proportion of cases, a radical cure of reducible hernia," * * * * com- menting on Avhich, later, Dr. Heaton says: " I affirm to be false in toto." In 1872 Heaton's work appeared, edited by Dr. Davenport. The spell was broken. He gave to the world his precious (?) discovery which, when stripped of the charm of secrecy, no one seriously noticed. In this monograph he says: " I lay it down as a cardinal principle in all operations for the cure of hernia that any inflammation, except the mildest grade, must be carefully avoided. If the surgeon cannot operate without producing the four cardinal principles of inflammation, as laid doAvn by Celsus, viz.: " Pain, heat, redness and swelling, he had much better let his patient alone, for such a result can not do good. Gradually con- vinced of the truth of the above consideration, I have, for a long- time, patiently sought for practical means of avoiding inflamma- tion, and after eight years of discouraging experiment have dis- covered a process which I call the method of tendinous irritation.'7 He claimed that active inflammation prevented the wearing of the truss or bandage, something so necessary in his radical cures to be worn six months or more. It is better, he said, to wear it a long time than for too short a time. His injection fluid was composed of one-half ounce of fluid extract of quercus alba, with 15 grains of the solid extract of the same. To this was added a grain of morphine. Sparton's operation for radical cure consisted in invaginating the sac, perforating it with a corkscrew which had a wide spiral, bringing the point out through the upper wall of the canal and threading it with a suture, leaving it in situ from four to five days, *J. C. AVarren, on Hernia. Introductory. HERNIA. 71 then AvithdraAving it and filling the canal with a metallic plate, which was secured by twTo sutures and retained in place until the parts consolidate. According to Spanton, this operation is specially suited to congenital inguinal hernia of young children. CHAPTER X. THE MORE ANCIENT METHODS OF TREATING STRANGULATED HERNIA. It has been seen that, until a comparatively recent date, the victim afflicted with strangulated hernia, in those cases which did not admit of relief by other than simple means, Avas left to die with- out operative intervention. As the ansesthetic properties of ether were wholly unknown till the fourth decade of the present century, surgeons Avere often driven to other expedients when called to relieve this always grave class of cases. Simple and tobacco clysters, purgatives, general bleeding, emetics, baths, postural treatment, and other expedients were re- sorted to with the hope of overcoming resistance. It was seldom that an operation was undertaken until all other measures failed. Surgeons possessed of even ordinary skill were comparatively rare in those times. Besides, in the absence of ansesthetics, dexterity and rapidity of execution were a sine qua non, but few Avho had unusual opportunities ever acquired these faculties. In consequence, a hernial operation on one borderino- on 72 HERNIA. 73 collapse always entailed so much torture, and was attended with such an enormous operative mortality, that few could steel them- selves to put a patient through the ordeal, except the stout-hearted, or the adept. Indeed, Saviard tells us that but few left the table alive after this operation, in the eighteenth century.* Heister had such faith in the relaxing power of tobacco that he declared if it were employed early enough every strangulated hernia could be reduced Avithout cutting. An interesting incident is related of the manner in which he became an advocate of cold-Avater douching as an expedient in strangulation. Being called to a young man who had a strangu- lated hernia, he brought several of his students. Tobacco clysters and taxis were tried in vain, and the hernia could not be reduced. While hesitating as to Avhat course to pursue, an old woman came along, and quickly poured a pitcher of cold water over the tumor, when it suddenly disappeared from sight in the presence of the much chagrined surgeon. Taxis, or digital compression with forcible reduction, is an expedient of great antiquity. And to-day, in spite of all which we have accomplished in the operative therapy of hernia, we must regard it as the safest of all measures in the treatment of stran- gulation, judiciously exercised. In former times it was often at- tended with more pain and distress, and with, perhaps, less suc- cess in affecting reduction than now. However, it is obvious that Avhen the patient was brought to a state of collapse by exhaustive emesis, by phlebotomy or tobacco narcosis, he must have been rendered quite insensible to moderate pain. We have been unable to devise anything yet which will re- place digital taxis, and from what can be gathered, the same essen- tial technique prevailed in the past as at the present. THE MANAGEMENT OF THE SAC IN FORMER OPERATIONS FOR STRAN- GULATED HERNIA. While the earlier operators for reducible hernia, usually, with detail and clearness, described their management of the sac in •Saviard Legons Chimrgicales, Ed. 1st, p. 134. 74 HERNIA. cases for radical cure, we are left in ignorance of how the sac Avas treated when kelotomy AAras first performed for strangulation. It would appear, hoAvever, that until the time of the illustrious Petit, the beginning of the present century, that the seat of steno- sis or stricture was ahvays regarded as being in the neck of the sac. Hence, in all cases this was freely opened and the constric- tion divided from the inside. But Petit Avrote with great force and conviction against the practice, and proved that in the majority of cases the constriction was in the tissues external to the pedicle of the tumor; that the opening of the sac was not only unnecessary, but was fraught with danger, and greatly added to the peril of the operation. He also claimed that in those cases in Avhich sac and all were re- turned en bloc, relapse of the hernia Avas less frequent. His Avritings in Continental Europe greatly influenced opera- tions, so that Avith few exceptions this reduction en bloc Avas generally thereafter adopted. In the British Isles, however, Petit's vieAvs were only adopted by but A^ery few, until 1850, when the question was again revived, and was powerfully advocated by Aston Key and Mr. Luke. Their appeal to the mortuary tables appeared to speak with such conclusive force against penetrating the serous pouch in strangulation, that many had to admit that it unquestionably added an element of danger to operations for relief. In Gay's statistics on hernia in Guy's Hospital, for 1856, it appears that when the sac was opened in operation for strangu- lated hernia, the mortality was 60 per cent., and in those in whom reduction was secured under operation Avithout opening it, but twelve to the hundred died. It must be understood, that those cases in which the sac was opened were the most serious. One would have supposed that the introduction of antiseptic methods in more modern times would have removed the objection against dividing and exploring the sac, as older operators Avere restrained from exposing the viscera through a fear of consecutive inflam- mation following. Such, however, is not the case. Speaking on this point, in his latest edition on surgery, Avhen the antiseptic theory was in full blast, Gross says: " Since Aston Key's essay, the method of returning the hernia en bloc has met Avith much favor, HERNIA. 75> both in this country and in Europe, and is hoav justly regarded as one of the established operations in surgery." In the United States it has not attracted as much notice as its real merits de- serve. This eminent author, nevertheless, did not hesitate to open the sac, though he Avas never in accord Avith antiseptic methods. Erichsen, Avriting in his "General Surgery," 8th edition, (1885), page 788, says: "If in operations for strangulation, on division of the fasciae, overlying the neck of the sac, the hernia can be reduced, it of course would be unnecessary to lay open the sac, and the patient's chances of recovery Avould be greatly en- hanced, more particularly if the operation be performed on old scrotal hernia of large size." Thomas Bryant promulgates essentially the same views, 3d edition (1882), page 471, declaring, " that when the cause of the constriction is found outside of the sac, as is usual in femoral hernia, the opening of the sac is rarely necessary, division outside being all that is required. The surgeon who opens the sac in every case, clearly often does what is unnecessary. In the very latest and one of the most valuable works which Ave possess on operative surgery, that of Frederick Treves, Manual of Operative Surgery, edition 1st, page 512, volume II, it is affirmed," that as a general rule the sac should be opened. In a few cases in which the strangulation is recent, and the symp- toms not severe, and in which but slight attempts at taxis have been made, the sac may be left unopened and the hernia reduced, without inspecting the gut. In every doubtful case, however, the sac should be opened." THE SUBCUTANEOUS SECTION OF THE STRICTURED NECK OF THE STRAN- GULATED SAC OR DIVISION OF CONTRACTED RING. Bouchut,* of Paris, was the first who recommended this method of treating constriction by subcutaneous division of the stricture. He advised it only when the operator was quite assured that the contractions Avere in the circular fibers of the ring outside the sac. He reported many successes in operations for strangulated femoral hernia in Avomen by his method. * Bouchut, Oper. Chirurg., Hemic, etc. 76 HERNIA. In 1852, the Pancoasts, father and son, and a few others in America, adopted the operation, after Bouchut's directions, but they soon gave it up as unsatisfactory and attended writh more than ordinary danger. THE MANAGEMENT OF MORTIFIED OR GANGRENOUS INTESTINE OR OMEN- TUM IN THE PAST. From Avhat can be ascertained through a search of ancient literature, it appears that for a time after operations came in vogue for strangulation, the suspected or actually gangrenous intestine was treated in tAvo ways only. It was either returned into the abdomen, or it was opened and an artificial anm secured. Sir Astley Cooper, and many others contemporaneous Avith him, advised that in all instances in which the gut Avas suspected, or only in the incipient stages of gangrene, it should be replaced in the cavity of the belly. There has been, for a long time, much difference of opinion about the proper treatment of the omentum in strangulation. Some returned it en masse, when free from mortification, AArhile others not fearing hemorrhage or subsequent inflammation, which, it was alleged, it might give rise to, excised it at the inner outlet. In the latter part of the last century surgeons commenced to open the intestine and empty it, in those cases in which its in- creased volume rendered its return difficult after the sac was ex- posed in strangulation. This practice was initiated in Germany by Mohedenkon, and practiced by Mein, Roggenbau, Kriiger, Kollrenter, Graffe, Ludwig, Roeke, Lofler, Dax, and Kelacker; in France, by Lenoir, Nelaton, Gosselin, De Roubaix, and others. Resection of the intestine for gangrenous hernia has been successfully practiced, says Gross, since 1727, by Ramdohr, Dieff- enbach, Kceberle, Kocher, Haggedorn, Nichodain, Czerny, "Mohe- denkon, Miner, Roggenbau, and Bird, of Illinois. Early in the nineteenth century, Astley Cooper, Callisen, Guthrie, and Brodie, had successfully experimented in resecting the intestine of the dog, but in every case in which this line of practice had been applied to the sphacelated boAvel of a patient suffering from hernia, death speedily folloAved. HERNIA. 77 CONCLUDING OBSERVATIONS ON THE OLDER OPERATIONS. So far has been traced the history of hernial treatment for the simple, reducible, incarcerated and strangulated, in the infant and adult, and in the male and female; in times Avhen the means for readily effecting hsemostasis or combatting inflammation were un- knoAvn or imperfectly understood; before pulmonary ansesthesia or the analgesic properties of cocaine were thought of. This review has been indispensable, before the subject of the \Tari- ous operations of our time for reducible or strangulative can be studied. By it Ave have seen Avhat has been done in the way of curing reducible and irreducible hernia, the degree of success attending interference and the extent of mortality. In strangulated hernia an endeavor Avas made to reach the consensus of opinion on the question of the treatment of the sac. When ansesthetics came into vogue and the antiseptic theory became practically a doctrine, an immense impetus was given to operative surgery, and of all the regions of the body there is none, perhaps, if Ave except the generative tract of women, in which a greater revolution has been wrought than in the hernial regions —the inguinal and femoral—of men and women Avhen occupied by hernia. Yet Avith all this advance, it must be said with all candor, that we can permanently cure but few reducible hernise by operative interference, and that the mortality following opera- tion for strangulation is considerable yet. Nevertheless, some substantial progress has been made of late, and methods have been devised which favor cure in proper cases, and operations for strangulation are being followed by a greatly reduced mortality, so that a great incentive remains for us to continue our efforts with a view of finally devising such a technique as Avill be at- tended Avith the least danger to life, and the greatest prospects of permanent relief of the infirmity. CHAPTER XI. A FEW GENERAL OBSERVATIONS ON OPERATIONS FOR RADICAL CURE OF REDUCIBLE AND IRREDUCIBLE HERNIiE, AS PRACTICED AT THE PRESENT TIME. Although there is a considerable number of operations for the cure of hernia, in Europe and America, at the present time being performed, still there can be little doubt but their number has been markedly diminished within the past tAvo years; in other Avords, that a reaction, definite and pronounced, has set in against the utmost indiscriminate surgical interference, which Avas the rule with a larger number of operators in the recent past. This is attributable to the firm position Avhich many occupied against a so general resort to sanguineous methods, for the perma- nent cure of an infirmity, which in general may be cured or borne by prothetic measures, and which is not very often attended with danger to life. Besides, as time passed, the number of re- lapses in those cases which had been reported cured, were becom- ing very numerous. And with not a few of them, the recurrent rupture, which had tumbled through a recently closed hernial out- 78 HERNIA. 79 let, had become more unmanageable and of greater volume than the original. In not a feAv, when a hernia of considerable size had been returned and confined on one side, another appeared on the sound side. With some, the scar-tissue along the canal had caused so much pressure on the efferent vessels of the testis, as to in- duce a painful varicosity of them, or atrophy of the gland. In three of my own cases, in Avhich there had been no return of the hernia, the patients, all males, seemed to be haunted by an oppres- sive, unaccountable melancholia, a mental alienation, which I inter- preted to arise from irritation of the spermatic filaments of the sympathetic and other nerve branches compressed in ligating the omentum or sac. The incompleteness or imperfection of the oure in many so-called successes Avas only too manifest by the subse- quent necessity of wearing the truss, spica-bandage belt, or ceinture. Again, after a time, as the structures which enter into a her- nia Avere more critically studied, a better acquaintance with the aetiology of the infirmity Avas had, and it Avas seen that many of the radical operations demanded an extensive division or mutila- tion of important structures in their continuity, confidence Avas re- placed by skepticism, and, in many cases, approval by condemna- tion. NotAvithstanding, hoAvever, the A-icissitudes through which modern operations for the radical cure of hernia have passed, the impartial, progressive and experienced must admit that they occupy a legitimate position in surgery, and in proper cases, skil- fully performed, serve an invaluable purpose. But the cases which are suitable or justify intervention are comparatively few, as already stated. For the purpose of being able to recognize those of the non- strangulated variety, Avhich are appropriate for operation, it may be well to first describe those in which mild, tentative measures suffice to effect a cure ; next those in which relapse is almost cer- tain to folloAv, and lastly, those patients suffering from a species of hernia, the removal or reduction of Avhich is attended with great danger to life. We would not operate on the infant or growing child unless his hernia was ungovernable to truss-pressure, or was so painful 80 HERNIA. that no support could be borne, or unless he Avere a cryptorchid or were suffering from a hernia in the unclosed vaginal process. The tissues of the infant are tender and highly vascular. The structures are at this stage of life in but their formative stages of development. The infant has practically no inguinal canal, both apertures being directly opposed to each other until nearly the third year. In large adult hernise, particularly direct inguinal and every other type of the malady of long duration and of considerable volume, Avhich causes extensive pathological changes at the rings, in the canals through Avhich they pass, in the sacs Avithin Avhich they lodge, and lastly in the viscera, the mesentery, omentum or intestine, no sort of operation can, in many of such cases, be re- garded other than a relief measure of doubtful propriety. Histo- logical, interstitial changes have advanced; pressure, tensionr Btrain and disturbance of nutrition have irretrievably altered the supportive girths of the loAver abdomen. The mesentery has elongated or lost its tonicity, and the intestine itself has increased in length. The valvular property of the canals is lost, and their ob- liquity has disappeared, nothing remaining but one large,. common portal, through wThich the protrusion emerges directly.. Those employed in occupations of a very laborious character are not a desirable class on Avhich to undertake the radical cure. With them the hernia is almost certain to return in a short time in an aggravated form, so that unless there are special and pressing reasons, hernia with this class should be left to bandage-pressure or the truss. Radical cure as an electiA7e measure should never, except for some special reason, be recommended in those whose occupations are sedentary, Avith those of abundant means and pos- sessing every facility to secure expensive and perfected retentive apparatuses, unless they endanger life. Nor is it often a justifi- able procedure in those very advanced in years. Relapse is almost inevitable in musicians who play Avind instruments, in public speakers, or those afflicted Avith asthma or chronic bronchitis, unless the broad belt is constantly worn. Operations are dangerous in all cases of voluminous hernia, unless they have been reduced by taxis before operation is con> HERNIA. 81 menced on them. To this class particularly belong umbilical and large laparotomy hernia'. The danger arises from the sudden return of large eventrations, which have, for a long time, been domiciled outside of the ab- dominal cavity, and have acquired their nutritiA*e supply mainly from the vessels Avhich ramify through tissues, among which the viscera have strayed. When pulmonary anaesthetics must be employed, we should not overlook the dangers attending their administration in those laboring under organic disease. CHAPTER XII. THE RADICAL CURE IN STRANGULATED HERNIA. There is no unanimity of opinion among surgeons on the question of combining measures for radical cure with the liberation of a strangulated hernial Those who oppose every sort of unnecessary manipulation when one proceeds to operate for this desperate condition, do so on the ground that as our patient is generally in a state of collapse we should compress the time for operation into the narrowest pos- sible limits. No statistics are extant which might determine the validity of this allegation, as to whether the mortality is actually increased in operations for strangulation wTith radical cure com- bined. However, it is rational to assume when our patient is in a state of great prostration and shock, the more quickly we can re- lieve the stricture the greater would be his chances of recovery. I have had one patient who was brought in for operation for strangulation die almost at once after he was placed in bed. 82 HERNIA. 83 Another, a middle-aged woman, died under our eyes, on the table, before the house-surgeon could complete the division of the con- striction. Three have died within an hour after they were re- turned to bed from the operating-room. But there is a large number of cases of strangulations which come under our treatment comparatively early. Since it is be- coming more generally known that early operations are safer, and the prospect of cure is held out by surgical intervention, this num- ber is rapidly increasing. Even in those cases presenting the most unfavorable symptoms, Avhen we can dispense Avith pulmonary anaesthetics, we may pro- ceed wTith more deliberation, and extend the period occupied by adding the necessary steps Avhich favor a radical cure. Since McBurney's operation was first devised, about three years ago, I have operated on twelve cases of strangulation, in every in- stance combining measures for radical cure, though not always employing the above-named method. The mortality in my hands has not been as high as it was previously, when nothing was attempted beyond reducing the strangulation. COMPARATIVE MERITS OF OPERATIONS FOR NON-STRANGULATED AND REDUCIBLE HERNIA, BY MODERN METHODS. It wTould be impossible for one to enumerate the almost infi- nite number of operations for the treatment of non-strangulated 'hernia, which have been devised and described during the past ten years. Every country has scores of them ; America, probably taking the lead. But comparatively few of them have been ap- proved of, or have been adopted by the profession, while many of those which wrere at first most eagerly accepted, and have been most extensively practiced, are becoming unpopular, and are found Avanting in the qualities claimed for them. Many were taken up because of their novelty and the manner in which those who first elaborated them claimed that they were almost never-failing successes. When reports commenced to come in, that they were found wanting in the hands of others, their authors, at times, resorted to Heaton's tactics, to the subterfuge alleging that in those cases of failure they bad not been properly performed. 84 HERNIA. Dr. William T. Bull, of "New York, presented a brochure at the annual convention of the " American Surgical Association," in 1890, the most interesting and valuable that has been written by any one, in any country, on the subject of modern operations for non-strangulated hernia. But in his essay he went to such ex- treme lengths as to deny that any operation whatever could be relied on to cure reducible hernia, He would regard no case as cured, which had not stood the test of three years. These he claimed Ave re uncommon. He col- lected his elaborate data from Avidely separated sources, and in- discriminately analyzed all the most modern and popular opera- tions, particularly condemning in unmeasured terms the so- called " open operations." Commenting on the varied, simple and complex technique of different operators, and the results of the cases treated by himself, after different methods, he concluded that the safest and most use- ful in the greatest number of cases was that one which was easiest and simplest of performance. This essay of Bull's has been followed by a reaction, for the views which he enunciated were something more than theoretical deductions, but were the outcome of a very large and extensive experience in the service of hospitals, which furnished him with an abundance of clinical material with wThich to support his con- clusions. He raised a forensic question, too, inasmuch as lie practically condemned as unjustifiable those operations Avhich • were being performed on painless, harmless hernise. So that noAv surgeons in America are more circumspect, and employ more cau- tion in selecting cases appropriate for sanguinary measures. The objectiATe point with all surgeons in all operations is fundamentally the same, viz., the restoration and retention within the abdomen of escaped protrusions. This object is con- summated only by removing the causes which lead to them, and restoring such a structural arrangement as will permit of normal physiological functions. The operation Avhich will accomplish these purposes w7ith the least danger to life, and the least mutila- tion of tissue, in the end, must survive and endure as the most acceptable. Surgeons are not in accord on the means by which this end may be best attained. HERNIA. 85 THE ESSENTIAL PRINCIPLES ON WHICH ALL OPERATIONS FOR RAOICAL CURE OR SURGICAL TREATMENT OF REDUCIBLE, NON-STRANGULATED HERNIA ARE PERFORMED. The fundamental, vital phenomenon indispensable to success, in the majority of hernial infirmities in adults, is local, adhesive inflammation, cell-proliferation, ultimately undergoing condensa- tion, and fibrous sclerosis. This phase of inflammatory hyperplasia is an active factor in the aetiology of hernia, but nowr it must be excited artificially, by the surgeon, in all direct operations for the relief or cure of it. In this particular, lime has brought no change in the therapy of hernia, THE AGENTS BY WHICH INFLAMMATION HAS BEEN INDUCED TO CLOSE THE APERTURE. These may be divided into chemical and physical. To the former belong subcutaneous injections of irritating liquids, the direct application to the tissues of caustic solutions, or actual cautery. As for mechanical agents their name is legion. Among them we may enumerate direct and indirect pressure; the seton, the suture or ligature, animal, vegetable or metallic. The mechanical technique of operation has undergone but trivial changes for centuries. The peritoneal investment or the sac has not yet been definitely dealt with in anything like accord among operators. Some lea\Te it undisturbed, except at its neck, which they ligate. Some twTist it, others reel it up and clamp it in the passage ; others inflate it Avith a rubber bag. By some, it "is caught up and woven into the divided rings. It is pulled down and pushed up. Finally, others have no use for it, and cut it oft inside the inner ring. Man}' have aimed to obliterate the inguinal canal, and at the same time preserve it, paradoxically as it may seem, for the passage of blood-vessels and other tubular structures. Efforts have been made to permanently approximate the tendinous pillars of the inguinal and crural outlets, and effect their union by the employ- ment of sutures, or by plastic inflammation. Many cut directly doAvn on the breach, turning back the in- vesting tunics, layer by layer, until the sac is exposed or opened. 86 HERNIA. When the toilet of the sac is completed and the apertures dealt with, they are again homologously replaced, sewn together, and covered in by what is knoAvn as the buried suture. Others, on the contrary, deliberately prevent primary union, and stuff the gaping wound with some irritating fabric which induces abundant cell proliferation, granulations, and adventitious tissue. The same diverging lines are pursued with the crural canal. The aim of many operators is to carefully preserve or restore it, while our latest completely destroy it. Diverse and manifold as are the methods by which reducible hernia has been and is treated surgically, the keystone of the arch of success is the utilization of a plastic solder, or cement sub- stance, the product of inflammation, which is designated scar or cicatricial tissue. The results of such operations, in a very large measure, de- pend on the perfection or permanence of the cicatricial welding of the divided parts together. Do such structures as the integument, the aponeuroses, muscle, tendon, or serous membrane ever regain their pristine retentive strength and elasticity after complete division and subsequent reunion by cicatricial tissues? And if they do in a measurable degree, which is the most durable and firm, that which succeeds prompt, primary union, or that which is yielded by granulation tissue ? If the first question can be answered in the affirmative, then, indeed, the range of hernial operations for radical cure is a wide one. On the contrary, if the opposite obtains, then such operations must be confined within very restricted limits. If granulation tissue is firmer and more unyielding than that which succeeds primary union, then the open treatment, with a suppurative sore, should be encouraged in every operation for the cure of hernia. CHAPTER XIII. THE MECHANISM OF HERNIA FROM A STANDPOINT OF STRUCTURE, FUNC- TION AND ABNORMAL CONDITIONS. However desirable it may be, yet it is quite impossible in a treatise which deals with the practicability or the possibility of curing hernia, to avoid a brief reference to that deviation from normal anatomy and physiology in the apertures prone to this in- firmity in the abdominal Avails. The inguinal-canal in the male is said to be caused by the de- scent of the testis, which occurs between the sixth and seventh month of utero-gestation. How it is formed in the female, the so- called canal of Nuck, is not capable of explanation. For here, surely, the generative glands do not leave the abdominal cavity. The testis in its march outward pushes before it from within, the parietal peritoneum, or transversalis fascia, which becomes the processus vaginalis ; some of the muscular fibers of the internal oblique, constituting the suspensory muscle of the testis, the ere- master; the aponeuritic fibers of the external oblique, from which 87 88 HERNIA. those dense felted fibers of the inter-columnar fascia are derived ; the superficial fascia, or cellular membrane; and the integument. Three arteries, several veins, nerves, and the vas deferens form the spermatic cord. These, as they emerge through the internal ring, are more or less bound together by fibro-cellular tissue very frequently, from the point at Avhich the spermatic canal be- comes obliterated above; and they are so adherent to the walls of their common, serous investment as to be separated only with difficulty. Frequently this is quite impossible Avithout laceration. The external or fibrous layer of the vaginal process is a thick, elastic sheath, which, unlike the inner peritoneal layer, is always, throughout life, an open sheath above; the interval betAveen it and the serosa being loosely occupied by connective tissue. In form it is that of a double funnel, being widely expanded above at its origin and again below for the testis. Some anatomists designate it the infundibuliform fascia. The inguinal canal is an oblique slit, which, including the rings in the male adult, is about three inches long. It commences internally about the middle of Poupart's ligament, or in the center of that line, which begins at the anterior superior, spine of the ilium and the spine of the pubis. It occupies an oblique position from above downward; commencing in the fascia transversalis,as it advances forward and downward passing anterior to the inter- nal oblique and transversalis, and posterior to the external oblique. The internal epigastric artery passes up between the peritoneum and fascia transversalis posteriorly, midway between the rings. The inguinal canal is always, in the normal state, completely filled by the elements of the cord or round ligament at its origin. Thia valvular vent is so adjusted that the greater the intra-abdominal or extra-abdominal pressure, the more completely is it closed. In this respect it is not altogether unlike the ureteral inlets to the bladder. In the infant both rings are so apposed that there is practi- cally no canal. In the adult the canal is funnel-shaped, being much narrower at its inner than at its outer opening, so that by invaginating the scrotum the tip of the index finger readily en- ters for two inches or more, until it is arrested at its inner ter- minus. HERNIA. 89 The external tendinous margins of its outlet are named pillars. Their anatomical elements consist of white fibrous^tissue, and are hence quite destitute of blood-vessels. The normal state of the ex- ternal ring is open, the viscera being amply walled back from pro- truding by the combined tendon of the oblique and transversalis muscles. The triangle of Hasselbach, in the normal state, ren- ders development of certain descriptions of inguinal hernia quite impossible. CONGENITAL DEFECTS OF DEVELOPMENT IN THE SPERMATIC CORD, THE INGUINAL CANAL AND OUTLETS, AND THOSE ARISING FROM PATHO- LOGICAL CHANGES. There is no region of the body in which nature so frequently fails in perfecting her processes of evolution as she does in that through which traverse the external parts of the male generati\*e appa- ratus. Had the male generative glands been retained in the abdo- men, as they are in some of the •quadrupeds, man would have been spared much misery. Why it is that they have been lodged exter- nally, is a mystery that our most astute physiologists luive been poAverless to solve. In the chapters on hernia in children it has been noted that the complicating changes that in- vite hernia are mal-descent or non- descent of the testis and cystic ■disease of the cord (Fig. 10). We yioav come to deal with pathological conditions of the cord and its .sheath, which have persisted with- out relief into adult life, or which, "having been apparently cured in FlG. 10. (Fciizet.) childhood, have relapsed in an ag- Congenital Hernia Before the Operation. graved form later in life. 90 HERNIA. It has been seen that normally, after the testis is lodged, the open, serous tubular strutcure becomes obliterated from above downward. But it may remain open, so that the tunica vaginalis and the peritoneal space become one common cavity. In this instance we will have a free passage for the omentum, or intestine, from within, outward into the scrotum. Hence, the intestine has no independent sac. In this class of hernia, the presence of a sac gives the operator no concern, for there is none. The fascia propria may close at the internal ring and remain open below, when the lower segment becomes distended by a serous accumulation; a hernia may come down, and while, though, there appears one common tumor, there are two independent sacs in this state. A small omental mass may engage in the canal of the sper- matic fascia, producing a genuine congenital hernia, Avhile the peritoneum has given way to pressure at the inner ring, and another hernia is on its way in the same direction. Large hydro- celes and voluminous spermatoceles, if unsupported in time, cause a great elongation of the cord and weakening at this internal portal. The relative positions of the rings have an important bearing as an setiological factor in the production of hernia; and as of late much is being done by surgeons to reproduce the displaced or dilated canal, it is Avell to endeavor to estimate to just what extent surgical manipulation or ingenuity may succeed in this direction. There can be little doubt but that with those strongly predis- posed to inguinal hernia, and when the infantile type is perpetuated, one ring lies in almost immediate juxtaposition with the other, and there is and has been practically no inguinal canal at any time. If there ever has been a normal inguinal vault in the her- niated, a large protrusion continually occupying it soon effaces every trace of it, and nothing remains but an immense, common orifice, a large open portal. Unhappily, with this derangement or destruction of the normal architecture in the inguinal region, though, we may in many cases partly prevent it, we are, as a rule, power- less to wholly repair the damage resulting from it. It is obvious, then, that in many cases it is absurd for opera- tors to lay down any common rule for the techinque of inguinal hernial operations, Avhich will apply to all. For instance, to de- HERNIA. 91 scribe the management of the sac, Avhen there is no such pouch present; to tell us how we must deal Avith the canal, when there is none, or hoAV the rings should be encountered, when, in fact, there is but one. Much has been Avritten on the manner in which we must pro- ceed in order to preserve the cord. But as there is neither cord nor testis in the cryptorchid, this it would seem should not em- barrass us in those cases. It is said that in about one in a hun- dred the testis has not cleared the inguinal canal in the new-born male, and that in one in five hundred it never leaves the abdomen.* Hence, in every case of hernia in the male infant the testis should be sought for. If it engages in the inguinal canal, and fails to com- pletely descend through the loAver outlet, it is a constant source of hernia, as by its presence it keeps the passage widely opened and favors the descent of the viscera. There can be scarcely a doubt but this irregularity of descent of the testicle is responsible for a very large proportion of ingui- nal hernia in the male. Camper, in dissecting 17 infants under three months old, found the fascia propria or peritoneal investment of the cord, con- tinuous with the general cavity, freely open on both sides in 11. It was open on the right side in 4, and on the left side in 2. Hence, in the 17 it wTas completely closed on both sides, at this age, in but one. There was no hernia. ♦Curling, on the Testis, page 203. CHAPTER XIV. INGUINAL AND FEMORAL HERNIA IN THE FEMALE, WITH OBSERVA- TIONS ON MALE FEMORAL HERNIA. The canal of Nuck, so called, which penetrates the musculo- aponeurotic planes of the lower abdomen of Avomen, differs from the male inguinal canal in transmitting through it no large tubular structure, but rather a fibro-cellular inpermeable cord, one of the supporting stays of the uterus, the round ligament. As Dr. W. C. Wile, of Connecticut, pointed out, in an extensive series of observations on apparent hernia in the inguinal region of the infant and adult female, that these protrusions consist very often, mainly, of cystic formations along the inner lamime of the infundibulum. Cystic changes in all the elements of the female generative apparatus are very common, not even the non-vascular ligamentous structures escaping. When those serous cysts undergo spontaneous absorption, during infancy or early childhood, no harm comes ; but when they attain considerable size and persist into adult life, their presence weakens the inguinal Avails and leads to hernia, 92 HERNIA. 93 FEMORAL HERNIA IN THE MALE AND FEMALE ; ITS MORBID ANATOMY AND PECULIARITIES. The pathological basis of femoral hernia is ahvays, primarily, dependent on defect of development, Many theories have been advanced to explain the morbid anatomy and structural devia- tions in evolution,Avhich are attended Avith visceral protrusion under the femoral arcade; yet, for the most part, they remain unsupported; hence our knovvledge of them still rests largely on hypothesis. In inguinal hernia in the male, the descent of the testis so clearly accounts for the breach in the abdominal Avails, the canal, and rings, that the modus operandi of this hernia is at once comprehensible and obvious. But with a hernia which insinuates itself on either side of or betAveen the femoral blood-trunks, as they leave the pelvis, we can adATance practically nothing as a causation. Nor is there, substantially, any good reason why femoral hernia should be more common Avith Avomen than with men. The crural arch is composed of the same structural elements in both sexes, though it is broader in females. As AAre study the physical con- formation of the parts concerned, and note the extreme obliquity of the course through Avhich a hernia must pass before it clears the sa- phenous opening in the fascia lata, we can appreciate the obstacle which this sharp curve must offer to an extrusion and circulation of the ingesta through a prolapsed coil of the intestine in this situation. Normally, as the vessels leave the pelvis in this situation, and occupy the femoral sheath, they are so protected by reduplica- tions of the parietal peritoneum, and are so firmly apposed and walled in by the cribriform fascia, that it is Avholly impossible for anv external substance to penetrate between their Avails. FIG. 11. Femoral Hernia. 94 HERNIA. In many subjects, however, we will notice at the point Avhere the vessels leave tbe cavity of the peritoneum, there is a layer of adipose tissue mingled Avith fibro-cellular elements, through Avhich the vascular channels pass. This has been named by Cloquet the Septum crvrale. Now, in not a few, we will discover a fringe of this fat, extending from the so-called septum along the inner surface of the common sheath to tbe saphenous opening. Tbe cabiber or diameter of the femoral canal depends on the presence and quautity of this substance, for Avithout it there is no canal. The deep layer of the superficial fascia, Avhich is extended over the boundaries of tbe saphenous opening, sometimes desig- nated the cribriform fascia, varies in thickness and density. The saphenous opening in the fascia lata, like tbe external outlet of the inguinal canal, has diameters very much out of pro- portion to the tubular structures to which it gives passage. Its superior and inferior borders, as well as its falciform pro- cess, the deep femoral fascia and the ligament of Gimbernat, are composed wholly of fibrous tissue. It is seen, then, that the femoral sheath, Avhich corresponds Avith the spermatic process, is a Arery much simpler organ in its construction, position, arrangement and relations than its proto- type, which passes over the arcade immediately above it; for it has no independent muscular envelope, nor does it transmit the duct of any secreting organ, but the great blood-trunks which pass through it. After the crural sheath reaches the saphenous open- ing, it acquires such firm and intimate adhesions Avith the walla of the vessels which it encloses, as to completely obliterate that interspace, Avhich, when caused by disease or artificially produced, is known as the femoral canal. Accordingly, when any extra- neous substance enters the canal from above, it is arrested at the entrance of the saphenous tributary, and here it must remain; or else in time make its way through the saphenous opening, carry- ing before it its mural support, the cribriform fascia and deep fe- moral, in which latter event we will have a complete femoral, and with the former an incomplete femoral, hernia. The numerous large absorbent glands which encircle the saphenous vein between the two layers of the superficial fascia, and are often found imbedded along the plane of the blood trunks HERNIA. 95 betAveen the septum crurale and the cribriform fascia, are nor- mally so adjusted as to give solidity and support to the walls of the femoral canal. In cases of lymphadenitis, which extends to the deep chain of the groin, the free plastic exudate, which is thrown out over the surface of the glands capsules, often causes such an extensiA'e ex- travasate, that when it is not completely absorbed, then its resi- due undergoes fibrous condensation and firmly Avelds all the tissues in the vicinity of the inflammatory changes into one mass, more particularly the envelope of the glands to the outer walls of the vessels. The position as well as the diameters of the saphenous open- ing ATaries, for it will be observed that it Avas many years ago pointed out by Bichat, that this portal in a large number of sub- jects did not always correspond in diameters or size in proportion Avith those of the subject. This same famous anatomist also noticed its varying obliquity and position. In women it will be found placed further inward, w7ith less obliquity in position and of greater dimensions than in men. It is •clearly evident, accordingly, that femoral hernia is wanting in that ■complexity of construction so •characteristic of the inguinal variety. Hence, Ave will not ex- pect to encounter those complica- ting pathological conditions so often here as we do in kelotomies, performed over Poupart's liga- ment. Yet they are sufficiently numerous to demand of us a famil- iarity with them before an opera- tion is undertaken for their relief or cure. It is well to remember that Ave may have a femoral and in- guinal hernia on the same side. The structural changes in the component parts of the femoral canal, necessary to make the advent of a hernia possible, involve, Fig. 12. Femoro Inguinal Region. 96 HERNIA. first, the apertures; secondly, the lumen of tbe femoral sheath,. and thirdly, the contents of the canal itself. It is self-eArident that Avith the canal hermetically sealed, nothing can possibly escape. But when it is remembered, that even under normally physiological conditions, the volume of what enters and leaves the canal is constantly changing, its diameters must likewise change, so that while they are under these conditions closed, they are not, so to speak, always filled completely. Second, the varying capacity of the femoral sheath. There can be no doubt but the diameters of the femoral artery are quite constant. The column of blood in this vessel is subject eATen in health to many influences, Avhich modify its volume and movement. The most con- stant influence perhaps is gravity; the next is ever-changing ca- pacity of the peritoneal cavity, particularly in married Avomen. Pathologically, any impediment in the inferior caATa, by tu- mors or enlargement of organs along its course, disease of it-i vah7es,or in its own walls,leadsto a dilatation and Aveakeningof the femoral vein. the event of it taking on atrophic changes, it leads to a widen- ing of the canal, and a descent of the viscera. The third, that which has reference to the contents of the fe- moral sheath independent of the vessels, is probably the most proxi- mate and direct of all exciting agencies, as a causative of hernia. In the greater part of diminutive, incipient femoral hernia- * we Avill discover on division of the tissues, and on exposure of the HERNIA. 97 canal, that the extrusions consist of omental tissue; that they are epiploceles. Through some fault of evolution during the formative stages of development in early foetal life, in some inexplicable manner a portion of omental tissue makes its way iuto the femoral sheath, after Avhich it may remain at the inlet, descend further doAvn, or pass directly through beneath the falciform pro- cess. It may be assumed that it often undergoes degenerative changes, or atrophies, and disappears. This is the only hypothe- sis on Avhich Ave can account for the frequency of epiplocele in femoral hernia. Normally, the omentum is above the horizontal plane of the internal femoral opening, so that the double perito- neal sac, Avhich Ave may occasionally meet with in inguinal her- nia, is seldom seen here. It is true that there are, at times, in cases of acute strangula- tion of a femoral hernia, no evidences of anything in the sac except a pinched knuckle of intestine; still, upon releasing the impris- oned boAvel, Ave will rarely fail to find along the track either free or adherent omental tissue of a varying volume, contour, or con- sistence. When this is firmly adherent to the Avails of the canal, or is restrained by a short, inelastic pedicle, it securely blocks the passage against intestinal transit. But Avhen, if it be loosely movable, and has, by its Avedge-like action, widely spread apart the Avails of the canal, then under a diversity of circumstances the free intestine, in close proximity, may slip down through, advancing onward beyond the situation at Avhich the adipose mass itself is lodged. In chronic old femoral, many of the land- marks of the surgical anatomist are practically lost. It is very often quite impossible to diagnosticate an incarcerated inguinal from an old femoral hernia. This is particularly true of the female, whose integuments are often under-padded by a A^ery thick layer of fat. And in many cases of large, impacted, chronic femoral epiploceles, it is quite impossible to recognize them from enlarged lymphatic glands. 7 CHAPTER XV. MORBID ANATOMY AND PATHOLOGY OF EXOMPHOCELES, EPIGASTRIC HER- NIA, EVENTRATIONS, OR LAPAROTOMY HERNIA. Umbilical hernia in the adult is seldom seen, except in infants and child-bearing women. It is well to have a clear compre- hension of its gross constituent elements, if Ave would the better appreciate what may be accomplished by surgical measures in seri- ous cases of this infirmity. While hernia in this situation in the male is rare, it is not entirely wanting; though it is with them usually of a small size, and is entitled to the designation only because it is in close prox- imity to the navel scar, for of its essential elements it contains none, and is outside of the umbilical aperture in many. With women it is attributable either to a rupture, or an elon- gation of the circular fibers which close in on the urachus and the round ligament of the liver at the umbilicus. In many the fusion of the muscle, aponeurosis and peritoneum are so firmly blended together at the annular aperture here, that the protrusion can advance in but one direction, and that is against the thin, wrinkled, 98 HERNIA. 99 integumental covering of the navel. It is marvelous how this can spread and expand, so as to reach a size as big as the fist, or even larger, when its coverings may become as thin as tissue paper. The contents of an umbilical hernia are omental or intestinal, or both. The reducible are usually enteroceles. Epiploceles are the most common in this situation in adult life, and are irreducible. The mechanism of a hernia here is altogether unlike that which occurs above and beloAv the ligament of Fallopius. In the latter situation we have canals and rings, through Avhich tubular structures pass, Avhich have a peritoneal invest- ment. In the umbilicus none of these are practically present. Here we have simply a weak spot in the upper abdomen, depen- dent on defective development and other causes. As there is no obliquity to the passage of emergence, and no bony supports, it is obvious that unless the opening, through which a hernia passes, is well buttressed by poAverful ligamentous or aponeurotic tissues, rapid eventration must often folloAv. In this situation, theoretically at least, one would suppose that a radically curative operation Avould offer the best prospects of success; as there is no impediment in the way of completely and solidly closing in the hernial Arent. Strangulation is not very frequent in umbili- cal hernia, though these hernise are commonly painful and are always sensitive, owing to their attenuated, integumental cover- ing; besides, they are quite prone to peripheral inflammation, ulceration and hemorrhage, Avhen their contents are omental. In aggraATated cases, the protrusion by causing a constant, well-sus- tained strain on the umbilical opening, in time so stretches or lacerates its borders that they give Avay, and any parts of or all the abdominal viscera except the fixed organs, may pass directly out of the abdominal cavity into this adventitious pouch. If Ave ex- clude the omental iiwestment, it cannot be said that hernia of any description in the upper abdomen has an independent peri- toneal covering. In this situation, also, we perceive that patho- logical condition which may be designated, rupture. As soon as the viscera leave the abdominal cavity en masse they by their presence excite irritation in the layers of the cellular membrane, subcutaneous tissues, or intermuscular spaces. This in turn causes an inflammatory plastic exudate, Avhich binds the 100 HERNIA. wandering organs to the parts into which they have trespassed. As a consequence of this neAv alliance, the source of their nutri- tive supply is changed, and hence, instead of the intestine being wholly provided by the vessels which course through the mesen- tery, it draws freely from the vascular supply of the cellular mem- brane of its neAv domicile. Those hernial protrusions of the greatest volume, hoAvever, Avhich issue through at the umbilicus, most frequently make their escape by a breach in the abdominal wall itself; although, as they emerge, they so press the tegumentary coverings of the navel forward as to mask their real origin. Epigastric hernise, or those Avhich are located anywhere be- tween the umbilicus and the tip of the ensiform cartilage, are most often encountered in the male sex. They may be so small as to quite escape detection, unless they become inflamed, or threaten strangulation. They are wholly of a congenital origin. In some manner, not understood, a small nodule of adipose tissue directly connected Avith the omentum makes its Avay through the medi- an line, imbeds itself Avith an adventitious sheath of cellular tissue, with which it forms adhesions. I met with such a case last Avinter, in a man fifty-six years old. For a short time he had symptoms of strangulation. There Avas vomiting, colicky pains and constipation. As he declined operation, by the hypodermic employment of morphine, Avarm applications and rest, the symp- toms passed aAvay. Over the tumor the tissues were swollen and exquisitively sensitive. He had it as long as he could remem- ber, and though he Avas all his life engaged in a laborious em- ployment it had never given him the slightest inconvenience before. Eventration or laparotomy hernia is essentially a traumatic infirmity. Since laparotomy is becoming so generally practiced in America by surgeons, particularly for treatment of diseases of the internal generative organs of the female, and for pathological conditions of the csecum and its appendix, these hernise are be- coming common sequelae of those operations. There can be no question of doubt about it, but a free incision into the abdominal wall or the peritoneal cavity is invariably fol- lowed by a weak bond, at any time liable to stretch or rupture. HERNIA. 101 It has been claimed that wdien the incision is made through the muscular planes, instead of the aponeurotic tissues, the chances of hernia folloAving union of the parts is considerably diminished. This has not been my experience, for the most intractible that I have met Avith Avere of the muscular variety, as has been stated. The morbid anatomy of a laparotomy hernia is very simple. There is a giving Avay or sundering of the parts the more deeply lodged, a gaping of the edges of the peritoneum, and an eventra- tion through the gap into the parts offering the least resistance. The pathological changes resulting are Avhat make many of them the most serious species of the infirmity that we haA^e to deal with in the Avhole category of hernia. As the intestine leaves the peritoneal cavity it produces a considerable elongation of the mesentery ; besides, by pressure and strain, it interferes Avith the mesenteric circulation and impedes peristalsis. As a consequence the general health suffers. The appetite fails and constipation follows. Along Avith this the necessary point a"appui in defecation is wanting, in consequence of the breach in the abdominal walls and defective muscular action. The eventrated parts become ad- herent to the tissues in which they are lodged, Avhich renders them irreducible, and, when ex- posed in operation, difficult to separate and free Avithout danger of damage to the viscera and con- siderable loss of blood. It is readily apparent when observing the broken irregular scar conse- quent on many laparotomies, that a hernia must follow if the parts are not braced constantly. (See Fig. 14.) Fig. 14. Three weeks after a Laparotomy for large Uterine Fibroid. CHAPTER XVI. LUMBAR, OBTURATOR, PERINEAL, PUDENDAL AND ISCHIATIC HERNIA. Besides the above, there are many other'phases^of structural defects or pathological changes which lead*to those conditions which are designated as hernia. They are those which are wholly internal, as diaphragmatic, and those Avhich involve Meckel's diverticulum, besides internal and external types, Avhich belong to the province of gynsecological surgery, such as prolapse of the bladder, the ovary, uterus, broad ligament, fallopian tubes, or the intestine into the vaginal outlet; or those cases of prolapse of the rectum through the anal sphincter, with or Avithout strangulation. But, with the exception of those which involve the female generative organs and the terminus of the rectum, these others of an internal order are so rare that many surgeons of large expe- rience have never seen them. Hence, this epitomized revieAv of those protrusions which are limited to the abdominal cavity, with a brief consideration of their elementary constituents, Avith morbid anatomy of lumbar, obtura- tor and perineal, pudendal and ischiatic hernia, will close this division of our subject, 102 HERNIA. 103 LUMBAR HERNIA. This is a pathological rarity. Sir Astley Cooper says he saw but one case. Lawrence does not mention it. The most complete and valuable contribution which we have on the subject is from the pen of Dr. Claudius Mastin, of Mobile, Alabama, to whom I am deeply indebted for his notes on this infirmity. In his brochure presented at the annual meeting of tbe Ameri- can Surgical Association in 1890, he Avas able to report thirty- three cases of lumbar hernia Avhich he had gathered from widely separated sources. But three were from American literature. Seventeen occurred in females and sixteen in males. Four folloAved accidents; two from spinal caries, one from old age, eleven came from injuries, three Avere congenital. Although Petit's triangle Avould seem to favor hernia, yet, as the obliquus internus and the latissimus dorsi so closely overlap on either side, and the lower convex surface of the kidney covers it in, its Aveakness is more apparent than real. The primitiA'e causation is said by all authors to be congenital defect of development. Of course, in traumatic cases folloAving punctured wounds, we have a direct, unequivocal factor in their setiology. Some of those recorded by Dr. Mastin Avere of this character. Of the latter, I have had one under my care in the Ninety- ninth Street Hospital, of NeAv York, in 1886. The patient, a young man of 20, Avas stabbed in different parts of the body ; though but one incision penetrated the abdomi- nal cavity. This one apparently transfixed Petit's triangle. When the patient entered the hospital he had lost much blood through the Avounds; and, besides, had hsematuria. He made a good re- covery, though a small hernia appeared at the site of the lumbar wound. After he left the hospital I lost sight of him. History of Dr. 31astill's Case.—Dr. Ma3tin's patient was a boy seven years old, Avho had a lumbar hernia, Avhich measured nine and one-half inches in its long axis and nine inches in its trans- verse diameter. He had also had a direct inguinal hernia on the same side (the left). It AAras partly reducible, and contained in- testine. It Avas comfortably controlled by a truss. In this case 104 HERNIA. it Avas apparent that there Avas a loss of substance in the obliquus and the latissimus dorsi muscles. This phase of hernia, like others of an unusual development, derives its greatest interest from a diagnostic standpoint, as en- largements here may often defy detection, and one may often be in doubt as to whether he has a neoplasm, hsematoma, or hernia to deal with. Second Illustrative case.—My patient, a derrick-man, AA^as acci- dentally, violently struck by the fly beam of a derrick, just over the right hip, on the inner side. He was able to rise and go home unassisted. A feAv days after, he came to me, AAThen I found a large spherical mass on the inner side of the quadratus lumborum muscle, on left side. I was at first in doubt as to its real nature. It seemed more like a traumatic hernia than anything else. It appeared to be slightly reducible and had a doughy feel. But there Avere no constitu- tional symptoms. Passing in an exploratory needle it Avas found to contain a limpid serous accumulation, Avhich I finally aspirated, and it did not refill. LUMBAR HERNIA IN FEMALE WITH CONTENTS OF SAC UNDERGOING MALIGNANT CHANGES. Dr. James Moran, of NeAv York, sent a case into my service, at Harlem Hospital, in January, 1891, for operation, of this de- scription. The patient was a married woman of 45 years of age. She had a fullness in the right lumbar region as big as her fists. She said that it had been there for several years, but that it never gave her any trouble until six months previously, when it became harder, painful, and AAras increasing rapidly in volume. After carefully examining her I concluded to make an ex- ploratory incision, and act according to Avhat it revealed. Mak- ing a long, free sweep of the scalpel, in an oblique direction from above downward, over the convexity of the fullness, I divided the integuments, and at once came doAvn on a thick inelastic capsule, Avhich had fused distinctly with the superficial fascia and the lumbar aponeurosis. After a difficult and tedious decortication it wras freed, until the broad aperture it had made through the fibers HERNIA. 105 -of the oblique muscles Avas reached, Here the detachable parts were dissected aAvay, after which a double toav of sutures trans- fixed its sessile pedicle. As it Avas traced into the cavity, it was found to be continuous Avith the omentum. Now a drainage tube was inserted, and the parts closed, layer by layer, as in the radical cure of ventral hernia. Her recovery was uneventful. Since she left the hospital there has been no her- nial return. Her former colicky pains have never annoyed her since, and the troublesome constipation of the bowels has given Avay to regular painless stools. Although this case Avas not one on Avhich an operation was deliberately undertaken Avith any definite end in vieAv, yet I can find no other cases on record of the same character, which had been operated on for the radical cure; and as these hernise only in the rare event of strangulation or neoplastic changes ever de- mand radical measures, we can understand why operations on them are almost never required. THYROIDEAN OR OBTURATOR HERNIA. Comparati\Tely little Avas known of this hernia until the remarkable memoir of Garangeot Avas presented to the French Academy, in the early part of the present century. A considerable opening is left in the uppermost segment of the thyroid-foramen for the passage of a nerve, artery and vein. Sometimes this space is incompletely filled, so that the omentum or intestine may croAvd the peritoneum through it and produce a hernia. The folloAving account is given by the author of a case which lie saAv post-mortem* " I found," he says, " on dissecting a Avoman, in her pelvis tAvo portions of intestine, Avhich had forced the peri- toneum through the superior part of the femoral foramin, and had each formed a tumor about the size of an egg between the anterior head of the triceps muscle, and, as these tumors Avere not suffi- ciently advanced to produce a projection of the subcutaneous fat, by Avhich they Avere thickly covered, no tumor could be per- ceived from Avithout.*' Among many other highly interesting cases, the same author mentions one of a woman Avho, after a fall, * Garangeot. 106 HERNIA. felt an extremely violent pain at the upper part of the right thigh,. over the course of the obturator nerve, near the labium pudendi, Avhich lasted three days, before he saw her. Garangeot discovered a hard, flat, painful tumor on the inner side of the thigh, about six inches in diameter. Raising the body and the knees, and gently but firmly rubbing the surface of it, it soon returned to the abdominal cavity with a distinct gurgling sound. The Avoman's nausea, colic, and retching, at once, ceased, and, within half an hour she had a free alvine discharge. Cooper said that up to his time no operation had ever been performed for strangulation of this variety of hernia. Malaval reported the case of Arnaud of a reducible, obtu- rator hernia. On account of the situation of the artery, in opera- ting, the incision of the stricture must ahvays take an inward and upAvard direction. In '< Ashhurst's System of Surgery " Ave learn that Hilton un- successfully opened the abdomen in search of an internal strangu- lation, and found a knuckle of the intestine in the obturator fora- men. His patient, Avho lost his life, had had pain along the course of the obturator nerve, but this important symptom had unfortu- nately been overlooked. M. Obre bad made an exploratory incision down on the saphenous opening, over a mass Avhich was lodged under the ad- ductor portion of the fascia lata. On dividing the fascia the pec- tineus muscle came into vieAV, and under this a peritoneal sac, as large as a hen's egg, w7as seen. This Avas opened, Avhen a loop of the small intestine was exposed. The strangulated edge of the obturator Avas divided, and the intestine returned. In the course of the operation the saphenous vein Avas opened, but Avas readily ligated. The patient made a good recovery. Roesel attaches much importance to the value of rectal ex- ploration as an accessory aid in these hernise. Dr. John Chiene, of Edinburgh (Ed. Med. Journ., Jan., 1887),. reports a discovery on dissection of a double obturator hernia in a female. In the sac of one Avas small intestine and in the other the ovary and fallopian tube. Of late years many operations have been reported for this hernia, though the mortality has been high. HERNIA. 107 PERINEAL HERNIA. This hernia presents about the same frequency in both sexes.. In men it descends betAveen the bladder and rectum, and in women between the rectum and vagina. It usually advances as far as the integument, though seldom sufficiently to cause a bulging of the perineum and a visible tumor. Commonly, its existence can be made out in the male only by an examination through the rec- tum, and in the female through the vagina. Mr. Bromfield {Chirurg. Observ., page 264,1857) cites quite a unique experience in a lad of seA^en years, on whom he Avas cut- ting for stone. " I divided the perineum," he says, " and was about to enter the bladder, Avhen a thin, diaphanous membrane made its appearance. The lad gave a scream when it broke, and a quantity of clear fluid escaped. After another scream the small intestine came down, through." He replaced the intestine, removed the calculus, closed in the parts, and the boy made good recovery ; no subsequent hernia following. In Astley Cooper's work, an interesting case is reported from the practice of John Limme, of Manchester. History of Case.—Patient Avas a lady who, though married se\Teral years, never had a child. She complained of vesical tenes- mus, difficult defecation, and occasional nausea, and came to this surgeon for an examination. He found a large SAvelling at the posterior part of the vagina, which compressed the os uteri later- ally. By firm and steady pressure he Avas able to return it com- pletely. She soon after conceived and suffered no more from her former infirmity. Dr. Smellie, in his Avork on Midwifery, cited the case of a woman who, five weeks before she fell in labor, had a tumor of this description, Avhich previously she could reduce herself, but now it Avas of increased size and very painful. He found her in great agony. The tumor Avas livid, with fiery, painful edges. She was lying on her back Avhen he saAv her. Noav he di- rected her to turn on her side. As she did the tumor broke in the middle, Avhen it gave issue to more than a pint of bloody ichor. She noAv exclaimed that the rupture had gone up, and her relief was great. Later he delivered her. Her rupture returned, though she Avas ahvays, thereafter, able to reduce it herself. 108 HERNIA. PUDENDAL-HERNIA. This hernia, as its name implies, is seen only in Avomen. I believe it is not uncommon in the child-bearing Avoman ; although as it almost never gives rise to serious inconvenience, it escapes notice. It must be remembered that hernia here, may become strangulated, nevertheless. It is usually situated in the inferior segment of the labium majus. Its cause is similar to that of peri- neal hernia, except that instead of passing by the vaginal w7all it penetrates and passes through it. Like the latter, too, it descends in the erect posture, and ascends on the dorsal decubitus. Cooper reports one such case, Avhich he successfully reduced by taxis. REPORT OF CASE SIMULATING PUDENDAL HERNIA. This case I Avas called in consultation to see by Drs. Pass- man, and George E. Hubbard, of this city, in the winter of 1888. The patient, a young Avoman, while hanging a picture, slipped from the chair on which she had been standing, in such a Avay that when she fell her crotch came astride the sharp back of the chair. A very large, extremely painful tumor immediately appeared in the right labium, which it Avas thought might be hernia requiring reduction or operation. This opinion Avas all the more rational, because of the situation of the fullness, its impulsion on coughing, and the fact that it could be partly reduced by taxis. On ex- amination, I found no constitutional symptoms pointing to hernia; besides, by examination through the rectum and vagina, I definitely ascertained its true character. It Avas a large hsematoma, Avhich disappeared in a few days. CASE 2.—PUDENDAL HERNIA, RIGHT SIDE. Patient, young woman, leading a " fast life," brought to me by her uncle (?). She had a large mass, nearly as big as a goose- egg, in the right labium, so that it noAv interfered Avith inter- course, which made it painful. It had been examined by others and pronounced a fatty tumor. But her history, the manner in which it came and disappeared, and a rectal examination, assured me that it was a hernia. There Avas a most pronounced impulse on coughing, and the straining of defecation ahvays increased its volume. By laying HERNIA. 10$ her on her back, Avith the shoulders depressed, and the hips raised, it could be almost entirely reduced. I advised her to keep this position in bed for a week. In the meantime, applied a compress against the pubic ramus, and kept the bowels Avell opened. It completely disappeared, and four years after treatment I saw her, and there had been no return. ISCHIATIC-HERNIA. This is the rarest of all those hernise protruding through the lower pelvic outlet. Cooper reports one, having occurred in the practice of Dr. James D. Jones, of the Barbadoes, and one of his OAvn. History of Cooper's case.—Patient Avas twenty-seven years old, with all the symptoms of internal strangulation. Purgatives, clysters and emetics Avere given* in vain. Cooper questioned his patient closely to elicit whether he had hernia. He denied that he had any. This eminent surgeon, embarrassed and perplexed, demanded an examination, which Avas granted, but nothino- could be discovered. Patient was ill from the 18th to the 25th of June. On the 24th he felt much better, and on the morning of the 25th got up. In the evening all his symptoms relapsed, and he sank before morning. It Avas only on dissection post-mortem, that Cooper discovered the seat of the trouble, in a strangulated coil of the intestine, lodged in the ischiatic notch. A FEW GENERAL OBSERVATIONS ON THOSE UNUSUAL ArARIETIES OF HERNIA HERE ENUMERATED. It is not customary in all treatises of this description to enumerate those of so rare a type as these here cited, as some of them have been omitted, in every work on hernia and general sur- gery that I have been able to peruse, both by the older and more modern Avriters. Nevertheless, I am convinced that they constitute a very important class, not of a kind perhaps, Avhich may be radically treated by surgical means, but are those, which, undiscovered, may lead us to assume that in a given case the obstruction originates from within, when the real seat of strangulation is external, to the peritoneal cavity; hence more readily and safely ap- 110 HERNIA. proached by relief measures. They all have many characters in common. 1st. They are more common in the female sex. 2d. When they do exist, being so deeply lodged in such unusual situations, unless a special and most thorough examina- tion is instituted, through the absence of a distinct prominence, they may be overlooked. 3d. They seldom lead to strangulation. 4th. When they are painful, are increasing in size, threaten obstruction, and cannot be controlled by a truss, they should be operated on. In all cases of sudden obstruction of the bowels, before the question of a median-laparotomy is for a moment entertained, all the hernial-apertures should be rigidly scrutinized. It is not enough that we question our patient; we must feel, with our own hands and see with our own eyes that all the portals of escape from every district of the abdomen are free and unimpeded. If one is in doubt, then, though the practitioner may imagine that a consultation may detract from his merit and imply that he is not competent to cope alone, with the case, yet he owes it, not only to his own conscience, but to the poor, helpless sufferer AATho has com- mitted his life into his hands, to leave nothing undone which might unmask the possible concealed seat of the malady and open the way to its safe and prompt relief. It is hardly necessary to add, that the only Avay to properly and thoroughly examine for hernia is on a table, Avith the trunk Avell exposed in a bright, clear light. Much may be learned in these rare cases, by a cautious ex- amination through the rectum and vagina. PART IV. CHAPTER XVII. MODERN OPERATIONS FOR NON-STRANGULATED HERNIA, REDUCIBLE AND IRREDUCIBLE. Since the adA^ent of the antiseptic epoch, a large number of operations of diverse technique have been devised ; in most cases those who devised and practiced them, claiming excellent results and few failures Avhen they commenced to practice them. In many important respects they Avere all alike. The mortality attending their performance Avas almost nil. In inguinal hernia the aim sought for, was to obliterate the hernial canal, without compromising the elements of the cord. As this wTas commonly known among operators, very many cases came under the scalpel for treatment, which AArould not have done so had there been much risk to life attendant on interference. Larger open incisions Avere now the rule, and subcutaneous invagi- nations were wholly cast aside. In order that each step in operation should be fully carried out, ill 112 HERNIA. it Avas necessary that the parts be laid widely open. Without this, it would be quite impossible to lay bare the rings, isolate an adherent sac, or manipulate the cord. In cases of complete inguinal hernia in the male, it is in- teresting to note the diverse manner in which the sac is treated. The majority of operators regarding its presence as a menace to permanent cure, as always being an extraneous substance, cut it away on a line with the parietal peritoneum. Others permitted it to remain, after its division, on a plane Avith the internal ring. Again, some alloAved it to remain intact, but with one or two rows of sutures run through its walls, from the base to the utmost sum- mit, undertook to radically efface its lumen. The operation of utilizing the entire sac and fixing it as a pad in the hernial aper- ture was again revived. The rings too have been treated in diverse AA^ays. Many re- gard an operation for radical cure incomplete without solidly suturing the pillars of the external ring, while others freely divide it in opening the canal to the inner ring, as in the open operation introduced by Dr. Charles McBurney, of New York, and others, Avho make it a sine qua non that the pedicle of the sac be extirpated at the internal ring. As has been noticed, the rings have been cleared of the sac in some cases, while others have at- tempted to plug them with the displaced sac. For the latter pur- pose, also, in epiploceles, a portion of the omentum has been an- chored in the canals and fixed Avith sutures. One of the most mod- ern operations, that of Bassini, of Italy, contemplates the entire destruction of the inguinal canal, by free division of the ringsy the spermatic cord being lifted out, and made to pass through another opening made for it. It has been recommended by Lawson Tait, that when an operation is undertaken for the removal of an abdominal tumor, any hernia present should be dealt Avith from Avithin, drawing the protrusion upward, and closing the canal with sutures passed through the peritoneum. Indeed, he even suggested this internal route for the treatment of strangulated hernia {British Med. Asso.r 1891). Many have regarded the presence of the spermatic cord as an insurmountable barrier to radical cure, inasmuch as its presence prevented the total obliteration of the inguinal canaL HERNIA. 113 But when one carefully studies all the etiological factors of an in- guinal hernia, this must be denied. Besides, Ave are informed that in those times when indiscriminate castration Avas permitted, a considerable number relapsed. The same general principles are applied to the treatment of femoral hernia as in inguinal, except of course such as apply to the management of the tubular structures. Though in our opera- tions on the inguinal canal Ave may by a wound or by cicatricial pressure, Aveaken the functional vitality, or cause atrophy of the testis, its felloAv being preserved, virility remains, while the same damage to the contents of the femoral canal might entail the loss of a limb. Hence, here any solid plugging of the canal, its firm approximation Avith sutures, or entire obliteration is quite out of the question. Its anatomical and physiological properties reduce Avithin very narrow limits, our efforts to radically deal with her- nia in this situation. In uncomplicated, adult umbilical hernia, on the contrary, there is practically nothing in the Avay of our endeavors to hermetically obliterate the vent; for, normally, there is nothing here that can, under any circumstances, be regarded as a canal, the patency of Avhich must be maintained. COMPLICATING ELEMENTS IN HERNIAL OPERATIONS. Before entering into the consideration of operation of selec- tion in cases Avhich present various anatomico-pathological ele- ments, it may be appropriate to first consider the impediments which often nullify our best efforts, or at all events prevent satis- factory results. It must generally be conceded that Ave are yet Avithout the ideal suture material. Aseptic, absorbable suture is so liable to slip, tear, or melt away before firm or solid union is effected, as to be unreliable for general purposes. Using heavy, chromicized strands Avill not help us, for their introduction into the tissues entails a vast amount of tearing, and, after being lodged, if not disposed of by absorption, they are sure to be a source of irritation. With a ligature ou the stub of a divided neck of the sac, should absorption occur before permanent fusion of the overstretched serosa, as this glides back into place an enormous breach in the peritoneal Avail is certain to 8 114 HERNIA. occur, and the most ungovernable description of relapsing hernia is sure to folloAV. To secure large vessels in the omentum with cat-gut is to needlessly imperil our patient's life. This material, Avhile often serviceable in peripheral hemorrhage, is not the safest in the sur- gery of serous cavities. If the soft parts, the muscles, ligaments, or aponeuroses in the abdominal walls, would tolerate foreign substances with the same impunity that the gums do mineral or metallic in dental surgery, then indeed Ave might proclaim to the world that practi- cally all hernise w-ere safely, rapidly, and radically curable. But there is the rub. They will not. True, some of the tissues, particularly the sero-cellular, often possess a singular toler- ance to insoluble materials, but the muscular structures, bones, and ligaments promptly resent their intrusion. What would be simpler than the free division of the peri. hernial structures, return or excision of the viscera, shutting off the general peritoneum with a strong silk-knot, solidly closing in the canal and rings with the same material, and burying all under the surface-suture ? But this subtance, by mechanical irritation, so often gives rise to ulceration Avhen imbedded in the subcutaneous tissues, that it makes its way to the surface, or is a source of painful SAvelling. When this is not a sequence of the employment of the subcuta- neous silk suture it often cuts its way through the tense edges which it approximates. The French surgeons have attempted to overcome the diffi- culty in using silver and gold, the " suture d'or" and " suture d'argent," but with the same result. Furthermore, as will be noticed later, there are anatomical reasons Avhy, unless permanent tolerance can be secured to an insoluble suture, the absorbable of any species whatever can serve nothing more than a very transient purpose, when utilized to obliterate a hernial hiatus. In our time, when anaesthetics afford us ample leisure, and inventive genius has placed within our reach perfected mechanical implements, a dangerous hemorrhage is not a common accident in hernial operations. Nevertheless, in those operations in which an adherent sac is HERNIA. 115 dissected, a considerable loss of blood by parenchymatous oozing is unavoidable. In detaching an extruded mass of omentum in a crural hernia I have accidentally opened the femoral vein, but moderate pressure controlled it, and it gave us no trouble during the healing of the wound. During the performance of a hernial operation for radical cure by Bassini's method, in Rome, I have seen the internal epi- gastric artery cut across. For an instant there Avas an enormous jet of blood, but the cool and skilful operator (Dr. Bastianelli) quickly seized the mouths of the vessel and promptly secured them. OAving to the manner in Avhich the sac is often intimately blended Avith the cord, in its separation the spermatic artery has been torn; or one may, Avithout the exercise of great caution, di- vide it for an adventitious band. As this vessel, when freed from the testis, is marvelously elastic, in a second after division its mouth may be drawn up beyond the internal ring, and permit of a A-ery dangerous bleeding before it can be secured. As the presence of free hemorrhage constitutes one of the most formidable dangers in all hernial operations, ample provision should be always made for effective hsemostasis in every instance, before they are undertaken. Next to hemorrhage in importance, in herniotomies, is inflam- mation, mechanical and septic. It is absurd to assume that by any sort of chemical solutions, or exclusion of infecting elements, we can wholly prevent inflammatory reaction, local or general, when we perform an operation which entails an extensive mutila- tion of the tissues. Inflammation may not run into suppuration; but free cell hyperplasia, tumefaction and tenderness, will invari- ably follow. And the inflammatory products, in the rapidity of absorption, are as much dependent on the general condition of the patient as the local treatment of the wound. In the old and cachectic I have seen it more than once run into gangrene. This usually was limited to the edges of the in- cision, which were thrown off by a slough, the parts healing from the bottom, by granulation. Gangrene of the testis is one of the consequences attendant on serious damage to the spermatic artery. 116 HERNIA. I have never seen general peritonitis follow herniotomy for radical cure. In this age of aseptic surgery it is needless to em- phasize the cardinal importance of rigorous cleanliness of every- thing in the region of the wound, when we are manipulating^ structures immediately continuous with the peritoneum. It is difficult to conceive of septic infection following an incision into healthy tissues, except through the grossest sort of neglect. CHAPTER XVIII. AN/ESTHETICS AND ANALGESICS IN KEL0T0MIES FOR STRANGULATION AND IN OPERATIONS FOR RADICAL CURE. To any one who has carefully studied the history of hernial operations in the past, and who compares their status at the be- ginning of this century, and in our OAvn times, it must be appar- ent that there has been nothing which has given them the position Avhich thej' occupy to-day, in any manner whatsoever, compared to anaesthetics and analgesics. We have seen that the mortality from kelotomy in pre- anassthetic times Avas enormous; perhaps because operative relief Avas sought only Avhen the patient was in extremis. The mental agony and horror at the very thought of surgical interference, no doubt, in many exceeded the physical sufferings. The operator must have been rapid in execution in these times. In many intricate, complex hernial cases safety is only possible in deliberation and a cautious dissection. But ansesthetica came and the patient Avas sent into dreamland. There were no more forebodings of pain nor of the infliction of it. Yet surgeons, for a long time, clung to the impression that 117 118 HERNIA. the patients' prospects of recovery largely depended on their celerity of action and rapidity in execution ; accordingly, an ope- ration for strangulation was but the work of a few moments. Old convictions die hard. In fact, one can scarcely be said to eATer quite outlive them. And so it was with surgery and ansesthetics, as it was only in Arery recent times that a younger generation ex- tended minutes into hours and completed the full details of every step, so that to-day in all simple and complicated cases, so com- plete is the technique of an operation for hernia that a single dress- ing often suffices until healing processes are practically complete. Notwithstanding the inestimable boon of painless operations in hernia, in ordinary cases of strangulation as they come into the surgeon's hands, their mortality when pulmonary ansesthetics are erupted after operation is yet very great. This was a startling revelation to me in my student days, when I so often saw death so promptly follow relief of strangulation by the most skilful operators of that time. The mortality attending my own operations, on four strangu- lated cases, in my early hospital experience, was so appalling that I had come to regard kelotomy for strangulation as always an opera- tion of first magnitude. If Ave should encounter a gangrenous intestine, cause a great loss of blood, or if general peritonitis supervened, we might account for the loss of life; but when an operation was simple, rapid and bloodless, and the intestine was healthy, yet death supervened within twenty-four or forty-eight hours; and to say that it was caused by septic peritonitis was not satisfactory, because Ave knoAv that general peritonitis rarely cuts off life in so short a time; besides, it has not been demonstrated that the operative mortality has been reduced since the advent of antiseptics in strangulation cases. No doubt the deplorable condition that some of those cases often present before the attending physician turns them over to the operating surgeon, often precludes any possible hope of relief by the intervention of art. For cases have been sent into our service at the Harlem Hospital in which, after violent protracted taxis, the intestine has been found ruptured in the sac, and pressed up through the rings to drain its contents into the peritoneal HERNIA. 119 cavity. In one Avoman the sac and boAvel were bursted by bruis- ing and pressure, so that, as the fascia propria Avas divided, intesti- nal gas and faeces Avelled up through the incision. Again, more than once, the patient has barely survived transportation to hos- pital, and was moribund, or dead, before preparations to operate were completed. Further, Ave Avill find not a feAv coming in, more or less collapsed, on Avhom but moderate and cautious taxis has been practiced, yet after a ,hypodermic of morphine, artificial heat, and a few hours perfect quiet, the spasmodic grip at the neck of the sac relaxes, and the hernia returns of itself, or by A^ery moderate taxis, and in a day or two the patient is himself again. So deep-rooted and general is the fear of death from opera- tions on strangulated hernia with medical attendants, that many advise or approve of th<.m only after every sort of palliative ex- pedient is exhausted. We very naturally inquire then Avhy, in simple strangulated cases, the mortality is so great ? But a limited breach in the tis- sues is made, no blood is lost and the operation is ndt a protracted one; yet Ave often lost our patients. My observations during the past ten years have convinced me that pulmonary anaesthetics very greatly added to the dangers in operations in strangulated hernia. I am not prepared to say in what manner their lethal action is more manifest in this class of abdominal operations than in any others; yet that total suppres- sion of the urinary secretion and secondary mortal shock often follow, cannot be denied by those called on to perform these opera- tions. As I have never used chloroform in an operation for strangu- lated hernia, I am unable to say Avhether these mortal sequelse are so common when it is employed. But from what Ave do know of the greater danger always attendant on its employment in other surgical operations, there is no apparent reason Avhy it should be preferred to ether, the pulmonary anaesthetic Avhich Ave always employed. Since Paul Reclus first called attention to cocaine analgesia as a valuable agent in operations in the peripheral structures, I have almost invariably employed it in all operations for strangu- lated hernia. In twelve operations for strangulations with cocaine, 120 HERNIA. ten promptly recovered. The cause of death in the one who suc- cumbed is a mystery to me. No post-mortem was permitted. In two of those ten which recovered, they Avere in such profound col- lapse that there was little prospect of their being able to come out of the coma of an ansesthetic. In one it AATas employed on a man bordering on the moribund state, avIio had been operated on im- perfectly two days previously, in Avhom stricture at the neck of the sac had been overlooked. His pulse was 140, Aveak and thready, the belly ballooned up by the imprisoned gases, and vomiting was incessant. The wound was reopened and the intestine liberated, the patient in full consciousness, but devoid of pain as the edge of the scalpel Avent through the tissues. He experienced immediate relief, and had a large movement from the bowels Avithin two hours after the operation, ultimately fully recovering. Cocaine is of priceless value in operations for strangulation. It certainly seems incomprehensible how it is, that an agent of such unique usefulness in this operation, has not, before this time, become better knoAvn in the ranks of the profession. By its judicious employment, as Reclus pointed out, Ave may dispense with skilled assistance in an emergency, the patient him- self giving the greatest aid. If he has diseased organs, their in- tegrity is not imperiled by the saturation of the system Avith a noxious agent. It is a positive haemostatic. There is no stage of suffocation and struggle, so common under ether ; and no violent retching or vomiting after operation, a time Avhen it is so import- ant to prevent sudden strain on the blood-vessels, or agitation of the traumatized intestine. Effective cocainization, hoAvever, demands a precise technique, every detail of Avhich must be observed, if Ave Avould not utterly fail, and throAv it aside in disgust, after our first trial. In a work on hernia it might appear that pulmonary anses- thetics are of sufficient importance to merit a full and separate consideration; but, as these are fully described in the current text-books, it is unnecessary to refer to them in detail at present, except in a cursory manner, and only the clinical phenomena often attendant on their administration. It goes Avithout saying that in an operation Avhich entails a tedious dissection, it necessitates as perfect immobilization of the HERNIA. 121 body and the part to be operated on as possible. It is also par- ticularly desirable that all violent movement in the abdominal muscles be restrained after hernial operations. Noav, with pulmonary ansesthetics, it is notoriously the case that a considerable number take ether or chloroform very badly. In some it is quite impossible to induce profound, protracted nar- cosis without inducing asphyxia. This may recur any time the anaesthetic is forced, so that it is impossible to operate on them with safety Avhile under profound coma. With another class a general muscular rigidity ensues through all the stages of ansethesia. As this invohTes the abdomi- nal as AArell as the respiratory muscles, it is easy to understand what an embarrassing complication it is, after the peritoneal cavity is opened and the intestine bulges through the opened neck of the sac. Violent emesis almost invariably sets in, as our patient comes out of ether in many of our most docile cases. But few escape this sequela, Avhile a considerable number vomit freely in the initial stages of ansethesia. No doubt the escape of the bitter, acrid ingesta into the trachea and lungs Avhile the patient is in the stupor of early ansethesia, is responsible for many mortal cases of post-operative pneumonia. Indeed, it would seem that the administration of an anaes- thetic, and its sequelse, are among the greatest dangers attendant on operation for strangulation. Chloroform is not attended Avith so many inconveniences, perhaps, as ether, but its lethal action is so often and so suddenly deadly, that unless there is some special condition present per- mitting its employment, it should never be employed. In my experience in strangulated hernia, pulmonary narcosis is always attended Avith a deepening of the collapse in the most serious cases. The ideal agent in hernial operations is one Avhich Avill temporarily deaden sensation Avithout effecting consciousness, and the employment of which is not followed by vomiting or violent muscular contraction. Such an agent is the alkaloid, ■cocaine, though its range of application in hernial cases is limited. In strangulated hernia its use should Avholly supplant pul- monary ansethetics. In non-strangulated hernise the. operations 122 HERNIA. for their radical cure, to complete in all their details, consumes so much time that the transient action of cocaine Avill not suffice, except in a very limited number of cases. In those Avho manifest a marked repugnance to ether, and are willing to suffer a little pain, an operation may be performed with the greatest satisfac- tion, as I have, on different occasions, demonstrated on men and women. Before describing the technique of cocainization in hernial surgery, it may be well to briefly notice the phenomena attendant on its application or administration. Cocaine gives a sense of exhilaration, buoyancy, and pleas- ure ; stimulating the brain to an extraordinary degree, and, at the same time, strengthening the heart's action, supplying pre- cisely thereby in the constitution what the despondent mind and flagging pulse most urgently need in all cases of strangulation. Locally, it paralyzes the periphery of the sac,sensory nerves: causes a marked contraction of the capillaries, through its action on the vaso-motor filament, and thuswise exerts a marked haemo- static action. It is needless to remark that Avhen administered locally, its action is not strictly concentrated on the parts into which it is injected, but it is also taken up by the general circulation; and hence, acts in a dual capacity: First, as a local analgesic ; and secondly, as a general stimulant. TECHNIQUE OF ADMINISTRATION OF COCAINE IN HERNIAL OPERATIONS.- CONDITIONS TO BE OBSERVED, ETC. Before Ave cocainize there are certain preliminaries necessary to observe of a special character. Contrary to the usual custom of administering the ansesthesia, on an empty stomach,some hours after a meal has been eaten, with cocaine it is ahvays well to operate under it as soon after a meal as possible. The patient should be given freely of an alcoholic stimulant, if the stomach can bear it, immediately before Ave commence to introduce the analgesic. It is now assumed that everything at the seat of operation has been rendered aseptic; that a pure drug and a good hypo- dermic syringe are provided. The needle of the syringe should be HERNIA. 123 from four to five centimeters long, and of sufficient firmness not to bend in going through aponeurotic structures. It should have a keen, smooth point. A one per cent, solution is of sufficient strength. I have never employed less than sixty drops, nor more than a hundred in a hernial operation. In other Avords, it is well neATer to go far beyond the average dose by the mouth—from one- third to one grain—when using cocaine subcutaneously. If we wish to cocainize without inflicting but the minimum, of pain, and secure our patient's confidence, it must be done with as feAv punctures of the integuments as possible. This is to be particularly desired in strangulated cases, in which the tumefied, contused parts are extremely sensitive. Hence, in order to effect this, the punctures through the skin should not exceed three or four in number, and should be in a continuous line OATer the long axis of the tumor; so situated, from above dovvnward, that the edge of the scalpel, as it is carried down through the integument, Avill intersect them. The syringe should carry, at least, from tAventy to thirty drops. After having been sent deeply into the tissues, the doAvmvard motion of the piston is commenced; at Avhich time the Avithdrawal of the needle must begin, in an oscil- lating movement, at such a pace that from three to five drops will have been sprayed in the tissues before the needle has reached Avithin six or eight millimeters of the deep layers of the integu- ment. Noav,gently turning the needle on its axis—its heel being the pivot—it is again and again sent in until an area, including a considerable radius, is effectually sprinkled. The needle, then, by this procedure, is made to penetrate in many different direc- tions, though Ave puncture only once. With but a few such punc- tures from four to five or six centimeters apart, a considerable district can be dealt Avith. Certainly one must hypodermize the tissues Avith as little delay as possible, Avhen he commences ; or else its local effects will have passed away before we commence the severance of parts, or we will observe, rather, symptoms of its constitutional action, which in women and children we Avish to avoid. Hypodermica- tion completed, the integuments and underlying soft parts are care- fully but quickly kneaded with the fingers, in order to thoroughly diffuse the cocaine through the tissues. Noav everything being 124 HERNIA. ready, just before the scalpel is taken in hand, if a syphon of car- bonated water is convenient, wThich has been well chilled, splash its contents suddenly over the surface of the integument. In cases when this has not been within reach I have found a pitcher of cold water, emptied from a height of tAvo or three feet, answers very well as a substitute. Hypodermication should not occupy more than three or four minutes; from its completion, until the division of the tissues is commenced, not more than five minutes should in- tervene. It may be well to note in hernial operations, that par- ticular caution must be observed not to puncture the extruded in- testine or the spermatic cord in male inguinal, nor the femoral vein or artery in crural hernia. Cocainization is an invaluable aid in subduing muscular spasm, early resorted to in those strangulated cases, in which operation is refused. For this purpose it is much to be preferred to ether or chloroform. Cocaine analgesia lasts about thirty minutes. Any operator of moderate experience can go through the necessary steps of an operation to relieve a strangulation in that period of time. It he cannot, then he assumes considerable risk, and scarcely does jus- tice to his patient, if an experienced operator is convenient and can be had. CHAPTER XVIII. VARIETIES OF OPERATIONS FOR THE RADICAL CURE OF HERNIA IN MODERN TIMES. Perhaps it might be alleged, inasmuch as it has been de- clared in a previous chapter, that as no operation has yet been devised Avhich would effect a permanent cure in all cases of hernia, or in every case of any single phase of it, that there Avould be no room for choice ; that one would be equally as efficient as another. This, hoAvever, is illogical reasoning, and only emanates from those prejudiced against every operation for hernia, and every species of sanguinary intervention in non-strangulated cases, or even a strangulated hernia when its reduction is impossible by taxis. But when it is remembered that almost no two hernial pro- trusions are precisely alike; that many are of a most complex type; that age, sex, occupation, anatomical structure and general bodily health each has an important bearing in every case, in inclining us to such a line of procedure as is most appropriate, it 125 126 HERNIA. is apparent that we must treat the various cases in a technique on essentially different principles. In the monorchid of early age, in which the testis and intes- tine are lodged together in the inguinal canal, our efforts will be directed rather tOAvard freeing the adherent testis and bringing it into the scrotum, than to meddling in any manner with the dis- placed protrusion, which Ave know usually wTith the growth of the child will finally lodge Avithin the peritoneal cavity. With the female, whose rudimentary inguinal canal contains no import- ant tubular structures, a technique will succeed Avith them that has no place in the male. As the dangers of doing damage to the elements of the cord are great, in separating the tough fibrous Avail of the sac from them in many inguinal hernise, wre can see Avhy, in the femoral type, this enucleation of the sac may be invariably advised, while in many of those protrusions passing over the crural arcade it should not ahvays be permitted. It is clearly evident, too, that we must vary our procedure in the small, easily reducible, and the large, old incarcerated variety. One man, for cosmetic or other reasons, humiliated by his deformity, about to be married or undergo a physical examina- tion, requests a radical operation; but if his general condition suggests syphilis or tuberculosis, few would care to make a breach in the tissues to expose the sac Avhen the same end might be attained by rest, puncture and pressure. So, too, with exomphaceles and eventrations, we must resort to different operative measures for them under varying circumstances. Of recent years we have had what are knoAvn as "open operations " for the cure of non-strangulated hernia. OPEN OPERATIONS FOR HERNIA. These may be divided into two classes : First, those in which a large, open rent is made in the soft-parts, thereby enabling us to expose and manipulate under the eye all the elements of the hernia. With these, as soon as the viscera and sac have been dealt with, the divided parts are so approximated, layer by layer, Avith a view of closing in the parts, by primary-union. This is the most common. HERNIA. 127 The second class are those essentially, of the same, in the ex- tent of incision, but the wound is purposely prevented from imme- diately uniting, by a gauze packing, introduced with a view of securing a filling in by granulation tissue and a cicatrix. The latter, except, in cases of strangulation attended with infection, has now, been quite generally discarded. These operations are essentially laparotomies. There are a great many derivatives of them, as a detailed description, of some of the most current of them—described later—will show. The fundamental objection against these, so-called open opera- tions is the extensh^e mutilation or division of the anatomical- structures Avhich their performance entails. The groin and scro- tum must be widely opened to enable us to free an adherent sac. To excise the neck on a plane Avith the general parietal peritoneum, the anterior Avail of the inguinal-canal must be split through its entire length to the internal ring. Noav, if the divided parts on reunion regain their pristine mobility and strength, as little or no danger to life is attendant on the incision, the closed-open operation, so to speak, is the ideal. But whether they do or not, in many phases of hernia of an im- pacted character, nothing approaching an effacement of the pro- trusion is possible, Avithout such free dissection. The antiseptic- theory gave an immense impetus to free and perhaps—one might say, without straining the truth—not infrequently needless and destructive, gashes into the soft parts, in this and other surgical ? maladies. We certainly do know, that a divided bone or tendon, never again, entirely recovers its full strength when cut through ; though, such division often serves invaluable purposes. Nor is there any reason why a free splitting through the ligament, ten- don, aponeurosis, and muscles of the lower abdomen may not leaA-e a weakness in the abdominal wall. HYPODERMICATION IN EFFECTING RADICAL CURE. The hypodermic syringe, shortly after its invention, was promptly utilized as an apparatus which had a place as a therapeu- tical aid in the treatment of hernia. It is one of the few agents employed in modern times for the treatment of hernia which was not well known centuries since. 128 HERNIA. We find the germ of it in the Avritings of Julius, in the third cen- tury, who recommended, after the hernia was reduced, the tract over which it traveled should be opened, lightly seared with the red iron, or with spirits, and be then closed in Avith the suture. It appears, that Avhen this method Avas first introduced it was so awkwardly employed that, though a few were cured of their hernia by it, yet the majority operated on developed peritonitis;. not a feAv suffered from erysipelatous inflammation and gangrene of the scrotum. And, as might be supposed, it AAras soon condemned and cast aside. We will see that after an interval, when the syringe became a perfected instrument, and when the pathological processes super vening after subcutaneous injection of pungent chemical solu- tions became better understood, hypodermication again came into use. Saturated solutions of chloride of sodium, concentrated alco- hol, tincture of iodine, extract of oak bark, and other irritants were employed. When we study the principles, on Avhich the claims of this peculiar therapy rest, and when it is utilized in special selected cases, it cannot be denied that it has a place and must be regarded as a most valuable adjuvant. It lost ground, and Avas cast aside for the same reason, that very many useful agencies have sunk into oblivion, often before their full merits have been properly tested, viz., because the champions of them made them a cure-all. With those desirous of a cure of their hernia, without a muti- lation, when this is an indirect, inguinal of small volume, and the sac with the viscera can be wholly returned, it is certainly rational to assume, that used in conj unction Avith other tentative measures, it may succeed. Indeed, there are too many Avell authenticated cases in which it has effected permanent cures to dispute its claims. In our time, we can render the injecting fluid absolutely aseptic, there can be little danger of infection, $or of any accident, except, directly charging a blood-trunk or penetrating the wall of the bowel. Hence, this procedure, when devoid of accident, in many, must claim preference to those, which entail the sacrifice of tissue; and, as a result may be followed by a relapsing hernia, perhaps Avorse than the one which their employment intended to cure. HERNIA. 129 The range of hypodermication as a means for treating hernia is very limited, for with the exception of such phases of inguinal hernia as stated, it is of doubtful, if any value. I am acquainted with no reported successful cases of femoral or umbilical hernia treated by this means. MODE OF ADMINISTRATION AND CONDITIONS TO BE PRESERVED IN HYPO- DERMICATION OF HERNIA. As in the hypodermic administration of cocaine the integu- ments must be thoroughly disinfected. We have a set of hypodermic needles of various lengths, strong and unyielding for different cases; as AAre will meet with those Avho have immense layers of abdominal fat, as Avell as the lank and lean. Warren, of Boston, invented a special syringe for these cases, Avhich, when introduced by a movement of the piston, underwent a rotatory motion, which in this Avay was supposed to have effectively saturated the peritoneo-ATaginal canal. The or- dinary syringe, nevertheless, is equally useful, and not so liable to get out of order. Of the many solutions recommended, probabl}T the prepara- tion of the charlatan, Heaton, is the most useful of all. For the basis substance, oak bark, is a powerful astringent; the pure alco- hol in it, an antiseptic Avith the morphine included, nulls all im- mediate pain. But a feAv drops of this solution, from three to ten, are ample to employ. Noav the finger having fully reduced the hernia, its tip is pushed still upward and backAvard,^ until the aperture of the in- ternal ring is felt, when the point of the needle is introduced over the nail, care being observed not to injure the cord, and to lodge the fluid in the loose, connective tissues, betAveen it and the fibrous walls of the infundibulum. After the fluid has been deposited, a narrow pointed conical pad must be applied, under a firm spica bandage, over the ex- ternal ring and canal. So much for technique; noAv there are many things Avhich must not be overlooked when this line of treat- ment is selected. Undisturbed, protracted rest, is indispensable. This must be carried out with rigor, or all fails, after the injecting fluid is it 130 HERNIA. lodged. Accordingly, in order to secure quiet to the inferior segment of the intestinal canal, for five or six days after opera- tion, the patient should have been freely purged the day before we operate, and occasional small doses of opium are needed after the intestine is cleared. To attain this same purpose the patient should be kept on low diet, and all solid food prohibited for ten days. As there is no wound inflicted in the procedure, there is none to dress. Yet, immediately over the internal ring, firm, methodical pressure must be continued uninterruptedly for four weeks to ten or more. In young subjects, Avith recent hernia, confinement to bed for a shorter time w7ill suffice than in older subjects, Avho have had large protrusions. The success of this simple expedient is dependent on two principles. 1st. With restitution of the ATiscera, Avith all Aveight and drag removed from the elongated mesenteric ligament, it regains its normal, contractile poAver, and swings the rolling intestine far enough away from the rings to prevent it from again engaging and slipping outward. 2dly. The injected fluid when properly lodged, affects the solid cementing of the hernial A7ent; 1st, by its pungent irritating prop- erties, exciting inflammatory exudate; and 2dly, by a condensa- tion and fibrous infiltration of this plastic material into the meshes of the adjacent tissues, in such a manner as to firmly con- tract and obliterate the pre-existing lax and open passage. Were it not for the fact that the viscera are commonly ad- herent in female inguinal hernia, for this type, in this sex, it Avould be the ideal. In the reducible inguinal, complete, of young women, this method should be fairly tested before any species of sanguinous proceeding is entertained. ACUPUNCTURE. The introduction of pins or needles introduced subcutaneously, transversely to the long axis or the canal, in simple, reducible male inguinal hernia has been employed, and we are assured with occasional success. The aim has been to secure adhesive inflam- mation, when the sac was held down by adhesions. Bv this HERNIA. 131 plan it is impossible in fleshy subjects to effectually obliterate the lumen of the funicular envelope beyond the external ring. It is an operation which, when performed with care, entails no danger to life, and in certain simple cases unquestionably has a place. In young children, in whom there is practically no in- guinal canal, it may be employed with good prospects of success. And if it should fail to cure the hernia, when proper precautions are observed, it can seldom do harm. The greatest danger attending its employment is the risk of injuring the structures of the spermatic cord. Hence, before the needles are introduced, the cord must be lifted out of its bed and drawn aside, leaving the walls of the sac freely isolated. The desideratum is to so adjust the needles Avith sufficient pressure as to effect occlusion of the serosa, without having them cut their way. out to the surface. In certain patients they cause so much pain as to require their early withdrawal. As acupuncture must be practiced chiefly by the sense of touch, and as tetanus or gangrene of the testis has been known to so often supervene after its employment, its application is feasible only within very restricted limits, and is justifiable only in the hands of the adept and in exceptional cases. CHAPTER XX. INVAGINATION. Besides the various means heretofore noticed to effect an obturation of the hernial portal, in the early part of the present century, none, for a time, en- joyed greater favor, Avas more widely employed, or was more free from danger to life, than fig. 15. the procedure first introduced - by Gerd}\ It Avill be observed that Gerdy's instrument Avas a rather clumsy and formidable machine (Fig. 15), consisting of a double lever, bulb and screAv, and two teeth. But it appears that he soon cast this aside and substituted for it another more simple contrivance, which consisted in a long, concealed cannulated, curved needle (Fig. 16), the 132 HERNIA. 133 employment of which Avas not attended Avith difficulty and was very generally employed. In employing this method the patient was placed on his back writh the knees drawn up. The surgeon now, with the index-finger of the left hand, reduces the protrusion, sac and all; after Avhich, after pressing upAvard and maintaining in position, close to the internal ring, a double looped silk ligature is sent out through the cannula, the finger serving as its guide, penetrating all the tissues, from Avithin outward, until it reaches the surface (Fig. 17), leav- ing a loop aboA^e, fixed in an ammoniated pledget of cotton. The point of the needle Avas Avithdrawn completely and again sent through, coming out on the surface about tAvelve milli- meters from the first, the loop presenting being engaged with a tampon as the first. The loops, now beloAv, are drawn on firmlv until the indented integu- ment below, completely blocks the | v | canal, and the serous surfaces of the fk^ ,:>>%, sac and parietal peritoneum are com- , . ^ / | pressed in direct contact with each # \ V)v | other. It will be noted here that f the needle is passed inward, some f distance beyond the pillars of the | internal ring. It is not clear, whether | It was intended that the general f cavity of the peritoneum was to be f entered and transfixed, or that the fascia Avas pushed, forward by the finger, the puncture being wholly extra peritoneal. It is not stated Iioav long the ligatures Avere left in situ, though it FlG. n. must haA^e been considerable time, First step in Gerdys operation. as they often penetrated their Avay through, before they were removed. Of this operation we are told, that with few exceptions, within a few months after the patient took his feet, the scrotum retracted, and the hernia returned. The author claimed that it was not on the principle of mechanical oblit- eration that a cure was sought, but rather, by a phenomenon of 134 HERNIA. Fig. 18. a retractive inflammation of the cellular tissues in the canal and rings. Active inflammation, tumefaction and suppuration Avere common sequelae of this | operation. The patient was I always enjoined to wear a truss $■ % for a considerable period after |^ w„"| this operation. This operation I \ | was not applicable to femoral £ / | hernia, nor the inguinal type in | the female. INVAGINATION BY OTHER | PROCEDURES. There have been since the | times of Gerdy very many de- rivatives of his original scheme. By Lehman, Wiitzer, Benns. Gerdys procedure completed; imagination Zeiss, Schuh, and Others differ- maintained bv a double suture. . . t ent variations were essayed. Signorone's operation was known under the name of " intro- retroversio cornutu; or chilissochisorrhaphie." This bold operator conceived the idea of so far invaginating the scrotum as to give it a turn OATer Poupart's ligament, pushing the integument out above or on one side of the femoral vessels, and fixing the scrotal tissues in the falciform fascia, at the saphenous opening; a pro- cedure, says Broca, as extravagant as it was barbarous. Maisonneuve, inspired, it is said, by a successful operation of Dupierris, of New York, after having invaginated the integu- ment as far as possible, divided the tissues from without inward ; thereby opening the peritoneal cavity, sutured the deeper layers of tissues together; and then secured the parts by a cutaneous stitch. Thierry proposed the folloAving modification of Gerdy's operation: He invaginated the scrotum with the little finger, then introduced a threaded, curved needle; Avhich,after emerging about six millimeters below the superior edge of Poupart's liga- ment, was reintroduced through the same puncture. Finally, the free ends were firmly knotted over a small pad of charpie and retained, until adhesive inflammation contracted the canal. HERNIA. 135 Coste, of Marseilles, proposed a cure for femoral-hernia by invagination. There Avas nothing neAv in the principle applied, or the technique employed. Yet Petrequin once obtained a suc- cess by it in a very severe case. The patient was a Avoman forty years old, who had a voluminous hernia. The crural opening would admit four fingers easily, as far as their roots. Petrequin after reducing the mass, cut aAvay the superficial layers of the skin and transfixed the broad edges of the ring with four heavy pins. The cure Avas complete after a month; but, as there Avas a tendency to relapse, it Avas rendered easily coercible with a truss. Giraldes conceived and practiced a similar procedure for the umbilical hernia of children. As seen in Fig. 19, it essentially consists in passing a suture completely through all the planes of tissue, encircling the umbilical operation, after hernial reduction, and drawing the free fig. 19. ends together over a pad of lint. AVUTZER S OPERATION AND ITS DERIVATIVES. Wiitzer conceived the idea of substituting a foreign body in invaginating, instead of the finger; and maintaining this in position x, until the inguinal canal had con- '£:::■,•..: tracted adhesions. Broca and Leroy, however, had anticipated this sur- geon, in having presented to the French Academy, in 1835, a memoir on the subject of maintaining invag- ination by special instruments. But Wiitzer perfected the operation, and through his Avritings popularized it. Wutzer's first operations Avere in 1838, and he named his instrument an Invaginaterion Kelek-leison. This instrument is applied in tAvo sections. One is a hollowed piece of wood with a smooth, conical point, which is introduced into the in- guinal canal its entire length. Then a curved needle is made to pass Fig. 20. Rothmund's Operation. 136 HERNIA. over the upper surface of this tube, emerging through a per- foration near the point, Avhen it enters the second piece. At this stage, a notch in the second plate fits into an up- right screAV, Avhen it is firmly fixed in position. Sigmund, of Vienna, Avith Spencer Wells and Bedford Davis, of invaginator of A'aiette. England, as late as 1861 were partisans of this method, though Wells Avarned his patients to be slow in discarding the bandage wrhen this method is adopted. Rothmund, of Munich, devised an arrangement very similar to Wiitzer's, except that it was more powerful, and instead of employing one suture in- troduced half a dozen. Valette made another modification of Wiitzer's operation, adding to it cauterization of the ante- rior wall. The instrument in place, a paste of chloride of zinc Avas applied in the center, or fenestrum of the anterior blade, and firmly held in position by a bandage until it had thoroughly destroyed the underlying tissues. Noav, the clamp Avas removed, and the slough- ing parts healed by granu- lation, after the slough Avas thrown off. This procedure cer- tainly effaced the canal, most surely, for the simple reason, that by this cruel device it was totally de- stroyed, and it is difficult to see how the spermatic cord escaped, or the peritoneal cavity ■^mmnmrm Fid. 22. Valette's Invaginator. Fig. 23. A'alette's Process. HERNIA. 137 was not invaded. It made havoc in the tissues, and when the patient survived, left a painful, deforming cicatrix, and did not guarantee a permanent cure. Yalette operated on six patients, losing but one, though there are no data shoAving the permanency in cure of those who escaped with their lives. Le Roy d'Etiolles, Langenbach, Wattman, Christopher Heath and others, each have made various modifications on Wiitzer's and Yalette's operations, AAdiieh in no essential manner varied from ■each other, except in unimportant particulars. All of these operations, embracing the principles of Gerdy's Kinloch's Kite-tailed Kinlocb's Process. Passage of the Thread. Tampon. invagination, have been repeatedly performed by a past generation of American surgeons, notably by Mott, Pancoast, Wood, Nathan Smith, Bigelow, Kimball and Post. The late Dr. R. A. Kinloch, the first surgeon in North America to successfully laparotomize for a gun-shot Avound in the intestine, in his lifetime also competed for honors in hernial sur- gery. Kinloch's operation in principle and detail but slightly differed from Wattman's and others. He had operated when he bad submitted his essay but twice; and, as neither patient had returned, he was unable to report on the permanancy of the cures effected. 138 HERNIA. Symme, Davies, Fayrer and Egea have reported operations performed by them by a special technique in invaginating. Fig. 2ti. Fig. 27. Kinloch's Tampon being inserted into Kinloch's Process. Tampons in place maintain- the canal. ing Invagination. Sotteau, by a special contrivance of his own, maintained invagi- nation by the aid of an instrument, Avhich permitted the mechanical apposition of the hernial orifices. The fundamental difference between this operation and those for invagination, already de- scribed, is that the author aimed to effect obliteration rather by se- curing closure of the portals, and rejuxtaposition of the fibrous walls by mechanical aids, than by ad- hesive inflammation. Sotteau's instrument is very invaginator of"sotteau. complicated. Sottean commenced HERNIA. 139 by anointing the wooden invaginator Avith an ammoniated po- made, which was then pressed firmly against a fold of the skin and carried far up the canal. A suture is now carried across the pillars and fibrous walls of the canal several times, Avhen the in- vaginator is withdrawn and the suture tightened. To secure continuous compression, the instrument here pre- sented is applied, when the hernia is very large and chronic. Roubaix reported a very remarkable case of an enormous crural hernia in a Avoman sixty-four years old. She was suffering from strangulation. There was gangrene of the intestine, and an artificial anus followed, which closed after four years' time. After a sudden strain, however, the old ;i- cicatrix in the abdominal Avail gave ^___f ::- .,' way, and a very large hernia fbl- "iff. ..:;%.. lowed, which no truss could control. llik •#' :^. 3 Now the case came into Roubaix's hands, when, by employing the operation of Sotteau, he succeeded in entirely closing the hernial aperture, dividing and cutting away the redundant integuments. Fig. 29. Sotteau's Invaginator with the wooden compressor in position. We are not informed as to the "^ durability of cure, as the patient was lost from sight after leaving the hospital; though it is fair to assume that this enormous deformity (Fig. 30) was entirely restored to its normal fig. 30. abode, and rendered at least coercible. Hernia operated on by Roubaix. In the second cut (Fig. 31), we see the deep shotted clamps in place, which effectually hold in place the inverted edges of the skin, and the superficial harelip pins. 140 HERNIA. It would seem from this illustration that as soon as the power- ful metallic braces were removed, after union of the parts, unless some sort of a strong, Avell fixed support Avere adjusted, there would be great danger of another eA^entration. Wood, of London, in 1858, made another modification yet, or rather added a neAv feature to the technique of hernial cure by invagination, for his method embraces the invagination of the sac and direct suture of the her- nial orifice. In 1863 he de- scribed in detail the Ararious steps of his new procedure. Wood aimed at obliterating the track by adding to obturation by in\ragination the contraction by suturing the pillars. It is a subcutaneous opera- tion, delicate and difficult of performance. Many have claim- ed that although Wood wrote at length on this operation and modifications which he made in it, yet his style or language was so ambiguous and confused, that a full and close description of it from him has never been ren- dered. To myself I must confess it has not been easy of compre- hension. In Wood's first operation he employed tAvo transfixion pins in each case. The pins Avere rather short, strong and curved. One passed below, through the integment, sac and ex- ternal pillars. The other pin entered in a more oblique direction to the inclined plane of the body, and included the neck, internal aperture and skin. By this dual procedure of invagination and Fig. 31. Roubaix's patent with the clamped pins in posi- HERNIA. 141 approximation enough of adhesive inflammation was hoped to folloAV to insure an obturation of the passage. Many English sur- geons have testified to the immediate curative effects of this opera- tion; but we have no proof that the truss could be dispensed with after cure followed. The same author devised a second procedure by invagino- suture. The instruments necessary for its performance consisted of a curved needle perforated near its point, mounted on a handle; a bistoury, a strong copper or silver Avire suture and a glass com- pressor. The operation was commenced by making an incision through the scrotum, introducing the index finger and invaginating the sac as high as possible, then introducing the needle, armed with a Fig. 32. Fig. 33. Radical cure by Wood's needle. Radical cure in inguinal hernia, AVood. strong hempen thread ; first transfixing the sac, then the internal pillars then the posterior and external walls. The free loop being brought out, it Avas securely tied. Now a conical, smooth block of non-corrosive substance Avas firmly applied to effect steady pres- sure. After two weeks the compress was removed, but the suture was continued longer (Fig. 32). Wood soon abandoned the use of 71260� 142 HERNIA. hemp, and on the last two hundred and seventy-five patients em- ployed silver wire instead. ^ ..,! Fig. 34. Radical cure of Inguinal Hernia. AVood's method by simple suture. Suture in place ; knotted on a compressor. This suture greatly simplified the operation; first dividing the aponeurotic tissues, then liberating and exposing the sac, m- 'I Fig. 35 Radical cure of Inguinal Hernia. Wood's procedure with silver wire in position. Fig. 36. Another procedure of Wood's. I 04 HERNIA. 143 paginating it from below, when the Avire sutures were again em- ployed, passing deeply through each pillar; the ends being secured with sufficient firmness to approximate the edges of the pillars and obliterate the infundibulum (Fig. 33). Wood made various modifications of his operations, which were set forth, at length and in detail, in the London Lancet, of May 29th, 1858. Dr. D. Hayes Agnew, of Philadelphia, Pa. (TJ. S.), made a modification of Wood's operation. Agnew devised a sort of bivalve speculum ; one blade of which, the .< under one, was concave on its in- ..%, ferior surface. The outer blade % was convex on its outer surface. The center of the lower blade was grooved for the passage of the needle. The blades could be opened and immobilized by a screw in the Fig. 38. Precede d'Agnew. Three sutures are in place. Fig. 37. Invaginator of Agnew, after Ashhurst. handles. The operation is begun by incising the integumental cov- erings of the scrotum, for two or three inches, just below the exter- nal ring. Now, by the use of a finger, the underlying structures are liberated or detached from each other, Avhen the closed speculum is introduced as far upward as possible into the inguinal canal. The speculum is so placed as not to injure the cord. Now, the blades are widely separated and fixed in an open position. After this a long curved-needle is made to traverse the grooved track on the surface of the anterior valve, which, at its extreme end, pierces and passes out through the skin. Another suture is, in a similar manner, sent in on the lower 144 HERNIA. conductor. At this stage, the free ends of the suture alone are- secured over a roller, while those inside, as in Valette's operation, are passed over a pledget of lint, and are firmly secured. Then three or four sutures are passed through the integuments along the plane of the inguinal canal. They are uoav tied, when the speculum is slackened and AvithdraAvn. For suture material, silver wTas employed for the long deep suture, and silk for the superficial parts. Over all a firm spica bandage was applied. The operations of Chisholm, Van Best, Jessett, Field and Thompson, are all derivatives of Wood's. Spanton invented a sort of cork-screwr instrument, with which he traversed the inguinal canal, after effecting invagination. In its application, as in Wood's operation, the skin over the superficial ring is divided, and the deep tissues detached with the finger. Nowr,. the index finger of the left-hand securing complete inA'agination and protecting the cord, this spiral arrangement is twisted alter- nately through the integu- ment, sac, and pillars until its point has made its way out above. The instrument is left in place until actiA^e inflam- FiG/39. Instrument of Spanton. Fig. 40. Introduction of Spanton's Instrument. mation is developed — from ten to fifteen days. Spanton operated on thirty patients Avith twenty-six successes and four HERNIA. 145 ameliorations. Many of his patients, it is said, could entirely dispense with the truss, after cure. Invagination of the sac and suture of the ring has been recommended for crural and umbilical hernia. Fig. 41. Fig. 42. Spanton's instrument in place. Radical cure of femoral hernia, by Wood's method. the skin Avas incised and the hernia AAras reduced, a heaAw absorb- able suture Avas substituted, to draAv the margins of the hernial orifices together, after which it is buried in the tissues. Mr. Bennett, of London {Med. Press, August 10th, 1892), has recently contrived another invaginating plan. It might be des- ignated " pedal invagination," as by it the sac is stripped and ex- cised, the remaining stub or neck being hiA'aginated. It is another modification of AVood's operation. By it the sac is cut off just outside the external ring, after being ligated, then a heavy needle, armed Avith strong silk, is passed doAvmvard from without, 10 146 HERNIA. through the abdominal walls, making it traverse the neck and project below the obturated part. The needle is then withdrawn, leaving the silk, one end coming out through the abdominal parie- tes ; the other, the outer side of the pedicle just above where it had been ligatured. The needle was then again passed, without thread, through the abdominal-Avails, but at a point just opposite to the first needle-puncture, and on the inner side of the ring, but Fig. 43. Fig. 44. Radical cure of femoral hernia by Wood. Suture in place in Wood procedure for radical Introduction of the suture. cure of femoral hernia. at a point opposite the first needle-puncture, the needle being this time made to project on the inner side of the neck, opposite to Avhere the thread came through it, the silk is iioav passed through the eye of the needle and the latter Avithdrawn, leaving the free ends of the silk projecting from the abdominal parietes, the result being a loop thrown over the obliterated end of the pedicle. Trac- tion is now exercised with the effect of turning the remains of the sac outside in, the apex being fixed to the peritoneum by securing the two projecting ends of the silk. HERNIA. 147 Mr. Bennett claimed for this procedure the advantage of the complete invagination of the remains of the sac, the re- sult being that the posterior portal was protected by four layers of peritoneum, while, by their consolidation, a firmer form of barrier is secured than by any other. In large, old her- nia, he ahvays employs silk, but in mild, recent cases, cat-gut. In completing the operation, he sutured the pillars before closing the wound. Indeed, the number of operations for invagination, which are all derivatives of Gerdy's,Wiitzer's, Valette's, and Wood's, is almost interminable; AAmich, though to rehearse them here, might be of interest to any one desirous of securing all the literature on the subject of invagination, in the therapy of hernia, as I conceive that it Avill serve no useful purpose, and as space will not permit, will not be considered. OBSERVATIONS ON INVAGINATION. InATagination, as an operation for radical cure, for a long time, alone, held the field against all others in reducible hernia. Its application, indeed, constitutes a distinct epoch, but its cause was suddenly cut short, when, in 1873, John Chiene, of Edinburgh, and Charles Steele, of London, at about the same time, revived the " radical cure " by the free, " open incision," employing, for the first time, antiseptic solutions and dressings in hernial opera- tions. This Avas the beginning of a revolution, which gave invagina- tion a staggering blow, and it seemed, for a time, that it had for- CATer driven Gerdy's operation, and its manifold derivatives, into oblivion. Hence, if operations by invagination Avere noticed here, it would seem that anything approaching a full description of them w7ould be a needless consumption of time, as a mere refer- ence to them for historical purposes should suffice. But, as Se- gond* so aptly expresses it, " antiseptic surgery will not radically cure hernia." And it is a question by no means yet decided among tke most extensive operators, whether our more modern operations, in all cases, are any improvement on some of the older and simpler methods. As a matter of fact, Dr. William T. Bull, at the meeting * Cure Radicale Des Hernies, p. 170. 148 HERNIA. of American Surgeons in 1890, declared that, after an extensiAre experience, he had concluded that in ordinary cases of inguinal hernia the simplest operation was as efficient in securing a per- manent cure as the more complicated. Besides, in support of this position of Bull's, Avhich was regarded as most preposterous at the time, the old-time simpler operations by in\Tagination are coming to the front again. CHAPTER XX. THE RADICAL TREATMENT OF NON-STRANGULATED HERNIA BY SUCH MODERN METHODS AS REQUIRE AN OPEN INCISION AND FREE DIS- SECTION OF THE SAC. In recent times, until the Listerian epoch of antiseptics, when the theories of the distinguished Scotch surgeon were very gener- ally accepted and put into practice—about fifteen or eighteen years ago—we can find no modern author on surgery recom- mend or justify a free division of the tissues in any description of hernia whatever, except strangulated, or such as immediately imperiled life or invalided the patient. For the reducible, the •congenital or incarcerated, the principles on Avhich they should be treated, on tentative lines, are given in fullness and detail, though in general, except, perhaps, in invagination in exceptional oases, no reference is made to any sort of sanguinary measures. The first to apply antiseptics to the surgery of hernia were the English. They were promptly followed by the Germans, who became extreme antiseptists, and commenced to cut freely on reducible hernias. The Americans, Avho are now largely influ- 149 150 HERNIA. enced by the German school, soon followed, while the French and Italians have been the latest in adopting kelotomy for the non- strangulated. Indeed, as recently as ten years ago, M. Paul Segond, from Avhose work I have so freely drawn in the historical parts of this monograph, in Paris, wrote with great energy and convincing argument against every variety of operation for hernia, unless the patient's life was in danger, or the hernia Avas incoercible to the truss and a source of constant distress. This distinguished author, however, at the French Surgical Congress in 1888, reported fourteen operations on non-strangulated hernia, and besides has since Avritten to me that he now regards those operations in a different light, and considers them, in non- strangulated hernia, in appropriate cases, as a very valuable sur- gical expedient. M. Felizet, three years ago, wrote a special monograph on the " Radical Cure of Hernia in Children," a translation of which, by me, has run through several issues of the Southern Medical Record. Dr. Justin Lucas-Championniere, of the Tenon and St. Louis hospitals, of Paris, early in this year published the most complete work that has yet appeared in any language, on the subject of hernial operations on non-strangulated cases {Cure Radicate des Hernies avec une Etude Statistique), in which he reports 270 opera- tions by himself, from June, 1881, to February, 1892. It cannot be said, hoAvever, that French surgeons, as a rule, favor radical intervention, or approve of the enthusiastic recommendations of Championniere. With the Germans, English and Americans. those operations are not now advocated so indiscriminately as they were but a few years ago. Nevertheless, to one going through the surgical hospitals of the British Isles and the conti- nent even now, the number of cutting operations for reducible hernia, which he will daily witness, is something enormous. They furnish an immense abundance of clinical material for operation. But, as thousands of the herniated have been treated by radical intervention Avithin the past ten years, it would seem that by this time some sort of consensus of opinion should be reached as to which operation is the simplest in technique and permanent in its effects. Besides, the precise extent of danger to life should be HERNIA. 151 indicated, and the proportion which has not relapsed. From what can be gathered from authentic sources, it appears that the mortality is about one per .cent, on non-strangulated cases. Bull says the mortality is practically nil. It is assumed that he must have reference to those recent cases occurring in the hearty and vigorous. In my oavii fifty-seven cases for radical cure in the strangulated and non-strangulated, in the past six years, there has been no death except in those of the former, which were collapsed Avhen operation Avas undertaken. Juillard maintained that as relapse occurred after all opera- tions for radical cure, it Avas immaterial what special method Avas adopted. If this surgeon intended to convey the impression that no case was permanently cured by operation for radical cure, it is quite needless to say that such a sAveeping assertion will not be supported by any impartial observer of considerable experience. But if he wished to be understood as claiming that no operation could guarantee against relapse in all cases, his declaration cannot be disputed. It is important that we are fully sensible Qf all the con- sequences which may ultimately attend these radical operations before we undertake them, or make any promises to our patients. In this connection it may be inquired: In the event of hernia re- lapsing after operation, is it as coercible as before anything was done by the surgeon ? With reducible, trussable hernia, when the open operation with free division of the tissues is performed, there can be no question but that with a considerable number, when they relapse, they are more unmanageable than they ever were before. I have seen a few of this description, which no sort of prothetical appliance could comfortably control. The open method, hoAvever, in certain cases, is the only one which Avill enable us to deal successfully with many phases of hernia. In order that a reasonable estimate may be made of the pre- cise or approximate value of the numerous modern operations which have been recently alternately vaunted, severely criticised, or condemned, and Avith a view of according to each its just merit, and demonstrating their defects and shortcomings, a brief 152 HERNIA. notice of a few of the more common and popular av ill be described here. For the purpose of reducing their description to a simple an- alysis, they may all be divided into— 1st.— Those in which the sac is ligated at the external ring, and permitted to remain in situ.—Reisel. 2d.— Those in which the sac is freely and completely dissected; the canal in inguinal hernia divided from the external to the internal ring; the sac ligated and cut away ; the parts again closed in, layer by layer.—Championniere. 3d.— Those in which essentially the same steps as in the preceding are carried out; but the divided inguinal canal is kept open, and the healing is by granulation.—McBurney. 4-th.—A complete detachment of the sac from its adhesions, and its utilization as a plug, to serve as a barrier against relapse.—McEwen. 5th.— The isolation and section of the sac and its excision at the internal ring; splitting the internal ring and lifting the spermatic cord entirely out of the inguinal caned ; then wholly obliterating the canal by tendinous approximation.—Bassini. It will be "apparent that this quintuple division, in the man- ual of operations, applies chiefly only to typical, indirect, uncom- plicated inguinal hernia. In large bubonoceles, in direct inguinal, in those inguinal of a congenital type, or in those in which evolution of the hernia through direct rupture of the sac has been sudden, as well as in femoral, umbilical, or many other phases of hernia, it has little or no application. The first feature of all those modern " open operations " which attracts one's notice, is the extensive division of sound, anatomical structures in their continuity. If Ave could but assure ourselves that this free cutting across or through muscle, tendon, or apon- eurosis were not in a certain sense a mutilation, and that the re- sulting cementing together of the divided parts Avould not dimin- ish the strength or pliancy of the traumatized structures, there would be little hesitation in deciding on the most appropriate course to pursue in any case. If in inguinal or femoral hernia Ave could obliterate a canal, and yet leave one, a difficult problem Avould be solved, as we will see further on. HERNIA. 153 THE MANAGEMENT OF THE SAC IN OPERATIONS FOR RADICAL CURE. Very much diversity of opinion yet prevails as to the man- agement of the sac in hernial operations for radical cure. In the operation recommended by Socin, Nussbaum and Reisel, the viscera are reduced, an incision is made through the in- teguments, the neck of the sac is isolated, ligated at the external ring and cut through. This course of incomplete dissection of the sac, or hernial cavity proper, is observed on the ground that as it is almost ahvays intimately adherent to and incorporated with the elements of the spermatic cord, its enucleation is not always possible, without doing serious damage to this organ. As a matter of fact in all cases, writh feAv exceptions, in reducible, irre- ducible and incarcerated complete inguinal hernia, the sac extends doAvn to the testis, and if it is so lodged, not alongside of but in the midst of the vessels, nerves and duct of the cord, it will always require a tedious dissection to entirely disengage it from the cord. This is of prime importance to remember when the modern opera- tion is undertaken, and the proper manipulation of the adventitious structure is considered. There does not appear any valid objection to leaving the sac lodged, when it is firmly held by old adhesions, and through which its nutriment supply is drawn. As noAV the sac has no further function to conserve, in obedience to a Avell-known laAv in the economy, it undergoes contraction with disintegration and absorption. In crural and umbilical hernia it is always considered important to completely enucleate the sac, as in these districts its Avails are generally free and its entire extirpation is supposed to permit the more complete consolidation of the tissues, on the per- fect sclerogenis of wdiich the barrier against relapse is secured. This operation, commonly known as Reisel's, though it Avasmany times performed before he described it, is the simplest of all open bernial operations, and applicable to certain definite phases of the infirmity. With these, it should be preferred to any other open operation. It is simplest of performance, entails the least mutilation and effects all that any operation can, without the dangers of many others. By it the elements of the cord are but slightly disturbed, the scrotum is not opened, nor the cavity of the peritoneum ex- posed to the risk of infection. 154 HERNIA. THE CLASS OF CASES IN AVHICH CERVICOTOMY AND DELIGATION SHOULD BE SELECTED. 1st.—Every case of non-adherent A-entral, crural, and umbil- ical hernia. 2dly.—In all inguinal hernia in Avhich there are: {a) great distention of the inguinal canal (large incarcerated bubonoceles): {b) those Avhich have no canal; (c) in all direct inguinal hernia. 3dly.—In those cases in Avhich, for various reasons, it is im- portant that we must operate with haste. 1st.—Although with very rare exceptions hernia is never met with, except as a visceral escape through some natural outlet of the peritoneal cavity Avhich serves as a passage to a tubular structure, yet it is quite unusual that the peritoneal investment which encloses it, is intimately fused Avith contiguous parts or vessels, except in the inguinal variety, so that, except Avith the latter, it is always well, unless special contra-indications prevent, to lift the sac out of its bed and amputate it high up. 2dly.—In large, old incarcerated bubonoceles, in Avhich it is discovered that the vessels and nerves of the cord are spread over the entire circumference of the sac, like so many strands or cords over the dome of a parachute, and haA~e become, through fibrous changes, so adherent as to be detached Avith difficulty and danger. enough has been accomplished when the sac is opened up to the internal ring or near it, its contents freely liberated and re- turned, its neck freed, twisted, stretched, and transfixed, and firmly secured by the multiple chain suture of Championniere, and cut across. With a view of destroying the epithelial and glandular coats of the sac, this having been Avell opened, the serous surface is freely sponged Avith strong alcohol or a solution of the chloride of zinc, so that its lumen may be immediately destroyed and an active reactionary inflammation excited, which will firmly weld everything outside the spermatic cord into one dense plaque of fibrous tissues. Those which have no canal.—In the infantile type of inguinal hernia, as there is practically but one ring and hence no canalr other tissues must be utilized7as a tampon. With them we wTill find a condition which will strike one as rather singular who is accustomed to regard rupture and hernia as synonymous terms, op HERNIA. 155 who ha> an impression that all hernial infirmities, Avith feAV excep- tions, do not present their initial morbid anatomy at or even be- fore birth, for, even within a Aveek or tAvo from birth, avc will nearly invariably meet with a thick, dense, adherent sac. In chronic gcrotoceles of those adAranced in years, Ave Avill meet a practical obliteration of the canal through the pillars having given Avay, and either orifice having so spread out, that all obliquity is lost and nothing remains but one large hiatus into Avhich three or four fingers may be readily introduced. When the radical operation is essayed in this undesirable class, Ave are not concerned Avith a physiological inguinal canal, for there is none. Marcy, in his work entitled the " Radical Cure of Hernia," however, describes a technique by Avhich, Avith the employment of the buried kan- garoo suture, the obliquity of the canal may be restored. It is obvious that Avith these chronic, or senile hernias, pathological changes haA7e Avrought such a radical alteration in the position, consistence, and relation of the gross structures and the minute histological elements, that we need hold out no hope for a cure by radical operation; as the most which Ave may expect to accom- plish is the comfortable reposition of the parts in such a manner that they may be painlessly and securely retained by a prothetic support after operation. As the greater part of these cases are complicated with spermatocele or hydrocele, and are irreducibly incarcerated, besides, as their abode has been so long in an acces- sory cavity, their sudden and complete return may react mortally on the respiratory organs. When, however, strangulation may threaten, or for other reasons an operation is decided on, having a full appreciation of the conditions before us, the question may arise as to whether or not it may be as well to cut at once down on the broad, thick neck of the sac. If it contains mesentery and intestine, cautiously isolate and reduce as in the case of bubon- ocele, and if Ave should meet with a mass of adherent omentum, free it Avell above from the inner surface of the infundibulum; make traction on its proximal pedicle, so that on division the ligated stump may mount high in the abdominal cavity and leave the mass of the epiplocele outside in the scrotum where it Avas. There is no danger of a slough, for its nutrition is rather from its adventitious connections, than the linear vessels Avhich course 156 HERNIA. doAvnAvard through the pedicle. This procedure has answered admirably in three cases in my hands. One Avas a Avoman,and two men. It spares an immense effusion of blood through capillary oozing, attendant on decortication; and the undisturbed parts beloAv give rise to no further annoyance. With this hernia the sac must be carefully closed with strong silk in divided sutures, and to my mind it is the only hernia in which the vivifying and solid suturing of the pillars is a judicious or useful procedure. It would be absurd to suppose that this immense open chasm, only coA7ered in by the peritonemm and integument, could resist the re-descent of the extrusion. Hence, the pillars must be brought together and firmly closed with silver-wire sutures. It is true that these may later give rise to irritation, but occasionally, as when buried in the fibro-osseous tissues of the patella, unless they cut through, by lateral tension, they may remain imbedded in the tissues almost indefinitely ; but of this more later. DIRECT INGUINAL HERNIA. This form of hernia is said to be more common in Avomen, and to occur about once in fiVe of all the inguinal cases. This is the figure as given by Cloquet.* My oavii observations convince me that these statistics are erroneous, as I have never met Avith but two cases, which by any stretch of the imagination could be regarded as of this type. On the contrary, even Avith these I had my doubts, as the parts through lapse of time and interstitial changes had so altered that it was quite impossible to say just precisely the type Ave had before us. It appears of late years that surgeons, or those whose province it is to deal Avith the morbid anatomy of hernia, quite generally ignore direct inguinal hernia as a pathological entity ; for in none of the latest and most complete works on hernia, by American and foreign authors, is it at all barely mentioned. And with American surgeons the con- fusing, cumbersome nomenclature of Cloquet or Gray is rarely adopted in their descriptions of hernial coverings. The intercolumner fascia may be very thick, or the conjoined tendon very thin, so that in a general collapse of all the aponeu- rotic coverings of the inguinal region, the isolation and recognition * Cloquet, Anatomies des Hernies. HERNIA. 15T of these independent structures -will often be quite out of the ques- tion. Fortunately, in the surgical therapy it will, in any event,. in no way effect technique. For we Avill deal Avith the pouch of the conjoined tendon precisely as we do the intercolumner fascia. The essentials in operation, then, are practically, identically the same in direct in- guinal as in large, ancient indirect. 3D.—CASES IN AVHICH URGENCY DEMANDS HASTE IN OPERATING. Probably Ave can conceive of nothing in life which to a greater degree is an unknown quantity than a surgical operation. The way may seem clear of every possible obstacle or accident; the patient's general condition is excellent, and everything points to consummate success at every step. We have studied our case;. have over and over examined the field, and, mentally, have repeat- edly gone through all the stages of an operation ; provided ample assistants, and anticipated, we imagine, all possible emergencies. But from the start everything goes Avrong. It may be quite im- possible to narcotize, or our patient may haAre violent, uncon- trollable muscular spasm. He may have incessant vomiting, a suffocative, respiration, or heart failure. Besides, at a time we need light the most, it is the worst. Our patient may be a bleeder, etc. All or any of Avhich may necessitate the bringing of an operation—particularly one Avhich involves the peritoneum—to a hasty close. Under these circumstances, although it may be desirable to enucleate the sac, yet the operative procedures may be simplified and shortened by the simple division of the neck of it, in the manner as previously described. In extremes of age and those suspected of organic disease, the reduction of the operative time is of great importance. Under these circumstances and in the class of cases here described as appropriate, cervisotomy may be utilized instead of another operation which entails a tedious and difficult technique. Championniere attaches great importance to the necessity of fall anaesthesia before we commence any sort of hernial operation, and rigorously excludes those afflicted Avith asthma and bronchitis. And Felizet, invariably as a prerequisite in herniated children, 158 HERNIA. insists that they should have passed through measles and Avhoop- ing-cough before any operation is undertaken on them ; and for the same reason, fearing bronchial troubles in Avinter, prefers the Avarm Ave'ather of summer for herniotomies performed with a view of radical cure. V SECOND DIVISION. THOSE OPERATIONS IN AVHICH THE SAC IS COMPLETELY DISSECTED AND CUT *AAVAY AFTER THE INGUINAL CANAL HAS BEEN DIVIDED THROUGH- OUT ITS ENTIRE LENiiTH ;• AFTER AVHICH, THE CANAL, EXTERNAL RING, FASCIA AND INTEGUMENTS ARE CLOSED, LAYER BY LAYER.-- (CHAMPIONNIERE.) This is the operation Avhich Championniere has performed on 274 patients, Avith slight modifications, on children and adults, males and females, in strangulated and non-strangulated hernia. His mortality in the non-strangulated, non-complicated, was prac- tically nothing. He has reported but few relapses, though it Avould seem from his writings, that he had not put his cases to an ordinary test, for he ahvays required his patients to immediately wear a broad belt, with a metallic plate applied, immediately OA^er the traumatized area. It practically serves the purpose of a truss, though it acts on a somewhat different principle. He recom- mends it indiscriminately after all radical cures, though it is not quite clear, whether it was to be worn continuously through life or not. Many are reported to have laid it aside after a time, with- out relapses. 160 HERNIA. This is essentially the same operation as first practiced by Reverdin; only the former always extirpated the sac, something which the distinguished Belgian sometimes omitted. Before detailing the various steps in this operation, it is well to fully appreciate the possible and probable results, which may ultimately result from the exten- sive dissection and mutilation, Avhich this operation renders im- perative, Avhen performed on a complete, indirect inguinal her- FlG. 40. (Chan.pionneire.) Fig. -15. Championneire Belt and Support, worn after operation. nia on the male, on the lines laid doAvn by its originator. First, the sac, the perito- neum, the cellular membrane, and infundibuliform layer of the fascia-transversalis, Avhich is not, as many anatomists teach, either anterior or posterior to the sper- matic, but in nearly all cases of reducible and incarcerated hernia? rather thrown in among the strandlike structure of tbe cord, so that, as we endeavor to roll out the sac, Ave must begin by endeav- oring to enucleate them Avith the finger-nail and scalpel, which Ave may, perhaps, accomplish in many ; but in not a few, this de- bridement or detachment, without doing irretrievable damage to the neural or vascular structures, is quite impossible. As one comes on the sac and finds it encased in those linear, cordlike chan- nels, on their way to or from tbe testis, there are none of them which can be definitely distinguished, except the artery of the testis, the pulsations of Avhich may be felt, and the thick, resistant sperm duct of the same organ. It is quite impossible to recognize HERNIA. 161 Fig. 47. Three independent layers of sutures after incision of the sac ; inclosing incision. the veins, when not varicosed; the cremasteric, or artery, of the vas deferens, as is also the spermatic nerve, and other branches from the external pudic and obtu- rator, which must be encountered on the way to the base of the scro- tum. Hence, in the tearing, teas- ing and picking Avhich must be done, to divest the peritoneal pouch from those elements which belong to the cord and testicle, extreme care must be observed. This step of the operation is always attended with more or less loss of blood, and laceration of nerve filaments. But the sac is finally freed ; though we may have had to go doAvn and peel it off the testis itself, as Avas done in one of my own cases in a congenital hernia. And let it be noted here that the fibrous elements of the sac possess great contractile power, I a proof of which we always observe. / g I For, while before reduction of the $ | f f hernia the sac may be distended as large or larger than the fist, w7hen empty its volume is no larger than the finger, or is even less at times. The scrotal adhesions being liberated, the cremasteric and intercolumnar fasciae being laid widely open, we arrive at the external ring. Here it is well to hesitate a moment and recall a few points in the anatomy of the inguinal passage. As has been pointed out under a description of structure and function elsewhere, the fig. 48. external ring is normally widely ^^a^^&SS^ Tcb'open; the canal from without, inward, oncinampiornniore1.)eure- taking the form of an inverted cone; 11 162 HERNIA. the base of which corresponds wTith the pillars or the borders of the conjoined tendon and the upper border of Poupart's ligament. Invaginating the integuments Ave can conveniently pass the finger along the entire length of the inguinal canal, which pursues an oblique direction to the internal ring, so miscalled, for there is no analogy whatever in the structural arrangement of either ring. As the finger is in the canal we will note, that as the abdominal contents were directly against the abdominal walls, their advance is opposed by the obliquity of this canal, which, the greater the resistance from within, the more closely it is closed, and next the canal itself, which is essentially a holloAved tube, having two distinct walls, the outer of which is composed of more muscular tissue than the inner. As we advance up the canal, it will be noted that the inner wall becomes thinner, and the outer more dense and muscular. Now, in following up the sac with the scalpel to the internal ring, all this delicate architec- ture is seriously deranged, if not for all time destroyed. An incision is made through the entire length of the canal, from the external to the inter- nal aperture, in order that the pedicle of the sac may be liga- ted on a level with the general peritoneum. It will be seen that by this act the obliquity of the inguinal slit is lost; the anterior, the thickest wall, is opened, and the canal is de- stroyed as a barrier againt ATen- tral pressure. Having cut away the neck of the sac, the proximal lumen Adjustment of the chain suture before division Is closed AVlth the chain SUture of the neck. (Championniere.) ^ Fig> -$o. 49), and returned when the parts are closed in by three layers of cat-gut sutures, and the external ring is closed with the same material. The late Fig. 49. HERNIA. 163 lamented Parkes, of Chicago, at the American Surgical Congress of 1888, declared that the suturing of the pillars was of no value as a prophylactic, as he had seen the Avails expand, and relapse occur as frequently when they were sutured as when they Avere not. Reverdin later expressed similar sentiments. When relapse or recidivation does follow after the operation, as the canal is gone, Ave must have practically a ventral hernia; a phase of the infirm- ity at once the most intractable and unmanageable, as now the the escaping viscera wander in any direction offering the least resistance, intruding themselves in the intermus- cular spaces and subcutaneous tissues, acquiring adhesions and becoming in . . ° L , -, . i -, i Fig. 50. time incarcerated and irreducible. proximal pedicle after ligation and In crural, umbilical or ventral hernia this operation, Avhen the sac is devoid of adhesions, is the ideal. In the inguinal hernia of the female, in whom the external ring is large and the passage very short, and in whose inguinal- canal there are no important structures analogous in function to those met Avith in the male, it no doubt may have a place, and serve a useful purpose in a considerable number of cases. As the incision with them to expose the canal will be near the median line, the hair of the mons veneris will often effectually conceal the scar. THIRD DIVISION. AN OPEN OPERATION AVHICH ESSENTIALLY EMBRACES THE SAME STEPS AS THE PRECEDING, BUT THE DIVIDED INGUINAL CA1JAL AND THE SOFT PARTS UNITE BY GRANULATION TISSUE INSTEAD OF PRIMARY UNION. --MCBURNEY. Although this operation Avas first practiced by Langenbeck^ it was more fully elaborated and instituted on an extensive scale by Dr. Charles McBurney, of New York. The fundamental objects claimed to be obtained by this " open operation" are the complete isolation of the sac on the same plane as the general peritoneum, and the filling in the breach in the tis- sues, made by the scalpel, with cicatricial tissue. McBurney claimed for the operation that it prevented any dimpling or funneling of the peritoneum, and hence the tendency to relapse, so common after all those operations which left a remnant of the sac in the canal. It Avas also maintained that the resulting ridge of scar tissue Avould serve as an efficient barrier against relapse. Of course this procedure would scarcely apply in any other than in typical inguinal hernia for it presupposes the presence of a sac, a canal, etc.; hence in a 164 HERNIA. 165 sacless hernia, in direct inguinal, infantile crural, it is not so prac- ticable, or in umbilical. If other operators have aimed at curing hernia by stuffing the canal or closing its lumen, the NeAv York sur. geon proceeded in a diametrically opposite direction to accomplish the same end, as eA^ery A7estige of the sac is swept away, the inguinal canal is opened from end to end, and deliberately kept so by sew- ing its divided edges above and below to the integument; and pack- ing the interspace, through which the spermatic cord passes, with a tamponade of gauze. Dr. McBurney reports a very large number of cases treated by this plan, nearly, if not all, for the non-strangulated. My own six cases in which this operation Avas employed for strangulated, as a radical measure, reported in the Journal of American Medical Asso. ciation, for June 17th, 1889, wTere the first in this country in which it had been utilized for this phase. Inasmuch as it afforded the surgeon every facility for manipu- lation and provided for ample drainage, it at first favorably im- pressed me as being specially adapted for strangulated cases. This operation par excellence demonstrates the marvelous re- sisting poAver of the peritoneum ; for, exclusive of it and the con- joined tendon, there is nothing to hold back the contents of the abdomen until cicatrization is complete. The obliquity of the • canal is not only destroyed, but the canal itself, with its coverings as well; so that in the event of relapse the hernia is only prevented from coming directly into space by the cicatrix. If this should rupture or sunder we Avould have precisely the same phenomena as Ave sometimes Avitness spontaneously occur in exomphaceles, Avhen the umbilical scar spreads out as thinly as tissue-paper, erodes or bursts and allows the intestine to pass directly through. Soon after Dr. McBurney's thesis on the technique of his opera- tion at the NeAv York Academy of Medicine, Dr. William T. Bull made a vehement attack on all sorts of radical operations for reduci- ble coercible hernia. McBurney's operation came in for a large share of his condemnation. This, he said, was conceived on vicious principles, and was based on views of reparative processes not in accord Avith the sound tenets of pathological changes, etc., that relapses must be inevitable, and when they did occur, they must be quite unmanageable. 166 HERNIA. Dr. James E. Kelly, of Charity Hospital visiting staff, hoAv- ever, reported several cases treated after this plan, and reported good results as to permanency of cure of the hernia, but mentioned that the cicatricial pressure on the cord had produced, in some cases, very painful sensations when the patient stood long. It does not appear that this operation has been very generally adopted. Although in my own hands it yielded quite good results in strangulated cases, the few relapses after it, which did occur, were of a most intractable character, which almost no truss could com- fortably retain. If we can depend on cicatricial tissue to permanently replace muscle and tendon, then, indeed, this operation offers many advan- tages, and might be utilized Avith benefit for those not belonging to the laboring classes. But we do know that the tendency of proliferation of connective tissue cells is always in the direction of resorption and condensation, and that scar tissue possesses neither the strength nor pliancy of a muscular sac ; but that, on the con- trary, when it finally ultimately undergoes complete fibrinous changes, and parts with its vascularity, it acquires a brittleness and fragility unable to withstand a sudden strain. The author of this procedure insists on it that a truss must not be worn after operation. In Championniere's operation the same rule is pre- scribed. But in contradiction of this injunction the Parisian surgeon insists that a ceinture, an encircling belt, with concaA^e plate, must be immediately adjusted, and constantly employed as a prophylactic against relapse. Although it is denied that this is constructed on the same principles as the truss, or serves a similar purpose, its close analogy is too apparent to be regarded in any other light than a mechanical appliance, Avhich serves essentially the same purpose. Dr. Bull, in his tirade against hernial operations, ridiculed the pretensions to radical cure when a truss must be applied on taking the upright position, and sarcastically remarked, that those only whjo were well trussed up could make any claim to be cured. Abbe, Wyeth, Weir, and others, Avho have performed the Mc- Burney, have advised the application of a light truss. In all my own cases I have taken the same precaution. In my first cases, in which I omitted it, relapse appeared early. Perhaps, when the HERNIA. 167 precise technique of McBurney is better understood and applied, we may dispense Avith this support after operation. Nevertheless, whether it, or any other surgical operation, effects a closure of the opening, a tendency to relapse will ahvays remain here, Avhich requires a support; and, besides, as a hernia is so apt to occur on the other sound side, after one portal is plugged in a large hernia, a double truss should be worn in the absence of a firm bandage. FOURTH DIVISION. COMPLETE DETACHMENT OF THE SAC FROM ITS ADHESIONS, AND ITS SUBSEQUENT UTILIZATION AS A PLUG, TO SERVE AS A BARRIER AGAINST RELAPSE.—MCEWEN-KOCHERS. The preservation and utilization of the sac as a tampon, we have seen in the historical part of this contribution, is a very an- cient procedure, and belongs, with anchorage of the testis, ovary, omentum, or intestine, to those procedures which might be desig- nated "obturation of the canal by autoplastic implantation." Dr. Wm. McEwen, of GlasgOAv, has recently revived and modified the operation. He has reported a considerable number treated by peritoneal occlusion, in which there have been, as far as he could learn, but few relapses. The operation, however, has not met with very much favor, and is not now as extensively practiced as it was when first intro- duced. Reisel in 1877 performed an operation quite similar to this. He dissected the sac away, and then, by invagination, pressed it up to the internal ring, and sutured it in the canal with catgut. With what result is not stated. 168 HERNIA. 169 The operation of McEAvcn, Avhich may be excellent in its re- sults when all the conditions are present to favor its success, is, nevertheless, in a general way, opposed by all orthodox principles in surgery. Independent of the necessary amount of tearing and laceration inseparably connected Avith the decortication of an old adherent sac, and impacting a foreign, heterogeneous mass in the canal, Avhen the cardinal aim in all hernial surgery is to restore normal relations and clear the passages of such substances as may favor, by their presence and irritation, the re-establishment of a condition Avhich an operation is undertaken to remedy. This procedure has no place as an adjuvant to kelotomy for strangulation—a condition in which, alone, the sac is usually free from adhesions—for the inA^esting peritoneal pouch in these cases is often more or less necrotic, as the result of inflammatory or other degenerative changes, which make its extirpation neces- sary. Then it often must be left free in the breach to contract or close in by granulation, if not exsected. As the nutrition is pro- vided, in all cases of adherent sacs, largely by the vascular supply through the perihernial tissues, Avhen this is totally cut off, as it always is in enucleation, the sac may undergo rapid atrophic or ulcerative processes and disappear; hence, in a short time leav- ing the canal about the same as though nothing had been done to obturate it. The varying capacity and consistence of the sac may be an embarrassing feature in a given case, as Ave will sometimes find this very large, thick, and tough, so that its gross volume is very much in excess of what Ave require or can utilize; AAmile, again, it is very diminutive and of a gauzelike thinness, so that it breaks down on even very moderate manipulation, and there is so little of it as to render it quite useless as a plant in the inguinal tract. This operation, without modification, certainly cannot be util- ized in the congenital type of hernia, or in a monorchis, in whom it is important that the inguinal canal be preseiwed clear of every impediment. In properly selected cases, with the young in sound health, and in uncomplicated inguinal hernia, particularly the female type, keeping the conservative aim in view of sacrificing nothing, but utilizino- everything, we must admit that this operation may be 170 HERNIA. applied Avith adA'antage. Dr. McEwen has personally informed me that this operation was not indiscriminately recommended for every phase of hernia, and had his sanction only in appropriate cases. In it, as in others already described, the pillars of the rings are approximated and sutured, after the wad of peritoneal tissue is turned on itself and imbedded in the canal. This step, in the event of the implanted sac undergoing homologous assimilation, can certainly serve no useful purpose ; while, on the contrary, should this fail, and permanent obliteration of the hernial opera- tion folloAv, Ave would have still, anatomically, an incomplete hernia resulting, Avith all the discomforts and ultimate dangers which might ensue. When, then, this species of peritoneal grafting, to fill in "dead spaces" or to wall back hernial re-descent, is resorted to, as much or more may be accomplished by leaving the external orifice open and dependent. McEwen, from 1879 to 1890, operated sixty-four times; five being crural hernia, seeing but one unfavorable result. FIFTH DIVISION. ISOLATION OF THE SAC, AVITH SECTION AT THE INTERNAL RING ; SPLITTING THE INTERNAL RING, AND LIFTING THE SPERMATIC CORD ENTIRELY OUT OF THE RINGS AND CANAL, AND THEN OBLITERATING THEM TOTALLY BY TENDINOUS APPROXIMATION.--BASSINI. The presence of the spermatic cord, the round ligament of the testis, has ahvays been regarded as an insurmountable barrier to the radical cure of inguinal hernia ; and, accordingly, different operators, since very early times, have either resorted to castration while herniotomizing or else endeavored to destroy the spermatic channel, from end to end, by displacement of the cord. Most certainly, when this operation, as performed by Bassini, of Padua, is carried out in all its details, we can never again have a relapse of an inguinal hernia, for by it every remnant of the in- guinal architecture has been swept away ; and, surely, Ave cannot have a hernia through a structure or parts which no longer exist. But we may inquire, can the spermatic cord be raised and trans- ported Avithout traction on the slack below, or without further Aveakening the abdominal Avail, in making another breach through sound parts ? 171 172 HERNIA. The tubular structures of which the cord consists, each approach the internal orifice at different angles, from different directions, and only converge and follow the same plane as they emerge from the abdominal wall externally. The cord is pro- tected throughout by a peritoneal investment, which though above it is sealed, is yet, nevertheless, continuous with the cavity of the peritoneum. We cannot, therefore, raise the cord from within the abdomen, for there none exists, and hence, in order to displace it, dangerous traction must be made on those delicate elements of it, which, at the internal ring, have effected a permanent lodgment. Besides, as it is only free from the outside of the ring, this is the part which must be raised and placed into the gap made in the abdominal wall to receive it. The displacement of the cord by raising a loop of it into the slit in the tissues, causes a double incurvation of it, so that in its new situation it takes the shape of the letter S. And hence this double curve, Avith the contractile compression liable to ensue as the soft parts close in around it, are physical causes which one would think would, in time, cause grave functional and organic disturbances in the vessels of the cord and testis. However, if these cause no changes other than a painless atrophy, as one testi- cle is ample for the preservation of virility, this is a sequela of -little consequence, and our patient would be left a whole man, as far as appearances went. This effort of preservation of the testis in hernial operation by the surgeon is always appreciated by the laity. Curling, in his treatise on " Diseases of the Testicle," cites an instance in Avhich a distinguished French surgeon Avas murdered by a patient from whom he had removed a testicle. In the case of an old, painful, in- carcerated hernia, in a clergyman of middle age, in whom I was invited My ,f to do the radical operation by Dr. FlG 51 Frederick G. Kneer, of this city, First stage in Bassini-s operation. when I explained to the gentleman HERNIA. 173 that when I exposed the parts by a deep incision, I might find it necessary to sacrifice the testicle on that side, he vehemently pro- tested against it, that it would unsex him, and impair his man- hood. Bassini's operation is intended to always obviate the necessity of castration. The next step in this operation, after the cord is fixed in the new opening, is to close the canal, bringing the divided end above and sewing it into the ,?. upper border of Poupart's ligament, thereby completely and solidly closing both rings and the canal, after which the cord is carried outside the deep fas- cia or fascia lata, and covered in Avith the superficial fascia and integument. If the cicatricial bond Avhich closes in the largest rent in the tissues could be depended on, this should be one of the most radically curative of all operations. If some sort of non- corrosive material could be found Avhich could be left imbedded in the tissues to permanently lock the gap- ing edges together, and should the reparative material provided by the economy prove adequate, our patient against return of his hernia. In Rome I was permitted the privilege of Avitnessing Prof. Leoni and Dr. Raphael Bastianelli perform several hernial operations in the surgical hospital of the Via Corsa by this method. They em- ployed silk suture for the tendinous structures, as they said that any sort of absorbable material could not be trusted, for it gave way before solid union was effected. They ahvays employed vigorous antiseptics, and had practically no mortality which could be attrib- uted to the hernial operations. Dr. S. E. Milliken, of New York, has largely employed this operation, and speaks well of the results. My own observations of its technique, and a study of the principles on Avhich its claims rest, have led me to take a decided position against it. No doubt it has given many operative suc- FlG. ")'_'. Second stage in Bassini's operation. might be fairly guarded 174 HERNIA. cesses, but in the event of relapse the succeeding hernia must be quite unmanageable. Bassini reported 251 cases of reduci- ble inguinal hernia operated on by him, in which he says there were but seven recurrences, though 198 of these cases passed from under his ob- servation within six months and a year after operation. The mortality in those cases treated by modern methods has been reported as very light. Svesson and Erdman had but one death in 106 cases {Nord. Med. WeL, Bd. 18); Charnponniere, one in 120 ; McEAven, one in 98; in Kocher's operations, 119, but one death. Indeed, this author goes so far as to say that there in no danger at all, and that when Third stage in Bassini's operation, fatal results folloAv these open opera- tions, they are imputable to antecedent conditions which would have cut off life if nothing had been done. Segond's* figures, hoAveA^er, do not bear out this ArieAV. He collected 219 cases up to 1880 Avith 20 deaths, or nearly a mortality of 10 per cent. The same author, in 113 cases, in which the results were published, found that 44 of them almost immedi- ately relapsed. Schede, Reisel, Weinlechner, Reverdin, Czerny, Esmarch, and McEwen have each reported post-mortem demon- strations of the perfection of curative consolidation by their various operations. Maas, of Fribourg, examined, after varying intervals, his own and Czerny's cases, and reported that they all had relapsed. Schede, Czerny, Socin, Tilanus, Langenbeck, Reverdin and others, ridiculed the pretensions of those surgeons who never ad- mitted relapses. Juillard candidly admitted that in his 22 opera- tions for radical cure he had had but one permanent cure. In this case he found it necessary to resect 18 centimeters of the intestine. After she recovered from operation, she had mental alienation, though tAvo years after there was evidence of relapse of the hernia. * Cure Radicale des Hernies, page 206. CHAPTER XX. miscellaneous open operations in inguinal hernia and those appropriate for strangulation; for femoral, umbilical and other varieties of hernia. In the recent " Sj-stem of American Surgery " (Diseases and Operations of the Abdomen, p. 177), an author says," Many opera. tions have been devised for the cure of hernia, which have for a time been popular, and then forgotten, or have fallen into disuse. The operations of Wood and Wiitzer are never practiced now, as these since the introduction of aseptic surgery have been entirely superseded by that of the open incision." This statement is practically correct; though the operations of Gerdy, Wiitzer and Wood in modified ways are yet being per- formed, as is seen by Bennett's operations. And, it might be added, that " open operations " for reducible hernia in America during the past two years are decidedly on the wane. To enter into a full and detailed description of the almost endless variations in the " open operations " would occupy a con- siderable space, and as the principles Avhich underlie them all 175 176 HERNIA. are fundamentally identical, no effort Avill be made to describe them here. It may be said, hoAvever, that in different cases no precise technique will answer for all, and that the operator must accom- modate his dissection to the manifold phases of the infirmity pre- senting in divers cases. Probably, if every surgeon would publish as his operation; one, Avho Avhen he found it necessary to so far deviate from the usual course and resort to a novel ex- pedient to accomplish his purpose, the names of operations for radical cure Avould occupy a very long list. For instance, in one of my own cases in Avhich I had a very thick stalk of omental tissue, after securing sepa- rately its vessels, and cutting off the main mass, I passed a strong cuiwed needle through the inner pillar of the ring (for there Avas but one ring), through the mass underneath, and out through the opposite pillar. I then re-introduced the needle at a point a full half inch below, and re- turned it in the same direction until it came out a little distance from Avhere it entered, AA7hen I firmly twisted the free ends and turned fig. 54. them in, covering in the parts by Congenital Hernia before the operation. gewmg the f&sc{& ^ integuments in_ dependency. This Avas a good case to test this plan on, as he had been operated on before for radical cure, with a prompt relapse. He was a hod-carrier, and now, after three years, there has been no trace of relapse. I have since seen practically the same operation performed in London by Dr. Barker. In another case of a child with an enormous ring and no inguinal canal, I have solidly sealed in the breach, employing large harelip pins, which penetrated the integuments on either side, using silk suture over the pins. I left three of them in for three weeks. HERNIA. 177 The gave rise to no irritation and served a most admirable purpose. No doubt many others have employed similar devices to ac- complish the same end. In open operations for congenital hernia, where there is no independent serous investment, we must utilize the spermatic fascia. In multiple hernia on the same side, direct, indirect, or inguino-femoral in encysted or neoplastic, a special and peculiar technique is required for each; hence, no formal operation will ansAver for all species, or but a very few simple types of them. Hence, it would be preposterous to allege that a specific proced- ure must be devised for each. Accordingly, this part of the subject will be closed with a feAv notes on two or three operations recently recommended. One is by Felizet, Avhich applies particularly to children's inguinal hernia, and another one will be given in full, because it is the very latest procedure devised up to date for radical cure by the open incision. The latter is by Theodore Kocher, of Berne. Felizet's operation in no Avay differs from all ordinary ingui- nal operations, Avhich require the enucleation of the sac and its severance at the neck. It is unlike these operations only in technique. In this operation an incision is at once made down to and through the sac, into Avhich a sort of oblong bag is inserted and is then inflated. (Fig. 55.) The author designates this a ballon or balloon. Having been inserted, an inflating tube is connected with a stop-valve, and blown into until it is fairly distended, Avhen the blow-pipe is disconnected and the operation of decorticat- ing the sac is commenced. The advantages Avhich the Parisian sur- geon claims for this device is that the empty sac, after the viscera are reduced, is rendered tense, so that the work of enucleation of the elements of the cord and adjacent tunics is more safely and expeditiously performed. As there is a firm resisting surface to cut ("Fetizlt.') 12 178 HERNIA. on, and besides the red color of the gold-beater skin giA^es such a tint through the gauze-like overlying tissues, one can easily escape doing damage to the sper- matic vessels. In fact, it is said that the opera- tion time is reduced one half or more. In spite of its apparent advan- tages, nevertheless but few sur- geons have utilized it, claiming that ■its introduction in itself was not without danger to life, and that in many cases its employment Avould be quite impracticable. The danger of infecting the peritoneum by intro- ducing this foreign body into the caudal protrusion of it was alleged against it. The inequality of capac- ity and Avant of uniformity and con- tour in the hernial sacs, besides scat- tered adhesions within them, ren- dered its use quite impossible and undesirable in a considerable number of cases. Felizet had the most happy results following its employment. As it, however, must demand some special practice on the cadaver before it can be readily adopted in average cases, it has failed of that success which was hoped for it. In the "Annals of Surgery," for December, 1892, there ap- pears yet another new open operation for radical cure of hernia, invented by Kocher, which the author claims has no analogue in surgical literature. That this assumption cannot be supported is abundantly demonstrated to anyone who critically examines the plates and description of the operation, which are here o-iven unchanged, as it comes from the pen of the translator. "We Avish to describe a neAv procedure for the radical opera- tion for hernia, which we perfected, and, after sufficient study, per- formed upon a series of cases and demonstrated before a number of surgeons. For itappears from the not yet completed observations of HERNIA. 179 our final results by Dr. Leuw, that the method which we had em- ployed has not fulfilled all of our cherished hopes. We have already explained to what degree this view has been modified. This procedure, Avhich, in the literature known to us, has no analogue, is best explained by the accompanying cuts, which were made after drawings by drawing-master Kiener, taken from nature during one of our operations. The method suffices to make tense the peritoneum in the region of the inguinal canal, and to fix it Fig. 57. Fig. 58. The primary incision in Kocher's method for Forceps introduced along inguinal canal and the radical cure of hernia. grasping the sac at its lower end. against the anterior abdominal wall. This is accomplished after the same manner as in the methods of Barker, Ball, and McEwen, with the difference that the stretching of the peritoneum is done in a direction opposite to the direction of the inguinal canal and the course of the hernia; and that the fixation of the peritoneum is done much more firmly, and in a more permanent manner. The skin and superficial fascia are divided over the inguinal canal and laterally outward in the direction of Poupart's liga- ment (Fig. 57), and the sup. epigastric artery ligated. At the anterior inguinal ring only the thin fascia of Cooper, which, as 180 HERNIA. Sac drawn out through lateral opening in external oblique aponeurosis. a continuation of the tense aponeurosis of the external oblique muscle, covers the spermatic cord, the cremasteric loops and the tunica vaginalis communis, which is especially well developed in hernia, are also divided. The struc- |; tures of the spermatic cord are now |f separated, in which, by holding them „_ towards the light, the border of a very thin hernial sac can be recog- nized. This is then carefully dis- sected and isolated from the struc- tures of the cord until it can be strongly drawn down and its pedicle exposed. The index finger of the left-hand is now introduced into the inguinal canal; and laterally from the poste- rior inguinal ring, a small opening is made through the aponeurosis of the external oblique muscle (see Fig. 60). A slender pair of arter}7 forceps is passed through this opening and through the loAver muscular fibers of the in- ternal oblique and transversalis mus- cles, folloAving the left index-finger as it is AvithdraAvn through the in- guinal canal and finally out of the external inguinal opening (see Fig. 58). With these the isolated her- nial sac is grasped and draAvn through the inguinal canal and through the narrow opening in its anterior wall—that is, in a lateral direction from its upper end. The hernial sac now hangs through a narrow opening above Poupart's ligament (Fig. 59.). It is drawn out as much as possible, and then, as Heliodorus did, and as Ball has recently advised, it is energetically twisted. The sac is, Iioav- ever, not remoATed, but strongly draAvn doAvn and laid over ihe Fig. 60. Sac twisted and laid down external to the aponeurosis covering the in- guinal canal. HERNIA. 181 outer surface of the aponeurosis of the external oblique muscle against the external inguinal ring, and in the direction of the in- guinal canal (Fig. 60). By this tension on the sac, as is shown in Fig. 60, the anterior wall of the unopened inguinal canal, and especially the tense aponeurosis of the external oblique muscle, are pressed inward and backward into a gutter. As the twisted sac lies tensely stretched in this manner, be- ginning at the upper and outer extremity, deep sutures are applied. The sutures are passed above the twisted sac, through the oblique fibers of the aponeurosis of the external oblique muscle and the underlying muscle fibers of the external oblique and trans- versalis, through the hernial sac itself and including the ligament of Poupart beneath it. These sutures—five to seven or more— bring together also the pillars of the anterior ring, to Avhich the lower end of the hernial sac is fastened. In case of a long sac, all that extends below the external ring is cut aAvay. In this manner a firm and solid pad or roll is secured over the entire length of the inguinal canal, which forms a better clam against the pressure of the intestines than an implanted patch of skin or periosteum. Furthermore, the peritoneum is drawn lat- erally on the stretch and firmly pressed to the abdominal Avail in the region of the posterior inguinal ring, where it is held by the torsion of the sac and the deep sutures. The operation is more certain Avhen the upper suture can be deeply applied laterally from the place of entrance of the spermatic cord into the abdom- inal Avail. We have employed the same method in cases of femoral hernia in this manner. The sac, having been completely isolated and twisted as strongly as possible, is drawn through a small opening above Poupart's ligament, and, in the manner above described, included in the sutures Avhich are passed through the pectineal fascia and Poupart's ligament for the purpose of closing the femoral ring. This, the latest fruit of an ingenious mind, and a distinguished surgeon, combines the steps of various operators. It embraces essentially nothing original, and is based on principles totally at A-ariance Avith sound surgical doctrines ; for of all the open opera 182 HERNIA. tions, so far recommended and practiced, this one must be par- ticularly proscribed, as it possesses all the weak points Avhich sur- geons have criticised in others without any of their redeeming features. The time has come when surgeons should " speak out," and let their blows fall where they will, when new procedures are submitted to them for their approval or rejection. The contributions of this distinguished German surgeon, here- tofore, have been numerous and valuable, but as to this last essay on a new operation, it must be said that the cases \vhich require or justify its performance must be few and rare. It will be seen by the cuts that the first step is to make a free incision 0A7er the internal inguinal district to the base of the scrotum, in all complete inguinal hernia. The second requires the division of all the coverings, down to the sac, until the outer ring is wholly freed, Avhen the sac is entirely detached and hangs free. The third step includes an opening through the external and internal oblique muscles, down to the internal ring, when the wall is again weakened by the division of the entire canal. The third and last step is seizing the sac, now free to the internal ring, and twisting it into a spindle, then transfixing it Avith interrupted sutures, and firmly closing in all the outer wall of canal and sac by securing the sutures, and closing the incision in the integument. The fundamental objections to this operation, are: 1st. The enucleation of the sac in old, incarcerated hernia; 2d, The division of the entire anterior Avail of the canal; 3d. The imbed- ding of the sac in the inguinal canal, for the reason that it is a foreign body, cut off from its former peripheral circulation, and being submitted to severe torsion, twelve twists, is almost certain to either slough or atrophy, and in no Avay, under the most favor- able circumstances, possibly compensate for the extensive mutila- tion, which its transportation to its neAv abode must entail. Per- haps, after all, these objections to this and other kindred open operations, the effects of which have been to secure a homologous tamponing of the abdominal apertures, may be and are rather visionary than practical, for it appears from recent writers that bone cavities may be safely and hermetically plugged with dead bone, sterilized cotton, or iodoform gauze. HERNIA. 183 Perhaps the next thing we will hear of will be a silver plate, or hard rubber plaque, to seal a hernial aperture, as was once done Avith shot holes through the cranial vault. LaAvson Tait's operation for the radical cure of hernia deserves something more than passing notice, not so much because it pos- sesses any practical value, as that it emanates from the brain of one who has been an epoch-maker and a breaker of new ground. The procedure, like most of Tait's best Avork, is strikingly bold, and decidedly original. Recognizing the basic principle that nothing in the way of cure can be accomplished in open operations for hernia, without opening the peritoneal cavity, this giant mind conceived the idea of doing the laparotomy at some distance away from the inguinal district, thus obviating the resulting weakness Avhich folloAvs so frequently these modern cutting operations over the rings. Another neAv principle Avas added, in drawing up the hernia from the inside, instead of pushing it from without, and applying the sutures and closing the ring from Avithin. The author acknoAvledged that he had never employed this newT plan on any cases, except those on whom he had performed a laparotomy for an abdominal disease, in Avhom, when a hernia was present, he ahvays utilized the occasion to AvithdraAv it into the abdomen, yet he Avould advise it for all ordinary and strangulated hernia. Tait's essay presented at the annual meeting of the British Medical Association, at Bournemouth, in 1891, did not receive the support of his fellow-surgeons. It cannot be said that the operation is impracticable, but there are such formidable objections to it that it is under special and peculiar circumstances only that it is at all permissible. The opening of the cavity of the general peritoneum is always attended with danger to life, and is liable to be folloAved by ventral hernia at the site of the scar. Could these objections be overcome, yet no guarantee can be given that the hernia will not return at its former site. If Mr. Tait or some other surgeon can shoAv us how the visceral fault can be eliminated in hernia by a surgical operation through the abdominal walls, which will not seriously imperil life, a great gain Avill have been made. For with all our modern operations, the mural element alone is dealt with ; while the prime etiological 184 HERNIA. factors of intra-abdominal capacity and [pressure, with excess of intestine and elongation of the mesentery, are entirely ignored. At the late meeting (92) of the Southern Surgical and Gynseco- Of logical Society, Dr. George A. Baxter presented an opera- tion which he claimed was essentially differ- ent in principle to any yet performed. There is, however, nothing radically new about the procedure, al- though the free di- vision of sound mus- A B—Deep superficial or forcial sutures. Cular tlSSUe above the C—Curved or crucial sutures. • , -i , -i D—Sutures closing the canal and scrotal openings. The sutures internal ring mUSt De to the lower border of the canal tiaversing the tissues. .,. . , (Baxter.) criticized as unAvar- rantable as a common practice, as is recommended by the author. The operation has yet had practically no statistical support. DALLAS' INSTRUMENT FOR THE CURE OF HERNIA. Dr. Alexander Dallas, of New York, claims to have devised an apparatus which will simplify the process and improve the result in the cure of hernia. By this method the patient is placed Fig. 61. Fig. 62. The Dallas Instrument. on his back, the parts cleansed and cocainized, Avhen a transverse incision is made through the integuments and the cord exposed- Now, the instrument is introduced and pressed upward until its point has passed into and through the internal ring, into the ab- domen, where the rasp-like surface of the instrument is exposed and the instrument is withdraAvn. This gives rise to irritation which is supposed to aid in exudation of lymph and occlusion of the canal. Dr. Dallas tells me that it is simple and always safe, and is usually radically curative. He denies that it is a derivative HERNIA. 185 of invagination, as I regard it, and that it is wholly new in prin- ciple. This instrument may serve a useful purpose, possibly, in certain selected cases, but we can see many formidable objections in many others, and can imagine not a few in which its indiscrim- inate or unskilful employment might work incalculable damage on the spermatic cord or in the peritoneal cavity, and yet give no promise of radical cure. CHAPTER XXI. OPERATIVE TECHNIQUE IN STRANGULATED HERNIA AND ITS COM- PLICATIONS, MANUAL AND INSTRUMENTAL. The dangers attendant on strangulation chiefly arise from: 1st.— Obstruction of the bowel. 2d.—Hemorrhage. 3d.—Inflammation and Gangrene. INTESTINAL OBSTRUCTION. One of the most prominent and constant symptoms of stran- gulation is constipation attended with colicky pains. If stran- gulation is sudden, vomiting and great prostration are]also present. But this is not always the case. I have known of a few cases, in which the patient has kept on his feet for one or two days after the initial colic Avas first noticed. As mechanical obstruction in the ATast majority of cases is extra-abdominal, bearing this clinical law in mind when such a condition is encountered, we will look to the portals of emergence for hernia. And this examination cannot'be too thorough, or we 186 HERNIA. 187 may overlook the seat of impediment, until its discovery is too late. Tavo years ago I Avas called to see the AvidoAv of a physician, AATho Avas supposed to be suffering from enteritis. She Avas being diligently poulticed and treated for inflammation; but stercoraceous vomiting setting in Avith threatening symptoms, I Avas called in. My first step Avas to examine for hernia. None was found in the crural or inguinal regions, but as my hand reached toward the umbilical scar, it came on a strangu- lated exomphocele Avhich had been overlooked. As she was now in extremis, operation Avas out of the question, and she succumbed a feAv hours later. In 1885 I Avas attending a man Avho had intestinal obstruc- tion. Nothing Avould open his boAvels, either by the mouth or rectum. I invited Prof. Dennis to aid me. Assuming that our man had internal obstruction, he Avas sent to the Ninety-ninth Street Hospital to be operated on that evening. When Prof. Dennis and myself arrived, the house surgeon, Dr. Weldon, informed us that he had discovered a small femoral hernia. Our patient now AAras in a bad state to undergo a capital operation, and hence, immedi- ately after "kelotomy, he went into mortal collapse. Let it be supposed that a hernia has been discovered ; when symptoms of strangulation arise, clearly the course to pursue is comparatiArely simple, as the end to attain is to remove the ob- struction. Noav, the promptness and manner in Avhich this is best at- tained, will in a large measure depend on circumstances. With Avomen, in A\diose sex strangulation is less common, though terribly mortal, interference mustbe judicious and prompt, or else all is lost. For of all operations she seems to bear kelotomy Avorst, Avhen strangulation is not relieved early. The measures of relief for strangulation may be reduced to three. 1st.—Rest. 2d.—Pressure (taxis). 3d.—Incision. REST. One, the subject of strangulation, should be at once put to bed, and be given sufficient morphine to secure relief from pain and 188 HERNIA. relaxation of spasm ; unless there are some special indications, no topical applications are necessary. After tAvo or three hours when repose is secured, pressure may be commenced. TAXIS. Taxis is a valuable expedient in strangulation. But it is capable of doing a vast amount of damage if employed Avithout discretion. It may be likened to the urethral bougie, Avhich, when gently and skilfully employed, will more safely and radically cure urethral stricture than any other known means; yet is capa- ble in rude hands of not only destroying the passage but life as well. So with taxis, moderate intermittent pressure will usually overcome most strangulated hernias, and effect reduction. The application of great force, or very long continued taxis, will not only be resisted, but Avill subject the extruded viscera to great danger. Hence, we need tact, as much as taxis, to succeed. When a hernia resists taxis we may chill the inguinal region with cold douching or iced applications applied at short intervals. Quite precise rules have been laid down in different text- books for the successful and safe application of taxis," in general surgery. But, practically, they have little or no application. In those directions laid down for the student and practitioner, a considerable degree of importance is attached to the manner in which the intestine is manipulated in the different phases of hernia; i. e., that the return of the hernia must be just the reverse of its descent, etc.; that the pressure must be applied in different directions in order to clear the various curves and angles, which the viscera take in the evolution of the hernia. These directions I have never found of any practical value. Indeed, Avhen it is re- membered that in the vast proportion of strangulated hernias, the greater part of the volume consists of effused serum, and the sac, the integral parts of nearly every hernia are almost invariably adherent, and hence entirely irreducible, attention must be directed to something more than the bowel. The cardinal points to be remembered in the application of taxis are not to employ too great force, nor make its application too protracted. If one seance fails, nothing will be lost by waiting HERNIA. 189 aAvhile, Avhen, often, on the second or third effort, the mass will return with surprising ease. There is a singular and striking an- alogy between the erratic, spasmodic action of an organic urethral stricture and the spasmodic grip of a hernial constriction. At one time the stricture is wholly impassable to the finest bougie, of eATen a hair's diameter, Avhile after an interval of rest, by a little coaxing, an instrument of considerable diameter may readily glide on to the bladder. And likeAvise Avith a strangulated hernia, our approach must be gentle, gradual and intermittent. Moderate, safe taxis should be unattended Avith pain,and hence, Avhen manip- ulations are of such violence as to make our patient " cry out" with agony, Ave are doing harm. The use of pulmonary anaesthetics, as an accessory means in reducing a strangulation, should be condemned as a general ex- pedient, It is well before taxis is commenced to empty the rectum and colon, and clear the stomach by a free emetic. These measures reduce inter-abdominal pressure, and effect, more or less, muscular relaxation. How long can one safely permit strangulation to remain Avith safety to the patient 1 This Avill depend. Though, in a general Avay,it maybe said, Avhen there are no very pronounced constitutional symptoms, from tAventy-four to forty-eight hours is the maximum in men, and in women not more than tAvelve hours at the most. If we incautiously administer morphine, its narcotic action may mask various symptoms; hence, except in the initial dose, to secure primary relief at the moment of strangulation, if given at all afterwards, it should be in very small doses. The symptoms Avhich portend great gravity are pronounced bodily prostration, reverse of the peristaltic Avave of the intes- tine, with fsecal vomiting and immense ballooning of the bowel. These symptoms should be anticipated by surgical interven- tion. But the medical attendant is often so hampered by divers considerations, that often the opportune moment for prompt action is past before he decides to turn the case over to the sur- geon for operation. If the patient be a person of means, the physician may hesitate, fearing that the presence of the surgeon 190 HERNIA. may imply a want of skill on.his part, or that he may lose the family through it. With the poor, their deep-rooted horror of all hospitals prevents them from yielding until the last moment, at a time Avhen their lives are greatly endangered by transporta- tion itself. In our times, Avhen kelotomy of itself is comparatively a safe procedure, and by combining radical measures Avith those for re- lief of strangulation, in a general Avay it may be laid down almost as an axiom that in all cases in which taxis fails, or serious symptoms threaten, twelve hours is the maximum time to wait, when immediate operation should be advised. Every practitioner should be competent to perform a kelotomy for strangulation. By this it is not to be supposed that all should be equally proficient, but that all, in an emergency, should be capable of im- mediately relieving constriction and releasing the bowel. PREPARATIONS AND DETAILS IN OPERATIONS FOR STRANGULATED HERNIA. The technique of operations for strangulation have, during the past fifty years, been enormously simplified and revolutionized. The change daAvned on the profession Avith the discovery of ansesthesia, the tolerance of the peritoneum, the introduction of asepsis, and the crowning achievement of all cocaine analgesia. There are but few things necessary in operation for strangu- lation. They are: 1st. Good light. (At night I prefer candle light to any other.) 2d. Plenty of pure Avater. 3d. A warm, clean room. 4th. Assistants, medical, if possible; one at least, if not one or two intelligent, cool-headed Avomen. Our operative arsenal is simple. A good table, toAvels, sponges with dressings. For instruments we need but a scalpel, a long- curved scissors, artery clamps (two or three), suture material, needles, retractors and needle-holder. We have mentally calculated on contingencies and are pre- pared to meet them. Now we are ready for our patient. The operath'-e areas have been properly prepared, and Ave have complied in every detail, as far as possible, with Avhat modern surgery demands in the Avay of HERNIA. 191 aseptic precautions in their broadest sense, and Ave are ready to commence our journey to the hernial envelope or the cavity of the peritoneum. The objective point, let it be remembered, is the constriction at the neck. All is lost if this is overlooked. Now, with amateur operators, Avho cut in an emergency, I Avould advise them to adopt someAvhat different tactics to those Avho are com- monly accustomed to perform capital operations. It Avill be noted in this monograph that very much has been said on the subject of the sac, and that in all the older treatises on the operative surgery of hernia it occupies an important position. Yet, notwithstanding all this, I would recommend the general practitioner not to worry himself in the least about it in strangu- lation cases. If the sac were a free, isolated pouch—the impres- sion which usually prevails—if its presence were constant, or if strangulation ahvays occurred within it, then, indeed, a familiar knowledge of its anatomical structure would be of prime import- ance. But as a free sac it has no place in the hernial anatomy of the body; it is almost never free from adhesions; it is not ahvays present in strangulation, and it is yet a disputed question Avhether the point of strangulation is within it or not. The first step then after a free incision is made, carrying this from the internal ring downward from four to six inches, is to divide and gently separate the parts, layer after layer, as one would open the coats of an onion, until he comes down on the imprisoned viscera. All hemorrhage being staunched, the index finger of the left hand is introduced over the nude viscera, which are gently pressed and everything divided over it, until its tip is arrested at the point of strangulation. Noav, at this stage, the older opera- tors would introduce a grooved director and split the annular constriction with a probe-pointed hernia knife, having due regard in the meantime in inguinal hernia for the internal epigastric artery, which latter vessel they seem to have had a morbid fear of dividing. For convenience in operating and safety I have for some time, discarded the probe, scalpel and grooved director, and instead of making one incision with a blade, I employ a scissors and notch the constriction in different directions; in other words, 192 HERNIA. when the precise seat of strangulation is reached and amply exposed, I take up a common dressing forceps, and seizing the free edge of the strictured ring, draw it downward and nick it with the point of a blunt-pointed scissors, in one or more places, until I am assured that resistance is amply overcome. To assure my- self of this, I again re-introduce the tip of my finger and make traction in the direction of the stellated gaps in the rings, when I withdraAv it and attempt reduction. If the bowel refuses to re- turn I make a fewr more nicks with the scissors and again dilate the ring, when all succeeds and the hernia is reduced. This multiple nicking of the ring is a great adA'antage over a single clean deep cut, for by it one is enabled to avoid opening the deep epigastric artery. Cut in what direction we may, the ring is not weakened to that extent it is when its fibers are severed completely through, with one gash through its fibers. When the free border is well drawn doAvn Avith the forceps, as we close the cutting edges of the scissors, the entire operative field is under the eye, and should hemorrhage occur, it can be subdued in an instant by the same measures Avhich we would employ should it occur elsewhere. After the intestine is reduced, the finger should be passed into the peritoneal cavity, and all adhesions in every direction freely liberated. It is of vital importance, before the wound is closed, to be positive that liberation has been ample and complete, or else the symptoms will persist, and our patient is lost, Noav that the hernia is reduced, a drainage tube is fixed in the lower angle of the wTound, and the parts sewed up en masse Avith a continuous suture. When the case goes Avell, as it should, after the second day the drainage tube is removed and another dressing applied. This will be the last, and should remain in for a week or ten days. This operation is one of emergency, Avhich is recommended when the object in vieAv is relief of strangulation. It is recommended for its safety and simplicity in every phase of strangulation wherever situated. Certainly, it is not a com- plete measure in any sense, and would not fulfil the requirements of advanced surgery as a measure of perfection, but it is recom- HERNIA. 193 mended only in imperative cases and Avith the inexperienced. After recovery a truss must be Avorn, or the hernia may return. But this may happen after any of our operations which have been praised the loudest. COMPLICATIONS IN STRANOHEATED HERNIA. If a large extruded mass in the inguinal region becomes strangulated in incision, we may come into a double inguinal (plate No. 63), of which but one has become strangulated. In this instance the condition of the overlying, investing, tunics will indicate in which the obstruc- tion is lodged. In old, incar- cerated hernia, undergoing strangulation, we must be pre- pared to deal with possible ad- hesions between the viscera and their investing pouch (the sac), and in this species of femoral' hernia find the omentum firmly adherent to the femoral vein. Such a case was sent into my service at the hospital, in June, 1891. The physician sending her in, supposed that she had an internal strangulation, and I Avas sent for to perform a laparot- FlG. 63. omy to relieve it. Direct and Indirect lDguinal- 'MasUse-)' In examination I found that she had a large mass, over the right saphenous opening, which she assured me she had from childhood, and which our house surgeon, Dr. Hammond, from its outline and consistence, assumed was an enlargement of the lym- phatic glands. My examination, however, convinced me that it was a hernia- At any rate, as she was in a collapsed state, a laparotomy was^ quite out of the question. Cutting down under cocaine, we came- on to a mass of omentum, which had no sac, but was so intimately adherent to the saphenous vein that its isolation necessitated] 13 194 HERNIA. rupture of this vessel. This, hoAvever, AATas easily sutured, and after liberating a small knuckle of intestine, nipped in the septum crurale the parts Avere closed in, Avhen she made a good recovery. The most formidable complication in all operations for strangulation, is gangrene of the boAvel. In many cases of strangulation in which Ave operate we will come on to a suspicious intestine. Its Avail has a dark, chocolate hue, and it has parted Avith its pearly, glossy surface. It is Avant. ing in that soft, resilient feel, of the normal intestine. In the presence of such a condition the safest course to pursue is to return the boAvel to the cavity of the abdomen, at once fix it in the Avound, make an artificial anus, do an enterotomy, or enterectomy. Sir Astley Cooper advised that when we came to an intestine, the vitality of which was in question, the best place for it was in the cavity of the peritoneum. This Avas the generally accepted course, until Professor Nicholas Senn, in 1887, at the International Medical Congress, produced his great Avork on experimental intes- tinal surgery on the dog, and recommended a reA7ival of intestinal anastomosis in man for conditions causing obstruction of the in- testine lumen. Since that time many operations have been performed for gangrenous intestine in strangulation. Those operations have been immediate and consecuth'-e; i. e., some have resected the bowel at the time of hernial operation, Avhile others have made an artificial anus, and Avaited until the patient had survived the shock of the primary operation before attempting resection of the intestine and reconstruction of its lumen. It Avas hoped that Avith the neAv devices for rapid anastomosis that resection of the suspected part Avould be a simple and rapid procedure, so that Ave might always assume that nothing except the healthy intestine Avould be replaced. HoAvever seductive and promising the theory of intestinal anastomosis Avas, practice has abundantly demonstrated that it is one of the most formidable procedures known to surgical art, Avhen applied in strangulation cases. Indeed, there are almost insurmountable impediments in the Avay of its performance; and, in fact, in those cases in which a HERNIA. 195 bursted, necrotic intestine has been found and an immediate anas- tomosis has been performed, there are but few cases on record which have survived. When local changes have so far advanced iis to induce complete gangrene of the constricted intestine, great constitutional depression is always present, which feAv rally from after the shock of a capital operation. Unless the bowel has given Avay and fa?.cal extravasation is present, the operation of primary resection of the intestine is an umvarranted procedure, in but very rare cases. I have many times returned the strangulated intestine Avhen, at the point of constriction, the pressure had cut a ring through the serous coat, and the constricted coil presented a most unpromis- ing aspect; yet in none has extravasation followed, and most of them recovered. I am acquainted with no recorded case of re- covery, in which a primary resection and enteroraphy have been performed after gangreneous perforation had occurred in the stran- gulated intestine, within the abdomen. At the late meeting of the American Medical Association {Detroit, May, 1892), Dr. J. Rausahoff, of Chicago, presented one of the fullest and most valuable contributions on this subject {Treatment of Gangrenous Hernia), from which I will give such parts as are pertinent to this part of our subject. He reported having performed 27 operations for strangulation, of which 4 were grangrenous, 3 enteroceles, and one epiplocele. It does not appear that any of them had ruptured at time of operation, but all were suspected. He reported 170 operations for strangulation, in Avhich real or suspected gangrene was present in 25. From various operators in the past twenty years 486 cases of strangulation, 14 per cent, were gangrenous or suspected. Dr. Rausahoff reported his own four in detail. His first case omental. Gangrenous part ligated and cut off. Result: death in twenty-four hours. Second case: Was restrained from operating because he wTas afraid the patient would not safely survive shock, and because he was ignorant of the precise pathological state in the sac. Gan- grenous perforation discovered only after death. 196 HERNIA. Third case. A gangrenous patch was discovered in the wall of the intestine. Intestine was reduced, but the suspected part was fixed against the incision in such a manner that should perfora- tion occur, the fseces could make their way outAvard, unhindered. Perforation occurred, though after a time the opening spontane- ously closed. Fourth patient, a woman of 56. Here he resected fourteen inches of the suspected intestine, bringing the ends into immediate contact. Patient recovering; alive and well nineteen months after. It seems that Raushdor was the first to resect the gangrenous in- testine successfully, in 1727. Pou]sen has reported twenty-seven cases with four recoveries. Of thirty-five so treated in St. Bar- tholomew's, but four were saved. {Brit. Med. Journal, June, 18^1.) In England, Baker, McCormick, Banks and Treves oppose immediate resection of the gangrenous intestine. In America, McCosh, Richardson and DaAvbarn each reported a successful case. The Germans are divided in opinion on the subject of immediate resection, while the French generally op- pose it. The question then lies between one of three things, when we cut down on an intestine suspected of gangrene, as to what shall be done. 1st.—Shall it be immediately returned ? 2d.—Shall it be fixed in the wound and an artificial anus established ? 3d.—Shall it be resected, sutured and returned ? It must be remembered that the suspected intestine alone, is being now considered. My experience Avould incline me to recommend the first al- ways as a routine practice, particularly with those unaccustomed to performing capital operations, or those who cannot command every possible facility to favor a successful effort, and that means a great deal. My next choice would be the second. For by it we are given time to prepare and observe Iioav our patient rallies from the first operation. The third should be regarded as an extreme and last resource Truth, candor and personal experience compel me to regard the HERNIA. 197 resection of the intestine for gangrene as one of the most desperate undertakings in surgery. In the hands of the most skilled and adapt it is a most trying ordeal, and when it succeeds such un- pleasant sequelae may occur as to destroy the permanency of cure Perhaps if the " anastomatic button " of Dr. J. B. Murphy, of Chicago, which promises to reduce these operations for intestinal continuity to a few moments, will accomplish what is promised for it, resection may become an established procedure in gangren- ous hernia. Perhaps I cannot do better in closing this part of the subject than quote further from Dr. Rausahoff, who, by the Avay, is an advocate of primary resection, who says: " Whan delay has brought the patient to the verge of collapse, and when shock from prolonged anaesthetics cannot be ventured, that must be done Avhich most readily gives relief to strangulation; for whatever be the procedure adopted in the condition indicated, the result will probably be the same: death within a few hours or days." With these sentiments I am in hearty accord. My own ex- perience with, not suspicious cases, but positive gangrenous per- foration, and one for resection of a suspect, is limited to four. The first was a woman in profound collapse, so that but little ether could be given. Coming on the sac, the intestine was found broken down by necrosis and fluid fasces, Avith gas Avelling up through the incision, and in a moment she Avas dead on the table. The second was in a young man, in Avhom the bowel was ruptured, after it had been down tAvo days by the medical attendant in forcible taxis. When I cut down on the sac it was found full of blood and feces, the boAvel having slipped up into the peritoneal cavity, carrying the incision up through both rings, the abdomen was found full of leaking fasces. Our man survived scarcely an hour after the mortified intestine was found and fixed in the wound. Third case, another young man, in whom a strangulation Avas actively poulticed for an abscess before he was sent into hospital. When I saw him he had pronounced septicaemia from fascal absorp- tion. Under cocaine the tissues wrere opened, Avhen it Avas found that the boAvels had burst, the fasces making their way through the sac into the subcutaneous tissues. It was hoped that as the artificial anus Avould permit a free vent to the pent-up fasces, he* 198 HERNIA. might overcome the toxasmia, but Ave were disappointed, and he died on the seventh day. Fourth case. This patient was a middle-aged man, who had strangulation but ten hours. He entered the hospital in the middle of the afternoon. When I Avas notified of the case, not feeling Avell that day, I sent word to the house surgeon to do the operation for strangulation. Three hours later, feeling a little uneasy about the case, I telephoned, inquiring how the patient had survived the operation, etc., when I Avas rather con- founded to hear that the operation was not then completed. I now left for the hospital myself, reaching there about a half an hour later, and when I entered the operating room the scene presenting Avas enough to startle and confound the stoutest. Our young internel by recent reading the current medical literature, was imbued with a notion that modern experimentation had so simplified intestinal surgery that it needed no apprenticeship or special practice to succeed with it, had cut away nearly three feet of this man's bowel. Indeed, there was nearly a wash-basin of viscera, steaming fresh in a vessel, when I entered. But iioav the trouble came, the proximal divided end was so close to the fixed cascumthat he had found it quite impos- sible to dam back the fasces, or bring the separated edges together. Blood and fasces issued promiscuously from every direction, so that our young operator Avas at his wit's ends, and badly rattled when this stage of the operation Avas reached. It Avas clearly apparent that if the blood torrent was not promptly arrested death must quickly end the scene. Hence, without any thought of antiseptics, after quickly washing my hands, I pulled the bleeding mesentery into the wound and clamped off the vessels. Thus, by carrying the incision further up, I Avas enabled to restore the continuity of the wound and complete the operation. Our patient survived three days, sinking finally from second- ary shock. • The suspected intestine Avhich Avas cut away, except for one or two small patches of necrosis, which occupied only the peritoneal coat of the outer wall, Avas sound and everyAvhere intact. Indeed, for one to undertake an enterorraphy on a gangrenous hernia, without ample experimentation on the lower animal, and HERNIA. 199 a thorough, practical knoAvledge of the physiological anatomy of the intestine, its relation and appendages, is little short of crimi- nality. POST-OPERATIVE TREATMENT IN STRANGULATED HERNIA AVHEN TREATED ON THE LINES HERETOFORE INDICATED IN EMERGENCY CASES. ItAvill be noted that the simple rudimentary technique, so far described for strangulation, is intended only for the purpose of re- lieving the constriction and averting immediate danger to life. However, for all practical purposes, particularly in old people or those folloAving sedentary pursuits, it is quite complete enough, unless there are complicating elements present, providing that thereafter a truss is constantly Avorn. But in our times an experi- enced operator is presumed to do something more than divide the constriction. In fact, in all ordinary cases, he is expected always to combine measures for radical cure Avith relief of strangulation. As the technique of these are essentially the same in strangulated and the non-strangulated, theyAvill be considered in the following chapter. Immediately after operation for strangulation the patient should be returned to a Avarm bed. If the operation has been performed at the right stage, and liberation of the intestine has been complete, there should be no severe pain. On the contrary, a great sense of relief should be experienced. Vomiting should wholly cease, tympanitis subside, and bodily strength return. The patient should be given nothing but a bland, fluid diet during the first forty-eight hours. The less, the better. On the second day, if a drainage tube has been employed, it should be remoA-ed, when other final, permanent dressing should be applied, not to be disturbed for ten days or two weeks, when union should be entire. I think it is well, in all cases, to keep the patient in bed for four weeks, in order to permit of entire consolidation of the deeper layers before permitting the Aveightof the superincumbent viscera being thrown on them when the upright attitude is again assumed. Unless there is some special reason, laxatives should not be given after operation. At this time it is important to give nature 200 HERNIA. repose, rest. The bruised, traumatized boAvel needs undisturbed quiet, and Avhen the proper time comes, will empty itself without being whipped into action, as it were, prematurely by irritants. On the contrary, in those suspicious cases, properly so called, opium should be given freely, until we are quite certain that the suspi- cious plagues in the serosa of the intestine haATe taken on adhesive inflammation, and the danger of leakage on the re-establishment of peristalsis is past. In any case of strangulation in Avhich there has been a per- sistance of grave symptoms, Avhich indicate a continuance of obstruction after operation, it must be assumed either that our patient has developed general peritonitis, or else that the opera- tion was incompletely performed, and a mechanical stenosis yet remains. The following is an illustrative case: During the past month of October ('92) I Avas sent for to per- form a kelotomy for strangulation in a young man. It Avas mid- day when the message came and I was not at home. Tbe physician in attendance, a gentleman of superior acquire- ments and considerable experience, believing that it would be unsafe to delay the operation until my return in the evening, inAated in a neighboring practitioner, and with his assistance per- formed an operation. This Avas on Friday. At noon, the following Sunday, another message came for me to see the case, when a condition was discovered fully detailed in a preceding chapter. The case is re-introduced here for its per- tinency, as illustrating hoAV a life nnuy be lost in those operations Avhen incompletely performed; as in this case must have been the result, had the unopened sac and undivided constriction not been discovered and properly treated Avhen the patient was on the verge of the moribund state. When general peritonitis folloAvs a kelotomy, in nine cases out of ten it must be charged to perforation. When it does occur, that paretic state of the intestine Avhich is an integral part of the malady is apt to delude the uinvary into regarding it as a mechanical obstruction, and instituting a line of surgical interference both mischievous and dangerous for its relief. But, should it appear Avith the continuance of grave symp- toms, that an impediment to the intestinal contents remained, then we must at once seek out the point of obstruction, re-entering HERNIA. 201 the cavity of the peritoneum by reopening the original in- cision. Sometimes when the intestinal coils have been reduced en masse, there may have been a matting or webbing of their Avails just inside the internal ring, Avhich may be easily detached with the finger with in the cavity of'the peritoneum. These con- secutive operations should be painless and bloodless, and per- formed with all possible haste. Hence, for this secondary meas- ure, as for all hernial operations of every description, one should make in its largest possible measure ample and thorough prepara- tion. Preparation of himself, his instruments, dressings and his patient, before the first step of operative manual is commenced. COMPLICATIONS IN STRANGULATED HERNIA. It is Avell to remember that a hernial sac may contain any of the floating viscera, and that in extruded omentum, in epiploceles, neoplastic changes may occur in its adipose or glandular elements, when we will encounter lipomata, or sarcomatous tumors. Some time ago (tAvo years) I gave my house-surgeon permis- sion to operate on the next case of strangulation which came into mj service. Soon after, a young Italian was admitted. When notified of his entrance, the house-surgeon was directed to proceed Avith the operation. Inquiring by telephone, in the evening, how the operation succeeded, I Avas informed that, when the second stage of the operation Avas reached, such a complex condition of things Avas discoArered that it Avas considered best not to advance further Avith the operation, but to close in the primary incision and Avait until I came up. The house-surgeon further added that since the man came out of ether, the Amounting had ceased and he was feeling A^ery much better. The folloAving day, Avhen I saw him, his colicky pains had disappeared and his general condition was good. Re- opening the incision of the day before, I came down on a large, sarcomatous mass Avhich enormously distended the scrotum, though it had not penetrated the tunica vaginalis, nor invoked the spermatic cord. FolloAving up its pedicle, it Avas seen to be continuous with a fringe of the omentum extending into the peri- toneal cavity. This Avas ligated high up and cut off, when the large pyramidal mass Avas rolled out of its bed in the inguinal 202 HERNIA. tissues. On microscopical examination it Avas found to consist mainly of multi-nucleated giant cells. The Avound healed promptly. Dr. W. H. Link, of Petersburg, Indiana, has called my at- tention to the sparcity of hernia in many fat men. I am not prepared to say that males with a large " corporation " are less prone to hernia than their leaner brethren, but in my experience with women the fat are more liable to the infirmity than others of their sex. However, fatty tumors are not uncommon in men of every build. And not unfrequently, Avhen a person is the subject of one in the inguinal region, and is suddenly taken with renal, gastric, or hepatic colic, if the medical attendant is not circumspect and guarded, he may imagine that his patient has a strangulated, in- carcerated hernia, and hasten to do an operation for a condition which does not exist. Such a case Avas sent into the Harlem Hospital for operation in 1888. After the house-surgeon, Dr. E. A. Williamson, had given the patient a small hypodermic injection of morphine, all the symptoms of strangulation vanished, though the hernial tumor and the overlying cellular tissues, Avhich had been rather roughly handled, in forcible taxis, had not reduced in volume. The mass was A^ery hard and Avell calculated to deceive the inexperienced. The clinical history convinced me that it was not a hernia. Cutting doAvn on it, it Avas found to be a benign fibro-lipoma. which had developed in the loose cellular tissues along the cord, CPIAPTER XXI. OPERATIVE TECHNIQUE FOR INCARCERATED, NON-STRANGULATED, REDU- CIBLE HERNIA AVHEN TREATED BY OPEN INCISION. At the outset of this important part of our subject, it cannot be too plainly stated, that no special operation Avill answer in eArery variety of any one given type of hernia, Avherever situated. Hence, in almost every case our technique must be so adapted as to meet special requirements. In all operations for inguinal hernia, we should carry our in- cision through sound structures only to such an extent as special indications require. This is of cardinal importance to observe. It is certainly to be hoped that no one can so far deceive himself as to believe that a united fractured bone, a divided tendon or muscle, ever possesses the same flexibility and strength as in their normal, unbroken continuity. For scar tissue, nature's solder or cement substance, a derivatiA^e of connective tissue bears little or no analogy in tensile power or elasticity with normal structures. Another reason Avhy Ave should cut as sparingly as possible through tissues in continuity is because, as a rule, the Avider the 203 204 HERNIA. breach when the open incision is made, the more unmanageable is the hernia in the event of relapse. MANIPULATION OF THE SAC. Before the special disposition of the sac is discussed, it may be well to have a clear understanding as to what we wish to ex- press when we speak of this adventitious pouch. Hence we in- quire : What is the sac ? Judging from the various diagramatic illustrations of dif- ferent operations and descriptions of different surgeons, Ave must conclude that all have not quite agreed on what constitutes a hernial sac. One would suppose, from the average description of this structure, that it is usually a mere pouch-like bag of serous membrane, which slips up and doAvn through the inguinal canal, and which, every time wTe reduce a hernia, it, with the A7iscera, returns to the cavity of the peritoneum. All this, hoAvever, is very far from the truth. The sac is something more than a serous membrane, for its fascia propria, sometimes called the fascia Cooperi, is a dense fibrous substance, separated from the serous by a cellular membrane, but ahvays in- timately adherent to it. The serous investment of the ATiscera, except in recent cases of strangulation of primary hernia, is ahvays more or less adhe- rent to the circumjacent tissues, the tunica A-aginalis, and the tubular elements of the cord. Hence, in the vast majority of cases of inguinal hernia, it is absurd to speak of reducing a sac, which is everywhere adherent, Avhich can in no Avay possibly be isolated and reduced without a free open Avound and a tedious dissection- The elements of the cords are often imbedded and quite intimately incorporated between the different layers of the sac. Hence, un- less its investments are peeled off with most delicate attention, the cord must suffer serious damage. When this is properly ac- complished, the serosa must be exposed by a linear incision running parallel with the long axis of the tumor, and be stripped by a process of decortication, Avhich gives us, not one, but two sacs; one, the large, fibrous pouch from which the serous investment has been raised, and one, the serosa, or true sac. Now, should the sac en masse, Avithout this dissection, be HERNIA. 205- isolated or cut off, the neural and vascular supply of the testis can- not escape serious injury. When an operation is performed in Avhich only the serosa is preserved, free and deligated above, the thick, fibrous investment of the sac, an integral part of it remains in the incision. Should this fibrous—the outer tunic of the sac—layer be cautiously sepa- rated from the cord, it can be cut away or it can be reeled up and fixed anyAvhere along the canal, as a tampon. If a her- nia can be permanently reduced, there would seem no good reason for its further retention, as it should have no further purpose to serve. Unfortunately, operators have not been clear, in all cases, in detailing the precise toilet of this infundibular process of the fascia tranversalis. But those who oppose resection of the sac, base their objections in clear and unmistakable terms. First, because of the danger to the ultimate nutrition of the testis in isolating the serosa from the separated strands of the spermatic cord; and, sec- ond, because, when it is retained in the event of relapse, this dense tissue serves once more as a protecting and limiting envelope to the descending viscera. Let not the new beginner perplex himself in searching for parts which often do not exist—those independent investments of the anatomists. In some he will search in vain for the spermatic fascia, when time, degenerative, and atrophic changes have assim- ilated all into one homogeneous, dense, inseparable wall of tissue. In ancient, very large, old scrotoceles the investments of a di- rect aud an indirect inguinal are quite indistinguishable; as all the ordinary landmarks are lost and pathological degeneration has wrought such changes that the remnants of normal structures have so altered as to be quite beyond recognition. Nevertheless in order to perform an open operation with a high cervisectomy, the serous envelope must, if possible, be freely isolated. If not entire, then as completely as possible. In reducible hernia it is always important if possible, to> operate while the viscera occupy the sac, for they steady it, and enable us all the more readily to proceed with the work of de- cortication. The importance of detecting the serous sac in all inguinal hernia, has been dwelt on at considerable length here, because its 206 HERNIA. recognition and proper manipulation is practically the keystone to the arch in all hernial operations in Avhich it exists. It should not be forgotten that we may find two serous sacs in an operation, or none at all. In the first, when the intestine pushes down before it an investment of omentum, this is seen. In the congenital hernia of anatomists the viscera tumble directly into the tunica vaginalis, side by side with the testis, when, of course, no independent sac is present. As there is no important tubular structure in the female in- guinal canal (the canal of Nuck), the operation and isolation of the serous investment of their hernias is not attended with the dif- ficulty or danger Avhich Ave encounter in the male. But, in the inguinal hernia w^ith a woman, as all her genera- tive system is internal, a prolapse of any or many appendages of it, often make their way into an inguinal hernial sac. Thus, in a young lady sent to me, for the treatment of a small, but very painful inguinal hernia, when the sac was opened an adherent OArary came into ATieAv, and Avas excised after its artery and the pedicle were ligated. Up to this time her life had been one of misery and pain from wearing a truss. Always during her menstrual epochs, the protrusion became swollen and ex- quisitely sensative,' giving her great distress, until menstruation ceased. A most remarkable case is recorded in the " American Journal of Gynae- cology," June, 1892, by Dr. D. P. Bar- ber, of Saginaw, Mich. The patient Avas a woman, 46 years old, who con- sulted the doctor one year before, for a protrusion in the left inguinal region, Avhich Avas groAving larger and more painful, so that a truss which she had worn for years before had to be cast Exsected Uterus in a Strangulated aside. As she Complained of ATao-ue Hernia.—Dr. Barber's «. ase. , . *■ o ' indefinite pains in the uterine and ovarian regions, the doctor made a vaginal examination, but could find no uterus. She was a married Avoman, though had been HERNIA. 207 barren; menstruating, hoAvever,Avith great regularity. An operation for cure of her hernia having been decided on, Avhen the mass Avas exposed, it was supposed to be a new groAvth; hence, ligating it high up it was cut off, Avhen it Avas found to consist of a portion of the left broad ligament, an ovary and the" uterus. The patient made a good recovery, and Avas entirely relieved of her former distress. Boyer (Tome IV, Chirurg. Malad.) cites several remarkable and extraordinary cases of the escape of the viscera in males. He had seen himself four in which the bladder had escaped through the inguinal apertures in males, in Avhich it had been cut on and opened, under the supposition that it Avas the sac. In one case of a young artillery officer he performed a lithot- omy, and removed a stone through the inguinal incision from the extruded bladder Aveighing three ounces; and cites several similar cases in the practice of others. The most marvelous of all which he records was the case of a lady of rank, who con- ceived after marriage in a herniated uterus. As time went on the hernia increased in volume until, as the time for her accouchment approached, the enormous hernia, now with its great weight and mammoth proportion, totally disabled her from exercise. At term a living infant Avas delivered through the divided hernial wTalls, but, as a great quantity of blood Avas lost and inflammation followed, the mother sank on the third day after delivery. MANIPULATION OF THE CONTENTS OF THE SAC AVHEN THIS IS PRESENT. Having opened the sac and liberated the adhesions to it from the contained viscera, if such exist when the intestine protrude, there is but one course to pursue, Avhich is to return it into the peritoneal cavity. Should, however, the hernial contents be omental, then there are two or three different courses open to us. The first is to reduce this as the boAvel within the ring. The second is to draw it and the slack in the canal well down, ligate it after multiple transfixion, cut it off after the plan of Championniere, and permit it to return. The third is to fix its pedicle in the canal or ring as a tampon, and close the integuments over it. 208 HERNIA. The first is the simplest course, and the most secure from immediate danger or ultimate unpleasant psycical phenomena. By this procedure the danger of hemorrhage from the stump is obviated, as are also the chances of septic infection diminished. But it is not to' be practiced, for the reason that it is one of the original aetiological factors of the infirmity. It lies just inside the ring after reduction, only waiting for another favorable oppor- tunity to re-descend. The second, when carried out with extreme attention to detail, is the most rational and successful. But very great care must be exercised in ligating the neck to securely close all the vessels in the omentum. If the vessels can be isolated and separately ligated without including the nerves, it Avould be the ideal procedure in hernial treatment of epiphoceles. For by it tAvo important, fundamental, aetiological factors of the infirmity Avould be removed. First, it reduces by excision of the omentum. intra-abdominal pressure; and,secondly,Avith its complete excision, the visceral element in causation has been permanently eliminated. The third, omental tamponage, entails excision of redundant omentum, while its pedicle is imbedded in the canal or ring. This procedure I have once utilized to advantage in a case, and many o^her similar, scattered cases are recorded in the modern literature of hernia, a recapitulation of which would serve no useful purpose at the present. RADICAL CURE OF FEMORAL HERNIA. The technique in operations for strangulation and radical cure in femoral hernia is essentially the same as for inguinal, except that while it is possible to Avholly obliterate the inguinal canal, as when castration is practiced, this is quite impossible with the crural canal or saphenous opening through which the femoral ves- sels pass to and from the loAver extremity. It is a matter of common observation with femoral hernia that, as a general rule, it is more incoercible to the truss than in- guinal. It is also well knoAvn that it is a hernia in which relapse is almost invariable, regardless of how treated by radical meas- ures. In operations for radical cure in this situation, Gerdy's prima- tive invagination and all its derivatives are eutirely inapplicable. HERNIA. 209 The operation Avhich should give the greatest success as a radical measure in enteroceles is the tamponage of the canal Avith the folded sac. The sac here can be rapidly and completely isolated, though when imbedded in the canal it may give rise to ulceration and slough away, as it does sometimes in McEwen's operation for inguinal hernia, yet its results, from a theoretical standpoint at least, should give the best results. My own experience in femoral hernia, in which I have attempted radical cure with relief of strangulation, is limited to four cases. One died. Two on whom I operated for strangulated femoral enteroceles had relapses within six months. In one, the last who had an epiplocele, the cure was complete and permanent after two years. In all femoral epiploceles, Avhen we are assured of their real anatomical character, and they are painful and uncontrollable, a radical operation may at times effect a permanent cure. TECHNIQUE IN OPERATIONS FOR RADICAL CURE OF FEMORAL HERNIA. A large, free incision is necessary in operations for radical cure, or strangulation in femoral hernia. In the majority of cases AATe AA^ill find that the sac has formed intimate adhesion, when it is present Avith the femoral vein and the septum crurale. In women, and in fat men, we Avill find the constriction in strangulation at a great depth from the surface, and in cases in which radical cure is attempted, owing to the extreme obliquity and depth of the canal, the neck of the sac is manipulated and deep sutures are in- serted with considerable difficulty. In all cases of large femoral hernia it is a good practice to close the upper free borders of the falciform process Avith the fascia lata, and in this manner reduce and narroAv the diameters of the widely gaping saphenous opening, thereby in a certain measure constructing a barrier against future relapse. In all cases of opera- tions for this phase of the infirmity, the truss should be immedi- ately applied on leaving the bed, and worn at least for six months. This operation in femoral hernia is adopted in the majority of cases, rather for the purpose of rendering a painful, unmanage- able hernia comfortable and coercible than to expect an "outand out" permanent cure. The former usually succeeds, Avhile the 14 210 HERNIA. latter with this type of viscual protrusion has not yet been realized in but few exceptional cases. RADICAL OPERATIONS FOR UMBILICAL, VENTRAL, AND LAPAROTOMY HERNIA. Pathological hernia are common in the walls of women's ab- domens, though they seldom occasion much inconvenience or danger to life. But they may become strangulated, or they may, as we have seen, burst and bleed, or ulcerate. Besides, they may occasion so much inconvenience, in rare cases, as to render one's life miserable, and require something more than palliative meas- ures to control them. In the adult, umbilical, or ventral hernia, truss pressure is not efficient. But as none of these operations on the abdominal walls for hernia can promise a permanent cure, or are free from danger to life, they will be undertaken only as an extreme resort. Our patient in these cases is prepared as for a laparotomy, which this operation practically is, and let us undertake no opera- tions here on an old asthmatic, or bronchitis man or Avoman, if we Avould be spared the humiliation of seeing a prompt and aggra- vated relapse before our patient is fairly on her feet. It is a ques- tion whether it is a justifiable procedure to undertake, as one of selection, on a child-bearing woman. In a general way hernial operations for radical cure are not to be recommended on one Avho is likely to pass through the travail of child-bearing, for the violent, spasmodic contractions of the muscles must almost inevitably tear through cicatricial seams at the hernial portal, and reproduce a condition much worse than the original. This must be especially the case with exomphoceles. Operations for umbilical hernia are much more difficult of performance than those which we have considered. Often there is no independent serous investment, but the viscera, spread in different directions, and forms adhesions Avith everything in contact with them. Their cutaneous investment has spread out in old cases as thin as tissue paper, and at the neck the recti muscles have so far spread out as to be perfectly brought together and retained in apposition, only with the greatest difficulty. HERNIA. 211 Our patient having been finally prepared for a capital opera- tion, Ave now proceed with its different steps. We must commence with a free linear incision, carried imme- diately over the convexity of the tumor. Some, having completed this incision, bisect it Avith another crossing this in its center in a diagonal direction. This second incision increases the area of mutilation, but it simplifies the dissection; and, as the thin integu- mental covering of the tumor is a redundant, useless structure, after the hernia is reduced, it is cut aAvay, no harm is done, in any event. As so-called umbilical hernioa seldom make their escape directly through the navel aperture, we will only occasionally come on to the urachus, or the round ligament of the liver. When these haATe, howe\rer, engaged, and been carried forward, their loose slack must be cut away ; their proximal ends being fixed in the opening. After liberating the sac, returning the intestine, its neck is transfixed in one or more places, ligated and amputated. When the mass is omental it should be cut aAvay, and its pedicle treated with great care before being dropped into the peritoneal cavity. In one of my OAvn cases, after excising the omentum, and returning the ligated stalk, Avhen dropped in, one of the ligatures slipped, and, for a moment, there Avas an enormous gush of arterial blood from the open vessel. In a moment the peritoneal cavity was filled Avith blood. Passing in two fingers, after quickly feeling in every direction, I came on the retracted omentum, drew it out again, through the wound, and firmly secured it before it Avas too late ; our patient, ultimately, making a good recovery. The vessels in an umbilical epiplocele must be securely ligated, each of the larger separately, with fine silk, and then the thin, investing serous envelope should be draAvn over the open surface and its free edges sewn solidly together. This latter step renders any further leakage improbable, besides, in a large measure, ob- viates the tendency to adhesions of the intestine with the free surface returned. All are agreed that, at least in umbilical operations, we must discard all measures Avhich interfere with primary union, hence, prompt and solid agglutination of the edges of the wound should be secured in every case. 212 HERNIA. There is some difference of opinion as to the manner in which this is most efficiently accomplished, some employing a " through and through " suture, Avhich includes the integument and the under- lying tissues Avith the serous membrane. Others prefer to sew the serosa with its fibrous coat in separate layers, and then close in all the overlying planes with one heavy suture. My own preference is for the latter, as by it we are the better enabled to effect a homologous approximation of the divided structures. There is no unanimity of opinion yet on the material to be employed for suture. Many employ the silk-worm gut, common twisted silk, or silver-wire, Avhile not a few prefer an absorbable material, and accordingly use kangaroo or cat-gut suture. In small non-adherent hernia in this region, it is quite im- material as to which is employed. But Avhen the hernia is large and the hiatus at the ring is considerable, the parts must be drawm together and held by some powerful, non-elastic suture, which will hold them in close union until healing is complete. For this purpose it has been recommended that silk be em- ployed in the serous layer, and heavy wire through the muscles and integument. In one of my own cases, in a large, fat woman, with an enormous exomphocele, everything went well after opera- tion until the second day, when a most irritable, violent cough set in, when vomiting and abdominal pain commenced. On removing the dressing it was found that primary union was nearly complete, and there was no unusual fullness at the seat of operation. It was supposed that general peritonitis had developed After tAvo days of great distress, Avhich was only relieved by large doses of morphine, she sank. On. post-mortem examination it Avas found that the internal seam of sutures had completely torn through, and that a kuckle of the small intestine had slipped through the opening thus made, and had become strangulated. The position of the umbilical opening is such as to interfere with constant and direct pressure. Besides, its close proximity to the diaphragm is so productive of such ceaseless motion, as to seriously interfere with that repose so needful in the repair of wounds. HERNIA. 213 EVENTRATIONS, LAPAROTOMY HERNIA, ETC., AND THEIR OPERATIVE TREATMENT. Ventral hernia, folloAving abdominal section, is a lesion of modern times. It is one of those unhappy sequelae so commonly seen after an abdominal section performed in any part of the abdominal Avails. Tait and others have thought that it might be avoided if operators cut Avide of fibrous structures, and penetrated the abdominal cavity through muscular tissues. My own expe- rience, however, is not in accord Avith this vieAv, for many of the worst cases Avhich I have met Avere those after operation in the appendix, in Avhich the incision entered through muscle only. That they are becoming of an alarming frequency may be gathered from the fact that * a single surgeon has recently reported one hundred operations, performed by himself, for this distressing affliction. Inasmuch as it is assumed that no operator escapes them, there must at this time be an enormous number so herniated in this countiy. The technique of their treatment is precisely the same as for laparotomy, but it is often greatly complicated by adhesions. When they are of very considerable size, and the degree of separa- tion is great, unless undisturbed coaptation of the refreshened, separated edges can be maintained over a considerable period of time, a prompt relapse on taking the upright posture is almost inevitable ; hence, in order to obviate this as far as possible, the deep, aponeurotic structures should be brought together, and retained with numerous silver wire sutures or strong silk, which have a deep grip in the tissues on either side. A stout, firm band- age should be applied, and the patient kept in bed, on a restricted diet, for at least two months before being permitted her full freedom again. POST-OPERATIVE TREATMENT OF HERNIA. When we clearly understand the groundwork of all abdomi- nal hernia, and recognize the fact that our measures by direct surgical intervention are directed to nothing but the mural element in the aetiology, it becomes at once apparent that the temporary * Dr. Joseph Price, Annals of Gynaecology, p. 141, Dec, '92. 214 HERNIA. closure of the escape portal, and the retention of the bowel, can- not be depended on as, a permanent condition, without a supple- mentary support. The elongated mesentery remains. I have seen the small intestine of a large Avoman measure scarcely ten feet, and the same gut in a short, thick-set man more than thirty- two feet long. This superfluous bowel and lax mesenteric ligament, then, should be braced or trussed up, even after the hernia has been cured. For this purpose, every person wrho has ever been laparot- omized, or wdio has had a hernial operation performed on him (or her), either for strangulation or radical cure, should for the re- mainder of life wear a broad, strong abdominal girth or belt of some firm, unyielding substance. With those employed at manual labor this is an imperative, necessity, Avhile, with others following sedentary occupations or living in ease or idleness, it may be in a few cases dispensed with ; or fabricated of a light, elastic material and Avorn intermittently only. If the belt is worn there will be little need of a truss; yet, when the tissues over the wound commence to bulge, and relapse is threatened, Ave must make no delay in falling back on the old truss apparatus, for under these circumstances nothing Avill take its place. MENTAL ALIENATION CONSECUTIVE TO HERNIAL OPERATIONS. With the exception of Juillard's case I can find no record of the above condition occurring in the practice of others, after her- nial operations. It is a Avell-known sequence, after laparotomy in many cases, particularly in those wherein an opening is made, immediately over the solar-plexus, in the epigastric region. But it has been my experience to see four well marked cases of a mild type, after hernial operations. In three the extrusion was omental. These were two men and two Avomen. The phase of mental aberration Avhich folloAved took the form of a persistent, oppressive melancholy. One was a case of strangulation in a woman, in Avhom a per- manent cure followed operation. The other three were operated on for radical cure on reducible hernia. In one a permanent cure following, the other tAvo relapsing. HERNIA. 215 I have no theory to offer as to the elementary pathology of this condition, but it is rational to assume that it may be attribut- able to mutilation of the sympathetic ganglia, caught up in the ex- tended omentum, or to compression of the nerve filaments of the solar system, Avithin the ligature applied to secure the blood-vessels in the pedicle. Despondency is a Avell-known clinical symptom in all abdom- inal visceral diseases. Noaa^, whether this mental depression, consequent on hernial operations is directly attributable to reflex irritation, transmitted to the cerebral centers, or not, is a matter of doubt; but, that a phase of melancholia is one of the sequelae of hernial operations, which involve the omentum, seems to me, from my OAvn experience, an indisputable fact. This consecutive phenomenon should be borne in mind as one of the possible unpleasant sequences of radical measures, which may follow in cases of non-strangulated hernia, when contem plating surgical interference. TREATMENT OF HERNIA, RELAPSING AFTER OPERATION. The general indication for treatment here is essentially simi- lar to those in which no operation Avhatever has been done; i. e., if they are small, painless, easily controllable, and not attended by symptoms of strangulation, they should not be interfered with, because the second operation, in many cases, affords no more immu- nity from recurrence than the primary, and ahvays entails an additional mutilation of tissue. But, when relapse has been prompt, after the first operation, and the hernia manifests a tendency to rapid groAvth, then another operation is a justifiable and commendable procedure. I have operated on others' failures, and, I presume, on the other hand, my cases of relapses have gone into the service of other surgeons for further treatment, Operations for Strangulated Hernia, With and Without Combined Measures for Radical Cure. ORDER. YEAR. AGE. DATE OF OPERATION. INFIRMITY. OPERATION. RESULT. 1st case. 1885. 50. May 14th. (Inguinal hernia.) Strangulated indirect. Male. Open incision ; division of constriction at neck of the sac, and reduction of intes-tine. Wound packed from the bottom. (Ether.) As this man was in collapse at time of op-eration, he sank six hours after return to his bed, of shock. 2d case. 1886. 42." December 12th. Strangulated inguinal hernia. Male. Open incision; excision of gangrenous omentum ; with free gauze drainage. (Ether.) Made a good recov-ery, and left hospital well three weeks after operation. 3d case. 1887. 31. June 27th. Strangulated femoral hernia. Female. Entered hospital on third day after strangu-lation in state of great collapse. Operation under ether. Open incision ; sac in situ. (Ether.) Death from shock and pulmonary oedema eight hours after oper-ation. 4th case. 1885. 42. July 13th. Strangulated direct inguinal. Female. Free division of parts and reduction of sus-pected intestine. Open treat-ment. (Ether.) Died of perforation of gut and pulminant peritonitis on second day. 5th case. 1886. 27. February 10th. Strangulated indi-rect inguinal, right side. Acute strangu-lation. Male. Open incision with reduc-tion of the sac. The latter was unopened. Wound healed by granulation, (Ether.) No mishaps; vomit-ing cured, and patient promptly recovered af-ter operation. Operations for Strangulated Hernia, With and Without Combined Measures for Radical Oure—Continued. ORDER. 6th case. 7th case. 8th case. 9th case. 1887. 1888. 1888. 10th case. 1889. 38. 41. 32. 71. 29. DATE OF OPERATION. April 12th. February 12th. May 20th. September 2d. June 12th. INFIRMITY. Strangulated, incar- cerated, left inguinal hernia. OPERATION. Strangulated femcral hernia of twenty-two hours' duration. Right side. Strangulated, indi- rect, inguinal, incar- cerated. Strangulated, ingui- nal, indirect. Twenty- four hours' duration. Strangulated, ingui- nal, indirect. Great collapse. Male. <)|>en incision; sac di- vided in situ; omento- enterocele firm, and extensive adhesions. (Ether.) Female. Long linear incision over the convexity of the tumor. Reisel's operation for radical cure combined. (Ether.) Male. Incision ; excision of the sac and quilled suture of canal; no drainage. (Ether.) Male. Usual long incision ; de- cortication of sac with its torsion and division. Wound healed by granulation. (Ether ) Male. Free hypodermic medi- cation, and but partly anaesthetized with ether. Oper- ation hurriedly performed for relief of strangulation only. (Ether.) RESULT. Death from shock ten hours after opera- tion. (No post-mortem allowed.) Patient made a good recovery, and now, after four years, hernia has not relapsed. Operation; recovery. Relapse of hernia after fifteen months. Operation; recovery. Relapse after six months. Never rallied from ether coma, and died two hours after opera- tion. Operah ons for Strangulated Hernia, With and Without Com bined Measures for Radical Cure— Continued. ORDER. YEAR. AGE. DATE OF OPERATION, INFIRMITY. OPERATION. RESULT. 11 th case. 1889. 37. November 12th. Strangulated, con-genital, inguinal. (Right, with ectopic testis.) Male. Free incision; castra-tion ; obliteration of the infundibulum, and solid hermeti-cal suturing of the ring. (Ether.) Death from shock six hours after operation. 12th case. 1890. 42. March 16th. Strangulated, umbil-ical. Had existed since first confinement. Female. Patient in a moribund state when seen. 13th case. 1890. 29. August 2d. Strangulated, ingui-nal epiplocele. Right side. Male. Free incision; decorti-cation of the sac, with complete excision of the omen-tum, close to the inner ring. (Ether.) Prompt recovery, and no relapse since. 14th case. 1891. 64. February 15th. Strangulated, femor-al hernia. Left side. Female. Open incision; con-striction at the falci-form ; process divided; hernia returned ; adherent sac left in the wound. (Ether.) Death from shock on the morning of the second day. 15th case. 1891. 36. March 12th. Strangulated hernia, right inguinal ; com-plicated with hydro-cele. Male. Open incision, with free decortication and abla-tion of the sac; and radical cure by method of McBurney. (Ether.) Good recovery. Her-nia relapse after four-teen months. to I—' 00 Operations for Strangulated Hernia, With and Without Combined Measures for Radical Cure—Continued. ORDER. YEAR. AGE. DATE OF OPERATION. INFIRMITY. OPERATION. RESULT. 16th case. 1891. 2*. June 12th. Strangulated, femor-al, incarcerated. Great collapse and depress-ion. Strangulated, ingui-nal hernia. Right side. Patient subject to her-nial disease. Female. Operation under co-caine analgesia (thirty minutes' duration). Radical cure by Championniore's procedure. Result — quite, the ideal in every particu-lar. No hernial re-lapse. 17th case. 1891. 1892. 52. December 12th. Male. Cocaine analgesia. One assistant. Release of the constriction, combined with Ball's operation for radical cure. Good operative re-sult ; but hernia prompt-ly relapsed. 18th case. 46. November 19th. Strangulated, right inguinal. Large scro-tocele. Male. Operation by house-sur-geon; resecting more than three feet of suspected intestine. (Ether.) Death from perito-nitis after forty-eight hours. 19th case. 1892. 40. June 12th. Cancerous infiltra-tion of strangulated epiplocele. Right side. Male. Primary operation lim-ited to incision down to the sac. After relieving stran-gulation, McBurney's operation for radical cure was performed. Prompt recovery from operation. Has been lost sight of. 20th case. 1892. 26. June 17th. Strangulation with perforation of bowels. Right inguinal. Male. On opening the sac it was found that by vio-lence the intestine had been burst, and returned, leaving the thin pouch filled with the intestinal contents. (Cocaine.) As toxaemia was pro-nounced when opera-tion for opening was made, he died after forty hours. Operat ons for Strangulated Hernia, With and Without Combined Measures for Radical Cure— Continued. ORDER. YEAR. AGE. DATE OF OPERATION. INFIRMITY. OPERATION. RESULT. 21st case. 1892. 41. May —. Strangulated, ingui-nal (left). Gangrene of intestine. Female. Open incision into the broken - down bowel. Artificial anus. (Ether.) Death on the table, before dressings were complete. 22d case. 1892. 26. September 12th. Strangulated, right inguinal. Duration two days, not very tightly gripped. Male. This was a case in which a second operation was necessary, through the constric-tion of the neck being overlooked by first operator. Champion-nitre's r. o. (Cocaine.) Good recovery. Too short time to speak of permanency of results. 23d case. 1892. 29. November 12th. Strangulated, ingui-nal (left). Gangrene of gut, with faecal infiltra-tion. Male. Free incision, and drain-age of faecal matter. Arti-ficial anus. (Cocaine.) Death from toxaemia on the fourth day. 24th case. 1892. 26. December 16th. Strangulated, ingui-nal (right). Six hours' duration. Male. Release of strangulation, with Championniere's operation for radical cure. Excellent operative result. to to o Operations for Radical Cure of Non-Strangulated Hernia. ORDER. YEAR. AGE DATE OF OPERATION. INFIRMITY. OPERATION. RESULT. 25th case. 1887. 67. December 12th. Indirect, incarcer-ated, inguinal. Right side. Male. Reverdin's operation, with sac left in situ. Satisfactory opera-tion. Relapse afterthir-teen months. 26th case. 1S88. o March 18th. Congenital, right inguinal. Incoercible to the truss. Male. Decortication of the sac, and its invagination in the canal with deep cat gut su-turing. Recovery. Relapse after two years. 27th case. 1888. 30. June 10th. Inguinal epiplocele, left side; incarcerated. Male. Excision of the sac with tamponing of the inter-nal ring with omental tissue. Recovery. No re-lapse up to a month ago. 28th case. 1888. 41. October 7th. Small, lacerated um-bilical, giving issue to free hemorrhage. Female. Excision of cellular tissue investment Deep, harelip pins were em-ployed, with cat-gut for deep suturing. Recovery. No re-lapse since operation. 29th case. 1889. 3 weeks. June 10th. Very large scrotal hernia, unmanageable to the truss. Male. Open incision; McBur-ney's operation. Recovery. Relapse after ten months. 30th case. 1889. 71. March lOih. Left inguinal; large and uncontrollable. Male. McBurney's open opera-tion. Recovery. Relapse after six months; but now easily manageable to truss. Operations for Radical Cure of Non-Strangulated Hernia—Continued. ORDER. YEAR. 1889. AGE. DATE OF OPERATION. INFIRMITY. OPERATION. RESULT. 31st case. 27. 46. 14. 9. May 14th. July 17th. Right inguinal her-nia. Painful. Male. Championnie're's opera-tion. Recovery. Relapse after six months; but no pain. 32d case. 1889. Left inguinal her-nia, complicated with ectopic testis. Male. Fixation of the testicle in the scrotum. Excis-ion of the sac, and immediate enclosure of the parts with three layers of suture. Recovery. There has been no relapse, though truss is constantly worn. 33d case. 1889. November 14th. Right inguinal her-nia,with encysted cord. Male. Excision of cyst and in-vagination of sac, with direct deep suturing of canal. Recovery. No re-lapse. Constantly wears a truss. 34th case. 1890. January 2d. Right inguinal her-nia ; incarcerated. Female. McBurney's operation. Recovery. No re-lapse for two years, when he was lost sight of. 35th case. 1S90. 8. April Pith. Small, left epiplo-cele ; irreducible. Reisel's operation; excision of neck, but sac left in situ. Recovery. Relapse after eighteen months. 36th case. 1890. 26. June 19lh. Large, right scroto-cele; iucoercible to the truss. Male. Sac resected, and com-mon ring closed with buried silver wire suture. Recovery. No re-lapse. Constantly wears a truss. to to to Operations for Radical Care of Non-Strangulated Hernia—Continued. ORDER. YEAR. AGE. DATE OF OPERATION. INFIRMITY. OPERATION. RESULT. 37 th case. 1891. 1891. 1891. 43. May 12th. July 7th, Direct, inguinal, left side; enterocele. Male. McBurney's operation, modified by suturing the internal ring with silk. Recovery. No re-lapse two years after operation. 38th case. 2. Incomplete, ingui-nal, large. Right. Cervicotomy. Sac left in situ, pillars sutured. Wound closed without drainage. Recovery. Relapse in eight months. 39th case. 3. September 19th. Double inguinal Male. Operation on one side only by Championniere's plan. Recovery. Relapse after eighteen months. 40th case. 1891. 24. November 9th. Femoral (right) epiplocele. Male. Tamponage of the fe-moral canal and sept ion crurale wiih omental tissue. Recovery. Relapse at the end of eighteen months. 41st case. 1891. 2. December 9th. Umbilical hernia; irreducible. Female. Free dissection and liberation of viscera. Refreshening and suturing ring, Recovery. No re-lapse as yet. 42d case. 1891. 4. December 27 tb. Inguinal hernia. Right side. Male. Championniere's opera-tion. No relapse after one year. Operations for Radical Cure of Non-Strangulated Hernia—Continued. ORDER. YEAR. AGE. DATE OF OPERATION. INFIRMITY. OPERATION. RESULT. 43d case. 1892. 1. January 12th. Umbilical. Small and irreducible. Female. Ligature of neck of sac and closure of the ring with cat-gut suture. Recovery. No re-currence January 1st, 1893. 44th cate. 1892. 46. January 19th. Large umbilical her-nia. Painful and in-carcerated. Female. Free dissection. Ex-cision of the omentum. Death fifty hours af-ter operation, from shock and peritonitis. 45th case. 1892. 24. January 27th.. Small, painful in-guinal. Left side. Male. Championniere's opera-tion. Recovery. Relapse after nine months. 46th case. 1892. 5. February 2d. Umbilical hernia, large and painful. Female. Reduction of hernia and subcutaneous su-turing of sac. Recovery. No re-lapse after January 1st, 1893. 47th case. 1892. 1. February 14th. Large scrotal. Right side. Male. Reduction of hernia, fol-lowed by invagination and suturing of the sac in the ring. Recovery. Truss worn constantly since. 48lh case. 1892. 27. February 21st. Femoral hernia. Right side. Incoerci-ble. Female. Excision of sac and obliteration of lumen of septum crurale by deep buried suture. Recovery. Truss worn constantly. No relapse. to to Operations for Radical Cure of Non-Strangulated Hernia—Continued. ORDER. YEAR. 49th case. 1892. 50th case. 1892. 51st case. 1892. 51. DATE OF OPERATION. April 2d. 52. April 16th May 7th. 5 2d case. 53d case. 1892. I 32. July 2d, INFIRMITY. 1392. I 24. Small, painful, um- bilical hernia. Large scrotocele (right), with hydro- cele. Small, bilical. painful urn- Incarcerated and in- coercible inguinal her- nia. Right side. August 7th. Small, reducible, right inguinal. (In applicant for police ) OPERATION. Male. Open incision. No sac. Small omental mass, tize of a marble, resected. Deep silk suture employed. No drainage. Male. First complete retention with trt ssfor one month. Second incision in ring and pil- lars approximated with by silk suture. Female. Reduction and subcu- taneous suture with chromocized cat-gut. Male. Free incision. Body of sac closed by quilled su- ture. Its neck divided. Wound closed in three layers of sutures. Male. Small incision over in- tercolumnar fascia; and injection into the perivascular elements of the cord, in inguinal canal, of twenty drops of strong alcohol. Recovery. Prompt union. Wears a belt. No relapse. Recovery. No re- lapse. Pad and belt constantly worn. Recovery. No re- lapse January 1st, 1893. Recovery. No re- lapse after six months. Recovery. Success- ful in every particular. No relapse. Wears belt. to to Operations for Radical Cure of Non-Strangulated Hernia—Continued. ORDER. i YEAR- AGE. DATE OF OPERATION. INFIRMITY. OPERATION. RESULT. 54th case. 1892. 34. August 29th. Reducible hernia; left inguinal. Female. Resection of a pro-lapsed ovary in canal. No drainage. Recovery. No re-lapse. 55th case. 56th case. 1892. 6. October 12th. Incoercible, right inguinal hernia. Resection of sac and closure of parts in four layers. No drainage. Recovery. No re-lapse. 1893. 43. 23. January 4th. Incoercible, left inguinal hernia. Exposure of sac, ligation of its neck, and quilting of the slack and solid suturing of rings. Recovery. 57th case. 1892. 1892. November 17th. Small, painful, fe-moral hernia. Female. Championnie're's opera-tion. Recovery. No re-lapse in two months. 58th case. 40. December 2d. Small, inguinal, pain-ful epiplocele. Reisel's operation. Recovery. No re-lapse in one month. to HERNIA. 227 RECAPITULATION AND SUMMARY OF OPERATIONS. In the recorded list of operation one of the first things that will be noticed, is the great difference in the mortality of opera- tions performed for strangulation, and for radical cure in the non- strangulated. In the former, since the general substitution of cocaine anal- gesia for pulmonary anaesthetics, unless our patients have been moribund, or the intestine is not gangrenous at time of operation there haAre been no deaths, both Avith those on Avhom I have oper- ated in hospital and outside practice. It Avill be obserAred, too, that the mortality in non-strangu- lated cases in my experience bears out Bull's statement that it is practically nil. At the present time, my purpose in contemplation, when I herniotomize, is not so much to secure a radical cure as to place the hernia in such a position as it Avill gi\re no inconvenience, and may be safely controlled by truss support. I have followed out no orthodox plan in operations, but am guided here on precisely the same principles as I would in per- forming an amputation, viz., totally disregarding all those specially designated operations, and in each case select such an one, A\rith or Avithout modification, as the conditions in each case may require. The operations Avhich I have latterly employed in adult, non- incarcerated hernia have been instituted more as relief-measures than as radical cures per se. And, hence, as an invariable rule, I advise, as soon as the patient takes erect attitude, the immediate employment of the broad belt or truss. The latter always when the hernial operations are large and the hernia has been an old one. INDEX. PAGE A Few General Observations on Operations for Radical Cure of Reducible and Irreducible Herniae, as Practiced at the Present Time................. 76 Agents by which Inflammation has been Induced.......................... 25 Ancient Management of Mortified Hernial Contents........................ 22 Ancient Methods of Treatment of Strangulated Hernia..................... 21 An Open Operation which Essentially Embraces the same steps as the Preced- ing, but the Divided Inguinal Canal and in the soft parts unite by Granula- tive Tissue instead. (McBurney)................................... 164 Class of Cases in which Cervicotomy and Deligations should be Practiced.... 154 Comparative Merits of Operations for Non-strangulated.................... 24 Comparative Merits of Operations for Non strangulated and Reducible Hernia by Modern Methods .............................................. 80 Complete Detachment of the Sac from its adhesions and its subsequent utiliza- tion, as a plug to serve as a barrier against relapse. (McEwen-Kochers).. 168 Concluding Observation on Older Observation on Older Operations.......... 23 Concluding Observations on the Older Operations.......................... 74 Conditions Requiring Truss in Children ................................. 6 Congenital Defects of Development in the Spermatic Cord, the Inguinal Canal and Outlets, and those Arising from Pathological Changes............... 85 Congenital Hernia..................................................... 2 Construction and Application of Truss in Children ....................... 7 Contra-indications of Surgical Treatment in Children...................... 9 Encysted Hernia in Children and Infants.................................. 5 Essential Principles for Operation for Radical Cure........................ 25 Eventrations, Laparotomy Hernia and their Operative Treatment........... 213 Femoral Hernia in the Male and Female; its Morbid Anatomy and Pecu- . liarities............................................................ 89 General Consideration.................................................. 1 Hernia in the Adult.................................................... 10 Hernia in the Female Child............................................ 9 Hygiene of Infancy.................................................... 2 Incoercible and Incarcerated Hernia in Youth............................. 9 Indications for Truss in the Adult........................................ 11 Inguinal and Female, with Observations on Male Femoral Hernia........... 89 In Hernial Operations.................................................. 215 Irregular Ventro-abdominal Hernia of Child-bearing Women............... 50 Isolation of Sac, with Section of Internal Ring............................ 171 229 230 INDEX. PAGE Laparotomy Hernia ........................................... ....... 1'-* Laparotomy Hernia................................... ................ 51 Mammoth Hernia .................................................... *" Management of the Sac in Former Operations for Strangulation............ 21 Mechanical Appliances, Indications, etc................................... 3 Mechanical Treatment of Ventral Hernia................................. 14 Mental Alienism Consecutive ........................................... 214 Miscellaneous Methods Effecting or Favoring Radical Cure.................. 66 Miscellaneous, Open Operations In ; In Inguinal Hernise and those Appropriate for Strangulation, Femoral, Umbilical and other Hernia................ 175 Morbid Anatomy and Pathology of Exomphaceles, Epigastric Hernia, Even- trations, or Laparotomy Hernia.................................... 95 Neoplastic Hernia.............................. ....................... 12 Observations on Operations for Radical Cure.............................. 23 Operation Technique for Incarcerated Reducible Hernia when Treated by Open Incision .......................................................... 186 Operation Technique in Strangulated Hernia and its Complications, Manual and Instrumental .................................................. 203 Palliative Treatment of Adult, Ventro-abdominal Hernia................. 52 Palliative Treatment of Ventro-abdominal Hernia......................... 15 Post-operative Treatment of Hernia ..................................... 213 Preparation and Details in Operation for Strangulated Hernia............... 190 Radical Cure, Femoral Hernia........................................... 208 Radical Cure of Reducible and Irreducible Hernia ........................ 16 Radical Cure in Strangulated Hernia..................................... 24 Radical Operation for Umbilical, Ventral and Laparotomy Hernia........... 210 Recapitulation and Summary of Operations............................... 227 Rest................................................................. 187 Simple Non-operative Measures in Infantile Hernia......................... 4 Subcutaneous Division of Neck of Sac.................................... 22 Surgical Operation for Infantile and Children's Hernise..................... 8 Taxis................................................................. 188 The Agents by which Inflammation has been Induced to Close the Aperture... 81 The Management of the Sac in Reducible and Strangulated Hernia.......... 64 The Management of the Sac in Former Operations for Strangulated Hernia.. 71 The Management of Mortified or Gangrenous Intestine, or Omentum, in the Past........................................... ................... 73 The Mechanism of Hernia from a Standpoint of Stricture, Function and Abdominal Conditions............................................. 84 The More Ancient Methods of Treating Strangulated Hernia................ 70 The Radical Cure of Strangulated Hernia ............................... 79 The Radical Cure of Reducible and Irreducible Hernia, by Direct Surgical In- tervention. Its Origin, Progress, and Present Position ... ........... 55 The Radical Treatment of Non-strangulated Hernia, by such Modern Methods as Require an Open Incision and Free Dissection of the Sac............. 149 INDEX. 231 PAGE The Subcutaneous Section of the Strictured Neck of the Strangulated Sac, or Division of the Contracted Ring........................... ......... 73 Those Operations in which the Sac is Completely Dissected and Cut Away, after the Inguinal Canal has been Divided through its Entire Length, after which the Canal, External Ring, Fascia and Integuments are Closed, Layer by Layer. (Championniere)......................................... 159 Treatment of Infantile Hernia .......................................... 3 Treatment of Laparotomy Hernia...................................... 16 Treatment of Laparotomy Hernia........................................ 54 Umbilical Hernia ..................................................... 14 Varieties of Infantile Hernia............................................ 8 Ventro-abdominal Hernia in Child-bearing Women ....................... 15 BIBLIOGRAPHY. Paul Segond. Cure Rad. des Hernies. Felizet, M. Cure Rad. des Hernies, chez les Enfant. Oribase. Hernise Descript. Carengrot. Medicine Moderne, Mai 17, 1886. Pare, Ambrose. Matieres des Chirurg. vol. ii. Celsus. Theory of Medicine. Translation Sydenham Society. Fabricius. Surgical Works. Translation by J. Tole. De Blegny. De l'Art d«i guerir des Hernies. Kochius. Dissertation on Hernia. Heister's Comments. Heister's Institutes of Surgery. Janon's Translation. Le Dran. Operations-Chirurgicales. Larrey, Baron. Les Blessures Inguinales. Louis. Operationes des Hernise. Bordenhaur. Caustiques pour la Cure Rad. des Hernia?. Scarpa. Practical Treatise on Hernia. Translated by C. Hodges. Desault. CEuvres Chirurg. Malgaigne. OZuvres Chirurg. Dupuytren. Elements Anatomicales des Hernia. Agnew. Operations for Hernia. Med. and Surg. Reports, 1860. Albert. Rad. Cure of Hernia. Wien Med. Presse. Curling on the Testicle. McEwen. Glasgow Med. Jour., 1887. Albertini. Radical Cure of Hernia. Gaz. des hopitaux, Milan, 1881. Parkes. Hernial Operations. Medical Register, June, 1886. Allis. On McDowell's Method for Cure of Hernia. Annals of Anatomy, December, 1881. Annandale. Large Inguinal Hernia treated by Operation. British Med. Jour., June, 1876. Wutzer's Operation. Gross, System of Surg., vol. ii, p. 577. Ashhurst, J. System of Surgery. Ball. Dublin Jour. Med. Science, May, 1885. Procedure for Rad. Cure of Hernia. Banks. Rad. Cure of Complicated Inguinal Hernia. Liverpool Med. and Surg. Journal. Bardeleben. Rad. Cure of Hernia. German Surg. Cong., 1882. ii BIBLIOGRAPHY. Bull, W. T. Operations for Rad. Cure of Hernia. New York Med. Jour., 1891. Rickitts, S. M. Hernial Operation. Jour. Am. Med. Assn., January, 1892. Barker. Cure of Hernia by Wood's Operation. Lancet, 1880, vol. i, p. 248. Barwell. Rad. Cure of Umbilical Hernia. Lancet, 1861. Price, J. Operation for Laparotomy Hernia. Annals Gyn. January, 1893. Beugrand. Rad. Cure of Hernia. Jour. Connaissances Med., 1836. Bell. Two Cases of Strangulated Hernia. Edin. Jour. Med., August, 1866. Bonnet. Cure Rad. d' une Hernia PropeVitoneale. These. Chir., Paris, 1874. Bouchut. Traite des Nouveaux N6s, 7th ed., 1878. Boyer. Traite Malad. Chirurg. Malades, t. viii, Paris, 1822. Ransohoff. Treatment of Gangrenous Hernia. Jour. Am. Med. Assn., October. 1892. Marcy. Surgical Anat. of Hernia, 1893. Brandt. Analytical Study of Rad. Cure of Hernia. Cent. fuer. Chirg., 1881. Bransby, Cooper. Operation for Reducible Hernia, Gerdy's Method. Gaz. des Hopitaux, 1841. Braun. Definite Results of Hernial Operations. Klin. Wochenschrift, 1881. Barber. Female Hernia and Complications. Am. Jour. Gyn., May, 1892. Bryant, T. Manual of Surg, 3d ed. p. 249. Bryant, J. D. New Operation for Rad. Cure of Hernia. Jour. Am. Med. Assn., 1890. Buchanan. Rad. Cure of Strangulated Hernia. Glasgow Med. Jour., 1861. Burkhart. Reverdin's Operation. Stuggart, 1880, Revue Romande. Fowler, G. R. Rad. Operation for Hernia. Annals of Surgery, February, 1893. Cavenne. Cure Rad. des Hernies Abdominales. Gaz. Med., 1845, t. xii, p. 608. Cooley. Operations for Hernia. New York Med. Jour., May 7th, 1893. Chiene, J. Rad. Cure of Inguinal Hernia, Reducible. Brit. Med. Jour., 1876. Chisholm. Method for the Radical Cure of Hernia. Med. Press, Dublin, 1863. Cooper, A. Surgery of Hernia. 2d. ed., p. 207. Coste. Cure Rad. des Hernies. Bull, de la Hos. de Chirurg., Paris, 1853. Heath, Christopher. Cases of Hernia Treated by AVood's Method. Brit. Med. Jour 1878. Cruveilhier. Cure of Congenital Exomphacele. Gaz. Heb., Mai, 1857. Czerny. Studies on Rad. Cure of Hernia. Wiener Medizin, 1877. Fergusson. Operation for Femoral Hernia. Lancet, February, 1860. Milliken, S. E. Hank Truss, Bassini's Operation. Jour. Am. Med. Assn January 1893. ' J' Colly, D. Cure of Congenital Hernia, Wood's Operation. Lancet, 1882. Demarquay. Hernia Treated by Iodine Injection. Le Semaine Med., 1856. Desormeaux. Congenital Umbilical Hernia. Bull, de Ther., 1864. Dey. Rad. Cure of Inguinal Hernia. Indian Med. Gaz., Calcutta, 1881. Diday. Rad. Cure by Iodine Injection. Gaz. Heb., 1855. Dill. Cure of Hernia by Gerdy's Method. Lancet, August, 1869. Dowell. Four Cases of Radical Cure. New York Med. Jour., 1876. Duplay. Traite de Chirurg., t. vi, p. 417. Durham. Hernia Operated on by a New Method. Lancet, June, 1882. Field. Modification of Wood's Operation. Med. Times, 1861. Fallin. Relative to Rad. Cure of Hernia. Bull, de Soc. Chirurg., 1853. BIBLIOGRAPHY. Ill Franklen. Invagination Method. Med. Amsterdam, 1880. Frey, B. Incision in Strangulation. Med. Standard, May, 1892. Gant. Science of Surgery, 1871, p. 921. Geissel. Rad. Cure of Hernia. Deutche Mediz. Woch. Gerdy. Rad. Cure of Inguinal Hernia. Acad. Science Jour., 1834. Gimelle. Report on Hernia. Jour, des Connaisances, 1835. Giraldes. Le"cons Cliniques, etc. Gaz. des Hop., 1869. Bennett. Rad. Cure of Hernia by Invagination. Lancet, October, 1892. Eassini. Operation for Cure of Hernia. Gaz. Heb., Aout, 1889. Godless. Rad. Cure of a Large Inguinal Hernia. Med. Times, 1881. McGillicuddy, T. Rad. Operation for Femoral Hernia. New York Med. Jour, January, 1887. Gosselin. Hernia Crurale. Diet, de Chirurg., t. x, Paris. McGraw. Modern Rad. Operations. Detroit Clinic, 1883. Del Greco. Cura Radicale dell' ernia. Firenze, 1880. Dowell, G. Four Cases of Hernia Treated by Wire Fixture. New York Med. Jour., t. ii, p. 547. Gross, S. System of Surgery, 5th ed., vol. ii, p. 572. Guerin, Jules. Note on Inguinal Hernia. Elem. de Chirurg., p. 554. Gussenbauer. Rad. Cure by Alcohol Injection. Cent, per Chirurg., 1882. Hayward. The Value of Surgical Operations in Hernia. Bull. Ther., 1853. Hamilton. Cure of Umbilical Hernia by Ligature. Brit. Med. Jour, 1877. Heaton. New Method for Treating Hernia. Boston Med. and Surg. Jour., May, 1887. Hill, John Hill. Observations on Rad. Operations for Hernia. Lancet, 1869. Holmes. A System of Surgery. Vol. iv, p. 669. Hunter, Ch. Fixation of the Testicle in Inguinal Hernia. Am. Jour. Med. Sci- ence, 1S78. Jameson. Implantation of Integument in Hernial Operations. Am. Jour. Med., 1853. Jessett. A Case of Cure of Inguinal Hernia. Lancet, 26th October, 1872. Juillard. Twenty-one Operations for Rad. Cure of Hernia, performed from 1876 to 1882. Obs. not published. Kinlock. Two_ Gates Operated/m for Bad. Cure. Am. Jcur. Med. Science, July 1860. Kirby. Lessons on Hernia. Med. Gazette, 1836, vol. i, p. 102. Kocher. Radical Operation for Hernia. Annals of Surgery, December, 1892. Kraske. Congenital Inguinal Hernia. Cent, fur Chir., 1882. Laurence. On Rupture. 2d ed. De Garmo. Types of Plernia. New York Med. Jour., 1892. Langenbeck. Modern Methods of Curing Hernia. Revue des Sciences Med., 1883. Le Dentu. Hernie. Diet, de Med. et Chirurg., t xii, p. 543. Lee. Rad. Cure of Non-strangulated Hernia. Med. Union, March, 1863. Leisrink. Modern Rad. Operations for Hernia. Untenlieb, Reviewed by Med. Mod., May, 1892. Leroy. New Apparel for Rad. Cure of Hernia. Gaz. Med., 1836. Lister. Value of Antiseptics in Hernial Operations. Lancet, 1880. Lucas Championniere. Treatise des Hernies, 1890. Maisonneuve. Cure Rad. per Injection. Acad, de Sciences, Gaz. Med , 1854. IV BIBLIOGRAPHY. Nussbaum. Operation for Hernia with Section of the Sac. Cent, fur Chi., 1877. Middleton. Cure of Hernia by Aid of the Testicle. Am. Jour. Med. Sciences, Octo- ber, 1878. Morse. Observations on Diverse Operations for Hernia. Cent. 1877. Morton. Rad. Cure of Hernia. Glasgow Jour., October 1860, p. 340. Nekton. Elements of Surgical Pathology, t 14, p. 212. Pancoast. Treatment of Hernia by Injection. Am. Jour. Med. Sciences, 1863. Petriquin. Procedure for Rad. Cure in Crural Hernia. Bull de Chir., 1853. Delorme. Historique et Bibliographique des Hernies. Diet, de Med. 1837. Reclus, P. Rad. Cure des Hernies. Gaz. Heb., 1882. Reverdin. Modern Operations for Rad. Cure of Hernia. Revue de Suisse, 1881. Ricord. Nouveau Procede" d' Injection. Gaz. des Hop., 1854. Reisel. Cure Rad. des Hernies. Central, fur Chirurg., 1877. Roubaix. Nouveau Procede Hernies. Bruxelles, 1854. Sabatier. Sansom's Edition, t iii, p. 475. Sanson. Hernies. Diet, de Chir., t x. Schmidt. Cure Rad. des Hernies. In Pitha and Billroth. Sedillat. Traite" de Med. Oper. 2d ed., t, ii, p. 334. Sigmund. Operation des Hernies. In Gaz. Hebdom, 1846, p. 200. Socin. Basel, 1884. Sotteau. Cure Rad. des Hernies. Gaz. Med., t vi, p. 312. Spanton. On the Cure of Hernia. Trans. Med. Cong., 1881. Wells, S. Contribution on Hernia. Brit. Med. Jour., 1859. Symine. Simplification of Wutzer's Method. Bull. Gen. Ther., 1861. Teevans. Wood's Method of Cure of Hernia. Lancet, 1879. Thompson. On the Cure of Hernia. Med. Times, 1861. Valette. Cure Rad. des Ing. Hernia. Acad. Chirurg. Paris, 1854. Velpeau. Memoire sur des Hernies. 2d ed. t iv, p. 217. Warren. Rad. Cure of Hernia. 1st ed., 1882. Warren, Joseph. Rad. Cure of Reducible Hernia. Glasgow Med. Jour , 1864. Whitson. Rad. Cure Original Hernia. Med. Times and Gazette, 1883. Wood. On Ruptures. 4th ed., London. Parsons, F. Hygiene in Infancy. Jour. Am. Med. Assn., 1891. Budd, C. Lectures in Obstetrics. University of New York, 1874, Petit, Louis. Lecons Chirurg., t iv, p. 517 Treves, F. Manual of Operat. Surg. 1st ed., p. 418 Erichsen. Manual of Surg. 4th ed., p. 718. Callisen. On Rupture and its Complications. Diet, of Surg., p. 1012. Guthrie. Surgical Lectures, Hernial Infirmity. Ed. 2d, p. 317. Brodie. Tobacco Clysters in Strangulated Hernia. Med. Gaz., 1837. Wile, W. C. Contribution of Cystic Growths in Canal of Nuck. Med Jour., 1883. Martin, C. Lumbar Hernia. Annals of Surg., 1890. Smellie. Obstetric Lessons. 2d ed., p. 412. Re"clus. Cocaine Analgesia. Gaz. Heb., Mars 12th, 1889. Gay. Rad. Cure of Hernia. Boston Med. and Surg. Jour., 1869. Bichat. Anat. Generale, t vii, p. 912. Kocher, T. Rad. Cure of Hei nia. Annals of Surg., December, 1892. J** ;' >%►. ^ £$ rr" #>W ^ vaster "'•' <#•' 4,^ ;i: ".r m.......»m #f-ter ^ 1 NLM001388849