1817
ARTES
SCIENTIA
LIBRARY VERITAS
OF THE
UNIVERSITY OF MICHIGAN
DE PLURIBUS
UNUN
TUEBOR
ZAMAN
SI-QUARIS PENINSULAMEAMES
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MODD099999999999
MEDICAL LIBRARY

617.4
m32




THE
ANATOMY AND SURGICAL TREATMENT
OF
HERNIA
BY
HENRY O. MARCY, A. M., M. D., LL. D.
OF BOSTON
PRESIDENT OF THE AMERICAN MEDICAL ASSOCIATION; SURGEON TO THE HOSPITAL FOR WOMEN, CAMBRIDGE;
PRESIDENT OF THE SECTION OF GYNÆCOLOGY, NINTH INTERNATIONAL CONGRESS;
LATE PRESIDENT OF THE AMERICAN ACADEMY OF MEDICINE; MEMBER OF THE BRITISH MEDICAL ASSOCIATION;
MEMBER OF THE MASSACHUSETTS MEDICAL SOCIETY ;
HONORARY MEMBER OF THE NEW YORK STATE MEDICAL ASSOCIATION; FELLOW OF THE BOSTON GYNÆCOLOGICAL SOCIETY ;
CORRESPONDING MEMBER OF THE MEDICO-CHIRURGICAL SOCIETY OF BOLOGNA, ITALY;
MEMBER OF THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNÆCOLOGISTS;
FELLOW OF THE SOUTHERN SURGICAL AND GYNÆCOLOGICAL ASSOCIATION;
LATE SURGEON UNITED STATES ARMY; ETC.
WITH SIXTY-SIX FULL-PAGE HELIOTYPE AND LITHOGRAPHIC PLATES, INCLUDING
EIGHT COLORED PLATES FROM BOUGERY,
AND THIRTY-SEVEN ILLUSTRATIONS IN THE TEXT
NEW YORK
D. APPLETON AND COMPANY
1892

COPYRIGHT, 1892,
By D. APPLETON AND COMPANY.
VERB
WOCOLA

TO SIR JOSEPH LISTER
THIS WORK IS RESPECTFULLY DEDICATED.
IN COMMON WITH A GRATEFUL PROFESSION,
I WOULD
ACKNOWLEDGE
HIS MONUMENTAL LABORS,
WHICH HAVE REVOLUTIONIZED THE SURGICAL ART.
ESPECIALLY AM I INDEBTED FOR THE FAITHFUL PERSONAL TEACHINGS
WHICH WERE RENDERED TO ME, HIS FIRST AMERICAN PUPIL.
WITHOUT THE STIMULUS AND PROFIT RECEIVED FROM HIS INSTRUCTIONS,
THIS WORK WOULD NEVER HAVE BEEN RENDERED POSSIBLE.
179808


PREFACE.
In offering the following work to the profession, the author has been actuated
by the belief that there exists the necessity for the better instruction of the surgeon,
as well as of the general practitioner, upon the anatomy and surgical treatment of
hernia.
Nearly a century ago Sir Astley Cooper commenced his monumental labors for
the better elucidation of this important subject, which resulted in his monograph,
replete with illustrations, copies in full size of his anatomical dissections, made with
the most painstaking care. This work was soon after followed by the scarcely less
valuable treatises of Scarpa and Cloquet.
The student of to-day can consult only with great difficulty these valuable works,
since even our large libraries are but exceptionally supplied with them.
The contributions of the last generation have added little of importance to the
anatomical or pathological investigations of the subject, and a lifetime devoted to the
purpose, under the most favorable circumstances, could scarcely enable one to dupli-
cate the work so well accomplished by these distinguished authors.
I have felt that I could hardly render a better service than by furnishing well-
executed copies of the magnificent illustrations contained in these rare volumes, the
value of which will certainly be appreciated by every member of the medical profes-
sion. Even in the days of Mr. Cooper the expense of his illustrative artistic work
exceeded five thousand pounds sterling. Owing to the liberality of the Messrs. Apple-
ton, I have been able to reproduce, by the very best processes of modern art, what-
ever illustrations have seemed to me of especial value, including, besides the works of
these famous masters, the beautiful plates from Camper, Darrach, Langenbeck, Bour-
gery, Blandin, Cruveilhier, Guthrie, Gay, and others.
The subject of hernia is invested with new interest owing to the revolutionary
methods of modern surgery, which make operative measures comparatively safe when
(v)

vi
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
undertaken with proper aseptic precautions, which were formerly fraught with the
greatest danger.
The earlier efforts of the surgeon were necessarily limited largely to the relief of
strangulated hernia ; whereas now the processes of reparation are well defined, and the
sufferer afflicted with a pronounced hernia may justly demand of the surgeon a cure
of one of the most common and serious disabilities to which mankind is liable. It
is not too much to insist that every practitioner of medicine, even if he declines the
responsibility of surgical procedure, should carefully familiarize himself in detail with the
subject, since the accidental complications incident to hernia occur so frequently that
the most limited in practice is often called to the serious consideration of a life issue
dependent upon his prompt recognition of the impending danger, and the delay of a
few hours only may cause a fatal result. So important did this appear to Mr.
Cooper, that he commenced his preface as follows: "No disease of the human body,
belonging to the province of the surgeon, requires in its treatment a greater combina-
tion of accurate anatomical knowledge with surgical skill than hernia in all its varie-
ties. Symptoms immediately threatening the extinction of life occur at times, and
in situations that afford but little opportunity for consulting the authority of others,
and demand in the surgeon a prompt resolution and decisive practice. Accurate ana-
tomical knowledge is frequently required to detect the presence of this disease at that
period at which alone the milder process of reduction is practicable; and still more is
the combination of skill and intelligence necessary to enable the surgeon to meet all
the occurrences which may happen when the use of the knife becomes the only method
of saving the patient."
While I have availed myself freely of the labors of my predecessors, I give, I trust
with judicial fairness, the proper credit to the various operative measures more recently
advocated for the cure of hernia, and I have drawn largely from my own experience.
I have practiced and taught the methods advocated for the cure of hernia for the
last two decades, and in repeated publications have, from time to time, presented my
experiences to the profession.
I append the following brief notes of the early great masters, which can not fail to
be of interest.
HENRY O. MARCY.
BOSTON, June, 1892.

PREFACE.
vii
-
PETER CAMPER.—Incones Herniarum, Editæ a S. T. Sommerring, Francof., folio,
1801. These plates represent several important points in the anatomy of inguinal
hernia, in the accurate and expressive style of delineation which was peculiar to Cam-
per. It must be observed that, although they were not published till after the author's
death, they had been engraved as early as the year 1757.
Astley COOPER, Bart.-Anatomy and Surgical Treatment of Inguinal and Con-
genital Hernia, London, folio, 1804; Anatomy and Surgical Treatment of Crural and
Umbilical Hernia, etc., folio, 1807. This valuable work appeared for the second time
in 1827, under the title of Anatomy and Surgical Treatment of Abdominal Hernia, in
Two Parts, edited by C. A. Key, Esq., who has added several notes.
RICHTER.–At the time of its appearance, the work of Richter, originally written
in German (Von den Brüchen, 8vo, Göttingen, two vols., 1778 and 1779, second
edition in one vol., 1785), and translated into French by Rougemont (Traité des her-
nies, 4to, Bonn, 1788), was the most comprehensive that had been published on this
subject. It will be always valuable for the clearness, good sense, and extensive re-
search, which are conspicuous throughout, and particularly for the description of
symptoms, and the practical directions, which derive great weight from the author's
long experience. Of the anatomy of ruptures he was quite ignorant; and SCARPA
alleges this circumstance as the motive for his publication, Sull'ernie Memoire Ana-
tomico-Chirurgiche, Milano, 1809, in Atlas folio; second edition, Pavia, 1819; trans-
lated into French under the title of Traité pratique des hernies, ou Mémoires ana-
tomiques et chirurgicaux sur ces maladies, Paris, 8vo, with Atlas, in folio; and into
English, with reduced engravings, in 8vo, by Mr. J. H. Wishart, as A Treatise on
Hernia, Edinburgh, 1814.
The expectations which the preceding publications of this consummate anatomist
are so well calculated to excite, are completely satisfied by the anatomical accuracy, the
taste, the masterly execution, and beauty of the original engravings, and the scientific
clearness and simplicity of the accompanying illustrations. The plates of the French
translation, although in smaller form than those of the original, are well executed, not
only representing all the anatomical facts, but possessing something of the beauty, of
those from which they were copied. As this and the English translation are in more
common use than the Italian original, I have frequently quoted them in the present
work; and for a similar reason I have referred to the French translation, instead of the
original German of Richter.
Dr. F. K. HESSELBACH, of Würzburg, published in 1806 a tract entitled Anatom-
ico-Chirurgical Treatise on the Origin of Inguinal Ruptures. This was republished
in 1814, in an enlarged form, under the title of Latest Anatomico-Pathological Investi-
gations concerning the Origin and Progress of Inguinal and Femoral Ruptures, with
a
2

viii
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
fifteen plates, 4to. It describes shortly but correctly the natural structure of the ingui-
nal region, and the anatomy of inguinal and crural herniæ; these subjects being
clearly and faithfully represented in the engravings. Although not to be compared, in
copiousness of detail and illustration, to the productions of Cooper and Scarpa, the
work is creditable to the talents and research of the author, if he was ignorant of the
facts previously ascertained and published by those justly celebrated men.
The last-mentioned work of Hesselbach, written in German, was translated into
the Latin, and published at Würzburg in 1816, under the title Disquisitiones Anato-
mico-Pathologicæ de ortu et progressu Herniarum Inguinalium et Cruralium, cum
tab. xvii, aeneis. The two additional plates contain delineations of an instrument de-
signed to assist the surgeon in detecting the source and arresting the progress of
hæmorrhage when arteries are wounded in the operation for strangulated hernia.
Dr. A. K. HESSELBACH, son of the author last mentioned, published at Würzburg,
in 1829, a short treatise on the anatomy, causes, and symptoms of abdominal ruptures:
Lehre von den Eingeweidebrüchen; der. Theil. Entstehung und Ausbildung der
Brüche.
Recherches anatomiques sur les hernies de l'abdomen; with four engravings, 4to,
Paris, 1817. This inaugural dissertation gives a short and clear description of the parts
in which inguinal and crural herniæ take place; of the cremaster; of the peritonæum,
and its prolongation in front of the spermatic vessels; illustrated by several interesting
figures
M. CLOQUET.-The Recherches sur les causes et l'anatomie des hernies abdo-
minales, with ten lithographic plates, containing seventy-eight figures, 4to, Paris, 1819,
was the thesis produced and published by M. Cloquet in the Concours pour la place
de chef des travaux anatomiques. This very instructive and interesting work is
founded on researches for which the large hospitals and dissecting-rooms of Paris
afforded unrivaled opportunities. The ingenious and indefatigable author had made
five hundred examinations of ruptures on the dead body, and more than six hundred
drawings; and he had represented two hundred anatomical preparations of herniæ to
the Faculty of Medicine in Paris. The subjects embraced in this memoir are: The
Causes of Hernia and the Mechanism of their Formation ; The Hernial Sac in its
various States; The Several Modes of Reduction, and some of the Means employed
by Nature for the Cure of Ruptures; and The Principal Diseases of the Hernial Sac.
The full and clear manner in which these points are treated, and the abundant infor-
mation which the author displays on all parts of the subject, make us regret that
he should not have found leisure to execute the general work on hernia which he
seems to have had in contemplation.
Commentarius de Peritonæi Structura, Testiculorum Tunicis, Corumque ex Abdo-

PREFACE.
ix
mine in Scrotum Descensu, ad Illustrandam Herniarum Nidolem ; 8vo, cum tab. xxiv,
æneis in folio, Göttingen, 1817. In the numerous well-selected and well-executed fig-
ures of this work the zealous and indefatigable author, who, as Professor of Anatomy
and Surgery at Göttingen, so ably sustains the reputation of that celebrated university,
represented most of the important points in the natural and pathological state of the
parts which are the seat of inguinal, crural, and congenital ruptures.


CONTENTS.
CHAPTER I.
PAGE
I
GENERAL CONSIDERATIONS ON HERNIA .
Definition of Hernia—Classification-Frequency as to Age, Sex, Occupation-Baxter's and
Kingdon's Tables.
CHAPTER II.
9
ANATOMY OF THE PARTS INVOLVED IN INGUINAL HERNIA .
Analytical Description of the Anterior Abdominal Wall—Formation of the Inguinal Canal-
Nerves and Vessels.
CHAPTER III.
CONGENITAL HERNIA
38
Description of Formation of Sac-Encysted or Acquired Congenital Hernia.
CHAPTER IV.
.
48
INGUINAL HERNIA
Causes and Conditions—Formation of the Hernial Sac-Changes in the Peritonæum-Pa-
thology of the Sac—Stricture at the Neck of the Sac—Strangulation of the Intestine by
the Peritoneal Envelopes.
CHAPTER V.
65
DIRECT INGUINAL HERNIA
Internal Inguinal Hernia of Hesselbach-Relation of the Epigastric Artery to—Pathology of
-Importance of Diagnostic Differentiation of—Operative Measures for.
CHAPTER VI.
71
INDIRECT REDUCIBLE INGUINAL HERNIA
Description of—Instrumental Supports—Trusses—The Stagner, Chase, Knight, Seeley,
Hood, Greene's Water-pad-Air-pad, etc.
CHAPTER VII.
IRREDUCIBLE INGUINAL HERNIA
78
Symptoms—Complications—Dangers—Treatment-Reasons for Operation.
(
xi)
(

xii
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
CHAPTER VIII.
PAGE
85
STRANGULATED INGUINAL HERNIA.
Symptoms—Conditions—Complications—Prognosis — Taxis-Dangers—Contents—Omental
-Intestine.
CHAPTER IX.
SURGICAL PROCEDURES IN STRANGULATED INGUINAL HERNIA
92
Taxis, when permissible-Herniotomy—Methods of_Importance of Early Operation-
Operative Details—Illustrative Cases.
CHAPTER X.
107
.
INGUINAL HERNIA (CONTINUED)— TREATMENT OF THE WOUND
Aseptic Conditions—Disposition of the Sac—Methods of Operation-Important Factors of.
CHAPTER XI.
115
FEMORAL HERNIA. SPECIAL ANATOMY OF THE PARTS .
Femoral Region--Anatomy of_Sheath of the Femoral Vessels—Origin of—Causes of Fem-
oral Hernia—Formation of Sac in-Contents of Sac—Location of Stricture—Symp-
toms of.
CHAPTER XII.
OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA
131
Taxis, Directions for-Surgical Procedures-Disposition of the Sac—Methods of Operation
-Closure of the Ring and Canal—Wood's and Author's Methods—Illustrative Cases.
CHAPTER XIII.
HERNIA OF THE FORAMEN OVALE
154
.
Symptoms—Condition-Frequency- Operation for--Cases.
CHAPTER XIV.
163
ISCHIATIC HERNIA
Definition of—Conditions—Camper's, Lawrence's, and Cooper's Cases.
CHAPTER XV.
CÆCAL HERNIA.
. 167
.
Pathological Conditions Peculiar to-Operations, Cases of.
CHAPTER XVI.
HERNIA OF THE OVARY
174
.
Cases of_Pathological Relations in--Surgical Treatment of.

CONTENTS
xiii
CHAPTER XVII.
PAGE
HERNIA OF THE BLADDER
183
Pathology of—Cases of-Complications incident to-Perineal Hernia.
CHAPTER XVIII.
UMBILICAL HERNIA .
190
Congenital and Acquired-Reduction of_History of Operative Measures for-Strangulation
in-Irreducible--Formation of Sac--Radical Cure of--Operations for-Author's Method.
CHAPTER XIX.
VENTRAL HERNIA
207
Causes of_Method of Cure_Cases of.
CHAPTER XX.
212
.
DIAPHRAGMATIC HERNIA .
Anatomical Characteristics—Difficulties of Diagnosis—Dr. Bowditch's Original Studies of -
Treatment-Cases of.
CHAPTER XXI.
COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES FOR THE RELIEF OR CURE OF HERNIA 218
Early recognition-Importance of-Changes in the Omentum-Intestine-Condition of
-Adhesions-Necrosis of Intestine-Resection of—Method of Reunion-Senn's Plates,
by means of-Author's Method of suturing-Briggs's Method of Treatment-Artificial
Anus-Review of Procedures by Various Operators--Illustrative Cases.
-
CHAPTER XXII.
258
EARLY OPERATIVE MEASURES FOR THE CURE OF HERNIA, HISTORY OF
Celsus—Paré, Heister, Petit, Camper, Cooper, Cloquet, Scarpa-Use of the Seton-Injections
for the Cure of-Subcutaneous Wiring-Wood's Operation.
CHAPTER XXIII.
THE ANIMAL SUTURE
282
.
Its History—Its Place in Surgery as a Buried Suture-Mode of Application-Histological
Changes incident to–Catgut, Defects of— Tendon, Advantages of-Kangaroo, Supe-
riority of.
CHAPTER XXIV.
OPERATIVE MEASURES INSTITUTED FOR THE CURE OF HERNIA UNDER MODERN METHODS OF
WOUND-TREATMENT (ANTISEPTIC AND ASEPTIC CONDITIONS) IN EUROPE,
History of.
308

xiv
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
CHAPTER XXV.
PAGE
OPERATIVE MEASURES INSTITUTED FOR THE CURE OF HERNIA UNDER MODERN METHODS OF
344
WOUND-TREATMENT (ANTISEPTIC AND ASEPTIC CONDITIONS) IN AMERICA
History of.
CHAPTER XXVI.
373
CONDITIONS RENDERING SURGICAL PROCEDURES FOR THE CURE OF HERNIA JUSTIFIABLE
Children-Age—Varieties of Hernia—Complications in.
CHAPTER XXVII.
OPERATIVE MEASURES ADVISED
FOR
THE CURE OF HERNIA–THE ADVANTAGES OF
THE
BURIED TENDON SUTURE
387
Factorage of the Problem-Reconstruction of the Obliquity of the Inguinal Canal-Com-
parison of Different Methods—Schede, Macewen, Bassini, and Marcy-Femoral Hernia
-Suturing of the Canal-Statistics showing Safety of Operation-Resultant Cures.

LIST OF ILLUSTRATIONS.
PLATE
PAGE
IO
.
21
66
36
.
.
58
.
I. Muscles, Aponeuroses, Vessels, and Nerves of the Anterior In-
guinal and Femoral Regions
BOURGERY (Frontispiece)
II. Superficial Dissection of the Groin
DARRACH
III. Dissection showing the Anatomy of the Structures involved in
Hernia.
COOPER
15
IV. Transversalis Fascia, Crural Sheath, etc.
DARRACH
18
V. Anterior Parietes of the Trunk
BOURGERY
VI. The Structures of the Inguinal Canal.
25
VII. The Parts concerned in Inguinal Hernia of the Left Side. GUTHRIE
27
VIII. The Parts concerned in Inguinal Hernia of the Right Side
30
IX. The Inguinal Regions of the Female .
BOURGERY (colored) 33
X. Muscles of the Trunk seen on their Posterior Surface
34
XI. Muscles of the Trunk seen on their Posterior Surface, Deeper
Dissection
COOPER
XII. Congenital Hernia
45
XIII. Hernia of the Left Side
SCARPA
50
XIV. Peritoneal Sacs of Different Hernia
COOPER
55
XV. Double Hernia, showing Large Sacs with an Artificial Anus
XVI. Double Hernia, showing one Oblique, one Direct
65
XVII. Double Hernia, same as above, shown from within
69
XVIII. Preparation taken from a Patient showing Internal Orifices of
Six Hernial Sacs
COOPER
70
XIX. Double External Herniæ. Congenital Hernia in a Child . BOURGERY (colored)
XX. Large Hernia, showing Sac and Contents .
SCARPA
XXI. Small Oblique Inguinal and Large Scrotal Hernia
COOPER
XXII. External Inguinal Hernia in the Male (dissected)
BOURGERY (colored)
90
XXIII. Anatomy of an Inguinal Hernia of the Left Side (Dissection
made in 1754)
CAMPER
93
XXIV. External and Inguinal Hernia upon the same Subject
BOURGERY (colored)
XXV. Large Scrotal Hernia, containing Omentum and Intestines.
Vessels well shown
SCARPA
XXVI. Left Inguinal Hernia. Peculiar Development of the Sac, with
Irregular Dispositions of Arteries
XXVII. Double Inguinal Hernia, one direct, one indirect
LANGENBECK
104
XXVIII. Anatomy of the Inguinal, Inferior, Abdominal, and Femoral Re-
gions
BOURGERY (colored) 114
XXIX. Abdominal Rings and Crural Arch in the Female
COOPER
119
XXX. Inguinal Canal and Crural Ring
BLANDIN
XXXI. Femoral Hernia in the Male
LANGENBECK
123
79
87
89
96
99
66
ΙΟΙ
.
I21
(xv)
3

xvi
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
PLATE
PAGE
COOPER
I 24
.
66
66
125
127
129
66
130
BOURGERY (colored) 131
GAY
133
134
135
SCARPA
COOPER
137
140
144
149
CRUVEILHIER
COOPER
66
XXXII. Different Dissections of Femoral Hernia in the Female
XXXIIA.
XXXIII.
in the Male
XXXIIIA.
XXXIV. Anterior and Posterior View of Two Inguinal and Crural Her-
niæ in the same Subject
XXXV. External Hernia in Women
XXXVI. External Femoral Hernia; also shows Parts dissected
XXXVII. Large Femoral Hernia Strangulated; shows Division of Con-
striction
XXXVIII. Large Femoral Hernia dissected to show Constricting Rings .
XXXIX. Strangulated Femoral Hernia, showing Constricted Loop of
Intestine and Vessels
XL. Three Different Views of Femoral Hernia in the Male
XLI. Dissections showing Different Views of Femoral Hernia in the
Female
XLII. Different Views of Preparations made after the Operation for
Crural Hernia
XLIIA. Different Views of Preparations made after the Operation
for Crural Hernia.
XLIII. Hernia of the Foramen Ovale
XLIV.
Two Views. Perineal Hernia
XLV. Internal View of the Ischiatic Hernia
XLVI. Posterior View
XLVII. Hernia of the Bladder
XLVIII.
Umbilicus, Three Views
XLIX. Anterior and Posterior View of a Double Umbilical Hernia
L. Different Views of Diaphragmatic Hernia .
LI. Different Views of Strangulated Hernia
LII. Various Cases of Intestinal Strangulation .
LIII.
in Artificial Anus
LIV. Constriction of the Intestine by a Loop of Omentum
LV. Intestinal Adhesions within the Sac
LVI. External Inguinal Hernia. Internal Inguinal Hernia
LVII. Large Deformed Peritoneal Sacs
LVIIA.
Epigastric Artery divided
LVIII. Varieties of Crural Hernia .
LIX. Transversalis Fascia, Special Dissection of
LX. Infantile Hernia. Infundibular Process of the Peritonæum
LXI. Inguinal Canal, Obliquity of. Transversalis Fascia .
LXII. Spermatic Cord, Arteries, and their Relations
LXIII. Anterior Abdominal Wall, showing the Large Deformed Inter-
nal Rings of a Double Hernia
LXIV. Dissection of the Deeper Parts in Inguinal Hernia. Suturing
of the Posterior Wall of the Canal
LXV. Illustrations showing Method of taking the Double Continu-
ous Buried Tendon Suture.
LXVI. Reconstruction of the Canal and Closure of the Parts in Ingui-
nal Hernia
149
155
158
164
166
189
192
207
216
220
SCARPA
BOURGERY
SCARPA
225
228
BOURGERY
COOPER
244
256
283
331
332
357
371
374
376
391
CLOQUET
.
.
COOPER
393
MARCY
399
401
411

LIST OF ILLUSTRATIONS.
xvii
WOODCUTS.
FIGURE
PAGE
MORTON
23
41
46
85
IIO
1. Connective-tissue Sheath of the Spermatic Cord given off from the Transversalis
Fascia
2. Congenital Hernia. Intestine within the Tunica Vaginalis
3. Infantile Hernia, Dissection of .
4. Deep Dissection of an Oblique Inguinal Hernia. Sac excised at Internal Ring
5. Marcy's Needle for the Application of the Double Continuous Suture
6.
Parallel Buried Suture for Coaptation of the Skin
7. Anatomy of the Femoral Region. Superficial Dissection
8.
Deep Dissection
9. Femoral Vessels and Femoral Canal.
10. The Relations of the Femoral and Internal Abdominal Rings, seen from within
II. Femoral Hernia .
66
II2
GRAY
116
66
117
118
I20
AGNEW
I 2.
MARCY
139
139
172
172
180
RIZZOLI
HOGUE
MARCY
BRIGGS
194
203
203
203
232
233
233
233
234
304
6%
MARCY
.
13. Large Infantile Hernia, Congenital, Two Months before Operation
14.
Two Months after Operation .
15. Hernia Foramen Ovale
16. Umbilical Hernia
17.
18. Umbilical Hernia, Method of Operation
19.
20. Closure of Intestinal Wounds. Method of Suturing
21. Retention Apparatus for retaining Intestine without the Body
22. Intestine held in Position by Pins
23. Intestine sutured ready for the Application of the Membrane to Cover the Wound
24. Intestine sutured and Membrane applied .
25. Photograph of Silk Ligatures extruded from the Bladder, Exact Size
26. Photograph of Child Sixteen Months of Age, before Operation. Large Scrotal
Hernia
27. Transversalis Fascia and Inguinal Rings, seen from within
28. Closure of the Internal Ring restoring Obliquity of Canal. First Stitch taken
29.
Suturing completed
30. The Cord Replaced, and the External Structures Loosely Sutured .
31. Deeper Structures concerned in Inguinal Hernia
32. Superficial Structures concerned in Inguinal Hernia
33. Femoral Hernia. Method of Closure, First Stitch .
34.
Several Stitches
35.
completed
36. Femoral Hernia. Relation of the Suture to Femoral Canal
37. Depression in Abdominal Wall as seen after Ordinary Closure of the Canal in Ingui-
nal Hernia.
381
392
397
398
398
GRAY
MARCY
400
400
405
405
406
406
66
410

PLATE I.*
MUSCLES, APONEUROSES, VESSELS, AND NERVES OF THE ANTERIOR INGUINAL AND
FEMORAL REGIONS.—ADULT.
1. Inguinal Region.
Preparation.—The superficial fascia removed,
the aponeurosis of the great oblique, uncovered,
is cut in the longitudinal diameter of the inguinal
ring so as to show the interior parts,
A. Interior of inguinal ring.
1, 1. Superior segment of the aponeurosis of
the great oblique muscle turned up.
2. Inferior segment of the aponeurosis of the
great oblique turned back upon the thigh.
3. Cremaster muscle likewise turned back
from below.
4. Muscular arch of the transverse and exter-
nal oblique in part dissected from above.
5,5. Especial envelope of the spermatic cord,
the anterior seginent of which has been removed
to show the interior of the canal.
6. Spermatic cord and vessels inclosed in the
fibrous cylinder of their special envelope.
7. Portion of the aponeurosis of the external
oblique preserved so as to close the external in-
guinal ring
8. External inguinal ring, giving exit to the
cord.
9. Internal pillar of the ring.
10. Free subcutaneous portion of the sheath
of the spermatic vessels enveloped by the dartos.
B. Aponeurosis of the external oblique.
C. Inferior extremity of the external oblique
muscle.
D. Portion of integuments and of the subcu-
taneous adipose tissue.
terior face to the vascular sheath, from which it
results that in the physiological sense there is no
femoral canal.
11,11. Fibrous loop formed by the femoral
aponeurosis, and which surrounds the passage of
the internal saphenous vein.
12. Internal saphenous vein.
13. Point where it crosses the aponeurosis so
as to unite with the deep femoral vein. It is this
disposition which necessitates the formation of
the loop of the femoral aponeurosis (11), and the
fibrous layer which covers the vessels.
14, 14. Inguinal lymphatic glands incased in
special sheaths of the aponeuroses.
15. Inguinal abdominal arteries and veins.
F. Internal surface of the thigh covered by
the enveloping femoral aponeurosis.
G. Fibro-cellular sheath of the sartorius mus-
cle.
16, 16. Femoral vessels accompanied with
their nerves and seen through a translucent layer
behind the muscle, which is cut in a diagonal di-
rection.
17, 17. Vessels for the nutrition of the sarto-
rius muscle.
18. Long branch of nerves peculiar to this
muscle.
19. Branch of cutaneous nerves.
H. Muscular partition of the fascia lata with
its vessels and nerves.
I. Muscular partition of the anterior right of
the thigh with its vessels and nerves.
K. Portion of the femoral aponeurosis which
covers the cut superior extremity of the anterior
right.
L. Aponeurotic fascia lata.
M. Portion of the vastus internus.
2. Femoral Region.
E. Aponeurotic layer which covers the femo-
ral vessels in front, the exit of which is shown
upon
the surface. This layer adheres by its pos-
* From Bourgery's Atlas, Paris, 1839.

ANATOMY AND SURGICAL TREATMENT OF
HERNIA.
CHAPTER 1.
GENERAL CONSIDERATIONS ON HERNIA.
THERE can be little excuse among the members of the medical profession for a
lack of interest in the subject which we present for consideration, since no condi-
tion of life, either rank, age, or sex, is exempt from this affliction. On account of
the frequency of its occurrence and the variety of forms it presents, hernia demands
the most minute and careful investigation into its history and treatment. This is
especially true, since impairment of usefulness does not occur so often from any
other anatomical defect as that of hernia ; and when portions of the abdominal vis-
cera protrude, for any reason, through the movable wall that incloses them, the con-
dition becomes at once one of great surgical importance, oftentimes fraught with
the gravest dangers and most serious results.
It is only by a continual zeal of perfecting our knowledge by means of careful
investigations and repeated observations that progress is gained in any department
of science, No disease, perhaps, to which the human race is subject, requires a
more accurate anatomical knowledge and prompt surgical skill than hernia in all
its varieties. The surgeon must be familiar not only with the normal condition of
the structures involved and their relation to each other and the surrounding parts,
but also with the pathological changes and the many complications which accom-
pany them, as well as the various methods of treatment.
Although the anatomy of the human body was most carefully studied and well
known to the surgeons of the earlier time, yet it has been only from the great
number of pathological studies and observations upon the dead body, aided by
microscopical investigations, that we have learned the true relations between the
inguinal ring and the hernial sac, between the sac and the viscera contained in it, as
well as between the coverings of the testicle and the spermatic cord, and thus im-
4

2
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
proved the methods of surgical procedure in hernia. Abdominal hernia is produced
by the protrusion of the viscera contained in the abdomen through the natural or
accidental apertures in the parietes of that cavity. The considerable variety of con-
ditions under which this disease occurs has led to the classification of hernia accord-
ing to the opening through which the abdominal contents have been forced.
I. Inguinal or Suprapubic Hernia.—In this variety of hernia the contents issue
by 'the inguinal canal. When small, especially if concealed by escape into, rather than
through, the parietal wall, it is called bubonocele; when they descend into the scro-
tum, scrotal hernia; if they extend to the labia majora, vulvar or pudendal hernia.
II. Crural or Femoral Hernia.—When the contents protrude through the femoral
canal and penetrate under Poupart's ligament, forming a tumor at the inner and
upper part of the thigh, it is termed femoral or crural hernia.
III. Infra-pubian Hernia.—When the viscera escape through the opening which
gives exit to the infra-pubian vessels at the foramen ovale of the pelvis, it then
takes the name of the aperture, and is termed hernia foraminis ovalis, or obturator.
IV. Ischiatic Hernia.—Sometimes a hernia takes place by the protrusion of the
viscera through the sacro-sciatic notch, projecting by the side of the sciatic nerve,
under the glutei muscles, and then it is called, from the aperture, ischiatic hernia.
V. Umbilical Hernia.—This variety of hernia is formed at or near the insertion
of the umbilical cord.
VI. Epigastric and Hypogastric Hernia.-When the hernia is occasioned by the
protrusion of the viscera above or below the umbilicus in the linea alba, we have
this variety of hernia.
VII. Perineal Hernia.Sometimes the abdominal contents descend between the
bladder and the rectum, or through the levator ani, and appear at the perinæum, con-
stituting a hernia of the perinæum.
VIII. Vaginal Hernia.-If the viscera pass between the uterus and the rectum,
forming a tumor in the parietes of the vagina, it is termed vaginal hernia.
IX. Ventral Hernia.—The term ventral is applied to all those protrusions of
the abdominal contents that pass through openings in the abdominal muscles or
their aponeuroses ; they occur more commonly between the two recti muscles above
the navel, when not the sequence of laparotomy.
X. Diaphragmatic Hernia.—This variety of hernia is not so common, but when
it does occur it protrudes through the diaphragm.

GENERAL CONSIDERATIONS ON HERNIA.
3
Herniæ are likewise named from their contents, as enterocele, epiplocele, etc.
Herniæ are also described as old or recent, reducible or irreducible, incarcerated,
strangulated, etc.
Abdominal herniæ are of frequent occurrence, owing to the mobility and varying
bulk of the viscera, the pressure to which they are subjected in all considerable
efforts and motions of the body, from the muscles which, in great part, surround
and inclose them; and the natural openings from the abdominal cavity greatly
facilitate the origin of such misplacements.
The importance of any given hernia is dependent upon the contents, the pressure
exerted, and especially the impairment of intestinal function, which may indirectly
arise when the intestinal canal itself is not included. When intestinal obstruction
occurs from any cause, life is imperiled, almost in a geometric ratio to its duration
-a fact which can not be too greatly emphasized.
Frequency.—The frequency of hernia is much greater than is usually supposed.
It has been variously estimated by surgeons of great experience in the treatment
of ruptures that from one eighth to one sixteenth of the human race is afflicted with
this complaint.
From the United States census report for 1880, under the head of vital statistics,
we find, out of 756,893 deaths taken at large, one death in every 600 was from
hernia. In 1,286 deaths from hernia, 141 were children less than one year of age.
In the city of Philadelphia alone 450,000 trusses are manufactured yearly.
From the elaborate tables of the late Dr. J. H. Baxter, Surgeon-General, U. S. A.,
we learn that the results of the examination of 334,321 “recruits, substitutes, drafted
and enrolled men of various nativities,” gave hernia as the cause of rejection in 16,901
cases, as seen in the following table :
DISEASE.
Number rejected.
Ratio rejected.
651
317
328
Hernia, kind not specified .
Hernia, umbilical.....
Hernia, ventral..
Hernia, right inguinal.
Hernia, left inguinal....
Hernia, double inguinal.
Hernia, right femoral.
Hernia, left femoral...
Hernia, double femoral...
1,947
0,948
0,981
25,718
16,212
3,488
0,829
0,329
0,102
8,598
5,420
Total for hernia of all kinds.
1,166
277
IIO
34
16,901
50,554

4.
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
CHART I.-HERNIA IN ITS RELATION TO SOCIAL CONDITION, COMPLEXION, AGE, HEIGHT, AND NATIVITY.
Showing the number examined, and the ratio rejected per 1,000 examined.
SOCIAL
CONDITION.
Number Ratio
exainined. rejected.
IO
20
30
40
50
60
70
80
90
Married
Single
159,393 68.748
174,928 33.974
COMPLEXION.
Light
Dark
217,292 52.335
117,029 47.244
AGE.
All Ages
Under 20 years
20 and under 25
25
30
30
35
35
40
40 and over
334,321 50.554
58,952 15.913
78,639 34.576
56,711 50.837
45,777 61.659
50,456 69.902
43,786 91.604
66
)
64
HEIGHT.
All Heights
Under 61 inches
61 and under 63
163
65
65
67
67
69
69
71
71
73
73 and over
66
501,068 44.475
3,747 36.296
20,838 44.006
71,038 40.357
132,087 44.698
144,650 45.897
88,792 44.588
32,313 47.442
7,603 43.404
66
66
NATIVITY.
All Nativities 501,068 44.476
1 Portugal
81 123.457
2 Spain
148 114.865
3 Hungary
89 89,888
4 Mexico
91 87.912
5 Germany 54,944 82.466
6 Italy
339 76.696
7 Switzerland
1,802 68.257
8 Holland
989 65.723
9 France
3,243 65.680
IO Poland
171 64.327
II Denmark
383 62.663
I2 Sweden
1,190 55.463
13 Wales
1,104 52.536
14 Russia
122
15 Norway
2,290 48.045
16 U'd States (White)
315,620 39.814
17 West Indies
380 39.655
18 England
16,196 39.160
19 U'd States (Colored) 25,828 38.292
20 Ireland
50,537 36.389
21 Scotland
3,476
34.234
22 British America 21,645 31.924
23 South America 79 25-316
24 U'd States (Indians) I21 .000
49.180

GENERAL CONSIDERATIONS ON HERNIA.
5
ол
“From this statement it appears that inguinal hernia was the cause of about
eighty-two per centum of all rejections on account of hernia, and that the cases of
right inguinal hernia exceeded in number all the rest. Other tables confirm, in a
most conclusive manner, this latter indication, to wit, that inguinal hernia of the
right side is far more prevalent than that of the left. The cases of umbilical and
ventral hernia were about equal, but inconsiderable in number as compared with right
inguinal.”
CHART 2.--HERNIA IN ITS RELATION TO LOCALITY.
Showing the number examined, and the ratio rejected per 1,000 examined.
5
IO
15
20
25
30
35
40
45
50
STATES.
Number Ratio
examined. rejected.
All States
I Minnesota
2 Vermont
3 Iowa
4 Wisconsin
5 Illinois
6 Missouri
7 Maryland
8 Michigan
9 New York
IO Maine
II Indiana
I2 Dis. of Col.
13 Kentucky
14 Pennsylvania
15 New Hamp.
16 Ohio
17 New Jersey
18 Massachusetts
19 Connecticut
20 Delaware
21 Rhode Island
22 West Virginia
501,003 31.631
6,489 54.246
7,224 43.051
6,846 41.046
21,945 40,283
81,126 38.398
8,576 36.381
16,920 34.043
12,179 33.418
95,576 32.738
20,479 3.1.398
29,279 31.251
6,954 30.917
16,028 29.760
12,686 29.667
10,013 27.964
37,700 27.905
15,388 27.359
36,380 26.883
11,017 26.414
6,361 26.254
4,072 24.804
764 20.942
If we admit that the tables of Dr. Baxter afford any criterion of frequency of her-
nia in the United States, the sum total of the individuals afflicted with hernia is not
less than three million. Since the tables were based upon the examination of about
half a million men within the limit of age to bear arms, a considerable proportion
of the same presenting themselves to be examined for this purpose, it may not be con-
sidered as an excessive proportion of the entire population.
Sex.—Malgaigne estimated the proportion of the whole population of France
which is ruptured to be one out of every thirteen males, and one out of every fifty-two
females ; including both sexes, one in every twenty individuals.

6
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
There have been furnished no requisite data for comparison of the relative frequency
of hernia in the two sexes. Anatomically, the structures favor the liability of hernia in
the male; the more violent exercise and severer labors of the male are also predispos-
ing causes. It is generally conceded that hernia occurs more frequently in the male.
Out of a gross total of 96,886 applications for trusses at the City of London Truss
Society, the males were 78,394, the females 18,492. Several authors give the propor-
tion as about double in the male.
Frequency of Hernia at Different Ages. According to M. Malgaigne, in three
hundred cases examined by himself,
26 occurred between the ages of 10 and 20 years.
45
30
66
40
163
80
This record is, however, to be explained by the statement that the ages are
taken from the entry of the visit of the patient, giving his age then, rather than when
he first knew the disease existed. Mr. John Croft reports a table of 2,401 cases of
hernia, of which 472 were in children under five years of age. Mr. Kingdon, in
the reports of the City of London Truss Society, for the years 1860 and 1861, tabu-
lated 9,296 cases of hernia. Of these, 60.8 per cent commenced before thirty-five
years of age, and 39.2 per cent after that age. Of the whole number, 2,516 were
60
66
20
(6
30
66
40
1860.
1861.
AGE.
Inguinal.
Femoral.
Inguinal.
Femoral.
Kingdon's tables.
Reports of Truss
Society, 1861 to
1862. Age at
development.
M.
F.
M.
F.
M.
F.
M.
F.
.:
27
17
23
19
27
37
26
16
19
I
2
6.
3
4
3
18
873908488
a moooo
1,100
416 * 1,764
248
301
680 S
885
1,053
38
981
14
31
18
1,938
45
21
58
473
181
91
115
284
348
381
334
320
271
258
167
147
97
59
32
Under I year.....
I to 5 years ....
6 to 10 years.
II to 15 years....
16 to 20 years...
21 to 25 years.
26 to 30 years....
31 to 35 years...
36 to 40 years....
41 to 45 years
46 to 50 years.
51 to 55 years....
56 to 60 years
...
61 to 65 years.
66 to 70 years....
71 to 95 years...
Totals...
976
563
192
II2
133
291
375
424
398
373
268
272
224
151
IIO
44
54
33
50
37
41
24
IO
19
18
30
18
16
1,909
55
59
47
32
26
16
31
15
37
54
70
68
49
30
27.
15
I2
3
7
933
731
646
490)
II
15
II
8.
1,377
II
I 2
II
I 2
6
6
846
356
9.
IO
8
4
3
I
II
2
7
5
2561
123 S
379
2 I
I
I
I
3
3
IO2
3,558
346
174
355
3,985
353
132
393
9,296

GENERAL CONSIDERATIONS ON HERNIA.
7
under five years of age. An analysis of the above table from Mr. Kingdon's report
teaches that the percentage of hernia in children is less than would at first seem, and
that, relatively, hernia is more common after thirty-five than before this age.
Occupation.—It is generally admitted that the laboring classes are more liable to
hernia. However, any reliable data are wanting to determine this, since all statistics
from our large public institutions are based entirely upon the application of those
whose needy condition demands, in a measure, a public charity. The wealthier classes
afford no opportunity for statistical knowledge. It is conceded that the general imper-
fect state of muscular strength and the lax condition of the tissues, dependent upon
sedentary habits, render hernia more likely to supervene suddenly upon violent strain.
Under such conditions, it is well known that herniæ are very common, although a
feeling of reticence makes reference to such suffering the exception.
Conditions.—Individuals suffering from hernia generally complain that they are
much more troubled to retain the parts in position when weakened or debilitated by
disease. The tissues are relaxed and less able to sustain strain. It is also commonly
observed that persons deficient in general strength and tone, as age advances, become
more subject to hernia. Another considerable class, in both sexes, after the middle
,
period of life, where a tendency to overweight is marked, producing an increase of
intra-abdominal pressure, become liable to hernia.
From infancy to old age the abdominal cavity must be subject to daily variations
in size and contents. The gaseous and fluid distention of the intestinal canal is often
excessive; the omental and parietal fat frequently increases with great rapidity; and
these conditions, of necessity, cause a constant strain upon the abdominal walls,
which must be elastic, and accommodative to movement. In women, the results of
over-distention from pregnancy, violent muscular effort in parturition, a lack of proper
tone and vigor of the parietal structures, which frequently ensues upon delivery, must
also be considered as causes of hernia, especially umbilical and ventral.
If individuals vary greatly in construction and composition, as to strength and firm-
ness of their tissues, it seems but a natural consequence that such conditions should
have a tendency to be transmitted to their descendants, and, as will be seen later, con-
genital hernia is very common. A constitutional weakness, especially of the parietal
peritonæum and of the mesenteric ligament, has been advanced, even by some of our
prominent authors upon the subject, as a cause of hernia. This is based upon the
assumption that, otherwise, the small intestines could not be dragged down so as to
:

8
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
reach below the rings, or into the scrotum. My own large experience in laparotomy
teaches me that the small intestines are, as a rule, normally quite free to be carried
below any possible escape through the base of the pelvis.
Herniæ have sometimes been classified as external and internal, complete and in-
complete : the former, when the abdominal contents protrude to form a tumor, obvi-
ous upon ordinary inspection; the latter, when some portion of the abdominal viscera
is so displaced as to impair function—as, for example, when the bowel passes through an
opening in the diaphragm, or into some cavity formed by peritoneal folds, or confined
by bands of adhesion. These changes are often attended with very grave dangers,
since they are not easy to define, and may as surely obstruct the intestinal canal as
when the viscera escape through an opening externally.

CHAPTER II.
INGUINAL HERNIA.
ANATOMY OF THE PARTS INVOLVED. .
SINCE every method for the surgical relief or cure of hernia must be dependent
upon an accurate anatomical knowledge of the parts involved, it is necessary to enter
into a careful study and consideration of their structural relations; and as inguinal
hernia is the more frequent variety, it may be well to select this for primal investigation.
In the dissection of an inguinal hernia, it is desirable to have a male subject, since this
variety is more common in men than in women; and when choice can be made, a body
which is rather thin is preferable, if the muscular system is well developed.
Position of the Subject.-In order that the abdominal parietes may be rendered
tense, the knees are bent and the inferior extremities are rotated outward. It is some-
times advantageous to inflate the abdominal cavity through a small punctured wound
in the linea alba. Commence the dissection by an incision which is to be carried
across from the crest of the ileum to the linea alba, where it should terminate a little
below the umbilicus; from this point continue the incision downward on the median
line to the root of and along the dorsum of the penis. The triangular flap thus in-
cluded should extend only through the skin, but should be dissected carefully, be-
ginning at the angle nearest the umbilicus, and detaching it from the subjacent layers
of connective tissue, until opposite the crural arch, or, perhaps better, upon the upper
part of the thigh. This portion of the dissection should be conducted with care, in
order to show well the superficial fascia of the abdominal parietes.
The superficial fascia which is thus exposed, covering the lower part of the abdom-
inal parietes, consists of two distinct layers, between which the superficial vessels and a
few small lymphatic glands are found. The external layer, to which the skin was
attached, consists chiefly of loose-meshed connective tissue, with more or less adipose
material interposed, depending upon the corpulence of the subject. Over the body of
the os pubis it is thicker than elsewhere, and this adipose tissue constitutes in the
female the mons veneris. The external layer of the superficial fascia passes over the
crest of the ileum and Poupart's ligament, to which structures it is only slightly adher-
5

IO
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
ent, and blends with the outer lamella of the superficial fascia of the groin. In a thin
subject, some small arteries and veins are observed distributed in various directions
underneath the external layer of the superficial fascia, the most important of which are
the superficial epigastric artery and vein. The artery is a branch from the common
femoral, arising but a short distance below the crural arch. Through a small opening
in the iliac portion of the fascia lata it ascends about midway between the anterior
superior spinous process of the ileum and the symphysis pubis, in an oblique direction,
upward and inward toward the umbilicus, and gives off branches to the integuments
on either side of its course, some of which anastomose with the branches of the deep,
or internal epigastric artery. The vein takes the same course of the artery from which
it is named and empties into the great saphenous vein.
The external or superficial pubic arteries and veins cross over the spermatic cord,
where it emerges from the external abdominal ring. They are distributed to the in-
teguments of the hypogastric region and to the superficial investments of the cord and
testicle. The external pubic vessels are very tortuous in their course, and care is re-
quired to dissect them without division. A few small lymphatic glands will be found
lying between the two laminæ of the superficial fascia, parallel with and immediately
above Poupart's ligament.
PLATE II.*
1
This plate exhibits, on the left side of the subject, the integuments reflected upon the thigh, to
display the tendon of the external oblique muscle of the abdomen, the fascia lata, and three ad-
ventitious fasciculi of fibers. On the left side a further dissection is made to expose the subjacent
structure.
spinous process of the ilium, and passing under
Left Side.
this sartorial portion of the fascia lata.
A. The reflected dermal and subdermal adi- b, C, b. The portion of the fascia lata which
covers the pectineus muscle; to be called, there-
B, B. The subjacent cellular tissue, called fore, the pectineal portion of the fascia lata.
fascia superficialis, reflected from the fascia lata, 2, 2. The semilunar edge of the pectineal por-
and tendon of the external oblique.
tion of the fascia lata.
C, C, C. The fascia lata.
C, C, C, c. The funnel - shaped portion of the
a, C, a. The portion of the fascia lata which fascia lata, being the external laminæ of the
covers the sartorius muscle, forming the anterior sheath of the crural vein, artery, and nerve; and
part of its sheath: it may, therefore, with pro- called the crural sheath, or the vaginal portion of
priety be called the sartorial portion.
the fascia lata.
1, 1. The outer pair of anterior superficial 3, 3. The branches of the vena saphena at
crural nerves, appearing at the anterior superior its junction with the ensheathed crural vein.
pose tissue.
* W. Darrach, M. D. The Anatomy of the Groin. Philadelphia, 1830.

PLATE II.
D
مر
کے باہر کیا گیا


INGUINAL HERNIA.
ІІ
ANATOMY OF THE PARTS INVOLVED.
4, 4, 4. The cribriform surface of the crural From this origin, as it seems, they first appear on
sheath, called so, on account of the numerous the outside of the tendon of the external oblique,
small perforations made by the entrance of then disappear, and, again issuing as two distinct
absorbent vessels. The fibers of this part of converging fasciculi, pass over the split in the
the sheath interlace with those of the pectineal tendon of the external oblique; from this spot the
portion of the fascia lata, the line of inter- fibers of the two fasciculi diverge, and, proceeding
lacement extending from the semilunar edge downward, they are continued over the reflected
of this portion to within a few lines of the edge of the tendon upon the fascia lata, viz., upon
pubis.
its ligament-like process, 5, 5, 5, and its deeper-
5,5,5. Converging fibers of the sheath, form- seated lamina, d, d. As this fasciculus proceeds
ing a ligament-like process. This process makes from the abdomen, they may be called the two
an attachment to the edge of the pubis, imme- abdominal fasciculi.
diately behind that made by the tendon of the h, h, h. The diverging termination of some of
external oblique muscle. In effecting this hori- the fibers of the tendon of the external oblique,
zontal attachment, the process makes a sigmoid called the upper pillar of the abdominal ring.
twist, in consequence of which a crescent edge is i, i, i. † The termination of other fibers, called
formed extending downward and obliquely out- the lower pillar of the ring.
ward. This edge is called the crescentic edge of k, k. The spermatic cord passing out at the
the fascia lata: to distinguish it from the semi- oval opening, called the abdominal ring. This
lunar edge of the pectineal portion of the fascia opening is made by the two pillars above noticed
lata, it may be termed the crescentic edge of the and the two adventitious fasciculi of fibers.
vaginal portion of the fascia lata.
d, d. A deeper-seated lamina of the fascia
Right Side.
lata. It proceeds from the inner edge of the A. The reflected integuments.
tendon of the external oblique,* and is thence B, B, B. The fascia lata.
continued downward to contribute to the forma- a, a. The external lamina of the fascia lata;
tion of the crural sheath.
divided and reflected to expose the inner lamina
6. A well-defined arched opening for the pas- (or layer) of the crural sheath.
sage of the middle pair of anterior crural nerves, b, b, b. The inner layer of the crural sheath,
figured in the plate.
the upper part of which is exposed on the left
e, e, e. One of the three adventitious fasciculi side of the plate, and noticed under the letters
of fibers above referred to. This fasciculus is evi-
dently derived from the fascia lata; near its C, C. A portion of the sartorius muscle, also
origin, the fibers are twisted into a cord; farther exposed by the reflection, together with the inner
off, they diverge, so as to be scattered on the ex- anterior nerves, and the destination of the middle
ternal and internal surfaces of the tendon of the anterior crural nerves.
external oblique muscle of the abdomen. As this C. The external oblique muscle reflected upon
fasciculus proceeds from the thigh, it may be
the thigh.
called the crural fasciculus.
d, d, d. The portion of the tendon which inter-
D, D, D. The tendon of the external oblique laces its fibers with those of the sartorial portion
muscle of the abdomen.
of the fascia lata. It may properly be called the
g88,888. The other two adventitious fascic- interlaced portion of the tendon of the external
uli of fibers above referred to. They are derived oblique muscle.
from the opposite side of the abdomen, apparently d, e, e, e. The portion of the tendon which is
from the tendon of the internal oblique muscle. reflected inward, and has its fibers inserted ulti-
d, d.
* Called Gimbernat's ligament, or inner edge of the tendon, etc. The fibers of the deeper-seated lamina are
erroneously drawn in a direction from above downward. They have the same general direction as the other fibers
of the fascia lata.
+ The oblique lines below and continuous with those under i, i, i are errors in the drawing. They should not
exist in it.

I 2
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
mately into the pubis in radiating lines. This is the fibrous interlacement over the pubis. It
called the reflected portion of the tendon; the seems to be an insulated portion of the internal
edge made by the reflection is termed Poupart's oblique.
ligament; the inner, or true edge of the tendon, H. Another fasciculus of insulated muscular
is termed Gimbernat's ligament.
fibers belonging to the transversalis rather than
f, f, f. The inner diverging fibers of the crural to any other muscle, and having delicate tendons
fasciculus, noticed on the left side of the place inserted into the pubis.
under e, e, e. They pass in at the arched opening i, i, i. A few delicately formed but strong
marked 6 on the left side, are scattered on the fibers, having an obliquely vertical direction:
inner surface of the tendon, and are united with they embrace the pubal part of the funnel-shaped
other fibers coming from the medium line of the sheath.
abdomen.
k. A small portion of the fascia transversalis
D. The internal oblique.
appearing in the midst of the three above-noticed
8,8,8. The spermatic cord removed from its
parts.
natural situation, covered with its cellular sheath, m. The upper portion of the crural sheath: it
and connected with the cremaster muscle and may be called the abdominal portion, since it is
situated above the lower edge of the tendon of the
F, F. A muscular fasciculus, which is not in- external abdominal muscle; or the transversal
timately connected with either the internal oblique portion, since it is interlaced at its upper edge (or
or transversalis muscles. Its tendon passes into brim) with the fascia transversalis.
nerve.
After having demonstrated the superficial vessels and glands, the deep layer of the
superficial fascia may be dissected. This is best effected by commencing at the angle
nearest to the umbilicus, and, holding the fascia tense, the delicate connective tissue
which unites it to the tendinous aponeurosis of the external oblique muscle is easily
divided. Care is requisite in the dissection about the external abdominal ring that the
thin membrane which passes from the margin of that opening downward may not be
divided. This layer, the external spermatic fascia, may be demonstrated by holding the
cord tense, drawing the testicle obliquely downward toward the opposite side. The
deep layer of the superficial fascia is adherent to the linea alba at the interior surface
of Poupart's ligament, especially its outer portion, where it is united with the fascia lata.
It is attached to the pubic portion of the fascia lata in front of Gimbernat's ligament,
and may be traced below the crural arch, covering the fascia lata of the thigh, and is
closely adherent to the saphenous opening. The two layers of the superficial fascia of
the abdomen are in marked contrast. The external lamella is formed of loose-meshed
connective tissue, which is always more or less loaded with fat. The internal lamella
is, on the contrary, very strong and elastic, and presents a smooth, compact, glistening
appearance, the lower portion of which is developed into a strong, firm, connective-
tissue sheath.
The superficial fascia of the abdominal parietes presents a noteworthy change as it
descends over the spermatic cord to reach the scrotum, where it is free from fatty tis-

INGUINAL HERNIA. ANATOMY OF THE PARTS INVOLVED.
13
sue and assumes a fibrous structure. The vermicular movements and gradual contrac-
tions of the scrotum which occur when these parts are exposed to cold, are dependent
upon the contraction of these fibers. Described under the limitations usually given to
it by the distinctive name of dartos, it is continuous superiorly with the superficial
fascia of the abdomen, inferiorly and posteriorly with the superficial fascia of the peri-
næum; its external surface is closely adherent to the thin skin of the scrotum, and it is
loosely joined, upon its internal aspect, by loose connective tissue, with the fibrous
sheath which invests the spermatic cord and the testicle.
There is prolonged from it an imperfect septum of connective tissue which sepa-
rates the testicles from one another. Fluids pass without much difficulty through this
sheath from one side of the scrotum into the other. It is beneath the dartos, into the
loose connective tissue which joins it to the fibrous sheath of the spermatic cord, that
serous fluid accumulates in the cedema of the scrotum and penis, frequently observed in
certain pathological conditions. Blood in considerable quantity is often extravasated
underneath the dartos in consequence of injury. Urine is frequently effused into this
loose-meshed connective tissue, producing enormous scrotal distention, followed by
most serious consequences unless properly recognized, consequent upon the ruptured
urethra a little anterior to the triangular ligament.
The A poneurosis of the External Oblique Muscle.—The tendinous expansion of
the external oblique muscle, which has been exposed by the foregoing dissection, is now
to be carefully studied. It will be observed, that in the hypogastric and iliac regions
firm bands of connective-tissue fiber replace the muscle, so as to weave its lower border
into a strong tendinous structure. This is so important that I transcribe the excellent
original description by Scarpa : “While a little below the umbilicus, the more particu-
larly about four fingers' breadth from the femoral arch and from the inguinal ring, the
aponeurotic fibers of this muscle are much stronger and thicker than those which are
observed above the umbilicus; and in the dead body, after the integuments are re-
moved, and left for some hours exposed to the open air, the lower portion of the apo-
neurosis of the external oblique appears opaque and dense, while the rest of the apo-
neurosis, in the vicinity of and above the umbilicus, preserves its transparency, and
allows the fleshy fibers of the subjacent abdominal muscles to be seen through it. At
the distance of about an inch and a half from the os pubis this more compact and elas-
tic portion of the aponeurosis of the external oblique divides into two parts; the
supe-
rior is larger than the inferior portion, and is inserted into the margin and upper

14
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
part of the os pubis, where it appears to form an intersection with that of the opposite
side, and to intermix with the ligamentous substance connecting the ossa pubis to-
gether, from which substance the suspensory ligament of the penis derives its origin.
" The other portion of the aponeurosis of the external oblique, the inferior part is
narrower, but more dense and elastic than the upper, runs obliquely from above down-
ward and from behind forward, above the femoral fossa, of which it forms the arch,
and is inserted by a firm tendon into the tubercle and spine of the top of the os pubis,
where it is likewise lost in the ligamentous substance which unites these bones. By
the divergence of these two portions is formed that aperture called the inguinal ring, in
an oblique direction from the side to the pubes; it is more of a triangular than elliptical
form. In the male, the spermatic cord, covered by the cremaster muscle, passes through
it, and in the female the round ligament of the uterus. In general, the aponeurosis of
the external oblique muscle seems to be formed by a series of small bands, disposed in
so many parallel lines, running from above downward and from behind forward, or in
the same direction with the fleshy fibers of the external oblique; from which circum-
stance this aponeurosis has the appearance of a simple web. And this interweaving
is observed in the whole extent of the aponeurosis, except at the place where it begins
to diverge for the formation of the inguinal ring. At this place it has no longer the
appearance of a mere web, but rather of a texture, intersected by several other tendi-
nous bands, crossing in a different direction from the first; the greater part of the latter
are detached from the femoral arch, extend over the top of the inguinal ring, and are
lost in the internal side of that ring. This intersection of the tendinous fibers of the
aponeurosis of the external oblique muscles, has some resemblance to the interweaving
of the tendinous bands which is observed in the aponeurosis of the diaphragm around
the tendinous opening through which the ascending vena cava passes. There can be
no doubt that the aponeurosis of the external oblique muscle, being denser and more
elastic in the lower region of the abdomen than in the upper one, and applied in
the manner of a belt, acquires a still greater degree of density and elasticity in the
vicinity of the lower margin of the abdomen and around the inguinal ring than in
any other place, from the additional covering and intersection of the above-mentioned
tendinous band; studying its function, one would be led to infer that by means of
it Nature, had intended to fix the limits of the inguinal ring, and to oppose the
further divergence of the tendinous pillars laterally. Indeed, no other intersection of
tendinous fibers similar to this, at least so far as regards the number and size of the


PLATE III.
!
e
d
e
c
с
6
n
9
o
P
i
q
k
r.
f
í
S
f
h
h
m

INGUINAL HERNIA. ANATOMY OF THE PARTS INVOLVED.
15
bands, is met with in any other part of the aponeurosis of the external oblique
muscle, nor in the subjacent aponeurosis of the internal oblique and transverse mus-
cles. Winslow thought that the tendinous strips just mentioned, which he called
lateral, do not exist in children; and, following him, some authors have doubted whether
a similar structure can be shown in woman. I can affirm that I have met with it in
children, and in women, whenever I have investigated it carefully.”
Sir Astley Cooper emphasizes the importance of the aponeurosis of this muscle as
follows : “ This tendinous expansion is provided in man to defend him from the acci-
dents to which his erect attitude would naturally subject him. In quadrupeds, to whom
the horizontal position is natural, the weight and pressure of the viscera are diffused
over the whole of the abdominal parietes; but in the human subject, when the abdom-
inal muscles and diaphragm are combining their powerful efforts to fix the ribs, to
enable the muscles of the upper extremities to act to the greatest advantage, the vis-
cera being forced to the lower part of the belly, muscular fiber would prove but a feeble
barrier, and hernia would probably be the inevitable consequence of muscular exer-
tion. This tendon rarely allows an intestine to escape between its fibers ; strength-
ened by an interlacement of texture, it supports the weight of pregnancy and of
dropsical accumulations, resists the pressure arising from excessive obesity and from
muscular contractions, and would altogether have exempted man from the occurrence
of inguinal rupture, were it not for the existence of two openings in it about
to be described.”
a
PLATE III.*
This plate is intended to show the insertions of the external oblique muscles, the formation of the
abdominal rings, and two of the fasciæ which are connected with Poupart's ligament, as well as the
course of the spermatic cord under the edges of the internal oblique and transverse muscles before it
reaches the abdominal ring.
a. Symphysis pubis.
b, b. Anterior and superior spinous process of
the ileum.
C, C. External oblique muscles.
d. Linea alba, extending down to the sym-
physis pubis, and formed by the union of the ten-
dinous fibers of the two oblique and transverse
muscles.
e, e. Linear semilunares, formed by the union
of the tendinous fibers of the external and inter-
nal oblique and transverse muscles.
f, f. The abdominal rings, formed by the sepa-
ration of two columns of tendinous fibers; the
upper inserted at a into each os pubis, the lower
inserted into the pubes at h, after passing behind
the spermatic cord.
g. The origin of some tendinous fibers which
proceed from the anterior spinous process of the
* The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia. Flate I. By Sir Astley Cooper,
London, 1804.

16
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
ileum, and, crossing the columns of tendon, assist ment, which runs upward to the transversalis and
in uniting them above the abdominal ring.
unites itself to the posterior part of the transverse
i, i. Poupart's ligament, or the crural arch, muscle and its tendon, and thus prevents the
which is extended from the anterior spinous pro- bowels from slipping between the lower edge of
cess of the ileum at b, to the pubes at h, receiving the muscle and Poupart's ligament, or between the
the lower column of tendon, which forms a part fibers of the muscle itself. That portion of the
of the abdominal ring, and which passes behind fascia which is placed between the spinous pro-
the cord to be inserted from the spinous process
cess of the ileum at b and the hole r is strong;
to the crest of the pubes.
but that between the hole r and the pubes
k. The fascia lata of the thigh, which is con- is often little more than condensed cellular
tinued from Poupart's ligament, and seen turning membrane, as that part is strengthened by the
in under the femoral vessels near the middle of tendon of the transversalis and by the epigas-
the fore-part of the thigh.
tric artery. A portion of the fascia is fixed in
1 Is the saphæna major vein of the leg going the pubes and another part of it passes behind
through the fascia to enter the femoral vein. Poupart's ligament to unite with the femoral ves-
m. Another part of the same fascia which arises sels.
from Poupart's ligament, and joins with the fascia r. The place at which the spermatic cord goes
lata, which it assists in forming.
into the abdomen. The fascia situated on its outer
n. The tendon of the external oblique muscle side and lower part is of considerable density, but
cut open to show the parts which are situated be- becoming thin upon its inner side, so as to show
hind it.
the epigastric artery and vein behind it; from the
0. The internal oblique muscle ; its lower edge of the fascia a thin layer is sent off which
edge, which arises from Poupart's ligament, is unites itself to the spermatic cord, which fascia in
raised and turned to show the parts behind it. It this dissection has been removed.
is inserted into the pubes behind the upper s. The epigastric artery and vein, situated be-
column of tendon which forms the abdominal hind the fascia transversalis, at first on the inner
ring:
side, and afterward behind the spermatic cord.
p. The transversalis muscle; its lower edge The epigastric artery is shown here by cutting the
also arises from Poupart's ligament, but is here fascia transversalis parallel to it.
raised and turned up. In its natural state it runs t, t. The spermatic cord, nearly two inches of
over the cord to be inserted into the pubes behind which are above and to the outer side of the
the abdominal ring, which it serves as a valve to abdominal ring, and still not in the abdomen;
close posteriorly.
it is also seen below the ring, running to the
9. A fascia, connected with Poupart's liga- testicle.
The External Oblique Muscle.—The external oblique muscle arises from the eight
lower ribs, passes toward the front of the abdomen, and joins in a broad tendon ante-
riorly. This union in a broad aponeurosis extends from the ensiform cartilage to the
pubis, partly on the side from which it originates, and partly on the opposite side; it is
also inserted into the spine of the ileum.
As the fibers of the lower and thicker part proceed obliquely downward and for-
ward, they separate, about an inch and a half from the pubis, into two distinct portions,
which constitute the pillars or columns of the abdominal ring. The upper and inner
of these, which is broader than the other, is attached to the upper edge of the pubis,
near the symphysis; some of its fibers descend and decussate with those of the opposite
side, being fixed to the fibro-cartilage which unites the two bones. The lower and

INGUINAL HERNIA.
17
ANATOMY OF THE PARTS INVOLVED.
outer, which is narrower but at the same time thicker and stronger than the other,
runs obliquely from above downward and from behind forward, to be fixed by a strong
tendon in the spine or tubercle and crest of the pubis.
The portion of the aponeurosis which extends between the anterior spine of
the ileum and the spine of the pubes is a broad band, folded inward, and con-
tinues below with the fascia lata, Poupart's ligament—sometimes called the crural
arch.
The portion reflected backward and inward from Poupart's ligament to the pec-
tineal line is called Gimbernat's ligament. The triangular opening formed by the
two tendinous columns at their insertion is known as the external abdominal ring.
Through this the spermatic cord passes in the male, the round ligament in the female.
The opening is directed obliquely upward and outward, corresponding with the
course of the fibers of the aponeurosis. The crest of the pubis is the base of the
triangle, the two pillars form its sides, the juncture of the pillars the apex, which is
strengthened by connecting fibers, curved from above downward. These crossing, inter-
lacing fibers are sometimes particularly strong in old herniæ, and are better developed
in men than in women. Although this opening is called a ring, it is not a ring unless
dilated by a hernia. In its longest diameter it measures about one inch; from one
tendon to the other only about half an inch. The center of the opening is about one
inch and a quarter from the symphysis. A very delicate fascia originates from the
tendon of the external oblique at the upper margin of the ring, passing over it and
uniting with the spermatic cord, which it accompanies in its descent into the scrotum,
and to which it is closely adherent. There is frequently considerable variation, as might
be supposed, in the exact relationship of the parts. The distance of the ring from the
symphysis pubis is oftentimes much less than an inch and a half; and it has been
observed so far from the median line as to be situated almost opposite the anterior
superior spinous process of the ileum. Occasionally another opening is to be found
through the tendon which is situated above and to the inner side of that which
forms the external abdominal ring, and through it the fleshy fibers of the internal
oblique muscle may be clearly distinguished, as they are only covered by some of the
fibers of the intercolumnar fascia.
The Internal Oblique Muscle.—The internal oblique muscle arises from the outer
half of Poupart's ligament, the crest of the ileum, and the lumbar fascia. The lower
edge of this muscle passes over the spermatic cord and blends with the transversalis
6

18
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
to form the conjoined tendon of these muscles. It is inserted into the six lower
ribs, ensiform cartilage, and linea alba. The conjoined tendon of the internal oblique
and transversalis muscles is inserted into the crest of the os pubis and pectineal line
immediately behind the external abdominal ring, and serves to protect what otherwise
would be a weak point in the abdominal wall. Sometimes the pressure is so great
a
from within upon this tendon that it fails as a support, and is carried in front of
the hernial sac, through the external ring, and then forms one of the coverings of
direct inguinal hernia.
At the linea semilunaris the tendon of the internal oblique muscle divides into
two layers, one of which passes in front of, and the other behind, the rectus muscle,
reuniting at its internal edge, where it enters into the composition of the linea alba.
In this manner the sheath of the rectus muscle is constituted. This division of the
tendon, however, can be traced only from the ensiform cartilage to about midway
between the umbilicus and the symphysis pubis. Below this point the whole of the
tendon passes in front of the rectus, leaving that muscle separated from the perito-
næum only by the fascia transversalis and subserous connective tissue. The tendinous
aponeuroses of the muscles of each side are united with one another throughout the
entire extent of the linea alba.
The portion of the internal oblique muscle which arises from the outer part of
Poupart's ligament merits especial description. These fibers pass obliquely downward
and inward nearly on a line with Poupart's ligament, and end in a tendinous aponeu-
rosis opposite the outer border of the lower part of the rectus muscle. Some of the
most inferior of these fibers are very much curved as they pass over the spermatic
cord, in the upper part of the inguinal canal, and, becoming tendinous, descend behind
the cord, where it is contained in the lower part of the canal and the external ab-
dominal ring, to be finally inserted along the similar fibers of the transversalis mus-
cle, into that portion of the pectineal line of the os pubis which is situated behind
the ligament of Gimbernat.
PLATE IV.*
This plate exhibits, on the right side, the fascia transversalis, the crural sheath, and the mode
of their connection with each other; and, on the left side, the ligament-like process of the fascia
lata, showing its manner of attachment to the pubis, and the seat of crural hernia.
* W. Darrach, M. D. The Anatomy of the Groin. Philadelphia, 1830.

PLATE IV.
G
E
B
d
8
Irth, duc des entit


INGUINAL HERNIA. 19
.
ANATOMY OF THE PARTS INVOLVED.
Right Side.
A. The reflected integuments of the abdomen
and thigh.
B. The reflected fascia superficialis.
C. The reflected external oblique muscle of
the abdomen.
a, a. The lower portion of its tendon, divided
in order to show that all its fibers are inserted into
the pubis more outwardly than has been generally
believed, and that none of them, therefore, can
possibly contribute to form the seat of crural
hernia.
D. The internal oblique muscle of the abdo-
men.
b, b. A section of the muscular fasciculus which
sends its tendon into the suprapubal fibrous inter-
lacement. Some of the fibers of this tendon seem
to be continued through this interlacement, and
to become the abdominal fasciculi, figured under
888,888, in Plate II.
,
E. The transversalis muscle of the abdomen.
C, c. Some muscular fibers, originating at the
place of exit of the cord, and inserted into the
pubis by long, tendinous threads. These fibers are
represented in Plate II under the letter H.
F. The cremaster muscle, detached from the
spermatic cord, and reflected upon the thigh, origi-
nating from the fascia lata, within the interlace-
ment of this fascia with the tendon of the external
oblique and outside the fascia transversalis, sepa-
rated from the transversalis muscle by the circum-
flex iliac artery.
d, d, d. The fascia transversalis, showing the
oblique and longitudinal direction of its fibers;
their interlacement with the upper edge of the
crural sheath on each side of the spermatic cord,
and the place of exit of the circumflex iliac artery.
e, e, e. The conical part of the cellular sheath
of the spermatic cord. It is continuous with the
cellular tissue found between the fascia transver-
salis and the peritonæum. At the under part of it,
two curved lines are exhibited, formed by the vas
deferens and the epigastric artery, which last is
traced by a dotted line.
cellular sheath of the spermatic cord, is called the
internal abdominal ring. It is an aperture pre-
senting three strong fibrous edges, two of which
are longitudinal, made by the fascia transversalis,
and one horizontal, made by the crural sheath.
Through this deep-seated triangular opening the
bowel, covered by the peritonæum, passes from the
abdominal cavity into the cellular sheath of the
spermatic cord, to become an inguinal hernia. By
it also, in some instances, the bowel is strangu-
lated.
g, g,g. The crural sheath below the tendon of
the external oblique.
h, h. Absorbent glands with their vessels,
which pass into the pelvic cavity through an
opening in the crural sheath.
i. An incipient ventro-inguinal hernia found
in one of the dissections.
f, f, f, f. The abdominal or transversalis por-
tion of the crural sheath, showing its connection
with the fascia transversalis by means of a strong
interlacement.
The space bounded by the margin of the
sheath and the edges of the two portions of the
fascia transversalis, on each side of the conical
Left Side.
A. The reflected integuments.
B. The reflected fascia superficialis.
C. The sartorial portion of the fascia lata.
D. The vaginal portion of the fascia lata.
a, a. A superficial layer of fibers, dissected
from this portion to show the line of separation
between the sheath of the crural vessels and that
of the sartorius muscle.
6, b. Branches of the vena saphena entering
the ensheathed crural vein by a common trunk.
d, d, d. The crescentic edge of the vaginal por-
tion, or crural sheath.
d, d, u. The ligament-like process of the vagi-
nal portion of the fascia lata, the true seat of
stricture in crural hernia. (See Plate II, 5,5,5,
and the description.)
E. The pectineal portion of the fascia lata.
c, c. The semilunar edge of the pectineal por-
tion.
e, e, e. The deep fissure between the pectineal
and the vaginal portion of the fascia lata.
8,8,i,i. Divided and displaced portions of the
tendon of the external oblique, showing, first, that
the portion i, i is interlaced with the fascia lata
(see d, d, d, in the description of Plate II); second,
that the portion g, g is more outwardly inserted
into the pubis than the ligament-like process of the
fascia lata, thereby demonstrating again that no
part of the tendon of the external abdominal muscle
contributes in any degree to form a seat of stricture in
crural hernia.
k, k, k. The abdominal or transversalis portion
a

20
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
>
of the crural sheath, showing its origin from the
iliac portion of the fascia lata.
m, m. A portion of the fascia transversalis, ex-
hibiting its connection with the part k, k, k of the
crural sheath, and its change into cellular membrane
as it ascends upon the abdomen.
n, n, n. The spermatic cord.
G, G, G. The peritoneal sac.
pp. The distended bladder.
r, r, r. The brim of the pelvis.
s, t. The crural vein and artery, with their
principal branches situated behind the fascia trans-
versalis, and dipping into the crural sheath.
The space bounded by the crural veins, the
brim of the pelvis, r, r, r, and the ligament-like
process of the fascia lata, d, d, u, is a small conical
or thimble-like cavity, into which the end of the
little finger may be thrust. This will be hereafter
named the ventro-crural passage. Through it the
bowel passes in crural hernia.
The Cremaster Muscle.—The principal fibers of the cremaster muscle arise from
the middle portion of Poupart's ligament, between the internal oblique and transver-
salis muscles, and from this point extend nearly to the external abdominal ring. On
the outside of the ring the cremaster muscle spreads its fleshy serpentine fibers in vari-
ous directions, until they all terminate in a tendino-membranous aponeurosis, which,
in the manner of a sheath, includes within it the spermatic cord with the cellular sub-
stance surrounding it, along with the vaginal coat of the testicle. The distinguished
anatomist and surgeon, M. Jules Cloquet, devoted especial attention to the mode of
formation of the cremaster muscle, and formed the opinion, after many dissections,
that the cremaster does not exist in the foetus before the descent of the testicle
into the scrotum; but that it is produced by the gubernaculum testis and testis
itself contracting adhesions, as they descend through the inguinal canal into the scro-
tum, to the middle portion of the muscular fibers forming the lower edge of the in-
ternal oblique muscle, and that, by thus dragging these fibers along with them in
their descent, a series of inverted loops are formed by the gradual displacement and
elongation of their intermediate and more movable portion.*
The cremaster branch of the epigastric artery furnishes the blood-supply to the
muscle, and the principal division of the external spermatic nerve is distributed to
its fibers. This muscle is generally wanting in the female, yet the lower fibers of
the internal oblique muscle are, in some instances, loosely distributed over the round
ligament of the uterus, where it lies in the lower part of the inguinal canal. Clo-
quet observed that oftentimes an oblique inguinal hernia is formed in the female.
The anterior surface of the hernial sac derives a partial investment from the inferior
fibers of the internal oblique, which are displaced and dragged downward by the sac,
* Vide Récherches anatomiques sur les Hernies de l’Abdomen, par Jules Cloquet, 4to, Paris, 1817, p. 15.


21
26
14
23
21
25
24
PLATE V.
1
13
15
A
29
5
16
17
13
8
19
310
B
20
12
17
27
28
29

INGUINAL HERNIA.
21
ANATOMY OF THE PARTS INVOLVED.
as the hernia is gradually protruded through the inguinal canal, very closely imitat-
ing the mode of formation of the cremaster muscle by the descent of the testis in
the male. Some individuals are possessed of a considerable voluntary power over
the contractions of the cremaster muscle, and are enabled to retract the testes as high
as the external abdominal ring, and in some instances even to withdraw them into
the lower part of the inguinal canal.
The Transversalis Muscle.—The transversalis muscle, in its lower portion, arises
from the outer third of Poupart's ligament and the crest of the ileum, and is inserted
into the linea alba. The lower fibers curve downward, and are inserted, together
with those of the internal oblique muscle, into the crest of the os pubis and pectineal
line, forming the conjoined tendon already described. The triangular ligament is a
band of tendinous fibers, which is continued from Poupart's ligament at its attach-
ment to the pectineal line upward and inward, beneath the inner pillar of the external
ring, to the linea alba.
PLATE V *
ANTERIOR PARIETES OF THE TRUNK.—ADULT.-NATURAL SIZE,
Right side of the subject; great oblique and femoral aponeurosis. Left side; small oblique and
superior part of the muscles of the thigh.
A, A. Anterior and superior ridges of the 9, 9. Oblique fibers, arising from Poupart's
iliac bones.
ligament, which, crossing the direction of the apo-
neurosis, close above the opening of the ring,
Right Side.
and, together, bind its two pillars.
B. Ridge of the pubis.
10. Superficial layer of the fascia-lata apo-
1. Inferior muscular fibers of the great oblique. neurosis, in front of the crural canal.
2, 2, 2. Aponeurosis of the same muscle.
11. Falciform fold of the aponeurosis, form-
3, 3. Section of the aponeurosis of the linea ing the free edge of the inferior orifice of the
alba.
same canal.
4, 4. Ligamentous small bands for strength- 12. Section of the saphenous vein which
ening, which form at their extremity the pillars passes through this orifice.
of the inguinal ring.
5, 5. Folds of the aponeurosis, or Poupart's
Left Side.
ligament.
From 13 to 13. Inferior muscular fibers of
6. External pillar of the inguinal canal. the internal oblique muscle.
7. Its internal pillar intercrossed upon
the 14. Arcade, formed above the cord of the
pubis with that of the opposite side. Deeper, spermatic vessels, by the last fibers, of which
there is a vascular aponeurotic slit.
some detach themselves in order to concur to the
8. Opening of the inguinal ring.
formation of the cremaster muscle.
* Bourgery, Plate LXIX.

22
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
15. Aponeurosis of the small oblique muscle.
16, 16. Gutter of Poupart's ligament.
17, 17. Aponeurosis of the great oblique in-
verted.
18. External pillar.
19. Superior attachment of Poupart's ligament,
or internal inguinal ligament.
20. Internal pillar. Between the two pillars,
the opening of the internal ring, crossed by the sper-
matic vessels, is seen. Above the internal pillar is
the aponeurotic slit indicated on the other side.
21. Sartorius muscle.
22. Fascia lata.
23. Anterior left of the thigh.
24. Bundle of the psoas and iliaca.
25. Pectineus.
26. First abductor.
27. Penis.
28. Cord of the spermatic vessels.
29. (Right side). Fascia-lata aponeurosis, un-
der the insertion of the same name.
The Transversalis Fascia.—The transversalis fascia covers the space between the
lower border of this muscle and Poupart's ligament. This fascia lies between the
transversalis muscle and the peritonæum. It is a part of the fascia which lines the
interior of the abdominal and pelvic cavities, with which it is directly continuous.
In the inguinal region this fascia is thick and dense, and is attached externally to
the femoral vessels and to the posterior margin of Poupart's ligament. It also forms
the anterior wall of the crural sheath of the vessels as they descend into the thigh.
Since the transversalis fascia was first pointed out by Sir Astley Cooper as ex-
ercising a most important physiological function, the value of which is greatly empha-
sized in its relation to the cure of hernia, by the restoration of the obliquity of the
inguinal canal, the original description of it by Mr. Cooper is of sufficient interest
to transcribe: “ When the lower portions of the internal oblique and transversalis
muscles are raised from their subjacent attachments, a layer of fascia is found to be
interposed between them and the peritonæum, through which the spermatic vessels
emerge from the abdomen. This fascia, which I have ventured to name fascia trans-
versalis, varies in density, being strong and unyielding toward the ileum, but weak
and more cellular toward the pubes. Midway between the spine of the ileum and
pubes, the opening will be seen which is now generally known as the internal ab-
dominal ring; the edges of it are indistinct, on account of its cellular connections
with the cord; when these are separated, the fascia in which it is formed will be
found to consist of two portions; the outer strong layer, connected to Poupart's
ligament, winds in a semilunar form around the outer side of the cord, and bounds
the aperture by a distinct margin, from which a thin process may be traced passing
down upon the cord. The inner portion, which is found behind the cord, is attached
to, but less strongly connected with, the inner half of the crural arch, and may be
readily separated from it by passing the handle of a knife between it and the arch.

INGUINAL HERNIA. ANATOMY OF THE PARTS INVOLVED.
23
It ascends behind the tendon of the transversalis, with which it is intimately blended,
passes around the inner side of the cord, and joins with the outer portion of the
fascia above the cord, being at length firmly fixed in the pubes; the inner margin
a
g
g
7
W2
C
b
Gyn. Staff Room University Hospital.
e
"
Fig. 1.—The woodcut represents the funnel-shaped sheath of the fascia transversalis laid open upon its front aspect,
so as to show the manner in which it incloses the structures which constitute by their union the spermatic cord:
a. The rectus abdominis muscle of the left side dissected. b. The pyramidalis muscle. C, C. The tendinous
aponeurosis of the external oblique muscle, dissected from its attachments, and reflected downward upon the
upper part of the thigh. d. The internal and superior pillar of the external abdominal ring, cut from its connec-
tions with the body of the os pubis, and reflected downward with the rest of the aponeurosis of the external obli
muscle, of which it forms a part. e. The corresponding portion of the internal and superior pillar of the external
abdominal ring, occupying its natural position in front of the body of the os pubis. f. The outer border of the
tendon of the rectus muscle, where it is continuous with the inner or pubic portion of the fascia transversalis (g).
g,g,g. The fascia transversalis, where it lines the inguinal region. h. The fascia transversalis blended with the
posterior edge of Poupart's ligament, so as to form with it the floor of the inguinal canal. The fibers of the
internal oblique and transversalis muscles have been dissected from their attachments to the iliac portion of the
crural arch and wholly removed. i. The funnel-shaped sheath of the fascia transversalis, laid open in front to
display the component structures of the spermatic cord, which it incloses. k. The funnel-shaped sheath of the
fascia transversalis, where it invests the spermatic cord, between the external abdominal ring and the testis; behind
this portion of the cord are observed some oblique fibers, which constitute the triangular ligament of the inguinal
canal. l. A portion of the great sac of the peritoneum. m. A tubular process of the peritonæum, which is fre-
quently to be found as a fibro-cellular band in front of the rest of the structures composing the spermatic cord;
it consists of the obliterated portion of the original processus vaginalis peritonæi. n. The epigastric artery, as it
passes deeply into the subserous cellular tissue, betwixt the fascia transversalis and the peritonæum, and along
the pubal side of the internal abdominal ring. 0. Dotted lines, which serve to indicate the course of the epigas-
tric artery, as it ascends in an oblique direction behind the fascia transversalis in its way toward the umbilicus.
p. The spermatic veins. 9. The spermatic artery. r. The vas deferens. s. The triangular ligament of the
inguinal canal.
of the ring is less defined than the outer, the fascia transversalis being doubled in-
ward toward the peritonæum, to which it is firmly attached. Thus, then, it appears
that the internal ring is not a circumscribed aperture like the external abdominal

24
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
ring, but is formed by the separation of two portions of fasciæ, which have different
attachments and distributions at the crural arch; the outer portion terminating in
Poupart's ligament, while the inner portion will be found to descend behind it, to
form the anterior part of the sheath that envelops the femoral vessels. The strength
of this fascia varies in different subjects ; but in all cases of inguinal hernia it
acquires considerable strength and thickness, especially in its inner edge; and if these
parts had been formed without such a provision, the bowels would, in the erect
posture, be always capable of passing under the edge of the transversalis muscle, and
no person would be free from inguinal hernia. The fascia transversalis may be traced
as high as the diaphragm ; and on the inner side it passes behind the rectus muscle,
where it begins to assume the character of cellular tissue.”
These observations of Sir Astley Cooper were confirmed by Hesselbach, who pub-
lished his studies upon the subject in 1806, only two years after the appearance of
Mr. Cooper's work, and very likely were made as original studies entirely independent
of the views of this master. Scarpa and Cloquet, somewhat later, demonstrated the
conditions described by Mr. Cooper, and emphasized their important physiological
value. Reference is frequently made to this fascia by subsequent writers, naming
it after Mr. Cooper.
The funnel-shaped sheath of the fascia transversalis, as it descends downward
upon the cord, is very clearly shown in the accompanying woodcut from one of
Morton's dissections. (Fig. 1.)
The Conjoined Tendons of the Internal Oblique and Transversalis Muscles.—The
lower border of the transversalis and the internal oblique muscles blend in an inter-
woven connective-tissue sheath, called the conjoined tendon. This connection is so
intimate that it is absolutely impossible to separate it, and is very properly considered
as one of the most important factors in the anatomical study of hernia, and is
worthy of minute description. These tendons are in part situated in front of the
pyramidalis and lower portion of the rectus muscle, being inserted into the linea
alba and crista of the os pubis. The inferior fibers are somewhat spirally reflected
downward and outward, to be inserted behind the ligament of Gimbernat, into the
inner part of the ileo-pectineal line of the os pubis, passing behind the spermatic
cord, as it lies in the lower part of the inguinal canal. This distribution of the con-
joined tendinous fibers closes up a considerable portion of the space which is included
between the epigastric artery and the outer edge of the rectus muscle, thus consti-


A
35
18
34
27
33
22
30
1
32
31
PLATE VI.
20
1
A
A
14
23
19
21
15
22
27
25
26
26
12
16
36

INGUINAL HERNIA. ANATOMY OF THE PARTS INVOLVED.
25
tuting a principal part of the posterior wall of the inguinal canal. This distribution
of these fibers aids materially in the formation of the obliquity of the canal, which
is an important factor of surgical consideration, to be noticed further in the surgical
measures for the restoration of the oblique direction of the inguinal canal, so im-
portant to maintain for the permanent cure of hernia.
19. Right Side.—Extremity of the fibers of
the little oblique inverted within, to let the apo-
neurosis of the transversalis be seen.
20. Idem.--Transversalis muscle.
21. Idem.-Last ties of this muscle in the gut-
ter of Poupart's ligament.
22, 22. Summit of the arcade which it forms
above the internal orifice of the inguinal canal.
23. Aponeurosis of the transversal.
24. Inferior tie of the pubis. It is the same
aponeurosis which is seen through the orifice of
the left inguinal ring.
25, 25. Of the Two Sides.-Thick edge of the
fascia transversalis which limits the superior ori-
fice of the inguinal canal outside, and then unites
itself with the gutter of Poupart's ligament.
26, 26. Idem.-Very fine portion of the same
fascia, which forms the internal edge of the ori-
fice. Behind a fibro-cellulous sheet are seen the
epigastric vessels which ascend parallel to the in-
ternal edge.
26, 27. Idem.-Ellipsoidal internal orifice of
the inguinal canal.
28. Right Side.-Superficial aponeurotic sheath,
applied upon the crural vessels.
29. Idem.—Section of the internal saphenous
vein, which crosses the femoral aponeurosis (in-
ferior crural ring), in order to join the femoral
vein.
30. Left Side.—Sartorius muscle.
31. Idem.-Fascia lata.
-
-
PLATE VI.*
ANTERIOR PARIETES OF THE TRUNK.--STUDY OF THE INGUINAL CANAL.
A, A. Anterior and superior spinous process
of the ilium.
B, B. Tuberosites of the pubes.
Left Side.
1. Inferior extremity of the great oblique.
2, 2. Its aponeurosis.
3, 3. Shreds of the aponeurosis, inverted to
show the interior of the inguinal canal.
5. Origin of Poupart's ligament.
6. Cut of the small bands, from whence the
internal pillar proceeds.
7. External pillar, implanted upon the spine
of the pubis.
8. Small band, whence the internal pillar
proceeds.
9. Internal pillar. Between the two pillars is
the inguinal ring.
10. Internal inguinal ligament.
11. Extremity of the internal pillar of the
right side.
12. First band of insertion to the pubis, sepa-
rated from the internal pillar by the arcade of
passage to the ilio-scrotal nerve.
13. Extremity of the aponeurosis which closes
the ring preserved in the form of a stay.
Right Side.
14. Origin of Poupart's ligament in the spinal
process of the ilium.
15. Aponeurosis, thrown back upon the thigh.
16. Its tie, forming the external pillar.
17, 17. Aponeurosis of the little oblique, in
front of the great right.
18. Left Side.-Last ties of this muscle in the
gutter of Poupart's ligament. The arcade which
it forms is raised up by a hook to let the trans-
versal be seen.
32. Idem.-Reflected mass of the psoas and
iliaca.
33. Idem.- Pectineus.
34. Idem.-Anterior right.
35. Idem.--First abductor.
36. Idem.-Penis.
* Bourgery, Plate LXX.
7

26
ANATOMY AND SURGICAL TREATMENT OF HERNIA,
(6
Mr. Morton * demonstrates very clearly the mode in which the conjoined tendons
of the internal oblique and transversalis muscles form the lower part of the pos-
terior wall of the inguinal canal, in the following manner : “Let the tendinous apo-
neurosis of the external oblique muscle be reflected, together with the spermatic cord,
upon the upper part of the thigh, so that the whole of the triangular space which
is included between the epigastric artery and the lower portion of the rectus muscle
shall lie fairly exposed to view. The index-finger of the left hand may now be placed
upon this space, a little above and parallel with Poupart's ligament, while with the
other hand traction is made alternately upon the lower fleshy fibers of the internal
oblique and transversalis muscles, which for this purpose should be separately detached
from their respective connections to the crista of the ileum and ligament of Poupart.
When these instructions are observed, the finger which rests upon the posterior
wall of the inguinal canal will be elevated, at every movement of the muscular fibers
held in the right hand, by the tension of tendinous fibers belonging to each muscle.
It will be perceived, at the same time, that the tendinous fibers belonging to the
transversalis muscle are more curved in their direction, and extend farther outward
from the border of the rectus than those appertaining to the internal oblique muscle."
The development and disposition of the fibers of the conjoined tendon are sub-
ject to considerable variation. Indeed, it is sometimes difficult to demonstrate their
presence in that portion of the posterior wall of the canal which they ordinarily
greatly strengthen and support. However, in such instances compensation is usually
found in the fascia transversalis, which has developed to a greater extent than ordi-
narily. It will be observed that the conjoined tendons, being thus located behind
the external abdominal ring, form the chief obstacle to the direct protrusion of the
viscera through this part of the posterior wall of the canal, forming, as it were, a but-
tress which tends to prevent the development of a direct or internal inguinal hernia.
The Internal Abdominal Ring.—The circumscribed space beneath the lower mar-
gin of the transversalis muscle was named by Sir Astley Cooper the internal abdomi-
nal ring. It is situated in the fibrous membrane of the transversalis fascia, already
fully described in the quotation from Mr. Cooper. It penetrates the transverse fascia
midway between the anterior superior spine of the ileum and the spine of the pubis,
and about half an inch above Poupart's ligament. It is oval in shape, and varies in
* Surgical Anatomy of Inguinal Herniæ.
Thomas Morton, London, 1841.


PLATE VII.
21

INGUINAL HERNIA.
27
ANATOMY OF THE PARTS INVOLVED.
size in different individuals, being much larger in the male than in the female. It is
limited above by the arching fibers of the transversalis, and internally by the epigas-
tric vessels. About its circumference, a thin, funnel-shaped membrane is formed from
the transversalis fascia, which is continued around the cord and testes and incloses them
in a distinct sheath.
In an oblique inguinal hernia this fascia forms one of the coverings of the sac.
This fascia is loosely connected with the peritoneum, and in fleshy persons a layer
of fat is here often found.
PLATE VII.*
THE PARTS CONCERNED IN INGUINAL HERNIA ON THE LEFT SIDE.
1, 1, 1. Integument.
up to the pubes. The fibers marked 6 are all mus-
2. Fascia superficialis.
cular; in some instances they are tendinous and
3. External oblique muscle.
aponeurotic; in others they are either wanting or
3 a. Its aponeurosis turned down on the so indistinct as scarcely to be distinguished from
thigh.
the fascia transversalis.
3b. Poupart's ligament.
7. The cremaster muscle given off from the
36. The insertion of the external oblique into internal oblique, and partly from the transversalis
the os pubis.
muscles seen lying upon the cord at 7 and passing
4 a. The internal oblique muscle passing under it from 7 to 8.
across the abdomen to assist in forming the 8. The portion of the cremaster usually con-
sheath of the rectus.
sidered as a second origin, but which is in fact its
46. A portion or slip of this muscle sepa- insertion after its fibers have proceeded the whole
rated from its attachment, and hanging down out- length of the spermatic cord and testis, forming in
side the spermatic cord.
this way a sling partly muscular, partly tendinous,
5. The superior fibers of the transversalis whereby it may be drawn up toward the abdomen.
muscle passing above the cord to their insertion 9. The rectus muscle, its sheath having been
into the pubis.
turned up.
6. The inferior fibers of the transversalis mus- 10. The pyramidalis muscle.
cle passing below the cord, forming the lower 11. The spermatic cord.
edge of the internal or superior opening of the in- 12. The cremaster artery, a branch of the
guinal canal, and inserted into Poupart's ligament epigastric.
The Inguinal Canal.—This name has been given to the oblique passage in the
iliac region of the abdominal parietes, through which in the male the spermatic cord,
and in the female the round ligament of the uterus, descend from the interior of the
abdomen to reach the structures with which they are connected externally. It is
about an inch and a half in length, and extends obliquely downward and outward,
parallel with and a little above Poupart's ligament. Through the internal abdominal
ring it communicates with the abdominal cavity, and terminates below at the ex-
* Guthrie, G. J., F.R.S., London, 1833, Plate I.

28
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
ternal ring. In its entire length it is limited, in front, by the aponeurosis of the
external oblique; in the outer third, by the internal oblique; behind, by the conjoined
tendon of the internal oblique and transversalis muscles, the triangular ligament, and
the transversalis fascia; below, by the union of this fascia to Poupart's ligament.
Oblique inguinal hernia always follows the line of this canal.
In the developmental processes of intra-uterine life, it is usually accepted that the
gubernaculum testis, contracting, carries with it the testicle, the portion of the perito-
næum which is to form the tunica-vaginalis, and the lower fibers of the obliquus internus
which constitute the cremaster.
Between the fifth and sixth months of intra-uterine life the gubernaculum testis
attains its development. It completely fills the inguinal canal, and lies behind the peri-
tonæum, anterior to the psoas muscle. According to Mr. Curling, the gubernaculum
divides below into three processes: the external and broadest is connected with Pou-
part's ligament in the inguinal canal; the middle process descends along the inguinal
ring to the bottom of the scrotum, where it joins the dartos ; the internal one is firmly
attached to the os pubis and sheath of the rectus muscle; some fibers are also reflected
from the internal oblique muscle on to the front of the gubernaculum. About the
sixth month the testis descends to the iliac fossa and the gubernaculum is shortened.
During the seventh month the testis enters the internal abdominal ring, carrying before
it a pouch of the peritonæum, the processus vaginalis. During the last month of preg-
nancy the testis descends into the scrotum, and the lengthened pouch of the perito-
næum is still open, communicating with the peritoneal cavity.
Usually, at birth, the upper front of this pouch has become closed, and the oblitera-
tion extends gradually downward to within a short distance of the testis. This remains
through life as a closed serous sac, the tunica vaginalis, which invests the outer surface
of the testis and epididymis, and is reflected over the inner surface of the scrotum.
During the descent of the testis the muscular fibers of the gubernaculum are gradually
everted, forming a muscular layer, which becomes placed external to the process of the
peritonæum, surrounding the gland and spermatic cord, and constitutes the cremaster,
In the female, a small cord, corresponding to the gubernaculum in the male,
descends to the inguinal region and ultimately forms the round ligament of the
uterus. A pouch of peritoneum accompanies it along the inguinal canal, analogous
to the processus vaginalis in the male, and this is called the canal of Nuck.
In the majority of new-born infants some portion of the unclosed canal still remains.
a

INGUINAL HERNIA. ANATOMY OF THE PARTS INVOLVED.
29
a
“In twenty-one cases, Seiler found four in which it was open on both sides, five in
which it was open on the right side, and four on the left. In fifty-three new-born
infants, Camper found twenty-three open on both sides, eleven on the right and six
on the left. Schreyer found in thirteen infants that the canal was open on both sides in
eight. Paletta gives the rule that the complete closure of the vaginal canal takes place
from the twentieth to the thirtieth day after birth.”*
When closure does not take place, the condition known as congenital hydrocele
exists—i. e., the fluid from the peritoneal cavity gravitates into the non-closed tunica
vaginalis, which becomes distended in a limited degree, as in hydrocele. The fluid
gradually returns when in a recumbent position. This is rare, but one well-marked
case has come under my notice, where this condition had pertained from infancy, and
the canal was permanently closed from the inflammation caused by a hard-pad truss.
Some time later, after a bath, in pulling himself, hand-over-hand, up into the port-hole
of a ship, the young man produced a hernia, which, however, was easily retained by a
light truss. The hydrocele did not recur.
As we have seen, the inguinal canal is not an open but a closed passage through
the abdominal walls—a passage for the transmission of important vessels, but so forti-
fied by fascia, muscle, and tendon as to hold its walls normally in close apposition,
bringing intra-abdominal pressure to bear, not in line with its opening, but at a wide
angle to it. Pressure thus disposed can never make an oblique inguinal hernia, but
rather will close the canal. A beautiful illustration of this is seen in the passage of the
ureter through the bladder wall.
A simple contrivance gives a very clear idea of the manner in which the inguinal
canal is formed. Let one take two slips of paper and cut two small holes in the center
of each. Let him then lay these holes opposite each other, and pass through them a
quill or pencil-case. When he has done this, he has a very good plan of the state of
the parts about the groin in the foetus. If he now holds the papers opposite him and
pulls to one side the one nearest to him, he will find by so doing that he comes to lay
the quill between the pieces of paper in the same way, that the spermatic cord, by
the extension upward and outward of the internal orifice of the ring, comes to be
lodged in the canal. He will also see that the length of the canal must vary according
to the greater or less extension of its posterior side. Elsewhere the author has expressly
* Practical Treatise on Hernia, J. H. Warren, p. 14.

30
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
stated that the inguinal and femoral canals are not properly canals, unless distended by
hernia. In a normal state they are simply flattened passages.
As described by Dr. Darling, the inguinal canal has the following boundaries :
Structures in front
Structures behind
Skin.
Superficial fascia (two layers).
External oblique (entire length).
Internal oblique (outer third).
Conjoined tendon of internal oblique and transversalis.
Transversalis fascia.
Triangular ligament.
Subperitoneal tissue and fat.
Peritonæum.
Fibers of internal oblique.
Fibers of transversalis.
Poupart's ligament.
Transversalis fascia.
Structures above
Structures below
PLATE VIII. |
Figure 1.
Figure 2.
The right side of the same individual whose A. The inferior and united edges of the in-
left side is shown in Plate VII. The drawing from ternal oblique and transversalis muscles, horizon-
which the engraving was taken was made by Mr. tally directed across the abdomen to the linea alba.
Clift. Sir Astley Cooper dissected the internal B. The crural arch, or Poupart's ligament.
parts, to show how far they accorded with the view C. The fibrous expansion detached from around
of them given in his work, and which is Fig 3. the inguinal ring—i. e., the ring exposed by the re-
A. Poupart's ligament.
moval of the intercolumnar fascia.
B. The tendon of the external oblique turned D. The internal or superior pillar of the ring.
toward the linea alba.
E. The external or inferior pillar of the ring.
C. The spermatic cord.
F. Muscular nooses or arches formed by the
D. The cremaster muscle.
cremaster muscle on the spermatic cord, and de-
E, E. The internal oblique muscle: at the rived from the inferior border of the internal
upper part its anterior surface is shown; at the oblique and transversalis muscles.
under part it is separated from the transversalis, a G. This is S in the original, and is described
little raised and turned upward and inward so as to as the aponeurotic fascia transversalis, which forms
show the under surface of the muscular fibers at E. the posterior wall of the inguinal canal in a spot
F. The transversalis muscle partly exposed where, of the three muscles of the abdomen, only
and raised in a similar manner; the under surface one is found, viz., the external oblique. This is
is shown by the line extending from F; the outer internal to the cord.
surface of the same muscle is shown by the line H. This represents the same thing, but ex-
extending from I.
ternal, or to the outside of the cord.
G. Fascia transversalis, outer division.
I. The spermatic cord.
H. Peritoneum.
1. The femoral vein, situated on the inside of -
I. The inferior fibers of the transversalis.
2. The femoral artery.
J. The femoral vein.
3. An opening made in the external part of
K. The femoral artery.
the crural canal (sheath of the vessel), to show
Joseph Warren, M. D., Hernia, second edition, p. 6.
† Guthrie, Plate II.

PLATE VIII.
FIG 1
E
B
G
B
F
А
H
I
E
D
I
K
A
J
FIG. 2.
FIG.3
K
B
berat badan
5
I
2
D
B.
D
A
I
6
1


INGUINAL HERNIA.
31
ANATOMY OF THE PARTS INVOLVED.
the anterior crural nerve, situated immediately on F. Its sheath froin the internal oblique and
the outside of it, and lying on the cellular struct- transverse muscles.
ure covering the psoas muscle.
G. Superficial fascia of the cord.
4. Saphena majora vein.
H. Spermatic cord.
5. A lymphatic gland and vessels.
I, I. The internal ring. By a mistake, the
6. Falciform or semilunar fibers situated at line running from I rather appears to stop at the
the junction of the vena saphena with the femoral cremaster muscle at D, than to go to the inner
vein.
ring.
7. The anterior wall of the crural canal, or K. The external ring.
sheath of the vessels, opened and turned outward N. B.—The difference between F and G of
and inward to show the canal.
Fig. 2, when compared with F and I of Fig. 1, is
remarkable; it is no less so when compared with
Figure 3.
C, C of Fig. 3 of the same plate, or with Nos. 5
A, A. Poupart's ligament.
and 6 of Plate VII.
B. Internal oblique muscle.
The French anatomists generally appear to
C, C. Transversalis muscle, arising from Pou- consider that formation of the transversalis mus-
part's ligament and passing around the spermatic cle to be the more natural one in which it runs
cord at the internal ring, so that the fibers of this across to the linea alba, without being inserted
muscle appear behind as well as before the sper- into Poupart's ligament, when the spermatic cord
matic cord, and thus the inguinal canal is rendered will be found lying on the fibrous layer of the
a muscular canal. This is a most important pro- fascia transversalis, as in Fig. 2, Plate VIII, at G;
vision in preventing hernia, and when hernia ex- and in order to show the loops formed of the cre-
ists it is often the cause and seat of the stricture. master by the testis in its descent into the scrotum,
D. The cremaster muscle, arising from Pou- they sacrifice the insertion of those fibers which
parts ligament between the internal oblique and do not take this appearance, as seen in Plate VII,
transverse muscles, and receiving fibers from the No.8. Anatomists only can judge which descrip-
transversalis behind the cord.
tion is most correct, and which formation is most
E. The rectus muscle.
commonly met with.
-
The Subserous Connective Tissue.-Between the inner surface of the transversalis
fascia and the peritonæum there exists a layer of loose connective tissue which is fre-
quently of considerable thickness, especially in corpulent persons, in whom it is so much
loaded with fat as to resemble the omentum in a remarkable degree, and for which
it may be mistaken during operations for strangulated hernia. The spermatic cord
receives an investment from this connective-tissue layer which extends into the scrotum.
The sac of an oblique inguinal hernia often descends into this loose structure, and
may cause a separation of the component parts of the cord. It is well to bear in mind
that fatty tumors may develop here—although of rare occurrence—and be mistaken
for hernia. Considerable accumulations of serum are sometimes met with in this con-
nective-tissue layer and along the line of the cord, known under the name of encysted
hydrocele.
This was called by Mr. Pott, who first described it, “ hydrocele of the cells of the
tunica communis." He reports a case, as an extreme instance of this disease, from
whom he drew off eleven pints of water.

32
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
The Spermatic Cord and Vessels.—The spermatic vessels, placed behind the peri-
tonæum, descend from the loins over the surface of the psoas and iliacus internus mus-
cles, and are connected to them and to the membrane by loose connective tissue, and
extend to the division between the two portions of the fascia transversalis. Here they
are joined, at an angle more or less acute, by the vas deferens, and the spermatic cord
which results from this junction, making a sudden bend inward, passes into the ingui-
nal canal through its upper or inner aperture. The vas deferens is placed in the canal
behind and toward the inner side of the vessels, and consequently under the fleshy
margin of the obliquus internus and transversalis muscles, the exact situation of its
passage being marked by a slight depression of the peritoneum. The cord thus goes
obliquely downward and inward, between the fascia transversalis and the aponeurosis of
the external oblique, being increased in size by the addition of the muscular fibers, called
the cremaster muscle, derived from the lower edge of the internal oblique and from the
crural arch. The cord finally emerges through the opening in the tendon of the obliquus
externus, and then turns suddenly downward, lying not so much on the bone, between
the two columns of the rings, as on the outer column itself, so as to cover the inser-
tion into the pubes.
Thus the vessels of the testicle, making two remarkable turns, pursue three different
directions in the successive parts of their course. “They descend, inclining at the same
time a little outward, from the loins to the opening in the fascia transversalis. Then
they bend inward and forward, between that fascia and the aponeurosis of the external
oblique, making a curve, of which the concavity is turned toward the pubes; the vas
deferens makes a sharp angular turn at that part. The spermatic cord makes a second
turn, with its convexity toward the pubes, and lastly descends straight to the testicle.” *
The cord, besides the vas deferens, is made up of arteries, veins, nerves, lymphatics, a
membranous sheath, and the cremaster muscle. The spermatic artery is given off from
the aorta a little below the superior mesenteric branches. Opposite the middle of Pou-
part's ligament it passes from the lower part of the abdomen and joins the cord running
to the testicle.
The spermatic vein, arising from the testis, returns along the cord to the abdomen.
Two small arterial branches are also generally a part of the cord: one, from the internal
iliac, accompanies the vas deferens; the other, a branch of the epigastric.
a
* Lawrence on Ruptures, p. 160.


PLATE IX.
Fig. 3.
7
10
3
11
-
8

INGUINAL HERNIA. ANATOMY OF THE PARTS INVOLVED.
33
a
The Epigastric Artery.—An accurate knowledge of the course of the epigastric
artery is essential in operations for hernia, since it is situated so near the spermatic cord.
This vessel arises from the iliac artery, behind Poupart's ligament, and passes upward
and inward close to the under and inner side of the cord, between it and the symphysis.
Here it gives off a branch to the cord. For nearly two inches of its course it lies pos-
terior to all the abdominal muscles, beneath the peritoneum. It ascends obliquely and
upward to the margin of the sheath of the rectus muscle. In its course it lies behind
the inguinal canal, to the inner side of the internal abdominal ring and immediately
above the femoral ring.
The epigastric varies considerably in its origin and branches. The position of the
artery concerned in hernia is the beginning of its course, close to the inner and under
side of the spermatic cord, where the latter issues from the internal ring. Here the
artery is generally three inches from the symphysis pubis, and is at the same distance
from the spine of the ileum.
The artery is accompanied by veins, of which the largest is constantly found on the
inner side of the artery. They end by a single trunk in the iliac vein.
PLATE IX.*
INGUINAL REGIONS OF THE FEMALE.
Figures 2 and 3. Female Basin.
7, Figs. 2 and 3. Arcade of the small oblique.
They are numbered alike. In Fig. 2 the right It is hooked upward in Fig. 3.
side shows the inguinal ring and the aponeurosis 8, Figs. 2 and 3. Internal orifice of inguinal
intact; on the left side the aponeurosis of the great canal.
oblique is cut and inverted; the inferior part of 9, Figs. 2. Fascia transversalis.
the transversal is taken away in order to exhibit 10 and 11, Fig. 3. Very dense intercrossed
the passage of the inguinal canal. Fig. 3 forms a bundles (formed by the transversi), which pre-
third view on the right side; it shows the manner vent, in woman, the production of inguinal hernia.
in which the transversal terminates inferiorly, and They are composed of a mixture of muscular and
its relations with the round ligament of the uterus. aponeurotic fibers, and are separated in order to
1, Fig. 2. Aponeurosis of the great oblique. give passage to the round ligament. 10. Superior
2, Figs. 2 and 3. Inguinal canal.
bundle, which passes in front of the other and in-
3, Figs. 2 and 3. Internal pillar.
serts itself into the pubis.
4, Figs. 2 and 3. External pillar.
11. Inferior bundle, which disengages itself
5, Figs. 2 and 3. Transversal fibers of union from under the first and returns to implant itself
of the small fibrous bands.
in the aponeurotic gutter.
6, Fig. 2. Left side; and Fig. 3, aponeurosis in- 12, Fig. 3. Round ligament of the uterus main-
verted. The circumference of the ring is preserved. tained by a hook.
* Bourgery, Plate LXXXII.
8.

34
.
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
The Nerves and the Lymphatics.—The lymphatics of the testicle and spermatic cord
are very numerous, and by anastomosis form trunks of considerable size which ascend
along with the spermatic veins, and terminate in the lymphatic glands which are situ-
ated upon each side of the aorta, in front of the lumbar vertebræ. The nerve-supply
of the cord consists of branches of the lumbar plexus, filaments from the mesenteric,
renal, and hypogastric plexus of the great sympathetic—-conditions which explain the
intimate relation of sympathetic disturbance which is often shown, where injury to the
testicle is followed by nausea, etc.
PLATE X.*
MUSCLES OF THE ANTERIOR INCLOSURE OF THE TRUNK, SEEN ON THEIR POSTERIOR SURFACE.—
INFERIOR EXTREMITY OF THE ABDOMINAL MUSCLES OF THE Two SIDES.-NATURAL SIZE.
sal (15)
From a to a. Vertical section of the coxal sertions of the little oblique and of the transver-
bone, which falls in the middle of the cotyloïdal
cavity.
10. Ligament of Gimbernat.
al. Oblique section, which goes into the hori- 11. Internal inguinal ligament.
zontal branch of the pubis to exhibit the crural 12, 12. Aponeurosis of the great oblique.
ring
13. Inferior extremity of the great oblique
a”. Plan of the vertical section of the pubis. muscle.
b. Segment of the cotyloïdal cavity.
From 14 to 15. Inferior insertion of the little
C. Anterior and superior iliac spine.
oblique and of the transversal in the gutter of Pou-
d. Portion of the iliac fossa, behind the section part's ligament (fold of the aponeurosis of the
of the iliac muscle.
great oblique and of the fascia transversalis).
e. Spinæ of the pubis.
16. Gutter which the fascia transversalis and
f. Birth of the descending branch of the pubis. the fascia iliaca form; it goes as far as the crural
g. Pubian symphysis.
ring.
17. Crural ring (superior internal).
Right Side,
18. Inferior extremity of the pyramidal. This
1. Inguinal ring
muscle has been removed for some few lines in
2. Small bands, which are crowded together to order to let the internal inguinal ligament be seen,
form the external pillars of the ring.
and continues higher up.
3. Their superior extremity, where they pro- 19. Portion of the aponeurosis of the little
ceed from the great oblique.
oblique which adheres to that of the great oblique.
4. Small band of the internal pillar.
20. Cut extremity of the great right.
5. Its superior extremity.
21. Inferior portion of the linea alba.
6. Superior band, separated from the pre- 22. Triangular ligament which forms its pubian
ceding by a small arcade.
tie.
7. Transversal fibers of connection to the
Left Side.
small bands.
23. Fascia transversalis upon the transversal
From 8 to 8. Shred of the fascia transversalis,
muscle and its aponeurosis.
which forms the posterior covering to the gutter 24. Internal and superior orifice of the in-
of the ligament of Poupart.
guinal canal (internal inguinal ring).
9. The same shred, inverted under the last in- 25. Its internal edge.
* Bourgery, Plate LXXI.

3,5
a
PLATE X.
20
15
35
23
28
19
d
14
12
32
32
d
16
8
21
33
1.5
25
33
30
6
7
ai
34
34
a
a'
28


INGUINAL HERNIA.
35
ANATOMY OF THE PARTS INVOLVED.
26. Its external edge, both formed by the
fascia transversalis.
27. Inferior extremity of the great right.
28. Gutter of the fascia transversalis, and of
the fascia iliaca.
29. Its enlargement in infundibulum, above
the crural ring.
30. Crural ring.
31. Ligament of Gimbernat.
Of the Two Sides.
32. Fascia iliaca upon the iliac muscle.
33. Plan of the vertical section of the psoas
and iliac muscles.
34. Section of the pubian tie of the pectineus.
35. Cut of the abdominal muscles at their iliac
insertion.
с
The Structure and Relation of the Posterior Wall of the Inguinal Canal.—Be-
fore completing the anatomical study of the parts involved in inguinal hernia, it is wise
that we examine the canal from the inner or peritoneal side. When the abdominal
parietes of the inguinal region is held as nearly as possible in the normal position, there
will be observed to be present in the peritonæum, upon each side of the median line,
three distinct depressions which have been called the fosse of the peritonæum; the
1
deepest of these is the most external, and is situated on the outer or iliac side of the
epigastric artery, and corresponds with the upper aperture or inlet of the inguinal canal.
It is just beneath this point that the spermatic vessels and the vas deferens unite as they
bend over the epigastric artery, previous to their entrance into the inguinal canal,
where they go to make up the spermatic cord. At this point the peritonæum readily
yields under pressure, and may be pushed forward to form a small pocket, extending
a little distance upon the anterior side of the spermatic cord, just within the upper part
of the inguinal canal. This marks the situation of the original processus vaginalis of
the peritoneum, which canal, in many subjects, is imperfectly closed, and occasionally
a probe may be easily introduced downward and in front of the spermatic cord, or
round ligament of the uterus. This sometimes remains open in the adult female, and
is familiarly known to anatomists as the canal of Nuck. It occasionally happens,
in the male, that a very narrow opening still exists, connecting the tunica vaginalis
testis with the peritonæum, the processus vaginalis not having been completely
obliterated.
In certain of the lower animals—the dog, for instance--this canal remains permanent-
ly open in the adult animal--a fact of little physiological importance in the quadruped,
but which would manifestly become a source of inconvenience and suffering in man, be-
cause of the change of the axis of the body. When this canal remains sufficiently open
to allow the passage of the abdominal contents, it is denominated congenital hernia.
Under these conditions a considerable quantity of serous fluid may gravitate into the

36
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
tunica vaginalis, and then it is known as congenital hydrocele. Irregular constric-
tions are sometimes found in this imperfectly closed peritoneal pouch which are filled
with serous fluid, producing small encysted hydroceles of the spermatic cord. This
peritoneal depression, opposite the internal abdominal ring, is undoubtedly the weakest
point of the abdominal wall in man, and is the most common site of hernia in the
male.
The second depression of the peritonæum is less deep and important, and is situ-
ated upon the inner side of the epigastric vessels. The third peritoneal depression is
the most internal, and is situated upon the outer edge of the rectus muscle, and it
appears to follow the line of the obliterated umbilical artery. It is directly posterior to
the external abdominal ring, and, should herniæ develop in the line of either of these
depressions, they would belong to the direct variety.
PLATE XI.*
MUSCLES OF THE ANTERIOR INCLOSURE OF THE TRUNK, SEEN ON THE POSTERIOR SURFACE.-
NATURAL SIZE,
Left Side : Small oblique and cremaster:
Right Side : Transversal; details of the in-
guinal canal; great oblique.
Of the Two Sides.
From a to a. Vertical section of the coxal bone
which falls in the middle of the cotyloïdal cavity.
a'. Oblique section which enters into the hori-
zontal branch of the pubis, to let the crural ring
be seen.
a”. Plan of the vertical section of the pubis.
b. Segment of the cotyloïdal cavity.
c. Iliac spine, anterior and superior.
d. Portion of the iliac fossa, behind the sec-
tion of the iliac muscle.
e. Spine of the pubis.
f. Birth of the descending branch of the pubis.
g. Pubian symphysis.
4. Suture of the aponeurotic layer of the trans-
versal which passes in front the great right.
5. Cremaster.
6. Infundibulum formed by its fibers round
the spermatic cord.
From 7 to 7. Extremity of the transversal
which is attached to the iliac crest in the gutter
of the ligament Poupart.
8. Gutter of the fascia transversalis and of
the fascia lata.
9. Fascia iliaca.
10. Crural ring.
II. Ligament of Gimbernat.
12. Pyramidal muscle.
13, 13. Aponeurotic layer of the transversal
which passes in front the great right.
14. Cut extremity of the great right.
15. Inferior portion of the linea alba.
16. Triangular ligament, which forms its pu-
bian tie.
Right Side.
From 17 to 18. Transversal.
19. Its aponeurosis.
20. Pubian' insertion. One portion of it is
Left Side.
From 1 to 2. Small oblique.
2. Last fibers of insertion under which the
cremaster begins.
3. Aponeurosis of the little oblique.
* Bourgery, Plate LXXII.

PLATE XI.
14
31
7
17
а.
а
21
13
9
d
8
d
7
18
2
22
13
5
25
52
244,
26
33
26
33
16
30
b
6
a
a
34
34
az
6
27
29
a 2
a2
f
f
12


INGUINAL HERNIA. ANATOMY OF THE PARTS INVOLVED.
37
cut outside, to let the superior contour of the in-
guinal ring be seen; the rest of it is hid by the in-
ferior ties of the transversal and of the fascia
transversalis.
21, 22. Gutter of the fascia transversalis and
the fascia iliaca. A little shred of the fascia
transversalis is preserved throughout its entire
extent.
23 to 24. Preserved shred of the fascia
transversalis which comprehends the superior
orifice of the inguinal canal.
23. Internal edge.
24. External edge, cut arbitrarily within
side to let the interior of the inguinal canal be
formed by the fillets of the aponeurosis of the
great oblique, the cremaster muscle having been
removed.
27. Orifice of the inguinal ring.
28. Tie upon the tendon of the great right,
from the inferior extremity of the fascia trans-
versalis.
29. Crural ring.
30. Ligament of Gimbernat.
31. Great right muscle.
32. Its pubian tendon.
On the Two Sides.
seen.
33. Plan of the vertical section of the iliac
muscles.
34. Section of the pubian tie of the pectineus
muscle.
25. Superior orifice of the inguinal canal.
26. Anterior inclosure of the inguinal canal

CHAPTER III.
CONGENITAL HERNIA.
BEFORE entering upon the description of the anatomy of the other varieties of her-
nia, it appears to be the best disposition of the subject to commence our researches
with the varieties of hernia which are incident to the inguinal canal, while having dis-
tinctly in mind the anatomical relations of the parts involved.
The first to be taken into consideration, although far less common, is that termed
Congenital Hernia. This, as has been already mentioned, follows the line of the un-
closed tunica vaginalis testis; and, although the student often has the greatest difficulty
in understanding its exact relations, yet viewed from the standpoint of the discussion of
the peritonæum in a subsequent chapter, it is the easiest of comprehension of all the
varieties. An unclosed peritoneal pouch, extending into the scrotum, is necessarily a
.
a
cause of weakness, and, when sufficiently large, invites the descent of the superjacent
abdominal contents.
The name congenital was first given to this form of hernia by Haller, who believed
that it could happen only at, or near, the time of birth of the individual who became the
subject of this affection, before the period at which the obliteration of the connection
between the tunica vaginalis and the peritoneal cavity was usually closed.
The original studies of Percival Pott * upon congenital hernia have so much inter-
est and value that I quote the following deductions which he made of the condi-
tions that produce it.
That the testicles of almost all children, though originally formed and lodged
within the belly, yet sooner or later after their birth are found either in the groin or in
the scrotum; that is, they are found on the outside of the abdominal muscle.
That the scrotum has no communication with the cavity of the abdomen, but
I.
2.
* An Account of a Particular Kind of Rupture frequently attendant upon New-born Children, and sometimes
met with in Adults; viz., that in which the Intestines or Omentum is found in the same Cavity and in contact
with the Testicle. By Percival Pott, Senior Surgeon to St. Bartholomew's Hospital. Second edition, London,
1763.

CONGENITAL HERNIA.
39
through the mouths or entrances of the membranous sacculi in which the testicles are
included.
3. “That when the testicles are got into the groin, or scrotum, by having passed
through the aperture in the tendon of the abdominal muscle, they are always found
enveloped in a loose bag, in which they were not contained while they were within
the belly.
4. “ That the entrances from the abdomen into these sacculi containing the tes-
ticles are generally to be seen open in a new-born child.
5. “That, by laying these sacculi open, the testicles are found within them naked;
that is, they are found in the same state with regard to covering as they were in while
within the cavity of the belly. ... If the testicles remain any time in the groin (a
thing not very infrequent), the communication between the sacculi and the belly con-
tinues open all that time ; at least I have always found it so, in all those whom I have
examined. When the testicles are got below the groin into the scrotum, the sacculi
which contain them assume a pyriform kind of figure, having their largest end low-
est; they are connected with the membranes of the scrotum so very loosely in young
subjects as to be separable with utmost ease.
“They still for some little time continue to communicate with the cavity of the
belly, by a large orifice capable in a mature foetus, or in a child newly born, of admitting
a common crow-quill. This the eyesight, the passage of a probe, or the descent of a
fluid poured upon the mouth of the opening, will prove to the satisfaction of any
inquirer; and if the sacculus be now laid open, either from its bottom upward into the
belly, or from its orifice within the belly downward, the most clear and convincing proof
will appear, that the membrane which constitutes the inside of it is a production of, or a
continuation from, that part of the peritonæum which lines the abdominal muscles, and
covers the spermatic vessels, etc. Upon this division of the sacculus it will also appear
that the testicles and epididymis within it have no other covering than what they
brought out from the abdomen, and that notwithstanding they are protruded into and
apparently contained within the sacculus, yet they still are (as they were originally)
behind the peritonæum.
“Whether it be by the weight of the testicle now become pendulous from the
spermatic cord, or from the action of the abdominal muscles, or from what cause I know
not; but soon after the testicles are got fairly into the scrotum, the orifices and passages
to these sacculi are closed and obliterated in such a manner that neither a probe nor a

40
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
fluid will now pass from the belly into them, nor from them into the belly. The pas-
sage of communication becomes closed some way above the epididymis, and the bag
by this means forms a cavity much larger than the testicle, which is loosely included in
it, and kept moist by a fine lymph constantly found there. The time at which this
communication is stopped by the passage being shut, is uncertain and various, for,
though it most frequently happens some time after the testicles are got into the scro-
tum, yet it is not constantly so; I have seen them open at four years old, and in an
adult, and others have seen them open at a time between these; but whenever they do
close, they form those bags which are then called the tunica vaginales testium, from or
to whose cavity there is no longer any passage.”
Mr. Pott closes his interesting dissertation with the report of four cases, adults,
where hernia of this character existed.
As we have already shown, in discussing the development of the inguinal canal, the
processus often remains open for quite a period after birth.
Hesselbach reported a case where he found the processus vaginalis canal open on
both sides in the body of a man, aged thirty-eight, but no protrusion of the abdominal
contents had occurred.
Velpeau reported three cases of the congenital form of inguinal hernia occurring in
the adult, in whom the testes had descended before birth.
The larger number of herniæ, occurring in infancy, belong to the congenital variety,
and this very rarely takes place in the female, even when the canal of Nuck remains
unclosed. Only within the present year I operated upon a woman, aged thirty, assisted
by Dr. R. Robinson, of Danielsonville, Conn., who brought the patient to me, where
that which appeared as a cyst, of about the size of an egg, was shown to have direct
connection with the general peritoneal cavity, through the canal of Nuck, the upper
portion of which was nearly closed by a small plug of adherent omentum.
It should be borne in mind that the testes, while yet within the cavity of the abdo-
men, are firmly adherent to the peritonæum, and in their descent into the scrotum
this portion of the peritonæum is still a fixed point, and enters into, and forms a part
of, the tunica vaginalis.
Congenital hernia is much more common in subjects where the developmental pro-
cesses are delayed, and, as a consequent, the testicle is interrupted or retarded in its
descent into the scrotum. Pott and Lawrence each reported cases where it was believed
that the congenital hernia was induced by a portion of the intestine becoming adherent.

CONGENITAL HERNIA.
41
a
to the testicle prior to its descent from the abdomen. This must certainly be very rare,
and it undoubtedly generally happens that such abnormal connection, when observed,
has taken place after the intestine had descended into the tunica vaginalis. (Fig. 2.)
The constriction in strangulated congenital
hernia is commonly found at the neck of the
sac and in the immediate vicinity of the inter-
nal abdominal ring. The coverings of a con-
genital hernia are of the same nature as those
belonging to the ordinary varieties of inguinal
hernia, with the exception of the peritoneal in-
vestment already carefully described.
As would naturally be expected, in congeni-
tal hernia, there is no marked depression to dis-
tinguish between the fundus of the hernial sac
and the upper part of the testicle, as is ob-
served in the other forms of inguinal hernia.
By special permission I have somewhat
recently carefully studied all the specimens,
illustrative of the various varieties of hernia, FIG. 2. — The wood engraving represents the man-
ner in which the prolapsed intestine, in a con-
which are contained in the Museum of the
genital hernia, is contained within the cavity of
the tunica vaginalis testis : a. The body of the
Royal College of Surgeons of England; and,
left testicle, covered in front and upon its sides
since this collection is especially rich in the pos-
by the tunica vaginalis testis. 6,6. The tunica
vaginalis testis, which is a process from the
session of the specimens prepared by John great bag of the peritonæum, and, remaining
open at its upper extremity, forms the sac in a
Hunter and Sir Astley Cooper, I have felt that
congenital inguinal hernia. c. The intercolum-
it would be of interest and profit to the pro-
nar fibers, which bind together the pillars of the
external abdominal ring. d. The superior or in
fession to select freely from the catalogue the ternal pillar of the ring. e. The inferior or ex-
ternal pillar of the ring. f, f. The superficial
descriptions of the same, as valuable illustra-
coverings of the hernial sac in the scrotum.
tions of the different varieties of the disease.
8,8. A fold of small intestine which, in the con-
genital inguinal hernia, descends into the cavity
The following series of specimens of congenital
of the tunica vaginalis testis, where it frequently
lies in apposition with, or is adherent to, the
hernia can not fail to be of interest.
body of the testicle (Morton).
2668. The sac of a congenital hernia, in which the testicle was situated at the external ring. A small
elongated growth of fatty tissue is attached to the upper part of the epididymis.—Presented
by Sir William Blizard.
2669. The sac of a large congenital hernia. The exterior of the sac is uneven and sacculated, through
9

42
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
the unequal yielding of parts of its walls; the testicle is situated at the lowest part.—Hun-
terian.
2670. The sac of a large congenital hernia, nearly full of healthy omentum, which is in several places
adherent to its walls.—Hunterian.
2671. An inguinal hernia, from some large animal, with small intestine and omentum protruded into
the cavity of the tunica vaginalis.--Hunterian.
2672. Part of the pelvis and abdominal walls of a young child, with the sac of an inguinal hernia,
nearly two inches long, on the right side. The sac is formed by the elongated and dilated
funicular portion of the vaginal process of the peritoneum; the testicle is directly below it,
and the cavity of the tunica vaginalis is closed above, and has no connection with the hernial
sac.—From the Museum of John Howship, Esq.
Arnaud reported a case where he operated for strangulation in which he found that
the intestine was not covered by a peritoneal sac, although he made the dissection with
the greatest care.
Scarpa observed, that “it is impossible to turn the bottom of the hernial sac upward
in congenital hernia, as may be done in common hernia, leaving the spermatic vessels
with the testicles in their situation; for it is not possible, in congenital hernia, to raise
and invert the bottom of the vaginal coat, forming the hernial sac, without raising and
at the same time turning the-testicle upward and the spermatic vessels which are in-
serted into it. Upon which point I can not mention but with horror the injury which,
from the want of this knowledge, was practiced upon the celebrated physician, Zimmer-
man, from the false persuasion under which the surgeon labored of being able to raise up
the vaginal coat without removing the spermatic vessels from their situation, and to tie
it at its neck, in order to prevent the return of the hernia, according to an erroneous
and already antiquated notion.”
A very rare variety of this kind of hernia is reported in the Medico-Chirurgical
Transactions, vol. xlix, by Mr. J. W. Hulke, F. R. C. S., which is of sufficient interest to
copy, and where it is quite too apparent that death was due to the improper use of
taxis : “A man, aged twenty-seven, was admitted into the Middlesex Hospital, January
20th, with strangulated hernia. The right side of his scrotum was distended by a large
globular swelling, which stretched upward along the groin to the anterior superior iliac
spine. The inguinal and scrotal portions were separated by an intermediate narrow
part, but an examination under chloroform-for there was too great tenderness to allow
handling without anæsthesia-proved that they were portions of a common cavity.
Except at its pubic end, the inguinal portion of the swelling was accurately definable-

CONGENITAL HERNIA.
43
the finger-tips could be dipped under its edge—which made it evident that it was not
beneath the aponeurosis of the external oblique muscle, but superficial to it.
“ In the left groin there was a similarly superficial oblong swelling, also reaching from
the internal ring nearly to the anterior superior iliac spine. It was flaccid and painless,
and felt coarsely granular. The penis was thrust toward the left, and nearly buried by
the right hernia. Pus oozed from the urethra. Neither testis could be felt in the
scrotum or groin. He lay on his back, with drawn-up knees, tossing restlessly, and
cry-
ing out from the severity of the pain in the rupture and belly. Pulse small, quick, and
compressible ; face pale; beads of sweat rolling off his brow; features anxious. His
extreme suffering made him so impatient of being questioned that I could only elicit
the bare facts that he had been ruptured since childhood, and that each rupture had
been reducible until that morning.
The left was plainly an omental hernia, and not strangulated. Its deviation from
the usual course of an oblique inguinal hernia was attributed to the non-development
of the scrotum connected with arrested transit of the testis. But the nature of the
right, the strangulated hernia, was not so evident. Supposing that the testis was in the
scrotum, its concealment was consistent with congenital hernia, and, if inflamed and
swollen (he had gonorrhoea), the testis, by preoccupying the scrotum, might have hin-
dered the descent of the protruding gut, and in this way have led to the formation of
the superficial diverticulum in the groin.
“ The taxis in a hot-bath having been already tried by the house-surgeon, chloroform
was given, and, reduction being still impossible, I operated at once, three hours from
the beginning of the strangulation, making a cut an inch and a half long in the axis
of the swelling, over the external ring. After dividing a little cellular tissue, the sac, ,
thin and transparent as gauze, was exposed. I was obliged to open it in order to reach
the ring, which lay deeply behind this part of it. After notching the external ring and
cutting three deeper constricting bands, the finger slipped into the belly, and there was
no other trouble in returning the gut than that occasioned by its great quantity.
“When the sac was empty I swept my finger round the under inner surface of the
internal ring, in order to make quite sure that the extruded bowel was completely inside
the belly, and in doing this I hooked something solid, which, being drawn gently down
into view, proved to be the testis hanging from a mesorchium ; it was replaced, and the
wound closed. The contents of the sac were several feet of dark-red gut, blotched
with extravasated blood, and some ounces of bloody serum.

44
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
Next morning he passed two copious, very offensive, loose, bloody stools, and he
died in the afternoon, the symptoms of acute peritonitis having continued unabated
from the hour of his admission. His body was examined on the following day. The
left hernia, that which had not been strangulated, was first dissected.
“When the skin and superficial fascia were reflected off the groin a lobulated, oblong,
hernial sac, reaching from the superior iliac spine to the bottom of the scrotum, came
into view. The upper and outer part of this sac lay upon the aponeurosis of the exter-
nal oblique muscle, in front of the inguinal canal and Poupart's ligament, its descent
upon the thigh being restrained by adhesion of the superficial and deep fascia along the
line of the groin. It contained a large mass of omentum and some turbid serum. The
great distention of the scrotum by the right hernia had masked the scrotal portion of
the left hernia during life. When the external ring through which the sac extended,
and the structures composing the front of the inguinal canal, had been slit, the testis
was found behind the omentum in the canal, not fixed to the posterior wall of this
latter, but hanging from a fold of peritonæum drawn from the parietal layer near the
abdominal surface of the internal ring.
The anatomical relations of the right hernial sac corresponded exactly to those of
the left, the only difference being that the superficial diverticulum did not ascend quite
so near to the iliac spine. The entire sac was inflamed, and it contained several ounces
of turbid serum.
On opening the belly the omentum was seen tightly stretched and gathered in a
fan-like form to the left internal ring. The transverse colon was also pulled down to
this latter, but not engaged in it. The abdominal cavity contained many ounces of
turbid serum similar to that found in the hernial sacs, and the serous surfaces were
everywhere inflamed. Ten and a half feet of small intestine had been strangulated ;
they were intensely congested and blotched with small submucous extravasations of
blood, but the most careful scrutiny with the naked eye failed to discover any breach of
the mucous surface—a feature of interest in connection with the copious bloody stools.
There were several large extravasations of blood in the mesentery of this portion of
bowel.
“The right testis hung freely entirely within the cavity of the belly, by a mesorchium
drawn from the parietal peritonæum at the pelvic brim near the internal ring.
“In ruptures associated with malpositions of the testis, where this has remained at
some point above the scrotum, the bowel has occasionally been found to have slipped


PLATE XII.
Fig. 1.
Fug.2.
Fig. 3.
Fig. 4.
12
6
I

CONGENITAL HERNIA.
45
by it into the scrotum, being in these cases received in the vaginal process of perito-
næum when the testis or epididymis has entered the internal ring, but acquiring a sac
when the testis or epididymis continues in the belly. More rarely the sac, on leaving
the external ring, has been found to have ascended upon the aponeurosis of the external
oblique muscle instead of passing into the scrotum, the commonly accepted explanation
being the resistance to the descent of the sac offered by the undeveloped scrotum.
“The case which I have described combines both these irregularities—the ascent of
the sac superficially along the groin, and its descent into the scrotum. Their occur-
rence is explainable by supposing that the undeveloped scrotum was sufficiently inex-
tensile to retard, but not altogether to prevent, the descent of the hernia. The hernial
sac on each side was an acquired one, and not a derivative of the vaginal process, since
the right testis and epididymis were within the belly, and the left testis, although found
in the inguinal canal, was not attached to it, but hung freely from a long mesorchium
attached inside the belly.”
PLATE XII.*
This plate shows the hernia congenita under its usual appearance; also the variety of congenital
hernia taken by Mr. Forster from a patient in Guy's Hospital. The other figures show different views
of preparations of inguinal herniæ, intended to show the mode of operating on each variety.
f. Testis.
& Strangulated intestine.
h. Bougie within it.
Figure 1.
a, a, a. Tunica vaginalis.
b. Testis.
c. Spermatic cord.
d. Hernial sac within the tunica vaginalis.
e. Mouth of the sac, which has been produced
by an adhesion of the tunica vaginalis, opposite
the abdominal ring.
f, f. Intestine.
Figure 2.
a. Strangulated intestine, the sac cut open.
b. The adhesions of the tunica vaginalis to the
mouth of the sac.
Figure 3.
Hernia congenita.
a. Abdominal muscles.
b. Abdominal ring and cremaster muscles.
c. Fascia upon the tunica vaginalis.
d. Tunica vaginalis.
e. Spermatic cord.
Figure 4.
Inguinal hernia in the female, strangulated
at the aperture into the abdomen.
a. Abdominal ring.
b. Poupart's ligament.
c, c. Internal oblique muscle and its tendon.
d. Transversalis passing over the hernial sac.
e. Fascia passing up to the transversalis.
f. Hernial sac below the abdominal ring.
g. The sac passing under the transversalis
into the abdomen.
h. Dotted lines marking the direction of the
epigastric artery as it runs under the muscies.
i. Knife placed with its side upon the sac, the
edge of which is to be turned forward to divide
the transversalis and internal oblique muscle at d;
cutting upward toward h would endanger the epi-
gastric artery.
* Cooper, Plate XI.

46
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
6
Encysted Hernia.—The encysted her-
nia of Sir Astley Cooper, sometimes called
acquired congenital hernia, or the infantile
hernia of Hey, is that where the ventral
orifice of the sheath is occluded, but the
canal remains open, continuous with the
tunica vaginalis. The hernia is formed, as
in the more common varieties, by the sac
consisting of the parietal peritonæum, but
it is forced with its contents into the open
tunica vaginalis. I have not met with this
form of hernia in operation, and, without
dissection, it might not be diagnosticated.
Sir Astley Cooper reported * the following
case, which he had the opportunity of see-
FIG. 3.—The wood engraving represents, by a side view; ing under the care of Mr. Forster at Guy's
the condition of the parts as they have been found
upon dissection in cases of infantile hernia. The Hospital: “A man was admitted into the
cavity of the tunica vaginalis of the left side has been
laid open, and the hernial sac, with its contents, is house with symptoms of strangulated her-
seen as it projects behind the posterior layer of that
nia, which the usual means failed to relieve
membrane: a. The body of the testicle, which is
covered anteriorly and laterally by the tunica vagi- and the operation proposed and urged, but
nalis testis. b, b, b. The tunica vaginalis, the cavity
of which is much more extensive than is ordinarily
the patient would not permit, choosing
the case; a free incision has been made into it, so
rather to die. On examining the body,
as to show more clearly the relative position of the
hernial sac and testicle to one another; and also the
after death, a sac was found within the
mode in which the posterior layer of it is projected
forward by the hernial tumor, which is situated im- tunica vaginalis, descending from the ab-
mediately behind it. C. A portion of the cellular
substance which separates the hernial sac (d) from
dominal ring toward the testicle. This sac
the posterior layer of the tunica vaginalis. d.
contained a portion of one of the small
The proper hernial sac, which is a fresh production
from the great bag of the peritoneum. e. A knuckle intestines which had become gangrenous.
of small intestine, contained within the hernial sac.
f. The intercolumnar fibers which bind together the
The stricture was at the mouth of the
pillars of the external abdominal ring. g. The supe-
sac.” (Fig. 3.)
(
rior and inner pillar of the ring. h. The inferior and
external pillar of the ring. i, i. The superficial in-
In the normal development, the serous
vestments of the hernia, where it lies in the scrotum
(Morton).
canal, through which the testis has passed,
becomes closed and is' obliterated; when this occurs, the hernia can no longer escape
a
*
* Cooper's Lectures, 1839, p. 380.

CONGENITAL HERNIA.
47
by this tract, and the sac is then formed by a yielding of the peritonæum over the pro-
truding parts. This is by far the more common condition.
A rare form of indirect inguinal hernia is where the loose-meshed connective tissue
about the internal ring extends down along the line of the cord, and the protruded
peritoneal pouch descends into this tissue and carries the tunica vaginalis of the testi-
cle in front of the tumor which is thus formed, instead of lying behind it, as is usual
in other forms of scrotal hernia. It is important to keep this variety of hernial pro-
trusion in mind, since otherwise the tunica vaginalis testis would be cut through,
forming as it does, directly in front, a double layer over the sac. A considerable num.
ber of cases are on record as having been observed by competent operators. Though
classed as a variety of infantile hernia, there is no especial reason to believe that it
may not occur at any period of life. If the operator takes care to differentiate the
testicle and its investment envelope from the hernial tumor, it will not be difficult
to avoid injuring these structures. The operative procedures for this variety of her-
nia, when strangulated, or undertaken for cure, are not different from those of the
more common forms of indirect hernia.

CHAPTER IV.
INGUINAL HERNIA-CAUSES AND CONDITIONS-FORMATION OF SAC.
Causes.—The construction of the abdominal walls is a beautiful example of Na-
ture's marvelous adaptability of means to the end to be subserved. The abdomen
must be always full, no matter how varied its contents, and subject to equable
pressure. The amount of pressure varies with contents, position of the body, and
muscular contractility of the abdominal walls. The anatomical relations of the mesen-
tery to the intestine are primarily less those of support than of limitations in physio-
logical action. The vessels and nerves are not put on tension, but lie without strain,
with, of necessity, a certain freedom of motion. Remove the supporting power of the
a .
abdominal walls in any direction and, necessarily, the intestinal contents will follow.
Were it otherwise, either a considerable percentage of the people of all countries must
be congenitally malformed, or hernia is not caused, as commonly attributed, by over-
strain, lifting, coughing, or any violent compression of the abdominal walls.
It is very probably true that a large proportion of the so-called immediate rupt-
ures are preceded by a train of causes leading up to the giving away at last, sud-
denly, of the weakened ring; but even these could not increase the length of the mes-
entery, unless first the dimensions of the abdominal cavity were materially changed.
In the so-called pendulous belly of multiparous women the intestines easily follow to
the very base, when the patient is in the upright position ; but I have yet to learn
that the yielding of the recti muscles is supposed to be caused by the lengthening
of the mesenteric ligament.
Constipation, dysuria, a harassing cough, are also direct as well as remote causes
of hernia. It is the common experience of those ruptured to ascribe the cause as
due to violent muscular exertion. The contents of the hernial sac are those portions
of the abdominal viscera subject to the widest latitude of movement, and it may be
owing to this that it has been assumed necessary to have first an elongated mesen-
teric attachment before the small intestine could form a part. Owing to this free-
dom of motion, portions of the omentum and small intestine, in the great majority

INGUINAL HERNIA.
49
of instances, form the contents, although portions of every abdominal organ have occa-
sionally been involved in hernia.
When the large intestine is involved, the part protruded is generally either the
cæcum or the sigmoid flexure of the colon, since these are less fixed than other por-
tions of the canal. When the cæcum, it occurs usually, as we should expect, upon
the right side; when the sigmoid flexure, upon the left, yet cases of the opposite are
on record, and also where both the cæcum and sigmoid flexure have been included
in an omental hernia. In fleshy and elderly people the omentum is generally heavily
loaded with fat, and on this account the omentum is rendered more liable to become
involved in hernia. Cases are on record where the bladder, uterus, ovaries, spleen,
stomach, and kidney have been found in the hernial sac.
From the anatomical description already given of the inguinal canal, we can read-
ily see that a modification of the intra-abdominal pressure, diverting it in the line of
the opening, is necessary at its very inception. It is now much more generally accepted
than formerly by anatomists and surgeons that, in a very large proportion of cases
of inguinal hernia, taking the direction of the cord its predisposing factor is found in
the defect of the imperfect closure of the peritoneal pouch which descends before the
testis. As we have seen, this variety has been called congenital hernia. The irregu-
.
lar depression in the peritonæum thus left at the internal ring affords a slight obstruc-
tion to the free movements of the abdominal organs. Thus, little by little, the thin,
yielding peritoneum is saccated, and a wedge-shaped pressure, at first slight and inter-
rupted, is formed in the line of the canal.
This pathological factorage having been established, it is easy to understand that
a comparatively slight force is ample to separate the structures which make up the
canal. The thin margin of the conjoined tendon yields, and then the force is
brought to bear upon the external ring of the canal, protected posteriorly only by
the aponeurosis of the fascia transversalis and the triangular ligament. Externally,
the upper border of the canal, protected by its re-enforcing fibers, which give great
support to resist forces acting from without, is yet imperfectly constructed to restrain
an impinging force acting from above downward.
When the contents of the hernial tumor have thus distended and distorted the
inguinal canal, the important barrier to its further progress is overcome. The perito-
neal sac protrudes over the spermatic vessels, and separates them from the delicate
fibers of the cremaster and superficial fascia.
IO

50
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
PLATE XIII.*
a, a. The inguinal ring of the left side.
6, 6, 6. Intersection of the collateral tendinous
bands of the aponeurosis of the external oblique,
in the vicinity of the inguinal ring.
C, c. Left femoral arch.
d. Suspensory ligament of the penis.
e. The os pubis.
f. An inguinal hernia of the left side.
8,8,8,8. Divergence of the fibrous bundles
of the cremaster muscle.
h. Continuation of the membrano-aponeurotic
sheath of the cremaster muscle, which envelopes
the spermatic cord and the vaginal coat of the
testicle.
i, i. The right inguinal ring.
k, k. Intersection of the tendinous fibers of
the aponeurosis of the external oblique muscle of
the abdomen in the vicinity of the right inguinal
ring:
1,1,1. The sheath of the cremaster muscle laid
open, on which, especially at its outside, are seen
the fibrous bundles of this muscle.
m. Soft cellular substance interposed between
the sheath of the cremaster muscle and the hernial
v. Remains of the muscular portion of the ex-
ternal oblique which has been cut away.
x. The linea alba of the abdomen.
y. The anterior # portion of the aponeurotic
sheath of the rectus muscle, formed by the union
of the aponeuroses of the external and internal
oblique muscles, divided and turned outward. ||
1, 1. The femoral artery on both sides.
2, 2. The femoral vein.
3,3. The abdominal artery or circumflex iliac.
4. Continuation of the right abdominal artery.
5, 5. The epigastric artery of each side.
6,7,8,9. Course of the right epigastric artery
behind the rectus abdominis muscle of the same
side.
10, 10. The origin of the epigastric vein of
both sides.
11,11. Continuation and distribution of the
right epigastric vein.
12, 13. The superior external pudendal artery
which crosses over the hernia immediately under
the skin.
14, 14. The saphena vein.
15,15. The anterior crural nerve.
16, 16. Two dotted lines, showing the direc-
tion which the viscera sometimes take in the for-
mation of internal inguinal hernia, or on the inner 4
side of the epigastric, in which case this artery
retains its natural situation.
A. The external oblique muscle of the abdo-
sac.
men.
n. The hernial sac formed by the peritoneum.
0. Small loop of protruded ileum.
Pip. The aponeurotic sheath of the rectus ab-
dominis muscle laid open for a certain space and
drawn to each side.
9, 9. Continuation of the aponeurosis of the
external oblique muscle of the right side of the
abdomen.
r. The right femoral arch.
s, s. The great sac of the peritonæum, through
which are perceived the bowels.
t. Posterior | portion of the aponeurotic sheath
which incloses the rectus abdominis muscle.
u, u. The rectus muscle of the right side re-
moved from its natural situation and drawn strong-
ly toward the left side of the abdomen.
B, B. The rectus muscle of the left side of the
abdomen.
C. The transverse muscle of the right side.
D. Portion of the glutæus maximus muscle.
E. The tensor vaginæ femoris.
F. The rectus femoris.
G. The sartorius.
H. The iliacus internus.
I. Tendinous origin of the second adductor
femoris.
* Practical Treatise on Hernia, by Antoine Scarpa, Paris, 1812. Plate I.
+ On its sternal and lateral aspect.
| Central
# Peripheral.
| Peripheral.
A Mesial.



INGUINAL HERNIA.
51
Formation of the Hernial Sac.—Except in the rarest of instances, the hernial con-
tents are inclosed in a portion of the parietal peritonæum, which is carried before
them, and this constitutes the sac—a cavity continuous with that of the abdomen.
At the outset, the size of the cavity is limited to that of the opening, which has gen-
erally a tendinous and comparatively unyielding border. Over the opening, however,
the parts are usually soft and weak, often loose fascia and integument, and, little by
little, the peritonæum stretches under the pressure into a bag of greater or less size
and varying in shape, but communicating with its origin by the original opening,
often not much changed, called the mouth or neck of the sac; the peritonæum at the
mouth of the sac is intrafolded or plicated.
When the contents of the sac can be returned, often the general functions go on
unimpaired, the subject suffering only a limited weakness and inconvenience. Changes
of vascularity and nutrition, however, usually soon ensue, the sac becomes thickened,
adhesions of the contents follow, and a general increase in bulk takes place. So long
as the contents of the sac can be returned, the hernia is called reducible. When the
hernial contents can no longer be returned to the abdomen, although the suffering
or inconvenience may not be extreme, it is termed irreducible. When, from press-
ure or constriction, the function of the contents is suspended, the hernia is then said
to be strangulated, and the narrow surrounding portion, usually at the neck, is
called the stricture.
The existence of a peritoneal covering, as a sac, is dependent upon the contents of
the hernia being made up of organs within the abdomen proper, as the bladder might
protrude entirely from below the peritoneal reflexion. Cystocele and rectocele, in a
sense, are also hernial tumors, but without a peritoneal investing membrane.
Hernia also exists without a peritoneal investment in wounds—e. g., penetrating
wounds of the abdomen—but, other than these, the peritonæum, more or less altered, is
constant in hernia as the chief component of the sac. The definition, earlier given to
hernia as rupture, was dependent upon the belief that a sudden giving away of the
inclosing parts generally included also an actual lesion of the peritonæum.
The Peritoneum.--The peritonæum lines the cavity of the abdomen, and is reflected
over all the organs contained in it, giving to each an external covering. This serous
membrane is thin, semi-transparent, and perfectly smooth on its internal surface, and is
lubricated by a fluid which not only gives it a polished appearance, but permits move-
ment of the organs upon each other and the restricting walls without friction.

52
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
а
The texture of the membrane is of connective tissue, disposed in obliquely crossing
layers, which give it much strength and yet render it of a yielding character; this is
further increased by elastic tissue entering, in a minor degree, into its composition. It
is covered with a squamous epithelium, and is very rich in vessels, nerves, and
lymphatics.
An interesting experiment is the dissection of a fresh peritoneum, and securing it
tense, like a drum-head. In this manner it will support a considerable weight for some
time, and upon its removal return to its original shape. If longer retained, it will relax
as a depressed pouch, and a careful observation will show that the structure has yielded
by an irregular separation of its component layers. The texture and strength not only
differ in different individuals, but notably in different parts of the same subject.
Where it lines the abdominal walls it is thicker, grayish-white, semi-opaque, and nearly
conceals the color of the adjacent parts; over the mesentery, on the contrary, it is often
nearly transparent. To the linea alba and the sheath of the recti muscles, the perito-
næum is very closely adherent, but is loosely connected with the lateral abdominal
parietes by a thin lamina of connective tissue. Its external surface is often rough
and irregular.
Physiologically, the peritonæum is subject to extraordinary changes, which are of
much importance, viewed from the standpoint of our present study, as evinced by the
ever-changing peritoneal investment of the stomach, intestine, bladder, in their rapid
expansion and contraction, and the uterus in pregnancy ; also the development of the
peritonæum over a rapidly growing ovarian tumor, or the distention of the abdominal
wall to several times its original surface in abdominal dropsy. After pathological
changes, the peritoneum is frequently restored to its former normal state. In cases of
sudden, forcible distention, particularly where the membrane is thin and adheres closely
to the abdominal parietes, or other surrounding parts, its texture yields partially, and
undergoes a loosening, or species of laceration, such as in the case of silks, or other
fabrics, we call fraying, the French éraillment; a kind of cicatrization follows, and leaves
marks or lines behind, indicating the nature of the occurrence. “ These éraillments,"
writes M. J. Cloquet, “happen particularly when the peritonæum, adhering to subjacent
parts by a dense, close, cellular tissue, is dragged or displaced. Hence, this partial lacer-
ation is frequent in the situation of the linea alba, from the distention of the abdomen
and the separation of the recti muscles; and I possess several remarkable specimens of
this kind. In the part which has been thus frayed, the peritonæum is preternaturally

INGUINAL HERNIA.
53
a
" *
thin, representing a network of slender fibers, leaving irregular interspaces, which are
filled with an extremely thin, transparent pellicle. This kind of change is observed, not
only in the peritonæum lining the abdominal parietes, and that which forms the hernial
sac, where it is very common, but also in the serous covering of the displaced viscera.
in the mesentery and intestine when they have been dragged and elongated in large
ruptures.”—(Récherches Anatomiques, p. 48.)
“ The locomotion or displacement, the extension or elongation, and the partial rupt-
ure or fraying of the peritoneum, account satisfactorily for the origin and increase of
the hernial sac; and the two changes first mentioned explain sufficiently the great size
which the bag sometimes attains. Scrotal ruptures may hang half-way down the thigh,
and sometimes nearly reach the knee; yet the whole inner surface of the swelling, in
which all the loose viscera of the abdomen may be contained, is lined by a continuation
of the peritonæum without any laceration or interruption."
M. Cloquet made many experiments upon the dead body, of much interest and value.
“ In some individuals the natural openings of the abdominal parietes are large and
loose; if we push the finger through, the peritonæum is carried before it, forming a pro-
duction which represents a hernial sac. Here the cellular tissue is not torn, but elon-
gated. When the pressure is discontinued, the membrane gradually regains its original
position. This experiment shows that the peritonæum is actually displaced in the for-
mation of a hernial sac; that it leaves the neighboring parts to pass into the aponeu-
rotic opening. The abdominal parietes lend the peritonæum which covers them to
form the hernial sac. The membrane is hardly stretched, and it forms folds in the
opening; in some instances it is both displaced and elongated, covering the finger
closely. In other subjects the peritonæum resists more forcibly, because it adheres
more closely to the parietes; the portion, however, near to the tendinous opening
becomes stretched; its laminæ separate and are partially torn, and may thus form a
very thin sac, different from that in the former instance, which has the material thick-
ness of the peritonæum. The displaced membrane in this case does not recover its
former position, and we find partial laceration in the fundus of the sac.”+
The peritoneal sac may be also formed by causes acting from without. It is a com-
mon occurrence, a number of marked instances of which have come under my personal
a
* A Treatise on Rupture, by W. Lawrence, p. 29, 1843.
+ Récherches sur les Causes et l'Anatomie des Hernies Abdominales, 1819.

54
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
»
observation, where a large, unsupported hydrocele has, by its dragging weight, caused
the depression of the peritonæum at the upper orifice of the inguinal canal to become
deepened, and finally well-marked hernia ensued. M. Cloquet cites an interesting case
of an old man with a large inguinal hernia. “The sac was five inches long; its orifice
was large and rounded, its cavity was divided into two parts by a fibrous prominent
ring. Below the latter the peritonæum was thick, whitish, and strongly adherent to the
external coverings; above, it was thin and transparent, as in the abdomen. The de-
scent of the thickened ring and the elongation of the sac had been obviously caused by
the weight of a large hydrocele of the tunica vaginalis, which adhered firmly to the
lower part of the hernial tumor. A convolution of the small intestine, two inches and
a half long and unadherent, occupied the upper division of the sac.”
Changes in the Hernial Sac.-In the protrusion of the peritoneum through an
opening in the abdominal parietes, it at first passes unchanged through the tendinous
ring, which is more or less firm and resisting. This ring supports the mouth of the sac
and determines its form and size. Since it passes generally through unyielding tissues,
the neck is relatively small, while the body of the sac, comparatively unrestricted, is
usually much larger. The direction or axis of the sac varies in its course, dependent
upon the obliquity of its openings. The form of the sac is necessarily modified by the
opening through which it escapes, by the tissues surrounding it, and the resistance
which is made to its progress. In consequence, the shape and size vary greatly, as in
scrotal, femoral, or umbilical hernia.
When the canal remains circular and tendinous, the sac has an elongated and a
somewhat cylindrical shape. This is generally true in inguinal hernia when it is con-
fined to the sheath of the spermatic cord. Having passed below this, the sac expands,
and may become globular or pyriform. On the contrary, when the sac has escaped
through a direct opening in the abdominal parietes, the resistance is comparatively
slight and equal in all directions, and the shape assumed is nearly spherical or somewhat
flattened, as in umbilical hernia.
In an imperfectly formed inguinal hernia, or bubonocele, the sac will be irregular and
flat, often escaping detection, unless the examination is made with care. While the size
and shape of the hernial tumor thus varies under the modifying influences of the sur-
rounding tissues, these, in turn, are changed under the pressure; the apertures of escape
being altered in size, length, and direction. “The thickness of the neck of the sac
varies much. In small ones of a conical figure, the peritonæum retains its natural


PLATE XIV.
Fig.S.
Fig.1.
Fig.3.
Fig. 2
P
0
..
in
.
J.
1
12
9
Fiq.ij.
Fig.5.
11
Fig.a.
il
os
d.
f
Fig.7.
f

INGUINAL HERNIA.
55
structure at this part, simply turning over and lining the aponeurotic ring. This is the
least frequent case; more commonly, in passing through the narrow aperture, it is
folded, puckered, contracted, and gains in thickness what it loses in extent of surface.
The whole circumference of the neck presents fine folds, radiated wrinkles, more or less
numerous and approximated to each other. If we distend these folds they are seldom
completely effaced, as the two membranous plaits which form each of them become
adherent; this puckering or gathering of the peritonæum necessarily increases the thick-
ness of the neck of the sac. These folds are the rudiments of those which form when
the mouth of the sac gradually contracts. It ultimately disappears, giving origin to
radiated marks, disposed like the rays of a star, indicating the place of its former ex-
istence. . . . Sometimes the neck of the sac presents a rounded, whitish, almost fibrous,
and very firm ring, either of uniform or varying thickness in different points of its
circumference.”
The changes which the neck of the sac undergoes are often very important in the
consideration of operative measures for relief or cure. It is generally adherent to the
ring through which it escapes; rarely it is attached at one side only; the peritoneal
pouch then becomes irregularly saccated, even two distinct pouches may form and
descend below the ring, having a common opening into the abdomen. A sac under
the pressure of a truss may be kept empty, and become adherent and closed at its
eck, and thus a cyst be formed.
.
PLATE XIV.
Figure 1.
Shows a sac taken from the body of a person
who labored under an inguinal hernia.
a. Its mouth.
6. The course of the vas deferens behind it.
c. Iliac artery.
d. Femoral artery.
e, e. Epigastric artery, passing behind the
mouth of the sac.
f, f. Spermatic cord, passing behind the sac
and through the abdominal ring to the testis,
g. The testis.
h. Mouth of the hernial sac.
i. The fundus of the sac, which just reaches
the abdominal ring.
Figure 2.
This gives a view of a hernial sac which has
passed no farther than the abdominal ring, so
that the whole of this sac is included between the
abdominal ring and the place at which the sper-
matic cord quits the abdomen.
a. Abdominal ring.
b. Poupart's ligament.
Figure 3.
Shows the hernial sac divided by several septa.
a. The tunica vaginalis testis.
* M. J. Cloquet, op. cit.
+ Cooper, Plate V, Part I.

56
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
b. Spermatic vessels.
C. Vas deferens
a Mouth of the hernial sac.
e, e, e. Septa seen in the sac, with small aper-
tures in them.
f The fundus of the sac.
a. Sac shut at the ring, but it was open to-
ward the abdomen above the ring.
b. The testis.
c. Spermatic cord.
d. Sac cut open.
e. Part at which the sac was closed by ad-
hesion.
Figure 7
Figure 4.
Shows a hernial sac closed opposite to the
abdominal ring, but open above the ring to the
abdomen. I think that no inconvenience would
arise from this, as the intestine could not descend
into the scrotum, and strangulation would not
probably take place above.
a. Tunica vaginalis.
b. Testis.
(, C. Spermatic vessels.
d. Mouth of the sac.
e. The place at which the sac is closed, which
is opposite to the situation of the abdominal ring.
f. The fundus of the sac.
Shows two sacs, one by the side of the other,
the one contracted by wearing a truss so as to be
no longer capable of receiving the viscera; the
other larger, and forming by the side of the
first.
a. The peritonæum.
b. Mouth of a newly formed sac.
c. Its fundus.
d. Contracted mouth of an old hernia.
e. Its fundus.
Figure 5.
A hernial sac, in which the spermatic cord has
been divided by it, so as to place the spermatic
artery and vein on the inner side and the vas def-
erens upon the outer side of the sac.
a. Abdominal ring.
b. Testis.
c. Femoral artery.
d, d, d. External pudendal artery.
e. Spermatic artery and vein.
f. Vas deferens.
g. Hernial sac.
Figure 8.
An omental and intestinal hernia irreducible
from adhesion; and membranous bands extend-
ing across the hernial sac.
a. Abdominal ring.
b, b. Columns of tendons forming the ring.
c. Transverse tendinous fibers passing to the
two columns.
d. Tunica vaginalis.
e. Epididymis.
f. Testis.
8, 9. Fascia coming from the abdominal ring
to cover the sac.
h, h. Hernial sac.
i, i. Membranous bands crossing the sac.
k. A piece of whalebone to keep the sac ex-
tended.
m. Intestine adhering to the sac.
n, n. Omentum, also adhering to the sac.
Figure 6.
Hernial sac shut at the abdominal ring by
adhesion, leaving a circumscribed bag, in which
water was collected.
A closed sac, developed in this way, may become attached to a more recently
formed hernia, and be itself carried down with the advancing tumor. These conditions
are fortunately very rare, but it should be kept in mind that they do occur, otherwise
when present they will greatly confuse the observer and render diagnosis of extreme
difficulty.
The pathological changes which may take place in the sac are various; direct inju-
ries, wounds, bruises, pressure from an improperly fitting truss, any violence may cause all
the conditions usually ascribed to inflammation elsewhere. Serous, bloody, and turbid
, ,

INGUINAL HERNIA.
57.
The great
secretions may occur. From a variety of causes the sac may become infected, and puru-
lent collections ensue. The sac itself becomes thickened and changed, so as to lose all
the appearances of a serous membrane. I have recently removed the sac in two cases
where it was several lines thick-one, an old hernia, so slight as to give little trouble
until, suddenly, strangulation of the intestine supervened by the escape of a loop
through the ring. The second, a hernia of only three months' standing, and yet it was
,
scrotal, and the omentum adherent to the much-changed walls of the sac.
variety of changes to which the hernial sac is incident have been dwelt upon in greater
detail, because of the importance which these pathological conditions have in relation to
the operative measures for the cure of hernia. Within the last few years much has
been written in regard to the proper disposition of the peritoneal sac, to which we shall
have occasion to make frequent reference in the subsequent pages of this work.
I have made a large collection of deformed, distorted peritoneal pouches which have
contained the contents of old large herniæ. A very considerable number of these I
exhibited at the American Medical Association meeting held at Newport, in 1889,
some filling a quart-jar when everted and stuffed with cotton. Not seldom the peri-
toneal sac, in old herniæ, may be seen with re-enforced bands crossing each other in a
variety of directions, the interstices of which present only thin translucent pouches.
In illustration, I add the interesting description of specimens as given by the cele-
brated surgeons Sir Astley Cooper and Dr. John Hunter.
a
2608. The internal orifice of a hernial sac, to show its valvular appearance."--Hunterian MS. Cata-
logue. The appearance is due to an angular thickening of the peritoneum nearly limited to the
margin of the mouth of the sac, which is thus reduced to a much less diameter than
any
other
part of the sac.-Hunterian.
2610. An inguinal hernia, of which the sac is contracted at the middle, so as to be nearly divided into
two parts. Both its cavities contain omentum.
Mr. Hunter left the following account of this preparation :
“ Winter, 1763.—We dissected a man who had a rupture of a particular kind, a sort of double
rupture on the same side, and in the same passage, and in the same sac. It appeared to me as
if produced at two different times: that the man had a small inguinal rupture for some time,
the contents epiploon, and that the mouth of the sac had contracted a good deal, so that no
return of the epiploon could be brought about. While in this state a second or new cause took
place; and instead of dilating the old sac, by pushing into it more epiploon, it pushed down the
old sac, and a new elongation of the peritoneum followed; so that here was a kind of second
rupture produced. This last was by much the largest.
“It appeared at first to be two distinct bags; but there was the first contraction of the sac
which kept up the communication between the two; and the epiploon passing through, forming
a small neck there."--Hunterian MS. Dissections of Morbid Bodies, No. 71, p. 101.
II

58
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
.
2613. An inguinal hernial sac, with the testicle, dried after the injection of their blood-vessels. The
cavity of the sac is partially divided by a transverse crescent-shaped fold or partition from its
posterior wall, which may have been formed and protruded like the more nearly complete
partition in the preceding case.—From the Museum of Sir A. P. Cooper. (See Fig. 3, Plate
XIV.)
2616. Part of a right inguinal region, together with the sacs of two oblique inguinal hernia on the
same side, dried after the injection of the epigastric, spermatic, and other vessels. The anterior
sac has a small mouth, is elongated, and measures four inches in length. The posterior sac is
larger and nearly globular; its mouth is wider, measuring an inch and a quarter transversely,
and is placed directly behind that of the anterior sac. The spermatic vessels and vas deferens
are attached to the back of the posterior sac and the lower part of the anterior sac; and the
epigastric vessels make a wide circuit, passing round and to the inner side of the necks of both
sacs. The spermatic veins are varicose. From the Museum of Sir A. P. Cooper.
The history of the case is published by Mr. Bransby Cooper, in the Guy's Hospital Reports,
vol. iv, p. 327 (London, 1839). The patient was sixty-eight years old. He had suffered pain in
the abdomen and vomiting for three days, and constipation for two days, though frequent pur-
gatives had been administered, when Mr. Cooper first saw him. He found the left inguinal re-
gion larger than the right, but this appeared to be due to the absorption of the fat on the right
side, on which a truss had been worn for many years. A small hernia had been returned on the
left side, and one could be made to descend on the right side by coughing, but could be at once
very easily returned. But the symptoms of strangulation becoming urgent, the left inguinal
canal was laid open. An empty sac was found therein, but no strangulated intestine. The
patient died next day; and on the examination after death it was found that the small anterior
and elongated sac shown in the preparation had been pushed into the abdominal cavity, to-
gether with a portion of intestine, strangulated by its neck. The reduction of this sac had prob-
ably been effected by the patient while reducing the intestine from the larger and round
posterior sac.
PLATE XV.*
On the right side is seen an oblique inguinal hernial sac upon the anterior part of the sper-
matic cord. On the outer side of this hernia appears an artificial anus, formed from a second
protrusion of intestine on the side of the former: at this opening the ileum had prolapsed, but
in making the preparation it was returned into the abdomen. Both these herniæ had passed
through the abdominal ring, and were situated on the outer side of the epigastric artery, which
has an unusual curve, produced by the long-continued pressure of the hernia. On the left side
a hernial sac is seen, which has passed down on the inner side of the epigastric artery and sper-
matic cord.
a. Symphysis pubis.
b. Anterior superior spinous process of the
ilium.
C, C. Abdominal ring.
d, d. Abdominal muscles.
e, e. Poupart's ligaments.
f, f. Femoral arteries.
£, £. Course of the epigastric artery upon the
right side.
h, h. Origin and course of the epigastric artery
on the left side.
i, i. Spermatic cord on the right side.
* Cooper, Plate IX, Part I.
*

PLATEXV.
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INGUINAL HERNIA.
59
j, j. Testes.
k, k. Vasa deferentia.
1. Spermatic vessels on the left side in a vari-
cose state.
m. Spermatic and epigastric arteries crossing
upon the outer side of the left hernial sac.
n. The artificial anus, by which for eleven
years the fæces were discharged.
0. The sac of the inguinal hernia, which was
the first that had descended in this man.
p. Hernial sac on the inner side of the epi-
gastric and spermatic vessels, which will be found
to have an inclination inward and upward toward
the pubes, and not, as in the common inguinal
hernia, toward the ilium.
9. The colon.
e
Of the Strangulation of the Intestine by the Peritoneum.* Stricture at the Neck
of the Sac; its Intimate Adhesion to Intestinal Contents; Separation and Cure.-
All surgeons of considerable experience have met with cases where the constriction
is due to the thickened peritoneal investment at the mouth of the sac, which, under
the effort at taxis, becomes disengaged from its attachment to the canal, and thereby
deceives the superficial observer in the belief that the hernia is reduced. Instead of
quoting from my own experience, I have preferred to select the following cases from
the rare but always interesting work of Arnaud, which illustrate exceptionally well
the danger, which the surgeon must ever bear in mind, from the difficulties and
complications which may unexpectedly arise during the operation for the relief of
strangulation. They are, moreover, among the earlier cases of this class which were
clearly understood and carefully reported; besides, they have a quaint flavor of their
own, and in the discussion of the instrumental procedures reveal a touch of the
humanities as to the methods of a rival, repeated in the experiences of each genera-
tion, although perhaps not formulated in the works to be handed down to posterity :
“ A young man of eighteen years of age, employed in the drudgery business of the wax
manufacture at Antoni, a little town about twelve miles from Paris, had been subject
to a complete hernia from his birth, which had never been rightly kept up. January 28,
1738, he was seized with colics, nausea, vomitings, and a suppression of his stools. The
surgeon of the place, who presumed that the disorder was a common strangulation of
the gut, made use of all the ordinary means in such cases, and called me into consulta-
tion on the fourth day. Upon examination I found the tumor complete, very hard,
and about the bigness of a turkey-hen's egg. I reduced it with great ease, but imme-
diately it came down again ; I reduced it a second time, and still it came down as
before, without the least change in its size or hardness. When I had reduced it the
third time, I followed it with my finger, to feel of what consistence it was, when
* Arnaud, Observation XIV, p. 408.

60
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
reduced; and, finding it then as hard as ever, I concluded there was a strangulation
formed by the peritonæum, and proposed the operation, as the only means of relieving
the patient. What I said seemed to surprise the surgeon-in-ordinary, who thereupon
desired that some surgeons of the neighborhood might be called in, to which I readily
gave my consent.
“ Nothing could therefore be done till next day; and in the mean time the patient
had a remission of three or four hours, and was so quiet when these surgeons came that
they could scarcely believe that there was a strangulation in the case, especially when
they found that the tumor could be reduced, and come down again with freedom, and
that none of the usual bad symptoms appeared. I assured them they would find the
symptoms return more violently than ever, when the remission was over; which accord-
ingly happened. The patient fell into an excessive vomiting, his belly grew harder, his
fever increased, etc., and then the operation was agreed to. I performed it in the pres-
ence of three consulting surgeons and the surgeon-in-ordinary. I had no sooner laid
bare the sac, than they were all convinced of the truth of what I had advanced. There
was an evident stricture of the hernial sac, reaching about a line below the ring. I
pulled the tumor gently outward, in order to judge of the precise length of the stricture,
which appeared then to be at least three lines. The whole tumor was shaped like a
pear; that part which was in the ring, resembling the stalk, was about an inch in cir-
cumference, and, as I have said, three or four lines in length. My next intention was
to open the sac; but it adhered so intimately with the whole surface of the intestine,
that it was impossible to open it, in the common way, without the greatest danger of
wounding the gut. In a case of necessity, indeed, I should not have regarded this cir-
cumstance, since I have frequently opened the intestine with success. But in the pres-
ent case I knew I could avoid that accident by going a little out of the common road
in operating. I dilated the upper part of the ring the length of four or five lines. I
drew the tumor as much outward as I well could, and desired an assistant to hold it in
that state; then I opened the peritonæum above the stricture, and introduced my probe-
pointed bistoury through the wound I had made in the peritonæum first into the cavity
of the belly, and then into the orifice of the sac. By this means, the dilation of the
stricture was accomplished with all imaginable ease ; and the intestine, though every-
where adhering to the surface of the stricture, and in a very tender state, being quite
livid, was not injured by the bistoury, because its rounded blunt point served to sepa-
rate the adhering parts, as I expected, indeed, it would, when I projected this method

INGUINAL HERNIA.
61
of operating. What argument might I not raise, from this, against Mr. Le Dran's
sophistry! But, to proceed: when I had thus dilated the stricture at the orifice of the
sac, I separated the lips from the intestine with an instrument which I commonly use
upon such occasions, the extremity of which is formed somewhat like a spatula ; then,
with the same instrument, gently worked my way down to the bottom of the sac, which
made room for introducing a director, and cutting up the sac in its whole length. Then
I proceeded to the separation of the sac and gut, which adhered all round. The adhe-
sion was of that kind which I call agglutination, except in one place, about the extent
of the nail of the thumb, where it was of the third kind, or that by incarnation. I
was fortunate enough to complete the separation all round without injuring the gut.
I returned the intestine, and dressed up the patient, who recovered perfectly in three
weeks, without any sensible exfoliation from the gut.”
Strangulation at the Neck of the Sac*—“In the year 1736 a man of a robust
.
constitution, of thirty-eight or forty years of age, with an inguinal rupture of the right
side, was seized with a strangulation of the gut. His surgeon-in-ordinary reduced
the tumor on the first day, but, not finding the symptoms in the least mitigated, he
thought proper, on the third day, to order a purging potion. Mr. Henry, the apothe-
cary, who had some scruples about the matter, did not think fit to give it him till
I had first determined the reduction to have been properly made. I waited upon
this patient, attended by Mr. Romanin, and understood, from the patient's own
mouth, that the rupture had always been a complete one, seven or eight inches
in length, and that for above fifteen years it had never been kept reduced. How-
ever, he had worn trusses of various kinds, with an intention only, as he was told,
of preventing the increase of the rupture; the ordinary cant of ignorant truss-makers,
who know nothing of the nature of the distemper they pretend to cure. Mr. Romanin,
as well as I, found the parts, in all appearance, so well reduced that he was at a loss
how to account for the continuance of the bad symptoms. The patient's belly was
extremely tense, his vomitings were violent, but not very frequent, and he brought up
what is commonly taken for fæces in such cases; he had no passage downward, not
even for one drop of oil, though he had swallowed four pints. I told Mr. Romanin
that I imagined the cause to be a strangulation, occasioned by a stricture of the
peritonæum; and that the stricture must certainly be upon that part of the sac which
* Arnaud, Observation V, p. 371.

62
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
had sustained the pressure of the pads of the trusses he had worn. What led me to
think so was the easiness with which, I was informed, the tumor had been reduced.
In order to satisfy myself more thoroughly, I examined the ring (which was very
wide), plunged my finger into it, upon the extremity of which I felt the resistance
of a very hard tumor; I ordered some assistants to raise the patient, and desired him
to make the proper efforts for determining the parts downward. By these means
the tumor was brought nearer to the ring, and I could then more distinctly feel its
resistance upon my finger, which was like that of a bladder distended with a fluid,
the inseparable character of a strangulated rupture. As I was now fully convinced
that the sac itself formed the strangulation, I proposed the operation as the only
means of relieving our patient. It was put off till next day, and then I per-
formed it in presence of my brethren, Messieurs Marsollan, Cadet, Foubert, La Faye,
and Romanin. When I had laid the ring bare, I found it so large that I could
not take hold of the lower part of the hernial sac; however, as the tumor seemed
to be of a larger diameter than the ring, I judged it advisable to procure a little
more freedom, by making two pretty deep scarifications. By this means I had suffi-
cient room for opening the sac, which I did to the extent of about an inch. Then
I attempted to bring the rupture out through the ring, laying hold of the two flaps
of the sac with my fingers and pulling toward me; but in vain. I was therefore
obliged to finish the operation in a much more laborious manner than would have
been necessary had I been able to come at the tumor properly. I introduced my
finger into the sac, in order to discover its depth, and to assure myself of the quan-
tity and kind of the bowel which it contained; and wherever I could convey my
finger I met with nothing but a portion of the intestine. The sac, however, was so
deeply situated that I could not reach its orifice. I was therefore obliged to make
a third dilatation of the ring. This incision was made through the middle of the
tendinous arch which forms the upper part of the ring; and as it was finished with-
out removing my finger, I had then room enough to carry my finger quite to the
orifice of the sac. By this means I discovered that the intestine alone was fallen
down; that it did not adhere to the sac, but was under a very violent strangulation
from the orifice of the sac. I withdrew my hand, and desired the gentlemen called
into consultation to examine and assure themselves of these facts, one after another,
which they all did accordingly. We found that the tumor ran along the musculus
rectus as far as within two small finger-breadths of the navel. It seemed to be nearly
.

INGUINAL HERNIA.
63
two inches in diameter at the lower part, and became gradually smaller toward its
orifice, so as to resemble a cone in figure. After we had made these scrutinies, I
tried again to bring out the rupture, but with as little success as before; the adhesion
which the sac had contracted with the contiguous parts upon which it lay, confined
it so much that it could not be moved. I was therefore obliged to contrive a safe
and sure method of cutting the strangulation ; for this purpose, I introduced the
middle finger of my left hand quite up to the mouth of the sac, and upon that
carried in my probe-pointed bistoury, in order to dilate the stricture, which I did to
the satisfaction of all the gentlemen present and the immediate relief of the patient.
“ As this singular disorder was very different from all the others, both in its kind
and in its situation, it was indispensably necessary to lay aside the common method of
operating and substitute a new one. In most cases, it is no difficult matter to con-
duct the knife upon the forefinger; the surgeon never loses sight of the instrument :
he places himself with his back obliquely toward the patient's feet and his face to-
ward the part affected, his elbow in the mean time resting upon the inside of the
patient's thigh. But in this case all these precautions were useless, since nothing
could be done but by guess, though feeling only could safely conduct the operator.
The depth of the sac, and its being filled with the gut, so as to leave little room
for the introduction of the finger, were two circumstances, which obliged me to con-
duct my hand a different manner from what is usual upon these occasions. My
back was turned obliquely toward the patient's head, my elbows were bended to a
right angle, my hand was bended considerably at the wrist, and thus I introduced the
whole of my middle finger in the sac. Though this posture may seem a little awk-
ward, yet it is the only one which could possibly have been used upon such an
occasion. Had I introduced my hand in the usual way, I should have dilated the
ring rather than the orifice of the sac, by the incision, because in that position I
could not have sunk my wrist enough. I introduced the bistoury, with its flat side
toward my finger, in order to avoid a further dilatation of the ring. When the point
of my bistoury had reached the stricture at the orifice of the sac, I carried it inward
under the edge of that stricture, taking the advantage of a small vacuity left between
the two portions of the doubled intestine; and in proportion as I pushed the bistoury
forward, I followed it with my finger, in order to conduct it in such a manner as
not to injure the intestine, and the better to judge when I had sufficiently removed
the stricture. While I was employed in this part of the operation one of the as-

64
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
sistants, laid hold of the sac, and kept it fixed, that it might not yield so as to escape
the knife. By the dilatation which I was obliged to make, I guessed that the con-
tracted part of the peritonæum which formed the stricture might be almost half
an inch in breadth. This operation being performed, every one present was satis-
fied, from the loose state in which we found the intestine, that the dilatation I had
made was sufficient. As it was impracticable to introduce two fingers into the sac
in order to return the intestine, I judged it advisable to leave the intestine to return
of itself. Neither did I think it proper to attempt laying open the sac the whole
way from its bottom to its orifice. This I knew was impracticable; besides, I was
upon my guard against an accident which might have ensued, and which is common
enough, though hitherto scarcely observed. Before the patient was quite dressed
he had a free and copious stool; and the first time I had occasion to remove the
dressing I found the intestine returned. From this time he daily went more and
more freely to stool, had no bad symptom, not even a feverish fit, and in a month's
time was perfectly recovered.”


PLATE XVI.
c
c
6
b-
9.
g
h
k
k
7
f
od
d
Ip
t
9
9
$
su

CHAPTER V.
DIRECT INGUINAL HERNIA.
By reference to the description of the peritonæum and its relationship to the parts
involved in hernia, it will be observed that the second depression of the peritonæum is
separated from the first by rather a firm connective-tissue band, called the umbilical
ligament. Nature has re-enforced this portion of the abdominal wall by a strong fascia
of connective tissue, called the triangular ligament, which serves greatly to strengthen
the fascia transversalis. The conjoined tendons of the internal oblique and transversalis
muscles do not usually extend beyond the umbilical ligament, so that this portion of
the abdominal wall is dependent for its support upon the above-mentioned connective-
tissue structures.
When the weakening of the abdominal wall occurs here, the opening from the
abdominal cavity is obviously more direct than in the ordinary varieties of inguinal
hernia. This was called by Hesselbach internal inguinal hernia, who pointed out that
it was situated internal to (nearer the middle line) the epigastric artery. Sir Astley
Cooper named this affection direct inguinal hernia, because, instead of following the
oblique course of the spermatic vessels, it passes at once through the posterior wall of
the inguinal canal, immediately behind the external abdominal ring.
PLATE XVI.*
In this plate a common inguinal hernia is shown upon the left side, taking its course through
the abdominal ring on the outer side of the epigastric artery, between that artery and the spine
of the ilium. The hernia upon the right side is that variety of the inguinal hernia which passes
from the abdomen on the inner side of the epigastric artery, or between that artery and the sym-
physis pubis.
a. Symphysis pubis.
b. Anterior superior spinous process of the
ilium.
C, C. The spine.
d, d. The acetabula.
e, e. Tuberosities of the ischia.
f, f. Abdominal rings.
g, g. Poupart's ligaments.
Cooper, Plate VII, Part I.
12

66
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
h. Linea alba.
0, 0. Spermatic arteries.
i. Aorta.
Pep. Spermatic veins.
j. Bifurcation of the aorta.
9, 9. Spermatic cords.
k, k. Iliac and femoral arteries.
S, S. Testes.
1. Origin of the epigastric artery on the right t. Oblique hernial sac upon the left side, situ-
side.
ated on the outer side of the epigastric artery.
m, m. Course of the epigastric artery on each v. Direct hernial sac upon the right side,
side, marked by dotted lines; the left side passing placed upon the inner side of the epigastric artery.
on the inner, the right on the outer side of the W. The spermatic cord passing on the outer
hernial sac.
side of the direct hernial sac, while it is seen on
n. Vena cava inferior.
the posterior part of that on the opposite side.
a
a
Scarpa thought, on the contrary, that it should be considered a combination of the
ventral and inguinal varieties, since, although direct, it passes through the external
abdominal ring, along the line of the spermatic cord. There is a variety of the direct
hernia which it is important to recognize. It has been already referred to under the
name of bubonocele. This latter, however, most often occurs when the hernial protru-
sion commences at the internal ring. The tumor thus formed is arrested in its further
development by the firm aponeurosis of the external oblique muscle.
In corpulent individuals it is exceedingly obscure, and may be overlooked unless
the parts are subjected to a most careful examination. It not infrequently happens,
especially in females, that the cause of suffering, produced by a small portion of incar-
cerated intestine, is overlooked until too late to avert a fatal termination, and when the
general symptoms of hernia, as evinced by local pain, nausea, vomiting, etc., occur, it is
of the utmost importance that a careful examination be at once instituted to determine
if hernia of this variety is the cause of suffering.
In direct hernia, as would be inferred, the spermatic cord is situated along the exter-
nal and posterior side of the sac. Cases are reported by Cloquet, Todd, and others,
where it is arched in front of the upper portion of the sac; and this would be important
to determine first, since in this position the ordinary dissection would cause a division of
the cord; indeed, this accident has occurred in some instances. It is necessary to bear
in mind the anatomical differences which define this variety of hernia. The epigastric
artery lies upon the outer side of the opening, and this, after all, may be considered as
the most important anatomical landmark.
The tendons of the internal oblique and transversalis muscles are inserted into the
pubes and connected with the fascia, which passes upward from the external oblique
muscle at Poupart's ligament. Occasionally these structures are unusually weak and
allow a protrusion of the abdominal contents quite nearer than usual to the median

DIRECT INGUINAL HERNIA.
67
►
line, and when hernia does occur in this locality it is situated upon the inner side of
the epigastric artery. Usually a careful study of the conditions in direct hernia makes
it not very difficult to distinguish from the indirect variety. The appearance of the
tumor below the abdominal ring differs from that of a small indirect hernia in being
situated nearer to the penis, and the spermatic cord passes on its outer side instead of
its posterior part, particularly at and above the abdominal ring. Within the abdominal
ring the sac may be carried directly upward, so that no part of it takes the usual exter-
nal oblique direction, but rather, on the contrary, passes somewhat inward toward the
linea alba. The dissection of a direct hernia, as given by Sir Astley Cooper, is as fol-
lows: “The sac first appears between the fibers of the tendon of the transversalis,
nearly an inch directly above the ring, generally protruding before it the fascia transver-
salis. It then passes under the lower edge of the tendon of the internal oblique mus-
cle. The epigastric artery runs upon the outer side of the hernial sac. The spermatic
cord has no connection with it above the ring. The hernia then emerges from the
abdominal ring, the spermatic cord being at its outer side, and it is covered with the
fascia given off by the tendon of the external oblique, but not by the cremaster
muscle.” *
As would naturally be inferred from the character of the tissues through which the
direct inguinal hernia makes its escape, this variety seldom acquires the large size so
often met with in indirect inguinal hernia.
The cause of this variety of hernia is often found in indirect injury. Mr. Cooper
instances one case which came under his observation in a lad, resulting from a kick
given by a schoolmaster; also another case, which resulted from being thrown from a
horse.
In old men, where the abdominal wall is weak, prostatic obstruction causing
dysuria and great straining in micturition is a common cause of hernia. Mr. Cooper
believed that the direct variety was quite likely to result from difficulties in micturi-
tion from any cause, and he gave, as a special illustration, Plate XVIII, taken from
a specimen in his possession which contained six herniæ, all of which are of the direct
variety.
When a direct hernia is reducible, and operative measures for its cure are not ad-
vised, it is important to remember that the truss used for its retention should be espe-
* See Plates XVI and XVII, which give a view of this variety of hernia.

68
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
cially adapted for its purpose, since the opening through which the sac emerges from
the abdomen is, in the adult, about one inch and a half nearer to the median line.
If the hernia is double, a central plate well padded is better than the usual variety
of double truss. It is important for the practitioner to keep in mind the anatomical
relationships which differentiate this form of hernia when the attempt is made for its
reduction, since the direction of the pressure to be applied is upward and inward, in-
stead of outward, as in indirect hernia, and it will readily appear that during manipula-
tion the body and limbs should be so placed that the recti muscles may be thoroughly
relaxed.
When strangulated, and operative measures are to be undertaken for relief, it is of
the first importance to remember that the usual division of the constricting ring in an
outward direction greatly endangers the epigastric artery, since this vessel is usually in
close proximity to the neck of the sac for a considerable portion of its outer and upper
border. Cutting directly upward and inward, this accident will be avoided. The divis-
ion of the epigastric artery may occur without the surgeon being aware of the fact.
Mr. Cooper gives several cases, of which the following is an illustration :
“A patient of Mr. Sterry's, surgeon in Bermondsey Square, had been for three
days laboring under the symptoms of strangulated hernia. The hernia was scrotal, and
as it had resisted every attempt at reduction, Mr. S. requested me to see him; the
operation being agreed upon, I performed it precisely according to the rule usually
laid down for dividing the mouth of the hernial sac; that is, upward and outward.
As soon as the division was made, a quantity of arterial blood was seen flowing down
over the intestine within the sac, and the bowel being immediately returned, a consid-
erable stream of arterial blood flowed into the sac. Pressure was made upon the groin
in the situation of the epigastric artery, in order to prevent the hæmorrhage, and appar-
ently with success; but, four hours afterward, Mr. Sterry was sent for on account of a
copious discharge of blood from the wound. He made a further pressure, but without
success, and the man died in ten hours after the operation, becoming gradually faint
after it, and the abdomen being distended with blood.” In M. J. Cloquet's experience,
who it will be remembered made careful dissections of over five hundred hernial sub-
jects, he found the proportion of direct to oblique inguinal hernia as one to five. This
is a much greater proportion than is usually accepted. It is, however, without ques-
tion that in the living this variety of hernia is comparatively rarely differentiated.


PLATE XVII.
后
​k
h
-b
»
d
d
ne
m
2

DIRECT INGUINAL HERNIA.
69
PLATE XVII.*
An internal view of the same preparation as that of the former plate, showing the orifice of
the hernial sacs, with the relative situations of the epigastric and spermatic vessels.
a. Symphysis pubis.
b. Anterior superior spinous process of the
ilium.
c. The spine.
d, d, d, d. Abdominal muscles drawn downward
to show the cavity of the pelvis.
e. The bladder.
f. The rectum.
g. Bifurcation of the aorta.
h. The inferior cava.
i, i. Spermatic arteries.
k, k. Spermatic veins.
1. Vas deferens.
m, m. Epigastric arteries and veins.
n, n. Origin of epigastric artery on each side.
0,0. Peritonæum.
p. Mouth of the hernial sac upon the left side,
taking the usual oblique course of inguinal hernia.
9. Mouth of the hernial sac on the right side,
situated upon the inner side of the epigastric ar-
tery.
By this plate it will be at once seen that the division of the stricture upward and opposite the
middle of the orifice of the sac will be in both species of hernia perfectly safe.
The definition of direct inguinal hernia is correct, although confusing; correct, in the
anatomical sense, as to origin and development, but incorrect and confusing, since, unless
its origin and development are kept clearly in mind, this comparatively rare variety of
hernia will be confounded with that form of indirect inguinal hernia which, from the
dilatation of the canal, has caused the obliquity of its course to be so changed as to be
almost altogether lost. When these pathological conditions have become thus pro-
nounced, it is equally proper to define it as direct hernia, since the protrusion of the
abdominal contents has now made its escape by a direct opening. It will be readily
observed that too much emphasis can not be made upon the distinctive anatomical dif-
ferences of these two varieties of hernia, since in the latter and by far the larger propor-
tion of the cases, the inguinal canal is the opening for escape along the line of the pas-
sage of the spermatic cord; while, in the variety under discussion in this chapter, the
cord and its vessels have no association with the outlet except the one already referred
to, where, in case of strangulation, it is important to differentiate the anatomical rela-
tions before division, in order that these important structures may not be injured.
It will be readily seen, from the foregoing, that operative measures for cure have a
radical difference in the two varieties, dependent upon the component structure of the
parts. In the direct hernia of Sir Astley Cooper, under consideration, after the disposi-
* Cooper, Plate VIII, Part I.

70
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
tion of the sac, the measures for which are the same, as elsewhere advised in the other
varieties of hernia, the closure of the opening is made complete, as in indirect inguinal
hernia in the female; whereas, in large old direct herniæ which have formed along the
line of the spermatic cord, the resultant cure must depend, in very large measure, upon
the restoration of the obliquity of the inguinal canal. Observe carefully the internal
relationships of the parts as seen in the following plate.
PLATE XVIII.*
This plate shows six hernial sacs, which were taken from a patient of Mr. Weston's, surgeon,
Shoreditch, who labored under a difficulty of discharging his urine, from a stricture and stone in his
urethra. Two of the sacs upon each side were placed between the umbilical and epigastric arteries ;
and one on each side is situated between the remains of the umbilical arteries and the pubes.
They
passed between the tendinous fibers of the transversalis, which they had separated, and entered the
abdominal rings, after which they were covered, as usual, by the fascia, which is extended from the
external oblique muscle over the spermatic cords.
a. Situation of the symphysis pubis.
b. The muscle removed from the anterior su-
perior spinous process of the ileum.
c. Abdominal muscles lined with peritonæum.
d, d. Spermatic cords.
e, e. Testes.
f, f. Remains of the umbilical arteries,
8,8. Epigastric arteries and veins.
h, i. Two hernial sacs on the left side, formed
between the epigastric and umbilical arteries.
j. Hernial sac formed between the umbilical
artery and symphysis pubis.
k, l. Two hernial sacs formed between the
epigastric and umbilical arteries on the right side.
m. Hernial sac between the umbilical artery
and the pubis on the right side.
* Cooper, Plate X, Part I.

PLATE XVIII.
c.
с
g
G.
2
d
Jd
e
e


CHAPTER VI.
INDIRECT REDUCIBLE INGUINAL HERNIA.
INSTRUMENTAL SUPPORTS.
As we have already seen in the discussion of the subject of hernia, by far the larger
number of those suffering from this affection are classed under this variety. Since the
days of the early writers upon surgery it has been clearly pointed out, that the ana-
tomical conditions which permit the escape of the spermatic cord through the abdomi-
nal wall, have caused this to be the weakest part of its structure, while for quite two
thousand years the difficulties have been fully recognized which make the surgical
attempt at cure so often result in failure. It is on this account that we invite the
reader to a most careful consideration of the subject.
Reducible Inguinal Hernia.—Under this division may be included by far the larger
number of the ruptured, the great army of semi-disabled, truss-bearing individuals of
every generation and race. The protrusion, more or less marked, gives a sense of
weakness and discomfort never absent, but varying greatly in degree. Every surgeon
should familiarize himself with inguinal hernia in its earlier stages. It is generally true
that his attention is not called to this condition until a small portion of the abdomi-
nal contents, omentum, or intestine has escaped through the external ring, and the
patient in alarm discovers a soft protrusion or tumor in this locality. When this has
taken place, the parts are usually easily reduced, and, in the horizontal position, in
order to secure a relaxation of the structures, the surgeon readily invaginates a portion
of the scrotum on the finger, carrying it directly into the lumen of the dilated canal.
Under these conditions, although the internal ring is dilated, and the peritoneal sac
has for a considerable period been in process of formation, the canal is not very much
foreshortened, and its obliquity is still in a measure preserved.
The abdominal contents find ready lodgment within the gradually enlarging sac,
and act daily as a wedge to dilate still further and deform the structures of the canal.
Under these conditions the surgeon usually contents himself by sending the invalid to
some instrument-maker with directions to be fitted with a truss, and feels that his duty
is completed without further observation of the patient. In most of our large cities one
a

72
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
or more mechanicians are found who have made a special study of trusses and their
application, as, for instance, in Boston, Dr. Benjamin Codman, of the firm of Cod-
man & Shurtleff, and Dr. Nathaniel Greene, of the firm of Leach & Greene, both
regular graduates of medicine, and especially skilled in the manufacture and fitting of
surgical appliances. But by far the larger number of trusses are fitted by apothe-
caries and those who at the best know little of the subject. It is of the greatest
importance that every physician, as well as surgeon, should make a careful study of
the proper measures for the retention of hernia, if possible more important in its ear-
lier stages, especially in the young, than when the disease is more advanced.
In the recumbent position, pressure upon the protruding parts causes them to be
returned into the cavity of the abdomen. In the larger proportion of cases a prop-
erly fitting truss retains the hernia. Often, however, after some unusual exertion, the
tumor becomes large, and its reduction is attended with difficulty. The individual
with such infirmity lives in constant danger. Accidents in great variety, often from
the most trivial causes, may produce strangulation of the prolapsed intestine, the con-
sequences of which will be fatal, unless early relieved by skillful measures. To pre-
vent this as far as possible, and make comfortable rather than to produce a cure, the
truss has been devised.
Instrumental Supports.—It is not my purpose in this treatise to enter into a
detailed description of, or especially to differentiate between, instruments of support.
Although the variety of trusses seems almost infinite when the stock of a large dealer
is examined, certainly confusing to the young or inexperienced, new patterns being
constantly offered as possessing some hitherto unknown merit, little real advance in
the art of truss-making has taken place since the days of Sir Astley Cooper, nearly
a century ago. After discarding the use of all other supports and bandages, as of
a
little value, often of damage, he describes the truss as follows:
“A steel truss is composed of a pad made of a supporting piece of iron, and
stuffed so as to take a conical form, the apex of which immediately compresses the
abdomen at the part whence the hernia threatens to descend. The pad is riveted
upon a long flat piece, tempered to a great degree of elasticity and curved to the
shape of the lower part of the body, which it embraces like a belt. The length of
this steel should be sufficient to pass from the hernia round the region of the groin
to about an inch beyond the spine behind, forming somewhat more than a semi-
circle, but compressed. Both the pad and truss are quilted with leather. A strap of

INDIRECT REDUCIBLE INGUINAL HERNIA.
INSTRUMENTAL SUPPORTS. 73
leather proceeds from the hind-end of the truss, which passes round the body, com-
pleting the circular belt by fastening upon the pad. ... Many surgeons, and almost
every surgeon's instrument-maker, have thought proper to vary the form of the truss,
and to prescribe different rules for the duration and force of the pressure, but almost
all have agreed in determining that the pressure should be made upon the abdomi-
nal ring.
This is precisely the circumstance, however, in which they are all defective; and,
indeed, it is the frequent failure of the purpose for which they are designed, when
made according to this principle, that has led to such a variety in the mode of their
construction. The object in applying a truss is to close the mouth of the hernial
sac and destroy its communication with the abdomen, and this object can never be
perfectly fulfilled by any truss which is applied in the usual manner upon the ab-
dominal ring, and extending from it upon the os pubis. In this case the cure must
be incomplete, because a considerable portion of the hernial sac remains uncompressed
toward the abdomen, which portion is that situated between the abdominal ring and
the opening of the sac into the cavity of the belly."
Even when the truss has been worn, apparently successfully for some time, over
the external ring, should this become closed under the pressure, the neck of the sac
is left open to receive the wedge-like dilating force of the abdominal organs, and the
supposed cure soon fails. Not seldom the pressure is directed so low as to injure
the cord, interfere with the nutrition of the testis by disturbed or impeded circula-
tion, and cause severe suffering. If cure is to be effected by a truss, it must prevent
the peritoneal pouch from protruding through the internal ring, allowing the internal
orifice to close, and the peritoneal sac, no longer holding a portion of the abdominal
contents, to contract and possibly to disappear. If such conditions can be maintained,
the inguinal canal becomes smaller and the connective-tissue structures in a measure
strengthened. If, on the other hand, a considerable amount of pressure is maintained,
quite toward the median line, absorption and atrophy of tissues ensue, and the ab-
dominal wall becomes thin and weakened.
The surgeon should not only practically understand the proper method of fitting
a truss, but should consider it a personal duty to see that the instrument is rightly
applied, of suitable strength, a well-fitting pad, and should give the sufferer the
requisite details of instruction as to its wearing. The skin in the region of the groin
will need attention for some time, as friction and soreness ensue. Often a fold of
13

74
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
India silk, as, for example, an old handkerchief, under the pad, is of the greatest com-
fort. Individuals, after middle life, may not expect a cure, and should be taught to
look upon a truss as a part of the impedimenta of subsequent living.
We can not do better than emphasize the direction of Sir Astley Cooper to
make the pressure over the internal ring, and, as a rule, not with a large pad. A
small, well-fitting pad, which the proper adjustment of the truss will allow to be retained
over the exit from the abdomen, is the end to be attained. While the curve of the
spring should be adjusted to the configuration of the wearer as far as practicable, it
should lie above the region of the glutei muscles; otherwise their action in locomotion
produces a constant movement of the pad.
Trusses may be divided into two general classes: the so-called French and German
or English. The former has a very light but highly elastic spring, clinging closely to
the body, and following up the retreating parts in every motion. Constant pressure
is preserved by it. On the contrary, the German truss has a much heavier spring,
shaped so as to conform to the outline of the body, and hence is less elastic and less
comfortable. It resists with great power any strain brought to bear upon the parts
in contraction, but presses only lightly, or not at all, when the body is at rest. Ameri-
can ingenuity has found a fertile field in truss construction, which of itself would
make a chapter of much interest. The small hard pad of wood or ivory, with a spring
constructed so as to carry the supporting force obliquely upward in the direction of
the canal (the White truss), often serves a valuable purpose. This is a modification
of the wood pad first devised and sold about 1833 as the Stagner truss. These were
greatly improved by Dr. Heber Chase and others. The water-pad, invented by Dr.
Nathaniel Greene, of Boston, made of rubber and filled with water, is also a valu-
able contribution to both comfort, and convenience. Where a light pressure only is
required, it is often of the highest value. An elastic rubber pad, filled with air, is a
modification of the water-pad, and has the advantage over it of being lighter, and it
is claimed to possess durability. This is a patented truss (“ Rorick's air-pad”), and is
well made by the Hastings Truss Company, of Philadelphia. These pads are adjusted
to all the various styles of trusses. My own experience in the use of these trusses
is
very satisfactory, although limited to a few cases especially selected for trial. They
are very comfortable, and when the pressure is required low down, the bearing upon
the pubic bone is less painful and injurious than when the firmer pad is used. After
a time the pad flattens and becomes far less serviceable.

INDIRECT REDUCIBLE INGUINAL HERNIA.
INSTRUMENTAL SUPPORTS. 75
Since we shall not again return to the subject of supports, it may be added that
femoral hernia requires an instrument adapted to make the pressure quite lower than
in inguinal hernia. In large, irreducible hernia, special supporting and constricting
bags, lacing or otherwise, have been devised, and when, for any reason, operative
measures are not advised, should always be carefully applied. Umbilical trusses are
made also in considerable variety, but in all the one general object is to obtain a
support to prevent the escape of the hernia, or, where this is impossible, to retain
from greater enlargement.
We have elsewhere shown that Celsus was familiar with the surgical treatment
of strangulated irreducible hernia, and that the surgeons of the Roman Empire con-
sidered that operative measures should be often advised for its cure. Bandages and
compressors were in use for the retention of hernia. Galen devotes considerable
space in his works to the description of supports and how to apply them. Pads
of wood and iron attached to a non-elastic girdle are described as being in use in
southern Europe six hundred years ago. The use of a soft iron girdle molded to
fit the shape of the body and adapted for the support of the pad is attributed to
Fabricius Hildanus in the sixteenth century, but it was not until the subsequent cent-
ury that the elastic steel spring came into use. At a meeting of the New York
Medical Society in 1889 the subject of hernia was freely discussed, and Dr. S. E.
Milliken's paper, upon “What Special Mechanical Treatment has Proved most serv-
iceable for each Variety of Reducible and Irreducible Hernia,” was so concise and
valuable that I quote as follows:
“ Inguinal Hernia.—The great majority of cases being inguinal, my remarks will
for the present be directed to this variety. For convenience and practicability I have
divided it into three degrees, as follows: 1. A simple bubonocele, when the viscus
remains in the canal. 2. The hernia is without the external ring, but the canal re-
mains oblique or intact. 3. The canal is obliterated and the external ring is enlarged.
This last degree is practically a direct hernia.
“The difficulty with which herniæ of the first and second degrees are retained is
usually not great when a truss is employed. The most satisfactory treatment has been
the use of one of the following five forms of truss :
"1. The spiral spring, of which there are many modifications, and which is too well
known to call for description. This style is especially adapted to patients that require
perfect freedom of the abdominal walls, as only a leather strap is in front. In cases of
.

76
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
6
the third degree, it is often necessary to attach a perineal strap, and even with this
procedure a few exceptionally difficult cases can not be retained.
“ 2. The 'Knight'truss, which has a band that is almost elliptical, and extends about
three fourths around the body; on the end is attached a malleable shank, with a round
or oval pad. The band should be so tempered that it can be fitted to the body after
it is covered. The mechanism is very simple, and, with the proper adjustment of the
shank, there are very few cases, even of the third degree, that are unmanageable. The
addition of a perineal strap assists greatly in keeping the pad in position. A double
truss can be made by attaching another shank about four or five inches from the
band that crosses the abdomen.
"3. A form of truss which differs from the above only in having no shank. The
· Seeley,' which is covered with hard rubber, and the celluloid • Pennfield,' are the most
durable examples of this form. This truss is better suited to the first and second de-
grees, because the pressure does not have to be made so low. It is also applicable to
the third degree, but is somewhat less efficient than the Knight.'
“ 4. A complete band, which is exemplified by the ‘Hood.' This truss has a tem-
pered bar on each side, that extends from the sacro-lumbar joint to the inguinal region,
where it is attached to a slotted steel plate, which is connected with its fellow on the
opposite side by a bar that is considerably heavier than those of the side. The pads
being also slotted, allow the truss to be adjusted to suit nearly all forms of inguinal
hernia. With a well-fitting band, the antero-posterior pressure can be regulated by the
thickness of the pad. Only in extreme cases of the third degree does a large pad have
to be employed.
“5. A truss with a complete band and a shank, which has proved quite efficient in
corpulent cases with large rings. This is simply a combination of the Hood' and
* Knight' trusses. The band, which is a single piece of bar steel, is fitted to the pelvis
and abdomen with the patient standing. It is especially important that the band
should come just beneath each anterior superior spinous process, to prevent upward dis-
placement. Although the band crosses the lower portion of the abdomen, it need not
restrict its movements, because it can be arched forward without decreasing the useful-
ness of the truss. The shank has to be slightly longer than on the Knight, but
otherwise is the same.
The band has about the same dimensions as that of the
Hood.' The use of this truss has been limited to those cases in which the hernia
was especially difficult to retain ; and care has been taken to get a perfect fit in each

INDIRECT REDUCIBLE INGUINAL HERNIA.
INSTRUMENTAL SUPPORTS. 77
66
instance. But for the majority of cases of inguinal hernia it is quite unnecessary to
make special trusses when such a variety of forms are ready at hand.
“ Femoral Hernia.—As the anatomical relations are much less varied in femoral
than in inguinal hernia, it is unnecessary to make any subdivision of this class of cases.
It is very rarely difficult to retain these herniæ, however simple the appliance may be.
The two styles of truss that are best adapted to its treatment are the spiral spring
and the Knight
“ Umbilical Hernia.—The most satisfactory treatment of umbilical hernia in chil-
dren has been with rubber adhesive plaster and a small pad. The plaster should not
be changed more frequently than once a week, and should be allowed to remain two
weeks if no excoriation is produced. In patients over three years of age a French
umbilical truss can be applied, but difficulty is often encountered in keeping the pad
in position. The percentage of incurable cases in children is very small, while in adults
it is the reverse. As only palliative measures are usually attempted with the latter
class, it is found that the abdominal supporter answers admirably.
“Irreducible Hernia.—In the majority of irreducible herniæ of the inguinal and
femoral types, operative treatment is advised, but there is a certain number of cases of
epiplocele which present only slight symptoms, and which decline to be operated upon.
In this class of cases the application of a simple spica, with a soft pad, reapplied every
day, often accomplishes partial or complete reduction after a week or ten days. This
method has been chiefly effective in cases of femoral hernia. Irreducible, umbilical
hernia is almost exclusively met with in the adult, and more than palliative measures are
rarely attempted. Should no symptoms of incarceration be present, the application of
an abdominal supporter usually partially reduces the mass; and this can be still further
assisted by the addition of a large flat pad.”
When operative measures have been undertaken for the cure of hernia, such as
are found recommended in another part of this work, too much emphasis can not be
placed upon the undesirability of adjusting a truss. I can not help thinking that
where, under the influence of the fear of the return of the hernia, a truss has been
applied, great damage is often done to the newly formed structures by the continuous
pressure. If, on the contrary, it is demonstrated that the hernia is commencing to
reappear, a light truss may be wisely advised.
a

CHAPTER VII.
IRREDUCIBLE INGUINAL HERNIA.—SYMPTOMS AND COMPLICATIONS.
Quite a variety of causes produce this condition. Usually the history is given
of a hernia which has existed for years, often not supported by a truss, or by one that
fitted improperly and had been discarded. More commonly the omentum is the first
troublesome factor; adhesions between it and the wall of the sac, and this again to the
contiguous parts, prevent return; as the opening shortens and enlarges, a loop of intes-
tine becomes a factor, and gaseous or fecal distention causes a further yielding of the
weakened parts; often symptoms of obstruction and pain, constitutional disturbance,
slight elevation of temperature, nausea, followed by vomiting, are the premonitory
symptoms of danger which precede actual strangulation.
Not seldom, although the tumor can not be reduced, a careful manipulation may
remove the temporary intestinal obstruction, the gaseous distention be overcome; and
the history of such cases is that of invalidism steadily growing more pronounced.
Rest in the recumbent position for some days, the hips higher than the shoulders,
and the parts supported, hot applications locally, light diet, opiates, enemata, etc., are
often demanded. In this way relief is obtained without manipulation or taxis, and
when these measures are resorted to they should be conducted with the greatest
care.
The size of the irreducible herniæ is sometimes enormous. Often when the patient
is about, the scrotal tumor becomes a deformity difficult to conceal. Birkett reports
the following : “ The largest double rupture I have seen was in a bricklayer, fifty-
five years old, whose bodily health, strength, and conformation in other respects
were good. The left hernial tumor was the largest, although it had existed only
about three years, while the right had been there twelve years. The lowest body of
the tumor very nearly reached to a level with the patellæ. Its circumference in its
largest part measured thirty inches.
* Holmes's System of Surgery.


PLATE XIX.
را
a
a
a
Fig4
9
b
P.
Fig1.
Fig.3.

IRREDUCIBLE INGUINAL HERNIA.-SYMPTOMS AND COMPLICATIONS. 79
PLATE XIX.*
Figure 1.
Figure 4.
Two external inguinal hernia (enteroceles). Double external inguinal hernia. That of the
Male, aged forty-six.
left side of enormous size. (Copied from a design
a. Tumor in the inguinal canal.
of Dupuytren.) The right hernia is yet reducible.
b. Contraction or obstruction of the internal The left hernia, irreducible, contains the greater
inguinal ring.
part of the intestinal mass. The abdomen, almost
c. Passage of the epigastric vessels under the empty, is pressed down.
tumor.
a. External projection of the hernial sac.
d. Scrotal tumor.
b. Section of the profile.
Figure 3.
Congenital external inguinal hernia (probably an
epiplocéle) in a child of seventeen months.
a
Besides the inconvenience of such tumors and their attendant suffering, the patient
runs many dangers. The greatest is that of strangulation of the incarcerated intestine,
although this is probably less than in reducible hernia, since the sac is nearly full and
thus less readily admits of a sudden increase of its contents. Injuries are common
from accidents. Mr. Cooper relates a case where death occurred in a few hours, after a
fall, from rupture of a portion of the ileum. He also quotes a case from Mr. Norris,
a contemporary surgeon, who showed him the specimen. “While running, and sud-
denly turning the corner of the street, he struck violently against a post. The middle
of the abdomen was the part that received the shock, from the effects of which he soon
appeared to have recovered, but on proceeding a little way he felt great pain in the
belly, and became very faint, which obliged him to sit down on the steps of a door. In
about ten minutes he was just enough recovered to be able to crawl to his home,
which was about two hundred yards off. I saw him on the following morning.
There was not the slightest appearance of injury on the part that had received the
stroke, but in the course of the spermatic process on the left side, extending into the
abdomen, there was a fullness and enlargement equal to a moderate-sized hernia. He
vomited quite frequently, his pulse was quick and extremely feeble, his countenance
was pale and expressive of the greatest anxiety, and he complained of acute pain all
over his belly. The abdomen, however, was quite soft, and the contents of the tumor
were easily returned into its cavity, but quickly came down again, when the pressure
was removed. These symptoms continued with the most torturing pain till the even-
* Bourgery's Atlas, Plate XXXIV.

80
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
ing, when he expired. Having obtained leave to open the body, Dr. Yelloly and my-
self met the day after his death for that purpose. The tumor was now larger than
before, discolored, and contained air, discoverable to the touch.
“The contents of the tumor were found, on opening it, to be air, blood, and water.
On examining the abdomen a similar fluid, to the quantity of a quart, was found
effused. An irregular aperture was perceived in the ileum, which readily admitted my
finger, and through which everything that had descended into the stomach found a
ready passage into the cavity of the body. No other injury of any kind to any of the
contents of the abdomen could be detected.” ?
Foreign bodies, introduced into the stomach, may be caught and retained in the
intestinal hernial loop, and serious trouble arise therefrom. Mr. Cooper reports a case
of a boy, aged thirteen, sent to the hospital, where a quantity of feculent material was
constantly passing from an irreducible scrotal hernia. Five weeks before, he had acci-
dentally swallowed a pin. This was withdrawn from the scrotal opening, but, after a
variety of efforts at cure, he was discharged, with the fistula still open. The case of
Mr. Gibbon, the celebrated historian, is given by Sir Astley Cooper, as an illustration
of possible danger. Its interest is quite sufficient for giving it entire :
Mr. Gibbon had been for thirty years subject to a scrotal hernia on the left side,
of which he made no complaint, and to which he applied no remedy to prevent its
increase. But in the summer of 1793, finding it grew suddenly uneasy, he became
alarmed, and consulted Sir Walter Farquhar and Mr. Cline. The tumor was then of
uncommon size, reaching to his knees, and very large at its connection with the abdo-
As some water was perceptible at the lower part of the tumor, it was tapped in
the month of November, 1793, and a large quantity of water was drawn off. In a fort-
night after, it was again tapped and three quarts of water were evacuated, without any
sensible diminution of the swelling. Six weeks after, the skin over the tumor having
inflamed and shown a disposition to ulcerate, the tapping was again repeated, January
13, 1794, when six quarts of water were discharged. Two evenings afterward he began
to complain of a pain in his stomach and soreness in the abdomen, and in the tumor
on pressure. He passed the night restlessly, but the next morning when he rose he
seemed in better health and spirits than usual. Soon after he became insensible, and
expired about eleven o'clock.
men.
а
* Sir Astley Cooper, second edition, Part I, p. 25.

IRREDUCIBLE INGUINAL HERNIA.
SYMPTOMS AND COMPLICATIONS. 81
“Mr. Cline asked me to accompany him to inspect the body. We found the abdo-
men nearly emptied of all the movable viscera, no omentum remaining within its cav-
ity, and of the intestines only the duodenum and cæcum. Even the pylorus was drawn
down so low as to lie upon the orifice of the hernial sac, into which all the omentum,
and all the intestines, except those I have just mentioned, had descended. They were
all uncommonly loaded with fat, and slightly inflamed. The hernial sac extended
nearly as low as the knee, its orifice was so large as to admit my hand within
it. Below the sac appeared a separate bag large enough to hold several quarts of
water, which, by its containing the testicle, proved to be the tunica vaginalis
testis.”
a
The practical questions arising from the consideration of irreducible hernia are those
of treatment. Often it is exceedingly difficult to determine the exact condition of con-
tents. If omental only, a truss may be fitted; if intestinal, the pressure of a truss would
prove dangerous. A small loop of intestine may be concealed in the omentum, and
not easily detected. If the truss proves painful, it should be worn with great caution,
or better omitted entirely. When a hernia becomes irreducible, it is almost certain to
grow worse steadily and endanger the life of the sufferer constantly. Operative measures
were considered, until the establishment of aseptic surgery, altogether too serious and
dangerous to be advised, even if the sufferer was willing to undergo the risk. The
ingenuity of the mechanic was called into requisition in the adaptation of a great vari-
ety of supports for the tumor, and the best results were undoubtedly obtained by con-
fining the invalid for a long period in bed, in the horizontal position, limitations of
diet, and the maintenance of more or less steady elastic pressure.
Many ingenious mechanical devices have been invented, not alone for the support
of the considerable tumors which are caused by irreducible hernia, as hollow pads or
cushions, applied to force the hernia to re-enter the abdomen, but also to secure a radi-
cal cure by the slow separation of the adhesions and restoration of the displaced organs.
One of the more ingenious of these methods is that of Dr. John C. Warren, of Boston,
where the scrotal tumor, more or less large, has adjusted to it a proper receptacle, and
graduated elastic compression is continuously applied for its reduction. Arnaud gives a
long description of his method of retention and reduction of large old herniæ, compli-
cated by adhesions. Instruments were fitted by him with the greatest care, and these,
together with what he calls proper medication, rendered it not alone possible to cause
14

82
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
the reduction of the tumor, however large, but oftentimes resulted in a permanent cure.
In illustration I quote the following case:
“Mr. Boudon recommended to my deceased father a man of forty years of age, and
of very strong constitution. He was extremely fat, and six feet and an inch high
(French measure). His name was Mr. Trogneux. He was an inhabitant of Clamsey,
in the diocese of Auxerre. He had an hernia from his infancy, which had never re-en-
tered. It was thirty-two inches in circumference at its lowest part, nineteen at the ring,
and sixteen in length. For more than ten years his penis had been lost in the bulk
of the tumor, so that the prepuce formed a kind of depressure like that of the
navel; so that in making water, his urine was diffused over all the tumor, which was
very troublesome to him. As he was a timber-merchant, his business obliged him
almost every day to ride forty or fifty miles on horseback, which induced him to
invent a large cavity in the fore-part of his saddle, in which he placed his tumor.
Being at last reduced to such a condition that he could no longer follow his business,
and being afraid that this disorder, no less terrible than insupportable, would soon put
an end to his life, he determined to apply for relief. It was in 1726 that he was intro-
duced to us. He found a great deal of comfort from the recent example which my
father and I gave him of the cure of a similar disorder. He submitted to everything
we prescribed, either for his relief or radical cure; but on condition, said he, that he
should have a little to eat; for he was a prodigious glutton. Persons of this kind
may observe a very strict regimen, even by eating a little. We may therefore recede
from the general rule in their favor, without any fear of doing harm ; for their great
appetite requires this kind of liberty. He was blooded several times, then purged, and
afterward used twelve or fifteen baths. Twice a day I made strong embrocations of his
abdomen with oil of melliot, and covered the whole tumor with a plaister, composed of
the emplastrum de Vigo, prepared with a good deal of mercury, of the diabotanum,
and the mucilages; and this plaister I renewed every four days. We made him every
morning take ten, twelve, fifteen, or twenty grains of mercur. dulc. He drank plenti-
fully, and had four emollient and purgative clysters injected every day. Every four
days we purged him with cassia, with an intention to evacuate the humors, and prevent
a salivation. This method succeeded very happily ; for the evacuations lasted sixteen
days and were so copious, that they every day redoubled the patient's astonishment. The
* Arnaud, p. 292.

PLATE I.
26


IRREDUCIBLE INGUINAL HERNIA.
SYMPTOMS AND COMPLICATIONS. 83
tumor during this time had lost three quarters of its bulk, and more than a half of the
remaining quarter we made to re-enter by the taxis: so that the hernia, being thus
reduced to an eighth part of its bulk, was in a condition to be contained in the hol-
low cushion of a truss. It afterward diminished insensibly for eight or ten days,
during which time we took care to fill the cavity of the cushion, in proportion as the
bulk of the tumor diminished. On the thirty-sixth day from the first venesection the
parts re-entered all together, and the testicle also. We then used a convex instead of
the concave cushion. The patient in a very short time resumed his strength and
flesh, and followed his business with a great deal more vigor than ever he had done.
The first thing he did at his return home was to render his wife pregnant, with whom
he had had no amorous converse for ten years before. He quitted the use of the truss
eighteen months after; that is to say, in 1728. Twelve years after, he had occasion to
come to Paris, where he called for me immediately on his arrival, rather to testify his
gratitude than for any other reason. But, as I did not know him, he put me in mind
of everything that had happened in 1726. I examined the parts, which I found so firm
and solid that one could have hardly imagined that he had formerly labored under an
hernia. The skin of the scrotum was returned to its natural state, only it was very
thick ; and the bottom of the scrotum which had approached to the ring, on account
of the herniary sac of the testicle, was fixed or glued over the ring. This portion of
skin seemed to make a kind of stopper, which filled the cavity of it. But though the
disorder had no appearance of a relapse, I ordered the patient to wear a truss by
way of prevention—the reasons of which I shall afterward give in a particular
instance.”
Modern aseptic surgery should relegate the entire class, almost without exception,
to operative measures for cure.
The peculiar complications which enter into the problem for the surgical cure of
large, old, irreducible herniæ are the adhesions, which unite the parts contained within
the sac to it and each other. As will be seen in the consideration of operative measures
for strangulated hernia," where these complications are discussed in detail, the adhesions
of the omentum to the sac and the fused state in which it itself is often found, are
comparatively unimportant, since both may usually be removed with safety and advan-
tage. On the contrary, loops of adherent intestine are to be treated always with the
* Chapter viii.

84
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
greatest care. When firmly united to the sac, it is better to snip portions of this
freely away and return within the abdomen, rather than use too much violence in the
separation of the adhesions.
The highest skill and judgment of the surgeon are often demanded in the safe and
proper treatment of such complications.

CHAPTER VIII.
STRANGULATED INGUINAL HERNIA.
Gyn. Stall Room University Hospital,
sac.
When the constriction of any portion of the contents of the hernial tumor is
sufficient to impede or impair the circulation of the blood, and thus endanger the
nutrition of the parts inclosed, arresting the passage of the fecal contents through
the intestinal canal, the hernia is called
strangulated. The neck of the sac is
usually the seat of the constriction.
In Chapter IV, page 55, I have de-
scribed in detail the physiological changes
which in the end develop into a firm,
thickened constriction at the neck of the
h
These plicated folds are caused by
the resistance which the hernial tumor
meets in its development as it passes
through the inguinal canal. Although
mentioned by many authors, the impor-
tance of the constriction thus made at
the neck of the sac is still greatly under-
estimated, and the surgeon has too often FIG. 4.- Dissection from the peritoneal surface of the
parts affected by an oblique rupture; peritonæum, its
in mind that the parts to be operated fascia and the transversalis fascia are removed. The
sac is cut off at its neck in the deep ring. The epi-
upon are only the anatomical borders of
gastric artery is seen below the neck, but has been
the more or less altered tissues which removed at the inner side to show conjoined ten-
don, h.
enter into the formation of the canal,
rather than the deformed, pathological peritoneal covering of the tumor which, in
its descent into the scrotum, has been folded over and over, and by inflammatory
processes consolidated into a dense, unyielding, constricting ring. The formation of
these plicated folds is very well shown in the accompanying woodcut.
" It was for a long time believed that all cases of strangulation in inguinal hernia

86
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
were owing to a constriction exercised by the ring upon the intestine. This erroneous
opinion has more than once led to fatal consequences. Acting upon this principle,
surgeons enlarged the inguinal ring, and restored the parts into the abdomen, thinking
that they had removed the strangulation; but the bad symptoms persisted, became
aggravated, and the patient perished without any evident cause for his death. These
unfortunate results soon attracted my attention, and became the subject of reflection;
presently, I was induced to think that the abdominal ring was not the only seat of
stricture, and dissection has since proved to me that, in a great number of cases, the
neck of the sac is the cause. Time has corroborated my views, and I believe that I
may now affirm that, out of nine cases of strangulation, eight are owing to a constric-
tion by the neck of the sac. This remark applies particularly to inguinal hernia; for
this disposition is rarely met with in femoral and umbilical hernia. The structure of
the parts explains the difference.” *
It may, however, occur in any portion, and there may be more than one con-
stricting band. The causes of strangulation are various. Obstruction may, and very
likely does, frequently supervene upon changes in the circulation and nutrition of
the intestinal loop within the sac. The venous return current impeded, there will
ensue, even in an old hernia, an increased weight, a suspension of peristaltic motion,
a retention of intestinal contents, resulting in an over-distention of the sac. It is
probable that, in most instances, the changes commence within the sac and its con-
tents, rather than in the constricting part. Once commenced, however, they mutually
react to the injury of both. There is usually a limited quantity of serum in the sac
of a strangulated hernia. This varies according to the character and duration of the
constriction. At first it is pale yellow, clear serum, then changes in color, and later
becomes turbid, with blood-cells freely mingled, even to the production of small clots;
the serum may become of a dark coffee-color. Not seldom it has a fecal odor, and
it is very probable that the fluid is often infected with bacteria from the intestinal
contents, escaped through the imprisoned walls.
The tissues covering the tumor exhibit changes coincident with those of the con-
These are more marked nearest the constriction, and lessen toward the sur-
face. Violent manipulation of the mass may, and often does, cause marked changes in
the integuments, ecchymosis of the connective tissue, oedema, and redness of the skin.
tents.
* Lectures on Clinical Surgery, delivered in the Hôtel-Dieu, of Paris, by Baron Dupuytren, surgeon-in-chief, 1835.


PLATE XX.

Plate XX.
Y
)
d
d
h
7
6
:-)
9
't
ti
Il
Bu


STRANGULATED INGUINAL HERNIA.
87
PLATE XX.*
a. A portion of the great sac of the perito-
næum laid bare, by means of the division of the
inguinal ring; the incision is extended upward †
into the fleshy part of the abdominal muscles.
b, b. The hernial sac formed by the perito-
næum.
C, C. Constriction formed by the neck of the
hernial sac, situated a little more I inward than
the inguinal ring.
d, d. Some rugæ or bridles of cellular sub-
stance arising at different distances around the
stricture formed by the neck of the hernial sac.
eee, f f f. The cellular substance external #
to the great sac of the peritoneum, which accom-
panies the hernial sac and the spermatic cord, and
is interposed between the proper sac of the hernia
and the aponeurotic sheath of the cremaster.
g. A small portion of the hernial sac removed,
within which is seen a portion of a fold of the ileum.
a
k, i, k, l. The external | covering of the hernia,
or the membrano-aponeurotic sheath of the cre-
master.
m. The greater bundle of fleshy fibers of the
cremaster.
n, 0, p. Distribution of the bundles and ser-
pentine fleshy fibers of the cremaster muscle.
9, 9. The vaginal coat of the testicle laid open.
r. The tunica-albuginea of the testicle.
s. Part of the epidydimis.
t, t. Varicose vessels of the spermatic cord,
surrounded and included within the cellular sub-
stance—an incipient circocele.
u. The integuments of the scrotum.
V, v. The muscular parietes of the abdomen
laid
open
for a small space.
x. A denuded portion of the rectus muscle of
the abdomen of the right side.
y. Continuation of the rectus muscle of the
right side within its aponeurotic sheath.
2. Crest of the os ileum.
Symptoms.—As generally observed, the first symptoms are local pain, a tumor
more or less large, if none existed before ; if an old hernia, a tenderness and increase
of swelling, a dragging weight, and a sensation of uneasiness in the hypogastrium,
This sometimes becomes so severe that it seems as if a cord was tied about the body.
The mechanical obstruction to the intestine is soon followed by more marked nerv-
ous symptoms; pain and restlessness supervene, with nausea and vomiting; this may
be accompanied by a desire to defecate, and straining at stool results in the passage
of little except flatus. Sometimes these general reflex nervous symptoms are so
prominent that the patient and physician both may fail to consider the cause as
one of obstruction, or think of hernia.
If unrelieved the general symptoms become more marked, the nervous anxiety
pronounced, the pulse small, hard, and quick, the temperature somewhat elevated, and
the nausea and vomiting severe. There is a gaseous distention of the intestines,
giving a tense, tympanitic abdomen. The vomiting becomes fecal, and no gas passes
the anus.
When these symptoms have become marked, the obstruction is not only complete,
* Scarpa, Plate IV.
+ Atlantad.
# Centrad.
# Peripherad of.
|| Peripheral.

88
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
but has existed longer than is consistent with safety. Every practitioner should study
the grouping of such symptoms and be early on the alert, since danger increases each
hour almost in a geometric ratio. The intestinal canal, between the obstruction and
the stomach, not seldom the stomach even, becomes by degrees distended with a
dark-brown-colored fluid; this rapidly undergoes fermentation, and sets free gas, which
greatly adds to the stretching of the intestine, causing a paralysis which is often slow
in recovering. The mucous membrane is deeply congested, the villi are turgid and
swollen, even the serous coat is much changed in color, and is often punctated, or
striated in patches of deep red. The intestine, on the contrary, below the stricture,
is decidedly pale, and contains little except mucus.
If the patient remains unrelieved, uncontrollable retching and vomiting ensue, pros-
tration supervenes rapidly, and death from collapse occurs. Life may be prolonged
until the constricted portion of the intestine ulcerates, and the escaped intestinal contents
set up a rapid septic peritonitis. At the beginning stage of prostration the active nerv-
ous tension abates, the nausea, especially if the patient is partially narcotized, lessens
or disappears. This should not quiet the attendants; on the contrary, it betokens
grave changes, a depression of the vital force, from which the patient never rallies.
The pulse, before full and rapid, is now slower and weak, the heart contracting with
little force. The cutaneous surface is much lowered in temperature and becomes
shriveled, the hands and feet cold and wet, the expression is one of anxiety and dis-
tress, the tongue dry and brown. The muscular system is relaxed, and the urinary
secretion is greatly diminished.
The patient may continue for some time in this state—the very threshold of death
-pulseless, scarcely seeming to breathe, yet with unclouded mental vision and able
to converse; a slight change only, and death supervenes. When death follows, the
local conditions often do not present changes sufficiently marked to have caused such a
serious result, and the fatal issue is very probably dependent upon the extreme nerv-
ous exhaustion or collapse.
Although local pain is considered a sign of peritonitis, it is difficult to determine
the inception of the peritoneal inflammation. It is often local, with a protective layer
of lymph effused. When arising from perforation, the pain is usually severe, and
death may follow from the shock to the nervous system, but usually from rapid in-
fection, as a septic poisoning.
The pathological changes of the contents of the intestine are of interest. The


PLATE XXI.

STRANGULATED INGUINAL HERNIA.
89
vomitus at first appears to consist chiefly of the ingesta; frequently of the substances
last taken into the stomach. Then the fluids become changed in color, odor, and
taste, by being mingled with the biliary secretions. The color changes from a green-
ish hue to brown, or even almost black, and later the odor becomes feculent—the
well-known stercoraceous vomitus. Blood-cells may often be found, and the color of
the serous fluid is deepened by that of the blood. Epithelium is constant in the
ejected material, often in patches, and the quantity of fluid in the intestine and stomach,
owing to the impaired venous return current, is often quite beyond expectation. In
a case of operation for volvulus, where I easily freed the intestine, and had closed
the wound, as the ether was removed, a spasmodic, continued vomiting ensued, and
death occurred from impeded respiration, although the head was carried forward with
tongue drawn out, and every effort made to clear the throat. It was estimated that
the ejected fluid exceeded two quarts.
In strangulated omental hernia the symptoms are much less severe. The pain is
often inconsiderable, the vomiting not marked, or is wanting, and the abdominal dis-
tention not pronounced. The intestinal function, although generally impaired, is not
suspended, and passages from the bowel are obtained with greater or less difficulty.
When fatal, death occurs from necrosis of the part, with subsequent general infection.
The danger from strangulation is greater in femoral than in other varieties, since the
constricting ring is less yielding, and the canal generally smaller.
Small recent herniæ are also more liable to strangulation and more easily over-
looked
PLATE XXI *
Represents on the right side a small oblique inguinal hernia, making its appearance at the internal
ring, on the outer side of the epigastric artery; and on the left side a scrotal hernia, with its coverings
displayed by dissection.
ܪ
a, a. Fascia superficialis coming from the ex-
ternal abdominal ring, and forming the external
investment of the hernia ; at its upper part the
transverse fibers of the external ring are seen.
b, b, b. Cremaster muscle thickened—seen de-
scending under the margin of the external ring,
and lost upon the tunica vaginalis at d.
c. Hernial sac.
d. Testicle.
e. Spine of ilium.
f. Tendon of the external oblique muscle, re-
flected to show the inguinal canal.
g. Abdominal ring.
h, h. Poupart's ligament.
i. Internal oblique muscle.
k. Rectus.
1. Femoral artery.
m. Femoral vein.
* Cooper, Part I, Plate III.
15

90
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
n. Margin of the internal oblique muscle, and taking its course through the external ring
turned upward to expose the hernial sac, and epi- into the scrotum.
gastric artery on its inner side.
Þ. An incipient hernia, appearing at the inner
0,0. Spermatic cord is seen emerging from ring midway between the spine of the ilium and
the internal abdominal ring behind the hernia, symphysis pubis.
A variety of hernia called bubonocele, where the hernial tumor is retained within
the canal, is often so small as to escape detection, unless specially sought, and may
be, on this account, all the more dangerous. The late Dr. A. H. Wilson, of Boston,
contributed a valuable paper upon this subject.* He reported a case where death
ensued from a concealed hernia of this character, which was not recognized until at
autopsy. The possibility of obstruction arising from this cause should be held in con-
sideration. Only very recently has the following case fallen under my observation:
F. B., age twenty-five, laborer; for some time subject to right inguinal hernia.
Became strangulated November 7, 1891. Two physicians attempted its reduction,
with supposed success. Intestinal obstruction continued, and the case was consid-
ered hopeless. Dr. John Couch, of Somerville, was summoned on the 13th, and I
operated on the morning of the 14th with his assistance. It was found that a loop
of the small intestine, still tightly grasped by the internal ring, had been forcibly
carried within the abdominal wall, no evidence of an external tumor remaining. The
division was made, the loop drawn out, and under the hot irrigation fluid the circu-
lation slowly returned, although the peritoneal coat was quite abraded over the intes-
tinal loop. The intestine was returned, and the wound closed for the purpose of
permanent cure. Free dejections followed, and a rapid convalescence supervened.
It is especially noteworthy that quite a week had elapsed, during which the ob-
struction had been complete, and for some days there had been a continuous sterco-
raceous vomiting. Such cases are instructive, but they certainly ought very rarely to
happen.
PLATE XXII.
the one, exterior or scrotal; the other, interior or
Figures 1 and 2. External Inguinal Hernia in the
inguinal, inclosed in the canal.
Male.
a, a. Portions of the skin and superficial
Figure 1. The hernia is shown dissected. The fascia.
aponeurotic contour of the external oblique ring, 6, b. Portions of the aponeurosis of the great
alone preserved, divides the tumor into two parts: oblique.
* Journal of the American Medical Association, August 25, 1883.
+ Bourgery, Plate XXXVIII.

PLATE XXII.
h
a
h
Fig.2.
a
k
b
С
h
bi
c.d
k
h
d
f
m
e
e


STRANGULATED INGUINAL HERNIA.
91
C, C. Cremaster muscle twisted in front of the
hernia. A portion of this muscle has been re-
moved, to show the inguinal canal.
d, d. Section of the scrotal envelopes of the
hernia.
e, e. Section of the hernial sac.
f. Thinned-out intestine and hernial epiploon.
g. Ileo-femoral vessels.
h. Epigastric vessels.
Figure 2. Interior of the hernial sac in its
dilated state, the contents removed.
i. Dilated external inguinal ring.
k. Internal inguinal ring.
1. Inguinal canal narrowed by the drawing
together of its two orifices.
m. Scrotal pocket.
&, h. Femoral and epigastric vessels.
8
Strangulated hernia, unless the tumor is reduced, is almost always fatal. In some
instances the wall of the intestine becomes adherent; a small slough occurs, leaving an
ulcerated opening through which a small portion of the fecal matter escapes, the larger
part descending through the intestinal canal, as usual. In other instances the incarcer-
ated loop sloughs, and an artificial anus is formed, through which all the fecal material
passes. Such complication may result in hernia of the rarer varieties. Somewhat
recently a patient entered the hospital with constantly recurring fecal dejections escap-
ing through the vagina. About two weeks previous she had been delivered with great
difficulty of a child at term, with a shoulder presentation. It was not recognized that
the vagina had been injured until symptoms of intestinal obstruction supervened.
After some days, fecal dejections came from the vagina. A loop of the ileum had
escaped through a vaginal rent, become adherent, and sloughed. As death seemed
imminent from starvation, after consultation an attempt was made at restoration by
laparotomy. The general peritonæum was not involved; the intestine was freed from
its attachment and withdrawn. The ulceration included about three fourths of the cir-
cumference. The edges were refreshed and reunited. Unfortunately, however, the
patient sank and died from exhaustion the second day.
The prognosis of strangulated hernia must be determined, from the foregoing con-
siderations, to be of a gravity dependent upon the character of the constriction and the
time since it first ensued. It may be accepted that there are few dangers to which
the race is liable that become so fearfully aggravated by delay.

CHAPTER IX.
SURGICAL PROCEDURES IN IRREDUCIBLE AND STRANGULATED INGUINAL HERNIA.
Operative Measures.—The dangers which follow after the proper performance of
the operation for strangulated hernia are in direct ratio to the complicated conditions
detailed in the preceding chapter. Birkett writes : * “We have never known an
:
instance of a patient dying in consequence of the bowel being liberated at too early a
period; but we have had to operate upon many whose chances of life were absolutely
sacrificed by the inexcusable delay which had occurred before the patient was submitted
to the operation. We make this assertion after a large experience, extending over
many years.” The statement of this eminent surgeon is in accord with the experience
of most operators. It is now generally conceded that the danger lies not in the opera-
tion, but in the conditions which demand it. It may be accepted that with proper
aseptic precautions the operation is practically safe. In an experience of over twenty
years, I have not had a single fatal case where the integrity of the intestinal canal was
not involved.
In this respect hospital statistics, as such, are of little value. The cases are sent in
late, often have been sadly neglected, and their condition rendered much worse by inju-
dicious and even violent efforts at reduction. The attendant is, at first, in the great
majority of cases, a physician little experienced in operative measures, and much valu-
able time is lost in “watching the case,” the administration of drugs, and leading up, not
only the friends, but himself to the conclusion that the case is involved in serious
danger. What should justly precede operative measures is a question of important
consideration. First, the careful differentiation of the factors in the problem pre-
sented. This will notably consist of a consideration of the character of the hernia
in its anatomical relations—its kind and variety, its formation and duration, the
constitutional condition, the state of the tumor, and the treatment already em-
ployed.
* Birkett. Holmes's System of Surgery.


PLATE XXIII.

Plate XXIII.
B
18
0
х
H
2
17
N
2
M
m
1
N
с
26
0
R
k
х
/
29
K
eu
in
J
n
y
mi
M
L
20
.
32
a
الم
X
F
ах
Eu Eu
سمر سروس
W
Α.
D
میر
E
P
u
3
amma
T
man
به با 1
در نی
T
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y
12
برای مو
الزمر )
w
ann
ha
a
zo
27
1
25
1
1
1
h
26
g
&
24
13


SURGICAL PROCEDURES IN INGUINAL HERNIA.
93
PLATE XXIII.*
ANATOMY OF AN INGUINAL HERNIA OF THE LEFT SIDE. (DISSECTION MADE IN 1754.)
A man, aged forty, emaciated by disease to which he succumbed, had suffered from a large hernia
of the groin.
Muscles.
in his treatise upon operations. It arises under
.
the skin of the penis and is separated by the adi-
A, B, C, D, E. External oblique muscle of
posa membrana, c.
the abdomen.
d, e, f, g, h. Epigastric arteries and veins
A, E, F, designate the insertion of this ten-
proceeding from behind the spermatic cord i, k,
don into part E of the ossa pubis; a part of
communicating with the posterior portions of the
which is covered by the abundant cellular mem-
recti muscles.
brane.
i, k, l. Arteries and veins and vas deferens,
D. Another tendon of the same muscle going partly covered by the peritoneum m, n, Y.
under the hernia and inserted into the tubercle of
u. Spermatic cord of the right side.
the ossa pubis, forming the outer side of the liga-
ment which is called Fallopian, is near to the apo-
Glands.
neurosis or sheath of the thigh (the fascia lata) in 21, 22, 23, 24. Inguinal glands adherent to
the part of the ilium nearest to the bone, which the muscular aponeuroses and fatty tissue of the
is seen most plainly if the cellular membrane is thigh.
separated with the skin. The muscles of these
x, y. Ligament of the penis.
two tendons being divided, one after another, the z. Corpora cavernosa of the penis.
ring E, D is formed.
1, 2, 3. Penis.
F. Aponeuroses of the oblique muscles cover- 3. Præputium.
ing the rectus abdominis.
4,5. Skin of the scrotum and inguinal region
H, I, K, L. Psoas muscles going out from the turned back.
common tendon L.
6. Left testicle.
M, N, 0. Iliacus internus.
W, W. Corrugated skin.
P. Adductor longus.
19, 20. Urinary bladder.
Q. Gracilis.
13, 14. Thigh.
R, S. Tensor vaginæ femoris.
15. Femoral vessels visible on the right thigh
T, T, T, U, V, W. Rectus abdominis; V, W, on account of the emaciation.
the broad tendon of which is inserted into the
pubis.
Peritoneum.
Bones.
m, n. Peritonæum enveloping the spermatic
X, Y. Bone forming the pubic basin.
cord extending from the pelvis (€).
Z. Substance of the first lumbar vertebra.
Y, o, p, q. Peritonæum covering the base of
C. Anterior extremity of the crest of the left
the bladder.
ilium covered by the aponeurosis of the tensor
r, S. Portion of the peritonæum covering the
vaginæ femoris.
abdominal muscles, this being especially desig-
16, 17, 18. Crest of the right ilium.
nated.
Diverticulum.
Vessels.
t, i, s. Diverticulum into which the spermatic
a, b, c. Branch of the external pudendal veins, vessels penetrate. It may be questioned if the
which is always cut in the operation upon an in- hernia had not existed upon that side in youth, or
carcerated hernia, a fact which Le Dran mentions perchance in infancy.
* Camper Peter. Icones Herniarum. Edited by S. T. Sommerung, 1801. Plate Sexta.

94
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Hernia.
E, D, 25, 26, 27, 28. Hernia covered by the
cremaster muscle, shriveled ; 9, 10, II, 12, col-
lapsed, skin for the most part removed. Thus it
is shown that the ring is connected with the cre-
master in part (7, D) and (E, 9). Surely it can
not be separated without a lesion. Hence it is
not improbable that the cremaster also has arisen
from the external ring.
Taxis.—The dexterous manipulation of a hernial tumor, by which it may be dis-
placed from its abnormal surroundings and restored to a normal condition, is termed
taxis. It seems almost universally accepted that this is a simple measure, and should be
resorted to without fear. Generally, when the physician is called, it is only after con-
stitutional symptoms of some gravity have supervened, and almost always efforts, more
or less persistent, have been made at reduction.
Often vomiting is present, and the tumor is swollen and tender. If this is the con-
dition, taxis at first should not be attempted. Place the patient in a position to relax
the muscles-on back, pelvis elevated, knees flexed, and tumor lifted—so as to relieve
the dragging on the neck of the sac and aid displacement by gravity. Hot applications
are sometimes of value; if the skin is red and tense, ice may be kept on often to great
advantage, and the general condition improved by a hypodermic injection of morphia.
Happily, a few hours' sleep and the hernia is, so to speak, self-reduced. If continued,
use very gentle manipulation, and if this fail, no longer delay to be prepared for sur-
gical interference.
Thus ready, thoroughly anæsthetize your patient. This is of the first importance in
the proper use of taxis, since it causes a relaxation of the tissues, obtainable in no other
way, and enables the operator to avail himself of every possible advantage of position,
,
of both the tumor and the surrounding parts. With much tact and care, gently en-
deavor to reduce the tumor, remembering that a constricted intestine, after twenty-four
hours, may be easily lacerated. If, for any reason, from the use of taxis, or violence of
accidental character, it is feared that injury to the sac or its contents has ensued, let
operative measures at once be undertaken.
Upon opening the sac, if the intestine is so discolored as to make it doubtful if
necrosis has not already taken place, pull down the loop beyond the line of constric-
tion, after the opening has been made sufficiently large, and carefully observe if the
circulation is slowly restored. This assured, it is safe to return it and close the wound.
If the intestine is injured, so that its integrity is in part or entirely destroyed, then
give your patient the advantages which modern surgery has so marvelously wrought
in the treatment of wounds of the intestine. The omentum, as well as the intestine,

SURGICAL PROCEDURES IN INGUINAL HERNIA.
95
often suffers injury in efforts at reduction, or by violence. This, of course, is of less im-
portance, but not rarely will it become wise to remove the inclosed portion as a meas-
ure much safer than to venture its return. I have often done this, with seeming
impunity, certainly without complication of danger.
The hernial sac may suffer from violence, either in being torn from its attachments
and the tumor with its peritoneal investment returned en masse, or the sac itself may be
ruptured under pressure, and the contents still further displaced into the subjacent parts.
In the first instance, it is very probable that the constriction of the neck of the sac will
still continue to surround and incarcerate the contents. Such cases are undoubtedly
rare, yet sufficiently numerous in the history of surgery to render the study of such
conditions interesting. They will be met with less often in the future, since the
teachings of modern surgery cause operative measures to be less feared, and con-
sequently efforts at taxis will not be as persistent. If there is evidence that
such a complication has resulted, surgical interference should at once be entered
upon.
When the sac has been ruptured and its contents in part displaced, it may be
difficult to determine the exact conditions, especially if the surgeon has not previously
seen the patient. The sac will be noticeably less tense, and the feel of resistance less,
but the all-important condition of intestinal obstruction remains, and, when this is the
case, operation must not be delayed. It may even, after the sac has been opened, be
at times difficult to determine the exact relations of the parts, but these must be care-
fully differentiated, since life itself will depend upon the proper restoration of these
to their normal condition.
Divide the constriction freely, pull down the intestine, and ascertain the exact
point of exit from the abdominal cavity; thus the opening, or neck, of the sac is
determined, and then there will be little further difficulty in enlarging it and restor-
ing the intestinal contents. This done, as before recommended, dissect out the sac
entire. Often certain portions of the surrounding tissues have been so much injured
as to involve their integrity, and these should also be cut away.
Somewhat recently I operated upon a strangulated hernia of three days' duration.
The intestine, fortunately, was surrounded by omentum, and its integrity not destroyed ;
but prolonged taxis, the day previous to operation, had resulted in not only marked
injury to the sac, but the tissues, for a considerable distance, were ecchymosed and so
devitalized that the dissection was carried several lines outside the sac, and the bruised

96
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
tissues removed, as also a considerable piece of omentum. Recovery was rapid, and
the cure at time of writing remains complete.
PLATE XXIV.*
This plate shows an external and an internal inguinal hernia, accidentally discovered upon the same
cadaver by M. Demaeaux, who placed it at my disposal.
tric artery
sheath, with that of the inguinal canal above.
Figure 1.
The peritoneum adherent everywhere to the en-
Shows the exterior view of the two herniæ velopes, the intestine held by its mesocolon was
covered with their envelopes after the removal completely irreducible, so that in order to cause
of the superficial fascia.
the intestine (8) to enter artificially and to show
A. External inguinal hernia, of moderate size. the passage which it has taken, we have been
B. Internal inguinal hernia, considerably obliged to make a section, the two layers being
larger.
removed of its mesocolon (i, i); in this section the
Figure 3.
frayed vessels of the flattened spermatic cord are
Shows the two hernia in the same relation seen. The epigastric vessels k pass below and
as in Fig. 1. It shows the cavities of the hernial within the hernia in the thickness of an aponeu-
sacs, the contents removed.
rotic loop (1), which represents the inferior curve
The aponeuroses of the two great external of the internal inguinal ring; the superior curve
oblique muscles are laid bare, showing the two is shown below by the tendon m. The femoral
bands, which circumscribe or inclose the external vessels, dissected at the crural arch so as to show
inguinal ring.
their relations, are seen under the peritonæum in
The internal and superior band (a) and the ex- the inguinal canal, with the origin of the epigas-
ternal and inferior band (6) are for the most part
removed, so as to permit the escape of the vis-
cera through the ring (c), the diameter of which is Figure 1, B. Reducible Internal Inguinal Hernia.
quadrupled, so that the space between the bands B. External surface of the hernial envelope,
forms a large triangle where the descending where are seen, notwithstanding their thinness, a
oblique fibers, much thinned, are nevertheless few fibers of the cremaster.
strengthened by the transverse inguinal fibers,
which are thickened and prolonged contrary to
Figure 3, B".
the ordinary condition within, where they inter- Interior of the hernial sac after the easy re-
sect upon the linea alba. At the circumference of duction of the intestine.
the inguinal ring they have considerable thickness, n. The orifice, three centimetres in breadth.
and form a very resisting aponeurotic arch. It is limited by the tendon of the great oblique
muscle; there is no properly so-called canal. The
Figure 1. Reducible External Inguinal Hernia.
hernia was absolutely direct. A portion of peri-
A. The surface is formed by the disappear- tonæum has been removed within and upon the
ance of the cremaster, the fibers of which are posterior surface of the sac, in order to show the
chiefly seen below and externally.
vessels of the spermatic cord disseminated behind
and a little outward.
Figure 3.
0. The epigastric vessels in their normal posi-
c. The aponeurotic arch.
tion external to the hernia.
h. The cavity of the hernial sac, in the dilated
* Bourgery, Plate XXXVIII. Bis.

PLATE XXIV.
a
a
d
d
с
b
6
G
А
B.
Fig. 1.
k
g
с
n
1
B2
i
In A?
h
Fig
. 3.


SURGICAL PROCEDURES IN INGUINAL HERNIA.
97
1
In the chapter upon the formation of the peritoneal sac it was shown that it may
rarely be double or multiple, and this complication should be borne in mind in the
reduction of a hernial tumor. The contents may pass a stricture and enter the ab-
dominal parietes, only to remain still without the abdominal cavity, the upper por-
tion of the sac remaining as a pouch with constriction at its inner orifice. Symptoms
of obstruction will continue, and these should determine as to operative procedures.
In all the foregoing conditions there can be but one rule-never assume, but de-
termine upon positive knowledge, the actual conditions. When in doubt, consider it
as a sacred duty you owe your patient to give him the benefit of it, and, if solved in
no other way, by resorting to operative interference.
For a long period the profession generally have held that surgical measures were
of such serious moment that they should be undertaken only as a last resort. This
belief seems to have arisen from the wretched results which have followed the gener-
ally delayed operation. Certainly it is not the teaching of the early masters. Sir
Astley Cooper recognized, even in his day, when the lack of anæsthetics and of the
requisite knowledge of proper wound treatment rendered the operation truly formida-
ble, the fatal error of delay. “The operation, if well performed in an otherwise healthy
person, is attended with little if any danger, and it is therefore natural to inquire why
it has so frequently been followed by the death of the patient. The great reason of
want of success in this operation is its being performed too late, so that the protruded
contents have proceeded to a state of gangrene, or so nearly approaching to the gan-
grenous condition that the long-inflamed parts are unable to recover their natural func-
tions, or else that the inflammation has extended to the viscera in the cavity of the
abdomen, continuing the consequence of the disease after the stricture which caused it
has been removed. It can not be too much lamented or condemned that so much time
is commonly lost before the operation is performed. To reduce the hernia, trial after
trial is made; the same means are often repeated; the tumor, by being often compressed,
becomes excessively tender, so that the mere cessation of the efforts at reduction gives a
comparative ease, which flatters the patient and his medical attendant that a part of the
tumor has disappeared; hopes are still entertained that an operation may be avoided,
till the rapid progress of the symptoms of danger points out the fatal error of delay, and,
when the operation is performed, too clearly demonstrates the impossibility of success.
* Sir Astley Cooper. Op. cit.
16

98
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
What more graphic picture could be drawn to-day of the fatal errors of delay than
by this great master of the early part of the present century ? The sooner this error is
eradicated from medical thought the better. Then shall we discover upon what fallacies
we have founded our opinions. If I write for no other good than to bring the question
of operative measures anew under a discriminating judgment, I shall not have labored
in vain. When the errors of omission are judged equally with those of commission,
then the serious responsibility of the adviser will be viewed in a new but just light.
HERNIOTOMY.
Preparation for Operation.—There may arise occasions where the necessity of
operative interference permits only a very limited preparation. Under these condi-
tions, the operation may be successful by the use of only knife and director, or even
without this latter instrument. However, it is always far better to have trained assist-
ants, if possible, and to make provisions for contingencies.
The instruments required are an ordinary scalpel, grooved director, artery and
tenaculum forceps, a bistoury with blunt point, commonly called a hernia-knife (that
devised by Sir Astley Cooper is still a favorite); needles, and reliable suture material.
In Heister's Surgery, first published in 1718, Le Dran's winged director is figured,
which consists of a heart-shaped broadening or expansion upon the middle of the in-
strument, about two fingers in width, the intent of which is to protect the intestines
from injury. There is figured also the bistoury of Le Dran, which is a hollow director,
in which is concealed a small knife which can be elevated at pleasure by pressure of
the thumb upon a lever. A steel spring immediately restores the blade to its sheath
when the pressure is withdrawn. The director of Le Dran was highly recommended
by Sir Charles Bell, and Le Dran's concealed knife is the prototype of a number of
modern instruments. M. Arnaud, and Le Dran,* both most distinguished continental
surgeons, each devoted a large share of attention to the cure of hernia by operative
measures. Arnaud invented the probe-pointed bistoury, which has continued in use
until the present. The heated discussion of these champions in the advocacy of the
respective merits of their instruments, † viewed from the lapse of more than a century
and a half of time, invests the subject with the comic side-light of a drama, otherwise
* Heister's Surgery. Table XXIV, vol. ii, p. 44.
+ A Dissertation on Hernias or Ruptures. George Arnaud, 1748, pp. 360-362.


PLATE XXV.

Plate XXV.
7
n
po
zda
6
8
m
5
d
9
G
B
13
6
9
2
I
D
E
2
F
с
ism
H


SURGICAL PROCEDURES IN INGUINAL HERNIA.
99
seriously tragic, when we take into account the terrible sufferings of the poor patient,
groaning under the agony of necessarily cruel and prolonged operations, performed
without an anæsthetic.
A very ingenious hernia-knife has been devised by Dr. Allis, of Philadelphia. It
is probe-shaped, with a movable sheath, directed by a nut to conceal or expose the
cutting edge, as desired. The best which I have seen is that of the late Dr. Joseph H.
Warren, of Boston, which combines the director and divider in a single instrument.
By pushing a thumb-screw in the handle, a fine saw is carried through the groove, and
the stricture is sundered in a very safe manner.
The patient, when fully under the influence of an anæsthetic, is placed upon a table
in a good light. The head is slightly elevated, the limbs nearly parallel with the body,
and the feet in a chair. An inflated rubber receptacle is placed under the hips to con-
duct the irrigating fluid into a pail. The bladder is emptied, and the parts carefully
shaved and cleansed with a 1-to-1,000 solution of bichloride of mercury.
a
PLATE XXV.*
a, a. The left inguinal ring.
b, b. Intersection of the collateral tendinous
bands of the aponeurosis of the external oblique,
in the vicinity of the inguinal ring.
C, C, C, C, C. The aponeurosis of the external
oblique muscle of the abdomen, divided along the
crest of the ilium and the linea alba, as far as the
vicinity of the inguinal ring.
d. The left femoral arch.
e, e. The membrano-aponeurotic sheath of the
cremaster muscle laid open.
f. Continuation of the sheath of the cremas-
ter muscle, which contains the spermatic cord and
the vaginal coat of the testicle.
8,8,8. The fibrous bundles of the cremaster
muscle.
h, h. Soft, cellular substance, interposed be-
tween the sheath of the cremaster and the proper
hernial sac.
i, i. The hernial sac formed by the perito-
næum.
k, k. A portion of omentum protruded and de-
scended into the hernia.
l, l. The aponeurotic sheath of the rectus
muscle of the left side, opened and turned
back.
m. The great sac of the peritonæum, with the
intestines shining through it.
n. The posterior + portion of the aponeuroti
sheath, which inclosed the left rectus muscle of
the abdomen.
0, 0. The left rectus muscle of the abdomen
laid bare, and turned very much toward the right
side of the abdomen.
p. The internal oblique muscle of the abdo-
men of the left side.
9. A portion of the great sac of the perito-
næum, which, after dividing the aponeurosis of
the fascia lata and raising the Fallopian ligament,
appeared externally | under the left femoral arch.
r. The common integuments of the scrotum.
1. The femoral artery,
2. The femoral vein.
3. The abdominal or circumflex iliac artery.
4. The origin of the epigastric artery.
5, 6, 7, 8. Continuation of the left epigastric
artery, behind # the neck of the hernial sac, toward
the rectus abdominis muscle of the same side.
* Scarpa, Plate II.
+ Central.
| Peripherad.
# Dorsad of.

I00
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
9. The origin of the epigastric vein.
A. Glutæus maximus muscle.
10, 11, 12. Continuation of the epigastric vein B. The tensor vaginæ femoris.
behind * the neck of the hernial sac, toward the C. The aponeurotic sheath of the thigh.
rectus abdominis muscle.
D. The sartorius muscle.
13. The saphena vein.
E. The rectus muscle of the thigh.
14. The anterior crural nerve.
F. The vastus externus.
15. A curved dotted line, showing the oblique G. The iliacus nervius.
course from the side to the pubes which the vis- H. The tendinous origin of the adductor
cera usually take in descending to form an ingui- muscles of the thigh.
nal hernia.
1. The gracilis muscle.
Operation.—Commence at the upper part of the external abdominal ring; extend
the incision downward over the tumor, in length sufficient for free manipulation of the
tissues, care being taken in extending the incision downward, so as not to open the
tunica vaginalis testis. It is better not to attempt to differentiate the layers composing
the coverings of the sac, since they are often much changed, and will be quite sure to
confuse rather than aid the inexperienced.
Carefully divide the fascia upon a director, or dissect by the use of forceps. The
only sure anatomical guide in the male will be the fibers of the cremaster, but these
are of little importance. When the sac is exposed, by grasping the tumor posteriorly,
fluid is generally perceived, distending it under the line of dissection. Also, when
pinched between the thumb and finger, the surfaces of the sac may be made to glide
upon each other; generally there is not much difficulty in determining the sac.
Through a small opening made in it, insert the director, and divide freely downward
and upward to the external ring. In small inguinal hernia the incision should be
made parallel with Poupart's ligament, dividing the tissues from below upward and
outward to the internal ring; in femoral hernia, on the inner side, or over the crural
ring, usually in a vertical direction. The sac, in recent herniæ, is vascular, of a bluish-
white glistening color; in old herniæ, it is often thick and opaque.
After opening the sac, the division is first made from above downward, since the
base of the sac is usually partly filled with serum, more or less changed, which serves as
a protection to the intestine. The finger is introduced into the sac and carried gently
to the ring. The exact diagnosis of the conditions can now usually be made, as well
as a correct knowledge of contents. The obstruction is generally found at the upper
border of the sac, near the internal ring. The finger, as early emphasized by Arnaud,
is generally the only director required and by far the best, since it teaches the constric-
* Dorsad of.


PLATE XXVI.

Plate XXVI.
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SURGICAL PROCEDURES IN INGUINAL HERNIA.
IOI
tion, its characteristics as to firmness, extent of thickness, and often the location of the
neighboring arteries. The probe-pointed bistoury is carried on the finger flatwise
through the stricture, which is divided by turning the edge of the knife against it.
I have often been surprised to note how little of the firm, tense band it is neces-
sary to divide. Usually a few fibers yield, with a peculiar grating sound; an incision
often only a line or two in depth is required, and the constriction is freed. Emphasis
has been made very properly upon the possibilities of cutting the epigastric artery,
but I can not help feeling that this danger is greatly overestimated. I have once
seen it divided, but it was easily secured, and caused no trouble. The old rule, based
upon very many special dissections, is a wise one-viz., to cut directly upward-
since in an oblique inguinal hernia, the artery is internal to the neck of the sac; in
direct hernia, external, and at times the canal is so much altered that it is difficult
to determine the relation.
PLATE XXVI.
a, a, a. The aponeurosis of the external ob- matic vessels run, in their passage to be inserted
lique muscle of the abdomen of the left side, cut into the testicle.
away along the linea alba and from within the i. The bottom of the hernial sac.
inguinal ring, and then turned back on the pubes. k. The neck of the hernial sac.
b, b, b, b. The aponeurotic sheath of the cre- 1, l. Soft cellular substance, the continuation
master muscle, as seen from the posterior | part of of that which accompanies the spermatic vessels,
the hernia, and laid open in its whole length; then behind the great sac of the peritoneum along
drawn upward from the bottom of the scrotum the posterior ( parietes of the hernial sac, and in-
toward the side, and turned back upon the abdo- terposed between the sheath of the sac and of the
men, along with the testicle of the same side. cremaster.
C, C, C, C. Bundles of fibers of the cremaster m. Smooth cellular substance covering the
muscle, which shine through the membrano-apo- left side of the urinary bladder, without I the great
neurotic sheath of this muscle.
sac of the peritoneum.
d, d. The vaginal coat of the testicle laid n. Prominence formed by the great sac of the
peritoneum under I the femoral arch, after divid-
e. The testicle.
ing the aponeurosis of the fascia lata and raising
f. The natural adhesion of the testicle, with the arch.
the vaginal coat in which it is inclosed.
0, 0. The great sac of the peritoneum, be-
8,9. The epidydimis.
hind 4 which are seen the convolution of intestines
11
h. The posterior # side of the hernial sac shining through.
formed by the peritonæum, behind | which sac, or p. The posterior ** portion of the aponeurotic
between it and the sheath of the cremaster mus- sheath, which incloses the rectus muscle of the
cle, likewise laid open and turned back, the sper-
abdomen of the left side.
open.
Scarpa, Plate III.
+ On the mesial side of.
| Dorsal aspect.
# Dorsal.
|| Dorsad of.
A Peripherad of.
0 Dorsal.
I Peripherad of.
I Centrad and sacra of.
#Centrad of.
** Central

102
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
.
2,9. The rectus muscle laid bare for a certain 6, 7, 8, 9. The continuation of the epigastric
space, and turned very much over to the right artery * behind the neck of the hernial sac, to the
side of the abdomen.
left rectus muscle of the abdomen.
r, r. The internal oblique muscle of the abdo- 10, 11, 12. The spermatic artery.
men of the left side.
13, 14, 15. The vas deferens.
s. The cellular substance of the scrotum.
16, 17, 18. The spermatic veins separated
t. The iliacus internus muscle.
from the artery and from the vas deferens.
1. The femoral artery.
19. The divided extremity of the epigastric
2. The femoral vein.
vein.
3. The abdominal or circumflex iliac artery. 20. The saphena vein.
4. The origin of the epigastric artery.
21. The anterior crural nerve.
5. A branch of the epigastric artery ramified
over the margin of the pubes.
Having freed the constriction, the contents of the sac are carefully examined.
If lymph has been effused and adhesions formed, separate gently, and wash carefully
in the warm sublimate before returning the intestine into the abdominal cavity; ex-
amine as to the returning circulation in the bowel, its integrity, etc. If omentum also
constitutes a part of the contents, gently unfold its compressed layers; if its integrity
is at all doubtful, remove, after having sutured across above the line of division. Thus
secured, I have never seen trouble from hæmorrhage. It is so vascular that separate
ligation of the many bleeding points is very troublesome.
Having returned the abdominal contents, the subsequent treatment of the wound
is to be conducted upon precisely the same principles as if the operation had been
undertaken to cure a non-strangulated reducible hernia. The factors of cure are,
however, less favorable for every reason, since the general and local conditions are
often of the gravest character.
I have thought fitting to introduce one of M. Arnaud's illustrative cases, taken
from his now very rare book, which is reported in such an interesting manner as
not only to be of value for the surgical lesson it teaches, but also as furnishing a most
graphic picture of surgical operations as performed at this early period. They cer-
tainly evince a skill, boldness, and wisdom worthy of commendation in any age :
In the month of November, in the same year, I performed the same operation
on a woman of sixty-seven years of age, in the same circumstances, in presence of Messrs.
Vermont and Talin. The hernia was inguinal, and the intestine was not alter'd by
gangrene; but it was so strongly adherent to the internal surface of the herniary sac,
and especially at the part of the ring, that the ring itself, the sac, and the intestine
* Dorsad of.
+ 1733

SURGICAL PROCEDURES IN INGUINAL HERNIA.
103
seem'd to form only one body, which resembled an old, hard, and callous cicatrix. The
membranes of the intestine were extremely thick in the part next to the ring. I
made a longitudinal incision in the intestine with a straight bistory; I introduced
my blunt bistory within it, and cut the intestine, sac, and ring at a single stroke.
A small quantity of bilious matter was discharged, which gave me reason to believe
that it would flow freely. I dress'd the wound as simply as it required. Next day
I found the patient almost in the agonies of death, and there had been no evacua-
tion since the operation, which I had perform’d the night before. Without searching
for the cause of this, any other where than in my incision, I again convey'd my
bistory into the incision as deep as I could, and enlarged the former incision. The
bilious matter was forthwith copiously discharged, and continued to flow for three
hours. In the evening I went to see the patient, and found her in as good a state
as I could have wished for; the abdomen had totally subsided, and all the symptoms
were alleviated; neither had I anything to struggle with, except the appetite of the
patient, who incessantly call’d for food. The wound was entirely deterged on the
fifth day, and Mr. Vermont, who was so good as to take charge of the patient, made
a complete cure in twenty-five days. The patient, who during the whole of this time
had not been at stool, by the anus, went to the close-stool two days after the per-
fect reunion of the intestine, and by means of a clyster discharged so large a quantity
of gross fæces that it was judged they had remained in the colon during the whole
of the disease. Such an instance of success seem'd as if it would have prolong'd
the life of the patient; but she died on the fourth day after the reunion of the
wound, in which there only remain'd a small ulcer, which was not so large as the
nail of one's little finger, and which the patient dress'd herself with a small plaister.
The cause of this woman's death proceeded from the ignorance of Mr. Vermont's boy.
She had a pressing necessity for going to stool; but, when there, could discharge noth-
ing. She sent for Mr. Vermont, whose boy came in his stead. He imagined that
her complaint proceeded from this, that the excrements were no longer discharged from
the wound. He therefore took a probe, with a design to reopen the intestine. He
tore the cicatrix, and cruelly pierced the intestine thro' and thro', as was found in
the autopsy which I made of the body. The bilious matter was extravasated into
the abdomen by the wound of the intestine, which corresponded to the cavity of the
abdomen. If he had known what he was about, he would have only simply renew'd
the first wound of the intestine, tho' that was not necessary; but it might have been

104
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
cured as well as at first, as is easily perceived by the examples I shall afterward give in
the cure of hernias with putrefaction.
“I found the cause of the difficulty the patient had in going to stool in the rec-
tum, which was full of gross, dry, and indurated fæces. A clyster or two would have
been sufficient to have facilitated the evacuation of this matter."
PLATE XXVII.*
a. Hernial sac of an external acquired ingui- m, m. Femoral vein.
nal hernia upon the left side, leading into the n. Epigastric artery extending from under the
tunica vaginalis communis.
hernial sac of the acquired external inguinal her-
b, b, b, b, b. Tunica vaginalis communis.
nia.
C, C. Peritonæum.
0. Epigastric artery of left side situated upon
d. Urinary bladder.
the internal side of the acquired external inguinal
e. Superior arch of the abdominal ring.
hernia.
f. Upon the left side, an obliterated portion 0,0. On the right side, arch of the abdominal
of the internal lamina of the peritonæum lying ring.
under the hernial sac.
p. Spermatic cord.
f. Upon the right side, fibers of the internal 9,9. Internal wall of the inguinal canal, dis-
oblique muscle.
sected to show its entire length.
g. Tunica vaginalis propria of the testis.
r. Upon the left side, hernial sac of the inter-
h, h. Vas deferens.
nal inguinal.
i, i. Femoral artery.
The following cases illustrate various complications of strangulated hernia: t
2611. The sac of an inguinal hernia, with the adjacent parts and a portion of small intestine which,
probably, was returned in an operation. The intestine (suspended above and separate from
the sac) appears to have been constricted in only a part of its circumference, and has mor-
tified; there is a considerable aperture in its coats, surrounded with thin flakes of lymph.
The sac, of bilocular form, is contracted; all the tissues around are thickened and consoli-
dated with it, and it is lined with lymph. The external ring has been divided, and a liga-
ture tied on something at its side.
The following case, from the Hunterian MSS., corresponds closely with this preparation:
" HERNIA.
“Mr. Roberts, watchmaker, had an inguinal hernia for many years, and wore a truss. It
became so well that he often left the truss off.
“ Tuesday, July, 1774, he was attacked with a vomiting, and a protrusion took place, with
all the signs of a strangulated gut, although not very violent; for, although sick at stomach,
he did not vomit. On Wednesday I saw him; no passage by stool could be procured. The
* Langenbeck, Conrad J. M. Handbuch der Anatomie, 1831-'42. Plate XIII.
† Museum of the Royal College of Surgeons of England.

PLATE XXVII
a


SURGICAL PROCEDURES IN INGUINAL HERNIA.
105
a
appearance was very small, only about the size of the end of the thumb, which terminated all
at once; but from that downward the spermatic cord seemed thickened. The parts were
so tender that he could hardly allow one to touch them. It did not give way to any of
our attempts.
“On Thursday, much the same; the pulse kept strong.
“On Friday I thought I had returned the part, for it had lost the sudden termination at
the lower part, and only appeared to be a thickening of the spermatic cord, and thought we
could feel the ring open and free. I imagined that I could get in my finger for a little
way. The pulse kept strong, but he was extremely ill all day, and had no passage.
“In the evening the pulse had lost considerably of its strength; was become small and quick :
he was much oppressed. It was now plain that all was not right respecting the rupture, and
I was now for performing the operation, but he declined it.
“I saw him at six o'clock; found him very low, his hands extremely cold, and alarming pulse,
hardly to be felt, and but little pain in the part, even upon pressure; and he could hardly
draw his breath, excepting when he did it by force.
“Mr. Hawkins was sent for, and we were of opinion the operation should be performed, al-
though but little could be expected from it. It was performed about eight o'clock: a small
bit of gut was found in the sac; just as much of the gut as took in its breadth, so that
there was a total stoppage. The moment the stricture was cut through, the contents of the
gut above rushed down, and burst the part which lay within the sac. The parts were left
in this situation and dressed. He died at five in the evening.
“Observations and queries on this disease and operation :
“To what was the deception owing? for there was certainly a decrease and change in the
feel of the parts: was it owing to the protruded gut being (at) first full, and, by squeezing, its
contents had passed the stricture and got into the gut within the belly; and, therefore, the gut
when alone appeared like a thickening of the cord? How was it that we thought we could feel
the ring, and that we could introduce a finger into it ? Was it that the gut was softer there, and
the ring felt hard all around, although there really was no passage ? or was it that the inflam-
mation below and close to the rings gave the feel of the ring, and the other part of the sac being
natural, allowed of its being pushed into it, and caused the deception ?”—Hunterian MS. Cases
and Dissections, No: 68.
2638. A right inguinal hernia. The sac is much thickened, and contains the cæcum, affected with
colloid cancer, together with a portion of the ileum and a portion of omentum adherent in front
and at the sides. The testicle and tunica vaginalis lie below the hernial sac, which can be
separated from them.
From a man aged sixty-four, admitted into hospital in a moribund condition, from obstruction
of the bowels, simulating strangulation. He had long been the subject of irreducible hernia,
,
and had never worn a truss. For full history and drawings, see MS. Notes, vol. ii, p. 148.
- Presented by John Gay, Esq., 1874.
2643. Part of the anterior wall of an abdomen, with a left inguinal hernia. It appears that, in an
attempt to reduce the hernia, the sac was pushed back, with the intestine in it tightly strangu-
lated by its neck. The sac, which is pyriform, and nearly three inches in its chief diameter, is
now placed on the outer side of the internal ring, between the abdominal and iliac muscles and
the peritonæum, part of it lying below the crural arch, and extending outward nearly as far as
17

106
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
the external iliac vessels. The sac thus forms a large tumor, projecting inward toward the
abdominal cavity, but is not discernible anteriorly; it is laid open from behind, and con-
tains dark-colored small intestines. The external inguinal ring is large, and so also is the
spermatic cord.
The patient, a stout man, fifty-three years old, had a hernia many years, but, always wearing
a truss, had suffered little inconvenience from it, and never had difficulty in returning it till one
day, when, without evident cause, it became tense and painful. It appeared to be completely
reduced by his surgeon, but the signs of strangulation increased, and on the fifteenth day from
their commencement he died.—From the Museum of John Taunton, Esq.
2655. The parts concerned in a small oblique inguinal hernia, dried after the injection of their blood-
vessels: from the left side of a woman. The aponeurosis of the external oblique has been
divided nearly parallel to the crural arch, and its two portions are widely separated, the external
ring being preserved. The lower margins of the internal oblique and transverse muscles are
turned upward. The fascia transversalis is also in part turned upward, so as to show the inner
border of the internal ring, and the neck of the sac passing through it. Part of the covering
which the sac received from the intercolumnar fascia is left beneath that part of it which pro-
jects beyond the external ring.–From the Museum of Sir A. P. Cooper.
2664. The parts concerned in an oblique inguinal hernia, with a large hydrocele of the tunica vaginalis,
on the right side. The hernial sac is nearly three inches in length, and its mouth is very wide;
it has descended so as to come in contact with the upper part of the distended tunica vaginalis.
The testicle, flattened and small, is in the lower third of the posterior wall of the distended
tunica vaginalis; at the back, the vas deferens and some of the vessels of the spermatic cord are
shown separated to nearly an inch from each other; large bundles of the cremaster muscle
descend over both the hernial sac and the hydrocele. The epigastric artery and vein are
shown winding under the neck of the hernial sac.—From the Museum of John Howship, Esq.
2667. The lower part of the front wall of an abdomen, with an oblique inguinal hernia on each side, a
hydrocele of the right tunica vaginalis, and varicocele of the left spermatic veins: dried after
the injection of the blood-vessels. The inguinal canals have been laid open, and the lower
borders of the internal oblique and transverse muscles are raised. By the pressure of the
herniæ, the rings on both sides are brought near each other, so that the sacs appear to have been
protruded directly from the abdomen. The vessels of the cord are separated.—From the Museum
of Sir A. P. Cooper.

CHAPTER X.
INGUINAL HERNIA (continued).
TREATMENT OF THE WOUND AFTER REDUCTION OF THE STRANGULATED
PARTS.
UNTIL the introduction and establishment of modern wound treatment upon a
truly scientific basis, the surgical treatment of hernia was a problem little if any modi-
fied or improved by the experience of a century. The dread of inflammation, suppura-
tion, and the terrible results supervening, when its locality was within the abdomen,
gave to the name of peritonitis a signification of fear unknown to the younger members
of the profession. Since the investigations and teachings of Mr. Lister, and the now
well-formulated factors of wound infection, the revolutionizing of surgery seems nearly
complete. In no operation is an aseptic condition of the wound more important and
obligatory than in hernia ; it is to be considered as a modified laparotomy, with always
the possibility of peritoneal infection.
In Mr. Birkett's * masterly article upon hernia, the treatment of the wound after
operation for strangulation is dismissed as follows: “The structures which have been
cut and disturbed by the incision should be placed in relation to each other, and the
divided edges of the integuments brought together with sutures. The number required
may be left to the discretion of the operator, but no more need be used than sufficient
to keep the upper two thirds of the wound united. For it is always advantageous to
leave an opening at the lowest end to allow of the escape of the blood and discharges.
A piece of wetted or dry lint may be placed over the incision, and a pad of folded lint
is adjusted over it by some surgeons. However, a bandage is not required in every
case, nor is it on any account essential.”
Dr. Warren,t writing in 1882, states: The wound is now drawn together by
sutures, and the dressing completed by adhesive plaster, compress, and a spica bandage.
* Holmes's Revised System of Surgery, 1881.
+ J. H. Warren, M. D. A Practical Treatise on Hernia. Second edition, p. 219.

108
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
.
Morphine or opium should be administered, both to secure rest and also to protect the
patient from that inflammation, always to be dreaded, peritonitis.”
In 1884, Mr. John Wood, * of London, writes: “ The edges of the wound are then
brought together with sutures sufficiently close, a drainage-tube being placed along the
bottom and out at the lower end of the wound, and the parts dressed and well padded
with carbolized gauze, tow, or cotton-wool, the whole secured with a spica bandage
and a support to the scrotum. ... In favorable cases, with little damage to the her-
nial contents, I have for many years been in the habit, at the end of the operation for
the relief of strangulation, both in inguinal and crural hernia, of taking away the sac
after tying it with catgut, and closing the tendinous hernial opening by my wire opera-
tion, and with the best results, both without and with the spray and gauze treat-
ment."
These quotations from the leading special authors upon hernia may be accepted
as the expression of a too general practice of to-day. Many other more re-
cent writers might be cited who repeat similar instructions; but these teachers
devoted many years of careful investigation to the subject, and yet they wrote the
above directions long after the establishment of the principles of antiseptic wound
treatment. Although the end to be attained, when the hernial wound is imperfectly
closed and a drainage-tube used, is the aseptic state, and for this purpose antiseptic
dressings in considerable variety have been advised, it is generally admitted that few
parts of the body are so difficult to maintain aseptic as the region of the groin. In
a following chapter which is specially devoted to the history in detail of the dif-
ferent methods advised for the cure of hernia, a full description is given of the
measures adopted by the most distinguished surgeons in the treatment of the wound
in order to secure the safest and surest results. The conditions in the operation
for the relief of a strangulated hernia, after the restoration of the contents of the
sac, do not differ very materially from those where the operation is undertaken
for permanent cure, and I am quite assured that it is the general opinion of
the surgeons of to-day that he who feels the operation is finished in the restora-
tion of the abdominal organs, without making the attempt at permanent cure, fails
in the performance of an important part of the obligation which he owes his
patient. The method which I do not hesitate to recommend, as giving the safest
J. Wood. Vol. V, International Encyclopædia of Surgery, p. 1135.
.

INGUINAL HERNIA; TREATMENT OF THE WOUND.
109
a
and best result, is the outcome of many years of special study, and is in detail as
follows:
Disposition of the Sac.—With one or two fingers of the left hand inserted into
the base of the sac, carefully separate it from its adhesions to the surrounding parts
quite within the internal ring. Having thus freed the sac, it should be drawn gently
but firmly downward by an assistant, so as to make the parts tense. It is then sewed
across its neck with a continuous double suture of fine tendon, and excised. The sutured
base of the peritonæum is gently carried within the internal ring.
The advantages of resection of the sac, as compared with other methods of its
disposition, will be discussed in a subsequent chapter. In congenital hernia it must be
remembered that the sac is the dilated, non-closed process of the peritonæum which
descended to form the investment of the testicle. Under these conditions the sac
requires different treatment. It is sewed across to form the tunica vaginalis testis.
The suturing is continued upward to close in upon the cord with its vessels, and the
sac is narrowed at its abdominal outlet, to prevent pouching of the redundant perito-
næum, and excised. The subsequent steps of the operation are conducted as in non-
congenital hernia.
The index-finger of the left hand is introduced from above downward through the
ring, the cord having first been gently lifted and carried upward toward the median
line. A firm strong needle, set in a handle, is used, curved
used, curved upon the flat, somewhat
similar to the Hagerdorn needle, with eye near the point. The needle is threaded with
tendon, and is guided by the finger in the wound in its introduction through the pos-
terior edge of Poupart's ligament on the outer side, and carried toward the median line
to emerge from behind forward through the thick aponeurosis of the fascia transver-
salis, with which often fibers of the transversalis muscle are blended, care being taken
not to wound the epigastric artery. The needle is then unthreaded, threaded with the
opposite end of the suture, and withdrawn. Stitches are repeated in this manner,
about one third of an inch apart, until the internal inguinal ring is closed from below
upward upon the cord, which is thus restored to its original point of exit from the
abdomen. (See Plate XXXIX.)
In old, large herniæ, where from dilatation the canal has become nearly direct, the
tissues composing the posterior border are so thinned and relaxed that it is sometimes
wise to modify the method of suturing by introducing several stitches before closing
the neck of the sac. In this way the finger is carried directly within the abdominal

IIO
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
double continuous tendon suture.
cavity, and the needle guided upon it, so as to include the redundant peritoneum, as
well as fascia and relaxed muscular fibers, and thus intrafold and still further strengthen
the tissues which go to form the posterior wall of the canal. When two or three
stitches have been taken, they may be left quite loose until after the suturing of the
neck of the sac and its resection.
Then a stitch or two more com-
pletes the closure of the internal
ring
The suturing is for a double
FIG. 5.—Dr. Marcy's needle, used in the application of the deep purpose—to close in and strength-
The eye is large and
en the weakened tissues about the
smooth, and a slot extends in both directions, so as to catch
and hold the suture from slipping. The point and inner side
large internal ring, but in doing this
are rounded, to prevent cutting the tissues.
we accomplish a far more impor-
tant object, which is to effect the restoration of the obliquity of the inguinal
canal. Having thus reformed the posterior wall of the canal, we replace the cord
and make a second and more superficial layer of sutures. The needle is introduced
from without inward through Poupart's ligament at a level with the reformed
internal ring and carried through the firm muscular and tendinous structures upon
the inner side of the canal. These stitches are continued downward and inward
upon the cord, until the external inguinal ring is restored to its normal condition.
The last stitch is knotted and cut close. The superficial tissues and skin are closed
by lines of buried continuous sutures. This is best accomplished by the use of a
curved Hagerdorn needle, carried from within, through the deep layer of the skin,
from side to side; thus the edges of the skin are evenly coapted without the
vestige of a stitch in sight. The surfaces are carefully dried and dusted with iodo-
form. Iodoform collodion is freely applied, into which are incorporated shreds of
cotton.
The operation should be conducted under irrigation, with the greatest care to pre-
serve the wound in an aseptic condition. This assured, drainage is not necessary. In
my earlier operations I reduced drainage to the minimum, by the introduction of a
few parallel-placed horse-hairs.
Even these, however, I have omitted for several years. Coapted surfaces, held
,
aseptically at rest, tolerate readily the limited effusion which is utilized in the processes
of local repair. The elimination of the drainage-tube renders the complete closure of

INGUINAL HERNIA; TREATMENT OF THE WOUND.
III
an aseptic wound possible, and prevents its further extraneous contamination. Repair
ensues as in a subcutaneous wound. The advantages of this method in the treatment
of the wound are the complete coaptation of the parts and the assurance of non-infec-
tion. By every method of antiseptic dressing with drainage, all surgeons admit the
great difficulty, and in children the well-nigh impossibility, of retaining the wound
aseptic.
As elsewhere stated, for quite twenty years I have used animal sutures in hernia and
special operations, where re-enforcement of the parts seemed desirable, and for the last six
years I have closed all aseptic wounds by the use of buried tendon sutures, the last layer
including the skin only. The object which I at first had in view was twofold: that
there might be no sutures to be removed, and that the so-called stitch abscesses might
be avoided. If the animal suture was very fine, when taken through the skin in the
usual way, either interrupted or continuous, it was observed that, if aseptic, the suture
soon separated in the deeper layer of the skin, allowing the external portion to come
away in a few days, attached to the collodion film which covered and protected the
wound. I, however, often noticed that, notwithstanding the most careful disinfection
of the skin, when primary union had occurred in the wound, there was occasionally
still a slight suppurative point at the stitch opening, from which material bacterial
cultivations could be easily reproduced. In order to avoid this and leave absolutely
no external line of sutures, I devised the following method of suturing, which I most
heartily commend for universal adoption.
Having closed the deeper structures, a fine Hagerdorn needle threaded with fine
tendon is inserted through the skin at some distance from one angle of the wound.
The needle is best held in the fingers, and is inserted into the deeper layer of the
skin, parallel to the divided edge of the skin and two or three lines from it. It
should penetrate through the cutis vera at quite a little depth from the edge of
the wound. The needle is then inserted in a similar manner through the deep
layer of the skin, beginning at a point exactly opposite the emergence of the suture
from the other side of the wound, each stitch being usually about one quarter of
an inch in length. The sewing is continued in this way through the whole length
of the incision, the needle finally emerging at some distance from its opposite
angle through the skin. If the suture is left loose, that portion between the stitches
would be at right angles to the wound. When, however, the suture is drawn upon

II2
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
carefully, it coapts the edges of the skin, quite after the manner of the lacing of a
shoe.
There is an advantage in having each end of the suture free at a little distance from
the angles of the wound, in order that coaptation may be carefully made by tension in
opposite directions. Otherwise, slight folds or puckers are liable to occur, which gives
a
FIG. 6.—Fine continuous tendon suture taken through the deep layer of the skin only as a blind running stitch, which
upon tension evenly coapts the skin by buried sutures.
the wound a wavy look. When carefully coapted the wound must be thoroughly
dried, in order that minute blood-clots may not separate the edges of the skin. After
this has been effected the coapted edges are sealed with iodoform collodion, which
makes a germ-proof dressing. When this has dried, the distal ends of the suture are
cut short and allowed to retract beneath the skin.
An aseptic wound thus closed must remain aseptic. I have recently seen a beauti-
ful demonstration of the probable cause of stitch-abscesses as usually taken. A very
considerable number of cultures have been made, in the laboratory of the Johns
Hopkins Hospital, from the epithelium of the skin after the most careful cleansing by
aseptic measures, the use of hot water, soap, brushes, etc., in all of which the demonstra-
tion was complete, that, in the normal condition of the skin of healthy individuals, the
dying yet firmly adhering epithelial cells were normally the seat of an active growth
of the staphylococcus pyogenes albus, so universal as a habitat of the skin that it is
worthy of being called pyogenes epidermidis albus, and hence the ready explanation of
that which hitherto has been the unknown cause of the so-called stitch-abscesses.
This is also the reason why the continuous, over-and-over suture, carried from without
inward, is more likely to be infected than the interrupted suture, and infection fol-
lows the use of silk, as a loose-meshed, twisted structure, more commonly than cat-
gut or tendon and least of all silk-worm gut or wire.
In the light of these experiences it is not difficult to understand why aseptic
sutures, taken as a blind or concealed running stitch, through the deeper layer only of
the skin, are invariably followed in an aseptic wound by primary union. A wound

INGUINAL HERNIA; TREATMENT OF THE WOUND.
113
thus closed has a double advantage over the ordinary method by the interrupted
sutures, even when primary union supervenes. The patient is relieved from the anx-
iety caused by the knowledge that stitches are to be removed—a procedure never with-
out something of suffering ; and, that which in certain portions of the body is of primal
importance, the minimizing of the cicatrix, which is oftentimes so slight, after a few
months, as to be distinguished with difficulty.
18

PLATE XXVIII.*
Muscles, APONEUROSES, VESSELS AND NERVES OF THE INGUINAL, INFERIOR ABDOMINAL AND
FEMORAL REGIONS.
15, 16. Section of the aponeurotic leaf of the
small oblique (15) and of the great oblique (16)
which cover the rectus muscle in front.
E. Fibro-cellular layer of the small oblique.-
This muscle and the great oblique are cut in pro-
file. The bottom of the layer is formed by the
cellular aponeurosis of the transversalis and trav-
ersed by the recurring iliac vessels (17) and by
the anterior branches of the lumbar nerves (18, 18.)
3. Inguinal and Femoral Regions.
1. Inguinal Region.
Preparation.—The crural arch is lifted from
below by a hook so as to show the infundibulum
of the sheath of the femoral vessels, the bands of
the
aponeurosis of the great oblique, and Gimber-
nat's ligament.
A. The lower border of the aponeurosis of the
great oblique, which forms the anterior fibrous
crural arch.
1. Posterior border which forms the anterior
segment of the crural arch under which pass the
large vessels.
2. Ligament of Gimbernat, which is the inser-
tion at the crest of the pubis of the aponeurosis
of the great oblique muscle.
3. Fibrous infundibulum, which is composed in
the anterior segment of the adhesions of the
sheath of the vessels, with the fibrous contour of
the crural ring
B. External inguinal ring.
4. Internal pillar of the inguinal ring formed
by little firm bands of corresponding shape; it is
cut half-way of its breadth so as to free the por-
tion of the sheath of the rectus muscle.
5. External pillar.
6. Cord and spermatic vessels cut at their
exit from the inguinal ring.
2. Abdominal Inguinal Region.
C. Aponeurosis of the great oblique, the su-
perficial fascia having been removed.
D. Inferior extremity of the rectus muscle
invested in its sheath.
7. Portion of the posterior wall of the rectus
formed by the posterior layer of the aponeurosis
of the transversalis.
8. Inferior portion of the muscular investment
covered by the subperitoneal fibro-cellular apo-
neurosis.
9. Epigastric vessels.
10. Anterior branches of the lumbar vessels.
II, 11. Anterior filaments of the lumbar nerves.
12, 12. Linea alba.
13. Umbilical ring.
14. Inferior triangular ligament forming the
pubian attachment of the linea alba.
F. Femoral vessels inclosed in their sheath
and united to the enveloping aponeurosis of the
psoas iliacus. Lower, the sheath of the vessels
dip down between the abductor and the vastus
internus (G)
H. Aponeurotic sheath of the pectineus mus.
cle.
19. Pubian attachment preserved.
20. Ramus of the pubis.
21. Nutritive vessels separated from the fem-
oral vessels.
22. Obturator vessels and nerves seen behind
the posterior aponeurosis of the sheath.
J. Muscular sheath of the first abductor.
23, 23. Nutritive vessels freed from the fem-
oral artery.
24. Nerve branch of the same muscle fur-
nished by the obturator.
25. Trunk of the obturator nerve seen through
from behind the posterior sheath,
K. Superior extremity of the layer of the vastus
internus.
L. Superior extremity of the sartorius.
M. Aponeurosis of the anterior right of the
thigh.
26. Superior extremity cut at the point where
it surrounds the exit of the iliacus.
27. Nutritive vessels furnished by the femoral
vessels, and accompanied by a filament of the
crural nerve and muscular vessels furnished by
external collateral branches. We see in outline
the external collateral vessels and their associ-
ated nerves.
N. Sheath of fascia lata, with its vessels and
nerves.
* Bourgery, Plate VIII.
(114)

PLATE XXVIII.
19
20
27
32
23


CHAPTER XI.
FEMORAL HERNIA.SPECIAL ANATOMY OF THE PARTS.
The superficial fascia of the thigh is composed of two layers. The thick, dense
upper layer is continuous with the fascia above, over Poupart's ligament, and down-
ward with the connective-tissue layer covering the thigh. Inclosed between it and the
deep layer are situated the cutaneous vessels, nerves, and the lymphatic inguinal
glands. The deep layer is a thin but dense membrane, is closely adherent above to
the lower margin of Poupart's ligament, and about one inch below is closely united,
in its circumference, to the saphenous opening in the fascia lata. It blends with the
posterior border of the sheath of the femoral vessels. In this locality it has been
sometimes described as the cribriform fascia, since it is perforated by the internal
saphenous vein and numerous blood-vessels and lymphatics, giving to it sieve-like
openings.
The fascia lata, in a dense connective-tissue layer, extends as a uniform investment
over the upper portion of the thigh. The passage of the internal saphenous vein gives
the name to the opening through which this vessel penetrates. The fascia, on the outer
side of the opening, is called the iliac portion. It extends from the anterior superior
spine of the ilium downward over the anterior group of the muscles of the thigh, is
attached the whole length of Poupart's ligament internally as far as the spine of the
pubes, and joins with Gimbernat's ligament in the pectineal line, where it blends with
the pubic portion. It is reflected, in an arched margin, downward and outward from
the spine of the pubes, forming the outward boundary of the saphenous opening. This
has been described as the femoral ligament of Hey, and it demands especial attention,
since in femoral hernia it is the principal seat of the constriction. It has also been
called the falciform process of the fascia lata. It has a well-defined, curved mar-
gin, and is adherent to the sheath of the femoral vessels. The pubic portion of the
fascia lata is its continuation upon the inner side of the saphenous opening, and
lies beneath the sheath of the vessels to which it is attached. The opening through
(115)

116
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
Sufferficial circumflex
il
superfioial Pascu 1/11,
Glang
Enternal
reflected
Opening
KARA
Dee
Sahhenous
Gland
which the internal saphenous vein thus obliquely passes to join the femoral is oval,
and measures about an inch and a half in length and half an inch in breadth. The
inner boundary is less well defined than the outer, since it is behind the level of the
femoral vessels.
Upon extension of the limb, or rotating it outward, the edge of the opening will
be rendered tense. Flexion
or inversion of the limb re-
laxes it, a fact to be borne in
mind when attempting the
reduction of a femoral hernia.
In the study of the anato-
my of the parts involved in
inguinal hernia, Poupart's lig-
ament was described as the
lower border of the aponeu-
rosis of the external oblique
muscle, stretching across, in
a strong tendinous band, be-
tween the anterior superior
spine of the ilium to the
spine of the os pubis and the
pectineal line. It is slightly
curved, with convexity down-
ward. The posterior border
FIG. 7.—The anatomy of the femoral region. Superficial dissection
has an arched form toward
(Gray).
the pubes, in consequence of
the expanded portion which is fixed into the pectineal line. This was called the
crural arch by Gimbernat. We are indebted to this distinguished Spanish surgeon
for the first accurate description of the parts, who published in Madrid, in 1793. The
history of the anatomical researches of the structures of this part of the body and their
relation to hernia constitute one of the most interesting chapters in anatomy. The
importance of a correct anatomical knowledge of these parts was recognized by
Albinus and Heister, and yet they describe the round ligament in the female as escap-
ing through an opening in the oblique and transversalis muscles. This error was
VIR
Widdle Croaneous N.
will
Gland
u 214]
LUI
perficial Facia

FEMORAL HERNIA.-SPECIAL ANATOMY OF THE PARTS.
117
Ant.
sup.
sp.
corrected by Garengeot, who derived his first ideas from the celebrated anatomist
and surgeon, M. Petit, who published his views in 1742. The sheath of the femoral
vessels was at this time a subject of marked discussion, and was then called the
cellular substance of Ruysch, who first pointed it out. This tissue, however, Heis-
ter considered as one of the two layers of membrane of which the peritonæum was
commonly supposed at this time to consist. Gimbernat's dissections were carefully
made and clearly and accurately described. He pointed out that a lamina of the
fascia iliaca passes over the pectineus muscle and is attached to the crest of the os
pubis, where it is united with the ligamentous expansion which bears his name and ter-
minates upon the same crest. His anatomical account of this sheath is as follows: “ By
this union is formed a species of
ligament which passes along the crest
immediately above the insertion of
the superior extremity of the pec-
tineus muscle; from this division of
the crural arch an aponeurotic sheath
arises at the top of the thigh, be-
ginning at the crural arch itself, close
to the body of the pubis, so that the
expansion which has been described,
and which is sent from the internal
edge of the arch, passing behind the
iliac vessels, forms the posterior wall
of the sheath, while the anterior wall
is formed by the external edge of
the fascia lata."
Sir Astley Cooper added materi-
ally to this knowledge by his inves-
tigations of the transversalis fascia,
FIG. 8.—The anatomy of the femoral region, showing fascia
already referred to in the description
lata and saphenous opening (Gray).
of the internal oblique ring in in-
guinal hernia. He demonstrated that a process of the fascia transversalis, in form-
ing the femoral sheath, constituting its front wall, passes immediately behind Pou-
part's ligament, and forms a connection with its thin posterior edge. Mr. John
Portparthe Ligament
AzoneU LOSES 01 SEXUERENSAGOBEEQUE
Portion
Tliad
Erléiform-processe
Spine
Pubo:
Waphe
nous Open
internal Saphenous L
MENU
a

118
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Gay,* who made an exhaustive study of the anatomical relations in femoral hernia
by the careful examination of over seventy subjects, states that “according to my ex-
EXTERNAL BEEQUE
下​心​司
​Pouhart
рә аш о..
unsversalis Fasol:
ACUS
a liya mer
Ant.Crural-
Iliac po
Wild
Artery
Vein
SEARTIER LEUS
Interior Layer
Femme
Sheath
Sarihe norts
Pubi
icho
fernal
F &
Fig. 9. — The anatomy of the femoral region. Iliac portion of fascia lata removed, and sheath of femoral vessels
and femoral canal exposed (Gray).
aminations of this structure, both before and subsequent to maceration of the parts,
it appears to be formed in the following manner: The inner portion of the fascia
transversalis, being extended behind the crural arch downward into the thigh, in front
of the femoral vessels, constitutes the front wall of their sheath, while lateral expan-
sions of this process—each taking a converse direction in relation to the other-con-
stitute the iliac and pubic walls. These unite behind the vessels, and in this manner
complete the sheath. Thus, in the part of the thigh under consideration the sheath
is wholly formed by an extension of the transversalis fascia.”
>
* On Femoral Rupture. London, 1848.


PLATE XXIX.
f
d
d
u
22.
W!
h.
,y
š
1
k
m
n...
0
2.
a

FEMORAL HERNIA. - SPECIAL ANATOMY OF THE PARTS.
119
PLATE XXIX.*
This plate is intended to exhibit a view of the abdominal rings and of the crural arch in the
female; the fascia lata of the thigh, the crural sheath, and the passage of the round ligament of the
uterus, from the internal to the external ring.
a. Symphysis pubis.
n. Femoral artery.
b. Tuberosity of the pubes.
0. Femoral vein.
C. Anterior superior spinous process of the P. Three absorbent vessels within the sheath:
ilium.
the first on the outer side of the artery; the second
d, d. External oblique muscles.
between the artery and vein; and the third on the
e. Linea alba.
inner side of the vein, which last has the course of
f. Linea semilunaris.
the crural hernia.
g. Crural arch, or Poupart's ligament, extend- 9, 9. Saphena major vein.
ing from the spinous process of the ilium at c r, r. Two absorbent glands sending forth the
beyond the tuberosity of the pubes at b.
absorbent vessels of the sheath.
h. Tendinous fibers crossing the columns of s. Arteria circumflexa ilii.
tendon of the external oblique; they proceed t. Epigastric artery.
from the spinous process of the ilium and the u. Tendon of the external oblique muscle
crural arch.
i. The abdominal ring on the left side; its v. Internal oblique muscle turned upward.
upper column inserted into the symphysis pubis, W. Transversalis muscle turned upward.
and the lower into the tuberosity, but afterward x. Fascia transversalis seen passing from the
extended forward toward the symphysis.
crural arch behind the transversalis muscle.
k. That part of the fascia lata of the thigh y, y, y, y. Round ligament of the uterus de-
which proceeds from the crural arch, and which scending through the opening in the fascia, in the
covers the muscles on the outer part of the thigh inguinal canal, and through the abdominal ring,
and femoral vessels.
to be lost in the fat on the pubis.
l. The inner portion of the fascia lata cover- 2. Course of the epigastric artery seen through
ing the pectineus and triceps muscles, and united the fascia transversalis.
with the outer portion of fascia behind the sa- +. Absorbent vessels on the left side enter-
phena major vein.
ing the crural sheath, at the part at which the
m. Crural sheath cut open.
crural hernia passes into the thigh.
laid open.
The space between the crural arch and the bone is almost entirely occupied by the
parts which descend from the abdomen. On the outer side are the psoas and iliac mus-
cles. On the inner side are the femoral vessels inclosed in a sheath. The oval-shaped
opening, for the passage of the vessels, is the crural or femoral canal. Through this
opening the abdominal contents escape in femoral hernia. The upper border of the
canal is called the femoral ring, and is continuous with the cavity of the abdomen. It is
larger in the female than in the male, and in its large transverse diameter measures
about one half an inch. In front it is bounded by the deep crural arch of Poupart's liga-
*
Cooper, Plate I, Part II.
+ I shall hereafter call this simply the spinous process of the ilium.

I 20
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Transvers
irsalin
Fazoia
a men
parts Lugam
Iliad Fasoi
Epigastric Vessels
Ab demind
Ring
Vessels
Femoral Arty,
VUS
ng
Femoral
Gimberna
( Lig?
Faso
Obturator Arty&N,
ment; behind by the pubes and the deep portion of the fascia lata; internally by Gim-
bernat's ligament, the conjoined tendon, the transversalis fascia, and the deep crural arch;
externally by the femoral vessels inclosed in their sheath. Poupart's ligament sepa-
rates the femoral from the internal portion of the inguinal canal ; directly above it lies
the spermatic cord with its vessels, in the male, and this may be divided in the operation
for strangulated femoral hernia. The epigastric artery lies across the upper and outer
angle of the rim, and is endangered by
cutting freely in this direction, but is
usually about one half inch from the
neck of the hernial tumor. Upon the
outer side of the ring is the femoral
vein. The ring is, as it were, bounded
in all directions by vessels, except pos-
teriorly by the ossa pubis, and internally
by Gimbernat’s ligament.
The obturator artery holds an im-
portant relation to the femoral ring,
when it arises, by a common trunk, with
the epigastric artery. This is the more
dominal rings seen from within the abdomen, right
important since this is the condition in
side (Gray).
every three or four individuals.
Occa-
sionally the vessel curves along the margin of Gimbernat’s ligament as it passes to
the obturator foramen, and when this occurs it is very likely to be divided in the
operation for a strangulated femoral hernia.
A delicate layer of connective tissue closes the femoral ring, and is described by
M. Cloquet as the septum crurale. It is a slight protection to a hernial protrusion; a
small lymphatic gland usually lies between it and the peritonæum. It is perforated by
numerous small openings for the passage of lymphatic vessels, and serves as much for
their connection and support as for closure of the ring. Beneath this septum a layer
of fatty tissue is usually found, lying directly upon the peritonæum. This is impor-
tant chiefly, since it might be mistaken, in a hernial protrusion, for omentum.
It is easily understood, from a study of the anatomy of the parts, that the femoral
ring, although re-enforced and protected in such a marvelous manner, must be a weak
point in the abdominal wall. By congenital defect, laxity of tissue, or by long-con-
FIG. 10.-The relations of the femoral and internal ab-


PLATE XXX
E
Y
Ꮒ
J
R
E
k
f
L
m
f
X
P
SO
B.
а
C
1

FEMORAL HERNIA. SPECIAL ANATOMY OF THE PARTS.
I21
tinued pressure, the peritoneal covering over the ring becomes pouched, and a lodg-
ment of abdominal contents serves as a wedge to force open the canal. The greater
size of the canal in woman, together with the firmer character of the inguinal ring,
renders this variety of hernia more common in the female.
PLATE XXX.*
INGUINAL CANAL AND CRURAL RING.
A. Portion of the thigh, seen outwardly. neurosis rises from the external edge of the right
B. Penis.
muscle.
C. The testicles.
V, V. Inferior edge confounded and horizon-
D. Hair of the pubes.
tally directed from the small oblique and trans-
E, E. Portion of the anterior abdominal in- versal muscles.
closure.
V, V, V, V. Muscular bundles of the cremas-
F. Anterior and superior iliac spine.
ter muscle formed by an emanation upon the cor-
G. Right muscle in its sheath.
don of the inferior edge of the small oblique and
H. Pyramidal muscle equally in its sheath. transversal muscles.
1. Aponeurosis of the great oblique.
X. Testicular cordon, in the middle of which
J. Hook which lifts up a portion of the apo- are seen the flexuosities of the testicular veins.
neurosis of the great oblique, detached over the Y. Ileo-scrotal nerves of the lumbar plexus.
crural arcade, where it forms the anterior inclos- Z, Z, Z. The adipose skin and tissue of the
ure of the inguinal canal.
abdominal inclosure, turned down. Fascia super-
K, K. Crural arch.
ficialis aponeurosis.
L. Inguinal ring crossed by the testicular a. Cordon knotted upon the fascia superfi-
cordon, and sending from its circumference a cialis aponeurosis, detached from the abdominal in-
fibrous expansion upon the cordon.
closure and turned back upon the thigh and the hip.
M. Fibrous expansion detached from the cir- b, b, b. Tegumentary vessels of the abdomen.
cumference of the inguinal ring.
c. Genital external superficial vessels.
N. Internal or superior pilaster of the ring. d, d. Anterior inclosure of the crural canal,
0. External or inferior pilaster of the ring. cut and turned back from inside to outside, to show
P. Place where the crural arch continues with the crural canal.
all the thickness of the fascia lata aponeurosis.
e. Large lymphatic ganglion, placed before
Q. Place where the crural arch adhered only the crural canal.
to the superficial layer of the fascia lata, which f, f. Openings of the anterior inclosure of the
here has been detached and overturned outside. crural canal, which are crossed by lymphatic ves-
R. Sinus, open in the upper part, which the sels.
crural arch forms in continuing backward and g. External inclosure of the crural canal,
above, with the fascia transversalis sinus, which formed by the deep leaf of the fascia lata, sup-
constitutes the inguinal canal.
ported upon the psoas and iliac muscles.
S, S. Fascia transversalis aponeurosis, which h. Opening made in the external inclosure of
forms the posterior inclosure of the inguinal pas- the crural canal, in order to show the crural nerve
sage, in a place where, of the three muscles of placed immediately outside of it, in the sheath of
the abdomen, only the external oblique one is
found.
i. Femoral artery, placed outside of the vessel
T. Place where the fascia transversalis apo-
of the same name.
the psoas.
* Blandin, Plate VI.
19

I 22
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
j. Femoral vein placed upon the inside of the
artery.
1. Internal saphenous vein.
m. Inferior opening of the crural canal, crossed
by the internal saphenous vein.
n. Fibrous falciform tissue placed at the con-
fluence of the saphenous and femoral veins.
Coverings of Sac.—The abdominal contents which make up the tumor carry
before them the peritonæum, which forms the hernial sac. External to it are delicate
investments of connective-tissue layers, derived from the subperitoneal fascia and the
septum crurale. Sir Astley Cooper named the subperitoneal layer of connective tissue
the fascia propria, and describes it as thicker than the peritonæum, close and firm in
its texture, embracing the whole of the tumor to its very neck; more or less adipose
tissue is interposed between this layer and the peritoneal covering of the tumor. Al-
though these layers of fascia are important, and have been described by the earlier
anatomists at great length, they are often so blended and fused as to defy distinction.
It is well to remember that the investment of a femoral hernia should consist of peri-
tonæum, fascia propria, septum crurale, crural sheath, cribriform fascia, adipose tissue,
and integument, and yet all combined usually make a very thin covering of the tumor,
and their dissection should be conducted with even greater care than in inguinal
hernia.
Contents.—The contents of a femoral hernia are similar to those of inguinal.
Omentum, however, is usually less common and is rarely found unassociated with a
loop of intestine. Sir Astley Cooper states that he met with omentum as the only
contents of the sac but twice. Mr. Lawrence observes that he has seen it more fre-
quently, and I have met it twice in my own experience. Hesselbach described a case
where the ovary and tube formed the contents of a crural hernia of the left side.
Femoral hernia is necessarily subject to comparatively few and unimportant variations.
In rare instances the hernial sac is found on the outer side of the femoral vessels in
front, or even behind them.
The tumor usually descends vertically, through the crural canal, along the inner
compartment of the sheath of the femoral vessels, as far as the saphenous opening.
Here the sheath is greatly narrowed and in close contact with the vessels; the super-
ficial fascia and crural sheath are closely attached to the lower part of the saphenous
opening, and by these obstructions the tumor is prevented from extending lower. In
its further progress it is directed forward, carrying before it the cribriform fascia, and
curves upward upon the falciform process of the fascia lata and lower part of the tendon
of the external oblique muscle, retained only by the superficial fascia and integument.


PLATE XXXI.
B
B
7
E
N
Q
s
K
d
RO
M
H

FEMORAL HERNIA.--SPECIAL ANATOMY OF THE PARTS.
123
PLATE XXXI.*
A, A. External oblique muscle.
B, B. Aponeurosis of external oblique muscle.
C, C. Sheath of the rectus muscle.
D. Linea alba.
E, E. Poupart's ligament.
F, F. Arch of the internal abdominal ring.
G. Suspensory ligament of the penis.
H. Penis.
1, I. Arch of the external abdominal ring.
K, K. Tubercle of the ossa pubis.
L, L. Abdominal ring.
M, M. Spermatic cord.
N, N. Fascia lata.
0, 0. Gimbernat's ligament.
P. Internal aperture of the femoral canal.
Q, Q. Anterior wall of the femoral canal.
R, R. Falciform edge of the external opening
of the femoral canal.
S, S. Superior edge of the external opening
of the femoral canal.
T, T. Inferior edge of the external aperture
of the femoral canal.
U, U. Fascia of the pectineus muscle.
V, V. Femoral artery.
W, W. Femoral vein.
X, X. Large saphenous vein.
Y. Common trunk of the epigastric and ob-
turator arteries, going out from the femoral artery.
Z. Epigastric artery.
1. Peritoneum.
2, 2. Anterior wall of the vaginal rectus muscle.
3. Rectus muscle.
4. Obturator artery.
5. Sac of the femoral hernia.
6, 9. Limiting lines marking the topography
of inguinal hernia.
7, 10. Limiting lines marking the topography
of femoral hernia.
8, 8, 8. Anterior superior spine of the crista
of the ossa ilium.
When in the canal, owing to its firm, resisting walls, the hernial tumor is small,
but after escaping from the saphenous opening it may become of considerable size. “In
the female it is generally very movable, and, being soft, and the skin not being discol-
ored, it may have the appearance merely of an inguinal tumor of one of the absorbent
glands; but in the male the skin is generally not so loose, the swelling not so dis-
tinctly circumscribed, and the tumor appears buried more in the substance of the thigh.
The largest size to which I have seen the tumor arrive was in cases of which I have
given plates in this work. The one was in the male, the other in the female; they
were each of them about the size of the fist, and each occupied the whole of the hol-
low, from the anterior superior spinous process of the ilium to the tuberosity of the
pubis. But my friend Mr. Thompson, Professor of Military Surgery, at Edinburgh,
mentions a case of a woman, laboring under an old irreducible crural hernia, in whom
the tumor extended half-way down the thigh. In this case the parietes of the abdo-
men were so thin that the peristaltic motion of the intestine could be distinctly per-
ceived. Upon the whole, however, it is unquestionable that the crural hernia is com-
paratively smaller than the inguinal, and on this account it is the more dangerous.” +
* Langenbeck, Table XI.
+ Cooper, op. cit.

I 24
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
The following measurements, from Sir Astley Cooper, are of value :
Male.–From the symphysis to the center of the orifice of the sac, two inches;
from the center of the orifice of the sac to the external iliac artery, one inch ; from the
center of the orifice of the sac to the center of the external iliac vein, three quarters of
an inch; from the center of the orifice of the sac to the origin of the epigastric artery,
three quarters of an inch ; from the center of the orifice of the sac to the inner edge
of the internal abdominal ring, one inch ; from the tuberosity of the pubes to the cen-
ter of the orifice of the crural hernia, one inch.
· Female.—Each measurement is from one eighth to one fourth of an inch more,
where the female pelvis is large and well formed, than in the male.”
PLATE XXXII.*
CONTAINS VIEWS OF THE ANATOMY OF THE GROIN AND UPPER PART OF THE THIGH IN THE
FEMALE.
Figure 1.
a. Symphysis pubis.
b. Spinous process of the ilium.
C. Abdominal muscles.
d. Abdominal ring.
e. Crural arch.
f, f, f. Fascia lata of the thigh.
8,8. Semilunar edge of the fascia lata.
h. Crural sheath or fascia inclosing the crural
vessels.
i. Saphena major vein.
k. Place at which the crural hernia descends.
h. Anterior edge of the crural arch, or Pou-
part's ligament.
i. Third insertion of the external oblique
muscle.
k. Ligament of the pubes, into which the ex-
ternal oblique muscle is inserted.
1. Portion of fascia transversalis, and tendon
of the rectus, passing behind the insertion of the
external oblique.
m. Fascia iliaca passing from the crural arch
over the iliacus internus muscle.
n. Orifice of the crural sheath, for the passage
of the crural artery, vein, and absorbent vessels.
Figure 2.
Shows the insertion of the external oblique
muscle into the pubes and its ligament, and the
fascia iliaca, or Gimbernat's fascia.
a. Pubes.
b. Spine of the ilium.
C. Acetabulum.
d. Thyroid foramen.
e. Column of tendon.
f. Another column.
g. A third column, making together two aper-
tures at the abdominal ring in the female, which
is not uncommon.
Figure 3.
Shows the crural sheath.
a. Pubes.
6. Ilium.
c. Abdominal muscles drawn up.
d. Transversalis muscle.
e. Its tendon.
f. Seat of the posterior edge of the crural
arch.
8, g. Fascia transversalis.
8,8
h. Inner portion of the same fascia.
i. Fascia iliaca.
* Cooper, Plate II, Part II.

PLATE XXXII.
Fig. 2.
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PLATE XXXII A
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Fig. 6.
2
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m
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Fig. 8; d
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k

FEMORAL HERNIA.-SPECIAL ANATOMY OF THE PARTS.
125
k. Femoral sheath.
d. Psoas.
1. Femoral artery.
e. Fascia iliaca.
m. Femoral vein.
f. Rectus abdominis.
n. Saphena major vein.
g. Junction of the fascia iliaca and transver-
0. Anterior crural nerve.
salis at the edge of the crural arch.
p. Fascia lata turned back.
h. Fascia transversalis.
9. Tendon of the external oblique muscle, i. Ligamentum rotundum, passing from the
drawn down.
abdomen through the fascia transversalis.
Figure 4.
k. Fascia transversalis, and portion of the ten-
don of the rectus raised.
Posterior view of the place at which the crural
1. Inferior column of the tendon of the exter-
hernia descends, as it appears when the peritonæum
is first stripped off.
nal oblique.
a. Pubes.
m. The abdominal ring.
b. Abdominal muscles.
n. The third insertion of the external oblique.
0. Iliac artery.
C. Round ligament passing into the inner ab-
dominal ring.
Þ. Iliac vein.
d. Femoral artery.
9. Epigastric artery.
e. Femoral vein.
r. Epigastric vein.
f. Epigastric artery.
s. Circumflexa ilii.
8. Epigastric vein.
t. Absorbent gland receiving the different cru-
ral absorbent vessels.
h. Depression at which the crural hernią first
descends.
v. Absorbent vessels passing through the
Figure 5.
crural space or ring which is seen situated be-
tween the third, or semicircular insertion of the
Posterior view showing the mode in which the external oblique muscle.
abdomen is shut from the thigh. The peritonæum W. A part of the posterior edge of the crural
is removed.
arch which forms one of the seats of stricture in
a. Pubes.
large crural hernia,
b. Ilium.
Figs. 5 and 6 were both drawn removed from
C. Abdominal muscles.
the body as they appear in the plate, which ac-
d. Rectus.
counts for the flatness of their appearance.
f, f. Junction of the fascia iliaca and trans-
versalis behind the crural arch.
Figure 7
g. Round ligament passing from the abdomen Crural hernial sac removed to show the open-
through the fascia transversalis.
ing by which it descends in the female.
h. A portion of fascia or tendon passing from a. Seat of the pubes.
the pubes to join the rectus.
b. Crural arch extending toward the ilium.
i. Fascia iliaca.
C, C. Abdominal muscles.
k. Iliac artery.
d. Crural arch.
1. Iliac vein.
e, e. Fascia lata.
m. Epigastric artery.
f. Semilunar edge of the fascia lata.
n. Epigastric vein.
g. Third insertion of the external oblique.
0. Anterior crural nerve.
h. Femoral artery.
Þ. Crural space, by which the crural hernia i. Femoral vein.
descends; it leads into the crural sheath.
k. Femoral sheath.
1. Abdominal ring.
Figure 6.
m. The orifice by which the crural hernia
A similar view, but with a portion of the fas- descends, formed on the outer side by the crural
cia transversalis raised.
sheath, on the inner by the semilunar insertion of
a. Pubes.
the tendon of the external oblique, and above in
6. Ilium.
part by the crural sheath and in part by the
c. Iliacus internus.
semilunar edge of the fascia lata. The division

I 26
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
in crural hernia is made at the upper and inner
part.
Figure 8.
Posterior view of the same preparation.
a. Seat of the pubes.
b. Abdominal muscles.
6. Iliac vein.
d. Epigastric artery.
e. Epigastric vein.
f. Peritonæum.
g. Hernial sac drawn from the aperture.
h. A fascia cut off which covers it.
i. Third insertion of the external oblique
muscle.
k. Fascia on the inner side of the vein.
1. Aperture by which the crural hernia de-
scends.
m. A line from this points out the posterior
edge of the crural arch, which assists in forming
the stricture of crural hernia.
In femoral hernia the location of the stricture varies. It may be found in the neck
of the hernial sac. This, however, is rare ; more commonly it is found at the junc-
tion of the process of the fascia lata with the edge of Gimbernat's ligament, or at the
margin of the saphenous opening. The edge of the constriction is usually sharply
defined, and its division, to the extent of two or three lines, is generally sufficient.
The sac may be multiple, although this is much more rare than in inguinal hernia.
Symptoms.—Femoral hernia is recognized by the same general symptoms as ingui-
nal hernia. When reducible, it disappears in the recumbent position, to return when
erect; it is distended upon coughing. Its intestinal contents are elastic and uniform
to the touch, and a gurgling sound is heard when it is returned into the abdomen.
The surface is less equal, and has a doughy feel when the omentum constitutes the
contents of the sac. Femoral hernia is usually diagnosticated without much difficulty,
since tumors of the groin are much less common than of the scrotum. There are
conditions, not infrequently, however, when the diagnosis is not easily determined.
Cases are reported where the intestine was divided under the supposition that the
tumor was a suppurating bubo ; also where, under a similar supposition, poultices were
applied, and death supervened from gangrene of the inclosed intestine. An enlarged
gland may also complicate the conditions, occurring in conjunction with hernia.
Cystic dilatation of a portion of the hernial sac may form a complication. I have very
recently operated upon a woman of about forty years of age who had suffered from
femoral hernia for twelve or thirteen years, much of the time wearing a truss. A por-
A
tion of the tumor became irreducible, and the truss could not be tolerated. The sac
was thick-walled, and the lower portion was occluded and filled with serum, making
a tumor the size of an egg.


PLATE XXXIII.
I'ig.l.
d
b
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Fig.3.
h
Be
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k

FEMORAL HERNIA.-SPECIAL ANATOMY OF THE PARTS.
127
PLATE XXXIII.*
VIEWS OF THE PARTS IN THE GROIN OF THE MALE, INTENDED TO SHOW THEIR ANATOMY.
c. Junction of the pubes and ilium.
Figure 1.
d, d, d. Abdominal muscles.
Posterior view of the external oblique muscle, e. Iliacus internus muscle covered by the fas-
of the external iliac artery and vein, and of the cia iliaca.
fascia iliaca.
f. Psoas muscle covered by a portion of the
a. Symphysis pubis.
same fascia.
b. Spinous process of the ilium.
8,8,8. Fascia transversalis lining the abdom-
C. Linea ileo-pectinea of the pubes.
inal muscles, and descending to the crural arch.
d. External oblique muscle and its tendon.
h. Poupart's ligament, or the crural arch,
e. Superior column of the tendon of the ab-
where the two fasciæ join.
dominal ring.
i. A process of fascia passing upon the iliac
. f. Insertion of the inferior column of the ring artery and vein, uniting them to the edge of the
into the tubercle of the pubes.
crural sheath.
g. The third insertion of the external oblique k. Internal abdominal ring, or upper aperture
into the ligament of the pubis, whence it is ex- of the inguinal canal.
tended toward the symphysis.
1. Spermatic cord passing through that aper-
h. Abdominal ring.
ture.
i. The fascia iliaca extending over the iliacus m. External iliac artery.
internus and psoas muscles.
n. External iliac vein.
k. The junction of the fascia iliaca with the 0. Epigastric artery and vein.
posterior edge of the crural arch, and it is seen ex- Þ. Third insertion of the external oblique into
tending near to the external iliac artery.
the pubes, covered, however, by the fascia trans-
1. External iliac artery.
versalis.
m. External iliac vein.
9. The space by which the crural hernia de-
[These vessels pass through an oval space, scends, the finger having passed into it before the
which is the beginning of the crural sheath, and drawing was made to push down the fascia which
which is bounded internally by the third insertion extends over it.
of the external oblique muscle, externally by the r. The thyroideal foramen.
fascia iliaca joining to the posterior edge of the
crural arch, behind by the process of the same
Figure 3.
fascia, and before by the posterior edge of the An anterior view of the groin.
crural arch.]
a. Symphysis pubis.
n. Posterior edge of the crural arch extending b. Spine of the ilium.
from the pubes to the ilium. That part of it c. Tuberosity of the pubes.
which is included between the two lines from n d. Crural arch, or Poupart's ligament.
forms the posterior stricture in large crural herniæ.
e. The place at which the crural hernia de-
0. Thyroideal foramen.
scends.
f. Superior column of the abdominal ring.
Figure 2.
g. Inferior column.
A posterior view of the parts of the groin h. Abdominal ring.
when the peritonæum is removed.
i, i. Fascia lata.
a. Symphysis pubis.
k, k. Semilunar edge of the fascia lata, some-
b. The seat of the spine of the ilium.
what larger in this subject than usual.t
* Cooper, Plate III, Part II.
+ To see this, it is necessary to cut away some fibers covering the crural sheath.

128
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
1, 1, Crural sheath covering the femoral artery 0. Iliacus internus muscle.
and vein, at the inner and upper part of which, at p. Seat of the crural arch to which the sheath
e, the crural hernia descends.
adheres.
m. Saphena major vein entering the sheath. 9. Portion of the crural sheath passing behind
n. A vein entering the saphena major.
the third insertion of the external oblique muscle.
r. Opening in the fascia transversalis for the
Figure 4.
passage of the spermatic cord.
Is intended to show the crural sheath, and the
s. Two lines which include the spot at which
insertions of the external oblique muscle.
the crural hernia descends, and which is situated
at the inner and upper part of the crural sheath. *
a. Pubes.
b. Ilium.
6. Superior column of the abdominal ring.
Figure 6.
d. Inferior column.
Shows the crural sheath cut open.
e. Abdominal ring.
a. Pubes.
f. Anterior edge of the crural arch, or Pou- b. Ilium.
part's ligament.
C, C. Transversalis muscle and tendon.
g. Fascia lata dissected from the crural arch d. Insertion of the external oblique turned
and turned back.
down.
h. Third insertion of the external oblique into e, e. Fascia transversalis at its inner part; the
the ligament of the pubes; to see which, the fascia epigastric artery and vein are seen.
lata and the origin of the pectineus muscle must f, f. Sheath cut open.
be raised.
g. Femoral artery.
i. Crural or femoral sheath covering the cru- h. Femoral vein.
ral artery and vein.
i. Saphena major.
k. Saphena major vein entering the sheath. k. Epigastric artery and vein.
1. Iliacus internus muscle.
1. Circumflexa ilii.
m. Pectineus muscle.
m. Internal abdominal opening for the sper-
matic cord.
Figure 5.
n. Space between the crural sheath and fem-
Shows the connection of the crural sheath oral vein, showing the part at which the crural
with the fascia transversalis.
hernia descends.
a. Pubes.
6. Ilium.
Figure 7.
c. Abdominal muscles.
Artery and vein removed from the sheath.
d, d. Transversalis muscle and tendon.
a. Pubes.
e. Tendon of the external oblique muscle cut b. Ilium.
through and turned down.
c. Fascia transversalis.
f. External portion of the fascia transver- d. Aperture in it.
salis.
e. Fascia transversalis.
g. Internal portion of the same fascia.
f. Anterior part of the crural sheath cut open.
h. Fascia lata turned back.
g. Femoral artery.
i. Crural sheath covering the femoral artery.
h. Femoral vein.
k. Crural sheath covering the femoral vein. i. Opening of the sheath from the abdomen.
1. Saphena major vein.
k. Iliacus internus.
m. Some part of the semilunar edge of the 1. Fascia iliaca forming the posterior part of
fascia lata.
the crural sheath, and sending forward a process
n. Anterior crural nerve.
between the crural artery and vein.
* To make a similar preparation, it is necessary that the semilunar edge of the fascia lata should be raised, and the
finger be carried behind the edge of the crural arch.


PLATE XXXIII A.
Fig. 5.
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FEMORAL HERNIA.-SPECIAL ANATOMY OF THE PARTS.
129
Figure 8.
Anterior view of the crural arch, a hernial sac
having been removed from it to show the orifice
by which the crural hernia descends.
a. Seat of the symphysis pubis.
6. Crural arch.
C, C. Fascia lata.
d. Semilunar edge of the fascia lata.
e. Crural sheath.
f. Abdominal ring.
g. Spermatic cord.
h. Femoral artery.
i. Femoral vein.
k. Anterior column of the crural sheath,
which requires division in the operation for the
crural hernia.
1. Lower column of the same opening.
m. The hole in the side of the sheath by which
the crural hernia descends.
b. Ilium.
c. Pubes.
d. Rectus muscle.
e. Other abdominal muscles.
f. Fascia transversalis.
g. Spermatic artery and vein going through
the internal abdominal ring.
h. Femoral artery.
i. Femoral vein.
k. Fascia between these vessels.
1. Epigastric artery.
m. The aperture by which the crural hernia
quits the abdomen.
n. The fascia forming the outer part of the
stricture.
0. That forming the inner.
P. Fascia and posterior edge of the external
oblique muscle forming that part of the stricture
which requires division in the operation, if the
division of the anterior column of the crural
sheath k, in the former figure, is insufficient.
Figure 9.
Posterior view of the same preparation.
a. Symphysis pubis.
a
“ It was easy
Varicosity of the femoral vein may be mistaken for a femoral hernia. Sir Astley
Cooper reports a case in which he was consulted for a supposed hernia.
to detect the nature of the case, for, although it disappeared in the recumbent position,
it was immediately reproduced, even if she continued in that position, by pressing upon
the vein above the crural arch and retarding the return of the blood. She died of
stricture in the colon; and, upon inspecting the body, I found that I could readily
thrust my finger into the crural vein, but that she had no hernia.”
A consideration of the anatomical conditions of the great vessels of the groin would
lead to the inference that femoral hernia must be rare in early childhood. It is only
after a considerable strain has been brought to bear for a long time upon the parts
that the connective-tissue sheath, enveloping the vessels, yields, and this rarely happens
until adult life. Kingdon states that he had met femoral hernia only once in the many
thousand cases which he had examined, and that was in a girl of eleven years of age.
Dr. De Garmo states that he had had under personal supervision a boy, eight years
a
old, with femoral hernia, which is the only case in his experience, and he has not found
record of its occurrence at so early an age.
I have lately been consulted in the case of a limited varicose femoral vein, more
than an inch in diameter, where, upon standing, a differential diagnosis was not easily
a
20

130
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
*
a
made. I am, however, assured that this condition is rarely found. Psoas abscess and
fatty tumors should also be taken into consideration as possible. Mistaken diagnosis,
confounding a femoral with an inguinal hernia, is not so very rare.*
This is of less importance in general practice, although intelligent efforts at reduc-
tion must depend upon a diagnostic recognition of the anatomical relations, and a fem-
oral hernia goes over into a dangerous constriction of the intestine more rapidly than
an inguinal. Inguinal and femoral hernia are rarely found occurring in the same sub-
ject. Femoral hernia is more common upon the right than the left side. The fol-
lowing plate from Cooper illustrates beautifully the two forms of hernia occurring in
the same subject.
PLATE XXXIV
Exhibits an anterior and posterior view of two inguinal and a crural hernia in the same subject.
The common inguinal truss may be applied for a small crural hernia; but in the larger, a truss which
approaches the right angle is required, as the motions of the thigh displace the inguinal truss when
put below the crural arch.
Figure 1.
Figure 2.
Anterior view of a crural and two inguinal Posterior view of the same preparation.
hernia.
a,
à. Seat of the spinous processes of the ilia,
a. Symphysis pubis.
the upper a pointing to the abdominal muscles a
b. Spinous process of the ilium.
little below the umbilicus.
C, c. Crural arch sending off the fascia lata of b. The bladder contracted.
the thigh.
c. The uterus drawn to the right side toward
d, d. Semilunar edge of the fascia lata.
the mouth of the hernial sac.
e, e. Saphena major vein on each side.
d, d. Ovaria.
f, f. Abdominal rings.
e, e. Fallopian tubes.
g. Sac of the inguinal hernia on the left side. f, f. Ligamenta rotunda.
h. Its fascial covering.
g. Orifice of the sac of the inguinal hernia on
i. Inguinal hernial sac on the right, its cavity the left side.
obliterated by adhesion.
h. Orifice of the crural hernia.
k. Sac of the crural hernia.
i. Sac of the right inguinal, shut by adhesion.
m. Its orifice, which had been dilated inward k, k. Epigastric artery and vein.
in the operation for this hernia.
*“Verhegen's reputed discovery of the difference between the seats of inguinal and femoral rupture introduced
a new era in the annals of hernial surgery. 'Alius huic vicinus locus est, ubi fiunt herniæ periculosæ et sæpe lethales;
scilicet, ubi venæ et arteriæ iliacæ tendunt ad crura.' Verhegen adds, adopting Paré's explanation of the mode in
which a rupture is formed, “Siquidem peritonæo paululum delato, aut quod rarissime contingit, rupto, descendet exigna
pars intestini ilii,' but proceeds in advance of his predecessor, “ibidemque partibus vicinis accrescit, ex quâ accrescen-
tia vidi particulam intestini ilii omnino occlusam, et ægrum miserere marientem,' etc.
“In this passage there appears to be a dim recognition of a seat of stricture, which includes the neck of the sac,
and parts contiguous to it, and of these parts the ligament of Fallopius or Poupart was supposed to be the principal.”
-Gay on Femoral Rupture, p. 56.
+ Cooper, Plate VI, Part II.

PLATE XXXIV.
Fig. 1.
7
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3
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PLATE XXXV.
Fig. 4.
Fig.2.
Fig.1.
а.
Fig. 3.
C
B
a
b
a

CHAPTER XII.
OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
Taxis.-In operative measures, a correct diagnosis is of the first importance. Fatal
errors have been made, otherwise avoidable. Attempt at cure of femoral hernia has
been far less common than of inguinal hernia, and operative measures have been insti-
tuted in rare instances, except to relieve intestinal obstruction. When strangulation
has occurred, the sharp, unyielding edge of the ring produces a much more dangerous
condition than in inguinal hernia, and calls for even more prompt measures for relief.
Cases are on record where death has followed from strangulation within twenty-four
hours after the accession of the symptoms. Not very rarely forty-eight to sixty hours
of compression of the intestine will cause necrosis. This supervenes all the more
rapidly in femoral hernia, since the size of the opening is small, and the edge of the
ring sharp and firm.
If reduction can not be safely secured under ether, by taxis intelligently conducted,
the thigh somewhat flexed and adducted, or rotated inward, operation must not be
delayed. Having relaxed the tissues as much as possible, press gently directly down-
ward upon the tumor. Pressure is to be kept up steadily for some minutes until the
surface of the tumor is brought even with the line of the crural arch, and then the
compression is to be continued upward and inward toward the abdomen. If, on the
contrary, the pressure is first directed toward the abdomen, the tumor is carried over
the arch, instead of under it, and the greatest danger may ensue from force thus
applied.
PLATE XXXV.*
Figure 1.
External inguinal hernia (enterocele in a fe-
male aged forty-eight).
(a) Globular swelling at the peritoneal orifice
(6) Contraction caused at the external ingui-
nal ring.
(c) Hernial tumor, which invades the large lip
and pushes back the vulvar opening in the oppo-
site direction.
of the passage.
* Bourgery, Plate XXXVI.

132
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Figure 2.
Large crural hernia (entero-epiplocele in a fe-
male, aged seventy). The thin and flaccid integu-
ments allow the projections of the circumvolu-
tions to be seen externally. This tumor, of which
the characteristics are exaggerated, renders the
diagnosis in some way very easy.
(6) Subcutaneous hernial tumor below and at
the exit of the crural canal.
(C) Ileo-femoral vessels.
(d) Dilated internal saphenous veins.
Figure 3.
Two crural hernia (enteroceles in a female,
aged forty-nine). The form of these two tumors
is of a more favorable kind than the preceding.
(a) Portion of the hernia inclosed in the acci-
dental crural canal.
Figure 4.
Sub-umbilical hernia (entero-epiplocele in a
female, aged sixty-seven). This woman has had
four children; the abdominal wall shows numer-
ous éraillements in the circumference of the her-
nia. The extreme thinness of the integuments
permits, as in Fig. 2, the intestinal circumvolutions
to be seen.
The direction of the incision through the integuments may be somewhat varied,
but usually it should be nearly vertical, and from two to three inches in length. It
should extend downward upon the inner side of the neck of the sac, and be continued
upward about an inch above Poupart's ligament. If the incision is slightly curved,
the concavity should embrace the neck of the tumor. M. Dupuytren and Sir Astley
Cooper advised two incisions, traversing each other either crucially, or meeting each
other at right angles, in the reverse lines of the letter T, to meet at a point over
the middle of the tumor.
Mr. Lawrence, however, advocated that the incision should run obliquely downward
and outward, beginning about an inch above the ring. Mr. Gay, on the contrary, gives
at great length his reasons for making the incision in an oblique direction, quite to the
inner side of the hernial tumor, since this carries one with greater safety to the seat
of the constriction.
This plan has certain manifest advantages, since by it the skin and hernial covering
are divided over the seat of the constriction, and the division of the stricture itself is
rendered easier. The method of incision advocated by Mr. Gay is that more generally
accepted and practiced. After the division of the integuments and fascia, usually a
a
well-defined membranous sac comes into view, and the landmarks to be especially
sought as guides for the safe manipulation of the sac are Poupart's ligament above
and in front, and Gimbernat's ligament at the pubic border upon the inner side.
Expose clearly Poupart's ligament in the dissection, and determine with the finger
the edge of Gimbernat’s ligament upon the inner side of the neck of the sac, care
being taken not to press upon the constricted portion of the intestine within the
ring:


PLATE XXXVI.
Fig: 1.
q
e
P
Fig. 2.

OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
133
PLATE XXXVI.*
The hernial sac and parts, the subject of this drawing, were discovered in the course of a dissec-
tion. The tumor did not present those external indications that led to a suspicion of its existence,
until the superficial and cribriform fascia had been cut through. The engraving was made from a cast
and drawing of the parts taken by Mr. E. Wilson, and is well adapted to show the parts prior to their
alterations by the processes of disease. The sac is denuded of its fascia propria. Any further descrip-
tion, but for the sake of junior students, would be superfluous.
a, a. Upper layer of the iliac portion of fascia f. Inferior pillar of the external abdominal
lata.
ring; or that portion of the crural arch which
b, b. Pubic portion of the same fascia, or pec- terminates upon the tuberosity of the pubis and
tineal fascia, forming the floor of femoral fossa. adjoining portion of the ileo-pectineal ridge.
-
Plate II, 1.
8. Spermatic cord.
c. Falciform process, and portion of the bor- h. Saphenous vein.
der of the saphenous opening.
i. Hernial tumor.
d. External or semilunar portion of the same A black line shows the situation and direction
border.
of the incision which is made through the integu-
e. Burns's ligament, or pubic portion of the ments into the femoral fossa, for the new opera-
arch formed by the lower border of the same tion.
opening
The opera-
The more common practice has been not to open the sac, but carry the hernia-knife,
on the finger, carefully between Gimbernat's ligament and the neck of the tumor, and,
cutting inward, divide a few of the fibers of the ligament. This done, usually, in very
recent cases, the tumor can be reduced en masse without opening the sac.
tion, thus conducted, is generally simple and safe, and may be selected if only relief from
the intestinal obstruction is sought. Even then it must be determined that the strict-
ure has been limited to a few hours, and that the intestine has escaped injury from
taxis, and also that there is no further constriction of the neck of the sac, which is
sometimes sufficient to cause serious complications, or even dangers resulting in death.
Should it be preferred to operate in this way, the conditions justifying it would be
manifestly exceptional, while under the protection of antiseptic measures little, if any,
additional danger ensues from the major operation. I can not doubt the wisdom and
great advantage of adopting, as the rule of practice, the opening of the sac before
any attempt is made to divide the stricture.
* Gay, Plate I.
+ See Plate XXXVIII, Fig. 2, e.

134
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
PLATE XXXVII *
Represents a hernial tumor and the adjacent parts of the thigh, as they are displayed by the re-
moval of the superficial fascia and the contents of the femoral fossa. The crural arch and upper layer
of the iliac portion of the fascia lata have been divided and turned back, to show the deep layer of that
fascia and its relations to Hey's ligament. The knife is passed from the femoral fossa behind those
seats of stricture which are here seen.
a. The hernial tumor with its cribriform cov- to the internal inguinal ligament of Hesselbach,
ering
below the under layer of the iliac fascia lata.
b, b. The crural arch divided and turned back. i. The femoral, or Hey's, ligament; or the deep
c. Pubic insertion of the tendon of the exter- crural arch.
nal oblique muscle.
k. Upper lamina of the iliac portion of the
d. Tendon of rectus.
fascia lata, divided vertically and thrown back in
e. Pubic attachment of the conjoined tendons order to display the deep lamina, with Hey's liga-
of the internal oblique and transversalis muscles. ment, and its continuity to the arched margin of
f. Portion of Gimbernat’s ligament, formed by the internal oblique muscle.
the outer pillar of the external abdominal ring.
1. The femoral fossa.
g. Portion of Gimbernat’s ligament, formed by m. Process from the deep abdominal fascia
the falciform process of the fascia lata.
which completes the upper arched border of the
h. Situation of the band of fibers belonging saphenous opening on the pubic side.
In the earlier days the danger of the division of the constriction with the knife was
considered so great, owing to the injury supposed to follow the cutting of the crural
arch, as well as wounding some of the large vessels by which it is nearly surrounded,
that Thevenir † invented his two-branched dilator. Arnaud, $ for a similar reason, ad-
vocated dilatation, which he effected by a crochet-hook. Leblanc # revived the use
of the dilator, which he applied to inguinal as well as crural hernia. Dilatation was
advocated by means of the various instruments by the operators of this period, even
as late as Richter and Scarpa. Breschet pointed out the dangers likely to ensue from
the use of these instruments, and the failure which often resulted in the insufficient
freeing of the constriction when dilatation alone was depended upon.
The dangers resulting from dilatation are manifest, since the ring constricts the
parts equally in every direction, and the forced separation of this by a two-bladed
divulsor must necessarily bring an equally increased compression upon the contents
constricted as upon the ring itself. The superior genius of Arnaud recognized this
fact, since the insertion of his hook into the ring would make the distention in one
direction only, and properly applied in the hands of this master brought the force
* Gay, Plate II.
+ Euvres de Thevenir. Paris, 1669.
| Arnaud. On Hernia, 1748.
# Nouvelle Méthode d'opérer les Hernies. Par M. Hoin, 1767.

PLATE XXXVII.
I f ed
e
my
6



PLATE XXXVIII.
a
9
o

OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
135
to bear away from the constricted intestinal loop. There was a still further gain
in its use in a more prompt restoration of the parts to their normal state, since
the constricting portions were supposed to be injured less by divulsion than by divis-
ion. With a properly constructed knife, however, the cutting operation has many
advantages, in freeing the constriction, over that of any other method.
PLATE XXXVIII.*
Figure 1.
a. The front wall of the femoral sheath, as
displayed on the careful removal of the iliac fas-
cia lata.
b, c. Its iliac and pubic walls.
d, e, f. The angles formed by the union of
these walls.
g, h. The septa by which the sheath is divided.
i. The upper orifice of the crural canal or cru-
ral ring
k. The venous compartment of the sheath,
1, 1. Lines showing the direction of the septa of
the sheath, the outer one being between the ar-
tery and vein.
m. The front margin of the lower orifice of
the sheath.
n. The crural canal.
0. Dotted line showing the relative position
of Hey's ligament to the front wall of the sheath.
p. The band of fibers appertaining to the
front wall of the sheath, described as the “fibræ
crassiores” of the internal inguinal ligament of
Hesselbach; also seen in Plate II, h.
9. Tendon of the rectus.
1. The pubic margin of the crural ring; the
septum crural had been pushed before a hernial
sac, by which the canal had been occupied,
s. The terminal portion of the saphenous vein.
Figure 2
Represents the front view of the thigh, with a
femoral rupture.
a. Dotted outline of the situation of the crural
arch.
b. Dotted outline of the margins of the saphe-
nous opening
d. Situation of the hernial tumor.
e. The situation and direction of the first in-
cision for the performance of the new operation,
OPENING AND EXCISION OF THE SAC.
As a rule, there can be no doubt but that in femoral hernia the sac should be
opened and examined. This is even more important than in the other varieties of
hernia, since, as we have shown, the sharp-edged narrow constriction sometimes causes
a fatal intestinal lesion in less than a single day.
Divide the fascia propria on a director, or by lifting the tissues from either side
by dissecting forceps, and a layer of fat will be exposed to view. This is important,
since it might be mistaken for omentum. The peritoneal covering of the sac should
be determined and opened with even greater care and caution than was emphasized
when describing this part of the operation in inguinal hernia, since the tissues covering
* Gay, Plate III.

136
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
the tumor are usually thinner. Generally a little serum escapes, which further deter-
mines the anatomical relation of the structures. The division of the stricture must be
subject to certain modifications, dependent upon the condition of the parts. It is
manifestly clear, from the anatomical consideration of the subject, that the outer border
of the ring is made up of the fascia, or sheath of the great iliac vessels, and that division
in this direction endangers the great femoral vein. In the male it is to be borne in
mind that the spermatic cord and vessels are usually found directly over the sac, but he
who is familiar with his anatomy, as every operator should be, will remember that
Poupart's ligament separates the cord and vessels from the neck of the femoral sac; how-
ever, injury to these vessels may occur from the confusing deformity of the pathological
conditions, and the accidents which have happened from the division of these vessels
have taken place at some distance from the ring.
When the conditions seem to indicate a danger to the cord or vessels, it should
be emphasized that these are to be first exposed and removed from the direction of
the incision.
If the line of the division is carried upward and outward, toward the spinous pro-
cess of the ilium, the epigastric artery may be endangered, but this is usually quite
half an inch from the seat of constriction, and if divided, is not by any means so seri-
ous a complication as has been generally supposed, since it can be easily secured and
controlled. The distinguished surgeon, Mr. Hey, who pointed out the ligament some-
times called by his name, advised that the knife should be introduced upon the inner
side of the sac, and the division be made directly upward. I can not myself, however,
doubt that the greatest security, in the avoidance of danger to the blood-vessels and
intestine, is generally maintained by introducing the knife into the middle part of the
hernial sac, anteriorly, and dividing the stricture from below upward and inward in
the direction of the umbilicus. If this course is pursued, the line of the incision will
be quite parallel to the inner side of the epigastric artery, and although the division is
a little deeper than if carried more externally, it does not seriously increase the com-
plication of the operation by the enveloping folds of the intestinal loop, which may be
retained within the sac and roll up about the finger. Some authors advocate the
wisdom of division of the internal fibers, re-enforcing the pubic insertion of the tendi-
nous attachment to the ossa pubis, still called after, the Spanish surgeon Gimbernat,
who dissected the parts with great care, and first pointed out that the firmest portion
of the ring consisted of these re-enforcing fibers, and advocated their division in femoral


PLATE XXXIX.

Plate XXXIX.
2
7
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6
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10
23
16
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OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
137
PLATE XXXIX.*
a, a. The femoral arch.
0, 0. The aponeurotic sheath of the rectus
b. Part of the aponeurosis of the fascia lata, muscle.
left adhering to the margin of the fallopian liga- p. The iliacus internus muscle.
ment.
9. Part of the external oblique muscle.
C, C, C. Aponeurosis of the external oblique 1. The femoral artery.
muscle.
2. The femoral vein.
d. The inguinal ring.
3. The saphenous vein.
e. The spermatic cord.
4. The epigastric artery.
f, f. Bundles of fleshy fibers of the cremaster 5, 6, 7. Continuation of the epigastric ar-
muscle.
tery.
8,8. The hernial sac formed by the perito- 8. The abdominal or circumflex iliac artery.
næum. A femoral hernia.
9. The spermatic artery.
h, h. The external + cellular coat of the peri- 10. A small branch of the spermatic artery.
tonæum, which, together with the inguinal glands The spermatic vessels are represented in this
and the aponeurosis of the fascia lata, covered the plate, raised by a hook. It is, however, quite evi-
hernial sac.
dent that, if these vessels had been left to them-
i. The loop of ileum protruded.
selves, they would descend, as in their natural
k. The external oblique muscle.
situation, to the vicinity of the edge of the fallo-
1, 1. An incision made through the fibers of pian ligament.
the internal oblique, and of the aponeurosis of the 11, 12. The continuation of the spermatic ar-
transverse, in order to expose the course of the tery.
epigastric artery, resting on the great sac of the 13, 14. The spermatic vein divided into sev-
peritoneum and running toward the rectus mus- eral branches,
cle.
15, 16. The vas deferens.
m, m. Division of the aponeurotic sheath of 17. The anterior crural nerve.
the rectus.
18. The place where the spermatic artery is at
n. The external | edge of the rectus muscle the greatest distance from the edge of the fallo-
laid bare, and a little turned back.
pian ligament.
hernia as the safest and best means of reduction. Were the anatomical construction
of the parts the only measures by which to determine surgical procedure, this view
would be the correct one; but it must be remembered that the obliquity of Gimber-
nat's ligament is such that this portion of the constricting ring is more deeply buried
within the tissues than any other, and consequently reached with greater difficulty.
This alone increases the danger of injuring the intestine by the knife. While, again, in
this form of hernia the intestine, in its escape from the abdomen, descends in an
inward direction and the tension which it is necessary to make upon it, in order to
withdraw it from the field of operation, may be sufficient to cause its rupture. This
danger was pointed out by Sir Astley Cooper in the following illustrative case, which
I quote from this author :
* Scarpa, Plate VIII.
+ Peripheral.
| Lateral.
21

138
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Mrs. Phillips, aged fifty years, was seized Februray 16, 1804, with symptoms of
strangulation in a hernia to which she had been subject for twelve years, during which
time it had been occasionally smaller or larger, but never completely reduced. On the
day above mentioned it suddenly increased, during a violent exertion, became very pain-
ful, and produced much uneasiness in the bowels, with frequent vomiting. On the 24th
Mr. Robert Kent was called to her, who advised her going to St. Thomas's Hospital,
and she was admitted on the 25th.
“The tumor was on the left side, its long axis passing in the direction of the crural
arch or Poupart's ligament, anterior to which it was situated. It bore so strong a re-
semblance to an incipient inguinal hernia as to deceive several of the most intelligent
pupils; but, on examining her, and drawing the tumor downward, I found the crural
arch passing above the sac, and the tuberosity of the pubes on its inner side, which
made the true nature of the case sufficiently obvious. The symptoms were not so
urgent as might have been expected from the duration of the disease, for the tumor
was not inflamed, the abdomen but slightly tense and painful, and the countenance did
not show any remarkable sign of anxiety ; her pulse, however, was quick and thready.
After an unsuccessful trial of the taxis and a tobacco clyster, I proceeded to perform
I
the operation.
An incision was made in the long axis of the tumor (transversely, therefore, to the
neck of the sac), and the fascia which it exposed was next divided to bring the sac in
view. This was next opened, and a little clear serum escaped. A director being intro-
duced, the opening into the sac was extended up into its neck, which showed both intes-
tine and omentum strangulated; the former discolored as much as is usual in these cir-
cumstances, but not to any remarkable degree. The intestine being drawn toward the
spine of the ilium, which was obliged to be done to reach the stricture, a director was
passed up into the mouth of the sac on its inner side opposite the pubes, and a com-
mon probed bistoury being passed upon this, the stricture was divided inward along
the margin of the pubes. The intestine was then easily returnable ; but, as the last por-
tion of it was entering the abdomen, a small quantity of feculent matter escaped from
the orifice of the sac, but too late to prevent the return of the intestine, which, had I
observed this circumstance sooner, I should have done, and made a small suture upon
it. The omentum was then returned, and the wound dressed. I saw her an hour and
a half afterward, when she complained of violent pain in the abdomen, and was ex-
tremely restless. I removed the dressings, and saw fæces discharged from the wound,
a

OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
139
à
on which I ordered a poultice only to be applied. The pain and restlessness continued
until her death, which happened within four hours and a half after the operation. On
examining the body, I found the fæces effused into the cavity of the abdomen, the intes-
tine universally inflamed, the portion of gut which had
been strangulated but little altered in color, but with a
hole in it opposite to the stricture. Whether in this
case the intestine gave way at the strictured part by
drawing it aside, or was injured by the knife, it is im-
possible to determine, but I was resolved never again
to cut inward, on account of the danger of tearing, as
well as of cutting the intestine.”
If the hernia is large or adherent, so as to demand a
FIG. 11.-Femoral hernia (Agnew).
more extensive dissection, it is manifestly important not
to extend the incision inward, since very little room comparatively can be secured
by so doing. Another serious objection to extensive division inward is the very fre-
quent disposition of the obturator artery, which often
embraces very closely the neck of the sac upon the
inner side. The division of this artery would be
serious, because of the difficulty of securing it thus
deeply situated
However, it has frequently happened in my ex-
perience that it seemed the wise procedure to divide
only the fibers of Gimbernat's ligament, and it is often
surprising to note that the division of a few of these
Fig. 12.-a, muscular portion of the cru-
ral arch occupied by the iliacus in-
fibers is sufficient to double the capacity of the ring,
ternus; b, psoas magnus; 6, crural
and thereby liberate the imprisoned contents of the
nerve, with iliac fascia in front; d,
Poupart's ligament; e, femoral ar-
tery; f, femoral vein, with the iliac
and transversalis fascia separating at Enlarge the opening sufficiently to admit the fin-
the inner edge of the muscles, g, and
passing in front and behind the ves-
ger, and, held in this way, carefully divide the con-
sels to form their sheath, with its
striction at its mouth, cutting inward and upward as
vertical membranous partition, h ; i,
Gimbernat’s ligament;j, femoral ring little as is required to liberate the intestine. Then
(Agnew)
examine, and, if warranted, restore the abdominal con-
tents. The next step is to free the peritoneal sac quite within the ring, and, mak-
ing it tense, sew through its base evenly with a double continuous tendon suture, as
sac.

1 40
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
advised in inguinal hernia. Cut the sac away and return the sutured base within the
ring. The subsequent steps advised for the completion of the operation are very sim-
ilar to those recommended when operative measures have been instituted for the radi-
cal cure of non-strangulated femoral hernia. It will be referred to again more in
detail when discussing the various methods adopted and recommended for the cure
of this dangerous affection.
The following plate from Mr. Cooper's work shows admirably the conditions of
development in the peritoneal sac of a pronounced femoral hernia. In Fig. I the
peritonæum is greatly thickened and altered in appearance. The changes in the mouth
of the sac are well marked in the constricted re-enforcement which is the result of the
alterations consequent upon the plicated folds having become intimately blended with
each other. It is noteworthy to observe that these alone are sufficiently firm to make
a strong constricting ring entirely independent of the tissues which go to make up
the femoral canal. It is also easily seen that a division upward and outward in any
considerable degree must have divided the epigastric vessels.
Fig. 2 shows in a manner rarely observed the various layers of tissue which make
up the covering of the tumor.
a
PLATE XL.*
This plate exhibits three different views of the crural hernia in the male. Fig. 1 is preserved
in the collection at Guy's Hospital. Fig. 2 is in my own possession.
p. Cremaster muscle.
9. Crural hernia.
r. The sac of the crural hernia.
s. The fascia propria, which covers the hernial
sac.
Figure 1.
a. Symphysis pubis.
b. Spinous process of the ilium.
C, C. Abdominal muscles.
d. The crural arch, or Poupart's ligament.
e. Semilunar edge of the fascia lata.
f. Tendon of the external oblique cut open.
g. Internal oblique and transversalis.
h. External portion of the fascia transversalis.
i. Internal portion of the same fascia.
k. Internal abdominal ring.
1. External abdominal ring.
m, m, m. Spermatic cord passing through both
apertures to the testis.
n. Testis.
0. Epigastric artery.
Figure 2.
Anterior view of another crural hernia.
a. Symphysis pubis.
b. Spinous process of the ilium.
C. Abdominal muscles.
d. Crural arch, or Poupart's ligament.
e. Abdominal ring.
f. Spermatic cord.
8. Testis.
h. Crural hernia.
i, i. Superficial fascia cut open and turned
back.
* Cooper, Plate V, Part II.

PLATE XL,
Fig. 3
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3
a
f
h.
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Fig. 2.
7
d.
Z
Z.
a
3
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272
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n


OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
141
k, k. Fascia propria of the sac laid open.
1, 1. Hernial sac opened.
m. Omentum seen within the sac.
Figure 3.
Posterior view of Fig. 1.
a. Symphysis pubis.
b. Spinous process of the ilium.
c. Ilium cut through.
d, d, d. Rectus and other abdominal muscles.
e. Linea semilunaris.
f. Posterior edge of the crural arch.
g. Fascia iliaca.
h. The iliacus internus muscle.
i, i. Fascia transversalis.
k. Internal abdominal ring.
1. Spermatic cord passing through the inter-
nal ring.
m. External iliac artery.
n. External iliac vein.
0. Epigastric artery and vein.
P. Sac of the crural hernia.
9. Mouth of the sac.
r. Absorbent gland between the hernial sac
and the iliac vein.
The Femoral Canal.—The next step in the operation is the closure of the femoral
canal. After having returned the sutured base of the peritonæum within the ring,
protecting the femoral vessels with the finger by pressing them in their sheath gently
outward, introduce a curved needle, as directed in inguinal hernia, page 109, from below
through the thick pubic portion of the fascia lata, forming the external lower border
of the ring, avoiding the internal saphenous vein, upward through Poupart's ligament, as
far outward as may be judged necessary to produce the proper coaptation of the parts
upon the vessels; unthread the needle, rethread with the opposite end of the suture, and
withdraw it. This makes a constricting loop, closing the outer border of the enlarged
femoral canal upon the sheath of the vessels. A second continuous stitch is taken
through the same tissues parallel to the first, from one third to one fourth of an inch
nearer the median line; the third continuous stitch is introduced into the portion of the
fascia lata, external and parallel to the saphenous vein, in the same manner as the first
and is carried upward to include Gimbernat's ligament and such portions of tendinous
structures as may have been divided. If the operation has been undertaken for strangu-
lation, three stitches are generally sufficient; but a fourth or as many more may be
taken as are required to close evenly and firmly the inner portions of the ring. By
suturing in this manner, the margins of the ring are firmly closed, the peritoneal pouch
is obliterated, and the thick re-enforced edge of the fascia lata is joined to the borders
of Poupart's ligament. The lower part of the canal is obliquely elongated and reformed
by drawing inward the weakened dilated upper and outer border of the saphenous
ring, and attaching it to the firm pubic fascia. The folding over of the fascia in
this way carries the saphenous opening quite a little to the inner side of its former
site, while the femoral vessels are undisturbed in their sheath. The superficial tissues
and skin are closely held in approximation by buried tendon sutures. The wound is

142
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
sealed with iodoform collodion without drainage. It is almost needless to remark that
the strictest aseptic care is maintained during the entire operation, in which irrigation
with a weak sublimate solution serves an important part.
There is but one rule, and it can not be too emphatically enforced : the aseptic
suture must be aseptically applied in aseptic structures, and the wound must be main-
tained aseptic.
The failure of either of the above-mentioned factors not alone
endangers the result, but may be followed by the most serious consequences.
In many instances the incision and dissection will not be required to be made as
extensively as above described. Experience will familiarize the operator with the
anatomical relations, but the wound should be made sufficiently large to enable him
clearly to determine the relationship of the vessels, and render certain the closure of
the parts involved. The operation for the cure of femoral hernia is doubtless more
difficult than that for the cure of inguinal hernia in the female, but less serious or
complicated than inguinal hernia in the male.
When the operation has been performed for the relief of strangulation under
proper precautions, the subsequent danger is very little if any increased by the resec-
tion of the sac and the closure of the wound as above directed.
Certain complications are likely to be met with in non-reducible or incarcerated
femoral hernia, but these are for the most part unimportant, since the incarcerated
portion is almost always omentum, and the lower part of the sac may be more or le
distended with serum. I have operated in two cases where the objective feature in
each was that of a small cystic tumor, the neck of the sac having been closed by
adhesions. The omentum, when thus retained, is generally so changed that it is better
to ligature or sew through its base, and resect it, returning the stump within the ab-
dominal cavity.
I have operated many times for femoral hernia in this manner, with never a subse-
quent symptom indicating danger, and, so far as I have been able to learn, without a
single recurrence of the hernia.
In the advocacy for the cure of non-strangulated femoral hernia much might be
written. This, however, is unnecessary, since it is universally conceded that the
sufferer from this variety of hernia is in greater or less constant danger from strangu-
lation, a complication of the most serious character. This form of hernia is much
less easily retained by means of artificial supports, and the individual obliged to wear
a truss is subject to much greater inconvenience by this than in inguinal hernia. If it
a

OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
143
can be demonstrated that femoral hernia is curable, then the advisability of the opera-
tion should be taken into consideration, and if it can be proved that the cure remains
permanent, it adds much to the argument in favor of operative measures; but when
it is demonstrated that, under proper precautions, based upon an accurate anatomical
knowledge of the structures involved, the operation is not severe, does not cause
long detention from active duties, does away with the punishment inflicted by the
life-long wearing of a truss, and is almost, if not entirely, without danger, there remains
no reason why all the sufferers from femoral hernia should not profit by surgical
measures and demand to be restored to the ranks of active service.
The operation for the radical cure is obviously much more simple when the con-
ditions pertaining to incarcerated or strangulated hernia are absent. The normal
anatomical relationship of the parts is usually not much changed. The tumor is gen-
erally small, the omentum or intestine easily returned, and the sac may be so thin
and small as to become an unimportant factor. The danger of infecting the general
peritoneal cavity scarcely exists, even in the hands of an inexperienced operator. The
wound does not usually require to be made nearly as large as where operation is
undertaken for a strangulated hernia, yet it is well to err on the side of a free dis-
section. The operator must be sure of the anatomical relations of the parts. The
femoral vessels must remain uninjured in their sheath. The greater danger attends
the introduction of the first stitch, since this closes the canal on the side toward the
vessels, and a puncture of the great femoral vein with the needle might result in the
most serious consequences. However, this warning is of little moment to the expe-
rienced surgeon, since the sheath of the great femoral vessels is the first anatomical
landmark to be located with exactitude.
The pathological conditions of femoral hernia in the female are well shown in the
following plate. The different views show that the development of the sac may occur
so as to produce a considerable variety of pathological conditions. Figs. 1, 2, 3, and 4,
,
taken from the same subject, are in this respect extremely instructive, and I am quite
sure few operators would find in these pathological factors material subservient for
their
use,
either in whole or in part, from which to make a pad for the re-enforcement
of the internal ring. On the contrary, this might be possible in cases illustrated by
Figs. 5 and 6, although the peritonæum is much thickened and changed; while in Fig.
7 is seen the view of a small hernia where the reduction of the sac en masse and its
fixation at the internal ring might be of advantage.

144
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
In conditions as here shown it is probably of little importance whether the sac is
returned or removed.
PLATE XLI.*
This plate is intended to exhibit different views of crural hernia in the female, in the order in
which the parts appear in dissection.
Figure 1.
First dissection of the crural hernia.
a. Symphysis pubis.
b. Spinous process of the ilium.
c. Situation of the crural arch, or Poupart's
ligament.
d, d. Tendon of the external oblique muscle.
e. Superficial fascia raised from the external
oblique muscl
f, f, f. Superficial fascia.
g. Saphena major vein, the superficial fascia
being cut away to show it.
h. A part of the superficial fascia attached to
the crural arch.
i. Abdominal ring and round ligament pass-
ing through it.
k. Superficial fascia raised from the hernia.
l, l. Fascia propria raised from the hernial
sac.
m, m. Hernial sac.
n. Omentum within the hernial sac.
0. Intestine within the hernial sac.
c, c. Abdominal muscles.
d. Crural arch.
e. Abdominal ring.
f. Ligamentum rotundum uteri.
g. Fascia lata.
h. Portion of the fascia lata over the pectin-
eus muscle.
i, i. Fascia propria, or protruded crural sheath,
which covered the hernial sac after the sac in Fig.
2 had been removed.
k. Attachment of the fascia propria to the
sheath of the femoral vessels.
1. A portion of the sheath covering the crural
vessels, exposed by removing the semilunar edge
of the fascia lata.
m. The opening in the sheath through which
the hernia had descended, above which is seen a
dotted line which marks the seat of the anterior
structure, and which is the part generally required
to be divided.
Figure 4.
A posterior view of the same preparation.
a. Seat of symphysis pubis.
b. Spinous process of the ilium.
c. Abdominal muscles.
d. Rectus muscle.
e, e. Muscles of the thigh.
f. Posterior edge of the crural arch.
g. Fascia iliaca.
h, h. Fascia transversalis.
i. Round ligament passing into the abdominal
ring
k. External iliac artery.
1. External iliac vein.
m. Epigastric artery and vein.
n. Obturator artery arising from the epigas-
tric, and passing on the outer side of the crural
opening
Figure 2.
Shows the form and contents of the hernial
sac which has been removed from Fig. 1.
a, a. Hernial sac.
b. Neck of the hernial sac.
c. Omentum within the hernia.
d. Intestine within the hernia.
e. Omentum at the mouth of the hernial sac.
f. The intestine at the mouth of the sac.
Figure 3.
Shows the origin and appearance of the fascia
propria.
a. Seat of symphysis pubis.
b. Spinous process of the ilium.
Cooper, Plate IV, Part II.
+ This is the preparation on which for several years I have been in the habit of showing the bag which incloses
the hernial sac, in my lecture on crural hernia.

PLATEXLI.
d
Fig.l. d
.
Fig. 2.
6
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Fig.3.
с
d
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PLATE XLI A.
Fig. 4.
d
2
Fig. S.
med 2c 6
a
f
h
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9
li
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o
n
2
Fig.T.
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Fig.6.
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Fig.5.
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he
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1


OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
145
0. Course of the epigastric artery behind the
round ligament.
p. Crural nerve.
9. Superficial fascia.
r. Fascia propria of the crural hernia, the
hernial sac having been drawn into the abdomen
to show this fascia distinctly.
0. Meeting of the insertion of the external
oblique into the ligament of the pubes with the
fascia iliaca.
p. The crural orifice by which the hernial sac
had descended, and a dotted line is extended from
it, marking the situation of the posterior edge of
the crural arch, covered by a fascia, which forms
the posterior seat of the stricture.
9, r. Fascia between the crural vein and mouth
of the sac; this opening is, therefore, formed
above by the sheath and the posterior edge of the
crural arch, on the inner side by the semicircular
insertion of the external oblique muscle, and ex-
ternally by a fascia descending on the inner side
of the crural vein, which is a process of the crural
sheath.
Figure 5.
A small crural hernia dissected.
a. Seat of symphysis pubis.
b. Spinous process of the ilium.
c. Tendon of external oblique muscle.
d. Anterior edge of the crural arch.
e. Abdominal ring.
f. Superficial fascia turned from the external
oblique.
g. Superficial fascia upon the fascia lata.
h. Crural vein.
i. Absorbent gland thrust down by the
hernia.
k. Superficial fascia opened where it covered
the hernia.
1. Fascia propria of the hernial sac.
m. Hernial sac unopened.
Figure 7
A small crural hernia in the female, showing
its passage through the crural sheath and its dis-
tance from the crural arch.
a. Seat of the symphysis pubis.
b. Spinous process of the ilium.
c. Crural arch.
d. Abdominal ring.
e. Fascia lata.
f. Semilunar edge of the fascia lata.
g. Portion of the crural sheath.
h. Saphena major vein passing into the crural
sheath.
i. Hernial sac inclosed in its fascia, which is
extremely dense, and is proportionally so as the
hernia is small.
k. The opening in the crural sheath through
which the hernia passes.
Figure 6.
The same preparation further dissected.
a. Seat of the symphysis pubis.
b. Seat of the spinous process of the ilium.
c. Tendon of the external oblique muscle.
d. Internal oblique and transversalis.
e. Fascia of the transversalis.
f. Tendon of the transversalis.
g. Inner portion of the fascia transversalis
passing to unite itself with the tendon.
h. The crural arch.
i, i. Round ligament.
k. The round ligament passing into the abdo-
men.
1. Femoral artery.
m. Femoral vein.
n. Origin of the epigastric artery,
Figure 8.
A small hernia in the male, to show the origin
of the fascia propria.
a. Seat of symphysis pubis.
b. A portion of the crural arch.
c. Insertion of the external oblique into the
pubes.
d. Portion of the fascia transversalis descend-
ing to unite itself to the crural vein.
e. Portion of the crural vein.
f, f. Edge of the fascia lata cut from Pou-
ff
part's ligament, and drawn downward to expose
the parts behind.
g. Fascia lata wrinkled by its falling down.
h. Semilunar edge of the fascia lata.
i. Saphena major vein passing into the crural
sheath.
k. The portion of the crural sheath which
covered the crural hernia, and forming the fascia
propria, the hernial sac having been entirely re-
moved, will be seen in Plate VIII.
1,1. The aperture by which the crural hernia
had descended from the abdomen.
m. A depression within the crural sheath, in
which a process of the hernial sac was contained.
22

146
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Mr. John Wood,* of London, perhaps the most celebrated operator for the cure
of hernia of this generation, writes as follows: “When, under the spray, the sac has
been opened, the stricture divided, the bowel and omentum drawn down and exam-
ined carefully, and the former found not essentially injured, with no ulceration at the
strangulated part, and no appearance of sphacelus, the operation should be concluded
by tying up the neck of the sac by strong catgut at the level of the crural ring, and
cutting off the sac just below. If the sac be large, the catgut should be made to
transfix it, and should be tied tightly on either side. Then, after passing the needle
through Poupart's ligament on the one hand, and through the pubic fascia lata and
Gimbernat’s ligament on the other, as above described, the needle should again be
passed horizontally through the pubic fascia lata just below its insertion into the pec-
tineal line, and the inner end of the wire hooked on and drawn through. Then the
two ends of the wire should be twisted together, and the loop drawn up and twisted
firmly down into the upper skin puncture. A drainage-tube should next be placed
in the lower part of the wound, reaching as high as the closed crural ring, and two
or three points of suture applied. Upon the protective a double pad of wet carbol-
ized gauze should be placed, so arranged that a groove is left to lodge the end of
the drainage-tube, and to give free exit for any discharge.
“Then the rest of the antiseptic dressing is to be applied, with plenty of loose
padding, especially on the inner side, to absorb the discharge, and a spica bandage
above all. If the discharge does not soak through, the dressing may be left for three
days, when, if primary union has occurred, as is most likely, the stitches may be re-
moved, and the drainage-tube cleansed and reapplied, shortened by about half an inch.
In another three days the dressing should be changed and the wire removed, the
tube, again shortened, being kept in until the next dressing in three or four days
The tube will then generally require removal.
“I have operated for the radical cure of crural hernia by the wire operation directly
after the operation of herniotomy for strangulation in four cases, all in women. In the
first two the spray was not used, but all the other antiseptic precautions were employed.
In the last two the spray and Lister dressings were used. All the patients recovered
without a bad symptom, each having a good, firm, resisting cicatrix; no return of the
rupture has occurred, as far as known, up to the present time.
more.
* Article on Hernia. John Wood, International Cyclopædia of Surgery, vol. v, p. 1161, 1884.

OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA. 147
,
“We should, no doubt, be prepared to expect a higher rate of mortality in this
operation than in that upon unstrangulated hernia. Very much will depend upon the
care and judgment of the surgeon as to the condition of the bowel and omentum before
venturing to return them into the abdomen, and upon his choice of cases in which
strangulation is recent. With due caution we may expect confidently that no higher
rate of mortality than is met with in ordinary crural herniotomy will be experienced;
and, if so, it certainly seems to be a shortcoming in surgery not to take advantage of
the open wound to cure, if possible the hernia by the same operation as that which is
necessary to relieve strangulation. It is well known that by not doing so the hernia is
left to become larger and more troublesome to retain, because of the crural ring being
cut so as to be more open and unprotected than before the operation. To be successful,
as a rule, cases must be operated on as soon as possible after a fair trial of the taxis, aided
by inversion and anaesthesia, has been made. But this rule also operates favorably in an
operation which is usually successful in saving the patient in inverse proportion to the
amount of damage done, chances lost, and time misemployed by ill-directed and un-
skillful use of taxis or other futile methods of treatment; and this especially in thin,
feeble, female patients after the middle period of life.”
The following case from Arnaud illustrates the danger which may arise from the
reduction en masse where the constriction at the neck of the sac caused death: “The
rupture was crural, and the tumor about the size of a common hen's egg, when the
symptoms first appeared. About ten or twelve hours after the first pain, which the
patient felt from the strangulation, I reduced the intestine, and during the two following
days it was left at liberty to come down, which it did whenever the patient coughed, and
sometimes went up again of itself with ease. But from that time during the remainder
of the disorder, which lasted eight or nine days, it came down no more. The patient
died on the ninth day, and on opening the body we found the bowels which had formed
the rupture still included in the hernial sac, and the tumor was increased to more than
two thirds of its first bulk. It was situated without the cavity of the belly, between the
peritoneum and inside of Poupart's ligament."
“A woman, aged forty-five, who had long been troubled with crural hernia on the
right side, was seized with symptoms of strangulated hernia.* They had begun at eight
o'clock in the evening, and (as she stated) were brought on by suddenly rising from
* Fig. 3 of the following Plate is the illustration of this interesting case given in detail by Mr. Cooper.

148
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
cess.
her chair. On the whole of the following day she vomited frequently, had great pain
in the tumor, and her pulse was small and frequent. Eight ounces of blood were taken
from the arm, and attempts were made to reduce the hernia by taxis, but without suc-
A tobacco clyster was thrown up, but that failed. At noon on the following
day the operation was performed. The intestine, which was discolored, was found
adhering to the sac; but these adhesions were separated without much difficulty, and
the stricture at the mouth of the sac was divided inward, or toward the symphysis
pubis; but several incisions were required before the aperture was large enough to
allow of the return of the hernia.*
“ As the intestine was about to be pushed back into the abdomen, its contents were
seen to escape from a considerable opening in it. It was therefore confined to the
mouth of the sac, and dressings being applied, she was put to bed. I saw her soon
after the operation, when she was in most violent pain, and she died at seven o'clock on
the same evening
“Dissection.—Having obtained leave to inspect the body, I found fæces extravasated
in the cavity of the abdomen. The intestines were much inflamed, and, as usual, red
lines appeared on them, passing longitudinally on the points at which they adhered.
The portion of intestine which had descended into the hernial sac was discolored, and
it was much inflamed above the parts; two openings were found in the portion which
had been placed at the mouth of the hernial sac. One of these openings had been con-
fined within the sac, but the other had escaped observation, and had been returned into
the cavity of the abdomen. It was from this that the fæces had been extravasated, and
so speedily brought on a fatal termination.”
Plate No. XLII, Fig. 4, from Cooper,t shows this too common complication, where
the surgeon, if inexperienced, fails to understand the conditions until too late to save
the life of the patient.
* I was not present at the operation, but was informed of the particulars by two very intelligent witnesses.
+ Cooper. Part II, p. 28.


PLATE XLII.
0972
Fig. 1.
3
d
e.
k
n N
Fig. 2.
h.
b
n
a
-4
a
m

OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
149
PLATE XLII.*
CONTAINING DIFFERENT VIEWS OF PREPARATIONS MADE AFTER THE OPERATION FOR CRURAL
HERNIA.
Figure 3.
A view of a preparation in which the intestine
was divided by cutting inward.
a. Seat of symphysis pubis.
b. Crural arch.
C. Abdominal muscles.
d. Fascia lata.
e. Femoral artery.
f. Femoral vein.
g. Hole in one fold of the intestine.
h. Hole in the other fold.
i. Hernial sac.
Figure 1.
Anterior view of a crural hernia operated on
by cutting directly inward.
a. Symphysis pubis,
b. Spine of the ilium.
C, c. Abdominal muscles.
d. Crural arch.
e. Abdominal ring.
f. Lower column of the ring inserted into the
tubercle of the pubes.
g. Fascia lata.
h. Saphena major vein.
i. Fascia propria, or protruded crural sheath.
k. Hernial sac included in the former.
1. Insertion of the external oblique muscle
into the ligament of the pubes, divided in the
operation.
Figure 2.
Posterior view of the same.
a. Symphysis pubis.
b. Spine of the ilium.
c. Ilium.
d. Iliacus internus.
e. Abdominal muscles.
f. Rectus abdominis.
g. Fascia iliaca.
h. Fascia transversalis.
i. Junction of the two fascia at the posterior
edge of the crural arch.
k. Internal abdominal ring, and the round
ligament passing through it.
1. Iliac artery.
m. Iliac vein.
n. Epigastric artery and vein.
0. Obturator artery passing from the epigas-
tric, but taking its course on the outer side of the
hernial sac.
p. Hernial sac.
9. The insertion of the external oblique mus-
cle, which had been divided in the operation in-
ward.
Figure 4.
Preparation of the hernial sac which had been
returned into the abdomen unopened.
a. Seat of symphysis pubis.
b. Seat of the spine of the ilium.
C, C. Abdominal muscle.
d. Muscles of the thigh.
e. Muscles of the outer part of the thigh.
f. Crural arch.
g. Femoral artery.
h. Femoral vein.
i. Large hole at the crural arch, by which the
hernia was pushed back.
k. Fascia propria of the sac, which was also
pushed into the abdomen.
1. Hernial sac.
m, m. Peritonæum.
n. Strangulated intestine.
0. Intestine above the strangulated part.
p. Stricture at the mouth of the sac remaining
undivided.
9. Mesentery.
Figure 5.
A large hernia which had been strangulated,
and for which the operation was performed by
cutting through the tendon of the external ob-
lique muscle, drawing up the spermatic cord, and
cutting the crural arch from the hernial sac.
* Cooper, Plate VII, Part II.

150
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a. Seat of the symphysis pubis.
b. Spine of the ilium.
1, C. Abdominal muscles.
d. Fascia lata.
e. Crural arch.
f. Abdominal ring.
g. Femoral artery.
h. Femoral vein.
i. Testis.
k. Spermatic cord.
1. Fascia propria.
m. Hernial sac.
n. A hook put under the spermatic cord to
draw it from the crural arch while the arch was
cut from the hernial sac.
The following description of interesting pathological conditions incident to femoral
hernia are taken from cases from the Museum of the College of Physicians and Sur-
geons of London :
2644. Part of an inguinal region, with the sac of a femoral hernia, which had been forced between the
peritonæum and abdominal muscles, after the intestine which it contained had been returned
into the abdominal cavity.
ity. It is of an oblong form and is not much thickened; it has been
opened, to show that it contains much omentum loaded with fat, but little hardened or altered.
Close to the neck of the sac, and internal to it, is the obliterated right hypogastric artery, which
is shown joining the urachus above. The pouch between these two cords is well developed.
Posteriorly the omentum may be seen, entering the neck of the sac.
Removed from the same patient as 2626. The sac lay immediately behind the femoral ring,
into which it bulged; the crural canal was very wide, owing to the free division of constricting
ligaments found necessary during the operation.—Presented by Dr. G. Granville Bantock,
1879.
2673. The parts concerned in a large femoral hernia in a man. The sac is nearly globular, but some-
what elongated transversely, measuring in that direction four inches and a half in diameter; its
mouth is transversely oval, and upward of an inch wide. It contained part of the right colon,
adherent, but not strangulated. Portions of the fascia superficialis and fascia propria are sepa-
rated from the anterior surface of the sac; they are all thin, and appear healthy in texture. On
the inner side, the spermatic cord has been pushed inward by the sac; externally, the sac over-
laps the femoral artery and vein and extends to within half an inch of the anterior crural nerve.
The epigastric artery is shown, running tortuously from the upper border of the sac, at the back
of the preparation. From the Museum of John Howship, Esq.
2676. An unreduced strangulated femoral hernia. The sac, of which the walls are much thickened,
has been laid open: it contains a loop of small intestine with omentum. At the back of the
preparation, the contraction of the intestine before the strangulated part, and the dilatation of
that behind it, are well shown.
The following account of the case was left by Mr. Hunter :
“Mrs. —, aged thirty-five, had a rupture for several years, but it was occasionally reduced,
though often with difficulty. At last she was attacked with it so severely that she could not re-
duce it herself, and sent for Mr. Thomson, surgeon, who found her with all the symptoms of a
strangulated gut.
“He attempted to reduce it; but at first could not. It was fomented, and the smoke of
tobacco was thrown up by the rectum. Cold sweats, a small, quick pulse, and hiccough came
on; at last he reduced it, but the symptoms did not in the least abate, and the straining with

PLATE XLIIA.
Fig.4.
Fig.3.
9.
d.....
2
a
m.
De
a
m
2
--12
i
-
Fig.5.
n
f.
os
d
a
1
m
k
5


OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA. 151
the vomiting produced the rupture again, which now became out of his power to reduce. He
proposed an operation, but she would not consent to it. She died, and was opened.
“ On opening the belly there was found a large quantity of the contents of the intestines
lying loose in the cavity of the belly. On examining further, a portion of the ilium and a small
portion of epiploon were found down in the hernial sac; and upon examination it was found
that the same gut which had come down at first was not down now; and the gut which had
been down first, and reduced, was (also) the ileum, which I found so much mortified as to have
given way in some places, forming several holes in it, through which had flowed the matter which
was found in the cavity of tbe belly.
“ Here was a complicated case beyond all relief; for if the second rupture had not happened,
she must have died; and, of course, if the operation had been performed for the second rupture,
she would also have died of the consequences of the first.
“ This case shows that when the symptoms of the rupture have gone very far, it is impru-
dent to reduce it, even if possible; but as it is impossible, perhaps, to tell when the mortifica-
tion of the gut is gone too far for reduction, it will, in general, be attempted while life exists,
with the hopes of a cure.
Upon the other hand, it may be asserted, or supposed, that, if it is not reduced, the person
must also die; but this is not so certain as the other, for the mortification of a gut simply does
not kill; it only kills from its consequences; and there is a material difference between a morti-
fied gut out of the belly and one within. The consequence of one within is absolute death;
but the one without in general endeavors at a cure by producing inflammation and suppuration
in the parts, which is producing a fistulous orifice or artificial anus.
" It is
very curious to observe in hernias that, while the gut is in the sac, and alive, no inflam-
mation of the sac or integuments takes place; but the moment the gut becomes mortified, or
dead, the stimulus of an extraneous body takes place immediately: an outlet is then endeavor-
ing to be made by the inflammation and suppuration of the sac, forming an abscess in it; which
matter, with the contents of the gut, is brought to the skin. While this is going on, the sound
gut within the abdomen, where it passes into the rings, adheres to those rings all around; so
that when the abscess is formed, burst, or opened, and the mortified parts sloughed off, these
ends of the gut open into the abscess, and not into the cavity of the belly.
“But although Nature is doing all this, yet she is seldom able to succeed; for the stricture
which was the cause of strangulation and mortification remains so tight as hardly to allow a
passage for the contents of the intestines. Perhaps it might be proper, even then, to dilate the
rings.”—Hunterian MS. Cases and Dissections, No, 63.
The following case shows an irregular distribution of the vessels :
2678. The right side of a male pelvis, with blood-vessels and other parts injected and dried. The epi-
gastric artery is given off by the external iliac, a quarter of an inch above the crural arch.
About two fifths of an inch from its origin it gives off a branch nearly a line in diameter, which
descends, winding round the inner margin of the femoral ring, in the course sometimes taken
by the obturator artery, when (as in the specimen next described) it arises by a common trunk
with the epigastric. After turning round the femoral ring, this branch passes under it; goes
toward the foramen ovale, and joins the trunk of the obturator artery, which is of ordinary size

152
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
and passes, as usual, from the internal iliac. The junction of the two vessels takes place about
half an inch previous to their united trunk leaving the pelvis. —From the Museum of Robert
Liston, Esq.
2626. A portion of ileum, showing a constriction marking off a small segment of the intestines, which
is narrower below than above the constriction. The mesentery is quite normal, and the se-
rous coat of the intestine perfectly smooth.
From a woman, aged sixty-nine, on whom an operation for femoral hernia was performed
forty-eight hours after the commencement of symptoms of strangulation. Before these symp-
toms the patient had never noticed any hernia. At the operation, Gimbernat’s ligament and the
fibers of the “deep crural arch” and the falciform process of Burns were divided, and the intes-
tine was easily reduced without opening the sac. After the reduction, the patient passed flatus
freely, but occasionally vomited, and fifty-four hours after the operation became suddenly faint
and died. The constricted portion of the ileum, here shown, lay free in the abdominal cavity;
it was not highly congested. The sac was found to have been itself reduced, lying behind the
femoral ring. It is preserved (No. 2644), and contained omentum.—Presented by Dr. G.
Granville Bantock, 1879.
2614. The parts concerned in a femoral hernia. The preparation shows the small, recently protruded
hernial sac in the usual situation of a femoral hernia, with the larger closed old sac below and
inclosing it, and two or three smaller closed sacs near its sides. The mouth of the recently
protruded sac is shown at the back of the preparation ; and, about an inch from it on its outer
side, directly over the femoral vessels, there is an appearance of another small peritoneal pro-
trusion; its orifice is on the inner side of the epigastric artery, and occupies the position of the
internal abdominal ring.
The hernia was operated on by Mr. Hunter, who left the following record of the case :
“June, 1782.—A woman came into St. George's Hospital with a strangulated femoral rupture.
She had had formerly the same disease in the same part; but it had been reduced, and she
afterward had no further trouble with it till now.
“After every attempt to reduce the present rupture, and failing, the operation was thought
to be absolutely necessary,
" When the tumor was laid bare, and Poupart's ligament exposed, I divided the ligament
from without, that I might return the contents of the sac without cutting into it; but I
found still that the contents would not move. I then made a wound into the lower part of the
sac, which appeared there to contain some fluid, and when this was exposed, it proved to be
a circumscribed cavity, and that the present hernia was the upper part of the tumor.
“ I did not open into the recent sac, which contained the protruded part, but attempted to
take off the remaining stricture, for it only consisted of the cellular membrane, etc., that line
the parts behind Poupart's ligament. When this was divided, the contained parts easily slipped
up into the abdomen. The wound was dressed with a pretty thick compress of lint, to press
the two sides of the sac together, that they might adhere.
“ She became extremely low; a kind of cold sweat came on : she took some cordials, a gen-
tle opiate to prevent the necessity of acting, and a clyster of warm water to soften, warm,
and soothe the bowels; but, about six hours after, she died.
“On opening the body I observed the following appearances :
“ The piece of gut which had been down into the sac was the ileum, near to the cæcum.

OPERATIVE MEASURES FOR STRANGULATED FEMORAL HERNIA.
153
The quantity was just so much as took up the diameter of the gut. It was of a darker color,
and appeared to be more pinched at the part inclosed by Poupart's ligament than where it had
got below into the sac; this part adhered to the mouth of the sac by a slight adhesion, viz.,
that formed in the six hours; therefore, not mortified.
“ The intestines above the strictured part were distended, below they were of the natural
size.
« There was not sufficient visible cause for the woman's death.
“ The case had been the following: She had had formerly a rupture in the same part, which
had been reduced, but not the sac, and the mouth of the sac had united, while the sac itself had
continued separate; but a new effort, or strain, taking place, a new rupture was produced at
the same part, and the old sac was pushed down further into the thigh.”—Hunterian MS.
Cases in Surgery, p. 473 ; and Cases and Dissections, No. 56.
23

CHAPTER XIII.
OBTURATOR, OR HERNIA OF THE FORAMEN OVALE.
a
The obturator artery passes forward below the brim of the pelvis to the groove in
the upper border of the obturator foramen, and escapes through this opening from the
pelvic cavity. The oblique canal thus formed by the horizontal branch of the pubes
above, and the arched border of the obturator below, is rarely the site of hernia. It has
been described under various names—as obturator, after the canal; the hernia of the
foramen ovale; the thyroid or sub-pubic femoral.
The hernial sac is never wanting, and consists always of a portion of the parietal
peritonæum carried before the contents through the canal. The sac is generally formed
slowly, because of the firmer attachments of the parts, and a careful history will usually
elicit symptoms of localized pain, cramps, and derangement of the functions of the intes-
tinal canal. When the canal is distended, the pain over the course of the obturator nerve,
from pressure upon it, is at times a very diagnostic symptom. The canal almost never
dilates to the extent found in other varieties, and in the great majority of cases reported
the condition was not discovered until after death, since an external tumor is exceptional.
Mr. Birkett, who has especially studied the subject, writes: * “ After passing along
the obturator canal, the hernial tumor emerges upon the thigh, below the horizontal
ramus of the pubes to the inner side of the capsule of the hip-joint, behind and a little to
the inner side of the femoral artery and vein, and to the outer side of the tendon of the
adductor longus. The tumor formed by the protrusion is covered by the pectineus
muscle. It may be distinguished, therefore, from crural hernia, by observing the relative
positions of the horizontal ramus of the pubes and of the femoral artery. These struct-
ures occupy, in fact, a position between these two kinds of hernia. In obturator hernia
they are in front of the tumor, in crural hernia they are behind it. In the former, then,
they are easily felt, in the latter they can not be without difficulty-not perhaps until
the hernia is reduced.
a
* System of Surgery. Holmes, vol. ii, p. 741, American edition.


PLATE XLIII.
Fig.1.
1.G.S.
ME
I.G.I.
P.B
E
SP
NV
E
E
Fig.3.
I.G.S
LG.S.
M
I.G.I.
Fig.2.
S.P
C.C.
U

OBTURATOR, OR HERNIA OF THE FORAMEN OVALE.
155
a
“In those cases in which either a fullness, slight hardness, tumefaction, or swelling
exists, coupled with well-marked indications of obstruction or strangulation in some
part of the alimentary tube, the difficulty of diagnosis is not so very great; but how
much embarrassment arises when those symptoms which betoken strangulated bowel
exist and a tumor is nowhere to be felt, let the numerous cases on record attest in
which the rupture has only been found after death!”
PLATE XLIII.*
HERNIA OF THE FORAMEN OVALE.
A poor woman of La Salpêtrière, aged about eighty, entered the infirmary on the 25th of October,
1832, with an obstinate constipation, otherwise in excellent health. A clyster of two ounces of castor-
oil was administered on the 27th; during the succeeding night the patient was seized with every symp-
tom of stoppage. M. Piédagnel had the kindness to send me word, and I went to the patient, who
indeed had all the symptoms—miserable pulse, cold extremities, large belly, but hard; continued vom-
iting. She vomited in my presence, the liquid coming from the small intestine, which is improperly
designated under the name of fecal matter.
There were two inguinal herniæ, the left the largest, which were easily reduced, and could not be
considered as the immediate cause of the symptoms. The patient was in full possession of her senses,
and yet was unaware of her danger. She died at one o'clock in the afternoon.
Opening of the Body.—The right inguinal hernia contained serosity and an intestinal convolu-
tion. The left was nothing but a herniary bag, whose orifice was puckered. The stomach was very
ample, excepting toward the pylorus, where it was abruptly contracted, and was reduced for about the
distance of an inch to the dimensions of the small intestine; it contained a great deal of fixed air and
a muddy liquid. A peculiar disposition of the intestine attracted our attention: four great circumvo-
lutions were directed obliquely downward from the left to the right. I unfolded the bowel, beginning
at the pylorus, and I soon discovered that this oblique direction was due to an intestinal loop which was
engaged in the sub-pubian canal of the right side. The displaced portion was situated at the union
of the two upper thirds with the lower third of the small intestine.
Figure 3 represents the manner in which the intestine was disposed behind the sub-pubian hole;
1, G, S is the upper end, which was distended by a great quantity of liquid; 1, G, L is the lower end,
which was contracted; M, the mesentery; S, P, the pubian symphysis; C, C is a cut of the cotyloidon
cavity; the gathering of the peritonæum, P, is seen at the moment of its engagement into the ring;
V, the bladder; U, the uterus. The ovaries and tubes, which have been preserved on the figure, per-
mit the relation of the parts to be well understood.
Figure i represents the sub-pubian hernia seen on the exterior. To exhibit it, it was only neces-
sary to take away the pectineal; behind this muscle was an aponeurotic sheet, very tenuous, through
whose transparency a red tumor could be perceived. This sheet removed, we came to the herniary
tumor, which was very small; the sub-pubian nerve and vessels, N, V, were situated at its external and
anterior side, the nerve before, the vessels behind; the external obturator muscle having been divided,
I saw that the largest part of the tumor was situated between the muscle and the aponeurosis of the
foramen ovale. A sort of thickness, very well depicted upon the figure, marks the point of union of
the two portions of the tumor.
The bag, S, S, being cut, a certain quantity of sanguinolent serosity escaped; the intestine, I, was
* Cruveilhier, Plate VI, No. 15.

156
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
red and injected. The intestine (Fig. 2) was withdrawn without much effort from the sub-pubian
ring; it was elongated, in form of the finger of a glove; it was neither thickened nor altered in its
organization.
When the symptoms of intestinal obstruction exist, a differential diagnosis may
sometimes be impossible. Localized pain, especially over the distribution of the ob-
turator nerve, has already been referred to. Movements of the hip-joint may be painful,
especially rotation outward, since this compresses the canal. Comparison and pressure
over the obturator foramen of each side is important, also a careful inspection of
Scarpa's triangle on each side. The pelvic opening of the obturator canal can be felt
by the finger in the vagina or rectum, and the additional evidence which such examina-
tion will give must never be omitted. Having detected a hernial tumor, the effort at
its reduction should be carefully made. The pressure is to be directed in a manner
to free the hernia from the ramus of the pubes, and carry it upward from beneath.
The neck of the sac lies behind the horizontal ramus of the pubes, occupies the
obturator canal, then makes its way sometimes between the superficial fibers of the
external obturator muscle, sometimes above them, and the sac is covered with the
fascia of this muscle. The obturator vessels and nerves, as might be supposed, vary
in their relation to the tumor. Vinson * found the artery upon the outer side of the
sac six times, upon the inner side an equal number of times, and behind it three
times.
Both sexes are liable to obturator hernia, but a large majority of cases on record
have occurred in the female. The anatomical differences of structure are a suffi-
cient reason. This form of hernia may be found as a complication in connection
with other varieties of hernia, and on this account it is more liable to be overlooked.
Mr. Birkett reports one case where there was a reducible femoral hernia on either
side; in three cases, a femoral hernia on the same side with an obturator; in one
case, on the opposite side; and in another case, an inguinal and obturator on the
same side.
The symptoms of strangulated intestine being clearly marked, it is the duty of
the surgeon to examine carefully under ether, and if uncertain as to the reduction
of an intestinal loop, he should operate promptly, as in the other varieties of hernia.
This is usually best effected by an incision directly over the site of the tumor.
* Günther's Lehre v. d. blutigen Operationen, Abschnitt xv, p. 146.

OBTURATOR, OR HERNIA OF THE FORAMEN OVALE.
157
The incision through the tissues should be parallel to the trunk of the femoral
artery, but sufficiently inside to avoid the femoral vein. The fascia covering the
pectineus muscle being exposed, the hernial tumor is more readily felt. The fascia
and the pectineus muscle having been divided in the line of the original incision,
usually a layer of fat is met with before the obturator muscle is brought into view.
This muscle must next be divided, since its fibers may completely screen the hernial
tumor; and it is not until the finger can be placed within the outlet of the obturator
canal that the operator is able to distinguish the pathological conditions with which
he has to deal. The section must be made with care, so as not to injure the vessels
and nerves.
When it becomes necessary to divide the neck of the sac, because of its relation
to the obturator vessels, it is better to cut directly inward. Here, as elsewhere, it
is important carefully to differentiate the sac, open it, and thus be assured that
its contents, which are usually only intestinal, have been freed and restored. This
done, the neck of the sac is ligated or sutured, and the sac excised. The wound
should be immediately closed by lines of continuous buried sutures and sealed with
iodoform collodion. The importance of opening the sac and the certitude of having
freed the intestine from constriction is emphasized by two cases which are reported
where operation was attempted, the hernial sac made “visible and tangible,” without
finding the inclosed intestine. Post-mortem examination, however, showed an obturator
hernia seated immediately beneath the site of the operation, which was proved to be
the cause of death.
In this variety of hernia the local symptoms may be so obscure as to be entirely
overlooked, and yet the evidences of intestinal obstruction demand prompt surgical re-
lief. Under these conditions, it is plainly the duty of the surgeon to make an explora-
tory laparotomy, and to find and relieve the cause of the obstruction; and this method
of procedure, now so safe under modern surgical precautions, is often to be advised,
since it enables the surgeon to determine accurately the condition of the intestine,
and make available suitable measures for its repair in perforation or gangrene.
Sir Astley Cooper reported a case, operated upon by M. Arnaud, where a portion of
omentum was removed with the sac, followed by cure, but he criticised the operation as
needless, and stated that, in a case of strangulation where other measures have failed,
" the operation of cutting the ligament which embraces the sac is the only hope of pre-
serving life. This operation must be extremely difficult, and, so far as I am informed, it

158
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
has never been performed.” The honor of having first demonstrated this variety of
hernia is apparently due to the elder Arnaud. In Arnaud's Treatise, so frequently re-
ferred to in this work, the following is found : “ Ruptures of the oval foramina of the
pelvis, which my father originally discovered, were at first rejected as impossible by M.
Duverney, a celebrated anatomist, but ten years after he found two of that nature in the
same person. He was, however, then paid in his own coin by those who seem to think
the rejection of novelties a point of honor. There were some who maintained this same
error till 1742,* when I performed the operation for a rupture of that kind in a young
lady of quality, which Messrs. Mataval and Grammont, surgeons, declared to be neces-
sary. Who could have given me courage to have performed the first operation of this
nature, had I not been minutely acquainted with every step which ruptures take in
their progress ?”
Duverney met it post-mortem, and communicated his observations to the Royal
Academy of Sciences, but they were not printed in their Memoirs. In a female, upon
both sides of the pelvis, the peritonæum had protruded through the openings of the ob-
turator canal, and formed tumors the size of an egg. They contained intestine, were
placed between the anterior heads of the triceps, and formed an external tumor. The
first publication in which the existence of an obturator hernia was clearly demonstrated
was by Garengeot.
A case is minutely described by M. Cloquet, in which a thyroideal entero-epiplo-
cele caused death. It produced no visible external swelling. The tumor was about
the size of a small hen's egg, and contained sphacelated intestine and omentum. It
was covered by the pectineus and adductor longus, and rested on the vessels and
In the very large number of dissections which Cloquet made for the purpose
of studying hernia, he naturally examined the thyroideal canal, and gave it as his opin-
ion that this variety of hernia was much more common than is generally supposed.
In post-mortem examinations, as usually conducted, I am sure the peritonæum in this
locality is rarely made the subject of investigation.
nerve,
PLATE XLIV
Contains two views of a thyroideal hernia (or hernia foraminis ovalis). A view of a perineal
hernia in the possession of Mr. Cutcliffe, of Barnstaple. Also a hernia congenita in the female, and a
crural hernia sent me by Mr. Allan Burns, surgeon, of Glasgow.
* Vide Memoirs of the Academy of Surgeons, vol. i, p. 715.
† Cooper, Plate XI, Part II.

PLATE XLIV.
Fig. 2
Fig.l.
772
.2
07
2
mn
d
272
Fig.3.
d


OBTURATOR, OR HERNIA OF THE FORAMEN OVALE.
159
Figure 1.
Thyroideal hernia.
a. Symphysis pubis.
b. Spine of the ilium.
6. Abdominal muscles.
d. Acetabulum.
e. Tuberosity of the ischium.
f. Ligament of the obturator, or thyroid fora-
men.
g. Crural artery.
h. Artera circumflexa ilii.
i. Spermatic vein.
k. Obturator artery.
1. Inguinal hernia drawn aside.
Gyn. Stair Room University Hospital
.
n. The urethra.
0. Prostate gland.
p. Vesicula seminalis.
9. Anus.
r. Mouth of the hernia.
s. Body of the sac.
t. Its fundus, terminating nearly opposite the
anus.
Figure 4.
m. Thyroideal hernia situated just behind the
pubes.
Figure 2.
Posterior view of the same preparation.
a. Symphysis pubis.
b. Tuberosity of the ischium.
c. Sacro-sciatic ligaments.
d. Ligament of the thyroid foramen.
e. Abdominal muscles.
f. External iliac artery.
8. Epigastric.
h. Circumflexa ilii.
i. Spermatic vein.
k. Internal iliac artery.
1, 1. Obturator, or thyroideal artery.
m, m. Internal pudendal artery.
n. Mouth of the inguinal hernia.
0. Mouth of the thyroideal hernia.
From Mr. Allan Burns :
1. The spine of the ilium.
2. The tubercle of the pubes.
3. The crural arch.
4. The abdominal muscles.
5. The inferior or external orifice of the in-
guinal canal. The canal itself in this subject is
very large and short, and contains
6. An incipient hernia congenita. The pillars
of the canal are here seen to separate from each
other fully an inch above the tubercle of the
pubis, by which the herniary tumor appears much
nearer to the spine of the ilium than it ought to
do, and on the opposite side, where it protruded
farther, it took the direction more of the crural
than of inguinal hernia.
7. The lower pillar of the canal inserted into
the tubercle of the pubes.
8. The upper pillar, in part, inserted into
the tubercle, but a production arising from it,
which encircles the head of the gracilis and tri-
ceps muscles, reaching to the posterior part of the
thigh, where it is lost. The healthy and morbid
action of this fillet has been already explained.
9. Gimbernat's duplicature protruded so as to
form an envelope of the herniary sac, which has
been removed to show the parts more distinctly.*
10. The opening which had been originally
placed in the center of the septum, stretched
across the crural foramen.
11. The falciform process of the groin receiv-
ing a part of the protruded duplicature, and con-
cealing from view the femoral vein.
12. The psoas aponeurosis covering the pec-
tineus muscle, and rising up between the vena
saphæna and deep-seated vein to join the falci-
form process.
13. The vena saphæna.
14. The (seat of the) femoral artery.
Figure 3.
Perineal hernia.
a. The lumbar vertebræ.
b. Spine of the ilium.
c. Sacrum.
d. Spinal marrow.
e. Symphysis pubis.
f. Erector penis.
g. Accelerator urinæ.
h. Bulb of the penis.
i. Corpus cavernosum.
k. Corpus spongiosum.
1. The rectum.
m. The bladder cut open, which it is not in
the preparation.
* I have called this the fascia propria of the hernial sac.

160
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
sac.
a
Hilton * reported a case simulating intestinal obstruction within the abdomen, to
relieve which gastrotomy was performed.
According to Mr. Birkett, the first surgeon to operate, followed by cure, was Mr.
Obré, of London, in 1851. Patient, a tall, stout female, aged fifty-one. He incised the
sac and its orifice, and returned a congested loop of intestine. The next report which I
find was in 1853, by B. Cooper.t Division was made and contents returned; recovery
was slow, but satisfactory. The same year M. Case $ operated, followed by cure. A
most interesting case is reported by Welsch, # where a portion of the end of the pro-
cessus vermiformis and a very small part of the urinary bladder were carried into the
An abscess supervened, followed by death.
Since the above dates I have found reported twelve operations undertaken for ob-
turator hernia, with seven recoveries.
The following case of right obturator hernia is reported by Mr. Charles Frith, |
of London. “A thin, feeble, elderly woman had suffered for a number of years from
a swelling at the upper and inner part of the right thigh. By careful manipulation the
contents of the bunch could be pressed upward, with a sudden gurgle. She had
worn a truss for years. Marked symptoms of intestinal obstruction had existed for
some days, and she was very ill when first seen. A tense, fluctuating, fist-size tumor
presented at the upper and inner part of the thigh. It was painful upon pressure.
The femoral vessels could be distinctly felt at the outer side, seeming to be pushed
aside by the tumor. Poupart's ligament could be plainly made out, and no hernia
could be felt in either the femoral or inguinal ring. A vertical incision, four inches
long, was made over the tumor midway between the line of the femoral artery and
the spine of the pubes; the adductor longus was pulled down and inward and the
sac brought into view. This was thick and tough, and upon division more than a
pint of blood-stained, offensive fluid escaped. The bowel was found deep down in the
upper and outer part of the wound. The thyroid membrane was nicked in a down-
ward and inward direction and the intestine returned into the abdomen. The sac was
dissected out and removed. Death occurred some hours later, from collapse. The
J. Hilton, Medico-Chirurgical Transactions. London, 1848, vol. xxxi, pp. 323-335.
+ Medical Times and Gazette. London, 1853. N. S. vi, 113.
| Bulletin Générale de Thérapeutiques. Paris, 1853.
# Med. Cor. Bl. d. Würtlembärtzl. Ver. Stuttgart, 1862.
| British Medical Journal, April 19, 1890.

OBTURATOR, OR HERNIA OF THE FORAMEN OVALE.
161
post-mortem examination showed that eight or ten inches of the intestine had been
strangulated—the portion of the ileum near to the ileo-cæcal valve."
Dr. Josef Englisch, of Vienna,* reports a second case of obturator hernia which came
under his observation, and figures a truss which he has constructed especially for its re-
tention. The article is of considerable length; the author reviews the literature of the
subject, and concludes that not more than two hundred cases have been reported, but
this teaches that obturator hernia has been recognized much oftener than is generally
supposed.
I have met with this variety of hernia only once. A girl of twelve years
was considered well until three days before death. She received a severe strain
from sliding down the banister-rail of a stairway. Continued at school the follow-
ing day; was seized with symptoms of intestinal obstruction, stercoraceous vomiting,
and was in extremis, when I was summoned by the late Dr. Moses E. Church,
of Cambridge. There was an illy defined, tender tumor upon the inner side of the
thigh below the pubes, the size of a small egg. The abdomen was tense and tym-
panitic. The fact that strangulation had existed for so long caused taxis under ether to
be undertaken with more than the usual care. Failing in this, and fearing the intestine
was necrosed, and possibly further intra-abdominal complication existed, I determined
to perform laparotomy, and in this I was aided by Drs. Church and G. W. Nash. By
careful manipulation of the intestine, gentle pressure being made upon the tumor, a loop
of darkly congested, small intestine was withdrawn and the wound closed. The recovery
from ether was unfortunately complicated by the vomiting of an enormous quantity of
dark fluid, a quart or more. The prostration was extraordinary, and death supervened
in a few hours. This and one or two other instances, where intestinal obstruction had
existed for a considerable period, have taught me to feel that, in such severe cases, a
careful washing-out of the stomach before operating is of the first importance.
Although rare, this variety of hernia has been treated here at the greater length since
in most works it is scarcely more than alluded to. I have no doubt it often escapes
observation, and death from obscure abdominal inflammation is the verdict generally
rendered. Since the great majority of hernial cases must come under the observation
of the general practitioner, it is well to emphasize the possibility of this very dangerous
variety.
* Wiener klinische Wochenschrift, December, 1891.
24

162
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
The only pathological specimen of this variety of hernia which I have ever seen I
examined last year in the Museum of the College of Physicians of London. The
following is the description given :
a
2689. Part of a pelvis, with a strangulated hernia of a small portion of ileum through the obturator
foramen on the left side. The sac is opened anteriorly; it protrudes straight through the fora-
men at its upper and inner part.–From the Museum of John Howship, Esq.

CHAPTER XIV.
ISCHIATIC HERNIA.
a
A FEW cases of this rare variety of hernia are on record. The tumor can not be dis-
covered until of a considerable size, since it is covered by the gluteus maximus. Law-
rence wrote that "it has never been diagnosticated upon the living subject.” Sir Astley
Cooper reported at length a case dying of intestinal obstruction where the autopsy
showed a strangulated ischiatic hernia, and he illustrated it with two plates, which I
give.
A brief abstract of the case of ischiatic hernia from the dissection of which Mr.
Cooper made his plates, is of interest.
On the 18th of April, 1800, Dr. Jones first saw a young man, a clerk in a mer-
cantile house, aged twenty-seven. A few hours previous he was seized with nausea,
retching, and violent pain in the epigastric region. Earnest effort was made without
avail to relieve the marked intestinal obstruction, until the 25th, when death super-
vened. pon dissection it was found that the ileum had descended on the right side
of the rectum into the pelvis, and that a fold of it was protruded into a small sac. Dr.
Jones reported the case to Mr. Cooper, who thought it worthy of further investigation.
Mr. Cooper, in his work, refers obscurely to the then common practice of obtaining
interesting specimens through the illegal service of the “ body-snatchers," and says,
After considerable difficulty the doctor and myself opened the body a second time, and
I removed the portion of the pelvis in which the hernia was situated, and which will
be seen in Plates XII and XIII of this work.”
“... In order to get at the parts more conveniently, a ligature was made on the
ileum just at the place where it enters the pelvis, and around all the intestines above
the pelvis; this gave a fair and ample opportunity of perfectly satisfying ourselves
with regard to the nature of the case; after which the intestine was gradually with-
drawn from the sac, in which it was rather firmly confined. On examining the surface
of that part which had been contained in the sac, it was found to have adhered at
two points by coagulated lymph. The strictured part of the intestine, and about three
a
(163)

164
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
inches of it on each side, were very black; the intestines from the hernia toward the
stomach were very much distended with air, and had here and there a livid spot on
them. There was also a dark-colored spot on the stomach just above the pylorus.
The colon, as far as its sigmoid flexure, was so rigidly contracted as not even to admit
the passage of air through it, but was of its natural color, and the inflammation had
scarcely extended to the cæcum.
“ Upon careful dissection of the parts after they had been brought to my house,
we found a small orifice in the side of the pelvis, anterior to, but a little above, the
sciatic nerve, and on the fore part of the pyriformis muscle. When the finger was
passed into this opening it entered a bag situated under the gluteus maximus muscle,
and this was the hernial sac in which the portion of intestine had been strangulated.
The cellular membrane, which connects the sciatic nerve to the surrounding parts of
the ischiatic notch, had yielded to the pressure of the peritonæum and viscera. The
orifice of the hernial sac was placed anterior to the internal iliac artery and vein below
the obturator artery, and above the obturator vein; its neck was situated anteriorly to
the sciatic nerve, and its fundus, which was on the outer part of the pelvis, was cov-
ered by the gluteus maximus. Anterior to, but a little below, the fundus of the sac
was situated the sciatic nerve; behind it, the gluteal artery. Above, it was placed near
to the bone; and below, appeared the muscles and ligaments of the pelvis.”
PLATE XLV*
Gives an internal view of the ischiatic hernia from Dr. Jones's patient. The preparation is in the
anatomical collection at St. Thomas's Hospital.
a. Section of the pubes.
b. Spinous process of the ilium.
c. Sacrum.
d. Iliacus internus muscle.
e, Psoas muscle.
f. Pyriformis muscle.
g. Coccygeus muscle.
h. Termination of the external iliac artery in
the crural.
i. Beginning of the crural vein.
k. Trunk of the common iliac artery.
1. Internal iliac artery.
m. Obturator artery, which may be traced be-
fore the sac as far as the obturator foramen.
n. Internal iliac vein.
0. Obturator vein passing behind the hernia
to the obturator foramen, from which another
vein (Þ) is seen passing into the iliac vein.
9. Hernial sac.
r. Its orifice.
The artery was injected with red wax, the
vein with yellow, which is the reason the artery is
so much darker than the vein in the plate.
* Cooper, Plate XII, Part II.

PLATE XLV.
6
h
2
72
m
h.
..
.
(1
2


ISCHIATIC HERNIA.
165
1
Camper also recorded a case where the ovary was in the sac.
Should ever the ques-
tion of operative interference be deemed advisable, Sir Astley Cooper recommended
that the safest direction in which the orifice can be dilated will be directly forward.
The following case is reported by Lawrence: * “ An exception must be made to this
remark if we admit, according to the general opinion, that the case described in Papen's
Epistola de stupenda Hernia dorsalis was an ischiatic rupture. A woman, at the age
of forty, perceived near the right side of the anus a small tumor, which gradually in-
creased into an immense pendulous bag, hanging down to the knee. She was obliged
to lie on the left side, to suspend the tumor from the back when at work, and to
elevate and compress it in order to promote the evacuation of the fæces. Frequent
borborygmi were heard in the part. It seems that this great infirmity did not mate-
rially affect the patient's health, nor prevent her from following laborious occupations, as
she died suddenly while employed in harvest-work, and her body was very fat. The
swelling resembled an oblong flask, narrowest toward the anus and increasing below.
Its length was an ell, and the circumference of the lower part half an ell. It formed a
cavity lined by peritonæum, containing all the small intestine, with part of the large and
of the omentum. The course of the stomach described a perpendicular line, and the
pylorus was at the entrance of the sac in the pelvis. The opening at which the parts
protruded is by no means clearly described. The circumstance of the swelling having
been perceptible when small, of its situation near the anus, and of its increase to so great
a bulk, make me doubt whether the parts had passed out at the sacro-sciatic foramen”
(Halleri Disput. Chirurg., tome iii). The following case is mentioned so shortly that it
also must be classed among the doubtful instances : “My father had occasion to visit a
child with a large tumor under the gluteii muscles, which became tense when the child
cried, owing to the tumor containing a large portion of the intestine.” (Monro. Mor-
,
(
bid Anatomy of the Human Gullet, etc., p. 380.)
M. Alex. Wassilieff + describes a case of this rare form of rupture. The patient,
a man aged fifty-four, was seized with pain in the left buttock when straining dur-
ing defecation. Symptoms of acute strangulation set in. After careful exploration
ischiatic hernia was diagnosed. The rupture was very tender. Taxis was undertaken,
after preparations for an operation, and the mass went back. Relief was almost im-
mediate. In the night, after a free escape of flatus, the symptoms recurred during
* Treatise on Hernia, p. 473.
Revue de chirurgie, March, 1891.

166
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
an attempt to defecate. Taxis again effected reduction, and a stout pad was fixed,
by means of a bandage, over the region of the great sciatic notch. M. Wassilieff
divides ischiatic hernia into a suprapyramidalis variety, where the intestine escapes
between the border of the great sciatic notch and the upper margin of the pyrami-
dalis. This is the commonest form, and if an operation be attempted the stricture
should be divided toward the notch. The subpyramidalis variety includes a form
where the gut escapes between the lower border of the pyramidalis and the lesser
sacro-sciatic ligament (supraspinous), and a form where it passes out between the
lesser and the greater ligament (subspinous), but it is doubtful whether subspinous
ischiatic hernia has ever occurred. Diagnosis is always difficult. The seat of the
tumor and the pain, which appears to be severe owing to the hardness of surround-
ing structures, as well as the general symptoms of hernia, are the chief guides to
diagnosis. The hernia may contain omentum, large intestine, small intestine, bladder,
or ovary. In operation, the skin incision must be parallel to the line of ligature of
the gluteal artery.
PLATE XLVI.*
A POSTERIOR VIEW OF THE ISCHIATIC HERNIA.
a. Anterior superior spinous process of the
ilium.
b. Crista of the ilium.
6. Sacrum.
d. Os coccygis.
e. One of the sacro-sciatic ligaments.
f. Acetabulum.
8, g. Sciatic nerve.
h. Gluteal artery.
i. Ischiatic hernial sac situated between the
artery and the nerve.
The weakening of the pelvic floor in woman from child-bearing is a common cause
of a downward displacement of the pelvic contents. By the earlier writers quite a
number of these lesions are described under different varieties of hernia, as pudendal,
vaginal, and perineal hernia; also hernia of the urinary bladder, through the vaginal
outlet, cystocele, etc. All these displacements are important and interesting, but come
more properly under discussion in the consideration of the injuries and diseases of the
female organs rather than in a general treatise upon hernia.
* Cooper, Plate XIII, Part II.

PLATE XLVI.
6
2
f
9
E
d


CHAPTER XV.
CÆCAL HERNIA.
A very considerable variety of pathological conditions are met with in hernia which
have been indirectly referred to already. An attempt has been made to classify some
of these conditions, designating them from the character of their contents. Most of
these varieties are rare, and yet it is well to know that such herniæ may be met with.
Perhaps as interesting as any of the rarer forms is that called cæcal hernia, because usu-
ally the cæcum is so fixed that it is not easy of displacement.
“Left inguinal hernia containing the cæcum and appendix, the latter having devel-
oped into a tumor.* A man, aged sixty-four, had suffered from hernia for fifteen
a
years, continuing, however, at his occupation as porter. For a long time the tumor
had not been entirely reducible, but was retained in position by a truss. After an
injury from a fall, it became larger, and for three days it had resisted every attempt
at reduction. On entrance into the hospital the tumor was soft, not tender, or pain-
ful on pressure. Inguinal ring readily admitted the extremity of the finger. It was
easy to determine the existence of a hard body, the size of a nut, as a part of the
contents of the hernial tumor. Taxis under ether having failed to reduce the con-
tents of the sac, kelotomy was performed by Prof. Pomcet. The contents of the
tumor were made up of the ascending colon with fifteen or twenty centimetres of the
small intestine. Slight adhesions fixed the intestine to the sac. The hard body
proved to be the extremity of the appendix vermiformis, the size of an almond, with
the pedicle about five centimetres long, the size of the little finger. This was liga-
tured and resected. After some days insanity developed without any explanation of
the cause, and he was removed from the hospital in this condition, repair of the wound
having gone on without suppuration. Examination of the appendix showed the
walls to be greatly thickened and the pouch filled with fecal material.”
The case is interesting, since we have already noted that hernia of the cæcum is
* Lyon Médicale, January, 1892, p. 14.
(167)

168
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
rare, and especially occurring upon the left side, and the pathological conditions
which had supervened in the appendix makes the case one of extreme interest.
R. S. Black * reported an interesting case of left cæcal hernia which was accident-
ally discovered.
Post-mortem.—"On lifting aside the coils of the small intestine, the large gut was
seen crossing obliquely from the right lumbar region at the lower level of the kidney
and applied to the posterior wall of the abdomen till it disappeared through the left
internal inguinal ring. On making firm traction, the bowel gradually slipped from
the ring, and the contents of the hernial sac were then seen to be the cæcum with the
appendix vermiformis and a small portion of the small intestine at its junction with
the cæcum. Eight or nine inches of the large intestine were thus included in the sac,
and there were no remains of a meso-cæcum.” Although the cæcum is oftentimes
rather loosely attached, which permits of considerable motion, it is exceedingly rare to
find it as a part of the hernial contents, and obviously much more extraordinary when
transposed to the left side of the body. A case of left inguinal hernia in a male con-
taining the cæcum is described in Billroth's Handbuch, 1878. Mr. Treves met with a
case occurring in a female where a left inguinal hernia contained the cæcum and its
appendix.
Mr. William H. Bennett | reported a case of cæcal hernia entirely wanting in a
peritoneal sac, in which strangulation at the internal abdominal ring existed with in-
tussusception through the ileo-cæcal valve. “A laborer, aged fifty-two, was admitted
into St. George's Hospital, October 26, 1889, with a large irreducible strangulated
scrotal hernia. An oval fluctuating tumor was exposed, which had not the appear-
ance of peritonæum and which was suspected to be intestine, although no peritoneal
sac had been seen. The constricting soft parts were freely divided, and yet the hernia
remained absolutely irreducible ; and as the tumor contained a hard mass of doubtful
character, it was opened, when a large quantity of perfectly clear fluid escaped. The
opening had been made into the cæcum, and projecting into it through the ileo-cæcal
valve was an invaginated piece of intestine three inches long. The cæcum was en-
tirely free from peritoneal covering, but behind it, adherent to the testicle, was a piece
of omentum lying in a peritoneal sac, presumably a reducible hernia, which the patient
had described. All attempt at reduction of the hernia and the intussusception failed,
a
* British Medical Journal, November 22, 1890.
† Ibid., February 1, 1890.

CÆCAL HERNIA.
169
·
and a temporary artificial anus was made. Patient died three days later.” The con-
ditions described were considered as unique by Mr. Bennett.
Mr. Treves, in discussing the case, stated “that, so far as he was able to learn, this
case was without parallel. He had collected fifteen cases of hernia of the cæcum, in
thirteen of which there was a complete sac, and in two so little as almost to justify
the statement that none existed. He mentioned a specimen in St. Bartholomew's
Museum, which was described at length in the catalogue as hernia of the cæcum
without a sac; but a careful examination showed that the hernia was of the sigmoid
flexure, and that there was a complete sac. He thought this specimen was respon-
sible for a good deal of erroneous teaching upon the subject.” Mr. Treves believed
that the presence of the clear, watery fluid was due to early oedema of the convex
side of the intussusception.
The following case of cæcal hernia, and the complications involved in the opera-
tion for its cure, are of interest sufficient to give in detail.
“H. H.,* aged fifty-three, had been a soldier, is healthy-looking, spare man. Right
inguinal hernia for eleven years. Had worn a truss. Two years ago hernia was
strangulated and reduced with difficulty, a hard lump since remaining in the ingui-
nal canal. April 15, 1891, hernia came down and could not be reduced. Constipa-
tion, nausea, severe pain, and tumor excessively tender. Sent to hospital, 18th.
There is a sausage-shaped swelling at the site of the right inguinal canal, which is
hard, tense, nodular, dull on percussion, and excessively tender. No impulse on
coughing. Below and continuous with this swelling, and filling up the scrotum, is a
much softer tumor which is neither tense nor tender. Ether was given, taxis em-
ployed without avail, and operation at once undertaken.
Operation. The parts having been properly cleaned and shaved, an incision
was made over the sausage-shaped swelling, and after cutting through the skin a
dense, hard mass was met with which appeared to be composed of fibrous tissue.
On extending the incision below this mass the thin, bluish wall of the sac was dis-
covered. This was incised, and immediately about two ounces of a straw-colored
fluid escaped. No intestine was found in the sac, and it was supposed the gut
slipped back when the fluid was evacuated. The sac was now slit up to the upper
* Case of Cæcal Hernia; Herniotomy; Wound of Bowel; Suture; Recovery. By Francis J. Shephard, M. D.
Montreal. Annals of Surgery, February, 1892.
25

170
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
end, through the thickened fibrous mass, and then an attempt was made to dissect
it out.
This was found to be a difficult task, as it was very adherent. The floor of
the sac was composed of an irregular cystic mass, with elevated ridges containing
large blood-vessels. This mass on close examination proved to be omentum, which
had become incorporated with the posterior wall of the sac. Posteriorly the sac was
so intimately blended with the spermatic cord that separation could not be effected
without destroying the vas deferens. So the cord was cut through and the testicle
afterward excised. The veins of the cord were enormously distended, and the whole
cord was in a state of cystic degeneration which formed a mass below the hernial
sac, causing the second swelling already alluded to. After a time I managed to
separate the sac and the structures incorporated with it. The neck, which seemed
to be thicker than usual, was fixed beyond the internal ring, pulled down, and then
tied with strong silk. It was now turned up and the scissors were used to cut it
off. The first cut made from below, much to my surprise, opened the bowel. The
ligature was immediately loosened, and it was now found that the cut had been made
into a collapsed portion of the cæcum which was closely attached to the upper part
of the posterior wall of the sac. In pulling this down farther, the appendix was
The cut in the bowel was about one and a half inch long, and the part of the
cæcum opened was quite free from fæces. It, however, was well washed and then
the cut was closed with a continuous suture of fine silk, and a Lembert suture over
this again. The omentum was separated from the sac, tied off, and returned. The
sac itself was ligatured below its attachment to the cæcum, and the part in front
cut away and then returned within the abdomen with the sutured cæcum. A radi-
cal cure was performed by suturing the conjoined tendon to Poupart's ligament.
The wound was sutured with silk-worm gut and a drain placed in the lower end.
“The patient's condition was excellent at the end of this prolonged operation, and
he had no vomiting afterward. Next day his temperature and pulse were normal; ;
there was some pain about the wound, but his condition was still excellent.
“On the 25th, six days after the operation, the wound was dressed, the tube re-
moved, and the stitches taken out. There was union by first intention. He went on
well, without a bad symptom, and was discharged from the hospital on May 16th,
with a small sinus persisting where the drainage-tube had been. He returned to the
hospital May 22d, saying he felt well and was attending to his work as usual. Had
some pain and tenderness about the center of the scar.
seen.
a

CÆCAL HERNIA.
171
“ June 5th returned again with a small suppurating point at center of scar, through
which protruded a silk ligature. This proved to be one of the ligatures which united
the conjoined tendon to Poupart's ligament. The sinus now quickly healed, and the
patient has felt well ever since, attending to his duties and suffering no pain. He
has never worn a truss. In this case there was no doubt a double hernia—viz., one
of the cæcum and one of the small intestines in front of the cæcum. The hernial
sac which contained the small intestines and omentum, had for its posterior wall a
layer of peritonæum covering the cæcum, and as it descended it pulled the cæcum
down with it. From prolonged use of a truss, and from inflammatory attacks which
had occasionally occurred, the sac was thickened, and the omentum so fused with it
that it really had become a part of the sac. Closely incorporated with the posterior
wall of the sac was the lower end of the cæcum, which was only covered in front
with peritonæum, and as it was empty and of the same color as the sac, from having
been herniated probably for some years, it was not recognized or even suspected,
until, when cutting off the sac, it was opened. As soon as this occured, the bowel was
pulled down, and then it was recognized as the cæcum, and the character of the hernia
was at once apparent. The cut in the bowel was immediately sutured, and no harm
resulted.
The removal of the right testicle was a necessary proceeding, for the cord and sac
were so blended that a separation without injury was not possible. In one way the
sacrifice of the testicle was a great gain, in that it helped to make the radical cure
more certain.”.
The only case of cæcal hernia which it has been my fortune to meet occurred
recently. A child of Mr. G., of Chelsea, Mass., aged two months, was sent me
by Dr. Samuel N. Nelson. It was otherwise a strong, well-developed infant. Since
birth the mother had noticed a soft swelling of the right scrotum, at times nearly the
size of a small fist. The tumor was tender on pressure, and could be only imper-
fectly returned into the abdomen. Operation the 9th of January, 1892. The ring
was large, admitting the tips of two fingers; the sac was an extremely thin layer of
peritonæum, containing a testicle. The cæcum, with three or four inches of the head
of the colon and several inches of the small intestine, made up the contents of
the hernial tumor. The appendix was unusually large, and was the first portion of
the tumor to protrude upon opening the sac. It was with extreme difficulty that
the intestine could be restored to the abdominal cavity, even after holding the little

172
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
fellow in the reverse position. Operation was performed in the usual manner, and an
easy and uneventful recovery followed. Dr. Nelson has recently reported that the
result is perfect.
HL
FIG. 13 is from a photograph taken
before operation.
FIG. 14.- The same after operation, showing the closure
of the skin by the buried running tendon suture.
e
The following case, which might be designated anal rupture, reported by Sir Ben-
jamin C. Brodie,* is of exceptional interest, in that this distinguished surgeon was equal
in his resources to the emergency of the extremely rare conditions, and promptly per-
formed laparotomy.
“ A middle-aged woman was seized in the evening with pain in the abdomen, and
sickness. After straining violently in the act of vomiting, she discovered an unusual
appearance, which led her to believe that she had suffered a miscarriage. The fol-
lowing evening she was admitted into St. George's Hospital. At this time not less
than two yards of small intestine, with a corresponding portion of the mesentery, were
seen protruding through the anus. The whole mass bore marks of a high degree of
inflammation, and the intestine was much distended with air and liquid fæces. On
examining the rectum with the finger, it was found that there was a transverse slit
on the anterior part of it about two inches above the anus, through which the pro-
trusion of the small intestine had taken place. On attempting to reduce the pro-
truded intestine, at first it readily re-entered the anus, but when about one half part
of it had disappeared, the reduction became difficult, and about one fourth part of it
* London Medical and Physical Journal, June, 1827.—Singular Variety of Hernia treated by Sir Benjamin C.
Brodie, Esq.

CÆCAL HERNIA.
173
could not be reduced at all. In fact, no method could be devised by which even a
part of it could be made to pass through the slit in the rectum, so as to resume its
natural position in the peritoneal cavity. The pressure of the hand caused the small
intestine to ascend into the rectum, where it lay only as long as this pressure was
continued, and nothing further in the way of reduction could be accomplished. Under
these circumstances, Mr. Brodie made a longitudinal incision of the linea alba, about
two inches in length, below the umbilicus. The incision was continued through the
peritonæum into the cavity of the abdomen, and the finger being introduced at this
opening, by gently pulling the small intestine, that portion of it which had protruded
through the slit of the rectum was readily drawn back into the abdomen. It having
been ascertained, by examining the rectum with the finger, that the reduction was
completed, the edges of the wound in the linea alba were brought together by sutures.*
After the operation the pulse was scarcely perceptible, the extremities were cold, and
the patient was sick, throwing up again immediately whatever she swallowed. In
about two hours the pulse was somewhat stronger and the extremities were warmer ;
but the restoration of the vital powers was imperfect, and after some hours they again
began to fail, and the poor woman died about six o'clock the next evening.
On examining the body, the peritonæum generally was found much inflamed, and
in many parts covered with a layer of coagulated lymph. That portion of the intes-
tine and mesentery which had formed the protrusion, was, however, less inflamed than
it had appeared to be previously to the operation. There was a transverse opening
in the anterior part of the rectum, without any marks of ulceration in the neighbor-
hood, whence it was concluded that the opening was the result of accidental lacer-
ation.”
* During the operation a part of the small intestine protruded through the wound of the linea alba, but it was
readily replaced after the reduction of that which had protruded through the opening in the rectum was completed.

CHAPTER XVI.
HERNIA OF THE OVARY.
The ovary forms a part of the hernial contents only very rarely, and yet sufficiently
often to be held in remembrance by the surgeon; and it presents pathological conditions
of such an interesting type, that I abstract freely from the valuable monograph by
Dr. Robert Barnes, * of London, who states that he has exercised especial care to
cite only those cases which present definite facts, and which can therefore safely be
trusted as a basis for physiological and pathological study. One of the earliest authen-
tic cases is recorded by M. Gouey, of Rouen, in 1716 : It was a case of gestation in a
hernial sac of the right groin. Gouey opened the sac, and extracted an embryo of
between two and three months' development. The placenta came easily on slight
traction. It had grown to the circumference of the external oblique muscle.”
“ Puech cites this case as evidence in proof of his contention that gestation in this
situation is proof of the pre-existence there of the ovary. This theory had been ex-
plicitly enunciated by Cruveilhier. Pott's classical case is almost the first well-authen-
ticated case (1756). A girl, aged twenty-three, went to St. Bartholomew's Hospital,
having a tumor in each groin, which had for several months caused her much pain.
She was healthy, and menstruated regularly. The tumors were soft, uneven, easily
movable, and lay externally to the tendinous apertures of the inferior abdominal wall.
Pott removed them. From this time she never menstruated; her breasts fell away, and
the muscular system became developed as in man.
“ Deault found in the dissecting-room the left ovary, tube, and the uterus in a her-
nial sac (1779).
Lallement (1816) relates a case described and figured by Cloquet (1831), of right
crural hernia containing the uterus, tubes, ovaries, a part of the vagina, and a piece of
* The American Journal of Obstetrics, January, 1883, vol. xvi, pp. 1-25. On Hernia of the Ovary, with Observa-
tions on the Physiological Relations of the Ovary, with the Relation of Cases observed, by the author, Robert
Barnes, M. D.
(174)

HERNIA OF THE OVARY.
175
66
severe.
epiploon. The hernia had existed for forty years. The right ovary had changed to a
cyst, and another cyst adhered to it.
Deneux relates a case: A pluripara, four and a half months pregnant, sustained a
fall on her knees and belly; she felt a dragging in the pelvis and right iliac fossa aug-
mented by the movements of the foetus. During labor the suffering was especially
A tumor was found at the inner edge of the left crural arch, irreducible, very
tender. On the seventh day after delivery the pain had become intolerable, therefore
operation for hernia was performed. A hydatid was found, and behind it an ovary.
Three fourths of the cyst and nearly all the ovary were cut off. The suffering was re-
lieved, and the patient recovered.
“ Mr. Cæsar Hawkins reports two cases : He operated for femoral hernia of the
right side on a lady about sixty-five years of age. She had worn a truss for many
years; it had not been reduced for a long time. Symptoms of strangulation set in.
Bowel had been incarcerated. The hernia was divided into two parts, one of which
felt like omentum. On opening the sac further, it was found to contain the whole
Fallopian tube and broad ligament, with a shriveled ovarium, and five or six inches
of intestine. On dividing the stricture the bowel readily went up, and so did also the
uterine appendages, but with some little adhesion to the sac. Recovery.
Of Case II he says: I have a very distinct recollection of having seen it in the
post-mortem room of St. George's Hospital. The chief feature noted was the elonga-
tion of the uterus, and which, with the Fallopian tube, formed a canal fourteen inches
long. The subject was an elderly woman, who died of peritonitis. The Fallopian tube
and ovary had been lodged for many years in the hernial sac.
Two cases reported by Dr. Oldham to the Royal Society are especially interesting :
CASE I. A girl, aged nineteen, had never menstruated. Eighteen months ago a
swelling suddenly appeared in the right labium; it gave pain, and then it disappeared.
Four or five months later a similar swelling again appeared, with great pain. It re-
turned several times. Dr. Oldham found a tumor the size of a goose-egg between the
external abdominal ring and labium, tense, firm; the surrounding tissues inflamed,
painful. On the left side was an oval body the size of a walnut, just emerging from
the outer ring, but readily slipped back into the canal. This was the left ovary; it was
quiescent. No trace of uterus or vagina could be found. The mammary glands were
fully formed. She married. For three years the right ovary was exclusively enlarged
then for two years the left ovary was more frequently affected. This accession of a

176
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
menstrual nisus was sometimes suddenly felt. It became doubled in size, and it was
plain that the whole, not merely a part, of the organ was involved. There was no
vicarious flux.
“ CASE II. A girl, aged twenty, never menstruated; tall, strumous-looking, in weak
health. Mammæ developed; no marked efforts at menstruation; pelvis fairly formed.
The ovary on either side just appearing at the external abdominal ring, readily returned
by pressure. Each was about the size of a small chestnut, not tender upon touch.
.
No trace of a vaginal canal or uterus discovered.
“ The late Mr. Holmes Coote published the following case : A young woman was
admitted to the hospital with symptoms of strangulated hernia. The ovary and part
of the Fallopian tube were found in the sac. A similar formation was found on the
right side. The left ovary was removed; thickened omentum was cut away; the sick-
ness and constipation continued. The patient died on the fourth day. The cause of
the sickness was assumed to be displacement of the stomach and arch of colon. Both
ovaries were developed. She had menstruated regularly. The uterus was quite
absent; the vagina was a short canal an inch and a half long.
“ Mr. Lawson reports a case: October 11, 1877.—The patient was a young woman
There was a small tumor of the right inguinal canal, presenting very much the appear-
ance of an undescended testicle in a man. Selecting a time after the menstrual period,
assisted by Dr. Meadows, I cut down upon the ovary, and came upon it and a rather
dilated Fallopian tube. I removed the ovary and left the Fallopian tube, passing a
hare-lip pin through the edges of the wound, and transfixed the tube so as to close its
orifice and fasten it in the wound. The patient recovered without a bad symptom.
The ovary presented numerous irregular spaces, varying in size from a pin's head to one
fourth or one half an inch in length, all filled with the same kind of serous fluid as
flowed from the pedicle.
“ A very instructive case has been reported by Dr. Leopold.* The subject was
twenty-eight years old. Menstrual molimina set in at fourteen, marked by pain, but no
menstrual discharge. The pain was centered in the left groin, and from the first day of
the molimen a mass there, the size of a plum, swelled and became very painful; on
the decline of the molimen it shrank to its ordinary size. She married at twenty. A
year later she came under treatment. The vagina was dilated by incisions and lami-
a
* Archiv. für Gynäkologie, 1879.

HERNIA OF THE OVARY.
177
naria tents, but it does not appear that the uterus was reached. A menstrual molimen
was now observed. The face became congested, and epistaxis set in. Then followed
a rigor, convulsions of the extremities, and lastly, for some minutes, a tetanoid spasm.
Then sweating came on, affecting the left arm and hand, the right side remaining per-
fectly dry. The mucous membranes vividly injected. No fever. The slightest touch
on the tumor caused great pain. The woman's sufferings had become so intense that
she had several times attempted suicide. The tumor was removed. On dividing the
peritonæum, what had been assumed to be the ovary was found to be the fundus of the
small uterus. From its outer pole arose the Fallopian tube, and from the inner pole
the cord which had been felt before the operation proved to be the round ligament.
The ovary and tube were first cut away, a ligature having been applied between them
and the uterus. It then being found that the uterus was two-horned, the left horn was
also cut off beyond a ligature. Recovery seemed complete. Examination proved that
normal development of ova and their extrusion may take place with a rudimentary and
closed uterus and defective vagina, and without the smallest blood-effusion in the uter-
ine cavity.
Boinet reported in 1858 the following case : The subject a child aged three. She
had a tumor in each groin, detected six months previous. The right tumor was as
large as a pigeon's egg. Both were solid. The left was reducible. At the autopsy it
was ascertained that both iliac fossæ were filled by enormous tumors which touched at
the median line. These tumors were the hypertrophied and degenerated ovaries.' A
portion projected into the inguinal canal. There was no uterus. The vagina was a
small cul-de-sac.
“ Scanzoni relates a remarkable case of uterine inguinal hernia, gestation super-
vening. The subject first menstruated at twenty-one. She was delivered of a child
when twenty-eight. Four weeks later, lifting a heavy wine-butt, she fell, and a hernia
the size of a walnut appeared in the left groin, which could not be reduced. It swelled
perceptibly at the menstrual period, but did not trouble her much at other times.
Four years later she had typhoid fever, during which profuse hæmorrhage ensued, and
it was surmised that the uterus had entered the hernial sac. She conceived a second
time, and aborted. Eight and a half months after, she conceived again.
She was
now thirty-nine years old, of strong, healthy frame. The tumor got as big as a man's
head, and covered the pubes. The foetal heart was not heard in it, but the uterine
souffle was. Pains set in, and retention of the urine. A catheter was passed into the
26

178
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
uterus and three ounces of tepid water injected. A dead foetus and the placenta were
expelled. Next day, after-pains were felt in the tumor. The tumor shrank, became
less painful, and she made a good recovery.
Englisch relates two cases of his own, and tabulates thirty-eight cases :
“ E. S., single, a school-teacher, aged forty-one, admitted to St. George's Hospital,
under Dr. Barnes, March 31, 1877. She had always enjoyed good health. Catamenia
punctual, not subject to leucorrhoea. She sustained a rupture in the left groin at
twenty-four, and has since been obliged to wear a truss. About three years ago she first
observed a second swelling a little below the old rupture. She had sustained no blow
or strain. This mass, she asserts, becomes almost twice its usual size at menstruation,
and is tender and painful. The mass, examined a week after the cessation of menstrua-
tion, is rather larger than a pigeon's egg. It occupies the upper half of the left labium
majorus, and lies obliquely from right to left. It is compressible and movable to a
slight extent. Manipulation causes very little pain. Its surface is smooth. Its length
is an inch and a half; breadth, one inch and an eighth. It is evidently quite distinct
from the inguinal hernia when the latter protrudes. The external abdominal ring is
unusually large.
“ As the periodical distress seriously interfered with the patient's occupation, and her
condition was not free from danger, it was determined, on consultation, to remove the
This was done by Mr. Pollock, on the 7th of June. The tumor was adherent
to the surrounding tissues, and had to be dissected out. There was no evidence of
any peritoneal connection, nor was any trace of a Fallopian tube seen. The patient
left the hospital at the end of June, quite well.”
Subsequent histological examination clearly demonstrated that the tumor was
ovarian. Dr. Barnes quotes the following case reported by Dr. Chambers to the Lon-
don Obstetrical Society in 1880, showing that a double hernia of the ovaries may be
present in the so-called hermaphrodite, thus simulating testicles :
“A woman, so reputed, aged twenty-four, had observed swellings in the groins as
long as she could remember. She had never menstruated or experienced menstrual
molimina. There was a short conical vagina, at the top of which was the opening of
the urethra. No uterus could be found. The herniated bodies were removed, and
were pronounced by Drs. Golobin and J. Williams to be imperfectly developed tes-
ticles. Sections showed the small tubules characteristic of these structures.”
It will be noted that there are several varieties of hernia where the ovary makes up
tumor.

HERNIA OF THE OVARY.
179
a part of the contents of the sac. It may escape from the abdominal cavity by the
umbilicus, by the inguinal ring, by the femoral canal, or through the ischiatic foramen.
Inguinal are obviously the most frequent, since the ovary would be more likely to fol-
low the opening which might exist for the passage of the round ligament.
Of Dr. Englisch's thirty-eight cases, twenty-seven were inguinal, nine femoral, one
right obturator foramen, and one ischiatic.
Dr. Byford, of Chicago, reported a case of complete hernia of the left ovary. He
removed it, and cure resulted. A very few cases are on record where the Fallopian
tube and uterus together with the ovary were found in the hernial sac.
Schmidt * wrote that inguinal ovarian herniæ are mostly congenital, and that when
congenital consist of both ovary and tube, but the acquired hernia contains the ovary
only. The broad ligament is generally dragged outward and the uterus is drawn near
the hernial ring, and therefore the hernia is irreducible. In acquired hernia the broad
ligament is greatly elongated. In one of Mr. Hawkins's cases the Fallopian tube
and uterus were drawn out to form a canal fourteen inches long.
A case of strangulated right ovary having passed through the femoral canal was
recorded by Mr. Owen in the British Medical Journal in 1873. Mr. A. E. Maglard,+ of
Glasgow, reported a case of strangulated hernia of the left ovary in the femoral canal.
Patient, aged seventy-five, first felt a small lump in the left groin three years ago. The
chief discomfort was the constant desire to micturate, which disappeared upon lying
down, and in this position she was enabled to return the tumor. Evidence of strangu-
lation occurred; the swelling was tender, and the tumor solid, about half the size of an
egg. Skin red; temperature 100°; pain pronounced. Adherent sac was peeled off, the
tumor isolated, the ligature placed about its neck and removed. Recovery satisfactory.
Microscopic examination showed it to be an ovary; in one part there was a cyst large
enough to hold a hazel-nut. Within it was a mass of soft, fat-like material, mixed with
blood. The most prominent symptom of the case was the difficulty of micturition,
always associated with descent of the ovary.
As an illustration of the conditions which may sometimes be found, I append the fol-
lowing case reported by Prof. Rizzoli, $ where not alone the ovary but a greatly dis-
tended and deformed Fallopian tube made up the contents of the hernial sac : “I
a
I
* Billroth, Handbuch der Allgem. u. Spec. Chirurgie, 1865.
+ British Medical Journal, April 9, 1892.
| Mémoires de Chirurgie et d'Obstetrique. Prof. F. Rizzoli, Paris, 1872. Translated by R. Andreini, M. D.

180
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
have already stated that to the varieties of congenital inguinal hernia that we meet
with in the male we must add a peculiar variety in the female, congenital hernia
inclosing the ovary and corresponding Fallopian tube. The 12th of May, 1844, we
received into the hospital of Ricovero, a female, forty-six years of age, who had
symptoms of a strangulated inguinal hernia. She said that her mother had told her
that at her birth she had noticed in the left inguinal region a small tumor of the
form and size of an infant's testicle. Because of this she was doubtful of her sex,
until a physician, having found the external genital parts perfectly formed, assured
her that she was a female. At the age of puberty the swelling increased and the
menses presented nothing remarkable. After marriage she was delivered of two girls.
She was twenty-two years old at the birth of her first child, and twenty-four when
the second was born. At the time of her last delivery she felt a violent pain in the
left groin, and shortly after the tumor increased in size, presenting all the symptoms
of a strangulated hernia. An attempt was made to reduce the hernia, but failed. Then
various bandages were tried, but the intestine came down again, and there was devel-
oped a labial inguinal hernia. At her entrance to the hospital the symptoms were
such that we thought the intestine had become gangrenous. Herniotomy was imme-
diately performed. When
the sac was opened, I found
a large loop of strangulated
ileum. Upon the reduction
of the intestine, a second
viscera presented having the
form and dimensions of a
new intestinal loop, b (Fig.
15).
FIG. 15.— Anterior view of the preparation of an inguinal-labiale hernia,
“I at once recognized the
including the ovary and horn on the left side. a. Left ovarian hernia.
tube.
Large ligament adherent to the inguinal canal. d. Right
It was enormously
e. Large ligament. f. Round ligament. g. Uterus. h. Uterine dilated, and adherent to the
neck. j. External orifice of the uterus. k. Vagina.
ovary (a) and to the inter-
nal wall of the inguinal canal. The serious lesion of the intestine caused me little
hope of success in the operation, although I had had already cases of strangulated
intestine which, although threatened with gangrene, had returned to their normal
condition after operation. I did not desire to cut away the ovary, as a few surgeons
a
b. Horn.
ovary

HERNIA OF THE OVARY.
181
advise, so I decided to cut the adhesions which united the peritoneum and the horn
of the ovary to the neighboring parts and return all into the abdomen. Notwith-
standing all our care, success did not crown our efforts. She died six days later.
“ The autopsy showed that the cause of death was the sloughing of the strangu-
lated intestinal loop which had been reduced. It showed also that the ovary (a)
contained in the hernia was greater than that of the opposite side (d), and that the
tube, enormously large, resembling a loop of intestine, had thickened walls and con-
tained a body that Prof. Alessandra believed to be a pathological ovum. The large
ligament which we had cut in order to reduce the ovary and tube, and the peritonæum
itself, had no trace of inflammation.”
Dr. G. Pacinotti reported the following interesting case of acquired femoral hernia
of the ovary, its removal followed by cure :
L. S., a housewife, forty years of age, and married, had always been well, except an
intestinal crural hernia, which some five years before became incarcerated and was suc-
cessfully operated on. She returned home, wearing as a precaution a truss. A year
after the operation she noticed that another hernia had formed in the opposite groin.
Although this was quite troublesome, she did not consult a physician. One day, after
a violent sneeze, the tumor suddenly increased in size, became more consistent and
painful on pressure, while she found that she could not reduce it, as she did before,
Still, she had no symptoms of incarceration, as she had had with the hernia of the other
side. The tumor increased in size and became more painful during the menstrual
periods. Finally, the hernia becoming more troublesome, she only obtaining relief dur-
ing menstruation by lying on her back with her thigh flexed upon the pelvis, she en-
tered the hospital. On examination, a swelling of the size of a pigeon's egg was dis-
covered in the middle of the base of Scarpa's triangle. It was covered with normal
integument, gave on pressure a feeling of unequal consistency ; above, it seemed
pediculated, was resistent and painful on pressure. The pain did not radiate to the
abdomen, but rather to the uterine region. The uterus was found in anteversion, and
drawn toward the side on which the hernia was situated. There were no enlarged
glands to be discovered. A longitudinal incision was made through the hernial sac, and
the ovary was discovered as a hard and fibrously degenerated body, occluding the open-
ing of the sac. Several small cysts of the fimbriæ of the Fallopian tube were removed,
the adhesions of the Fallopian tube broken up, and the ovary returned entire into the
pelvic cavity. The hernial sac was then removed entire, and the neck of the sac stitched

182
ANATOMY AND SURGICAL TREATMENT OF HERNIA,
as high up as possible. Four sutures were placed through the crural ring, and the skin
sutured over the whole with silk. Union took place by first intention.*
The herniated ovary presents a small ovoid tumor, circumscribed, resisting, without
change of color of skin, and always more or less painful; its size rarely exceeds that
of a walnut. The pain is increased by pressure, and extends in the direction of the
broad ligament toward the uterus. The uterus itself is often deflected, so that its
fundus is included toward the opening from which the ovary escapes. If the patient
stands up, or lies on the opposite side, the pain is increased, and is attended by a
sense of dragging. This variety of hernia is attended neither by vomiting, colic, nor
constipation, and does not by itself return into the abdomen.
The ovary, when within the sac, may become inflamed, contract adhesions, and be
shut off from the abdominal cavity. It may also undergo a considerable variety of
pathological changes. Cases of cystic degeneration have been reported, sarcoma, etc.
The surgical treatment of hernia of the ovary is generally indicated. Dr. Barnes
advises this : “ Even if it should appear that the hernia is reducible, it will generally be
preferable to remove it than to return it within the abdomen.” When the ovary has
escaped through the ring it is always painful. A truss can not be borne, and if re-
turned within the abdomen it is retained with great difficulty. When not strangulated,
the pain is often so severe as to make its removal necessary. No special direction is
indicated as to the surgical procedures to be undertaken for the cure of hernia of the
ovary.
* La Sperimentale, No. II, 1890. Dr. G. Pacinotti, Camerino, Italy.

CHAPTER XVII.
HERNIA OF THE BLADDER.
The older writers described under this name the varieties of cystocele in woman
dependent upon the loss of, or relaxation of the perineal floor, usually incident to, or
following the injuries attendant upon delivery. As defined at present, these seriously
disabling conditions do not properly come under the term hernia, and their discussion
is foreign to the purposes of this work.
Portions of the bladder may become displaced through the openings of the abdomi-
nal wall forming part of a ventral hernia, resulting from injury or an imperfectly closed
wound after a laparotomy; or they may escape through the femoral ring, or an opening
in the pelvic floor; but much more frequently it occurs as a part of the contents of an
old, direct, inguinal hernia. Hernia of the bladder must necessarily be rare, since the
anatomical disposition of the parts is such that, in the normal condition, the fundus of
this organ rises above the brim of the pelvis only when the cavity is distended; and
it is generally true that, when the very rare condition of hernia of the bladder is
met with, it is owing to adhesions to other organs which have become displaced, and
thus this viscus is dragged down into an abnormal situation. Under conditions of
this character the bladder has been found to form a part of a large scrotal tumor, the
emptying of which could only be effected by lifting the mass above the level of the
brim of the pelvis. In large, old herniæ the elongation of the peritoneal sac gradually
draws into the ring that portion of the peritonæum which is attached to the bladder,
and the bladder itself becomes little by little involved in the protruding mass. When
only the anterior part of the bladder is involved, it will have developed without a true
peritoneal covering, since that portion alone is included beneath the reflection of the
peritonæum. An illustration of this condition is found in the appended case reported
by Mr. Percival Pott, which is of sufficient interest and value to be quoted entire :
“A poor fellow who worked with a farmer at Islington came to St. Bartholomew's,
with a troublesome swelling in his scrotum. The tumor was large, tense, of a pyri-
form figure, palpable, contained a fluid, gave no pain but from its weight when full,
(183)

184
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
and had every mark of a hydrocele, except that the testicle was perfectly distinguish-
able at its bottom. While I was hesitating concerning this circumstance, the man said,
Sir, I can get rid of it all by urinating, but it fills again in a few hours, especially if I
drink.' Upon my seeming to disbelieve what he said, he took up his scrotum, and,
squeezing it together with some violence, discharged the whole by the urethra."
“A boy, about six years old, was seized with an acute pain about the region of the
pubes; it lasted nearly an hour and a half, and suddenly ceasing he became perfectly
easy. During the time the pain lasted he could not discharge a drop of water, although
.
he endeavored to do so, but as it ceased he urinated freely. A few days later, a
tumor about the size of a pea was discovered in the spermatic process, just below the
groin. By slow degrees it descended lower and lower, and increased in size; when it
had got to the upper part of the scrotum the boy found himself more frequently urged
to make water, but without pain. Within the space of five years it got down to the
bottom of the scrotum, and then it increased much faster than before. At the age of
thirteen he was sent to London, as the swelling was now troublesome upon motion.
Some, who first saw him, deemed it a scirrhous testicle and advised castration, to which
the friends of the boy would not submit. From the most careful examination I could
make, I could not think it was formed of the testicle; but, on the other hand, I could
not find any testicle on that side. The swelling was perfectly equal in its surface, was
indolent, had a stony, incompressible kind of hardness, was troublesome from its weight,
but never occasioned pain in the back or loins; it had all the appearance of being
dependent from the spermatic process, which process had neither the feel nor the
appearance of being diseased. The trouble it now gave the boy, and its disposition to
increase, seemed to authorize its removal. I therefore proposed and undertook it. I
made an incision through the skin and cellular membrane the whole length of the process
and scrotum, by means of which I discovered a firm, white, membranous cyst, connected
loosely with the cellular membrane in the same manner as a hernial sac. I dissected
all the anterior part of this bag, quite clean, and found that, as I traced it upward, it
became narrower and seemed to proceed from the upper part of the groin. In clearing
it from its posterior connection I discovered a testicle, which lay immediately behind the
body forming the tumor, and was small, flat, and compressed. The dissection of this
and of the spermatic cord from the bag and from its neck gave me some trouble, but
when I had finished it I found that the cyst was dependent from and continuous with
a membranous duct about the breadth of the largest wheat-straw, or, what it was more
a

HERNIA OF THE BLADDER.
185
like to, a human ureter, which passed out from the abdomen through the opening in the
muscle. When I had cleared this duct from all connection with the spermatic cord, I
cut it off immediately above the tumor, and upon the division there issued forth about
four ounces of a clear liquor, and the mouth of the cyst, expanding itself, disclosed a
stone exactly resembling what is found in the human bladder.
“ As there was not the least evidence of fluid, either in the bag or in its neck, be-
fore the division, its immediate effusion, and the appearance of the stone, induced me to
believe that the case was a hernia cystica. In order to be certain, I stayed some time,
and when I thought a quantity of urine might have passed from the kidneys, I desired
the boy to try and make water; he did so, and a large stream of urine flowing through
the wound instead of through the urethra, put the matter out of all doubt. He was
dressed superficially, had no bad symptoms, though this portion of the bladder was
totally removed; his urine came through the wound in his groin for about a fortnight,
but as that wound healed it resumed its natural course, and the patient has remained
free from complaint ever since, except that, the natural size of the bladder being lessened
by the extirpation of a part, he is obliged to discharge his urine rather more frequently.”
Mr. Cooper * had met this rare condition only twice. In the case reported in
detail he was summoned because of a strangulated ventral hernia ; he discovered that
the patient, a man in advanced life, was the sufferer from vesical hernia.
Some years later he was enabled to make the autopsy. A large inguinal hernia
of the right side had descended into the scrotum so as to occupy its lower part.
The hernial sac was formed of peritonæum, as in the common inguinal variety. It
contained both omentum and intestine. Upon inflation, the bladder became nearly as
large as an ostrich's egg. The bladder was situated behind the peritoneal sac, to the
posterior part of which the anterior surface of the viscus closely adhered; posteriorly it
was connected by cellular membrane to the scrotum and to the tunica vaginalis of the
cord. On tracing it upward it was found to ascend through the external abdominal
ring into the inguinal canal, where it maintained the same relative situation to the cre-
master and spermatic vessels as in the scrotum ; it thence descended through the inter-
nal abdominal ring into the pelvis.
Scarpa t reported an interesting case in a female infant born with the external orifice
of the urethra closed by a membrane. An umbilical hernia formed, and afterward a
+ Wishart's edition, p. 385.
* Op. cit.
27

186
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
urinary fistula at the same place. The girl having reached the age of eighteen the
umbilicus protruded about four inches. An incision was made in the above-mentioned
membrane, which was of considerable thickness, and a canula introduced into the blad-
der by the urethra, by means of which the urine took its natural course. The fistula
closed, and the tumor at the umbilicus disappeared.
A number of cases are on record where a large portion of the bladder had de-
scended to the bottom of the scrotum. Mr. Lawrence notes a number of such in-
stances, with references to their publication. He also quotes, from Clement, † a case
where the history and the dissection are given of a patient whose entire bladder had
passed through the inguinal canal into the scrotum, where it had become enlarged by
distention so as to form a tumor of enormous magnitude. The patient, a very corpulent
man, about sixty years of age, had been troubled with a swelling for about twenty-five
years. It was small at first, and slowly increased to its immense size, having varied
but little during the greater part of the time above mentioned. The patient could not
pass urine without first raising the rupture toward the belly and then rolling it about
for a short time, when the urine would pass in a full stream, though he was unable to
make much at one time. He had been able to take considerable exercise, and was in
fairly good health, until within two weeks of death, which was the result of apoplexy.
The true nature of the hernial tumor does not seem to have been suspected during life.
The circumference of the swelling was twenty-nine inches; its length, fourteen inches
and three quarters. The whole penis was retracted within the integuments, and the
urine had been discharged through an opening resembling the navel. One of the tes-
ticles could be distinctly felt at the middle of the tumor, but the other was not discov-
erable before the parts were dissected. Although the rupture was so large as to extend
generally over the pubes and occupy both inguinal regions, the protruded parts
came through the left abdominal ring. When the inguinal canal had been exposed
and opened, a portion of the colon was seen traversing it, distended with fæces,
but not inflamed or compressed, as the entire hand could be passed through the
opening
The tumor was found to consist of a sac resembling an enormous hydrocele, from
which two quarts of fetid urine escaped by the rupture of a part which had become red
a
* Lawrence. On Ruptures, p. 455.
+ Observations in Surgery and Pathology, pp. 144, 145.

HERNIA OF THE BLADDER.
187
and pointed before death. It was now ascertained that this sac was the urinary bladder,
which had passed through the abdominal ring.
The following interesting case has been furnished me recently by Dr. Horace E.
Marion, of Boston:
J. E. Daged seventy, came under my care suffering from what he called “rheu-
matism in the hip.” A careful examination convinced me that he was suffering from
malignant disease of the liver. For nearly a year he had had much trouble in uri-
nating. He had an enormous scrotal hernia. Of late, when he desired to micturate,
he was obliged, using his own words, “to pump it out." This he did by grasping
the scrotal tumor and compressing it. He could then eject a stream from an almost
.
hidden penis. This he would do as one would press the bulb of a syringe, until
the bladder was evacuated. On passing the catheter I could detect its course down
into the scrotal tumor, and on withdrawing the urine the tumor almost dis-
appeared.
An autopsy by Dr. W. F. Whitney showed not only malignant disease of the
liver but also of the prostate gland, with secondary deposit extending out toward
the iliac fossa. It was also easy to demonstrate the bladder in the scrotum, adhesions
first having been established. The prolonged and violent straining on account of dis-
eased prostate had evidently given rise to this very unusual condition of hernia of
the urinary bladder.
Mr. Arthur T. Norton, of St. Mary's Hospital, furnishes an interesting article
upon the radical cure of irreducible hernia, in which he reports a case of irreducible
inguinal hernia which contained large and small intestine and bladder. The scrotal
tumor measured ten inches in length and nine in breadth. The patient could not
pass his urine without a catheter, and stated that he had had considerable diffi-
culty for some years in emptying the bladder, and in order to do so, he had been
obliged to lift the scrotal tumor. The sac was greatly thickened, and contained a
considerable quantity of omentum, the cæcum with the vermiform appendix, ascend-
ing colon, small intestine, and the bladder. The intestines were everywhere adherent
to the sac, and the adhesions were separated with difficulty. After these were freed
it was discovered that the bladder was likewise fixed in the sac, and this, having been
separated, was returned first into the abdomen. The intestine was replaced, the
omentum ligatured and cut away, the sac dissected, ligatured at the internal ring,
and removed, the operation lasting nearly two hours. The patient recovered with a

188
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
suppurating wound, although the operation was performed under antiseptic precau-
tions. He was discharged in about six weeks, cured.*
When vesical hernia is uncomplicated, its diagnosis is not especially difficult, but
this rarely occurs unless from congenital defect, and, as in the last case reported, it
is more commonly met with as a complication in an old, large, irreducible hernia.
Further complications may supervene, decomposition of urine taking place, the
formation of calculi, endangering life and demanding surgical interference. This latter
procedure would not be difficult if undertaken under more favorable conditions, when
this viscus could be easily returned into the abdominal cavity; pathological changes
in the organ being so little marked that its restoration to normal conditions would
be probable. Even when the pathological changes are pronounced, operative meas-
ures are advised for the cure of this distressing condition. The bladder must be
carefully freed from its attachments and restored to its normal position. The exist-
ing complications are to be dealt with as their conditions demand; the peritoneal
pouch, if existing, must be removed, and the abdominal opening closed. A catheter
should be retained for a considerable period, with frequent irrigation of the bladder,
until the walls of the organ have had sufficient time to become, at least in a meas-
ure, restored to their normal anatomical and physiological condition.
The recent literature upon the subject of vesical hernia is comparatively meager;
and since, when met with, it is usually a complication dependent upon long pre-
existing hernial displacement of other organs, the radical treatment for the cure of
hernia which is now so very generally practiced will render this distressing malady
less frequently met with in the future than in the past.
A few cases of perineal hernia are on record. This variety is certainly very rare,
and yet more rarely recognized before death. Scarpa reported at length a case oc-
curring under his own observation where, some years later, he made a post-mortem
examination. The man attributed the cause of his hernia to a violent exertion with
the legs apart and the body bent forward, when a tumor suddenly formed at the
right side of the anus as large as a small nut, which receded on pressure. In one
instance the intestinal contents became strangulated, but were reduced. The ileum
passed into a hernial sac, of which the orifice, nearly an inch in diameter and round,
was situated at the right side of the rectum and bladder, and it was protruded in
* The Medical Press and Circular, November 18, 1891.


PLATE XLVII.
Fig.3.
Fig.2.
Fig./.
1.
b
Fig.4.
Fig.6.
di
Fig. 5.
Fig. 7.

HERNIA OF THE BLADDER.
189
the interval between the right side of the anus, the tuberosity of the ischium, and
the point of the coccyx.
Scarpa devised a truss which this patient wore, and by which he kept the hernia
reduced. It consisted of an oval pad attached to a circular steel spring surrounding
the pelvis. Several cases of perineal hernia are on record as the result of injury.
PLATE XLVII *
Figure 1.
b, b, b. Oblique inguinal hernial sac cut open
Represents a peculiar variety of internal her- to show the bladder.
nia, formed by a fold of peritonæum that in- c. Tumor, formed by the bladder, covered
cludes the remains of the umbilical artery. The
The only on the fore part by peritoneum.
case occurred in the practice of Mr. Ring.
d, d. Represents an outline of the bladder
a. Pouch formed by the peritonæum.
within the abdominal cavity.
b, b. Remains of the umbilical artery inclosed e. Testis.
in the fold of peritonæum.
Figure 6.
Figure 2.
Shows Fig. 5 more completely dissected.
Represents a steatomatous tumor in the situa-
a. Neck of the hernial or peritoneal sac.
tion of inguinal hernia in the female.
6,6. Hernial sac cut open, as in Fig. 5.
a. Site of the external abdominal ring.
c. Aperture of communication between the
b. Fatty tumor proceeding from the inguinal protruded portion of the bladder and that within
canal and forming a tumor over the pubes some-
the abdomen; the bladder being in this view cut
what resembling inguinal hernia.
open.
c. Femoral vessels.
d. Interior of the bladder exposed.
e. Epigastric artery, taking the same course
Figure 3.
as in oblique inguinal hernia of the common kind.
Is a drawing of a steatomatous tumor upon f. Abdominal muscles
the spermatic cord.
a. The tumor, consisting of lobes, which give
Figure 7.
it the character of omentum.
An outline, explaining the descent of the
b. Spermatic cord.
bladder into the scrotum, and the manner in
C. Testis.
which a vesical hernia receives only a partial cov-
Figure 4.
ering of peritonæum. The outer reflected line
Shows a stricture at the inner ring, formed by represents the peritoneum descending through
the abdominal ring, and giving a partial covering
a band given off by the fascia transversalis.
to the fore part of the bladder. The inner line
Figure 5
represents the bladder protruding through the
Is a drawing of a vesical hernia.
abdominal ring; showing that the lower and back
a. Shows the situation of the external abdomi- part of the viscus has no peritoneal covering.
nal ring.
* Cooper, Plate XIII, Part I.

CHAPTER XVIII.
UMBILICAL HERNIA.
This variety of hernia might have been placed in order after inguinal, since it
is of such frequent occurrence. I have, however, thought best to discuss the herniæ
of the pelvic region as a group.
The connective tissue which closes the umbilical opening is much thinner than
the surrounding parts, and the peritonæum is very much more closely adherent than
at any other portion of the linea alba.
The umbilical opening through the tendon is not larger than a quill, and is
formed, like the apertures we have already considered, for the escape of the vessels.
It will be remembered, however, that these vessels are extra-peritoneal in their de-
velopment and course. The umbilical arteries arise from the internal iliac arteries
by the side of the bladder, and are continued to the navel, between the peritonæum
and muscles. The umbilical vein after entering the ring is continued between the
peritonæum and muscles; this forms the round ligament of the liver. Thus we ob-
serve the peritoneum, in normal development, is never absent beneath the umbilical
site.
Umbilical hernia is often seen in infancy and childhood, but is usually small and
easily controlled; it frequently protrudes in a pointed, dependent tumor, generally
contains intestine, is easily returned, but usually sensitive upon pressure. Derange-
ment of the digestion is frequently caused by it. In adults the tumor is in consid-
erable variety of shape and appearance. This is dependent less upon the size of the
opening than upon the resistance offered to its extension. In thin persons it be-
comes pendulous, circumscribed, and often pyriform in shape. In fat people it often
extends upward as much as in other directions, is sometimes flattened, and quite con-
cealed by the thick abdominal wall.
While, in children, the contents of an umbilical hernia escape through the um-
bilical ring, in adults it is rare. M. Petit met it only twice in a large number of
cases, and he believed that the viscera almost always pass through an opening sit-
(190)

UMBILICAL HERNIA.
191
uated either below, above, or in the adjoining parts, which aperture is produced by
the separation of the fibers of the linea alba. M. Boyer * gave the following reasons
for this: “The umbilical ring is obliterated after birth, and forms a cicatrix as much
more firm as the subject is advanced in age. The surrounding parts are much weaker,
and consequently resist less well the viscera if any pressure is brought to bear upon
them. Thus, when a distending force acts upon the umbilical region, the aponeurotic
fibers separate, and form a rent through which the viscera escape. In adults the
resistance of the ring is so great, as compared with that of the linea alba, that if the
contents escape through the ring it is probably due to some congenital weakness.
Umbilical hernia in adults is usually made up of the epiploon, rarely of intestine
only, frequently of both. Congenital umbilical hernia is so called because it is formed
while the foetus is yet within the uterus, and may commence at any time during
pregnancy.”
He classified umbilical hernia as congenital and acquired, the latter showing itself
soon after the sloughing off of the umbilical cord. The parts which form this hernia
escape from the abdomen through the umbilical ring by pushing before them the
peritonæum which forms the sac. Some have doubted the existence of a sac, but
if one dissects carefully an umbilical hernia he will find a sac, whatever the size or
age of the tumor. It is true that this sac is thin, and so closely united to the skin,
especially in the place corresponding to the top of the tumor, that it must be sought
for with great care. The neck of the sac is always very short, round, and forms
a sort of ring. The envelopes of the hernia consist of skin, a layer of cellular tissue,
and the sac. Boyer reported the following case: “A woman, aged sixty, had been
afflicted with an umbilical hernia twenty years. The skin which covered the tumor
had become so thinned that the intestinal folds were perceptible whenever distended
with gas. In lifting a basket, the skin was torn to the extent of six or eight lines,
and the intestine escaped. Five hours after the accident I was called, and I found
that an intestinal loop, ten inches in length, distended with gas and almost violet-red
in color, had escaped through the rent. The pulse was weak, and the countenance
visibly changed. It was impossible to return the intestine without enlarging the
opening. I had made only a very small incision, when so large a quantity of intestine
escaped that it was with great difficulty returned, and I was obliged to suture the
* Treatise upon Surgical Diseases.
M. Le Baron Boyer, 1834.

192
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
skin in order to retain it. The patient grew worse, and died at the expiration of
twenty hours.”
The coverings of the sac are usually intimately blended, and often distended so
as to be extremely thin. Then nothing of anatomical factorage can be determined,
and even the peritoneum which always lines the sac can scarcely be differentiated.
The sac in rare instances may be double. The contents of the sac may be intesti-
nal, omental, or both-in large herniæ usually intestine and omentum. The contents
can be generally distinguished without difficulty.
Women are much more often the subjects of umbilical hernia than men. This
is dependent in large measure upon child-bearing, the distention of the abdomen by
the gravid uterus, pains of parturition, ovarian tumors, etc.
Women who are espe-
cially corpulent are more liable to large umbilical hernia than any other class. In
these instances the omentum has generally become thick and heavy from a deposi-
tion of fat.
PLATE XLVIII.*
Shows three umbilical herniæ, one of which is curious on account of two small omental herniæ
being formed through orifices in the hernial sac. Figs. 7 and 8 show two views of a ventral hernia.
.
Figs. 2 and 3 were drawn by Mr. Cliff.
e. Fascia over the sac.
f. Hernial sac. The fascia, sac, and integu-
ments adhering together at the umbilicus.
g. Opening of the sac.
h. Omentum descending to the sac.
i. Omentum adhering within the sac.
Figure 1.
The common appearance of umbilical hernia.
a, a, a. Integuments.
b, b. Abdominal muscles.
C, C, C. Peritonæum lining the abdominal mus-
cles.
d. Mouth of the hernial sac.
e, e. Hernial sac.
f, f. Termination of the linea alba around
the mouth of the sac; also seen below at b.
g. Fascia lining the integuments and cover-
ing the sac.
In this preparation some omentum adhered
within the sac, which was not included in the
drawing.
Figure 2.
Umbilical hernia in a very fat
person.
a, a. The common integuments.
b. The umbilicus.
C, C. Adeps between the integuments and ab-
dominal muscles.
Figure 3.
Umbilical hernia.
a, a. Integuments of the abdomen.
b, b. Integuments on the sac.
C, C, C, C. Cicatrices from ulcers on the integu-
ments.
d, d. Hernial sac.
e, e, e. Omentum within the sac, but a part of
the sac absorbed so that it adheres to the skin
from I almost to k.
f, f. Intestine ruptured by a fall. (See
case.)
g. An omental hernia.
h. A smaller omental hernia.
*
Cooper, Plate IX, Part II.

PLATE XLVIII.
Fig. 3
Fig. 1.
a
a
с
ba
f a
g
d.
Z
с
Z
a
d
----
е
g
C
b a
Fig. 2.
6
h
7
e
с
kh
h
a
e
Fig. 7
Fig. 8
B
f
9
3
с
с
a
6
ď
d
e
a
a
8.


UMBILICAL HERNIA.
193
i. The hole in the sac through which the
larger passed.
k. The hole in the sac through which passed
the smaller.
1. Two other holes in the hernial sac.
C. Hernia.
d. Fascia turned from the sac.
e, Hernial sac.
Figure 7.
Anterior view of the ventral hernia.
a, a, a. Integuments.
b, b. Tendon of the external oblique, and rec-
tus muscle behind it.
Figure 8.
Posterior view of Fig. 7.
a, a. Peritoneum lining the abdominal mus-
cles.
b. The mouth of the hernial sac.
c. The umbilical vein within the sac.
Umbilical hernia is without question more commonly met with in the earlier
months of infantile life, owing to an arrest of the processes of closure about the cord,
which usually takes place prior to birth. I have myself seen one or two cases where
I
I felt the hernia was clearly attributable to an accidental pulling upon the cord at
the time of delivery before its division.
This considerable class of little sufferers are invariably troublesome patients for
treatment, since it is with the greatest difficulty that mechanical means can be ap-
plied to prevent the escape of the abdominal contents, and the colicky pains to which
they are subject are greatly increased by crying. This is, however, not usually a dan-
gerous form of suffering, and a spontaneous cure is generally effected in early life.
It is the better plan carefully to adjust a compress of some sort over the opening,
and teach the mother the means of its retention. This is the method that naturally
occurs even to the most superficial observer. It is advocated in the works of Celsus
and Scultetus, and the plate of lead now in common use, covered with linen or
leather, was recommended by Heister.
Children are sometimes born with a deficiency of the structures about the um-
bilicus. At one side of the cord there may be seen a considerable protrusion, with
only the peritoneal covering, through which the intestines may be observed. Rarely,
even this may be wanting. An illustrative case has been furnished me by Dr. Will-
iam Hogue, of Charleston, W. Va. The boy was born with non-closure of the abdomi-
nal wall. The intestines passed through the opening and extended as far as the pubes.
The opening was about two inches in diameter. The child was otherwise well devel-
oped. The bowels were replaced, leaving the funis out, and the abdominal walls were
drawn together with adhesive plaster. The opening was permanently closed in about
six weeks.
I quote the following case because of its peculiar conditions: “A male child,
28

194
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
seen.
weight ten pounds, was delivered on January 9, 1892.* There was an entire arrest of
development in the skin and muscles of the umbilical region of the abdomen, the
edges of the skin forming a perfect circumference
of a circle whose radii were two inches, and ad-
herent by a rounded edge to the peritonæum and
reflected covering of the cord, which was spread
over the whole mass adherent to the mural perito-
næum. The umbilical cord passed out from the
lower edge of the hernia, and one and a half inch
from the pubis. The color of the mass at birth
was a dark bluish-black, and the coverings so thin
that the movements of the viscera within could be
Realizing that I had a desperate condition
of affairs to deal with, and being undecided just
then what to do, I covered the whole mass with
dry bichloride gauze, bandaged firmly with a flannel
Fig. 16.—Etching from photograph of Dr.
Hogue's case. Well, strong boy of roller an inch and a half wide, and had the child
four years. Slight bulging of the ab-
dominal wall about umbilicus, but dressed, giving directions to handle carefully and
causes no suffering.
prevent crying as much as possible. The same day
I began to hunt up authorities upon umbilical hernia, and failed absolutely to
find in any work on surgery at my command any report upon, or instructions
for, dealing with such a case. Wyeth, Ashhurst, Erichsen, Reference Hand-book,
etc., were searched, but in vain. In Gross's Surgery, vol. ii, p. 712, issue of 1859, is
a very accurate description of the condition, and the only thing of the kind I
could find. He says: “When umbilical hernia is large, death usually takes place
in a few days after birth from the effects, apparently, of peritoneal irritation. If the
child survive, an attempt may be made,' etc. Seeing no possible chance for this child
to survive, with the large area of peritonæum to be exposed when the cord covering
should slough off, I decided that there was nothing to do but to attempt an operation.
Accordingly, on Monday, January 11, 1892, and fifty-three hours after birth, the opera-
tion was made. With the assistance of Dr. James C. Bloomfield and Dr. John Ger-
:
* Medical Record, March 5, 1892. An Enormous Congenital Umbilical Hernia without Cutaneous Covering-
Operation-Recovery. Samuel C. Benedict, M. D.

UMBILICAL HERNIA.
195
dine, the latter giving the anæsthetic, I began by attempting to dissect up the now
dead and yellowish-white membrane covering the peritonæum. This was the most
difficult part of the whole work, as it was firmly adherent to the external surface of
the mural peritonæum, and the dissection had to be carefully done in order to avoid
tearing or cutting the peritonæum, which was as thin as a cobweb and tore
upon
the
slightest tension, exposing more than once the cavity. After dissecting off, as best
I could, to the skin circumference, I divided, close down to the lower portion of the
wound, the umbilical cord and vessels, now a dried and shriveled mass and giving
no blood upon section. It had been hoped that I could pare the rounded edges of
the skin, and, by tension upon it, invaginate the peritonæum and so approximate the
edges in a perpendicular line. This was found impossible, as, besides the firm union of
the skin, to the peritonæum, the liver and spleen occupied a large portion of the her-
nia, the intestines being at the lower portion only. I then penetrated the skin circum-
ference with a pair of fine-pointed conjunctival scissors, curved on the flat, and cut the
skin closely to the peritonæum all the way round, leaving a ring of skin an eighth of
an inch wide, approximately, still adherent to the peritonæum. The skin was then dis-
sected up for two or three inches to the sides before sufficient was obtained to approx-
imate, and even then with difficulty, by reason of the great intra-abdominal pressure.
“ The approximation was made upon the subcutaneous surface rather than upon
edge of skin, in order to get a broader contact. This was held together by three
silver pins, an inch long, wound with silk in the figure-of-8 way, and intermediate
apposition obtained by black silk interrupted sutures. The line of approximation
was about four inches long, and perpendicular, and this was first dusted with iodo-
form, strengthened by adhesive plaster, covered by narrow strips of rubber tissue,
bichloride gauže, cotton, and a firm flannel bandage. Bichloride solution was used
for personal cleanliness, carbolic acid for instruments, and boiled sodium-chloride
solution for wound surfaces.
“ The operation lasted fifty minutes, the child, two days' old, taking only half an
ounce of chloroform and rallying promptly and in good condition. Directions were
given for one drop of paregoric every hour or two, if necessary to quiet the child,
and we left, satisfied that peritonitis would develop within forty-eight hours. We
were agreeably disappointed. There was never any elevation of temperature or ab-
normal rapidity of heart's action, the child resting nicely with not over an average
of a drop of paregoric every four hours.

196
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
“ The wound was not examined until the third day, when it was found that the
skin had become adherent over the peritoneal surface and along the line of approxi-
mation, although there was considerable redness a half-inch or more outside of this
line, this gradually subsiding. Upon the fifth day it was found that the tension had
loosened the silver pins, so that they, with the sutures, were removed and their place
supplied by adhesive strips. On the tenth day I found a separation of the edges
about an inch in length, and exposing a granular space of peritonæum one quarter
of an inch wide at the widest part. This was drawn together by strapping, and a
rubber plaster band, three inches wide, passed around the body, and laced over the
gauze covering the wound, answering the purpose of resisting the great intra-abdomi-
nal pressure so well that to-day (January 30th) there is a complete union everywhere.
The child has never acted other than any child of its age, has nursed regularly and
with avidity, bowels and bladder acting normally. Paregoric has been used occa-
sionally, chiefly at night, but never over six drops during the entire night, and the
child was always easily aroused from sleep. There is now nothing to show for the
hernia but the line of cicatrization, four inches long, which is a finer truss than any-
thing else could be.
"When the little fellow cries or strains there is a slight round bulging at the
umbilical opening, but not enough to give cause for further uneasiness, and this is
kept down by a silk elastic bandage. The case as it now stands is an unanswer-
able argument in favor of a strictly aseptic mode of procedure, by which a cure has
been made of a condition from arrest of development which I do not believe has
ever before been attempted with success following.”
In attempting the reduction of an umbilical hernia the recti muscles must be re-
laxed. A knowledge of the character, contents, shape, and tension of the tumor is
requisite for the proper manipulation in taxis. Often, grasping with the hand and
directly lifting it from the ring will materially aid in its reduction, at the same time
gently kneading the neck of the tumor with the other hand. Once reduced, it is impor-
tant to retain it with a truss. Instruments in some variety are to be found, but the
essential is compression over the opening. This is often made easily and effectually by
a firm bandage around the body, with a conical-shaped pad to fit the depression.
Umbilical hernia may become irreducible from the same causes which produce
irreducible hernia elsewhere. The most frequent is the adhesion of the omentum.
When irreducible, the tumor sometimes grows to an enormous size, disabling the

UMBILICAL HERNIA.
197
sufferer, if not endangering life. Ulceration of the integuments rarely occurs, but
when it takes place it greatly complicates the danger. Some years since I had under
observation a large hernia where the ulceration was so extensive as to lay bare to a
considerable distance both recti muscles. The abdomen was of very exceptional
weight, and cure was effected only by support and prolonged rest in the horizontal
position.
A large cup or basin-shaped pad may often be of value in supporting the tumor
produced by an irreducible umbilical hernia. A band carried over the shoulder can
be arranged to relieve in part the weight when a circular belt is insufficient.
Strangulated umbilical hernia is not infrequent. It may not be as urgent as in
inguinal or crural hernia, yet Sir Astley Cooper reported a case which proved fatal
within eighteen hours. The danger lies, of course, in the close constriction of the neck
of the sac.
Here the opening through the linea alba is a circumscribed ring, entirely
inelastic and firm, resisting the knife like cartilage. The intestine is often in a meas-
ure protected by a thick pad of omentum. In a case of a strangulated umbilical
hernia, where stercoraceous vomiting had continued for three days—a patient of Dr.
H. L. Chase, of Cambridge, March, 1881—I freed a loop of very dark-colored intestine,
slightly ulcerated at its mesenteric attachment, and returned it. It was surrounded by a
mass of necrosed omentum, double-fist size. This I sewed through beyond its constric-
tion, and excised. The entire sac was resected, and the wound closed with animal
sutures, followed by a rapid and permanent cure. The intestine undoubtedly escaped
necrosis because of its omental surrounding.
Even at so early a day as when Celsus wrote, efforts at cure of this form of hernia
were recognized as legitimate. After describing various other methods, he recommended
the following: “The patient is first to be laid upon his back, that the intestine, or
omentum, may be returned into the abdomen, and the umbilical perforation being
then empty, the slit is to be tied together from the bottom with a needle armed
with two threads, each of which are to be fastened with two knots on opposite sides
of the wound, by which means the parts above the ligature will be compressed with
it and fall off, and a firm cicatrix formed beneath.” Celsus also advised that it was
often wiser to open the sac before applying the ligature, in order to secure the safety
of the intestine and omentum, having returned the contents of the sac with the
finger before the introduction of the ligature. When this had been done, he recom-
mended the use of caustics, or the actual cautery, in order, as he thought, to secure
>

198
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
>
a stronger cicatrix-a method which we recognize to-day as of chief importance be-
cause of its antiseptic value.
Paulus Æginatus adopted the method as described by Celsus, and it was long
practiced by the Arabian surgeons. Avicenna, Albucasis, and Guy-de-Chauliac give
descriptions of this method in their respective works. Ambrose Paré advocated the
ligature without the opening of the sac, and stated that, when properly applied, it never
fails of a cure. Dessault was in the habit of operating by ligature without the open-
ing of the sac, the ligature at first rather loosely applied, and a day later the sac was
tightly constricted by a new one. Lawrence * refers to this operator as follows: “Des-
sault has performed the operation in a vast number of instances and with uniform suc-
cess. Children were brought to him every week at the public theatre where he lect-
ured, and had the ligature applied in the presence of the students; but they were then
taken home and brought back daily to be dressed, until the cure was complete.”
Mr. Lawrence admits that, in the great majority of cases, this method was fol-
lowed by cure in the hands of Dessault, but he thinks this great surgeon ascribed to
the ligature, “ a safety and certainty of cure which the experience of others has not con-
firmed, and that he has not fairly represented the advantages of compression."
Saviard is reported as having adopted this operation, cases of which he recorded
in the early part of the eighteenth century. Heister also recommended this method, of
which he gives a detailed account, using in strangulated cases what he called the latent
scalpel, invented by Le Dran. After the division had been made and the contents of
the sac returned, he closed the ring by a knotted suture, and dressed the wound with
lint smeared with a balsamic preparation well wet with spirits of wine. This first
dressing was not removed for three or four days, after which he advised its renewal
daily until the cure was effected. If the patient was an infant or child, he did not rec-
ommend any support to be worn after the operation, but he advised the adult ever
after to wear a girdle, to strengthen the parts and prevent a relapse of the hernia. Ga-
rengeot transcribed the method recommended by M. Petit, in which he used his scalpel
armed with a button at the point. Petit dressed his wound in a manner singularly
like that which has found favor recently with some of the New York surgeons, under
the name of the McBurney method. He filled the opening with a pledget of lint, or
a ball of linen fastened by a thread, dipped in the white of an egg. The external
* Lawrence. Treatise on Hernia, p. 472.

UMBILICAL HERNIA.
199
.
parts were anointed with the oil of roses. Petit reported a case which was well in
five days after the operation.
Although operations for the relief of strangulated umbilical hernia were frequently
undertaken for a permanent cure upon the Continent, such surgical procedures did
not find favor at this early period in England. The distinguished London surgeon,
Percival Pott, gave to hernia such special consideration that he published a separate
work upon the subject. After referring briefly to the operations above described, as
advocated by the ancients for the cure of umbilical hernia, he commented as follows: *
“ The objections to either of them are so obvious that it is hardly necessary to say any-
thing concerning them, though in this age of quackery and credulity I should not
wonder to see them revived and practiced. ... In young subjects and small herniæ, a
bandage worn a proper time generally proves a perfect cure; and in old persons and
large tumors, it is hardly to be supposed that anybody can think of any but a palliative
cure, the hazard of producing a mortification being so great.
“ But suppose the subject to be young, and the tumor of such size and in such state
as to make it unlikely that a bandage would do more than palliate; that the skin cov-
ering the tumor is so lax as to make it improbable that it should ever recover its former
state and lie smooth, and that when it has been removed the cicatrix shall bind so
tight as to prevent the future protrusion of any of the contained parts; yet who can
tell what may be the consequence of this destruction of parts, and this indilatability of
the skin in a state of pregnancy? I mention this because I have seen very terrible
mischief from the bursting of a cicatrix on the navel during gestation ; though the scar
was from an abscess opened by incision, and consequently could not be supposed to be
equal, either in size or resistance, to one produced by the before-mentioned operation.
“The umbilical, like the inguinal hernia, becomes the subject of chirurgic operation
when the parts are irreducible, by the hand only, and are so bound as to produce bad
symptoms. But though I have, in the inguinal and scrotal hernia, advised the early use
of the knife, I can not press it so much in this; the success of it is very rare, and I
should make it the last remedy. Indeed, I am much inclined to believe that the bad
symptoms which attend these cases are most frequently owing to disorders in the
intestinal canal, and not so often to a stricture made on it at the navel as is supposed.
a
* A Treatise on Ruptures, by Percival Pott, Senior Surgeon at St. Bartholomew's Hospital. Second edition,
altered, corrected, and improved. London, 1763.

200
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
,
I do not say that the latter does not sometimes happen—it certainly does ; but it is
often believed to be the case when it is not.
“When the operation becomes necessary, it consists in dividing the skin and her-
nial sac in such manner as shall set the intestine free from stricture, and enable the
surgeon to return it into the abdomen, if sound, and not adherent; but if it is gan-
grenous or mortified, the altered part must be removed, and the fecal discharge be
derived through the wound; by which means some few have preserved their lives, if
such state can be called living.”
Sir Astley Cooper considered operations for the relief of strangulated umbilical
hernia, although in a more hopeful light than Mr. Pott, as attended with the gravest of
dangers, and only to be recommended as a last resort. In common with his predecess-
ors, he detailed at length many measures to be brought into requisition in the hoped-
for reduction prior to operation. He reported a considerable number of cases where he
operated, some of which were followed with the happiest results; but where the intes-
tine was adherent to the sac it was allowed to remain, only freeing the constriction.
In the illustrative case cited, the operation was performed May 18, 1804. The divided
parts were sutured, and all the stitches were removed except one, on the 26th. The
wound was treated with a poultice, and the patient was discharged June 15th, perfectly
cured. He gave the following directions : “ After the parts are returned, great care
should be taken to close the wound by sutures ; this is required in all operations for
hernia, but especially in the umbilical, where the passage into the abdomen is nearly
direct, and in which, after the strictured bowel has been relieved, peritoneal inflamma-
tion often proceeds to the destruction of the patient's life.”
Scarpa, who published somewhat later, recognized that the great danger in the
operation for strangulated umbilical hernia is owing to the injury of the incarcerated
intestine, and says most cases are unsuccessful because the operation is almost always
performed too late.
Until within a very recent period few complications in surgery have been held in
greater fear, since the infective peritonitis which very generally followed operative meas-
ures usually ended fatally. I am constrained to believe, from my own experience, that
by far the larger number of cases of strangulated umbilical hernia are still improperly
treated, owing to this dominating fear. · As in the other varieties of hernia, prolonged
and repeated attempts at reduction, with the application of far too great and often-
times ill-adapted force, are made ; and even after failure by these measures, inexcusable
a

UMBILICAL HERNIA.
201
delay frequently follows before the physician, the friends, and the patient are educated
up to the undertaking of what they consider the dernier ressort-surgical interference-
and which, indeed, if relied upon at this period of the disease, is associated with extreme
danger-a danger to be emphasized as dependent not upon the surgical measures under-
taken for the relief, but upon the condition of the incarcerated abdominal organs, which
have been subjected to the criminal manipulation and neglect of an incompetent
adviser. The number of lives lost annually for want of proper treatment is far greater
than is generally supposed, and it is hardly possible to emphasize too strongly the con-
demnation of the Micawber-like policy which is the too common practice in dealing
with this serious lesion.
There is but one surgical rule to be adopted in the treatment of strangulated umbili-
cal hernia; an immediate and careful attempt at reduction should be made under ether,
and, this failing, the constriction must be at once divided. This generally necessitates
the opening of the sac, which is important even in recent cases, in order that the sur-
geon may determine the condition of the constricted contents. When it is found that
these admit of a safe return into the abdominal cavity, the problem confronting the
surgeon is, Shall an effort be made to effect a permanent cure of the disability ? I
think the consensus of surgical opinion is in favor of an affirmative reply, and that the
large, old, deformed sac should be resected and removed as a pathological factor. Hav-
ing done this, the more common method advocated is to join the pillars of the ring
with deep interrupted sutures, preferably wire, the application of an antiseptic dressing,
and a supporting abdominal bandage.
The question at issue is, to determine if cure is possible, and if the measures pro-
posed for this purpose are of a character to warrant their adoption ? To Dr. H. R.
Storer, of Newport, R. I., formerly of Boston, is due the credit of having first in
America deliberately undertaken the cure of umbilical hernia. This was in 1866, and
the operation was followed by primary union.
That cure is effected by removal of the sac and closure of the opening in the
abdominal wall, few can question ; and that the cure generally remains permanent,
there is abundant proof. The danger of the operation has been considered sufficiently
great to regard the risk unwarrantable, and this is the factor of the problem that needs
most careful elucidation.
The operation undertaken for the cure of umbilical hernia, when the contents of
the tumor are non-adherent and can be restored, may justly be considered as an explora-
29

202
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
-а
tory laparotomy, to be done with all the care of the modern aseptic operator. He
who is skilled in making and maintaining an aseptic wound has little to fear, since the
danger is almost altogether summed up in the one word—infection.
In large, old, irreducible hernia the operation is less simple; adhesions of the omen-
tum are unimportant, although there may be bleeding points in the separated parts.
The omentum itself is not seldom so altered at the point of constriction about the
ring as to be separated with difficulty, and so deformed as to make its return within
the abdominal cavity ill-advised. It is not, however, a serious complication to remove
considerable masses of omentum and to control the resultant hæmorrhage. Sew
through the base of the unconstricted part of the omentum with one or even two
lines of continuous sutures. It must be remembered that necrosis, by a too firm com-
pression such as very commonly follows from ligation, is to be avoided. Compres-
sion evenly applied, although quite moderate, is sufficient to control any ordinary
hæmorrhage. Resect and return the healthy base of the omentum within the abdomi-
nal cavity. When loops of intestine are adherent, much care is demanded in sepa-
ration, and oftentimes it is wiser to resect a portion of the sac at the point of adhesion.
A few light-running stitches are sufficient to intrafold this—a precaution to be recom-
mended before returning the intestinal loop into the abdomen.
In umbilical hernia the sac differs essentially from the condition in which it is found
in the other forms of hernia, in that the whole peritoneal pouch is generally closely
united to a thinned-out cutaneous investment. This skin, covering the sac, is of no
value in the restoration of the parts; its vascularization is greatly diminished, and when,
under favorable circumstances, a portion of it is retained for a special re-enforcement
to the parts, its vitalization is so defective as to break down easily and complicate the
repair processes. It is therefore better, as a rule, to resect the peritoneal sac and its
external envelope quite to the margin of the ring. The re-enforced bands of connect-
ive tissue which surround and fortify the ring are subject to considerable modifications
of treatment, dependent upon their disposition. When the opening is small, two or
three deep stitches may be sufficient to unite the edges of the ring and hold them in
firm apposition. If the opening of the ring is considerably larger and the edge of the
ring sharp and firm, I recommend, as a general rule, the dissection of the peritonæum
quite within the edge of the ring, and joining it with a line of continuous tendon
sutures before resecting, as advised in the treatment of the sac in other varieties of
hernia. This has its advantage, in that the abdominal cavity is thus shut off from

UMBILICAL HERNIA.
203
extraneous contact, and the subsequent steps of the operation can be conducted, if
desired, under the protection of irrigation. Moreover, it refreshes the edge of the
ring, which favors a better reunion of the parts. The edges of the ring are often
b
dc 6 a
e
FIG. 17.
FIG. 18.
FIG. 19.
Fig. 17.--Umbilical hernia. a, a. Integuments. b. Fat. c. Abdominal muscles. d. Peritonæum. e, e. Hernial sac.
f. Mouth of sac, umbilical ring.
FIG. 18.—The peritonæum united after resection of the sac. The abdominal wall divided laterally for coaptation.
a. Skin. 6. Fat. C. Abdominal muscles. d. Peritonæum. e. Line of resected peritonæum. f. Outline of
rounded sac. 8, 8. Lateral division of abdominal wall.
Fig. 19.—Diagram of the abdominal wall after union of the parts. a. Skin. b. Fat. c. Abdominal muscles. d. Peri-
tonæum. e, e. Line of union of abdominal wall after coaptation.
advantageously split laterally, which permits the coaptation of the parts by a double
row of buried continuous sutures.
Again, it is sometimes wiser to resect the ring altogether and close the walls of the
abdomen, as in an ordinary laparotomy. I do not hesitate to advise the use of the
deep, double, continuous tendon suture, applied in the same manner as recommended
in femoral hernia, only the needle and tendon should be of a larger size, and the sutures
taken at a considerable distance away from each side of the margins of the opening, in
order to coapt and evert the inclosed portions. By the introduction of the sutures in
this manner, as also in the splitting of the edges of the ring laterally, the object gained
is the thickening and re-enforcement of the parts.

204
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
use.
The superficial tissues are to be joined by a line of light-running sutures, as also the
skin itself, the needle penetrating from side to side the deeper layer only, and the dress-
ing is completed by the application of iodoform collodion, re-enforced by a few
fibers of cotton. Since the patient generally has heavy abdominal walls, it is well to
apply a rather firm, wide bandage. Almost the only subsequent care necessary is to
maintain the patient at rest, in a position where the recti muscles are not called into
I have had occasion to operate on a very considerable variety of umbilical herniæ
according to the above method, and in a number of instances have resected large por-
tions of omentum ; I have never seen any ill results therefrom, and in no case where the
integrity of the intestine was not involved has the patient even approached the danger-
line. So far as I have been enabled to follow my cases, cure has not alone been speed-
ily obtained, but it has remained permanent.
Dr. Championnière, * of Paris, writes: “I believe the urgency for the cure of umbili-
cal hernia very great, and I do not hesitate to advise every young woman, whether the
hernia be large or small, to be operated upon, since she is doomed to a life-long painful
and dangerous infirmity. Now, the operation is excellent, and the danger is not materi-
ally greater than in other varieties.”
Sänger † contributes an interesting article upon the radical operation for the cure
of umbilical hernia. He has collected, since 1879, twenty-seven cases, with only one
death; of these the hernia returned in seven cases. He thinks the indications for opera-
tion for cure are, all cases of strangulated hernia, and those large and painful tumors
which are retained imperfectly by a truss. He divides the tissue about the ring in two
layers and unites with silk sutures. He reports three cases which he has operated upon
by this method, followed by cure. He operates with antiseptic precautions, resects
the sac, and dresses with a strong, firm bandage.
Before the days of the proper understanding of the active ferments as factors in the
surgical problem of wound treatment, emphasized by the most serious results, when-
ever their incubation occurred within the abdominal cavity, we may well understand the
fear and trembling associated with the name of peritonitis. The experience of the
centuries had taught that the peritonæum was the “ noli me tangere” of surgery. Upon
this, in large measure, is yet based the general belief of the medical profession to defer
* Études sur la Cure radicale de la Hernie, non-étranglée. Jour. de Méd. et Chir., 1888.
+ Centralblatt Gynäkologie, July, 1890.

UMBILICAL HERNIA.
205
operative procedures as a last resort. This has been emphasized in a much greater
degree in the consideration of operative measures undertaken for the cure of umbilical
than of inguinal and femoral hernia.
The time is not far distant when the cure of this oftentimes disabling and danger-
ous condition will be considered as safe and simple as an exploratory laparotomy, and
under proper precautions almost devoid of danger.
The description of the following catalogued specimens, which have been carefully
dissected and preserved in the Museum of the College of Physicians in London, can
not fail to be of especial interest, since they give us a detailed account of the surgical
measures attempted by some of the most distinguished surgeons of the time:
2630. Portion of the intestine of a child, from a strangulated umbilical hernia. It is said to have
been wounded in an operation to reduce it; but the form of the aperture in its coats—which
is small, oval, with evenly circumscribed and abrupt thin edges, without protrusion of the
mucous membrane—makes it more probable that it was perforated by ulceration or slough-
ing. Its peritoneal surface is thinly covered with lymph.—From the Museum of Sir A. P.
Cooper.
2687. A portion of the anterior wall of an abdomen, with part of the sac of an umbilical hernia
and its contents, from a woman who died twenty-four hours after the operation for hernia
was performed and the contents of the sac were returned. The sac was very large; the
part which remains has thick walls strongly fasciculated on their internal surface. The re-
turned omentum is closely adherent to every part of the mouth of the sac, and the returned
intestine is adherent at the back of the omentum.
Mr. Hunter used to say of it: “This is a preparation where Nature had done everything
in her power; it is of the umbilicus of one on whom I performed the operation, and who
died in a little time after ; and here you may see that the epiploön has, after the operation,
adhered all round to the inner edge of the wound.”—Hunterian Reminiscences, by Mr. James
Parkinson. London, 4to, 1833, P. 88.
2688. A large umbilical hernia containing small intestine, and, at the upper part, some hardened
omentum. The greater part of the sac and its coverings has been removed. An incision an
inch and a half long was made into the front of the intestine during life, for it was found,
in the operation performed for the relief of hernia, that the intestine had sloughed beneath
and near the stricture. A quill is passed into the sac and through its neck into the aper-
ture produced by the sloughing in the intestine. Except at this aperture the intestine is
everywhere adherent to the mouth of the sac, and shreds of lymph and false membrane are
attached to its outer surface.
The patient, a woman thirty-seven years old, had the hernia many years. The operation
was performed on the eleventh day after strangulation commenced. The cuticle had begun
to separate, the skin was purple, and a part of the sac over the aperture in the intestine
had sloughed. The intestine was freely opened, the omentum was cut off, and the stricture
was not divided. The patient died six hours afterward.

206
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
After death, it was found that fæces had escaped into the abdomen through the aperture
produced by the sloughing of the intestine. This aperture, as the preparation shows, ex-
tended into that part of the intestine which was within the abdomen as well as into that in
the sac immediately beyond the stricture.
The case is recorded in the Edinburgh Medical and Surgical Journal, vol. xxi, p. 293,
,
April, 1824.—Presented by Joseph Swan, Esq.
-
Dr. W. W. Potter,* of Buffalo, reported an interesting case of large umbilical hernia oper-
ated on in 1877, which contained a lobe of the liver and constituted a portion of the con-
tents of the sac.
He introduced deep sutures. Recovery followed, and, when heard from five or six years
after (as by recent report), the cure remained permanent.
* Umbilical Hernia in the Adult. Buffalo Medical and Surgical Journal, January, 1879.


PLATE XLIX.
Fig.1.
Fig. 2.
a
a
d.
a
a
a
Fig. 6.
07
9
Fig. 3
Fig. 3.
6
G

CHAPTER XIX.
VENTRAL HERNIA.
*
This form of hernia assumes an importance for present consideration entirely
disproportionate to that of an earlier period, since within the last few years lapa-
rotomy has become so very frequent as to be of daily occurrence in a great variety
of abdominal diseases. It is variously estimated by different authors that ventral
hernia follows the closure of the abdominal wound after laparotomy in from five to
ten per cent of the sum total of cases. Although not very common from other
causes, it may occur alike to both sexes and in all conditions of life. It may be
situated in any portion of the abdominal parietes, but for obvious reasons it is more
likely to occur at or near the median line, between the umbilicus and the pubes.
As a result of the surgical division of the abdominal wall, it may happen from de-
fective union in consequence of improper closure of the parts, the common cause of
which was first pointed out by Sir Spencer Wells a number of years ago, from the
fact that operators often failed to include the peritonæum in the line of their sutures.
This leaves a more or less gaping wound, from within outward, of the parietal wall,
and when hernia occurs from this cause it will be generally found without a peri-
toneal investing sac.
a
PLATE XLIX.
Contains an anterior and posterior view of a double umbilical hernia ; also anterior and posterior
views of the umbilical hernia, showing the danger of cutting the intestine within the abdomen ; and
two views of a ventral hernia, situated in the linea alba, about two inches above the umbilicus.
Figure 1.
Double umbilical hernia.
a, a, a. Abdominal muscles.
b. Linea alba.
c. Large umbilical hernia. The sac opened.
The skin adheres to it.
d. Small umbilical hernia situated to the left
side of the former, and the sac is opened.
*“I have been surprised to find that thirty women out of over three hundred, or nearly ten per cent, have
ventral hernia."- Dr. John Homans on Three Hundred and Eighty-four Laparotomies for Various Diseases. Bos-
ton, 1887.
+ Cooper, Plate X, Part II.
(207)

208
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
g. Intestine adhering to the orifice of the her-
nial sac.
h, h. The omentum glued to the mesentery
and to the hernial sac, forming a pouch toward
the abdomen.
Figure 5.
Figure 2.
Posterior view of the same preparation.
a, a, a, a. Abdominal muscles.
b. Linea alba.
c. Orifice of the larger umbilical hernia.
d. Orifice of the smaller hernia.
e. A band of tendon situated between the two
hernia.
Figure 3.
Umbilical hernia, anterior view.
a, a. Linea alba.
b, b, b, b. Recti abdominis.
6, c. Lineæ transversales.
d. Hernial sac within which the omentum is
seen adhering.
e. Omentum.
Anterior view of a ventral hernia.
a, a. Abdominal muscles.
b, b. Linea alba.
C. Umbilicus.
d. Fascia over this hernia.
e. Hernial sac.
f. Portions of fat between the fascia and the
sac.
Figure 4.
Posterior view of Fig. 3.
a, a. Recti abdominis.
b, b. Peritonæum.
c. Remains of the umbilical vein.
d, d. Remains of the umbilical arteries.
e, e. Epigastric arteries.
f. Linea alba.
Figure 6.
Posterior view of Fig. 5.
a, a. Abdominal muscles.
b, b. Peritonæum.
C, C. Portion of adeps at the umbilicus.
d, d. Umbilical arteries.
e, e. Umbilical vein.
f. Mouth of the ventral hernia.
g. Fat adhering to the mouth of the hernial
sac, into which the umbilical vein is seen to pass.
Another and not infrequent cause of ventral hernia following abdominal opera-
tions is found in imperfect or non-union of a portion of the abdominal wound from
the use of the drainage-tube, and from localized abscesses, more commonly called
“ stitch abscesses.” These are usually the result of a localized infection, dependent
upon careless or at least imperfect and unsatisfactory treatment of the abdominal
wound, too oftentimes considered an unimportant factor in abdominal surgery. As
Sir Spencer Wells pointed out, when the interrupted suture is used for closing an
abdominal wound, it should be introduced carefully through the various layers of the
abdominal wall, including the rectus muscle or the firm connective-tissue aponeurosis
which unites the recti on the median line and the peritonæum. The relationship of
these parts must be carefully restored in tying the sutures. I can not myself doubt
that the much better method is to close the different layers of the abdominal wall
in lines of buried tendon sutures. Since the adoption of this method, in quite more
than one hundred cases of laparotomy, I have had but one case of ventral hernia.
This occurred in a woman, after the removal of a large uterine myoma, where the
abdominal wall had been for a long time extremely attenuated.
Ventral herniæ may assume proportions of such exceptional character as to pro-

VENTRAL HERNIA.
209
duce a tumor of extraordinary size. I operated in one case, assisted by Dr. Samuel
N. Nelson, followed by complete cure, where the exit of the tumor was a little to
the left of the median line, below the umbilicus; it was irregularly lobulated in shape;
the dependent portion, when the patient was in the erect position, was some inches
below the crest of the pubis, making a tumor in size nearly that of an adult head.
The patient was photographed, but unfortunately the negative proved defective.
In 1887, Dr. James R. Chadwick,* of Boston, published an article upon the sur-
gical treatment of hernia following laparotomy, based upon an operative case shown
in photographic illustration. “The operation lasted over two hours. An incision
was made through the wall of the sac at the lower angle of the cicatrix, and the
whole sac subsequently laid open with the scissors in the median line nearly up to
the navel. The transverse colon, its mesentery, and numerous coils of the small
intestines were quite firmly adherent to the lining membrane of the sac at its upper
angle, requiring long and careful dissection to detach them. About ten fine inter-
rupted silk sutures were passed by means of Peaslee's needle through the integument,
three inches of fat, and finally through the middle of the rectus muscle on each side,
fully an inch back from the edge of the cleft.” Recovery was satisfactory, and the
union firm at the expiration of five months. Dr. Chadwick, after a thorough search,
found only twelve published cases, of which seven were tabulated by Dr. W. Gill
Wylie, of New York. Six of Dr. Wylie's cases followed the use of the drainage-
tube, the seventh a second operation where the first had failed.
Two cases of ventral hernia, with cure, are reported by E. F. Neve:t
Case I. A boy of eighteen suffered from a firm, flattened tumor, measuring five
inches by four, situated in the median line between the umbilicus and ensiform cartilage.
The tumor consisted almost entirely of an organized blood-clot, together with a small
portion of omentum, which was ligatured and removed. The abdominal opening did
not exceed three fourths of an inch. The peritoneal sac was about the size of a filbert,
which was removed and the wound drained. Recovery excellent.
CASE II. Hernia, size of a child's head, containing omentum and intestine. Corpu-
lent woman, aged forty-five. Neck of sac two inches above the umbilicus, diameter of
ring two and a quarter inches. The sac was dissected and removed, the wound closed
a
* Reprint from Gynæcological Transactions, vol. xii, 1887.
+ British Medical Journal, June 8, 1889.
30

210
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
with sutures. Suppuration supervened, but in four weeks the patient was discharged
cured."
Dr. A. P. Dudley reported a case of strangulated ventral hernia in a woman ninety
years of age, upon which he operated.*
More than a year ago I operated upon a ventral hernia which followed the third
laparotomy, performed in one of the public hospitals of Boston, for the cure of dis-
eased ovaries and tubes. The cicatrix was about four inches in length, and three
distinct herniæ had formed on the line of the imperfect union, associated with adhe-
sions of loops of the small intestines—a condition which for months had rendered
life miserable. The intestine was freed, and the entire cicatrix was resected, followed
by primary union and a firm, strong restoration of the parts. It is not rare to find
examples of ventral hernia in the median line above the umbilicus. These, so far
as I have had the means of observation, are small in size, oftentimes giving little
or no discomfort. Occasionally they interfere with the process of digestion, causing
nausea, flatulency, and pain.
Scarpa explained the reason why he considered the greater frequency of ventral
hernia occurring above rather than below the umbilicus, as due to the less compact
structure of the linea alba above the umbilicus and the more close approximation
of the recti muscles in the lower portion of their course,
Several cases have come to my notice of ventral hernia occurring in the lat-
eral portions of the abdominal wall from various causes. When a ventral her-
nia is small and reducible, it is generally not difficult to retain it by the applica-
tion of a properly fitting truss. If irreducible and troublesome, as it is likely to
be, although its contents consist of only omentum, it is better to attempt its
cure by surgical interference rather than by the application of the hollow-pad
truss.
Strangulation of this class of hernial tumors is comparatively rare, since, from the
anatomical construction of the parts, a well-defined, circumscribed, inelastic ring is
much less likely to be found than in the other varieties of hernia. If, under ether,
the hernial contents are not easily reduced by tạxis, operative measures must be un-
dertaken immediately, and the rule here, as elsewhere, closely followed of an attempted
cure by surgical procedures. The technique is exceedingly simple, consisting of reduc-
* American Journal of Obstetrics, No. 23, p. 528. New York, 1890.

VENTRAL HERNIA.
2II
tion of the hernial contents, resection of the sac, and a firm closure of the abdominal
walls as recommended in umbilical hernia.
It is well to remember, especially in very fat subjects, that a small hernia of the
linea alba near the ensiform cartilage may be easily overlooked, and the true cause of
occasional uneasiness of the stomach and vomiting escape undetected. It should not
be passed without mention, that under rare conditions tumors other than hernial may
be met with which sometimes render the diagnosis extremely difficult.
My late friend Dr. H. A. Martin, of Roxbury, sent me a tumor for examination,
fist size, which he removed from the median line, about midway between the umbilicus
and the pubis, which proved to be a calcified uterine myoma, with the hernial opening
through which it had escaped completely closed. A photographic reproduction of a
microscopical section of this tumor will be found in a work which I published some
years ago upon uterine myoma. As an illustration of the error in diagnosis which
may lead a surgeon to operative interference, I quote the following case, which occurred
in the experience of Scarpa : “A few years ago a woman about fifty-five years of age
*was brought into this school of practical surgery, rather fat, but of a weak habit, and
habitually hysterical, who in the preceding night had been attacked by very violent in-
testinal colic, in consequence, as was said, of an incarcerated hernia. Her abdomen was
very tense, and painful to the touch, the lower extremities were cold, the pulse small,
nausea, inclination to vomit, and suppression of stools. A little below the umbilicus,
toward the left side of the linea alba, there was a small tumor about the size of a large
nut, of the natural color of the skin. Persuaded that this tumor was a true incarcerated
hernia of the linea alba, and conscious that these herniæ, like the umbilical, are most
prone to pass into gangrene, I proceeded immediately to the operation. Having laid
open the integuments, I did not find the least vestige of a hernial sac. The contents
of the tumor were small masses of hard fat continued into a pedicle, which evidently
passed through the linea alba, and was removed by a stroke of the knife. I then ascer-
tained the true nature of the disease. The general tepid bath, repeated emollient glys-
ters, fomentations, and the use of castor-oil by the mouth in small doses, procured
alvine evacuations, and the colic disappeared in a short time. The small wound was
not long in healing."
a

CHAPTER XX.
DIAPHRAGMATIC HERNIA.
FORTUNATELY, diaphragmatic hernia is very rare. However, when lesions of this
great muscular curtain which partitions off the organs of the body occur and dislo-
cations of the organs supervene, it follows of necessity that the suffering is most
severe, often resulting in fatal consequences. On this account the bibliography of
the subject is very considerable, and a detailed study of the different phases of the
disease is of exceptional interest. The limitations of the present work, however,
make it necessary that this chapter be less complete than most of those preceding,
since the conditions pertaining to diaphragmatic hernia are those which permit only
very rarely of surgical consideration. Sir Astley Cooper gave a comprehensive re-
view of the conditions usually present in this form of hernia; but perhaps the most
detailed and exhaustive study of the subject, made by any author, is that of my late
master, Dr. Bowditch,* who published an exhaustive résumé with all the data at that
time available, and with his rare acumen made a careful analysis and classification
of the varieties, both in kind and degree, symptomatology, etc.
As we have already observed, in treating of the other varieties of hernia, the
weakest portions of the great elastic envelopes which surround and inclose the abdomi-
nal organs are found in the course of the vessels which necessarily emerge therefrom.
This inherent weakness is the more common cause of diaphragmatic hernia. When,
for any reason, it develops gradually, it is classified, as in the inguinal and femoral
varieties, as a form of acquired hernia. A considerable proportion of the cases, how-
ever, are due to a defective development of the structures, and on this account have
been denominated congenital. A third class result from injuries, and therefore are
called traumatic.
In Dr. Bowditch's table, which includes all the cases of which he was able to
* A Treatise on Diaphragmatic Hernia. Dr. Henry I. Bowditch, Boston, 1853.—Reprint from Buffalo Medical
Journal.
(212)

DIAPHRAGMATIC HERNIA.
213
a
find a record-eighty-eight in number—twenty-six were congenital, and this class comes
naturally first under our consideration. Of these, the first division comprises those
who die at, or immediately after birth, since, when the diaphragm is so defective as
to be wanting in its physiological action, respiration is impossible. The infant may
be otherwise well developed, the placental nutrition not having been impaired.
It may aid in the diagnosis to determine the location of the heart, since in this
condition this organ is often found more or less displaced.
In the second subdivision, the sufferer may survive a number of years, but must be
necessarily an invalid, dyspnoea being rather constant, or supervening upon slight exer-
tion. Constitutional disturbances exist, the digestion is so imperfect as to cause ex-
treme emaciation, but the objective symptoms, in large measure, are grouped about an
imperfect and difficult respiration.
Notwithstanding pronounced conditions of defective development, a number of
cases are on record where the general nutrition has gone on without any marked
degree of impairment, allowing the individual to pursue some light occupation with-
out serious suffering. Although a considerable opening exists, the abdominal organs
are not displaced, or, at the most, are subject to dislocation in a temporary way.
When this variety of hernia is congenital, the displaced organs are not contained in
a peritoneal sac, for obvious reasons. In the acquired form of this hernia a sac usu-
ally exists.
Anatomical Characteristics.—Because of structural relationships the hernial open-
ing is more frequently upon the left side of the diaphragm. The great mass of the
liver, to which it is posteriorly united, serves as a protection to the right side. The
right crus of the diaphragm is longer and stronger than the left. The left side of
the diaphragm contains two distinct depressions opposite the spleen and the stomach.
In the analysis of the eighty-eight cases tabulated by Dr. Bowditch, hernia of the
diaphragm occurred upon the left side forty-one times, on the right side eighteen
times, and in only three of this large number of cases (the left side) was the sac
demonstrated; while of the eighteen herniæ upon the right side, in eleven the sac
had formed, and in two of these it was double. In seven of the eleven cases the
opening existed just to the right of, and posterior to, the ensiform cartilage. From
this cartilage is given off a thin fasciculus, which leaves a small triangular space on
both sides of it, which is completed only by the serous membranes of the abdomen
and chest, and it is very probable that the sac usually commences to form at this

214
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
weak point. In some cases the sac has been found passing up into the mediastinum
and thence into the right pleura.
Dr. Bowditch gives a diagram of a transverse section of the body, which shows
that the right pleural cavity is normally much nearer the median line than the
left.
The opening through the diaphragm is rounded, oval, or semicircular. This has
been observed in most of the reported cases, and it is doubtless dependent upon the
anatomical structure of the diaphragm, the muscular fibers of which are disposed in
a somewhat circular direction. The contraction of these fibers tends to produce a
rounded opening, a disposition of the parts which prevents the closure of the defect
in case of injury. Of Dr. Bowditch's cases, eleven were the result of recent severe
injuries, in two of which death was instantaneous.
The relative frequency of hernia of the different organs, as analyzed by Dr. Bow-
ditch, is as follows: "Stomach, 44; large intestine, 39; omentum, 30; small intes-
tine, 29; liver, 17; spleen, 13; pancreas, 6; mesentery, 2; kidney, 2."
In the complications resulting from the displacement of the abdominal organs,
there must be more or less impairment of their functions; and intestinal obstruction
caused by a loop of the bowel being caught in the hernial opening gives resulting
symptoms quite similar to those from the escape of the viscera through any of the
openings in the abdominal cavity. As a rule, in this variety of hernia, the thoracic
disturbance and the interference of the respiration are commonly the most marked
symptoms, dependent upon the impairment of the functions of the diaphragm and
the mechanical displacement of the organs of the chest, the lungs being almost inva-
riably compressed.
It is not easy to diagnosticate diaphragmatic hernia. Dr. Bowditch stated that
in the whole number of recorded cases this has never been made but twice, and in
these cases it was too late to be of service. We must do better than our prede-
cessors; better, likewise, than we ourselves have done, and recognize the affection be-
fore the commencement of the fatal attack.” Of the entire number, symptoms of
actual strangulation occurred in thirteen cases, all of which proved fatal. Dr. Bowditch
suggested: “Finally, as a last resource, might not an operation for cutting the stran-
gulated ring be effected? It never has been done, though Laennec suggested it.
Yet I see no good reason why it may not be possible to recognize, by the physical
signs, the side at which the disease exists, and the probable amount of the affection.

DIAPHRAGMATIC HERNIA.
215
Having learned these two points, and having tried other means for its relief without
success, ought we not to undertake the more serious operation with the scalpel ?
“Where should the incision be made? Sacs commence about the lower and front
part of the mediastinum; therefore, near this is a proper place to commence the in-
cision. Passing along the edge of the ribs for the space of three or four inches, we
should divide the muscles, and come upon the peritonæum covering the lower part of
the diaphragm, and reflected thence upon the inside of the abdominal muscles. It
would be possible (I think) to push aside this membrane and not enter the cavity of
the peritoneal sac until we might be able to make out the exact place of stricture,
and there a very slight incision only would be necessary. But, in this operation,
there is at present so much of difficulty, owing to the proximity of important organs,
and to the distention and alteration of position of the abdominal organs, that it will
probably have few to perform it, especially as the disease is so rare that no person
would be likely to have more than one or two opportunities for operating during his
whole lifetime."
The following case from Sir Astley Cooper is illustrative :
“W. R., aged thirty, was admitted to Guy's Hospital February 5, 1804. Fracture
of the six lower ribs of the right side from a fall. Death occurred the following
morning. Autopsy showed a small wound of the right .lung.
On pushing down the vault of the diaphragm, a fold of intestine of livid color
was discovered; and, upon extending the examination into the cavity of the abdomen,
a portion of the intestine, which proved to be the ileum, was found proceeding up-
ward behind the liver into the cavity of the chest, through a large opening in the
diaphragm. This opening, which appeared lacerated, was situated about two inches
from the cordiform tendon, in the muscular portion of the diaphragm, and on its right
side. The aperture was filled by the intestine, around which a very firm stricture
existed. It had been strangulated by the muscle itself; and from the livid state of
the intestine only nineteen hours after the accident, the strangulation seemed to have
been unusually complete. The hole in the diaphragm had been occasioned by the
broken point of the tenth rib, which had penetrated the muscle when it was in a state
of expiration, and the muscle had withdrawn itself from the point in inspiration, so
as to leave the opening through which the intestine had protruded.
“ The viscera in the cavity of the abdomen appeared little altered in any other
respect, but about a quart of bloody serum had been extravasated into both cavities.”

216
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
PLATE L.*
DIFFERENT VIEWS OF DIAPHRAGMATIC HERNIA.
Figure 1.
Phrenic hernia, produced by fracture of the
ribs.
a, a. Dorsal vertebræ.
b, b, b. The ribs.
C, C, C. The fractures of the ribs.
d. The diaphragm.
e. The intestines within the abdomen.
f, f. The intestine strangulated through a
laceration of the diaphragm.
a, a. The liver.
b. The stomach.
C, C, C. The colon.
d. The bladder.
e, e, e. The small intestines within the left
cavity of the chest.
f, f. The diaphragm.
gig. A bougie thrust through the aperture in
the diaphragm, by which the intestines had passed
into the chest.
h. The heart.
i. The right lung.
Figure 2.
Phrenic hernia in the fetus.
The late Dr. George A. Otis + reported in detail a case of diaphragmatic hernia,
with an illustration of the specimen, to show that “the accepted doctrine that wounds
of the diaphragm, whether in the fleshy or tendinous part, never unite, but remain
with their edges separated ready for the transmission between them of any of the
loose viscera (Guthrie), is confirmed.”
,
“CASE DXCII.—Private C. C., aged twenty-two, was wounded at Gettysburg, July
2, 1863, by a musket-ball, which penetrated the left wrist and the lower part of the
left chest. Death occurred the following November. A careful autopsy was made.
Right lung diminished in size; only a small portion of the left lung visible, extending
from the first to the second ribs, and lying directly in the median line. The left chest
was filled with the stomach, greatly distended with air. Consolidation of the left
lung was complete, a portion of it sinking in water. The diagnosis of the condition
had evidently not been made prior to death.”
Two very interesting preparations of gunshot-wounds of the diaphragm exist in
the museum at Netley. “In both instances, the stomach, colon, and omentum formed
the hernial protrusions. In one, death occurred a year after the wound, from strangu-
lation induced suddenly after a full meal; in the other, the soldier continued at duty
twenty-two years after the wound, and then died from other causes. All the cases
* Cooper, Plate XIV, Part II.
+ Medical and Surgical History of the War of the Rebellion, Part II. Surgical Volume, p. 185.
| In the Museum of the British Army Medical Department, preparations 1,152 and 1,153 represent diaphragmatic

PLATE L.
Fig.3.
Fig. 2.
al
JUL
N
g.
а
h
a
6
d
7
C.


DIAPHRAGMATIC HERNIA.
217
>
which occurred in the Crimea, in which an opening had thus been established between
the cavities of the chest and abdomen, proved fatal. . . . In case of recovery, the risk
of hernial protrusion and strangulation should be explained to the patient.”
Modern surgery has rendered the exploration of the abdominal cavity comparatively
a safe process. Guthrie advocated the advisability of opening the abdomen and the
withdrawal from the thorax of the displaced organs in diaphragmatic hernia. Quite
forty years ago, Dr. Henry I. Bowditch, as we have shown by quotation, clearly sug-
gested its possibility.
The difficulty appears to be, even in the chronic cases, the determination of diag-
nosis, although in marked cases it would not seem to be difficult. This having been
established, and the suffering such as to endanger life, I do not question that it is
the duty of the surgeon to make an exploratory incision; withdraw, if possible, the
abdominal organs from the thoracic cavity, and if, as we have seen from the analysis
of the recorded cases, it commonly happens that the opening in the diaphragm is
near the ensiform cartilage, an effort should be made to effect its closure. I have
failed to find record of an instance in which this has been attempted. But a number
of the reported cases teach that this could have been effected had the attempt been
made by a skillful surgeon. There is abundant proof that diaphragmatic hernia occurs
more frequently than has been generally supposed; I have found record of seventy-one
cases published since the date of Dr. Bowditch's tabulated statistics.
Hernia not seldom exists within the abdominal cavity, caused by a displacement
of some portion of the intestinal canal through an opening in the omentum, mesen-
tery, or by some adventitious product of inflammatory character—the retroperito-
neal hernia (mesenteric hernia of Cooper), for example. These intestinal obstruc-
tions are of a most dangerous character, and may be very difficult of diagnosis. The
consideration of them, however, comes more properly under abdominal surgery, which
at present offers to the general surgeon a chapter of greater interest than ever before.
There is but a single rule. When the obstruction to the intestine endangers life,
an exploratory operation must be undertaken in order to determine the conditions
accurately, and, if possible, restore the parts to their normal state and function.
hernia (Wilkinson's cat., p. 155). In St. Bartholomew's, specimen 74 of series xvii is an example (cat., p. 334). At
the New York Hospital Museum, specimens 406, 407 are both examples of traumatic phrenic hernia (cat., p. 189). In
the Boston Medical Improvement Society's Museum, 493, a dry specimen, is a hernia through an old stab-wound of the
diaphragm (cat., p. 141.)--(Medical and Surgical History of the Rebellion, p. 185.)
31

CHAPTER XXI.
COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES FOR THE RELIEF OR CURE OF
HERNIA.
It has long been the verdict of surgical opinion that operative measures for the
relief of strangulated hernia should be undertaken with promptitude, and yet it is
astounding in how large a proportion of cases a useless and dangerous delay occurs
before such service is called into requisition.
There can be but one rule, and it is impossible to emphasize too greatly its enforce-
ment, regardless of the variety of hernia or the causes which have led up to the stran-
gulation of a portion of the abdominal contents. Each hour of delay in its reduc-
tion adds to the difficulty of its accomplishment, and almost in geometric ratio
increases the danger to life. There can be no question that the duty of the practi-
tioner, as soon as the condition of strangulation is made apparent and slight efforts at
reduction have failed, is at once to etherize his patient and apply taxis with all the
skill and caution at his command. In case of failure at reduction, he should either
proceed at once himself to operate, or secure such surgical assistance as he may be
able to procure. I can not question but that it should be held as an imperative duty
that every practitioner of medicine, located where he can not command competent
surgical aid, should so fit and qualify himself as to be competent to perform the opera-
tion for the relief and attempted cure of a strangulated hernia. The life-trust is a
sacred one, and the delay of even a few hours makes the conditions worse, with the
chance of greatly endangering the results. I have sometimes thought that operative
measures for the relief of strangulated hernia should be taught as a part of the emer-
gency courses in surgery, since the strangulation of an intestine unrelieved leads as
surely to death as any of the accidental conditions to which mankind is liable. The
one and only sad feature of my experience in the operation for hernia, extending over
more than twenty years, is the condemnation which has so frequently followed from
operating too late. Even now, I often see cases occurring in the hands of practition-
ers, who, although well informed in a general way and competent to discharge the duties
(218)

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
219
a
intrusted to them, after an effort at reduction of a strangulated hernia, narcotize their
patients to relieve pain, apply hot fomentations locally, poultices, etc., waiting in an
expectant way for the relief which Nature is unable to give. If I write for no other
purpose than to ring out anew the alarm and summons to a prompt rescue of impend-
ing danger, my effort will not be in vain.
Although in a considerable measure this has been the teaching of the surgical pro-
fession for the centuries, since the introduction of ether into general use, we have in
this one agent alone that which is more valuable than all others combined to aid us in
the reduction of hernia. When we contrast its use with that of the various measures
which it replaced, we are indeed grateful for the greatest boon ever furnished the surgi-
cal profession. The remedies most relied upon, prior to ether, were bleeding to faint-
ness, and the use of the injection of a decoction of tobacco in amount sufficient to pro-
duce almost a deathly sickness. Even these remedies are not yet entirely without
their advocates. The greatest possible harm that results from any attempted medi-
cated relief is in the fact that it consumes time, and is a dangerous process of educat-
ing the physician, as well as his patient, up to the point of surgical measures which it is
so all-important promptly to determine.
Regardless of earnest warning to the profession and the community alike, the sur-
geon will from time to time be obliged to determine what is best to do after constric-
tion of the abdominal contents has endangered the vitality of the organs involved.
The subject may be properly divided, and I shall take into consideration first its least
important factors.
The Integuments. The skin and the tissues which cover the sac in hernia vary
greatly in appearance. Ordinarily they are themselves not involved in a way to
impair their vitality, although the greatest of danger may exist directly beneath them.
In large scrotal herniæ there may be a general oedema, infiltration beneath the skin,
with redness and greatly increased sensitiveness of the cutaneous surfaces. This may
go on, little by little, to mortification. The same may be true in the coverings of a
femoral hernia. It is perhaps more commonly met with in old, large umbilical herniæ.
The cause of this change and its significance are important in teaching the conditions
of the contents of the sac. Although the changes in circulation and nutrition in the in-
vesting envelope are in a measure interfered with from pressure, the necrosis which
supervenes may oftentimes be traced directly to the infective changes which have com-
menced in, and extended without, from the imprisoned loop of intestine. Septic

220
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
poisoning, thus set up, spreads rapidly, and the partially devitalized tissues become
an easy prey to further bacterial infection.
The important practical lesson to be deduced from these changes is to understand
that, when these pathological conditions exist, it is very probable that they are the pre-
cursors of dissolution, and that surgical aid, although rendered, gives only a forlorn
hope of cure. This is all the more important to note, since in this extreme state of
the disease the pain has frequently disappeared, the swelling lessened, the patient is
bright and hopeful, and the attending physician greatly encouraged in the expectation
of recovery. This seeming improvement is generally of short duration, and death not
seldom suddenly supervenes from a general toxemia.
The Sac.—The parts inclosing the misplaced abdominal organs not seldom are so
changed as to involve their integrity. This, however, is of less importance, as I have
elsewhere shown that the general verdict of authority is in favor of the removal of
the sac, and I have given at length my own reasons for the enforcement of this as
a general rule for surgical guidance, although subject to certain exceptions. Cer-
tainly, whenever there may arise any question as to the devitalization of the sac, there
can be no doubt but that there is only a single rule to be enforced : it must be removed.
Occasionally the surgeon will meet with complications, caused by injury to the sur-
rounding tissues by misdirected efforts toward reduction. I have more than once seen
this condition, and felt obliged to dissect away a certain amount of tissue the vitality
of which had been endangered by the bruising of the parts.
As an illustration of the pathological conditions occurring in the sac and the tissues
enveloping the hernia, I insert the following plate from Scarpa. Fig. 4 shows exceed-
ingly well the changes incident to the peritoneal envelope in a marked case of hernial
constriction.
PLATE LI.*
Figure 1.
d. The omentum surrounding the protruded
a, a. A loop of ileum protruded at the left intestine.
groin.
e. The omentum forming a sort of ring b, d, e,
6. The omentum adhering to the finner side strangulated the loop of intestine, and is firmly
b
of the neck of the hernial sac.
attached to the # posterior part of the hernial sac.
C, c. The edge of the omentum which did not f. The place where the omentum produced
adhere, turned back on the fouter side of the the strangulation of the intestine in the greatest
hernial sac.
degree.
* Scarpa, Plate V.
+ Mesial.
| Lateral aspect.
# Dorsal aspect.


Plate LT
Fig. 3.
Fig.1.
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9
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پراسرار
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Fig.2.
P
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6
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6
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Fig. 4.
کرا

PLATE LI.
PI. V.
bang
Wote


COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
221
g. The bottom of the hernial sac.
p. Part of the left rectus muscle.
h. The* external covering of the hernia
9. Part of the great sac of the peritonæum.
formed by the membrano-aponeurotic sheath of
the cremaster muscle.
Figure 3.
i, i. The vaginal coat of the testicle laid open. a, a. The aponeurosis of the external oblique
k. The testicle.
of the right side.
1. The epididymis.
b, c. The integuments of the groin and of the
m, n. The integuments of the groin and scro-
scrotum.
tum.
d, d. The hernial sac.
0. The right testicle inclosed in the scrotum.
e, e, e. The omentum protruded in the hernia
Þ, 2, 9. The aponeurosis of the external ob-
and adhering to the bottom and sides of the her-
lique muscle of the abdomen.
nial sac.
r, r. The left inguinal ring.
f. A strip of omentum like a ribbon, adher-
s. The ventral aorta.
ing to the neck, to the sides and bottom of the
t. The inferior vena cava.
hernial sac which compressed the loop of intestine
u. The lumbar vertebræ.
at its middle so as to form two small loops, one
X. A portion of the left psoas muscle.
on each side of the omental band.
y. Part of the great sac of the peritonæum.
g, g. The two small loops of intestine dis-
tended with air, and projecting on each side of the
Figure 2.
omental band f.
a. A portion of the aponeurosis of the exter- h, i. Continuation of the sheath formed by
nal oblique muscle of the abdomen constituting the membrano-aponeurotic expansion of the cre-
the superior | or internal pillar of the left ingui- master.
nal ring.
k. The spermatic cord.
b, b, b. The hernial sac formed by the perito- 1. The testicle.
næum.
m. The epididymis.
C, c. The ileum in the cavity of the abdomen.
d. A loop of it protruded in the hernia.
Figure 4.
e. Part of the omentum in the cavity of the a, a. The aponeurosis of the external oblique
abdomen.
muscle.
f, f. Fissure formed in the omentum by the b, b, c, c. The hernial sac laid completely open.
loop of intestine protruded in the hernia.
d, d. Constriction of the sac a little below its
&, g. Adhesion of the omentum posteriorly # middle.
and to the sides of the hernial sac.
e. The superior cavity of the hernial sac.
h. A complete ring formed around the loop of f. The I inferior cavity of the hernial sac.
intestine by the omentum lacerated about its mid- 8, 8, 8. The deep fossa of the superior cav-
dle, and adhering posteriorly || and to the sides of ity of the hernial sac.
the hernial sac.
h, h. A dotted line, marking the bottom of
i, i. Hard and callous edges of the preternat- the 1 inferior cavity of the hernial sac behind the
ural fissure of the omentum.
testicle.
k. The spermatic cord pushed toward the i, i. Membrano-aponeurotic expansion of the
A outer side of the hernia.
cremaster, lying over the tunica vaginalis testis.
1, 1. The vaginal coat of the testicle.
1,1. The vaginal coat of the testicle laid open.
m. The epididymis.
m. The testicle.
n. The testicle.
n. Part of the epididymis.
0,0. The integuments of the groin and scrotum. 0,0. The integuments of the groin and scrotum.
>
* Peripheral.
+ Atlantal.
# Mesial, as to insertion.
# Dorsad.
| Dorsad.
A Lateral aspect.
0 Atlantal.
1 Sacral.
t Atlantal.
Sacral.

222
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Omentum.-As would naturally be inferred from its shape, position, and function,
the omentum will very commonly form a portion of the extruded part of the abdomi-
nal contents in all varieties of hernia. Although manifestly far less important than
the intestine, omental hernia, called by the earlier writers epiplocele, is a cause of great
discomfort and suffering, and of frequent danger. In nearly all the varieties of irre-
ducible or adherent hernia the omentum forms a part. Very commonly, when the
intestine is involved, the omentum is also an accompanying portion-entero-epiplocele.
Not seldom, in delayed cases of operation for strangulated hernia, the omentum has
been so long and closely constricted as to cause its necrosis, although its vitality, as a
rule, is much less liable to be endangered than that of the intestine. . When necrosed,
withdraw the parts sufficiently from the wound to make the line of demarkation clearly
apparent; disinfect carefully, and apply, with all possible aseptic precaution, constric-
tion (sutures to be preferred to the ligature) through the vitalized portion, and excise
above the part of which the vitality is in danger. It is well to emphasize, that a com-
mon surgical fault in the deligation of tissues is, that the part inclosed in the ligature
is so tightly constricted, as to cause necrosis by the ligature itself. One of the lessons
of modern surgery is, that the ligature must never be applied with a force sufficient to
effect this, even in the occlusion of the larger arteries. It frequently is advisable to
remove very considerable portions of omentum when operating upon large irreducible
herniæ for the purpose of complete cure. In these conditions, not seldom the omen-
tum makes up the great bulk of the tumor, and it has been so long retained in the
sac that it has become greatly deformed. Although in a measure constricted, it is
not devitalized, and the nutrition has gone on in such a way that the fatty deposit in
its meshes has produced a tumor of very considerable size. This is so blended
together that it can be unraveled with difficulty, leaving many minute bleeding points,
which renders it unsafe for its return into the abdominal cavity. It may, again, be so
changed as to make it impossible to separate it from its inherent adhesions, and there-
fore its removal becomes necessary. Some of the modifications to which the omentum
is liable in large, old, retained herniæ are extremely complex and confusing. Whenever
these changes have gone on to a degree which renders it unwise to attempt the restora-
tion of the omental mass, it should be removed. The portion through which the division
is to be made, is oftentimes far too large to admit of safety by including it in a single or
double ligature. It should frequently be subdivided into a number of parts; and the
method which I commend as easy, simple, and effective, is the use of the double contin-

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
223
uous animal suture, frequently referred to in this work. It encloses effectually every por-
tion of the tissue involved, which may be subdivided by the stitches to any degree con-
sidered desirable. These should never be drawn too tightly; and if the operator is in
doubt that the occlusion is not sufficient to control hæmorrhage, it is better to intro-
duce a second line of sutures a little away from the first. It is surprising to note how
effectually a moderate uniform compression controls a bleeding, which otherwise would
be serious. Another advantage arising from this method of suturing is, that a broad
fan-like edge of omentum can be thus divided, and returned very little puckered,
or deformed, thereby serving far better its physiological function. I have oftentimes
removed large masses of omentum in the manner here recommended without any
serious consequences; and I have never seen a single patient where the hernial
operation was undertaken for any purpose, in which I have considered the changes
which have occurred in the omentum, and the measures devised for its remedy, to have
endangered the life of the individual.
Intestines.—When a constriction about a loop of intestine has been maintained for
a considerable period, it is interesting and important to note the changes which have
taken place in the parts involved. The danger is, of course, dependent in direct ratio
with the force applied at the point of constriction, and its duration. This may be so
great as to cut off entirely the venous return-current, or the blood-supply furnished to
the parts. Necrosis rapidly ensues, and death has supervened within fifteen to twenty
hours. It is more likely to occur in the varieties of femoral hernia. Oftentimes the
danger from constriction is greatly delayed from the loop of the intestine being
surrounded by a large cushion of fatty omentum. This is more commonly found in
the umbilical variety, where strangulation supervenes in the case of an old irreducible
hernia.
After operation for the relief of a strangulated hernia, the first and most important
question to determine is the condition of the inclosed intestinal loop. Upon the judg-
ment of the operator depends frequently the life of the patient. The intestinal loop is
changed in color to a dark, livid tint; it is frequently surrounded by a small quantity of
purulent serum, and covered with patches of recently effused lymph. This material is
almost certain to be infective, probably from bacteria that have been conveyed
from the contents of the intestinal loop under the pressure exercised upon its walls.
The first duty of the surgeon is to recognize this factor, and disinfection should
be immediate and most thorough, otherwise the implantation of ferments within

224
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
the abdominal cavity may induce peritonitis, and death result. This is best effected
by irrigation. Gently separate any adhesions which may have formed at the neck
of the sac, after which withdraw the loop of intestine without the wound, and mark
the changes that supervene in the circulation of the inclosed part under the stimulus
of the warm irrigating fluid. If the line of demarkation is not clearly defined, and
the dusky hue slowly fades as the circulation is re-established while the inclosed loop is
unloaded of its contents, by the peristaltic contractions, we may safely return it within
the abdominal cavity. It not seldom happens—at least I have observed it in a num-
ber of instances—that the peritoneal coat about the point of constriction has become
so weakened that it separates easily upon slight tension. If lesion of the peritoneal
coat of the intestine exists, it is better to intrafold the separated edges with a fine run-
ning continuous suture. This I have done several times, followed by recovery. It is
well to remember that the strength of the intestine lies mainly in its connective-tissue
sheath, and injuries to its peritoneal coat, although considerable, are chiefly dangerous
from infection which may there find lodgment and develop. The extent to which the
intestine, in strangulated hernia, may be affected with necrosis varies from a small spot
to a more or less considerable portion of the entire canal. This is dependent upon the
constricting force which often bears very unequally upon the part involved. As may
be supposed, the tissues primarily and to the greatest extent affected by this change lie
directly beneath the surrounding ring, and not seldom in small herniæ a very limited
portion of the intestine is subjected to close constriction. I recall a case of femoral
hernia, operated upon some years ago, followed by relief, death supervening from gen-
eral peritonitis, where the autopsy disclosed a minute opening into the small intes-
tine, and the whole portion of the bowel involved in the stricture was apparently not
much larger than the thumb-nail. If the surgeon finds a very limited necrosis, as in the
case described, with or without an opening, it is better that he intrafold the part in-
volved and unite over it the healthy peritonæum by lines of fine continuous sutures
with the running Lembert stitch, care being taken not to penetrate through the mucous
coat of the intestine. Under such conditions, should Nature be able to repair the dam-
age after the surgical relief of the stricture, without an opening in the intestinal wall, the
suturing, if made carefully as directed, would probably not add to the danger of the
outcome, by the stenosis of the canal. In the event of a slough forming, the general
peritoneal cavity would be protected by the rapid lymph effusion which takes place,
re-enforcing and burying the lines of suturing.
a


PLATE LII.
Fig.4
Fig.3.
d
CORO
Fig.6.
6
С
a
Fig.
b
e
B
C
a
е
Fig.2.
Fig.5.
a
6
А
co

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
225
a
When marked conditions of gangrene have ensued in the constricted portions of the
intestine, the mortified part is usually of a dull, yellowish-gray, or slate color. When it
is relieved from constriction, it no longer retains its form, but collapses like wet paper,
owing to having entirely lost its power of contraction. The contrast between this por-
tion and the vitalized surrounding part is very marked. This is generally of a bright,
or dusky red color, and is easily excited to contraction.
It is possible for even the experienced surgeon to be in doubt as to the vitality of
the constricted loop of intestine. If so, it is advised that he delay further steps in the
operation for a little while, and watch the changes which ensue under the stimulus of a
hot irrigating fluid, after having removed the constriction from the intestine, emptied it
of its contents, and placed it in a position favorable for the unloading of the vessels
through which the circulation has, for so long a time, been impeded.
PLATE LII.*
VARIOUS CASES OF INTESTINAL STRANGULATION.
Figure 1.
dental crural canal. The femoral vessels are seen
(Borrowed from Scarpa.) Strangulation of
on the posterior wall.
an intestinal loop by the neck (a) of a hernial
b. Shows the strangulation of the intestinal
sac, with constriction caused by two appendices loop through the peritonæum, which has been
(6 and c) of a portion of the large epiploon (d),
torn under the pressure and allowed the intestine
which passes in front of the intestinal loops, while
to pass without forming a hernial sac.
another portion (e) passes behind.
Figure 5.
Figure 2.
Case shown in three views A, B, C. The
(Taken from Dupuytren's collection.) Stran-
large intestine is narrowed in the angle of union
of the transverse and descending colons. The
gulation of two intestinal circumvolutions, upon an
adult male, by a loop of the large epiploon adher-
stools were suppressed for thirty-nine days before
death.
ing to their peritoneal tunic.
a. A small portion of bone, which seems the
Figure 3.
first cause of irritation, was found imbedded in
the thickened intestine.
Strangulation, in a young woman, of the cæ-
cal extremity of the ileum by a fatty appendage
b. An annular narrowing of the opening to
of the cæcum.
less than a centimetre.
c. Adhesions of the fatty appendices strength-
Figure 4.
en the strangulation.
Crural hernia in a male. Internal strangula- d. An adhesion of the intestine with a com-
tion from a tear in the peritonæum. A crural mencing erosion (e).
hernia with strangulation has been reduced; but f. The transverse colon, with thickened walls,
the effects of the strangulation have remained. dilated below the strangulation into a large cav-
a. The primitive site of the hernia in the acci- ity (f).
* Bourgery, Plate XXXII.
32

226
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
g. The descending colon, on the contrary, is valvular folds very numerous in the cæcal extrem-
thinned out in its walls and greatly contracted. ity of the ileum, which has caused the narrowing,
then the swelling, and, at last, the symptoms and
Figure 6.
effects of an intestinal strangulation.
A singular case of abnormal development of
a
Having found that necrosis has supervened, the all-important question of subse-
quent operative measures must now be determined. Here, unfortunately, precise rules
for direction can not be formulated. One of the most noteworthy triumphs of modern
aseptic surgery is in the treatment of wounds of the intestine. Even several wounds, or
the resection of the entire intestine, does not necessarily involve a fatal result. Such
patients sometimes make seemingly easy and rapid recoveries. Owing to the encour-
agement given by this brilliant chapter of surgical experience, it has seemed possible to
many that it should modify our rules for guidance in injuries of the intestine resulting
from the comparatively slow constriction in hernial incarceration. I must myself admit
having been among the first gladly to accept, and, as I had hoped, to profit by the
lesson; but in each case of resection of the intestine which I have made in preference to
an artificial anus, death has supervened—five cases in all. I do not think that it by any
means follows that life would have been preserved had I adopted the opposite course,
but this experience has taught me to enter carefully into the consideration of the
differences in the factors presented in the problem before us. We must remember that
in cases of necrosis in strangulated hernia usually some days of constitutional disturb-
ance have preceded, that a general condition of septic poisoning is present, and that the
great vital forces are extremely depreciated.
Mechanical changes have supervened especially in that portion of the intestine
above the constriction, and active and extreme conditions of fermentation have taken
place in the watery contents with which the intestine and stomach are too commonly
distended. Scarpa called attention to this condition, which it is so important to know,
and wrote: * “The extreme distention of the upper part of the intestinal canal, and the
increased action excited in it to free itself from the distending and irritating cause, are
the principal source of the acute pains which the patient feels in the whole circumfer-
ence of the abdomen, and especially in the umbilical region, which are much greater
than those occasioned by the strangulated intestine. This state of violent irritation and
increased action, always accompanied by great inflammation, and afterward gangrene, is
* Treatise on Hernia, p. 266.

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
227
what, properly speaking, kills the patient, rather than the incarceration of the intestine
included in the hernia. I am of opinion that if the rupture of the strangulated intestine
occurred much more speedily than it commonly happens, and before that portion of the
intestinal tube continued from the stomach were subjected to the enormous distention
and excitement, such as are observed in the bodies of those who have died of strangu-
lated hernia, the event of this severe disease would not be, at least, either so quickly
or so frequently fatal.”
It is impossible to formulate rules for guidance in the treatment of the intestine
which has become gangrenous from hernial constriction.
Very naturally the first factor, already emphasized, is the general condition of the
patient, which too often peremptorily forbids the necessarily difficult and somewhat
prolonged operation for the resection of the gangrenous portion and the coaptation of
the vitalized parts.
When this is the condition, the only alternative is an artificial anus, with the possi-
bility of a radical operation at a later period. It is well to remember, even here, that
the portion of the intestine involved must govern in a considerable measure the decis-
ion of the operator, since, if high up in the intestinal tract, the processes of digestion
are necessarily so limited that starvation may ensue.
Fortunately, the extreme conditions which supervene in a strangulated gangrenous
hernia allowed to go to a natural terminus, are now rarely met with. When they do
occur, adhesive processes usually precede, and the sound portion of the intestine is
rather firmly agglutinated to the neck of the hernial sac, which serves as a protection
to the abdominal cavity. After the separation of the gangrenous parts retraction
ensues, drawing inward the divided extremities of the intestine, as also the modified
neck of the hernial sac, which in a measure forms a substitute for the loss of tissue, and
the feculent material descending from the superior orifice of the intestine, by making a
semicircle, passes into the lower part of the bowel. When operations are undertaken
in these extreme conditions, temporary relief only is possible ; the adhesive processes
which have supervened should be left undisturbed, and only a safe exit established
for the feculent material which so greatly distends the obstructed, overloaded intes-
tine; and this, in any form of hernia, involving any portion of the intestinal canal, is
called an artificial anus.
The accompanying illustration, from Scarpa's work, shows the pathological condi-
tions exceptionally well.
a

228
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
PLATE LIII.*
næum.
g.
Figure 1.
c. Segment of the ileum included in the stran-
a, a, a. Part of the great sac of the perito- gulation caused by the neck of the hernial sac.
d. Remains of the circumference of the intes-
b, b, b, b. The part of the great sac of the
tinal canal where the mesentery is attached,
peritonæum, which formed the neck of the her- which was not strangulated by the neck of the sac.
nial sac, and which is converted into a membra-
,
e. The mesentery.
nous funnel, or passage of communication be- f, f. Part of the great sac of the peritonæum.
tween the two apertures of the intestine divided 8,8. The hernial sac stripped of the A exter-
by gangrene.
nal covering formed by the aponeurosis of the cre-
c. The superior forifice of the divided intes- master, and degenerated into a pulpy substance
tine.
of a brown color.
d. The finferior orifice of the intestine.
h, h. The precise place where the ileum was
e, e. The place where the hernial sac strangu- strangulated by the neck of the hernial sac.
lated the intestine.
i. The spermatic cord stripped of the sheath
f. The promontory or projection formed by of the cremaster.
the approximation, in a parallel line, of the two k, k. The vaginal coat of the testicle, after
portions of the intestine divided by the gangrene. the removal of the aponeurotic sheath of the cre-
The intestinal canal uninterrupted on the master, within which it is inclosed.
side next to the attachment of the mesentery.
1. The testicle.
h, i. The furrow along which the feculent
m. The epididymis.
matter descended, passing from the superior ori- n. The spermatic vessels in the vicinity of
fice of the intestine into the membranous funnel, their insertion into the testicle.
whence it was directed into the inferior aperture
Figure 3.
of the intestine.
k, l. Fistulous canal of the groin, formed a. The ( superior portion of the ileum.
partly by the remains of the neck of the hernial b. The I inferior portion of the ileum.
sac, partly by the aponeuroses of the abdominal C, C, C. The ileum laid open, including that
muscles, and by the common integuments of the portion of it which had been strangulated by the
neck of the hernial sac.
groin.
m. The # superior part of the ileum.
d. The promontory formed by the approxi-
n. The || inferior part of the ileum.
mation of the two portions of the intestines a, b,
0. The mesentery.
in a line parallel to each other.
p. The aponeurosis of the abdominal muscles,
e. Deep depression of the superior portion of
turned back upon the femoral arch.
the ileum above the I promontory.
9, 9. The crest of the os ilium.
f, 8. The furrow by which the feculent matter
r, r. The articular cavity for the head of the prepared to descend from the superior orifice of
femur.
the intestine into the membranous funnel, after
s. The fat.
the separation of the gangrened portion of the
t, t. Tuberosity of the ischium.
strangulated intestine.
h. The continuation of the internal membrane
Figure 2.
of the intestine.
a. The superior portion of the ileum.
i, i. The seat of the strangulation caused by
b. The inferior portion of the ileum.
the neck of the hernial sac.
I Atlantad of.
#Orifice leading to the stomach.
* Scarpa, Plate IX.
+ The orifice leading to the stomach.
| The orifice leading to the rectum.
# The part leading to the stomach.
| The part leading to the rectum.
A Peripheral.
0 Portion leading to the stomach.
| Portion leading to the rectum.


Plate LIII.
Fig.1
n
m
9
9.
g
a
f
---
Fig. 3.
Frgia
6
a
b
d
Fig. 4
b
m
a

PLATE LIII.


COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
229
k, k. The hernial sac, after the removal of the
aponeurotic sheath of the cremaster, changed in
texture, in consequence of the preceding inflam-
mation.
1. The spermatic cord.
m, m. The vaginal coat stripped of the apo-
neurotic sheath of the cremaster.
n. The epididymis.
0. The testicle.
Figure 4.
a. The extremity of the ileum.
b. The colon.
c, c. The cicatrix of the integuments of the
groin.
d. The colon adhering to the cicatrix of the
integuments of the groin.
The measures adopted for the cure of this most unfortunate condition furnish an
exceedingly interesting and instructive chapter in surgery, but it is foreign to the pur-
pose of this work to enter in extenso upon its discussion, and therefore I am obliged to
refer the reader interested in this subject to the larger treatises upon general surgery.
If it is determined to operate by the resection of the gangrenous portion of the intes-
tine, it is essential that the preparations be made previously so complete that no time
shall be wasted, as the prolongation of operative procedures adds greatly to the danger.
If possible, the surgeon should have had previous experience in operating upon animals,
since the technique of intestinal surgery is entirely different from that of ordinary oper-
ative measures. Careful coaptation of wound-edges and the accurate apposition of
serous surfaces must be effected. Very much time is spent in the tying of fine wet
sutures, with fingers sticky with blood, in the soft, slippery intestine. The interrupted
sutures, as usually applied, are from twenty to thirty in number, and the numerous knots
produce much more extensive inflammation and adhesions than result from the use of
the continuous suture. The so-called Lembert suture, in which the needle enters and
emerges through the peritoneal surfaces of the intestine, the latter point being several
lines away from the cut surface of the bowel, marked an important advance in intes-
tinal surgery, since by it the divided edges are inverted into the bowel, and that portion
of the peritoneal covering of the intestine included by the suture is coapted, and speed-
ily becomes firmly agglutinated by effused lymph.
For a number of years I have felt that the continuous Lembert suture, as ordinarily
applied, was faulty ; since this incloses necessarily the peritonæum in a series of
constricted loops, which cause a wavy or puckered line of union.
A very simple modification, coapting evenly the peritonæum yet more rapidly, is
effected by introducing the needle through the peritonæum and the tough connective-
tissue layer of the bowel, avoiding the mucous membrane, parallel to the cut surface of
the intestine, a little less than a quarter of an inch from its edge. This stitch should in-
a
a

230
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
clude about one eighth of an inch of the surface, and enter exactly opposite the point
of emergence in the corresponding section of the bowel. Thus one stitch follows an-
other until the complete circuit of the intestine is made, each stitch as taken being
drawn sufficiently tight to appose accurately the peritoneal surfaces. It will be found,
when thus united, that the cut edges are inverted to the extent of the distance of the
line of sutures from the divided edge; that the suture itself not alone firmly coapts the
peritoneal surfaces with accuracy, but that it is itself completely buried within the
tissues, and, if carefully done, without any appreciable constriction of the caliber of the
bowel. In several instances I have applied a second line of sutures parallel to the first,
and three or four lines distant from it, as a still further guarantee against failure.
The operation is briefly described as follows: Having withdrawn sufficient of the
intestinal loop from the abdominal cavity to make it easy for manipulation, press back
the intestinal contents with the thumb and finger several inches in either direction,
naturally the one from above being the more important in hernia. At the selected
points compress gently the bowel with spring forceps, properly constructed, the broad
blades of which are covered with rubber. Resect the necrosed portion and irrigate
the parts carefully. Wash the intestinal canal with the bichloride-of-mercury solution,
having first properly protected the abdominal cavity. Unite the mesenteric attach-
ments of the sundered loops with care, and then join the cut ends of the bowel equidis-
tantly with four interrupted sutures, the especial object of which is to hold the intes-
tine for guidance to accurate coaptation. A fine straight needle, threaded with a care-
fully selected tendon, is introduced at one side of the mesenteric attachment by an
inverted Lembert stitch, fastened in a loop-knot or tied in the ordinary way. Then
introduce rapidly but accurately what, for want of a better definition, I have called the
parallel, buried continuous Lembert suture, since it is taken always parallel to the line
of division, in the manner described for the skin suture, introduced through the deeper
layer only, for the coaptation of the cutaneous surfaces. A portion of intestine can be
thus united post-mortem, which will hold a considerable column of water.
The advantages of uniting the intestine in this manner are emphasized as follows:
1. It gives the most perfect coaptation.
2. It is less difficult than any other method.
3. Its application is more rapid ; the operation, under favorable circumstances, can be
completed in fifteen minutes, even if re-enforced by a second line of sutures. It is, of
course, important that the stitches should be so taken as not to involve the mucous

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
231
a
membrane. Intestinal obstruction and its complications, with the attempts at relief and
cure, have an interest and value rarely exceeded in any of the modern contributions to
surgery. We are largely indebted to the experiments and extended observations of Dr.
Nicolas Senn, of Chicago, who has worked out the task which he assigned to himself
with a patience, skill, and fidelity, rarely excelled in any department of original research.
His methods of union by the use of bone-plates and sutures, peculiarly his own, offer
many advantages, but reproduce the same fundamental idea referred to in another
chapter by devices which were successfully carried into effect in a former century;
and were it necessary to apply special means to prevent the undue narrowing of the
lumen of the canal, the trachea of a calf, as then recommended, would serve an admi-
rable purpose. Dr. Waldo Briggs, of St. Louis, has recently carried on a series of
experiments upon the resection of the intestine, closure of wounds, etc., which I judge
of sufficient importance to abstract freely from, by his special permission, and he is to
be congratulated for having demonstrated the advantages of his method by two suc-
cessful operations upon the human subject. Dr. Briggs's object is to be assured of the
safe closure of the intestine before its return into the abdominal cavity. He writes:
“ Believing that some of these dangers, at least, could be avoided if a method could
be devised by which the intestine could safely be maintained outside the abdominal
cavity, where it could be examined at will by the surgeon, until the process of repara-
tion was sufficiently advanced to justify him in returning it to the cavity, I undertook
a series of experiments upon dogs, which proved that not only was this feasible, but
that, under the precautions and circumstances about to be detailed, Nature assists the
reparative process, and that in a marvelously short space of time union between the
wounded parts (the severed ends of an intestine from which a portion has been excised,
for example) is so complete as to obviate all danger of relaxing sutures, fecal extrava-
sation, etc. Not only is this the case, but inflammation is reduced to a minimum and
peristaltic action in the intestine apparently completely suppressed.
“The features of my method by which these effects are produced, and which differ
from all others hitherto suggested, are :
“1. The maintenance of the wounded intestine outside the abdominal cavity during
the preliminary stages of reparation.
“ 2. The use of an animal membrane as a covering of the wounded portion of
intestine and the sutures.
“ The precautions usually observed in similar laparotomies are followed in preparing
a

232
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
the animal for the operation. The hair is shaved off the abdomen, the surrounding
surface is washed first with carbolic or campho-phenique soap, and, after drying, with
pure campho-phenique. Of course, the instruments and all material used in and
around the operation are carefully asepticized, etc. The subject is placed in a trough,
bound as usual in such cases, and thoroughly anæsthetized. The incision is made in
the linea alba, or at a point on the surface nearest to the part upon which it is desired
to operate.
“ After entering the cavity, a loop of the intestine embracing the portion to be
operated upon is drawn up through the opening. If enterectomy is to be performed,
compression is made on each side of, and at least one inch and a half from, the pro-
posed line of incision, by rubber bands or by clamps or forceps whose blades are cov-
ered with soft rubber tubing. The section is then made either diagonally or straight
through to the mesentery. The abdominal wound, intestine, and surrounding parts
are carefully and thoroughly cleansed with warm water, and the severed ends of the
intestine are brought together preferably by the loop or
button-hole suture, as in Lembert's method (Fig. 20),
though, owing to the protective and cohesive action of the
membrane, any suture that will coapt the edges may be
used.
FIG. 20.—Showing method of The membrane, which may be taken from any of the
serous surfaces of a recently slaughtered animal (bullock,
sheep, and hog membranes having been used by me, and each giving good results),
is now taken from the four-per-cent solution of carbolic acid in which it has been
resting and applied to the intestine so as to cover the sutured ends and stitched
to the mesentery by a few light sutures, either continuous or interrupted, of the finest
cat-gut.
“In my earlier operations and experiments, in searching for the best manner to
maintain the loop of gut in the wound, I used rubber bands, stretched across the
latter from lip to lip and held in place by pins. This arrangement enabled the wound
in the abdominal parietes to adapt itself to the breathing of the animal, and kept the
intestine gently but firmly held within the same. At that stage of my work I also
used thin India-rubber gauze to protect the intestine until I was ready to return the
latter to the abdominal cavity. When, however, as the result of a happy suggestion,
an asepticized animal membrane was substituted for the India-rubber, I found that the
1215
11h
Thu
hu
gibi
16
suture.

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
233
ia
Cross sect.ro
1
bas
1
CO
I
a
tendency of the substitute to adhere quickly and closely to any freshly wounded,
abraded, or serous surface with which it came in contact, produced adhesions with the
edges of the incision which were difficult to
break up without causing considerable hæm-
orrhage. I therefore devised the apparatus
or ring shown at Fig. 21, the object of which
is to protect the lips of the incision through
3
the abdominal parietes, and to give support to
the pins which separate the loop of intestine
Longitudinal Sees
FIG. 21.-1, Ring seen from above, a a' fenes-
and keep the same in place. This ring, shown
trations for passage of pins ; 2. cross section ;
in perspective plan and section in Fig. 24, is
3, longitudinal section of same. One half to
one third natural size.
oval in shape, 3'' in its longer and 1.5" in its
shorter diameter. The one I am now using is made of block-tin, but I think a
lighter one of hard rubber would be better.
" The membrane having been applied and lightly stitched to the mesentery, the
abdominal ring is now applied, being slipped over the loop of intestine and fitted into
the wound in the parietes. Two long steel pins, A and B, are now passed through
the skin, slit in ring, membrane, and mesentery, on one side and out in reverse order
.M
R
R
С
AD
В
D
FIG. 22.
FIG. 23.
FIG. 22.—Showing ring in place, and the loop of intestine held in position by pins. The mesentery is not shown, in
order to allow course of pins to be seen. M, membrane, shown in section only. m, the dotted line, marking lower
edges of membrane. R, ring. S, surface of abdomen.
FIG. 23.–The ring, intestine, etc., seen from above, the membrane covering gut being removed to show sutures and
course of pins. m, membrane, showing method of passing pins A and B. R, ring. S, surface of abdomen.
a
on the other, as shown in Fig. 22. Pins C and D are then passed, in a similar manner,
through the side of abdominal wound, ring, serous coat of lower ends of loop of intes-
tine, above and below, and out in reverse order, as in A and B.
33

234
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
A
B.
“A batting of absorbent cotton, the smooth surface of which is well covered with
pure glycerin, is now placed (glycerinated side downward) over the exposed gut, and
the whole covered with a dry layer of ab-
sorbent cotton sufficiently large to com-
--
pletely protect the wounded surfaces.
Bandages are unnecessary.
“ When, in the course of three or four
FIG. 24.—Showing method of closing incised wound hours, the cotton covering is removed, a
in intestine and applying the membrane. The
artist has shown far too many stitches in the
remarkable transformation will be found
latter, as one or two very light tacks to serous
to have occurred. The membrane, which
coat of gut on each side are all sufficient.
when applied to the intestine fitted loosely
and irregularly, will be found lying smoothly and tautly stretched over the surface with
which it has been placed in contact, and so closely and firmly united thereto at
every point as to form practically a part of the intestinal walls.
Its physical appear-
ance seems also to have undergone a change ; from the flabby,“ dead” look which it
had when first applied, it has assumed a “living” appearance, and its edges, above and
below (at line m, Fig. 22), have smoothly beveled themselves, so that, except for the
difference in color, it would be almost impossible to discover the line of juncture.
Even now, only four hours after the operation, the gut may be dropped back into
the abdominal cavity with full assurance that there will be no giving way of stitches,
and no separation of the joint or splice made at the line of juncture of the severed
ends of the gut.
" It is better, however, to wait two or even four hours longer before withdrawing the
pins, removing the ring, and letting the intestine fall back into the cavity and closing
the incision in the abdominal parietes.
“In none of the experimental operations that I have made since adopting the use of
the animal membrane has the temperature of the subject at any time gone beyond
101° Fahr.
“ From the moment that the loop of gut is fixed in the external wound peristaltic
action seems to cease, and is not resumed until the gut is dropped back to its place. In
no instance has a subject had an action from the bowels while the gut was in the posi-
tion named; and in every instance, as soon as the gut was dropped back and the
external wound closed, the animal had a copious evacuation.
“The extra-abdominal method, as I call this for lack of a better term, seems to me to

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
235
a
be applicable in all laparotomies for wounds, injuries, or diseases of the intestinal tract,
except, of course, in those cases of multiple perforations caused by gun-shot or other
agencies, where the wounds are found at widely separated points. In these, after appli-
cation of the membrane, the intestine should be dropped back into the cavity at once.
“It also seems to me that the use of the animal membrane, as described, has a wide
range of application in surgery. Among the more prominent operations wherein I
believe it will be found extremely valuable, I may mention its application to the ped-
icle after ovariotomy, whereby the danger of adhesions will be very much lessened or
entirely obviated. It may also be used as an application to the stump after amputa-
tions of the uterus, and to surfaces denuded of skin by burns or other injuries.
“Dr. F. L. James, a number of years ago, called my attention to the uses made of
animal membranes by hunters and trappers in their rude surgery in cases of emer-
gency, and also as coverings for surface wounds of all descriptions. Recently, in inves-
tigating the matter afresh, I found that butchers and men employed about slaughter-
houses are nearly all aware of the great value of animal membranes in the direction
mentioned, and are in the habit of applying them to cuts and fresh wounds of every
description.
“ To sum up, in conclusion, the remarkable features of the operation as developed in
the course of my experiments, I will note :
" 1. The great rapidity and firmness with which the membrane adheres to the intes-
tinal surface.
“ 2. The absence of any notable degree of shock produced by keeping the intestine
outside the abdominal cavity during the healing process.
very short time required for repair to the intestine to progress sufficiently
to warrant the restoration of the latter to the abdominal cavity, viz., five or six hours,
a This is just about the time, too, when the inflammatory process for healing
the abdominal incision is commencing to set up.
“ 4. The absence of peristalsis during the period that the loop of intestine is kept
outside the abdominal cavity.”
The exudation into the intestinal canal, when constricted, is truly enormous,
and frequently the patient is constantly vomiting large quantities of fermented fluid
with stercoraceous odor. It has happened in two cases, after I had finished the
operation for the relief of intestinal obstruction, that death followed from impeded
respiration, caused by the pouring out, rather than vomiting, of a large quantity of
"3. The
as a mean.
>

236
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
fluid from the stomach. Profiting from the sad lesson taught by these experiences
when operating in extreme cases, I have since emptied and carefully washed out the
stomach with a stomach-pump before undertaking operative measures.
Dr. J. Mason Warren * reported a case of strangulated hernia where death super-
vened from the introduction of fecal matter into the oesophagus.
· The operation was performed with great rapidity, only occupying a few minutes.
Some serum was found in the sac, and the intestine much congested. The stricture
was divided and the intestine replaced. The ether was discontinued at about the
middle of the operation. The edges of the wound were brought into apposition, the
patient breathing tranquilly, and the usual preparations made to return her to bed in
the ward. Suddenly the patient (who had made the usual groans and sighs of a
person recovering from ether) made an effort to vomit, and was placed on her side to
facilitate the escape of the fluids from the mouth. These efforts were once or twice re-
peated, when the face became livid, the pulse began to fail, and a loud subcrepitant râle
could be heard all over the chest, the symptoms resembling those of a person asphyxi-
ated from drowning. All the usual remedies were employed to restore her vital pow-
ers, but the pulse and respiration gradually failed, and she died in the course of ten or
fifteen minutes. Autopsy following day. Stomach and intestines entirely filled with
a large quantity of yellow fluid of a very fetid odor. The mouth and fauces were also
filled with a similar fluid. On opening the air-passages this same fluid was found to
have penetrated the most remote ramifications of the bronchiæ. . . . At first sight I
thought I had met with a case of death from the use of ether; but the autopsy re-
vealed the nature of the case.”
Prof. Küster † calls attention to an accident which happened to one of his patients
during operation for the radical cure of hernia, which had a fatal termination. The
patient, a man of fifty-six years, was brought to him suffering with symptoms of an
incarcerated hernia on the right side. Operation for the radical cure thereof was
performed. Upon opening the hernial sac, a quantity of cloudy fluid escaped, and
the omentum and mesentery made their appearance. The contents of the sac con-
sisted of ascending colon, transverse colon, cæcum, appendix vermiformis, about three
feet of small intestine, with considerable fatty mesentery. Reposition of this intestinal
>
* Surgical Observations with Cases and Operations. Boston, 1867, p. 157.
+ Centralblatt für Chirurgie, 36, 1890, Pittsburgh Medical Review.

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
237
mass was exceedingly difficult, in spite of enlargement of the ring; it appeared as if
the abdominal cavity was too small for the reposed mass. However, after persistent
endeavors it was accomplished. Some time before this it was observed that respira-
tion had become shallow and rapid and the face cyanotic, while there was no attempt
at vomiting, nor even nausea. After closure of the abdominal cavity, the patient
ceased breathing completely, though the pulse remained full and strong. Inasmuch as
artificial respiration proved unsuccessful, the pulse began to weaken, and the pupils to
dilate, Küster rapidly opened the trachea, whence immediately enormous quantities of
gastric contents emerged. By means of a catheter the trachea was cleansed and arti-
ficial respiration was continued; all efforts proved fruitless, however, and the patient
died.
Post-mortem examination revealed enlargement of the heart, due to excentric hyper-
trophy of the left ventricle, with a great deal of atheromatous degeneration of the
aortic walls and valves; the coronary arteries were abnormal, the papillary muscles
degenerated; the lungs oedematous and almost airless. None of the bronchial tubes
contained any of the gastric contents; the bronchial mucous membrane was highly
hyperæmic, the mucus of mild acid reaction. The stomach was empty and collapsed,
the intestines inflated, with many portions of blue-black color, but glossy all over. The
explanation of the accident is evident. The forcing-in of the great hernial mass into
the abdominal cavity, diminished in size in adaptation to the lesser bulk of abdominal
organs, increased the intra-abdominal pressure to such an extent that the contents of
the stomach were forced out through the oesophagus into the pharynx, whence it was
carried into the bronchi during inspiration.
The practical part of this experience is that, before operating upon hernia of long
standing and large contents, the stomach should be washed out carefully, in order to
facilitate reduction of the hernial mass and to anticipate the accident just described.
Although the line of demarkation between the dead and living portion of the in-
testine may be somewhat clearly defined, it is not by any means so clear that the latter
is uninfected and its vitality sufficient to warrant the surgical measure of resection.
However, resection may be more favorably considered, dependent upon that portion of
the intestine which is involved in the stricture. This is illustrated by the case of vagi-
nal hernia already reported resulting spontaneously in an artificial anus into the cul-de-
sac of the vagina behind the uterus. Here we had a most favorable position for an
artificial opening, but the portion of the bowel involved was so high up in the small

238
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
intestine as to interfere very seriously with the processes of digestion, and death from
starvation was imminent.
When the constriction occurs so high up in the intestinal tube as to endanger
life from defective nutrition, it should cause resection of the intestine to be considered
at the primary operation. Oftentimes it happens that about the necrosed portion of
the intestine, presenting at the ring, rather firm adhesions have already taken place.
Nature herself was making ready to relieve the system by a spontaneous opening. In
this instance the surgeon should limit his endeavor by making the opening free, great
care being taken not to break up the adhesions already formed (Hunter).
Suppose this to have been effected and the wound properly cleansed, an effort
should be made to unload the upper bowel and restore peristalsis, not forgetting that
the rectum and lower portion of the large intestine may also suffer from retained
fæces.
A considerable number of cases are on record where adhesions have united por-
tions of the bowel within the ring; an opening in front of this has taken place, which
after a time closed, and the normal function of the intestine was restored. It is under
conditions of this character that it may be accepted that only a portion of the intestine
was involved.
In the great majority of cases where necrosis of the intestine has occurred, the sur-
geon will be at no loss in determining it. Adhesions about the ring will have already
ensued, and an opening into the intestine completes the operation. Under these con-
ditions the outlet of the bowel is usually small, and it may be difficult to free the intes-
tine from its contents through the opening. This risk, however, had better be incurred
than the attempt to enlarge it, since in so doing it is easy to break up the adhesions,
which is Nature's only method for protection from a general infection. Subsequent
treatment is simple. Having emptied the intestinal canal, small doses of saline laxa-
tives are to be given sufficiently often to produce loose dejections, and fluid food
should be taken in small quantities, often repeated.
In the event of protective adhesions not having been formed, or if broken down
at the time of operation, the division of the constricting ring should be made suffi-
ciently free, the upper part of the loop pulled down, so that the vivified portion may
extend quite a little beyond the lips of the wound. The intestine is now carefully
stitched to the edge of the divided ring by two rows of continuous suturing, care being
taken that the stitches do not entirely penetrate through the wall of the intestine.

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
239
The wound is then properly cleansed and its upper edge packed with a slight layer
of iodoform gauze; the necrosed part is divided, and the intestine emptied. It is often-
times wise to introduce within the intestine a large drainage-tube, which admits of a
better protection of the wound from the outflowing fecal material. It is surprising to
note the rapidity with which a patient will rally from conditions which a few hours
before seemed to render dissolution imminent.
It is interesting to study the subsequent processes of repair in such a wound. The
upper end of the intestine slowly retracts; the lower part of the intestine adherent to
the wound is generally kept open without difficulty, and, little by little, the fæces pass
from above downward under the restraint afforded by the protective dressing.
Scarpa was the first to demonstrate the reparative processes which go on under such
conditions, and showed that the ends of the intestine can never reunite to restore
properly the anatomical relationship of the bowel, and that the repair processes, when
sufficient to close entirely the external wound and to restore the continuity of the canal,
are completed by appropriating a portion of the peritoneal sac which contained the her-
nia. This he called a membranous funnel. His demonstrations were based upon many
observations made upon the lower animals, and the careful study of post-mortem condi-
tions of patients in whom restoration of the intestinal tube had thus been effected and
who had died from other diseases. His conclusions are as follows: "Afterward, the
two orifices of the intestine, retracting gradually more beyond the ring into the cavity
of the abdomen, and the neck of the hernial sac along with them, the latter begins to
form the membranous funnel, and then some marks of incipient communication are
observed between the two portions of divided intestine. But as this funnel or mem-
branous passage between the two orifices of the intestine is still very narrow, in com-
parison with the size of the external wound, so the quantity of feculent matter passing
out by the wound is much greater than that which takes the way of the rectum.
Finally, the intestine, daily rising more up into the cavity of the abdomen along with
the neck of the hernial sac, and the base of the membranous funnel necessarily enlarg-
ing while its apex contracts, together with the external or peripheral wound, the pas-
sage of communication between the two orifices of the divided intestine at last becomes
so large as to permit the fæces to abandon the fistula entirely, and, making a half circle
from the superior orifice—the orifice leading toward the stomach—they enter the infe-
rior aperture—the orifice leading toward the rectum—and pass solely by the natu-
ral way.”

240
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
e
It is clearly evident that the angle in which the portions of the injured intestine
join will be dependent upon the amount of necrosed tissue, varying from a small por-
tion of its walls to that of the whole diameter of the canal. When this latter has taken
place, the two portions of the intestine may lie almost parallel, as Sir Astley Cooper
described it, joined like the barrels of a double-barreled gun. This necessitates the
sharp angle to which the flow of the intestinal fluids is subjected, which the membra-
nous funnel of Scarpa, formed from the hernial sac, can never entirely compensate, and
must mark subsequently the site of a more or less pronounced intestinal obstruction.
In direct ratio to the stenosis occurs an important change in the intestine above the
constricted part, sometimes dilated and deformed in the most surprising degree. These
conditions explain the oft-recurring attacks of colic and abdominal pains to which such
patients are liable, and end not rarely in a fatal result from rupture of the thinned
intestine, as abundant examples of autopsy have demonstrated.
Pathological conditions of this character are important to have in mind when
operations for cure by resection of the intestine are taken into consideration. Very
likely laparotomy, either at the site of the constriction or in the median line with
resection of the intestine, may be wisely discussed. However, the limitations of our
subject prevent extended inquiry into one of the most interesting problems of modern
surgery. Rather reluctantly I am constrained to believe that, under the favorable
conditions above outlined, it is better that we content ourselves with an artificial anus,
and defer the attempt at curative measures until a later period. It is only just to note
that in the present state of experience the question is an open one, admitting of great
differences of opinion. But when we take into account the extreme condition and too
often imperfect surroundings of the patient operated upon, we can easily understand,
his frequent inability to endure the severe strain of so serious surgical measures.
The whole subject is hedged about with difficulties, which I can not doubt the sur-
geon will be less often called upon to encounter as the need for prompt surgical
relief is better understood and more earnestly advised.
The cure of an artificial anus and fecal fistula by other and less radical measures
than laparotomy and resection are also interesting questions of surgical inquiry which
would furnish material for an entire chapter, but we must refrain from the discussion
of these as foreign to the subject under consideration.
Resection of the Intestine at the Primary Operation.--If the surgeon has deter-
mined that the conditions make it advisable to resect the intestine at the time of the

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
241
operation for strangulated hernia, the procedures are as follows: First, having freed the
parts about the constriction sufficiently to bring the ends of the intestine well into the
operative field, protection of the abdomen and its contents must be made as far as
possible. A pair of spring forceps, the blades of which are covered with rubber, are
applied to compress the intestines at a considerable distance above the division. The
parts are cleanly washed with a sublimate solution, the ends of the intestine resected, and
joined by one of the several measures to be commended for favorable consideration with
which the surgeon is most familiar. The use of decalcified bone plates, as devised
and recommended by Dr. Senn, of Chicago, or a ring of catgut, of the proper
size, may be used for the purpose of a rapid joining of the divided ends so that the
lumen of the intestine may not be diminished. If these are not at hand, or it is judged
undesirable to use them, the intestine may be quickly and firmly united by interrupted
silk sutures, including the entire thickness of the bowel, the stitches taken at a dis-
tance of about one third of an inch apart. There is no objection to the use of silk in
the making of these sutures, since they will be ultimately eliminated into the bowel.
These interrupted stitches are to be supplemented by a row of fine continuous tendon
Lembert sutures. I have, in several instances, applied two rows of these running sutures
with ease and great advantage. They must not penetrate the intestine, and are best
applied by means of a fine round-pointed, common sewing, or a fine Hagerdorn needle.
Care is requisite in the use of the continuous running suture not to pucker the parts by
overtension; and, if this is kept in mind, there is really little need of foreign material
within the canal to prevent the diminution of its lumen. The edges of the divided mes-
entery must be carefully joined and the bleeding points properly secured before return-
ing it within the abdomen. The continuous suture has a great advantage over the inter-
rupted in a better adaptation or adjustment of the parts, and, even when applied in two
lines, occupies much less time than the adjustment of a single row of interrupted sutures.
This operation is always attended with difficulty, since the intestine is never easy to
handle, and the divided ends have a tendency to contract and evert the mucous mem-
brane. It is on this account that interrupted stay sutures are first advantageously
placed directly through the divided edges of the opposing intestinal surfaces which are
to be introflected and coapted as mentioned above.
I operated upon a patient of Dr. H. C. White, of Somerville, where the abdominal
tumor, an umbilical hernia, was the size of an infant's head, and already necrosed. We
resected seven inches of small intestine and joined with a double row of fine continuous
a
34

242
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
/
animal sutures. We also removed large masses of gangrenous omentum. Death super-
vened, sixty hours after, from exhaustion. At the autopsy it was demonstrated that
there had been no hæmorrhage or general peritonitis. There was a free effusion of
lymph about the line of union, and the intestine, at the line of juncture, held water
after removal from the body.
When the intestine has been successfully joined, carefully cleansed, and the com-
pression forceps removed, it is replaced in the abdominal cavity. There is a consider-
able gain in doing this operation under constant irrigation, not alone because of keep-
ing the operative field clean and under immediate supervision, but more especially is
it advantageous on account of the too great abstraction of heat which ensues from a
long atmospheric exposure of large peritoneal surfaces. For this reason it is better to
maintain the irrigating fluid at, or a little above, 100° Fahr. Subsequent surgical proced-
ures are not unlike those already described in detail in uncomplicated cases of hernia.
It is interesting to note that many of the modern surgical procedures were long ago
anticipated. In order to support the ends of the bowel and prevent subsequent con-
traction of the point of union, many ingenious devices were recommended. Fabricius
Aquapendente condemned the practice, which had been instituted in his time, of intro-
ducing into the intestine, before suturing, a hollow piece of elder, or a portion of intes-
tine, or the trachea of an animal. Duberger * advised a portion of animal trachea ;
Ritsch, a cylinder of varnished paper. The former removed a piece of intestine of two
fingers' length and united the ends with sutures over a piece of a calf's trachea, followed
by a speedy recovery.
Heister preserved in his collection a portion of intestine two feet in length, with
its mesentery, which was removed in a gangrenous state by Ramdohr, who was the
first to introduce the superior into the lower end of the gut, and retained it by sutures.
The case was one of crural hernia; the intestine was resected, and recovery followed.
M. Jobert modified the method of Ramdohr by first turning in upon itself the
lower end of the divided intestine. M. J. Cloquet reported to the Royal Academy
of Medicine a case of strangulated hernia in which the whole diameter of the bowel
had mortified. He sutured the intestine after the manner of Jobert. The parts were
returned as soon as it had been ascertained that nothing escaped from the bowel on
* Mém. de l'Académie de Chirurgie, tome iii, p. 188.
+ Morbius Observat., Méd. Miscellan., præside Heister, 1730, Obs. 18.

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
243
pressure. . At the time of the report fifteen days had elapsed, and everything promised
an early cure.
Lawrence mentioned the methods of M. Denons and Ammusat, as quoted from
Velpeau and Fleury. These consisted in introducing three hollow metallic cylinders
into the intestine, and fastened by sutures, the bowel thus charged being returned into
the abdomen. Mr. Lawrence comments thus: “A patient who could survive the in-
fliction of such surgery must be endowed with great tenacity of life.”
These surgical procedures, some of them undertaken more than a century ago, are
extremely interesting prototypes of new devices under present discussion; and it may
be indeed questioned if any artificial means recently recommended can serve a better
purpose than the properly prepared trachea of a calf.
Dr. Waldo Briggs, * of St. Louis, applied his method of extra-abdominal intestinal
surgery to herniotomy, with a report of two cases, which is novel and interesting. He
was led up to it by a series of comparative studies, already quoted, in which he cov-
ered the line of excision and closure of the intestine with membrane taken from beef
kidney, which in a brief period becomes firmly attached to the intestine while yet the
latter is extraneous to the abdominal cavity. After fourteen hours the parts were
normal in appearance, and union seemed complete. The intestine was returned to the
abdominal cavity, and the external wound closed in the usual manner. Recovery was
rapid, and at- no time was there any indication of shock, and the temperature never
exceeded 99.5°. In the first case the necrosis did not exceed in size a silver quarter
of a dollar; this was dissected out, and the edges closed with Lembert sutures. The
second case is of sufficient interest to quote entire. “Mrs. N., female, sixty years old,
suffering for many years with a femoral hernia of left side. Strangulation had occurred
two days previously to my being called into the case. On my first visit I found the
patient suffering intensely. There was an almost continuous vomiting of stercoraceous
On examination I found that immediate operation was necessary, and an
incision of the sac laid bare an omental mass about the size of the adult human hand,
very much decomposed. This was ligatured and removed, and the ring enlarged.
The intestine, on being withdrawn, was found necrosed for about two inches, com-
pletely gangrened. The gangrened portion was at once exsected, and the ends united
with fine silk by Jobert's method. Beef membrane was applied, as heretofore described,
matter.
* St. Louis Medical and Surgical Journal, January, 1891, p. 41.

244
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
>
and the pins which were placed in position to hold the intestine outside were passed
through the side of the sac and omental plug. On the next day an ulceration was
discovered about a quarter of an inch from the line of juncture, through which fecal
matter was oozing. I at once incised, leaving open, with expectation of uniting when
a perfect line of demarkation had formed. The urgent symptoms of strangulation were
relieved by the operation. In the course of a few hours the intestinal wound was
firmly closed and the gut returned to the cavity. The patient made a complete and
rapid recovery ; and while, during the first few days, the pulse was rapid, varying
from 112 to 120, at no time did the temperature go above 99.5° Fahr. Two weeks
after the operation the patient was sitting up, and she is now attending to her house-
hold duties as usual.”
Dr. Briggs very properly emphasizes the importance of a free division of the
constriction in order that the circulation in the intestine may be impeded as little as
possible while external to the abdomen.
Although I have purposely refrained from a discussion of intestinal obstruction,
produced by constrictions occurring within the abdominal cavity, as a subject foreign to
this work, which necessarily causes the omission of mesenteric hernia, I deem it impor-
tant to note that constriction of the intestine producing death may happen, caused by
bands of the omentum. The following plate taken from Scarpa is a beautiful illustra-
tration of this condition, where death supervened, from a loop of the ileum having been
firmly held by a bridle of omentum, although the hernia was reduced. Under these
conditions it would have been extremely improbable that the life of the patient could
have been preserved by adhesions to the abdominal wall and the formation of an arti-
ficial anus. It will also be noted that, when constriction of the intestine occurs, as high
up in the canal as here figured, resection of the intestine is the only alternative, since
the nutritive processes would be so impaired as to endanger life, even if an artificial out-
let was safely established.
PLATE LIV.*
a, a, a. The omentum in the cavity of the ab-
domen.
b. The anterior portion of the omentum,
that which was spread over the intes-
tines.
c. The I posterior portion of the omentum
which insinuated itself posteriorly # behind some
turns of the intestinal canal.
d. A bridle or noose formed by the two
above-mentioned portions of the omentum b, c.
or
Scarpa, Plate VII.
+ Sternal.
| Dorsal.
# Dorsad.


Plate LIV.
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PLATE LIV.


COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
245
e, e. The place where the omentum which had
protruded into the hernia was cut away.
f. The remains of the omentum contained in
the hernia.
8, 8. The loop of ileum strangulated by the
bridle or noose formed by the two portions of the
omentum b, c, d, e, e.
h, h. The bottom of the ileum which reap-
peared without the abdomen after it had been re-
duced.
i, i. Constriction formed by the neck of the
hernial sac.
1, 1. Part of the great sac of the peritonæum.
m, m. The hernial sac.
n, o, p, q. A very considerable portion of the
ileum included in the noose formed by the *ante-
rior and posterior † portions of the omentum b, c, d.
C,
r, s. Continuation of the intestinal canal un-
der the noose formed by the omentum.
t. The beginning of the colon.
U, u. The appendix vermiformis.
v. Glutinous adhesion of the omentum to the
ileum beyond the strangulation.
x. The testicle.
Dr. Maurice H. Richardson,* of Boston, contributed in 1889 a valuable paper on the
surgical treatment of gangrenous hernia, with a report of four cases. The intestine
was resected in one case, followed by death from shock the evening after the opera-
tion. In a second case the resection was made through the small intestine, which
was gangrenous, and joined by a single row of Lembert sutures, occupying only twenty
minutes in their application. The vomiting ceased immediately after the operation ;
the fecal dejection occurred the third day, and recovery was rapid. In commenting
upon the operation, attention is called to the time consumed, which should be minimized
as much as possible and secure accuracy. The amount of intestine to be resected should
be limited to an inch on the sound side of the constriction. Preference is given to
Lembert's interrupted sutures applied in a single row. The author believes the danger
of artificial anus and subsequent resection fully as great as that of an immediate
excision. “So far as I have been able to find, the first case of successful termina-
tion of gangrenous hernia at the Massachusetts General Hospital, from its founda-
tion to the present day, is the case reported in this paper. With the exception of
the first case all were treated by incision or artificial anus. At the Massachusetts
General Hospital, in ninety-four cases of all kinds of strangulated hernia upon which
an operation has been done, there have been fifty-two recoveries and forty-two deaths
a mortality of forty-four and three fifths per cent; excluding the cases which were
practically moribund on entering, the mortality would be considerably diminished.”
Dr. W. W. Keen,t of Philadelphia, favored lateral anastomosis by the method of
Dr. Abbe, and reported a recent case where he had seen Dr. Abbe operate. As the
* Sternal.
+ Dorsal.
I Transactions of the American Surgical Association, 1889.
# Transactions of the American Surgical Society, 1889.

246
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
result of a fistula which had existed for six months, the patient was emaciated to
the last degree. “The intestines were exposed, and two cravats of iodoform gauze
.
passed through a hole in the mesentery above and below the fistula. The fistulous
portion of the bowel was then removed, and the two ends were turned in and closed
with a continuous suture. A slit was then made in the two portions, and into these
openings were slipped two rings made by winding catgut into loops and then
securing the strands by transverse winding. Each of these rings had four sutures
attached, one at each end and one at each side. After the rings were inserted the
two portions of bowel were brought together and secured. Around the outside
a continuous Lembert suture was passed, bringing the opposed peritoneal surfaces
in contact. Not more than thirty minutes were required for the operation after
the intestines were released.” The patient made a rapid and uninterrupted re-
covery.
Dr. H. H. Mudd, of St. Louis, reported seven cases of gangrenous herniæ. In
one case he excised and sutured the bowel with perfect recovery. The method of
operation is, in a measure, peculiar to himself. He compresses the intestine at right
angles with catch-forceps near to the line of demarkation. He then carries six inter-
rupted Lembert sutures into position before excising the gut, leaving outside of the
forceps a line of the intestine in which there are no sutures. Then the intestine is
emptied of contents by backward pressure with the aid of an assistant, and held
while the bowel is excised and the sutures tightened. Then a line of fine continuous
catgut sutures encircles the bowel. This expedites the operation, which Dr. Mudd
thinks can be done in fifteen to twenty minutes.
Statistics of Excision and Suture.—Schmidt gives a mortality of 71.1 per cent;
Makins collected fifty-five cases, with a mortality of 52.7 per cent; Reischel in 1884
collected fifty-six cases, mortality 52 per cent; McCosh collected one hundred and
fifteen cases, mortality 50 per cent.
Artificial Anus, Primary Operation.—Kärte records one hundred and eleven
cases of gangrenous hernia treated by formation of an artificial anus, with one hun-
dred recoveries, eleven deaths. Coffens reports twenty-eight cases: twelve recoveries,
sixteen deaths. Schmidt reports a mortality of 85.5 per cent. Hermann reports eighty-
three cases: seventy-six recoveries, seven deaths; twenty-six had fistula left. Weil
records fifteen cases: two recoveries, thirteen deaths.
Resection of Artificial Anus.—Matins records forty cases : 38 per cent mortality.
a

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
247
Haemel records forty-three cases: twenty-seven recoveries, eighteen deaths; 37 per
cent mortality.
Dr. T. A. McGraw, of Detroit, analyzed the cases as to location and inflam-
mation, upon which should depend, in large measure, the advisability of operation.
He has found that the continuous Lembert suture can be applied in one fourth of
the time of the interrupted suture.
Dr. George W. Gay,* of Boston, contributed an interesting paper upon the treat-
ment of gangrenous hernia, in which he gave it as his opinion that “it is extremely
difficult to lay down any definite rules for guidance. In extreme conditions it may
be doubtful to operate, and if undertaken it is better to save time by making an arti-
ficial anus, trusting to the future for closure of the same by Nature or art.” He re-
ported an interesting case of a large umbilical hernia, where strangulation existed
for twenty hours. Five and a half inches of gangrenous intestine were cut away with
its accompanying mesentery. The bowel was closed by two rows of continuous silk
sutures, one including the muscular coat, the other a Lembert, involving only the
serous layer. Death occurred on the fifth day. The autopsy showed fecal extrava-
.
sation at the junction of the intestine and mesentery. A similar case, operated upon in
the same manner, made a good recovery.
Dr. H. L. Burrell, of Boston, reported in the same journal four cases of gangrenous
hernia operated upon at the Boston City Hospital. The first case was interesting in that
the hernial tumor was large, consisting of omentum, fist-size, surrounded by a coil of
small intestine seven or eight inches long, of a dark plum-color. The primary wound
was diminished in size by sutures and packed with iodoform gauze. On the fifth day a
segment of the ileum came away two and a half inches in length, including the lumen
of the intestine. On the fifty-sixth day the patient was removed from the hospital by
his friends, and the subsequent history is unknown. At this time there was a fecal
a
fistula, but fæces were also passed per rectum. Sharp attacks of pain were occasionally
referred to the abdominal wound, and, when severe, a coil of intestine was distended
near the site of the ring, giving evidence of intestinal obstruction. The second and
third cases proved fatal on the second and eighth days after operation; in both an artifi-
cial anus was made. The fourth case is chiefly interesting from the fact that the re-
covery after the formation of the artificial anus was so satisfactory. Forty-second day.
a
* Boston Medical and Surgical Journal, March 3, 1892.

248
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
.
The wound had closed completely; the patient was having normal movements. The
patient was seen two years later, at which time he had suffered no inconvenience from
the operation, and considered himself cured. Wore a truss constantly, and has a dis-
tinct impulse under the scar tissue. . . . I have never attempted to do an intestinal
resection for gangrenous hernia, and have always felt that it was a hazardous under-
taking, and that it would be better to establish an artificial anus, and, if the patient
recovered, to do a secondary operation and resect the intestine at one's leisure.” Dr.
M. H. Richardson, in the same journal, reported an interesting case of intestinal resec-
tion for the cure of old fecal fistulæ resulting from a gangrenous hernia of the right
side. Dissection was made, freeing adhesions, and about four inches of the intestine
was removed. The bowel was closed with a single layer of interrupted Lembert
sutures, the tissues being everywhere protected by iodoform gauze, which was not
entirely removed for some days. The wound was closed after about six weeks, and the
patient now remains well.
Hab* has recently written at considerable length upon gangrenous hernia. In six-
teen collected cases the intestine was resected and sutured immediately when operating
for hernia ; nine cases died and seven recovered.
Poulsen † collected twenty-three cases of primary resection of the intestine with
immediate suture, with only five deaths. These operations were performed between
1883 and 1889, and very likely include some of Hab's cases.
Having reviewed the surgical measures now advocated and given some of the
results, it has seemed to me wise to append the following most interesting cases,
as illustrative of the operative measures in use among the celebrated surgeons of the
early part of the present century.
STRANGULATED GANGRENOUS HERNIA-REMOVAL OF SIX FEET OF INTESTINE
-
ARTIFICIAL ANUS—CURE.
“In 1732 I was called to Ibonvillé, a town about forty miles from Paris, to see
M. Doudeuill, a man of sixty years of age, who had a complete hernia twenty-six
inches in circumference. It descended to the middle part of the thigh. The tumor
was very soft, and seemed as if it would re-enter easily. The patient told me that
* Deutsche Ztsch. f. Chir., 1891, xxxii.
+ Hospitals Tidende R. 3. Bd. 7, pp. 349-373.
| Treatise on Ruptures. Arnaud, Observation 17, p. 341.

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
249
it was nearly six years since it had arrived at the same bulk; that it was almost twenty
in assuming that largeness; that for four or five years past he was afflicted with
colics and faintings, which often obliged him to sit down for relief, and support the
tumor with his hand; but that for eight or nine days past he felt a great deal
more pain than usual. For five days he had vomited his fæces, and went but very
little to stool, though the wind was freely discharged through the anus. The tumor
was soft and very sensible. From these signs I concluded that adhesions were the
cause of these symptoms, and therefore thought the only method to be taken was to
perform the operation. Nothing could be added to the general remedies, which had
been used with all possible care. I took the advice of M. Coste, surgeon of Miru,
who agreed with me on the pressing necessity for the operation. I apprised the
patient's friends and himself of the danger there was in undertaking an operation of
this kind; but stated, at the same time, that there was no other method of preserving
his life. The courage of the patient, who was a man of robust constitution, was
animated by the hope of a cure, though uncertain, so that he prevailed on his friends
to consent that I should perform the operation, which I did in this manner: I laid
bare the whole tumor by dissecting all the intestines, which made only one body,
with the herniary sac, which was of a considerable thickness. I used all the neces-
sary precautions not to open the intestine, in which attempt I succeeded. However,
it was gangrened in a great many places, which were of different bulks and figures.
Some of them were round, others long, others triangular, and others of irregular
figures. Some of them were half an inch broad and long, some were two, and
others three inches. But there were distances between them, consisting of five or
six inches of the sound parts. I at last laid all the parts bare, after an hour and a
quarter's hard labor. Then, being fatigued to such a degree as almost to have lost
the use of my limbs, I was obliged to rest myself, and in the mean time covered
the tumor with a fine linen cloth soaked in tepid water. I deliberated with M.
Coste on the method to be taken in order to finish the operation. The confusion
of the parts, by means of the thick and fleshy adherences which kept them together,
and the mortification which had seized most of them, made me propose cutting off
all that was without the abdomen. I told the patient this ungrateful piece of news,
which, instead of terrifying him, augmented his courage. The large portion of the
mesentery, which sustained the ileum, which was less altered than the colon, was the
principal object of my attention. I could not remove this intestine without dreading
35

250
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a hæmorrhage from the mesenteric vessels. In proportion as I made the ligatures
I cut the intestines where the tied vessels terminated. I then tied the vessels of the
cæcum with a single thread and cut that intestine. I made three or four ligatures
on the mesocolon, and cut the intestine which it sustained and which was very gan-
grenous in all its length, which consisted of about eight or ten inches. All this
parcel of the intestine thus cut successively, according to its length, being totally
removed, there no longer remained anything in the scrotum except the testicle, which
was found, and included in its membranes, and the mesentery with the ends of the
colon and the ileum, each of which came about two inches without the ring. There
was no portion of the epiploon in the tumor. My design at first was to stitch the
two ends of the intestine together, but the determination they had taken to come
out of the abdomen was such an obstacle that I could not have succeeded in this
attempt. They came out in such a manner that the colon passed above the ileum,
and was situated toward the penis, while the ileum lay toward the thigh. Besides
this circumstance, they were intimately adherent not only to each other but also to
the ring itself. In order to have joined their extremities it would have been neces-
sary to detach these adherences, which was not possible; it was therefore necessary
to leave them in this situation. As the ring greatly compressed the two ends of the
intestine, and as the fæces had not a sufficiently free discharge, I made a dilatation in
the ileum and ring by introducing my buttoned bistoury into the remaining part of
the ileum, which I boldly divided. But I acted otherwise with respect to the ring,
which I was obliged to disengage on the side of its inferior pillar. I only made a
small dilatation in it, on account of the epigastric artery, which in such cases is
very near this pillar. The fæces were forthwith discharged in a very large quantity, and
the excrements were involuntarily voided for ten or twelve hours without intermission.
Notwithstanding the many ligatures I had made, a great number of small vessels
which had escaped discharged a good deal of blood during the operation. I per-
mitted this discharge so long as it did not incommode me, both to facilitate the
evacuation of the vessels and because I had nobody to assist me except a woman,
who secured the parts while the patient himself held the candle ; for M. Coste was
obliged to leave me on account of some pressing business. I dressed the wound
with dry lint, with which I covered the mass of the mesentery. I left the extremi-
ties of the intestines free, only covering them with a simple pledget dipped in the
yolk of an egg. I compressed the mesentery as regularly as I could by means of
a

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
251
compressures and a bandage. The hæmorrhage ceased, but it was only for twelve
or fifteen hours; for I was obliged to dress the patient twice in the night, and to
use the strongest styptics, in order to brace up the extremities of the small vessels,
which either could not be comprehended in the ligatures or which had escaped from
them, and whose orifices were become much larger, and permitted so great a quan-
tity of blood to be extravasated that the patient must have died if I had not con-
tinued with him; for M. Coste was obliged to go to his own home, which was
about three miles distant. Next day there supervened a hiccough so violent that I
a
thought the patient could not surmount it, for he was several times likely to die for
want of intervals sufficient for respiration. The great quantity of blood he had lost
by the hæmorrhage, and by two copious venesections, did not permit me to seek
for relief in the aperture of a vein; I was therefore obliged to use laudanum in sub-
stance, the dose of which I augmented by half-grains every half-hour, so that in
two hours he took four and a half grains of it, which at last alleviated the hiccough.
He remained about five or six hours, as it were, intoxicated and without sleep, but
during that time he enjoyed an agreeable tranquillity, and the hiccough was so di-
minished that nothing dangerous was to be dreaded from it. It continued, however,
three or four days, but always became less and less. By the examination we made
of the quantity of the intestines I had taken away we found that there was more
than seven feet of them. The patient, by the care of M. Coste, was cured in six
weeks. Three months after the cure I advised him to come to Paris, that I might
try to reunite the extremities of the intestines. Messieurs Petit, Le Dran, Morand,
and Verdier, whom I called to consult on the means which might be employed to
remedy this inconvenience, found that the reunion was so much the less impractica-
ble because the direction which the ends of the intestine had taken could not have
permitted it during the operation; besides, the portion of the ileum was so retracted
that it was hardly possible to perceive it. It formed a kind of body like a hen's
arse, whose margins re-entered internally. The colon had totally disappeared. All
the part of the mesentery which had remained out of the abdomen after the operation
was so dissolved that no mark of it was to be felt either in the scrotum or about
the ring. It afterward created no trouble in the dressings. This remark is of great
importance, because it lays a foundation for some reflections on the cause of that
perplexity which a part of the mesentery remaining without the abdomen created
to M. Le Dran in the operation described in the sixtieth observation. Our patient

252
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
was therefore obliged, during the remainder of his life, to use an artificial anus. But
his industry rendered this inconvenience more supportable to him than it would
have been to any other person. He was very careful not to offend others by the
bad smell, which they must necessarily feel if he had not subjected himself to some
little pieces of art and contrivance which freed him from that disagreeableness which
his misfortune must have otherwise produced. He had made several pessaries of
.
cork covered with wax, in the form of a bottle cork, proportioned to the bulk and
largeness of the intestine, and about an inch and a half long. This pessary was
tied with a small cord to the principal compress. He introduced it into the intestine
and laid three or four other compresses on the former. He secured the whole by a
bandage composed of a single circular and a slip, which passed under the thigh from
behind forward, in order to be fixed to the circular by a pin.
. He undid this
apparatus every morning and evening, in order to empty it as occasion required.
He was sometimes obliged to facilitate the discharge of the excrements, though
always of a very liquid consistence, by means of a clyster. At other times the
smallest portion of the fæces was not discharged into his apparatus. By this means
he enjoyed six years of perfect health, and at last died of an indigestion.”
Operations for the Cure of Artificial Anus.*
2727 a.* A portion of skin removed, some time before the death of the patient, from the margin of
the artificial anus last described.
The history of the case was thus recorded by Mr. Hunter:
« HERNIA
“ An Italian was taken into St. George's Hospital with a bubonocele. It was an old rupt-
ure, which had been reduced at different times, but at last came down so large as not to allow
of being returned.
“When he came in it had been down nine days, which gave rise to the appearances I ob-
served in the operation. He had all the symptoms of a strangulated hernia, now reduced to the
last extremity; therefore no time was to be lost.
“Upon exposing the contents of the sac and cutting through the stricture, it was found to
contain epiploon inclosing the gut. The epiploon on its external surface everywhere adhered
to the sac, but these adhesions were recent; however, I was obliged to use force with my finger
to separate them. When this was done I unraveled the epiploon and exposed the gut, which
adhered by its external surface everywhere to the epiploon. This I separated with ease, except
at the lower part, where the adhesion was pretty firm ; however, it gave way, but I found the
* Catalogue of Pathological Specimens.

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
253
substance of the gut was gone there, and that it only adhered round the hole in the gut. I cut
off the whole of the epiploon; the whole of the intestines were reduced except where the hole
was, and that part was fixed in the rings by two stitches.
“Quære: Would it not have been better practice not to have separated this union, but
have reduced it in the united state, so that the epiploon might have become part of the gut;
or have reduced it all to (except ?) this part, leaving it in the sac, and healing the parts over it ?
“ The wound healed up to the openings of the gut, which were very large, making a slit
about three inches in length and about one inch wide; with the inside of the gut a little pro-
tuberant or inverted, with the fæces coming this way. When the parts were perfectly healed
and the cicatrix all round became pliable and soft, I tried to bring the skin on each side to-
gether over the opening, which I found I could easily do. I next endeavored to prevent the
fæces coming this way, by applying a large piece of sticking-plaster over the whole [hole ?],
over that a thick compress, and over the whole a steel spring-truss, to make a compression.
I found by this means that the fæces found the lower orifice of the gut, and came away by
the anus.
“Finding that, if the fæces were prevented coming through the wound, they then could
pass the right way, I thought it was worth trying how far it was in my power to close up this
opening entirely.
"I conceived that if I was to remove the edges of the skin all round the opening and make
it a fresh sore, I might then be able to unite them across the opening by the first intention; to
I
which experiment he readily consented. It was now made a fresh wound all round for half an
inch in breadth; the two surfaces were brought together, and kept there with the hare-lip pins,
as also with compresses on each side to support the pins; but part of the fæces worked through
between the two surfaces and prevented the union, although the larger part of them went the
right way.
“When the sore began to granulate, I next tried to unite them as before; but, as before,
the same cause of prevention took place, and it again proved unsuccessful. Upon the healing
of this sore all round, the opening into the gut was much lessened by the contraction of the
granulations.
“Finding that I could not succeed in the union by the first intention, nor by means of
granulations, and finding that the opening was much lessened by the method above taken, I
conceived, if the same operation were repeated, that I might be able to bring the opening into a
very small compass, and probably might be able afterward to close it entirely up.
“ The man submitted to the operations the second time, and when this was healed the open-
ing in the skin was not above an inch long. He now left the hospital till the parts became
fit for some other trial; but he made his complaint a means of support, which was probably
an easier mode than that arising from industry; and on the benevolence of the nobility and
gentry of this country he lived comfortably himself and supported his sisters till his death,
which was in consequence of a pulmonary consumption. Upon opening the body we found the
gut which had protruded was the ileum, about two feet from the cæcum. Upon the inside of
the belly it appeared as if the gut only adhered to the peritonæum as it passed across, for it
almost went straight across without making an angle; for the gut was nearly as broad or thick
at this part as at the two adjacent loose parts; so the canal of the intestine was continued freely
across the opening, and almost without any diminution. By introducing the finger into the ex-

254
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
ternal opening it came directly into the gut at this adhesion, and could thence be pushed into
either part of the gut.
“As a certain portion of the gut was lost by mortification at this part, and as also a certain
portion more was retained down in the ring to admit of adhesions there, both of which we must
conceive was nearly, if not wholly, the diameter of the gut-but most probably making the gut
make an angle there, so as to make the opening appear double, one going into each part of the
gut, and the angle forming the septum—then it becomes a question, How came the gut to be
so complete at this part ? only seeming to pass across, making no angle, only having an open-
ing on the adhering side, which communicated externally without the least appearance of there
having been any loss of substance. The only way to reconcile these two contradictory facts is
to suppose that Nature had been employed in perfecting the gut within the abdomen, and which,
probably, was assisted by the stopping of the mouth of the external opening, with a view to
force the fæces the right way, which, obliging that side next to the abdomen to stretch, did
dilate, and which would dilate inward toward the cavity of the abdomen; and this would also
be assisted by every motion of the intestines within the abdomen; for every motion would be a
pulling or dragging of the intestines inward, so as to take off the angle. It had not pulled in-
ward that part of the intestine which lay in the wound, for there it still lay.”—Hunterian MS..
Cases and Dissections, No. 54.
On a drawing of the parts, preserved as No. 1384, it was written, “ The preparation is in
the possession of Mr. Ford.” It was presented to the museum by Mr. Copeland, Mr. Ford's
nephew, but no record could be found of the exact time or circumstances of the patient's
death.
In his lectures Mr. Hunter used to say of this case: “A man in St. George's Hospital had a
hernia, for which I laid the integuments open, and then the sac, when I found that the intestine
had a tendency to mortify, and had formed adhesions to the sac. These adhesions, which were
newly formed, I separated, when that part of the intestine which had adhered to the sac gave
way, and the excrement came out. I therefore returned the intestine, and retained the torn part
to the external wound, which became the anus; but there was still an open communication be-
tween the upper and lower parts of the gut, so that, could the opening in the groin have been
stopped, the fæces would have passed the natural way. To produce this, I dissected off the
skin round the opening, and then brought it into contact with ligature, compress, etc.; but this
would not do, although the granulations, by their contractions, lessened the size of the opening.
I therefore repeated this operation, hoping that at last I might quite close it; but all my efforts
were in vain.
“Now, in the above case, I acted like a blockhead, being ignorant of what Nature was here
doing; for (admire her work) she was forming adhesions of the intestinesall round that mortified,
whereby she would not only have preserved the continuity of the canal, but by this same pro-
cess would have prevented any escape of the fæces: all which I prevented by separating those
adhesions. If the case was to happen again, I should not separate the adhesions after taking off
the stricture.”—Hunterian Reminiscences, by Mr. James Parkinson, p. 41 (London, 1833, 4to).
2627. A portion of small intestine, of which the mucous membrane is of a dark-brown tint, from con-
gestion ; its mucous membrane is thickened and finely granular or velvety, as if from effusion
of lymph. It had been strangulated in an inguinal hernia for eighteen hours.
From a man, aged twenty-seven, who had hernia for six or seven years. The truss which he
a

COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
255
Gyn. Stafi Room University Hospital
.
wore broke; soon after, the hernia came down and he began to vomit. Herniotomy was per-
formed, but without relieving his symptoms.—Presented by Dr. Goodhart, 1876.
2628. Portion of small intestine, about eighteen inches long, which was strangulated for twenty-four
hours. It is dark-colored and distended; there are numerous shreds of lymph upon its perito-
neal surface, but no marks of constriction.—Hunterian.
2621. A piece of omentum, completely gangrenous from strangulation.
From a female infant aged three months, with right inguinal hernia. The sac was opened,
the neck or pedicle of its contents ligatured with carbolized catgut, and the mass which is
preserved was removed. On the twelfth day all parts were healed.—Presented by Richard
Rendle, Esq., 1872.
2634. A large, oblique inguinal hernia of the right side. The sac contains the lower end of the ileum,
the cæcum, with its appendix, a portion of the ascending colon, and a large piece of omentum.
All the coverings of the hernia appear thickened, indurated, and consolidated. From the
Museum of John Howship, Esq.
2635. An inguinal hernia, containing a cæcum and its appendix, with the end of the ileum. The ter-
mination of the appendix is fixed to the lower part of the sac; the rest of it is free. Of that
part of the cæcum which has not passed into the hernia, one half only is covered with perito-
næum.—Presented by Sir William Blizard.
2636. Part of a cæcum, with a portion of the abdominal walls, showing hernia of the vermiform appen-
dix, which, passing through the internal ring (held open by a green glass rod), lies in the ingui-
nal canal. This has been laid open so that the appendix may be seen attached to its walls by a
fibrous band at the extremity. A bristle is passed through the vas deferens, and a glass rod
into the vaginal process of the peritoneum behind.
From a clergyman, aged fifty-six, who had long worn a truss for incipient right inguinal her-
nia. Increased swelling and pain were at length noticed in the right groin, followed by an
abscess and fecal fistula, through which a small piece of bone came away. He then completely
recovered, but died two months later from other causes. (See MS. Notes, vol. I, p. 294, and
i
Trans. Path. Soc., vol. i, p. 269, 1848.—Presented by Dr. Thurman, 1871).
2637. A diverticulum of the ileum protruding into and adherent to the anterior surface of the sac of
a direct inguinal hernia. The diverticulum is funnel-shaped, and connected with the bowel
exactly opposite the attachment of the mesentery. It measures one inch and a half in length
and is pervious throughout; its coats are similar to those composing the intestine, Its distal
end is adherent to the outer end of the hernial sac, which is an inch long, and passes obliquely
downward and forward in the substance of the abdominal wall. Its orifice is situated immedi-
ately to the inner side of the obliterated hypogastric artery. A sinus opening at one end
through the skin passes obliquely inward, and communicates at the other end with the ileum near
the apex of the diverticulum. The diverticulum may, judging from the history, have been
formed by an adhesion, drawing out a portion of the intestinal wall into a tubular form.
From a woman, aged seventy-seven, admitted into the hospital one month after she had been
taken ill with vomiting and obstinate constipation. On admission she was much exhausted; her
tongue was brown and dry; the bowels acted naturally, though still much constipated; the dif-
fuse cellulitis of the right groin was present. In a few days a large bleb over the middle of
Poupart's ligament, in the midst of the inflamed area, burst and discharged watery fluid and

256
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
-
fecal matter. Three months later the patient died of severe diarrhea. The case is recorded in
the Trans. Path. Soc., vol. xxvi, p. 109.—Presented by Dr. T. Stretch Douse, 1875.
2642. Portion of small intestine, which was strangulated in a hernia, and was burst, probably in an
unsuccessful attempt to reduce it. A rent extends round half the circumference of the intes-
tine; its edges are not ulcerated, nor do they appear much altered in texture. The marks of
constriction are evident.—Presented by Sir William Blizard.
2645. Portion of small intestine, with the inguinal hernia in which it was strangulated. The part
strangulated includes the whole circumference of the intestine; it was so completely filled with
the portions of the skin of an apple or potato, which now lie below it, that it was impossible to
return it. In the efforts at reduction, part of the neck of the sac and of the peritonæum round it
were separated from their connection and pushed into the abdomen.—Presented by Sir William
Blizard.
PLATE LV.*
Figure 1.
g, h, i. Natural adhesions of the appendix
a, a. The cæcum.
vermiformis, with the part of the peritonæum
b, b, b. The natural adhesion of the beginning
which has protruded and forms the hernial sac.
of the colon and of the cæcum to the great sac
k. The extremity of the ileum.
of the peritoneum, as is observed in the natural
1. The insertion of the extremity of the ileum
into the colon.
state in the right ileo-lumbar region.
c, d, e, f, g. The hernial sac formed by that
m, m. Dotted lines pointing out the position
portion of the peritoneum which in the natural
of the extremity of the ileum, and of the begin-
state occupied the right ileo-lumbar region.
ning of the colon within the abdomen in the right
h. The extremity of the ileum close to its in-
ileo-lumbar region.
sertion into the colon.
n, n. The aponeurosis of the external oblique
muscle of the abdomen.
i. The beginning of the colon.
k. Fatty appendix of the colon.
0, 0, 0. The hernial sac.
1. The appendix vermiformis.
Þq. The vaginal coat of the testicle laid
m, n. The membrano-aponeurotic sheath of
open.
r. The testicle.
the cremaster muscle laid open at the place where
it surrounds the vaginal coat of the testicle.
Ś. The epididymis.
0,0. The integuments of the scrotum.
t. The spermatic cord.
Pq. Dotted lines pointing out the termination
of the ileum and the beginning of the colon within
Figure 3.
the cavity of the abdomen.
a, b. That portion of the left colon which,
r. The epigastric artery.
previous to its descent into the scrotum, was nat-
s. The epigastric vein.
urally connected with the great sac of the perito-
næum in the left ileo-lumbar region, in the vicin-
Figure 2.
ity of the great iliac vessels of the same side.
a, a. A part of the cæcum protruded in the This loop of the left colon is seen raised on pur-
hernia.
pose from the bottom of the hernial sac, and
b, c. The natural adhesion which connects the drawn outward,t in order to show clearly the nat-
cæcum and the beginning of the colon with the ural union of this intestine with the portion of the
peritoneum in situ in the right ileo-lumbar region. peritoneum which has descended and forms the
d, e, f. The appendix vermiformis.
hernial sac.
* Scarpa, Plate VI.
+ Peripherad.


Plate LV.
Frg.l.
Fig. 2
n
12
m
P
m
wat
Q
a
Tv
k
b
a
a
9
Fig. 4.
Fig.3
Fig. 5.
d
b
m
h
a
b
he
Z
h

PLATE LV.
Fig
Men


COMPLICATIONS INCIDENT TO THE SURGICAL MEASURES.
257
d, d. A thin and transparent membrane uniting
the intestine with the bottom of the hernial sac.
On the intestine being drawn gently upward, *
this membrane assumed the form of numerous
ligamentous bridles.
e, e. The intestine seen through the thin
membrane which keens it united with the hernial
sac.
C, C, C. The natural bridles or ligaments of the
left colon connecting it to that portion of the
great sac of the peritonæum protruded and form-
ing the hernial sac.
d. The lateral ligament of the colon.
e, e. The hernial sac.
f. The neck of the hernial sac.
g. The cellular substance interposed between
the hernial sac and the membrano-aponeurotic
sheath of the cremaster muscle.
h, h, h. The membrano-aponeurotic sheath of
the cremaster muscle.
i, i. The sheath of this muscle divided at the
place where it tightly surrounds the vaginal coat
of the testicle.
k, k. The vaginal coat of the testicle.
1. The testicle.
m, m. The integuments of the scrotum.
n. A part of the rectus muscle of the abdomen.
0, 0. The aponeurosis of the external oblique
muscle in the vicinity of the left inguinal ring.
f, f. The membrano-aponeurotic sheath of the
cremaster muscle, with the vaginal coat of the
testicle laid open.
g. The testicle.
h. The epididymis.
i. The spermatic vessels surrounded by the
cellular substance of the cord.
Figure 5.
a, a. A congenital omental hernia.
b. The testicle.
c. The epididymis.
d. Part of the omentum, which has assumed a
cylindrical form, protruded into the hernia.
e, e, e. Fatty appendices of the omentum.
f, f. Strong adhesions of the omentum to the
bottom of the hernial sac, or, in this case, the
vaginal coat of the testicle.
Figure 4.
a, a. A loop of the ileum protruded into the
hernia.
6, b. The hernial sac laid open.
C, C. A part of the hernial sac thickened and
indurated.
* Atlantad.
36

CHAPTER XXII.
HISTORY OF OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA.
a
a
An exhaustive review of the various measures undertaken for the relief or cure
of hernia, during the centuries since the art of surgery has been preserved in a written
record, would be altogether out of place, even in a work which has for its purpose a
complete discussion of the subject. However interesting such a research might be-
and to the lover of antiquity it certainly is so—it would necessitate a review, in large
measure, of the various phases of surgical thought and the repetition of certain funda-
mental factors, subject to individual modifications. The distinguished Parisian sur-
geon, George Arnaud, who published, in 1748, his Memoir upon Hernia, stated, in
the preface of his interesting work, that, prompted by a zeal to exhaust every re-
source of knowledge then available upon this subject, he caused a thorough search
to be made in the great libraries of Paris, and a copy of all that had been written
upon this subject to be transcribed for the purpose of publication. So great, how-
ever, was the magnitude of the work undertaken, he found that the manuscript copy
thus furnished would make over three thousand pages in quarto, and therefore he
wisely desisted from his ambitious design. If we add to this the contributions of a
century and a half, he who should undertake the subject would indeed labor under
the embarrassment of riches.
Rupture was certainly recognized at a very early date.* Dr. J. D. Bryant,t of
New York, writes as follows: “The subject of hernia is an ancient one, and has
associated with it the dust and traditions of the earliest times of medical and surgi-
cal matters. It can be safely assumed, I think, that the consideration of means of
relief from this affliction was but a step behind the first occurrence of the affliction
itself, and the age of the affliction is best measured by the length of the time of
the establishment of the present relations of the abdominal contents and their walls
* Leviticus xxi, 17-20. In the old editions was rendered “herniosus."
+ Transactions of the New York State Medical Society, vol. vi, p. 110.
(258)

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA.
259
causes.
with each other. The person who had the first hernia was the first person to con-
template means of relief from it, and no doubt soon learned to seek the same relief in
the recumbent posture and from manual pressure that these measures afford to-day.”
Hippocrates pointed out different varieties of hernia, and described some of the
Celsus, the great Roman author, who lived in the time of the Emperors Au-
gustus and Tiberius, wrote with a care and exactitude that would reflect honor
upon any age. He advised the opening of the hernial sac with the knife, the division
of the constriction, and the return of the intestine into the abdominal cavity. He
separated the sac and ligatured it. He tied the spermatic cord and removed the
testicle. He cut away a part of the scrotum and united the lips of the wound in
such a way as to form a solid cicatrix. He observed that it is the habit of some to
cauterize the parts with caustics, or the actual cautery. This method he thought advis-
able where the rupture was very large or the patient subject to humors, but remarked,
“ The patient should be of good habit, and neither an infant nor an old person.”
Paulus Ægineta modified the operation of Celsus by separating the sac and
cutting it below the ligature, in this way saving the testicle and cord. He ampli-
fied in many ways the teachings of Celsus, giving in detail descriptions of the varie-
ties of ruptures, emphasizing those in which the intestine is involved. He pointed
out the different causes and symptoms, describing the changes which take place from
the distention of the peritonæum, and taught the conditions under which it may be
necessary to cut the constriction in order to restore the abdominal contents. Albu-
casis practiced after the method of Celsus, emphasizing more strongly the applica-
tion of the actual cautery, searing the tissues to their very base. Lanfranc devised
a pair of forceps or pincers, in which there was a longitudinal slit, for the purpose of
introducing a red-hot instrument. The parts including the neck of the sac were
thus seized and pierced. The object of this method was to protect the surrounding
parts from the effect of the cautery and preserve the cord. Guy de Chauliac recom-
mended the cautery as very successful in repeated applications, until he had de-
stroyed the sac, and reported many cases without injury to the testicle. Rosset
reported, in 1559, a number of operations by different surgeons which he distinctly
stated were performed after the method of Celsus, first making, with the utmost
care and caution, a division of the parts, cutting away the sac, and stitching up the
wound. These cases were followed by complete cure. In one case he described the
removal of a portion of necrosed omentum “the bulk of two hen's eggs.”

260
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Severinus advocated the cautery, but commented as follows: “He who useth the
actual cautery ought to have a solid judgment, with a certain foresight which is not
so easily to be described. These gifts of the mind are from Nature, and improved and
preserved by long practice and use.”
Claudinus used the actual cautery in a way to produce several crusts, in order to
make the skin shrink and grow callous and firm. Albucasis preferred a cautery shaped
like a half moon. All insisted upon a low course of diet, a loose condition of the
bowel, and absolute quiet in bed, even forbidding the use of the arms.
Heurnius, commenting upon the value of the cautery when properly applied, as the
cure by the use of iron and the demand of large fees, said, “ It is the unhappiness
of this iron age that it can be sweetened with nothing but gold.”
Houstoun, who published in 1726, after reviewing the advantages of the cautery
as early used, lamented the neglect of its use in too many instances in his day, and
asked, “What may be expected from the actual cautery were we as well skilled and
dexterous in its application as the bold and wise ancients were?” When the best
results were obtained from the methods above mentioned, an instrumental support
was applied for the retention of the hernia, to be worn permanently.
The caustic treatment succeeded the cautery, and was advocated for similar reasons.
An eschar about an inch in diameter was to be made over the external ring, and by
repeated applications the tissues were thus destroyed, including as much of the sac as
could be safely done without injury to the cord. This was advocated by a physician
named Little as a secret remedy, and so important was it made to appear, that King
George the First bestowed upon him the sum of five thousand pounds for making
known the remedy.
The object to be attained was a cicatrix firmly closing the ring. This procedure
was in use for a considerable period, and was advocated by Guido, Lanfranc, Parey,
Scultetus, and others. Many dangerous complications and unsatisfactory results were
recorded by these writers. The danger, the suffering, the frequent return of the
hernia behind the cicatrix, compelling the use of bandages, caused these measures
gradually to fall into disuse.
As improvements upon the above methods, followed the punctum aureum and the
royal stitch. Since these two methods were attempts in the direction toward which
the pendulum of modern opinion has again swung, I quote from the ever-interest-
ing work of Percival Pott, a surgeon famous for all time: “The punctum aureum

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA. 261
was performed as follows: The bowel being emptied by purging and the hernia re-
duced, an incision was made through the skin and membrana adiposa down to the
spermatic process. This incision was to be of such length as to permit the operator,
either with his finger or a hook, to take up the said process and to pass a golden
wire under it; the wire was to be twisted in such a manner as to prevent the intes-
tine from slipping down again into the hernial sac, but not so tight as to intercept
or obstruct the circulation of the blood to the testicle. Some operators preferred a
leaden wire to a golden one, and others a silk ligature. ... The royal stitch was per-
formed in this manner: The intestines being emptied, and the portion which had
descended being replaced, an incision was made, so as to lay bare the spermatic cord,
about two inches in length, from the abdominal opening, downward. When the
process was freed from the cellular membrane it was to be held up by an assistant,
while the surgeon, with a needle and ligature, made a continuous suture from the
lower part of the incision to the upper in such a manner as to unite the divided
lips of the wound again, comprehending the cellular membrane, and thereby endeav-
oring to straighten the passage, as they called it, from the belly into the scrotum,
without injuring the spermatic vessels. The operation is described by many of the
old writers, with some small variation from each other, both in the manner and in
the instruments, but all tending to the same end, and all proving that their idea of the
disease and of the parts affected by it were erroneous and imperfect.”
Ambrose Paré gave a careful description of the operation by twisting about the
neck of the sac a small gold wire four times backward and forward, so that the two
ends of the wire could come together and the ends be filed off, without compressing the
spermatic vessels. This Heister objected to upon theoretic grounds, because he could
not understand how the wound could heal from the constant irritation produced by
the wire, and on this account there must be a continual ulcer at the site of the
wound. Arnaud ascribed this device for the cure of hernia to Berault. He stated
that French surgeons adopted its use, substituting often iron and lead wire to save
expense. It became the common practice of the surgeons of the time; and even
Arnaud, who condemned the method, apparently having never practiced it, admitted
that it was ingenious, and that great advantage followed from reducing the size of
the hernia by destroying the sac and rendering possible retention by instrumental sup-
ports. Sermecrus described a method he learned among the Russians, and recom-
mended it as of the greatest advantage in adults where the intestine could not be

262
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
retained in the abdomen by a bandage. Heister illustrated this method by a drawing,
but it consisted only of the separation of the sac, which was tied with a strong thread
as nearly as possible to its neck, and the ligature left hanging in the wound, which was
dressed in the usual manner until it spontaneously separated. This method Heister
recommended in the main for adoption. He emphasized that the “intestine should
be treated so tenderly as rather to divide the part to which it adheres, even if it be
the testicle itself, than injure its own proper coats. In the next place, the sacculus
of the peritonæum is to be freed from all its parts and secured by a ligature, tied
round near the ring of the abdominal muscles, made of a flaxen thread, waxed, and
three or four times doubled; after which that part of the sacculus below the ligature
is to be extirpated, and the wound dressed as before ; after the ligature is digested
off it forms a sort of tubercle, or hard cicatrix, which, being joined by scarification
to the lips of the wound, firmly resists the pressure of the intestine and prevents it
from subsiding into the scrotum.”
Heister did not think it of special importance if the epigastric artery was divided,
since it could be at once tied. If the intestine was wounded, it was sutured and fastened
by a thread to the wound. He advised, as a rule, the opening of the sac before liga-
turing, in order to ascertain the condition of, and return the abdominal contents, which
he pointed out were often in a state that demanded special care, when the parts
were found to contain humors by which it seems to have been understood that patho-
logical changes had supervened.
Drainage was in general use, at least in Paris, although it is supposed to be of mod-
ern origin. Dionis (Pierie), of Paris, published in 1708 upon this subject. He recom-
mended the opening of the sac with caution, taught the principles of dilatation of the
ring when necessary, and removed portions of compressed omentum. After the opera-
tion he filled the wound to its very base with lint soaked in the yolk of egg and
oil which was held in place by a bandage. These procedures were practiced in France
for many years. According to Heister, Videnmanus and Dionis directed the tent to be
made about the thickness and length of the finger, and wrote that “it ought not to be
extracted until it falls off of itself by suppuration of the parts; but Petit condemned the
use of these as pernicious, by irritating the parts and admitting the external air ; yet I
can not but acquiesce in their use, when there is a repeated discharge of putrid humors
to be made from the abdomen, otherwise it may be sufficient, according to Petit, to
apply a thick pellet only for the more speedy agglutination of the wound.” Here is

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA. 263
a
clearly foreshadowed the idea of modern drainage in wounds; and, since parallel fibers
of lint in considerable abundance were used, the method is not unlike that recently rec-
ommended by Dr. Morris, of New York, for the purpose of abdominal drainage.
When the removal of these unhealthy fluids was not deemed necessary, it was gen.
erally advised to dress the wound after Petit's method. This consisted in filling it to
the base of the ligatured sac with pellets of compact lint dipped in a fluid made of the
white of an egg shaken in the spirit of wine. This was covered by several compresses
moistened with the spirit of wine and firmly secured by a spica bandage. The dress-
ing was removed in two or three days, the wound washed with warm spirits of wine, and
new dressings applied. When the wound was firmly healed, a light truss was fitted,
which, if the individual was young, was to be worn for a year or more ; if an adult, to
be worn for life. We see in this method almost the exact counterpart of that which
has been recommended by Dr. W. McBurney, of New York; and although the albu-
men may have been useless, we find a very good antiseptic dressing in the spirit of wine.
I quote from Arnaud a quaint description of a then common method among the Turks,
which gives an interesting picture of the cure of rupture in the East at this period.
“ Demetrius de Cantimir, Prince of Moldavia, related, in the History of the Ottoman
Empire, translated by M. de Joncquières, vol. ii, p. 397, that the inhabitants of Albania
and Epirus, otherwise called by the Turks Arnaut, excelled in the cure of ruptures;
and after he had spoken of their skill in many respects, he related a process which he
observed himself.
“As to the cure of ruptures (says he) they undertake it upon all sorts of people and
at all ages ; their method is coarse, but yet successful. When I was at Constantinople
I had the operation performed upon my secretary, who was an elderly man, in my own
palace. Having agreed as to the expense, they tied the patient down upon a broad
plank, and secured him from his breast to his feet with proper bandages; then the
operator made an incision in the inferior part of the abdomen with a kind of razor or
bistoury. The peritoneum being opened, he pulled out about the bulk of a hand of the
internal substance, under the skin, and drew up the intestine, which was fallen into the
scrotum, into its proper place. Afterward he sew'd up the peritonæum with strong
thread, and a knot at the end to hinder it from slipping; and the lips which hung over
were cut off with the same razor. Then the wound was rubb’d with hog’s-lard, and
cauteriz'd with a red-hot iron. Before the dressing was applied they lifted up a little
the legs of the patient, who was almost dead, and pour'd the whites of nine new-laid
a
a

264
ANATOMY AND SURGICAL TREAMENT OF HERNIA.
a
eggs into the wound; and if that liquor fermented and bubbled within the space of an
hour or two, it was a certain sign of a cure; on the contrary, if there was no appear-
ance of that kind in three hours, they made no favourable prognostic. They attribute
ill success to the age or weakness of the patient, which obstructs the cure, for they never
doubt of the efficacy of their method; and indeed there seldom die two out of an hun-
dred of those whom they undertake. After two or three days they repeat the use of
the whites of eggs, and all this time the patient is kept extended upon his back, with-
out giving any signs of life or having any great sensibility. The operators did not
suffer him to take anything, but thought it sufficient to moisten the tongue from time
to time with a little water. The fourth day they took him out of bed, as yet secured
upon a plank; he then soon came to himself, and with a feeble voice complained of his
pains. They then gave him two or three spoonfuls of warm water to comfort him; and
the three following days he drank broths, recommending to him, above all, not to over-
charge his stomach, and not to touch anything solid. The seventh day they untied
him and put him into a bed; but, for fear he should stir his legs or turn upon his side,
two of his physicians continually kept their eyes upon him to prevent it. Every day
the application of the whites of eggs was renewed; but from the ninth to the twelfth
day they were reduced to six eggs; and as soon as they were poured upon the wound
they fermented more than before. On the fifteenth day the white of a single egg could
scarcely be admitted, yet they did not desist while any would enter, and there was
the least appearance of a fermentation. That sign being over, they covered the wound
with a plaister made of pitch, oil, etc.; then the patient had liberty to stir his feet, and
to lie on his side. Every morning, before the patient took any nourishment, they
gently pulled the end of the thread, to see if they might leave off the ligature, which
depends upon the strength of the patient. To some, forty days are necessary, to others
thirty, and in some the thread may be taken away in twenty, when, by the help of a
second plaister, the cure is completed. Here we see a surprising operation, of which I
was eye-witness, and which is nevertheless practiced with success by a savage people
ignorant of science.' This operation is so surprising, that we could scarcely believe it
had it not been related by so respectable an author; but it gives men of judgment a
notion of the talents of those people very different from that of the author.”
The operation for the cure of hernia involving the sacrifice of the testicle was in
common practice for a considerable period, with excellent result, until it was forbidden
by an edict of the Emperor Constantine. He punished with banishment all those who
a

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA. 265
performed castration, to be followed by death if they ever returned to the empire.
He likewise decreed the confiscation of the house in which the operation was done.
This law, however, was intended to inflict punishment upon the common practice of
castration of children in order to supply the demand for eunuchs, although the surgeons
who thereby attempted the cure of hernia were included in its jurisdiction.
Under the leadership of the master-minds of Sir Astley Cooper, Scarpa, and Clo-
quet, the attention of surgeons was directed to the anatomical factors of the problem
which were presented in strangulated hernia. It was, indeed, rare that any other com-
plication caused even these master-surgeons to consider favorably operative measures.
Viewed from the light of our present knowledge, it must be admitted that the treat-
ment of wounds during the early part of the present century was far less satisfactory
than in the generation which preceded. An illustration of this is shown by a quotation
from the last edition of Mr. Cooper's valuable work : “When the operator has returned
the protruded contents of the hernial sac, he should clear it of any blood which it may
contain, and, having nicely adjusted the sac and its coverings, bring the edges of the
wound together, confining them by sutures. The needle and ligatures should be passed
through the integuments only, and great care should be taken to avoid penetrating the
sac, which might occasion a dangerous extension of the inflammation. A piece of lint
should then be laid on the wound, with a compress of linen over it, and these pressed
pretty firmly down upon the groin by the T-bandage, so as to close the orifice of the
hernial sac. The patient is then to be carried to bed in a horizontal posture, and,
while this is doing, the surgeon should support the wounded part with the palm of his
hand, to prevent the intestine from being forced down by the motion of the
patient."
In Lawrence's last edition on Hernia, published in 1843, he repeated the directions
given by Mr. Cooper, and commented upon the management of the wound “as a very
simple affair, that which was known until the present generation as the cold-water
treatment of wounds.” He advised that the sutures should be cut out in thirty-four to
forty-eight hours, and stated that he had “ often seen primary union after operation for
strangulated hernia, without requiring any attention that could be called dressing."
He also pointed out the dangers which are likely to ensue if the sac is interfered
with; and Schmucker and Langenbeck seem to have been almost the only men dur-
ing the first half of the present century who attempted its removal. A careful sutur-
ing of the canal in order to produce firm closure does not seem to have been advo-
0
37

266
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
cated by any of the surgeons until within a comparatively recent period. Wounds
which suppurated were usually treated with poultices.
Ligature of the sac has been in vogue from an early day. The distinguished
Prussian surgeon Schmucker dissected the sac, and opened it to be sure that it
was empty, and then, ligaturing as closely as possible to the ring, cut it away.
This he did, however, in only two cases. The elder Langenbeck made careful ana-
tomical dissections, and published at length the results of his clinical and surgical
experiences * (see plates, pp. 104, 123). I quote the description of his operation as
given by Lawrence :
“I divide the integuments over the swelling, without pinching them up into a
fold, clear the hernial sac, push back the prolapsed parts, and place a ligature on the
neck of the sac close to the ring. The tightening of this ligature gives no pain.
If the sac has been completely detached from all its connections below the ligature,
it perishes; if, on the contrary, it has been separated only sufficiently for passing the
ligature, and still remains connected with the scrotum below, it becomes inflamed, and
the scrotum itself is affected with inflammatory enlargement, as after the radical
operation for hydrocele. The detachment of the ligature occurs from the ninth to
the fourteenth day. If the case is an external inguinal hernia, the sac must be sepa-
rated from the spermatic cord. I detach it just below the ring, to a sufficient extent
to allow the application of the ligature, and leave the rest undisturbed in its situa-
tion. To separate the entire sac from the scrotum and from the tunica vaginalis
propria testis would cause much irritation. The operation is much easier with small
ruptures which have not descended into the scrotum, and in internal inguinal her-
nia where the spermatic cord, with its tunica vaginalis communis, lying on the other
side of the swelling, is not so closely connected with the sac. It is most easy in fem-
oral hernia, where the entire sac can be readily cleared. I have already performed
this operation twelve times with the most successful results, and all the patients are
capable of the hardest labor without wearing a truss. Two years have elapsed since
I first put my method in practice on a youth sixteen years old with a large scrotal
hernia, in whom there is at present no appearance of a new protrusion. A year ago
I operated on a crural hernia in a female domestic, who does the hardest work with-
out having experienced any return of her complaint. The ligature causes adhesive
W
a
* Bibliothek für Chirurgie, B. II, 1808.

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA.
267
inflammation of the serous surfaces, and the neck of the sac becomes closed up to the
abdomen like the portion of an artery which has been tied.”
Lawrence, * in commenting upon the operation, although he placed great emphasis
upon the importance of the sac as a factorage of hernia, stated : “But, in truth, some-
thing more is required : we want a remedy that should contract the tendinous open-
ing; for, while that remains preternaturally large, a new protrusion is a highly prob-
able occurrence.”
The operation for the cure of hernia was advocated at a much earlier period by
Arnaud, Sharp, Petit, Abernethy, and others, who reported their experiences; but,
while a considerable number of cures followed, a considerable number of those oper-
ated upon were dangerously ill, and some cases resulted fatally. It is painful to note
the bleedings, purgings, etc., undertaken to combat the inflammation, as it was then
understood. Surgical operations by what might be called the open method for the
cure of hernia slowly fell into disregard, to be revived only in our own time. At least
they fell into disrepute with the profession, and were relegated to the hands of the
peripatetic pretender, who for a long time reaped a rich reward by cultivating this
abandoned field of surgery, so strong was the desire of the suffering to obtain relief
by any means promising cure.
At this period, and for a long time afterward, we may trace a legitimate effort
of the surgical profession to profit by the monumental labors of Camper, Cooper,
Cloquet, and Scarpa, and effect a cure of this distressing complaint. Their teachings,
however, fell upon a barren soil in the subsequent generation, save in the hands of
a few of the leading surgeons in general hospitals, where late operations were per-
formed for the relief of strangulation, but these were for the most part fruitless be-
cause of the delay, thus bringing even these measures into disrepute.
The teachings of the great master, Sir Astley Cooper, found a worthy American
exponent in Dr. John Collins Warren, of Boston. When only twenty-two years old,
writing home to his father, July 9, 1800, from London, he stated: “Mr. William
Cooper, my old master, is succeeded by his nephew, Mr. Astley Cooper, as lecturer;
a young man of the greatest natural abilities, and almost adored at the hospitals.
His practice is directly the reverse of his uncle's. Old Mr. Cooper would say: 'Let
Nature alone; she will open that abscess infinitely better than you can.' The other
* Treatise on Hernia, p. 103.

268
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
says: 'Had you dilated that abscess from top to bottom at first, it would have been
:
well long ago.' The obligations that I am under to Mr. Cooper are infinite. He
has always treated me with the most particular attention, and suffered no opportu-
nity of instructing me to pass by. I wish it were possible to return in the smallest
degree the favors with which he has loaded me.
In the Warren Anatomical Museum, No. 2364, there is still preserved a portion
of omentum four and three quarter inches in length, removed from a crural her-
nia, where the strangulation had already existed seven days. Dr. Warren was then
twenty-seven years of age. Of his experience he wrote: “
When I began to oper-
ate in Boston, many of the great and difficult operations had never been performed.
My father had done a great number of amputations, and had successfully removed
many cataracts. He had also repeatedly done the operation of lithotomy—that is,
he did it four or five times altogether. I have done it since then, including opera-
tions of lithotrity, thirty to forty times. But the operation for strangulated hernia,
that of aneurism, and many others, had not been done in Boston. The first cases of
hernia upon which I proposed to operate excited great opposition on the part of friends
of the patient and surrounding physicians. In consequence of this difficulty I lost
two or three patients in the outset, from delay : one, an only son of the Rev. D.
Baldwin; the other, an only son of B. B., Esq. In consequence of these occurrences
I determined to operate soon, or not at all. This became known to physicians, and
they fell into the plan of operating early. Since this arrangement I have lost scarcely
any patients in operations for strangulated hernia. In the winter of 1805 I was sum-
moned to the wife of Dr. C., of Amherst, N. H., and, accompanied by Dr. Gorham,
rode in an open vehicle on the snow, the best part of a cold night in February,
to Amherst. The disease had lasted seven days. The hernia was crural and large.
The intestines adhered to the peritonæum, and I dissected the peritonæum from the
intestine through a large space, cut off a considerable portion of swelled omentum
which could not be reduced, and which is still to be seen at the Medical College, and
reduced the adherent intestine. The patient recovered, and lived many years afterward.
The operation of strangulated hernia became at last so familiar, that it cost me no
more anxiety than the extirpation of a tumor, especially since the introduction of
ether." +
* Life of J. C. Warren, vol. i, p. 37.
+ Life of J. C. Warren, vol. ii, p. 90.

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA. 269
For many years I find no record of any attempt at revival of methods of cure.
In 1818, Dr. Jamieson,* of Baltimore, reported a case of permanent cure following
the dissection and implantation of a tongue of tissue into the crural canal. After
plugging the canal, skin-flaps were united over it, thus making a plastic operation cov-
ering the parts.
P. N. Gerdy published his method in 1835. This consisted in inflaming, by the
application of ammonia, a portion of the skin of the scrotum and invaginating it
within the ring, and retaining it by suturing through the ring. This operation was
variously modified, the most interesting of which was the device of M. Belmas,t in-
vaginating the ring with an inflated bag of gold-beater's skin. The hernia was first
returned, the sac exposed, and the empty bag carried as far as possible toward the
neck or ring. A cannula fixed in the bag was then used to inflate it, where it was
retained in the sac. Afterward pieces of gold-beater's skin were used, instead of
the inflated bag. A number of cures resulted. The chief interest pertaining to this
operation lies in the experiments which led to its adoption, since M. Belmas demon-
strated that these tissues when placed in the serous cavities of animals became adher-
ent and were incorporated as a part of the living structures. These experiments were
the legitimate antecedents of animal sutures, and might easily have led up to the use
of tendon or catgut thus applied for the closure of the ring.
M. A. Bonnet, of Lyons, published his method of the introduction of three or four
pins through the integuments of the sac and the twisting of the points so as to com-
press the included parts—a sort of hare-lip pin.
The wood pad was employed accidentally by a laborer, with the result of cure.
The pad was variously modified, and called the “ Stagner” truss. From the report of
a committee appointed by the Philadelphia Medical Society, in 1835, I quote: “An
irritation of the skin and subcutaneous cellular tissue is produced by the pressure of
the hard, unyielding, and rugose block, and is gradually extended to the tendons be-
neath, as well as to the serous membranes of the sac which is closed and obliterated
at its neck, the whole mass of integument, tendon, cellular tissue, and the sac being
agglutinated by the process of adhesion, in such a manner as to oppose an insuper-
able barrier against the exit of the intestine.”
"
* American Medical Recorder, vol. ii, p. 128.
+ De la Radicle des Hernies. Rev. Méd. franc, et étrang. Paris, 1838.
Bulletin général de Thérapeutique, May, 1836.

270
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Later the pads were made smooth. I have seen excellent results from their use;
and in one case followed by cure, in a young student, the pad was worn for a time
under so firm a spring that it was nearly imbedded in the swollen parts. Only within
a few days a man presented himself, wearing a truss with a thick wood pad of his own
construction, which, he said, " held him when all others had failed.”
Wutzer,* of Bonn, improved upon Gerdy's method of invagination, by the inven-
tion of an instrument through which was carried a needle. Both were allowed to
remain in situ for eight or ten days. A truss was recommended for some months sub-
sequent. Permanent cure, however, proved the exception.
The use of the seton may be traced far back in the history of surgery; and
when the inflammatory processes which supervene are taken into consideration, it
is easy to conceive its supposed adaptability for the cure of hernia. The seton was
introduced into the hernial sac, for this purpose, early in the present century. No
definite results are reported, and the practice has for a long time been generally aban-
doned. Dr. Holthouse, † however, has given such an exceptionally interesting state-
ment of its use that I quote the following : “Cases are sometimes met with in which,
owing to the smallness of the inguinal canal, the finger can not satisfactorily make out
the structures involved in the operations which I shall have presently to speak of, and
under such circumstances their performance can not be altogether free from risk.
For these, the seton operation may be instituted, and from my experience
it, de-
rived, however, from a limited number of cases, I am disposed to regard it with more
favor than is usually accorded to it. True, I have not done it of late years, but that
is because I have met with scarcely any cases that were not amenable to the superior
operation by the rectangular pins, which act both on the sac and on the canal. The
following, however, is an example of the seton operation :
“G. E., aged seventeen, was admitted into the Westminster Hospital for an oblique
inguinal hernia, which had descended into the upper part of the scrotum, and existed
three months. It was easily reduced, and no truss had been worn for it. On the
31st of July, 1860, the bowels having been previously cleared by castor-oil, a seton
composed of eight threads of silk was drawn through the inguinal canal, the patient
was put on low diet, and a grain of opium given at bedtime.
* Wutzer. C. W. Weber. Radicale Heuling beweglicher Leistenbrüche, Bonn, 1840.
+ On Hernial and other Tumors of the Groin and its Neighborhood, with Practical Remarks on the Radical
Cure of Hernia. Carsten Holthouse. London, 1870.

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA.
271
August 8th.-Seton removed, very little pain or suppuration having been caused
by it. Has not had any unfavorable symptoms, and looks and feels perfectly well.
Middle diet, with half a pint of porter, was ordered, and a truss with a weak spring
was applied
“ August 10th.—Continues well; some tenderness is felt on pressure over the ingui-
nal canal, and the truss causes pain in the parts; it was therefore removed, with an in-
junction to the patient to place his hand over the site of the internal ring during defeca-
tion or straining
August 21st.—Discharged cured, but wearing a weak truss. Wounds very nearly
but not quite healed.
September ist.- Presented himself at the hospital, the wounds being now quite
healed. The truss was taken away.
“ October 13th.—Continues very well, and has gained flesh. He is working as a
bricklayer's laborer, without a truss.
“ August 31, 1861.—A month ago, or exactly one year after the performance of the
operation, the rupture suddenly came down again while he was making a violent mus-
cular effort. He has been nearly constantly at work without a truss ever since his
discharge from the hospital. Notwithstanding the hernia eventually returned in this
case, the operation can scarcely be called an unsuccessful one.
Indeed, it appears
extremely probable that, had the patient delayed going to work a little longer, or had
he been in a station of life which called for less bodily exertion, there would have
been a pronounced success. This view is supported not only by the cures resulting
from the use of a truss only, and to which allusion has already been made, but
by the following dissection of a case in which this principle of operating was
adopted :
“A German, forty-seven years of age, affected with a scrotal hernia of the right side,
was operated on by Prof. Carnochan, after Rigg's method, on the 2d of May, 1857;
the operation was completely successful. Toward the latter part of July pulmonic
symptoms made their appearance, and on the oth of September he died of tuberculosis
of the lungs. Post-mortem roth of September.—Upon opening the cavity of the peri-
tonæum the orifice to the hernial sac could not be traced, the internal ring being firmly
closed around the cord. On the outer side of the peritonæum, and just below the situa-
tion of the internal ring, was found a small rounded body of a yellowish color, supposed
to have been the remains of the hernial sac. The upper portion of the inguinal canal,
-
a

272
ANATOMY AND SURGICAL TREAMENT OF HERNIA.
for nearly an inch, was closed by plastic exudation, which had become organized and
somewhat fibrinous in its appearance, while the canal at its lower part and the external
ring were to appearance in their normal condition, though the cord throughout the
entire length of the canal seemed to be imbedded in plastic formation. The skein
of silk used in this case being too large for the puncture made by the instrument,
it was not introduced more than one inch, which will explain the facts mentioned
of the lower portion of the canal and external ring being in their normal con-
dition; while at its upper portion both the canal and internal ring were firmly
closed."
In explanation, it should be mentioned that Rigg's operation is identical in prin-
ciple with the seton operation. The method of performing the seton operation is
as follows: "A fold of scrotum is carried up on the finger as high into the ingui-
nal canal as possible; a strong curved needle, set in a handle and having a large eye
near its extremity, is next passed along the palmar aspect of the finger, thrust through
the anterior wall of the canal, and brought out on the surface, about half an inch or
more above the center of Poupart's ligament; it is then threaded with the number of
threads previously determined upon, and medicated or not, as the case may be, and
withdrawn through the same opening at which it was entered. The upper and lower
ends of the thread are tied together, and pressure made over the outside of the canal
with a compress and bandage. The threads are allowed to remain in the canal till a
sufficient amount of inflammation appears to have been excited, and are then with-
drawn at periods varying from three to nine days.”
M. Velpeau operated a number of times by opening the neck of the hernial sac
and introducing the tincture of iodine. The success which so often followed the
operation for hydrocele by injection led him to adopt its use for the cure of hernia.
An assistant compressed the inguinal canal so as to prevent the fluid entering the
abdominal cavity; a mixture of six drachms of tincture of iodine in three ounces of
water was introduced, and, after pressing it into all the parts of the sac, it was allowed
to escape. No serious symptoms followed, but the imperfect results led him after a
time to abandon its use.
Dr. Pancoast, of Philadelphia, in his work on Operative Surgery, published in 1844,
reported the injection of tincture of iodine, or tincture of cantharides, half a drachm,
introduced into the sac by means of a small syringe, fitted with a fine canula which
is first carried free into the sac. The canula was withdrawn, and a compress, placed
Also
es
su

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA.
273
under a truss, directed to be worn. His cases numbered thirteen, operated on in 1836,
and were all benefited. Some worked at farm-labor a year after the operation without
wearing a truss, and there was no return of the hernia.
Dr. E. M. Moore * gave a brief account of cases operated on by Dr. Pancoast
when he was intern under the latter, as follows: “The operation for the radical cure of
hernia had not at that time been performed on this side of the Atlantic. Four cases
were treated by injection. Dr. Pancoast was so fearful of peritoneal inflammation
that he had a fine trocar made and a small gold canula. The point of the trocar was
round, so as to avoid cutting the tissues and thereby causing hæmorrhage. This instru-
ment was plunged into the tissues at the neck of the sac, and forced down to the bone
so as to insure a sufficiently deep injection. The trocar having been removed, twenty-
five drops of the officinal tincture of cantharides were injected. The cut produced by
the needle healed immediately, but the irritation caused by the injection was very con-
siderable. The swelling was marked, and very hard along the line of the cord. At
first some alarm was felt lest the peritoneum should become inflamed; but this did not
happen, and the patients progressed favorably as far as the hernia was concerned. Un-
fortunately, one of the patients died of typhoid fever. The ultimate results, in two of
the other cases, were not known, as the histories of the patients after the operation
could not be traced. One of the cases presented an enormous scrotal hernia. After
the injection the swelling of the parts was very great, and the cure apparently satisfac-
tory, but the patient refused to wear a truss, and the hernia returned. Some time aft-
erward, Dr. Moore took care of a case operated on by another physician for the radical
cure of an ordinary inguinal hernia. The operation consisted in cutting and tearing
through the tissues until the neck was reached, and then introducing six drops of oil
of cloves by means of an ordinary glass syringe. The patient was placed in bed, and
advised to wear a truss even while recumbent. This, it was subsequently learned, he
neglected to do, even rising from bed without adjusting the truss. Neverthe-
less, he made a perfectly successful recovery, and, although he returned to his work
—that of waiter at a hotel—without using a truss, there was no return of the
trouble.”
Dr. John Watson,t of New York, published upon the subject in 1851. The process
* Transactions of the New York State Medical Association, vol. vi, pp. 139, 140.--Discussion by E. M. Moore, M. D.
+ The Radical Cure of Reducible Hernia by the Injection of Tincture of Iodine.- New York Medical Times, 1851.
38
- 326
At

274
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
of injection with iodine was revived in Paris in 1854-²57, with favorable results, as re-
ported by Boinet, Demeaux, Jobert, Maisonneuve, Nélaton, and Ricord.
The injection method, of by far the widest repute and general adoption, is accred-
ited to Dr. George Heaton, of Boston. He first published his results in 1843.* He
used the fluid extract of oak-bark.
The late Dr. Joseph H. Warren, t of Boston, the most famous of Dr. Heaton's fol-
lowers, wrote: “ But the honors of the true hypodermic injection, without any prelimi-
nary incision, I think, after much careful research, in the literature of surgery, belongs
to the late Dr. George Heaton, of Boston, who, after eight years of discouraging ex-
periment, discovered a process which I call the method of tendinous irritation, by the
injection of a solution of quercus alba. Since he performed successful cures by his
new method as early as 1840, and experimented, as he tells us, eight years previous to
this, we are carried back to the year 1832, when he first conceived his method. His
first operations were performed with Dr. Jaynes, of St. Louis.” The operation as per-
formed by Dr. Heaton created much discussion in Boston. It was generally adversely
criticised, and his methods were claimed by some to be unprofessional. There can be
little doubt but that he pursued the investigation of the subject with enthusiastic
devotion and with good results, if not always followed by entire cure. Dr. J. H. Dav-
enport edited Dr. Heaton's book,/ which contains much that is novel and interesting.
There is appended a list of one hundred and forty cases
one hundred and forty cases “from the many hundreds,”
with brief notes of each.
Dr. Warren began operating upon hernia by the Heaton method soon after the
author's death. He stated,# in a note to his second edition, that he “is convinced the
credit of the origination of the method belongs to Dr. Pancoast; that to Dr. Heaton is
due the discovery of the exceptional value of the thick extract of the oak-bark.” Dr.
Warren thought that this peculiar effect was due to non-absorbability of the particulate
elements of the bark, and, by their remaining in the tissues, a much greater exudation
of the cell elements occurs. He greatly modified and improved the instruments
to be used, both needles and syringe, and changed somewhat the medicamenta em-
ployed.
* Boston Medical and Surgical Journal, 1843, pp. 217, 219.
+ Warren, On Hernia. Second edition, 1882, p. 129.
1 Cure of Rupture. By George Heaton. Boston, 1877
# Op. cit., p. 366.

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA. 275
Among the recipes commended the following is preferred:
... 3 ij
R Fl. ext. querci albæ (reduced by distillation one half).
Alcohol, 90 per cent.....
3 ss.
Ether sulph ....
3 ij
Morphia sulphatis..
Tr. veratri viridis ....
3 ij. M.
Inject from 5 to 20 drops in small and recent herniæ, but 25 to 50 drops in old and larger
herniæ.
grs. iy
Dr. Warren also modified the operation by not injecting into the sac, but “into the
rings and around the sac.” This he considered very important.
For a considerable time following the publications of Dr. Warren the operation
was performed in various parts of America and in Europe. The exudations which
supervene, as I have myself seen, are very considerable, the pain and suffering not
severe, the danger in competent hands is slight, but the results are certainly not as sat-
isfactory as the profession was led to expect.
In the volume of the Transactions of the American Medical Association, 1861,
page 251, is a most interesting paper by Dr. Thomas Wood, of Cincinnati, upon
the radical cure of hernia by a subcutaneous closure of the external ring by suture,
“This is effected by a needle constructed for the purpose, curved so as to form about
one third of the circumference of a circle of two inches radius. It has two spear-points,
with an eye in the center of the shaft large enough to admit a silk braid one eighth of
an inch wide.” The sac is reduced, the finger carried into the ring through the invagi-
nated scrotum, and upon it the needle. The cord having been protected, the needle, as
may easily be inferred from its construction, carries the suture, inclosing the ring in a
loop, and the ends of the suture are brought out from the opposite sides. These are tied
over a compress and removed in from ten to fifteen days. Dr. Wood reported three
operations, followed by cure. In submitting his paper to the profession he stated that
“ he does it feeling confident that it will be appreciated according to its merits.”
Dr. John Wood, of London, first published his method of subcutaneous operation
by suture in 1857. His experience is now probably greater than that of any other liv-
ing operator, and his method has been and is so extensively in use, that I copy from
his most recent publication * his operation for the radical cure : “The patient being
* International Encyclopædia of Surgery, vol. v, pp. 1140-1143.

276
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
a
placed on the table, the parts shaved clean and purified, and an anæsthetic administered
so as to get the muscles relaxed, an oblique incision is made with a small, sharp-pointed
tenotomy-knife, well washed in a one-to-twenty carbolic lotion, in the front of the scro-
tum over the fundus of the rupture, three quarters of an inch long, and through the skin
and superficial fascia. The handle of the knife is then used to separate the integument-
ary tissues from the deeper fascial coverings of the hernia, or cord, so as to form a
circle of detached integuments large enough to be invaginated into the hernial canal
without drawing up the skin into the superficial ring. A stout-handled needle curved
in the segment of a circle, with a sharp point, blunt shoulders, and a large eye near the
point, is used for carrying the wire. This should be well-annealed and flexible cop-
per wire, silvered over, thick enough not to cut the tissues when drawn tight, but not
so thick as to be at all inflexible. A piece about twenty inches long, briskly rubbed
so as to render it flexible and clean, dipped in a one-to-twenty solution of carbolic lotion,
and then in carbolized oil (one to five), should have each end bent into a hook three
quarters of an inch long, and evenly curved so as to pass easily through the eye of the
needle. The forefinger, oiled, should then be passed into the scrotal puncture and
made to invaginate the fascia and sac into the hernial canal, as far as it will go into the
deep ring behind the lower fibers of the internal oblique muscle, which should be raised
well upon the finger. To the inner side of the finger will then be felt the raised edge
of the conjoined tendon, lying on the outer side of the rectus abdominis muscle. The
needle must now be carefully and slowly passed along the finger until its point can be
felt plainly by the bulb of the digit placed behind the conjoined tendon. The point
should next be directed inward, so as to take up the tendon and to transfix it and the
aponeurosis of the external oblique which covers it. Its point will then be seen to
raise the skin. The skin must next be drawn toward the median line, and the needle
directed by its stout handle so as to bring its point out through the skin one and a half
inch external to the puncture, and through the deeper tissues. One end of the wire is
then hooked on to the eye of the needle, and is drawn with it by a slight jerk through
the tissues, emerging at the scrotal puncture. The needle is next detached from the
wire and the finger again passed into the canal. Now the spermatic cord is to be felt
for, lying in a groove formed by the union of Poupart's ligament with the fascia trans-
versalis. The cord is to be pushed gently inward, and the point of the finger placed
in the groove which it occupied, and lifted forward, so as to elevate Poupart's ligament
at its center, and with it the outer pillar of the superficial ring.

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA. 277
The iliac artery may be sometimes behind the finger, which lifts up the tendinous
structure from its immediate contiguity, and protects the vessels from injury. The
needle, passed again along the front of the finger a little to its outer side, is then pushed
through Poupart's ligament till its point raises the skin. The latter is now pulled
inward until the point of the needle can be made to pass through the same puncture in
the skin of the groin which the wire already traverses. The opposite end of the wire
is next hooked on to the needle, drawn down as before through the scrotal puncture,
and then detached. There is now a wire loop at the groin, and two hook-ends at the
scrotal puncture, opposite the latter; the sac is then pinched up by the finger and the
thumb, in the same way that a varicocele is separated from the spermatic duct when
submitted to operation. An assistant seizes it with the finger and thumb, also in the
same way, at about two inches distance, both assistant and operator recognizing the
situation of the spermatic duct. The needle is then passed at one corner of the scro-
tal puncture across the sac, in front of the duct, and out at the other end of the scrotal
puncture. The skin here is so elastic that the puncture stretches sufficiently to allow
this to be easily done. The inner end of the wire—viz., that which traverses the con-
joined tendon-is next hooked on to the eye of the needle and drawn across behind
the sac.
Care must here be taken, by dealing with the wire roundly, not to make an
acute bend or kink, which would put a needless difficulty in the way of its subsequent
withdrawal. The wire should be drawn down so as to get straight parts in the tissues,
and to bring the loop an inch or so from the skin surface. The two scrotal ends are
then twisted two or three times around each other, the operator observing the direc-
tion of the twist, so as to be able readily to intwist the wire when it is to be with-
drawn. The loop of the wire above is now seized and drawn firmly upward, so as to
invaginate the scrotal fascia into the hernial canal as high up as the deep hernial open-
ing, and then it is twisted firmly down, in the same way and with the same precau-
tions as the lower ends. The ends and loops are then bent over toward one another,
the former cut off to a convenient length, passed through, and bent on to the latter. In
large cases, where the superficial ring is very patulous, the wires may be crossed in
the canal, and the needle passed through the pillars near the pubis, after the sac is
invaginated. Thus the lower opening of the hernial canal may be more effectively
closed. In these cases a cylindrical pad of glass or boxwood may be used with advan-
tage to secure the loop, and for the ends of the wire to be twisted over. A pad of
lint, large enough to exercise compression, is fixed under the bight of the double wire

278
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
loop which has been formed, a little carbolized tow is put over the scrotal puncture
to catch any discharge, and a flannel spica bandage is applied, the ends of which, on
being tied, should be made into a sling or suspender to support the whole of the
scrotum and penis. The patient should be placed in bed, with the shoulders well
raised and the knees tied together and bent over a long bolster, with a prop for the
feet to keep the body firm. The bowels should be opened on the morning of the
operation, and then left until some discomfort is experienced. Opium - should be
given for the first twelve hours—one grain every four hours—until pain ceases or
sleep comes on. The diet should be of milk and beef-tea, with ice to relieve any
nausea left by the anæsthetic. The discharge is trifling and of a serous character.
The bandage rarely requires to be touched till three days have elapsed, when it may
be removed entirely, with the pad of lint. A lump of well-teased antiseptic tow
placed under the wire will be sufficient dressing. The scrotum should be well sup-
ported. The wire should be kept in from eight to twelve days according to the
amount of reaction set up, the lower ends of the wire acting as an efficient drainage
conductor. At the end of this time the wire may be untwisted, and it will then be
found that the two parallel, straight portions of the wire, which originally passed
through different tracks, have by slow ulceration joined each other in the same track,
and that they will come out together by cutting off their lower ends with pliers
and pulling upon the upper loop. If by reason of slight kinks there is any diffi-
culty in this, the wire may be straightened by pulling at each end with pliers, and
the ends may then be drawn together or singly. The upper opening usually closes
soon after their withdrawal, and a truss may then be applied with cotton-wool be-
neath it, and the patient may be allowed to get up and lie on a couch until the
a
lower sinus heals. ... The effect of this operation is to unite in one cicatrix the
sides of the inguinal canal as far up as the deep ring, together with the pillars of
the superficial ring, the union of which supports the invaginated, twisted, obliterated
sac, with its intimate coverings of external and internal spermatic and cremasteric
fasciæ. The conjoined tendon of the internal oblique and transversalis muscles is
connected firmly with the deep part of Poupart's ligament, and upon this union de-
pends, for the chief part, the success and permanence of the radical cure. Thus the
valvular arrangement of the front and hinder walls of the canal is restored and
strengthened by adhesion, and the rounded knuckle of bowel can no longer enter
the deep ring; and thus the most effectual preventive of the formation of a hernia

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA. 279
.
in the healthy inguinal canal is restored, and even strengthened, by the operation.
Unless this is accomplished the cure is not satisfactory, and one of the chief causes
of failure in the hands of the inexperienced is the want of dexterity and experience
in obtaining a hold upon the conjoined tendon with the needle-point, at the first
stage of the procedure. . . . By the method just described I have operated upward
of two hundred times consecutively, with not a single seriously bad symptom occur-
ring. The average period of convalescence has been about a month from the opera-
tion to the healing of the lower opening; the average time in bed about eighteen
days. Before adopting the use of the wire, thread and compresses were employed;
and while the steps of the operation were imperfectly understood and carried out,
and when, perhaps still more important, cases were operated on somewhat indiscrimi-
nately, three deaths occurred in the first one hundred cases: one from pyæmia, one
from erysipelas, and the third from peritonitis, all having been published at the time
in the medical journals. Two of these were decidedly from hospital or other infec-
tion, while the third case was a peculiar one; the necropsy clearly showed that fatal
peritonitis had been set up by a knuckle of intestine which had been involved in
the sac before the operation, with the truss pressing upon it. In no case has any
trouble arisen from hæmorrhage, nor have there been any signs of injury to the epi-
gastric, femoral, iliac, or other vessels.”
In the evolvement of thought in the same direction should be mentioned the
operation by Dr. Agnew, of Philadelphia,* which consists in the use of an instrument
for invagination, and then the subcutaneous sewing of the ring with wire. Three
other sutures, also of wire, were used to inclose the canal.
The late Dr. Greensville Dowell,+ of Texas, devised a most interesting modifica-
tion of subcutaneous suturing with interrupted silver wire sutures, using a needle
like that of Dr. Thomas Wood, of Cincinnati, but with an eye at each end instead
of in the middle. The sutures were introduced in a manner not unlike that of Dr.
Wood. He first published in 1866. He advised from one to seven sutures as
required for firm closure. A little before his death he wrote me as follows: “The
result of my operations, so far as I can learn is : One hundred and three cases, treated
by myself; twenty-five cases partially relieved, two cases made worse. One child
* Medical and Surgical Reporter, Philadelphia, 1864-65, vol. xii, pp. 461-463.
+ Medical Record, New York, vol. i, p. 266.

280
ANATOMY AND SURGICAL TREAMENT OF HERNIA.
source.
died in seven days after the operation, with congestion of the brain. Cured, seventy-
six. So far as I know, all these remain well; some have had partial return of the
hernia and worn trusses. Several were operated on twice, and failed both times. I
know no particular reason for the failure except that the ligatures were put in too tight.
... I simply put a piece of lint over the ligatures and saturate it with collodion."
I knew Dr. Dowell, and greatly admired his inventive genius and fertility of re-
His operation has been performed by many of his associates with good
results.
It will be observed that, in the operations for subcutaneous suturing, the funda-
mental idea is not unlike the old, abandoned operations. by the “punctum aureum
and suturing of the ring, in various ways, by the early fathers of surgery. To this,
however, Dr. Wood brought correct anatomical knowledge, and by his method of
suturing sought to bring together the pillars of the ring. By the rare tact and ex-
perience of the master, he secured better results than any operator preceding him-
much better, indeed, than his followers.
Dr. David W. Cheever, of Boston, surgeon of the City Hospital, in 1870, reported
twenty-four cases operated on for cure, with two deaths. In commenting upon the
operation, he writes: “ Hernia has long been one of the opprobria of surgery. To
cure it no operation is certain. The operation of Mr. Wood seems the most reason-
able one proposed. It will cure a certain number of children and young adults.
It will fail to cure others. Mr. Wood, it must be remembered, claims some seventy
per cent of success. We can show barely twenty-five per cent." From Dr. G. W.
Gay's * report I quote the following : “ During the past five years herniotomy has
been performed twenty-six times for strangulated or irreducible hernia. Thirteen
ruptures were inguinal, six died; twelve femoral, five died; one umbilical, died. Of
eleven patients over fifty years of age only two recovered; while of fifteen under
that age twelve resulted favorably. The average duration of convalescence was about
a month; in the fatal cases death resulted at periods varying from five hours to
eighteen days; about five days being the mean duration of life. The cause of death,
so far as could be determined, was as follows : Exhaustion, six; peritonitis, four;
tetanus, one; erysipelas, one ; total, twelve out of twenty-six operations. ...
"Twelve patients suffering from inguinal rupture were operated upon for a radi-
* Medical and Surgical Reports of City Hospital. Boston, 1882, pp. 267-271. G. W. Gay, M. D.

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA. 281
cal cure.
Wood's method was resorted to in four instances, with temporary relief.
The so-called Heaton operation was performed eight times; six cases were partially
successful, and two were complete failures. All these patients left the hospital
wearing a truss or bandage, and their subsequent condition is unknown. No radical
operation has been performed upon any of the other varieties of hernia during the
past five years. We have ventured to give a brief account of our personal experi-
ence with the Heaton operation, and have recorded all the cases operated on by us,
both in hospital and private practice; the results are stated as fully as possible. All
were cases of inguinal hernia, and, with the exception of those specified, were sup-
posed to contain intestine. Only those patients are called cured who have remained
well for at least one year after discarding all support to the rupture. .
“ Number of patients, fifteen. Cured, four. Relieved, eight. Not relieved, three.
“ Number of ruptures, eighteen. Cured, five.
Cured, five. Relieved, eight. Not relieved, five.
“ Number of operations, twenty-three.”
The criticisms which I think we are now warranted to make, owing to the safety
of properly treated operative wounds, is that subcutaneous surgery is blind surgery,
and blind surgery is, as a rule, bad surgery. A subcutaneous wound is better by be-
ing such, only that it is less liable to be, or to become, an infected wound. The prob-
lem of hernia, as we have endeavored to show, by the careful study of the anatomi-
cal relations of the parts, and the formation of the peritoneal sac, re-enforced by the
experience of the centuries, is one containing factors which necessitate treatment by
a careful dissection of the parts, in order to furnish the best measures for resultant
The peritoneal sac is a redundancy of extraneous tissue, and should be treated
as a factor to be eliminated. This has been the stumbling-block in the surgical treat-
ment of hernia during the centuries, often recognized as such, but because of the too
generally occurring septic infection of open wounds, and high mortality when in this
locality, considered of unwarranted danger. This is one of the fundamental faults in
the treatment of hernia by the injection method, and by the subcutaneous suturing
of the ring. In both the above methods, also, there is an attempt to fill the ring by
material foreign to its primary construction. In the first, by a large exudate, often
incorporating the sac; in the second, by drawing together blindly the parts incor-
porated which at best imperfectly restores the tissues to their normal state, and may
include tissues which it is important to exclude.
Experience had long ago taught that the complete closure of the canal and rings
cure.
39

282
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
-а
gave much the better result. It was in recognition of this that castration became
for a long time the adopted method, and continued so until prohibited by law, not be-
cause the hernia failed of cure, so much as that a considerable class suffered loss of
virility—a choice of evils which many voluntarily made when all surgery, as compared
with the present, was necessarily almost brutal.
Mr. Wood, by his subcutaneous wire suture, can make at the most only two stitches
in his effort to occlude the canal, yet he recognized the necessity of close approxima-
tion and wrote, “ To insure success, complete union must be established along the
length of the canal.” Drs. Agnew and Dowell increased the number of stitches in
order the better to secure this result. In part, also, to remedy this fault, the very inter-
esting modification of Mr. Wood's operation was devised, namely, the extremely in-
genious and original instrument by Mr. Spanton,* whose good work as an operator is
well known in England. The cork-screw instrument is at once needle and suture, and
is to be commended for its advantages over the so-called Wood suture.
The methods of subcutaneous suturing are, for obvious reasons, marked improve-
ments upon preceding operations for the cure of hernia. These improvements, how-
ever, are but modifications of the general idea which, we have seen, dominated the pro-
fession for centuries: to close the canal by some subcutaneous method, through the fear,
born of experience, of the dangers incident to septic infections of the locality. Such
fatality was quite sufficient to justify the general opinion, and it required a large amount
of the heroism of conviction to put into execution, in operations undertaken for the
cure of hernia, the methods of antiseptic wound-treatment.
I introduce here the following beautiful plate from Bourgery, which is especially
instructive because of the demonstration of the deformity of the internal ring which
is the necessary accompaniment of old, large herniæ. Figures i and 2 teach the diffi-
culty, or well-nigh impossibility, of cure by the processes of injection which have been
under discussion in the present chapter, even if the hernia is non-adherent and easily
reducible. Figures 3, 4, and 5 are exceptionally well-selected illustrations of the
changes which the internal ring undergoes in inguinal hernia, and show at once the
hopelessness of its permanent occlusion by the measures under discussion.
* D. W. Spanton. British Medical Journal, London, vol. ii, p. 322, 1879.


PLATE LVI.
Fig. 5
Fig
d
a
6
C
е
Fig. 4
a
Fig.2.
a
b
e a e
B
Fig. 3.
А
С

OPERATIVE MEASURES ADVOCATED FOR THE CURE OF HERNIA. 283
PLATE LVI.*
Figure 1.
Figure 4.
External Inguinal Hernia in a Female. The Peritoneal Orifice of the External Inguinal Her-
hernia is dissected, to show plainly the hernial sac. nia.
This bilocular sac, with a moderate constriction a. Internal infundibulum orifice of the dilated
which formerly corresponded to the ring when the inguinal canal.
sac was simple, presents to us upon the cadaver b. Border or internal pillar of the peritoneal
the same case that we sketched, a few months orifice.
since, from the living (see Plate XXXV, Figure 1). c. Epigastric artery, which arises under the
peritonæum of the external iliaca.
Figure 2.
d. Cord of the spermatic vessels.
Bilocular External Inguinal Hernia, in a man f. External iliac artery and vein.
aged fifty years. In this case, analogous to the
preceding, the hernia is an entero-epiplocele, with
Figure 5.
two continuous hernial sacs, separated by a stran-
Accidental Crural Canal, which has given pas-
gulation at c.
d. The inferior sac incloses only the epiploon.
sage to a hernia, the viscera of which have been
removed.
b. The superior sac shows in addition an in-
testinal loop.
a. Contour of the abdominal orifice forming
Figure 3.
the first layer.
b. Contour of pubian orifice, closer pressed,
Two Hernia, containing omentum and intes-
formed by the aponeuroses. The pubian layer,
tine, upon the same subject. The point of view is
with the covering of the external crural ring, is
taken at the interior of the abdominal cavity,
visible through this elliptical orifice.
going into the peritoneal apertures of two hernial
c. Upon the other side the edge is formed by
sacs. The nature of each of these hernia is in di-
the femoral aponeurosis; between the two is seen
cated at sight by their respective distance from
an elliptical orifice, which is only the accidental
the linea alba.
crural ring forming under the integuments of the
A. External Inguinal Hernia. Here the cord
thigh the entrance to the hernial sac.
of the spermatic vessels, situated below and out-
ward, is masked by the viscera.
Accessory Parts.
a. The epigastric artery, which passes below,
and is seen again in the thickness of the pillar at d. External iliac artery and vein.
the internal edge of the orifice.
e. Epigastric artery, situated without and
B. Internal Inguinal Hernia. The dilatation above the crural orifice.
of the orifice has crowded back its external pillar f. Spermatic vessels, a little deviated from
very near to the internal inguinal ring, in which their course, the orifice of the peritoneal ring be-
we see the cord of the spermatic vessels insinu- ing carried somewhat higher than normally.
ating itself.
g. Fætal cicatrix of the testicular prolonga-
C. This pillar, at the external edge of the ori- tion of the peritonæum.
fice, incloses the epigastric artery, situated con- h. Deferent canal.
sequently without, and which we see extends be- i. Obliterated umbilical artery.
yond upon the line of section.
k. Bladder.
* Bourgery, Plate XXXIX, Bis.

CHAPTER XXIII.
THE ANIMAL SUTURE: ITS HISTORY, AND ITS PLACE IN SURGERY, ESPECIALLY WHEN
BURIED IN THE TISSUES.
In the previous considerations upon the cure of hernia I have endeavored to show
that the ligature or suture carried through the neck of the sac was a very important
factor; that the sac should be resected and cut away, and its sutured base returned
within the ring. I have also emphasized that, in the large and difficult class of inguinal
hernia in the male, the most important factor in surgical procedure consists in the resto-
ration of the obliquity of the canal, and that this can be effected only by the use of
sutures applied through the deeper structures, in order to strengthen the weakened tis-
sues and close the internal ring from below upward upon the cord. This necessitates a
line of sutures which must remain buried deeply in the wound without the causation of
subsequent trouble. Although the closure of the remaining tissues might be effected
by interrupted sutures, subsequently to be removed, I think I have clearly shown, by
the abundant experience of others as well as my own, why these structures should also
be closed by sutures to be left undisturbed, or buried in the tissues. Inasmuch as the
curative measures for hernia are so largely dependent upon the suture and its method
of application, and that the use of the buried animal suture in an important degree
revolutionizes the treatment of all aseptic wounds, I have determined that the subject
of animal sutures is of sufficient interest and importance to devote to it a distinct
chapter.
Investigations upon the origin of means adapted to a given end clearly teach that
active minds have already subjected its chief factors to careful analytical study, although
certain phases of the problem are ever presenting themselves under new aspects. Domi-
nated by such thought, Solomon taught that “there is no new thing under the sun,"
and it is quite probable that the animal ligature was known and used by the Egyptian
surgeons at a period antedating this wise Jewish philosopher.
The connective tissue of animals was early utilized for a great variety of purposes
when it was necessary to secure great strength and high tension. The Homeric poems
>
(284,

THE ANIMAL SUTURE.
285
afford familiar illustrations. In the Odyssey, the strings of the old Greek harp are de-
scribed as made from the twisted intestine of the sheep. The ancient Egyptian harp
is said to have been strung in a similar manner. The celebrated Arabian writer
Rhazes, who practiced in Bagdad A. D. 900, described the stitching of wounds of the
abdomen with the strings of the harp; and Albucasis also mentioned the stitching to-
gether of wounds of the bowel with a fine thread from the twisted intestine of an
animal.
The careful student of the early history of surgery finds abundant evidence that the
ligature was used as a hemostatic agent at a very early date. Celsus, at the end of the
first century, described the ligature as of ancient origin, and stated that it was used by
the Alexandrian school of medicine, with the teachings of which he seems to have been
familiar. He advised placing two ligatures upon the vessel and dividing it between
the points of tying. Galen recommended its use; and Vesalius, in the sixteenth cent-
ury, mentioned the ligature as a relic of the past, greatly underestimated in value
because of the lack of anatomical knowledge. Its first application in amputations, on
account of gunshot-wounds, was doubtless by Ambrose Paré. At this time such
wounds were cauterized with boiling oil, in the belief that gunpowder in some way
poisoned the wound.
Special studies, however, for demonstrating the value of the material used for liga-
tures do not appear to have been made in the early history of surgery. Indeed, there is
little doubt that, whatever the material used, it was always considered as a foreign body
to be ultimately eliminated from the wound; and the material, selected for its strength
without special reference to the irritation which might be induced thereby, was natu-
rally the thread, silk, or hemp which was in ordinary domestic use.
To our distinguished countryman, Professor Physick, of the University of Pennsyl-
vania, is undoubtedly due the honor of having first introduced into surgical practice in
modern times what is known as the animal ligature. His ligatures were made of
chamois-leather, and he and Dr. Dorsey usually rolled their ligatures on a marble slab
to make them round and hard. The advantages claimed for the ligature by Dr. Phys-
ick were that, being composed of animal tissues, they would serve long enough to
obliterate the artery and be speedily removed by the absorbents, thus avoiding the diffi-
culty arising from a foreign body, however minute. These ligatures were used in this
country to a great extent, and Sir Astley Cooper demonstrated their superiority in his
own operations.

286
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
“ Dr. Hartshorn used strips of parchment for his ligatures. My friend * Dr. H. G.
Jamieson, Professor of Surgery in Washington Medical College, Baltimore, has for a
series of years been employing the animal ligature in an extensive surgical practice.
He has used it in many amputations of the limbs and of the mammæ; he has tied the
carotid, the iliac, the femoral, the radial, the posterior tibial, the spermatic, and other
arteries, with the buckskin ligature, and in no instance had secondary hæmorrhage; and
he states that he has never seen anything of his ligatures, and, of course, his wounds
have generally healed by first intention. Dr. Jamieson gives to Dr. Physick the honor
of having first introduced the animal ligature, but he contends that the practice of rub-
bing or drawing, to harden the leather, is highly reprehensible. He advises to tie the
artery with a buckskin ligature very soft and little broader than the thickness of the
skin, taking care not to tie it too tightly. He states, as the result of his observations
and experiments upon sheep, dogs, and other animals, that a capsule will surround the
ligature, if the capillary vessels be not much disturbed, or the vessel will be surrounded
by an abundance of lymph and the ligature dissolved.”
The method of Ætius and Celsus, revived by Abernethy, of applying two ligatures
and dividing the artery between them, Dr. Jamieson condemned as unnecessary, since
by a single flat buckskin ligature the artery may be obliterated without destroying its
continuity. Hence, he opposed all indissoluble ligatures of whatever material; he
declared it not only to be unnecessary, but highly hazardous, to cut the inner coats of
the vessel, as recommended by Jones, and others, and agrees with Scarpa as regards flat
ligatures; but, by the use of the buckskin, he has no need, like him, to remove his liga-
tures on the fourth day. For a very able and interesting account of his views, which are
of the highest practical importance, I would refer to the thirty-seventh number of the
Medical Recorder, published at Philadelphia in 1827, and from which I quote the
following extracts :
“We believe that the animal ligature will secure the patient from all these dan-
gers except one—to wit, the awkwardness of the surgeon; and even in this respect
the animal ligature is preferable, not requiring the precision of management essen-
tial to the cutting ligature. If the ligature is cut from the leather with care, it will
always admit of being tied sufficiently tight, but can never be made to cut the coats,
provided it is made of soft buckskin and not hardened by drawing it. It is less likely
* Cooper's Medical Dictionary, sixth American edition, vol. ii, p. 130, edited by Dr. M. Reese, M. D.

THE ANIMAL SUTURE.
287
to slip when somewhat insecurely applied, because, being elastic and soft, it is spread
over a small space of the vessel, and almost immediately adheres by its glutinous prop-
erties. It lies more securely, while the cutting ligature, resting on a mere line, and
having neither adhesive properties nor the advantage of a small vacuum between the
vessel and the ligature, as is the case with the flattish adhesive ligature, is more
likely to slip off. Besides, as we cut off the ends close, there is no risk of pulling them
away by an accidental jerk of the hand. In support of these assertions, we have to
offer the experience of several years' practice, during which we have used no other than
the buckskin ligature, and no such thing as a secondary hæmorrhage has ever occurred
in our practice, extending alike to cases of aneurism, tumors, and amputations. ...
“We are, moreover, decidedly of the opinion that in no case whatever have we had
reason to suppose that the healing of a wound, accidental or surgical, was delayed by
our ligatures; we never see anything of them after their application. ... Mr. Cooper
tied the femoral artery in a female, aged eighty, with a ligature of catgut steeped in
water, which was cut close, and the wound was healed on the fourth day, and must
therefore have healed by first intention. In many cases we believe the catgut would
answer as well as the buckskin, but we are confident that a flattish ligature holds best
and is most convenient. It may be proper to mention that this case occurred in 1817,
three years after Dr. Physick's use of the leather ligature. ... If we are right in the
opinion which we have just expressed, Dr. Physick is entitled to the credit of bringing
into use the best ligature as to the material, but here his claim is at an end. Dr. Phys-
ick and Sir Astley Cooper have shown the advantage of using a substance which will
serve as a ligature till the artery is obliterated, and be speedily afterward in the power
of the absorbents, so that they will remove it. ... We will now proceed to point out
our own views, and endeavor to support them by experiment:
“ First, we believe that with an artery sufficiently healthy to admit of its obliteration
by the adhesion of its sides, it is best done by a ligature which will neither cut its coats
nor strangulate, except in parts, the true vasa vasorum, so that the continuity of the
vessel shall not be destroyed, although we obliterate its caliber.
“ Second, we believe that if an animal ligature of suitable material be properly
applied, the vessel will be obliterated, the wound may be healed by first intention, and
the ligature will not cause suppurating inflammation; but in due time, being dissolu-
ble, the whole will be removed by the absorbents. There will be no break of continu-
ity in the artery, the materia arteriarum will be removed, and the vessel which, during

288
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
the state of inflammation and the effusion of lymph, was converted into a cord, will
pretty soon afterward be resolved to a flat string of white cellular substance.
“ EXPERIMENT I.—Twenty-two days after tying the carotid artery of a sheep with
buckskin ligature, the wound was found entirely healed, the artery obliterated, upon
one side of which was a little yellowish matter which proved to be a portion of the
ligature.
“ EXPERIMENT II.-Twenty-five days after tying the left carotid of a dog there were
seen on either side of the vessel two little yellowish knobs, which proved to be the
two ends of the ligature in the state of yellow pulp. The knobs were completely en-
veloped in a strong membranous capsule, the same capsule inclosing both knobs, and its
fibers plainly seen crossing over the artery. ... On the lower side, where the coats were
not cut, in splitting open the vessel to examine its interior, there was an actual adhesion
of the leather to the inner coat. The string was softened into a pulpy consistence, and
near the inside of the vessel was evidently covered with organized lymph, and extended
along its edge on one side some distance. When the string was gently pulled, one
plainly saw a delicate membrane, passing off from the artery and ending on the string in
fringed extremities. This attachment of the vessel by a new formation existed on both
sides of the artery. The capsule covering the knobs or ends of the string was fully
equal in strength to the outer coat of the artery, and therefore there was no tendency
to hæmorrhage."
It will be observed that in all the essentials the experiments of Dr. Jamieson, un-
dertaken for a similar purpose, were not unlike those of Sir Joseph Lister, repeated
half a century later ; and the former, at a period when so little was expected of
the American people in the way of literary productions, to say nothing of scientific
research, that one of England's famous critics asked, “Who reads an American
book ?”
In the history of ovariotomy in the United States, by the late Dr. Peaslee, it is
stated that Dr. Nathan Smith, Professor of Surgery in Yale College in 1821, tied the
arteries with leather ligatures (narrow strips cut from a kid-glove), which were returned
into the peritoneal cavity, and the incision was closed, followed by recovery.
Dr. John Bellinger,* of Charleston, S. C., in 1835, successfully performed ovariot-
omy, tying two arteries in the pedicle with animal ligatures.
* American Journal of Medical Sciences, 1837, vol. xxi, p. 380.

THE ANIMAL SUTURE.
289
a
Professor Paul Eve,* of Nashville, Tenn., wrote in 1876: “I have been in the
habit of using the sinews of the deer for ligating vessels, for forty years. The tendons
of the deer, dried and torn in shreds and rolled into ligatures, are what I employ.
They are absorbed. I have occasionally used them as sutures.”
These fragmentary experiences, drifting down to us through the years, teach that
there was more or less blind groping after a something that should serve a better pur-
pose than that which the routine of daily practice, in the use of hemp or silken liga-
ture, afforded. It was reserved for the present generation to make possible a scientific
basis for the better consideration of ligatures and sutures in their application to the
living structures. In the light of our present knowledge of surgical pathology, the
opposition to the ligature in the days of Ambrose Paré, which we have been wont to
attribute to the conservatism of ignorance and stupidity, is invested with a new and
vital interest. The amputated limb, seared with the hot iron as a hemostatic, a meas-
ure most barbarous and revolting, gave as a result an aseptic wound. Repair was
necessarily slow and tedious, but abundant granulation supervened to protect from
septic absorption before decomposition ensued.
The constricting ligature, the septic pocketed wound, with little care as to cleanli-
ness, gave such secondary fatal results, that we are led to wonder that the innovation
of the ligature in the closing of the great vessels became the established practice
Had it not been for the frightful dangers from secondary hæmorrhage after the use of
the cautery, slow healing giving imperfect results, it may well be questioned if even the
indomitable spirit of Ambrose Paré could have made the innovation survive his own
time.
A deeper philosophy sought solution of the problem as to the causation of suppu-
ration in wounds, and if its prevention were not within the possibility of the rule
rather than the exception. The studies of Pasteur, Tyndall, our own Jeffries Wy-
man, and others, undertaken for the solution of the problem of spontaneous genera-
tion, brought fruitage to the human race little dreamed of by these wise philoso-
phers. The genius of Mr. Lister seized upon the application of the thought, and with
a patient, investigating spirit and painstaking toil he worked out the fundamental factors
of the role of ferments in wounds. It was not until rules could be formulated, based
* Transactions of the International Medical Congress, Philadelphia, 1876.-Antiseptic Surgery, by John T. Hodgen,
M. D., p. 528.
40

290
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
upon the scientific deduction that operative wounds should be free from suppurative
processes, hitherto considered almost necessary concomitants, that the proper condi-
tions for the study of ligatures and sutures were rendered possible. Of necessity in inti-
mate association with the question of the treatment of operative wounds, arose de novo
a most interesting chapter devoted to the best means of controlling arterial hæm-
orrhage.
It was clear that the hitherto prevailing method of ligation, having the ends of the
ligature long, extending from the wound, by so much at least prevented primary union ;
while cutting the ligature short, and closure of the wound, were fraught ever with dis-
astrous consequences, when the septic ferments were thereby deeply buried. When
aseptically applied, the constricting silken ligature too often proved an irritating foreign
body, to be ultimately slowly eliminated.
In retrospect, with present knowledge, what seems simple factorage of the problem
proved extremely difficult of solution. The conservatism of opinion, the prejudices of
the large number of the surgical authorities of the time, wedded to present measures,
misled by other phases of dominating thought—the so-called vital processes of inflam-
mation, irritation, cell-proliferation, etc.—engrossed the subject with many difficulties.
The demonstration that fermentation and suppuration in a wound resulted from the in-
troduction of a something from without, was the first real step of progress. To elimi-
nate that something was the next problem for solution. It was clearly shown that the
torsion of an artery to procure rupture and intrafolding of its interior coat causes perma-
nent closure of the vessel, and that the living structures, unpoisoned by germ infection,
possess the power of easy disposition of the aseptic necrotic portion devitalized by
violence.
Histological study demonstrated that the necrosed part does not undergo the
changes which had formerly been supposed necessary for the elimination of dead ma-
terial, known as suppuration, gangrene, etc., but that the part becomes invaded by liv-
ing cells, which little by little produce a local change marked by early disappearance of
the necrosed tissue. This naturally led up to the thought, could not extraneous animal
tissue be prepared in a way that, introduced into the vitalized structures, a similar re-
sult would follow.
Repeated experimentation taught that small pieces of dead tissue preserved in car-
bolic-acid solutions, incorporated into the living structures, were disposed of in a manner
not unlike the necrosed portion of a twisted artery, and led to the inference that animal

THE ANIMAL SUTURE.
291
a
tissues properly preserved could be used for the constriction of vessels. In looking
about for suitable material of animal type to be used as ligature, the catgut prepared
for musical instruments was naturally suggested. It proved comparatively easy to
render the material non-infective, by immersion for a considerable period in an aqueous
carbolic solution, but being a soft, slippery strand, it lacked the necessary qualities for
making a secure knot, and by its early softening in the tissues, it loosened and thereby
failed to secure the end sought. A long immersion in an oily solution of carbolic acid,
to which a very little water had been added, produced a marked change of structure-
a kind of tanning process thereby resulted which gave to the material the quality of
less easily softening in the tissues, as well as the better retaining a firm knot, which was
ultimately disposed of by the surrounding structures.
I know of no series of original studies better worthy of admiration or emulation
than Mr. Lister's experiments, undertaken for this purpose upon the lower animals,
and the laws of England necessitated his resorting to the Continent in order to make
possible his investigations. The resulting changes shown to have taken place histo-
logically in catgut ligatures applied to the vessels of the lower animals, examined at dif-
fferent periods, taught that the cell-proliferation at first inclosed, and later on penetrated,
the carbolized ligature, until, little by little, it became replaced by living connective-tis-
sue cells—a discovery the importance of which is scarcely fully appreciated even at the
present time. Mr. Lister's experiments were limited to the ligation of vessels, and
there has resulted from his teachings the surgical treatment of the great arterial sys-
tem with a safety hitherto deemed impossible. The larger vessels are now tied in con-
tinuity in close relation to their bifurcations, even the greater trunks, with a seeming
impunity little less than startling.
Returning from my studies in Edinburgh under Mr. Lister in 1870, liberally sup-
plied with a variety of the antiseptic materials which he then advised to be used in
operative treatment, I not only made use of catgut for the ligation of vessels, but acci-
dent early furnished me the opportunity for a new application of the ligature in the
form of buried sutures. On February 19, 1871,* I closed the ring, necessarily greatly
enlarged for the reduction of a strangulated hernia, with deep sutures of catgut. This
I did in order to retain the abdominal contents, because of a severe asthmatic bronchitis
* A New Use of Carbolized Catgut Ligatures for the Cure of Hernia. -Boston Medical and Surgical Journal,
November, 1871, vol. viii, p. 315.

292
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
.
from which the patient was also a sufferer. The resultant permanent cure of the hernia,
with a marked proliferation of tissue along the line of the buried sutures led me to
inquire if the sutures buried in the part had not been disposed of in a manner similar
to that demonstrated by Mr. Lister, resulting about the catgut ligatures surrounding
the arteries.
I instituted a series of experimental histological studies upon the lower animals,
and demonstrated that, along the track of an aseptically buried suture, cell-proliferation
rapidly supervenes, and that new cells invade the softened structure, and, pari passu with
its absorption, a living band of connective-tissue cells replaces the whole line of the
suture. If rapidly absorbed, the proliferated cells are minimized; as the process goes
on more slowly, the change becomes more distinctive, until, in young animals, in ten to
fifteen days all trace of the suture as a foreign material is lost. The value of such
re-enforcement of the tissues along the line of the sutures became at once apparent in
their application to the cure of hernia, and, little by little, I early extended their use
to the closure of wounds of every description, publishing * from time to time my
results.
In the pursuance of my studies I early had occasion to examine a great variety of
the specimens of catgut offered in the market, although from the first I adopted what
seemed to me the wise precaution of preparing my own sutures. In catgut there
are of necessity certain inherent defects. Its method of preparation is not generally
known to the profession, who have rarely questioned the product beyond the condition
in which it is offered for sale, as prepared for the musician. The best of these varieties
usually comes from Italy, prepared from the intestine of the sheep of the mountainous
districts. The small intestine necessarily undergoes maceration, until the strong con-
nective-tissue layer, which, as a fibrous sheath unites the mucous and muscular coats of
the intestine, is loosened and can easily be separated, in a manner not unlike that prac-
ticed in the preparation of the intestine of the pig for the making of sausages. This is
split by a cork armed with sharp blades drawn through the circular sheath, dividing it
into sections to produce the desired size. These ribbons are twisted, dried, and often-
* The Radical Cure of Hernia by the Antiseptic Use of the Carbolized Catgut Ligature.—Transactions of the
American Medical Association, 1878. Animal Ligatures.-Annals of Anatomy and Surgery, 1881, p. 252. The
Animal Ligature.- New England Medical Monthly, June 15, 1883, p. 387. The Surgical Advantages of the Buried
Animal Suture.-Transactions of the American Medical Association, July 21, 1888. The Animal Suture: Its Place in
Surgery.--Transactions of the American Association of Obstetricians and Gynecologists, 1889.

THE ANIMAL SUTURE.
293
times sand-papered to give evenness of surface, and usually put up in skeins from twelve
to fifteen feet in length—the catgut of commerce.
The connective-tissue cells of the fibrous coat of the intestine are irregularly dis-
posed, the fine fibrils more commonly crossing diagonally to the longitudinal axis of
the intestine, a wise distribution of this strengthening portion of the intestine to allow
considerable change in its shape: When carefully examined under a low-power lens,
the fibers are seen to be irregularly interlaced, not unlike a strip of cloth cut diagonally.
The gut, even in the dry state, has a perceptible yield on tension, and every musician
knows the care requisite to protect his strings against moisture. Frequent allusion is
made in the classics to the care demanded of the bowman in this respect, when it was
customary to string the weapon with animal products.
The above condition is readily apparent if a piece of catgut is macerated until it
can be easily unfolded. Moreover, its division is rarely uniform, and when sandpa-
pered the removal of the irregular projections causes oftentimes large abrasions or
rents. No matter how prepared for surgical use, ultimately the result obtained will
depend in considerable measure upon the integrity of its structure, since the compo-
nent cells are, little by little, separated by the penetration of the new proliferating tissue.
In the first stage of preparation, the long maceration of the material, remaining for a
considerable time a putrefying mass, necessarily damages it, not only by softening the
adhesion of the cells, but infecting them with bacteria; and in the use of the catgut for
all surgical purposes it is important, as the first step in preparation, to destroy any
germ infection that may remain. After this has been effected, no method which I have
tried gives a result equal to that formulated by Sir Joseph Lister :
Dissolve one part of chromic acid in 4,000 parts of distilled water, and add to
the solution 200 parts of pure carbolic acid or absolute phenol. In other words, I
use a 1-to-20 watery solution of carbolic acid, only that the carbolic acid is dis-
solved not in pure water but in an exceedingly dilute solution of chromic acid. But,
minute as is the quantity of the chromic acid, it exerts, when in conjunction with
carbolic acid, a most powerful effect upon the gut. The first effect of the addition of
the carbolic acid to the chromic solution is to change its pale-yellow color to a rich
golden tint; but if the liquid is allowed to stand without the introduction of the
catgut, it changes in the course of a few hours to a dingy reddish brown, and a con-
siderable amount of gray precipitate is formed. If, however, catgut about equal to
the carbolic acid is added as soon as the ingredients are mixed, the liquid retains its

294
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
brightness, and the only change observed is a gradual diminution in the depth of the
yellow color; the precipitate, which I presume still occurs, taking place in the sub-
stance of the catgut. As soon, therefore, as the preparing liquid has been made, cat-
gut equal in weight to the phenol is introduced into it. If you have too large a pro-
portion of catgut, it will not be sufficiently prepared; if you have too small a quantity,
it may run the risk of being over-prepared. At the end of forty-eight hours catgut
steeped in such a solution is sufficiently prepared. It is then taken out of the solution
and dried, and when dry is placed in one-to-five carbolic oil. It is then fit for use."
It improves by age, and is better not to be used until after it has been several
months in carbolic oil. The preliminary disinfection of the gut is of the first impor-
tance, since preservation of the hardened structure in the carbolized oil may not pene-
trate to the destruction of bacteria within the strands.
I have elsewhere published † in detail the micrococcal infection, developing only
along the line of the buried sutures, of four consecutive surgical cases, giving evi-
dence upon which I deduce the conclusions that it could have been owing only to this
inherent defect of the catgut, which had been selected from freshly opened preparations,
preserved in carbolic oil, and sent me from London.
From an interesting communication by Drs. Burrell and Tucker, $ of Boston, I
quote the following extracts bearing upon this point: “A great deal of difficulty had
been experienced from time to time in the use of catgut in the formation of stitch
abscesses, and the following methods of preparing silk and gut were put to trial. ...
“The original catgut, as taken from the carbolic oil, was cultured, and found to show
organisms in every case. Eleven specimens of silk and gut were taken from their
ligature bottles. The silk was found to be perfectly sterile, while the catgut was found
to have growths on all except the smaller sizes.
" It is difficult to understand how germs can live that have been immersed in an al-
coholic solution of 1-to-1,000 corrosive sublimate, but it is suspected that the hardening
of the catgut prior to complete sterilization shuts up within the substance of the gut
* In several instances I have known sutures to be ruined by a misunderstanding of the above directions of Mr.
Lister, much too large a quantity of chromic acid having been used. It may simplify to remember that the quantity is
about four grains of chromic acid to a quart of a saturated solution of carbolic acid.
+ The Surgical Advantages of the Buried Animal Suture.- Journal of the American Medical Association, July
21, 1888,
Ligature and Suture Materials.-Medical Communications, Massachusetts Medical Society, article xxv, by H.
L. Burrell, M. D., and G. R. Tucker, S. B.

THE ANIMAL SUTURE.
295
a certain number of organisms, which remain latent until they are placed in living tis-
sưes, when the catgut swells, the germs are set free, and stitch abscesses result. Rever-
din reports a series of experiments in reference to the sterilization of catgut. He
found that crude catgut, which had not been kept in fat to preserve it, which was ex-
posed four hours to a constantly increasing temperature, maximum 140° C., and then
placed for a day in oil of juniper and kept in alcohol, was aseptic. This he had
used clinically for eighteen months, with perfect results.
“ V. Boret has cultured the catgut preserved by Reverdin in bouillon, glycerine, and
sugar at different temperatures and found that there was no reaction at the end of six
weeks. Boret has tried the other methods of sterilizing catgut, and found that bac-
teriologically and clinically they failed.
Conclusion.—Small catgut was found, as ordinarily prepared, to be always sterile ;
large catgut, never ; silk, always sterile. As catgut is too valuable a material to be
discarded, the writers would advise the method of Reverdin by heat, which is bacterio-
logically a good one.”
Dr. Macewen * published a very interesting article, giving his method of preparing
catgut so as to render it more reliable, by immersing it in a watery solution of chromic
acid (one to five) and adding one part of this to twenty of glycerine. Remove in
two months, and preserve ready for use in carbolic acid and glycerine (one to five).
By varying the strength, gut is prepared possessing different degrees of resistance to
absorption in the tissues. My own experience of animal sutures prepared in this way
has not been satisfactory. I have also used catgut prepared in oil of juniper and kept
in alcohol, but think it inferior to chromicized gut. Owing to these inherent defects in
catgut, in common with other surgeons I was led to inquire if there were not animal
tissues better suited for surgical use.
The tendinous structures of the body present the connective-tissue cells parallel and
firmly united to each other. Although generally thus disposed, there is considerable
variety in the arrangement of the cells, making a parallel separation much more uniform
in some tendons than in others. As far as possible I entered into a detailed investi-
gation of all animal tendons of sufficient size for surgical purposes with varying results.
The tendons of the hind-leg of the moose and caribou, soaked in a sublimate solution
a
a
* Chromic Gut: Its Method of Preparation and Behavior in Living Tissues. William Macewen, M. D., Glasgow.
--- Annals of Anatomy and Surgery, 1881, p. 128.

296
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
until soft, were the first tested. A considerable portion of the tendon can be sub-
divided sufficiently fine for sutures, in length from fifteen to eighteen inches.
The late Dr. John H. Gilman,* of Lowell, called my attention to tendons from the
whale, stating that he had “used them with great satisfaction in the ligation of ves-
- sels.” Specimens were sent me from Provincetown four feet in length and of sufficient
strength to draw a cart, but the ultimate fibrils were interlacing, while the whole tendon
was interspersed with adipose cells. I obtained ligatures also from the whale tendon
which were made under the direction of Dr. T. Ishiguro,ť of Tokio, surgeon-in-chief of
the imperial Japanese army. The mode of preparation is given as follows: “First, a
whale's tendon is dissected by the points of the needles, and teased out until the fibers
look very like those of hemp; secondly, the longest and finest fibers among them are
selected, and they are then spun together as ordinary silk thread.” There can be no
question but that ligatures thus prepared are very serviceable, but the specimens fur-
nished me were not suitable for sutures.
The Sioux Indian women in the Northwest taught me, in 1882, their manner of
sewing buffalo-skins with the tendinous structures derived from the fascia lata of the
buffalo, which they preserve for this purpose by drying and smoking. During the sum-
mer of 1889 I obtained from Mr. Harry Adams, of the Hudson Bay Company, in Win-
nipeg, Manitoba, specimens from the fascia lata of the moose, prepared by the Indians
as a substitute for that from the buffalo, now extinct, called by them astis. They use
it in the dry state, stripping it as they sew, occasionally wetting it in the mouth. Good
tendon sutures in any quantity can be obtained from this source. My specimens, how-
ever, are not more than fifteen inches long, and are quite inferior to the tendons from
the tail of the kangaroo. Some years since, a distinguished Russian surgeon sent me
specimens from the reindeer, finely divided and slightly twisted. These I prepared, and
used with good result.
In 1880 Dr. S. G. Simmons, of Charleston, S. C., sent me admirable specimens of
tendons from the tail of the fox-squirrel, with the statement that he had often used
them for delicate surgical purposes with great satisfaction. This tendon is composed of
exquisitely beautiful parallel fibrils, which can be subdivided without fraying to the size
of fine threads. Their extreme length, however, scarcely exceeds nine inches. Reason-
* Boston Medical and Surgical Journal, October, 1880, p. 433.
+ The Whale Tendon as a Substitute for Lister's Catgut Ligature. E. A. Otis, M. D.-Boston Medical and Surgi-
cal Journal, September 30, 1880, p. 331.

THE ANIMAL SUTURE.
297
ing from comparative studies, it seemed to me highly probable that the kangaroo
should have a tendon similar in quality, traversing the entire length of the tail.
Through the kindness of the late Mr. Alonzo H. Newell, of Boston, for many years a
prominent merchant in Australia, I secured some most excellent specimens from the
wallabee, one of the smaller species of the kangaroo.
At the International Medical Congress held in London in 1881,* in a paper upon
the cure of hernia I mentioned the use of the tendon suture from the kangaroo and
other animals as especially to be commended. Reference to my recommendation of
the kangaroo tendon and its value in surgery was some time later made in an Austra-
lian publication. This came to the notice of Dr. Girdlestone, who wrote me that he
had used kangaroo tendons for some years with great satisfaction, and that he had pub-
lished the results. The tendons should be taken from recently-killed animals, quickly
sun-dried, and kept dry until ready for further preparation. This prevents primary
decomposition, which we have pointed out as unavoidable in the preparation of catgut.
When soaked until soft they are easily separated into as fine strands as desired with
remarkably little waste, and give threads from the size of hairs upward, and from
eighteen inches to two feet in length, exceptional specimens being even considerably
longer. Kangaroos are very numerous in Australia; their skins have a very consider-
able commercial value, and hundreds of thousands are exported annually; yet it has
been with the greatest difficulty that I have succeeded, until quite recently, in securing
tendons more than sufficient for my own use, although I sent carte blanche orders to
various parties in Australia.
Quite recently I have made arrangements with commercial firms in Australia for
furnishing kangaroo tendons for surgical purposes in an abundant supply. These have
been prepared under my personal supervision, and can now be obtained from the
various dealers in surgical materials at a cost somewhat in excess of that of catgut, to
which they are in every way greatly to be preferred.
In an interesting article published in 1882 by Dr. Girdlestone,& he emphasizes the
use of the tendon entire as a ligature rather than as a suture. “ In their preparation they
should not be removed from the tail en masse, but one at a time, without force, as, if
* The Cure of Hernia. Transactions of the International Medical Congress, 1881, vol. ii, p. 446.
+ Tendon Ligatures. T. M. Girdlestone. -Australian Medical Journal, 1877, vol. xxii, p. 356.
| The Surgical Uses of Kangaroo Tendons. T. M. Girdlestone, F. R. C. S.-British Medical Journal, February
18, 1882, p. 228.
41

298
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
split longitudinally, they could not be relied on. Every diameter that was required was
attainable, so that there was no occasion for splitting; neither should two or more
tendons be twisted together, as it destroys their flattened form.” The advantage
claimed is that they may be used as flat rather than round ligatures, constricting the
artery with less liability of cutting the vessel. The construction of the tendon is very
similar in all varieties of the kangaroo, no matter of what size the animal may be. It is
composed of independent strands which run without subdivision to the very extremity
of the tail. Each tendon is attached to a separate fasciculus of muscle. These vary,
as may naturally be supposed, in size, corresponding to that of the different species.
The strands from the larger animals, in their natural state, are altogether too large
for surgical purposes. They admit, however, of subdivision very much more readily
,
than the tendons from any other animal, but when thus divided are less strong than
whole tendons of the same size, yet they are of nearly equal value when used as a
continuous suture. When able to select the material best suited for surgical purposes,
the tendons from the medium-sized animals are quite to be preferred. In 1890 Dr. C. H.
Mastin, of Mobile, favored me with specimens of tendon from the tail of the opossum.
As might be inferred, the construction of the tendon is the same as in the Australian
marsupial species. They are exquisitely fine, strong, and delicate, but are scarcely more
than ten or twelve inches in length. The larger varieties of the common rat have the ten-
dons of the tail similarly disposed, but are hardly long enough to be of any practical value.
In the Medical News for December 5, 1891, Dr. E. Oliver Belt, of Washington,
states that he has made extensive use in ophthalmic operations of a fine fiber derived
from the rat's tail. The tail is skinned and soaked in water for several days, when, on
slight manipulation, it splits into perhaps a hundred fibers, each about eight inches long.
They are placed in alcohol, and about once a month, for two or three days at a time,
they are soaked in a 1-to-5,000 solution of corrosive sublimate. Dr. Belt recommends
these fibers in cases where a strong and fine animal suture is required. He says they
are much finer than those prepared from the opossum's tail, which he had seen used
by Dr. Chisolm, of Baltimore.
Dr. Dudley,* of Texas, has written an interesting article upon the use of the ten-
don of the lepus, or mule-eared rabbit, as a material for ligatures and sutures. Dr.
* Animal Ligatures and Sutures. H. W. Dudley, M. D., Hillsboro, Texas.-- Transactions of the Texas State
Medical Association, 1884, p. 133.

THE ANIMAL SUTURE.
299
Dudley does not state the portion of the animal from which he obtained the tendon,
but described them as “an aponeurosis of muscles rolled upon each other, susceptible
of being torn into minute threads, if so desired.” He first had occasion to use the
tendon of the lepus as a suture, in the fresh state, in 1881, finding he had no silk in his
pocket-case. He has continued the use of these tendons with the greatest satisfaction
to the time of his report.
Dr. Bernes * published an interesting study upon animal ligatures in 1874. Al-
though his experiments were not conducted with the care demanded to-day, yet they
are of interest and importance as original studies. They include a large number of ex-
periments upon the lower animals with catgut, both carbolized and uncarbolized, perito-
næum cut into strips and rolled as recommended by Dr. Agnew, and beef tendon dried,
split into fine shreds and twisted, as well as silk, which was taken as a standard of com-
parison. “The extreme non-irritating properties of the tendon, coupled with its ca-
pacity for fine division, render its slow absorption of decided advantage, since a vessel
can be secured with a strand of it so fine as to produce no irritation, and yet sufficient
time elapse before its disappearance to render any danger from secondary hæmorrhage
as remote as in the employment of silk, by which the vessel is usually severed in the
course of a very few days. . . . It will be seen that the tendon ligature fulfills all the
requirements set down at the beginning of this paper as a substitute for the material
now in use. . . . It is, beyond all doubt, ultimately absorbable, so that a ligature of it
can be cut off close to the knot and left in the wound. The tendon is by no means so
absorbable as catgut.”
The use of the animal suture requires the same and the only precautions that are
requisite for the successful application of the ligature. It must be in itself aseptic; it
must be aseptically applied in an aseptic wound. When thus applied, the range of its
uses should be extended to all operative wounds. It is difficult to conceive if any pos-
sible advantage is to be derived in the treatment of any aseptic wound by leaving it
open—the so-called open-wound method. Before the rôle of bacterial development in
wounds was understood, when it befell from chance rather than from scientific care
that primary union supervened, it is easy to understand how many, who dreaded the
daily experiences of fermentative material retained in pocketed wounds, not only
refused to rely upon drainage with occasional irrigation, but insisted, as far as possible,
.
* Animal Ligatures. Joseph Bernes. -- Philadelphia Medical Times, August 8, 1874, pp. 708–713.

300
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
upon allowing no recess in which purulent material could gather. In order to effect
this, the lips of the wound were separated and kept apart by dressings, so that the
wound might heal by granulation from its very base. This was manifestly safer for the
patient, and the result attained was not unlike that from the repair processes which
supervene in the secondary healing of infected wounds; but those who still advocate
this method thereby confessedly acknowledge their lack of confidence in the modern
methods of wound treatment, and their inability to protect wounds from infection. In
rare instances it has been claimed that the resulting cicatricial union gives an increased
strength to the parts involved—an opinion which it seems easy to demonstrate is
unscientific and contrary to the general consensus of surgical opinion. If it is correct
to assume that the theoretic perfection in wound treatment, which it is the ambition of
the surgeon to attain, means a reunion of the divided parts, the anatomical relationship
to be restored and maintained, then the buried animal suture holds a higher place in
surgery than ever hitherto considered.
If the suture itself is replaced by vitalized structures, then its proper application
becomes of the highest importance, the value of which the profession even to the pres-
ent time with few exceptions fails to appreciate. Given, as illustration, the joining of a
divided retracted nerve or muscle, and its restoration to subsequent perfect usefulness;
the sundered cervical tissues after a hysterectomy where the delicate joining of the peri-
tonæum allows no open wound for hæmorrhage or absorption; the reunion of the ab-
dominal wound after laparotomy, where the peritonæum is independently united by a
layer of buried sutures, and where the linea alba or the muscular aponeurosis of the
sheath of the recti is carefully rejoined, since the adoption of which method I have not
had a single case of ventral hernia; or, again, in the amputation of large tumors of the
breast, where the remaining tissues are carefully coapted, so that retention and pocket-
ing of fluid are impossible, rendering drainage not only superfluous but harmful.
I would not underestimate the importance of drainage in wounds that are neces-
sarily septic, and in this class of wounds the interrupted silk-worm gut or silver-wire
suture is to be preferred. The recent discussions upon the uses and advantages of the
buried animal suture are both interesting and profitable. A valuable article, based upon
original observations, was published in Germany by Dr. Werth,* in which he advocated
* Ueber die Anwendung versenkten Catgutsuturen bei Operationen in der Scheide und am Damm. Dr. Werth,
Kiel.–Centralblatt für Gynkologie, November 8, 1879, p. 561.

THE ANIMAL SUTURE.
301
the use of catgut as an interrupted buried stitch in the repair of the perinæum. These
were taken between one and two centimetres apart, the gut tied and cut short upon
the
knot. In cases where the surfaces to be coapted were large, a second row of stitches
was similarly placed. Great care was exercised in making the application under aseptic
precautions, and most satisfactory results were obtained.
Schroeder * repeatedly used catgut as a buried continuous suture and commended
it highly. Dr. A. Martin,t of Berlin, is less enthusiastic, and writes: “I myself have
tried catgut sutures according to Werth's method five times; the results were not
favorable, but I must admit that in two of these cases the catgut may have been too
old."
Doléris | recommended knotting the thread, from time to time, of the continuous
suture, and believed the buried catgut is absorbed in seven or eight days. He re-
ported to me when in America, in 1887, a still further satisfactory use of the buried
animal sutures. Bröse # wrote approvingly of buried catgut sutures rendered aseptic
by a corrosive-sublimate solution and preserved in absolute alcohol.
Dr. C. B. Keetley | published a valuable article upon the uses of the buried su-
He ascribed to Professor Esmarch's assistant, Neuber, and Professor Küster,
much valuable original work with the use of the buried suture, especially in amputa-
tions, thereby doing away with drainage. He wrote: “Küster read his paper at the
last meeting of the Society of German Surgeons. In the discussion that followed,
Esmarch having stated that, with these sunk sutures, drainage-tubes could be alto-
gether dispensed with, he was asked, “What ! after excision of the hip?” He there-
upon answered, shortly and decisively, “ Yes.” In conclusion he said: “I have to
say that it is only in strictly antiseptic surgery I would venture to recommend the
use of these sutures; but that in the case of all surgeons who have faith in the anti-
septic theory and practice they will find in buried sutures an effective and beautiful
addition to their methods."
Mr. John Wood 4 wrote in regard to femoral hernia : “ Latterly I have found
ture.
* Centralblatt für Gynäkologie, July, 1885.
+ Martin. Diseases of Women. English edition, 1888, p. 170.
| Archives de Tocologie, February, 1885.
# Centralblatt für Gynäkologie, 1883.
| The Buried Suture. C. B. Keetley, M. D.-British Medical Journal, May 2, 1885, p. 880.
A Lectures upon Hernia and its Radical Cure, 1885.

302
ANATOMY AND SURGICAL TREAMENT OF HERNIA.
the use of tendon ligature so satisfactory that for this operation I prefer it to wire.
The wound usually closes over it and heals by adhesion at once, and there are not the
pain and inconvenience of the withdrawal of the wire. So far the endurance of the
tendon, when buried in the tissues, has been long and satisfactory enough to main-
tain the cure, which has been watched, noted in some cases about two years."
My own experience with the buried animal suture commenced with its use in
the case of hernia above referred to in 1871; and this, with other cases where the
cure was believed to be referable to the buried suture, was first published in the Bos-
ton Medical and Surgical Journal, November, 1871. In 1878 I contributed a paper
upon the cure of hernia, based upon the resection of the sac and closure of the parts
with buried sutures, at the meeting of the American Medical Association. A further
contribution upon the same subject, emphasizing the value of the tendon suture, was
published, in 1881, in the Transactions of the International Medical Congress. These,
and several other articles giving the results and surgical advantages of the use of
the buried animal suture and its adaptability to special purposes, were reprinted and
widely distributed to the profession, in Europe and America.*
If the premises which I have assumed in the early discussion of this article are
correct, that a properly prepared aseptic animal suture, aseptically applied, retains its
strength sufficiently long to hold at rest the coapted parts until primary union is
effected, and then itself slowly disappears after having fulfilled its function, to be in
a measure replaced by vitalized connective tissue, there can be little wanting to
attain the theoretic perfection in the suturing of wounds. The first observations which
I published, perhaps naturally, provoked only criticism and incredulity, and the re-
sults were considered rather as accidental. But the evidence, already accumulated
and presented to the profession by a great variety of observers in different parts of
the civilized world, is quite sufficient to substantiate this claim.
Silk has justly held a high place in the esteem of the profession, because of its
exquisite perfection of preparation and it has been claimed, if rendered aseptic, that
Animal Ligatures.-Annals of Anatomy and Surgery, July, 1881, p. 232. Cure of Hernia by the Antiseptic Use
of Animal Ligatures.-Transactions of the International Medical Congress, 1881. Animal Ligatures.- New England
Medical Monthly, June, 1883. The Restoration of the Perinæum by a New Method.- Journal of the American Medi-
cal Association, October 27, 1883. Reprint. The Surgical Advantages of the Buried Animal Suture.- Journal of
the American Medical Association, July 2, 1885. Reprint. The Perinæum : Its Anatomy, Physiology, and Methods of
Repair after Injury.- Philadelphia, 1889. A Treatise on Hernia. The Radical Cure by the Use of the Buried Anti-
septic Animal Suture.- Published by George S. Davis, Detroit, Mich., 1889.

THE ANIMAL SUTURE.
303
.
a
it was equally safe as a buried suture. Mr. Lawrence, the distinguished English sur-
geon* already referred to, made many interesting and valuable studies upon the liga-
tion of vessels with silk cut short and buried in the wound. His efforts to minimize
what he considered the irritating foreign material are very instructive: “The method
I have adopted consists in tying the vessels with fine silk ligatures and cutting off
the ends as close to the knot as is consistent with its security. . . . Of the silk which
I commonly employ a portion sufficient to tie a large artery, when the ends are cut
off, weighs between one fiftieth and one sixtieth of a grain.” He adds, “ Although I
have not yet ascertained what becomes of the pieces of ligature after the wound is
united, I have never seen abscesses or any other bad symptom occasioned by them.”
Mr. Lister early experimented very carefully with silk steeped in various substances,
immersed in melted wax and carbolic acid to render it aseptic. In further proof of
its innocuousness, it has been claimed that it is also an animal product, and that the
tissues should be capable of assimilating it into their own structures. My distinguished
friend Dr. Pancoast, of Philadelphia, believes the fault lies in large measure in the
introduction of lead during its preparation, and that hence the use of iron-dyed silk
is greatly to be preferred. “It is innocuous, does not produce suppuration along the
track of its thread, and the color adds much to the ease with which it may be dis-
tinguished for its removal." These are advantages, doubtless; but the necessity of re-
moval emphasizes the fault in material, and not in the color, or skill of application,
which renders it manifestly unfitted for use as a buried suture.
The general verdict of surgical opinion—and it has most certainly been often re-
peated in my own experience—is that aseptic silk, aseptically applied, may be incor-
porated into the tissues, but remains encysted, and often, after a considerable lapse of
time, causes irritation, and is expelled as a foreign body.† Somewhat recently I re-
moved a silk suture three years after its introduction ; although buried in the tissues, it
was still unchanged.
The following is a photographic illustration of exact size of silk ligatures which,
after the most severe suffering for many weeks, ulcerated through the base of the blad-
der. This is, in brief, the history of the patient : Mrs. Dr. C-had for some years
a
* New Method of Tying the Arteries in Aneurism, etc. William Lawrence.—Medico-Chirurgical Transactions,
vol. vi, p. 156.
+ See Discussion upon Silk Ligatures and Sutures buried in Wounds.- New York Medical Journal, September 14,
1889, pp. 296–297.

304
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
FIG. 25.
a
suffered from pelvic trouble, and early in the winter of 1892 she entered the private
hospital of, and was operated upon, by one of the most distinguished surgeons of New
York city. The ovaries and tubes were removed, followed by a satisfactory recovery,
and she was discharged at the expiration of four weeks. Somewhat later severe pelvic
pain ensued with much infiltration and fixation of the
pelvic structures. Vesicle irritation and tenesmus were
extreme, and even partial relief was obtained only by
the very free use of opiates. She came under my ob-
servation the latter part of May, when she had already
passed by the urethra one single and one double liga-
ture, the two smaller ones seen in the illustration. No
relief followed, and upon examination a soft calculus of considerable size was detected.
Assisted by my friend Dr. Daniel T. Nelson, of Chicago, I dilated the urethra,
crushed and removed a calculus about the size of an almond, which had for its nu-
cleus the larger double knot shown in the figure. It is a fair criticism that the liga-
ture used was exceptionally large and consequently would be encysted with greater
difficulty. That it was aseptically applied we can not doubt, not alone from the skill
and wisdom of the operator, but from the subsequent history of the case. Even when
large, the aseptic silk ligatures applied in tissues which are maintained at rest may
be encysted and give no further trouble; but when applied in parts, as in the
pelvic structures, which are constantly subject to movement, the encapsuling of the
ligature often fails, and it is then thrown off with greater or less suffering as a foreign
body.
At the meeting of the British Medical Association, in 1890, Mr. Timothy Holmes,
of London, one of the most distinguished of living surgical authorities, delivered a
valuable address upon the surgery of the large arterial trunks, in the discussion of
which I had the honor of participating. In the consideration of ligatures he wrote : *
Silk admirably fulfills four of our five conditions. It is of trustworthy composition,
easily tied, may be relied on not to untwist, and can be tied with any degree of force
or gentleness; but it is questionable whether it is so far unirritating as to bury
itself in the tissue of the artery and become absorbed or disintegrated without setting
up suppuration and coming away—that is, dividing the artery. . . . Stout catgut liga-
* British Medical Journal, November 15, 1890, p. IIIO.

THE ANIMAL SUTURE.
305
.
.
tures are very handy, and I have used them on most of the great arteries and with uni-
form success; but they are certainly not of trustworthy composition. . . . Ox aorta
appears to me an admirable ligature, and I used it with perfect ease and success in tying
either the external or common iliac artery in 1879. But the kangaroo tendon ligature
has seemed to us to unite all the advantages of the ox aorta, and to be also somewhat
more manageable and more smooth, so that it has been employed at St. George's in
almost all such operations now for many years. ... Tendon ligatures are of uniform
and trustworthy composition, fashioned by the hand of Nature, instead of being pre-
pared by a process involving an uncertain amount of decomposition. One of the most
interesting papers bearing on the subject is Mr. Dent's, in the Medico-Chirurgical
Transactions, vol. lxiv, describing the microscopic examination of a tendon ligature, ten
days after its application to the carotid artery, by Mr. Pollock. . . . In passing the liga-
ture, it broke while the second knot was being tied, and therefore a stout piece of cat-
gut was also tied around the artery, but no trace of the latter was found post-mortem.
The ligature tendon was found still firm, its knot buried in a mass of lymph, the exter-
nal coat of the artery uninjured, and not ulcerated, the internal coat ruptured in places
by the ligature, and with its inner walls lying in contact, the tendon buried in and
closely connected with the arterial wall, infiltrated with small, round, granular cells, or
leucocytes, and permeated by blood-vessels which Mr. Dent believed to be of new for-
mation. As far as a single case goes, nothing could be more satisfactory, as proving the
unirritating character and firm grasp of the tendon ligature.” .
Mr. Holmes quotes * from a paper by Mr. Ballance and Mr. Edmunds : “ Here it
will suffice to say that the authors do not regard silk as a perfect ligature for aseptic
wounds, but recommend the use of a small, round absorbable ligature, preferring tendon
for this purpose, for the following very conclusive reasons: a. The structure is con-
tinuous throughout, and there are no spaces, as there are in catgut, due to twisting
in its preparation. b. It does not split or crack during absorption, which takes place
from the surface. c. It is easily made aseptic. d. It is only gradually, and after a
long time, acted upon by the living materials which encompass it. They add that
kangaroo tendon is very convenient for practical use, being strong, of ample length,
and becomes as supple as silk by soaking for half an hour in tepid sublimate
с
* Ligation of the Larger Arteries in their Continuity: an Experimental Inquiry.-Medico-Chirurgical Transac-
tions, vol. lxix.
42

306
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
a
solution; and they believe the tendon ligature to be trustworthy for at least two
months.”
Mr. Bennett May, in opening the discussion, gave decidedly his preference to the
tendon ligature. “Judging from my experience of it, as a buried suture elsewhere, it
appears to be very lasting, and tolerated well in the tissues. Then, it is a material which
can be tied very tightly without cutting the coats. I should also carefully shut up the
I
wound throughout its entire length, and securing, if possible, primary superficial union,
leave Nature to deal with the deep parts in her own way.”
The mode of application of the buried animal suture is of the greatest importance.
Without exception, it should be a continuous suture, since thus more perfect coaptation
of the parts is obtained, while knots are avoided as far as possible. It thereby equalizes
the compression of the inclosed tissues, since if one stitch chances to be too tightly
drawn compensation is secured by the yielding of the adjoining ones. It is also im-
portant to minimize the material consistent with careful coaptation. It should join like
tissues, periosteum to periosteum, muscle to muscle, deep fascia to deep fascia, and skin
to skin, after deep incisions of all kinds. It should support the parts always without
any constriction of tissue. These important ends attained, it matters comparatively
little by what manner of stitch the suture is applied. The opinions of operators will
be modified in preference for those methods with which they are most familiar and to
which they are accustomed.
For many reasons, in the uniting of the more important structures, I consider it a
manifest gain to include the tissues by a double suture, taken by means of a needle with
eye near the point, which allows the ends of the suture to be introduced through the
same puncture from opposite directions. This of necessity incloses, and should coapt,
but must not constrict, the tissues involved. The advantages of this stitch are most
apparent in certain operations, and I have especially advocated its use in the closure
of the canal in hernia, in suturing the pedicle of uterine and ovarian tumors, and in
perineorraphy. For wounds in or resection of the intestine I have repeatedly used a
double layer of tendon sutures—the Lembert stitch, taken as a continuous instead of an
interrupted suture. The finer-curved Hagerdorn needles are the best. The needle
pierces the peritonæum as in the Lembert stitch, entering and emerging about two lines
from the sides of the wound. This intrafolds and evenly coapts the peritonæum. In
resection of the intestine, or if an incised wound is long, I take a second layer about
one fourth of an inch outside the first, coapting more peritonæum, and thereby burying
a

THE ANIMAL SUTURE.
307
a
entirely the first line of sutures. Post-mortem intestine thus joined will hold water,
and in a well-vitalized subject the effused lymph irr a few hours entirely covers in the
affected part.
The advantages of this method are simplicity, rapidity of operation, avoidance of
knots, a minimum of manipulation and of injury to the tissues involved, even and sure
closure of the parts—all of which are factors of the first importance to a good result,
as well as to the security and non-irritability of the tendon suture.
As far as possible the suture should cross the wound at right or acute angles, and
not lie parallel with it. For the coaptation of large wounds, as in the amputation of a
breast, I find it a decided advantage to use a running stitch, taken from side to side,
both ends left externally free, tension upon which evenly coapts the sides of the wound.
Fine tendons are thus introduced in two, three, or more layers, commencing at the very
base of the wound. The 'skin itself is evenly coapted by a blind running stitch, taken
parallel to the incision, through the deeper layer only. This evenly unites the edges of
the skin, while the suture itself is buried beneath it. The wound is dried, dusted with
iodoform, covered with a layer of iodoform collodion, re-enforced by a few fibers of
absorbent cotton. The ends of the deep lines of the running sutures, after sufficient
tension has been exercised to produce coaptation, are fixed in the collodion and
cut off.
The subsequent dressing matters little; a soft pad of cotton may give comfort by
its support, but if the wound is aseptic at the close of the application of the iodoform
collodion, it being presupposed that each step has been taken with modern aseptic pre-
cautions, primary union will supervene, and drainage is not only needless, but is a
positive disadvantage and danger.
Aseptic wounds thus treated give a simplicity of detail which is really surprising
when contrasted with the clumsy and bungling antiseptic dressings which this method
—the aseptic application of buried animal sutures—is destined to supersede. In con-
clusion, the role of the buried animal suture may be accepted as a corollary to
antiseptic surgery, upon the basic principles of which it is founded as a scientific
deduction,

CHAPTER XXIV.
OPERATIVE MEASURES INSTITUTED FOR THE CURE OF HERNIA UNDER MODERN METHODS
OF WOUND-TREATMENT (ANTISEPTIC AND ASEPTIC CONDITIONS) IN EUROPE.
The currents and counter-currents of surgical opinion have nowhere, in their entire
history, a better illustration than that of the surgical measures advised for the cure of
hernia. The student who will take the trouble to read the review given in a previous
chapter of this work, all too briefly, of the various methods which have been put into
practice in one generation, only to fall into disuse and be forgotten in a subsequent one,
will note that, in the earlier part of the present century, the pendulum of opinion swung
as far away from the attempt at surgical procedures for the cure of hernia as at any
time perhaps since the days of Celsus. Even now, when the modern surgeon invades
every cavity of the human body with a seeming impunity which borders almost upon
recklessness, the cure of certain forms of hernia is generally acknowledged as the oppro-
bium of our art, and if ever to be undertaken, only in cases of the rarest exception. In
contrast with this, I call attention to the following quotation from Arnaud,* who pub-
lished in 1748 : " It is only since the beginning of the present age that cures truly sin-
gular have been performed. The knowledge which has been acquired in anatomy, and
the discovery of new kinds of ruptures, have enabled skillful surgeons to correct the
methods prescribed by former authors, and to invent new ones, according to the exi-
gency of the case. This superiority in the knowledge of anatomy has taught them
methodically to treat ruptures accompanied with putrefaction, which used within these
twenty years to be abandoned to the mere care of Nature. It has given them the
boldness to cut away with success two, four, or even six feet of the mortified intestine,
in order to secure the rest from gangrene. By this exact knowledge in anatomy they
are cured of their prejudice concerning the epigastric artery in inguinal ruptures. They
have learned to preserve the spermatic vessels in crural ruptures of men ; nor is there
any rupture, however complicated with adhesions, which they do not surmount. To
* Treatise on Hernia. George Arnaud, London, 1748.
(308)

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 309
open the intestine in case of necessity, and to search out in the recesses of the abdomen
the very remote strangulations, are achievements only to be found in the most modern
surgery, which is not without expedients even in desperate cases. To repress any
doubt of this truth, nothing is necessary but to look into the Memoirs of the Academy
of Sciences at Paris, where the most surprising cures of this kind will be found; such
as the people looked upon to be supernatural, until they were insensibly familiarized to
the miracles of art. He who reads Mr. Garengeot's Treatise of Operations, will see the
dexterity requisite in the different methods necessary for the cure of these diseases, and
find all the means of success laid down according to the greatest masters which our
nation has seen in the last or the present age.”
The revolution in the surgical treatment of wounds had its inception, as we have
pointed out, with Sir Joseph Lister, whose marvelous genius and indefatigable industry
surmounted all obstacles. His inspiration came from the studies of Pasteur and others,
including our own Professor Jeffries Wyman, upon fermentation and its dependence
upon vital rather than chemical causes. The results of his labors for the benefit of his
race have never been exceeded by any devotee to the healing art, and his name must
be indissolubly associated with the treatment of wounds so long as surgery remains a
branch of science. The demonstration seemed complete that, in an aseptic wound,
aseptically maintained, the repair processes proceeded under the same favorable condi-
tions as in subcutaneous wounds. The factors in the problem to be solved were the
best method of preventing contamination in the wound when open, and retaining it
uninfected during the process of repair.
No chapter in the history of surgery surpasses in interest that of wound-treatment
in the last quarter of a century. The biological investigations of bacterial growth in
its omnipresent energy and potent influence for good or ill over the human race is still
so recent, that we are as yet unable fully to appreciate or fairly judge of its importance
and value. Truth is ever more marvelous than fiction; and the new world to which we
are introduced by means of the modern microscope, although infinitely small in its
individual membership, possesses a power infinitely great over the higher organisms, from
birth until death. So fundamental and far-reaching are these hitherto unknown factors
of biological character that they underlie and in large measure modify our very exist-
ence. Without their potent energy, it seems, from our present knowledge, that the life
processes themselves would, within a very short period, cease to develop, dependent as
they are upon the never-ending round of transmutability of material upon which life

310
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
itself must exist. By the misdirected force of this invisible power the higher organic
life is ever threatened, known to us under various names by which we call many of
the more common and fatal diseases. Introduced into wounds, these organisms may
become agents endowed with the highest potency of a death-dealing character. From
a clearer knowledge of our invisible vital surroundings, many of the hitherto inscrutable
mysteries, fraught with pain and suffering and the foreshortening of our very existence,
are being made plain to us. The hidden rocks and reefs, so fatal during all the centu-
ries to the barks of life launched upon the great ocean of existence, with painstaking
care are being mapped and charted; and this work of the present generation is elevating
medicine and surgery from an art into a really great science: God's own law of wonder-
working from the infinitely small to the infinitely great-science, the knowledge which
has its better definition as pure and simple truth.
The first application of antiseptic measures for the surgical relief of hernia of which
I find record was, as seems natural to expect, by Mr. Lister during his early experi-
mental studies. On this account I quote somewhat in extenso the following case of
operation for strangulated inguinal hernia : *
“H. R., aged twenty-one, admitted to the Royal Infirmary at Glasgow, July 30,
1869. After an unsuccessful effort at reduction under chloroform, Professor Lister
proceeded at once to operate.
The parts having been shaved, and well washed with a solution of carbolic acid,
one to twenty of water, an incision two and a half inches long, extending into the scro-
tum, was made through the skin upon the neck of the tumor. The external ring, be-
ing found to form a constriction, was divided with a probe-pointed bistoury, and taxis
again tried, but without success. Mr. Lister accordingly proceeded to open the sac.
A considerable quantity of serous fluid escaped, and a piece of omentum six inches
long by five or six wide, and very black in color, was exposed. It was folded in a
cloth dipped in a one-to-forty watery solution of the acid and turned to one side. Be-
side this was found a fold of intestine of deep claret color. A testicle also slipped up
A
into view from the lower part of the wound. Mr. Lister, introducing his finger, now
discovered a second very tight and firm constriction, apparently the conjoined tendon,
which he divided with a probe-pointed bistoury, the tissue crying under the knife. The
neck of the sac, forming a third constriction, very tight but thin, yielded before the
* Glasgow Medical Journal, November, 1889, p. 123.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE.
311
!
-
finger-tip. The intestine having been well washed with a one-to-forty solution was now
returned, and the omentum was uncovered and examined. It had assumed a rosy, vas-
cular appearance, circulation being evidently re-established. One part, however, about
an inch wide, considerably ecchymosed, and somewhat detached from the rest, was liga-
tured with antiseptic catgut and removed. The remainder was returned. The wound
was thoroughly sponged with a one-to-forty solution, and closed by points of inter-
rupted catgut suture. All instruments, and the hands of those engaged in the opera-
tion, were dipped in a one-to-forty solution.
· The dressing consisted of a piece of antiseptic lac plaster, as recommended by
Mr. Lister, coated with gum-copal to prevent irritation to the wound, overlapping
about an inch, this in turn being overlapped for three or four inches by two layers of
lac plaster without the copal coating. A pad was placed over the region of the wound,
and the whole secured by bandaging.
July 31st.—Pulse, 72; temperature, 100.7°; dressing not disturbed.
· August ist.-Pulse, 62; temperature, 99º.
August 2d.-Wound dressed for the first time under a constant stream of one-to-
forty solution of carbolic acid. The wound not quite united, as between the stitches in
nearly its whole length altered clot is visible. There is some fullness about the incis-
ion, as if from retention of discharge, but no irritation or tension.
“ August 4th.-Wound redressed; on firm pressure two or three drops of orange-
colored serous fluid escaped from the lower angle of the wound. Otherwise unchanged.
“ August 7th.—Some of the stitches have been absorbed in their deeper parts, and
have been lifted off. Some others have been divided. There is a layer of lymph over
the wound, concealing the amount of cicatrization. No pus can be squeezed from the
incision, but the testicle has been dragged up from the scrotum and is lying beneath it,
accounting for the fullness already mentioned and the sickening uneasiness produced
by pressure.
August 11th.—The wound is found to have stretched considerably; the edges are
cicatrizing, and there is no odor.
“ April 16th.—The wound is perfectly sweet, and cicatrizing beautifully.
September 8th.—Patient dismissed, the wound being almost wholly cicatrized.”
This case is especially noteworthy, from having been done under antiseptic precau-
tions, and, as may be seen in the report, the repair processes supervened somewhat
slowly, but without suppuration.

312
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
No note is made of the disposition of the sac, and it is not probable that a perma-
nent cure was anticipated. The anatomical disposition of the parts was peculiar, and
the wound especially troublesome, from the tendency of the testicle to become with-
drawn within the canal, and this certainly could not have happened if the external ring
had been carefully sutured.
The case may surely be considered one of the early triumphs of the new method
of wound-treatment, applied to one of the most difficult regions of the body.
The first case of which I find record, where the canal was closed by animal sutures,
is that by Mr. Charles Steele, of Bristol, England. The operation was performed in
May, 1873, on a boy eight years old, and the canal was closed by two catgut sutures.
The recovery was rapid, and the hernia remained for six months cured, when strangula-
tion occurred, and the operation was repeated, with the use of three sutures. Recovery
was perfect, and a truss was applied. When reported, the cure remained, and the parts
were firm. Mr. Steele wrote: * “While I thought out and performed this operation, as
an original matter, I do not assert that I originated the operation; in fact, it seems to
me the most likely measure to suggest itself to any surgeon's mind when considering
the subject, and I dare say several have performed it.”
Professor Thomas Annandale,ť of Edinburgh, operated upon a case of strangulated
femoral hernia in January, 1872, in which he tied the neck of the sac with catgut, and
removed it with some adherent omentum. The result was so satisfactory, that he
wrote: “I have adopted this method in all cases since operated upon; but during the
last two years I have, in addition, stitched the margins of the abdominal opening to-
gether.” He commended unhesitatingly "ligature of the neck of the sac, with excis-
ion of the same, and stitching together the margins of the abdominal opening." He
used catgut and Listerian antiseptics.
To Professor Czerny, $ of Heidelberg, is accredited in Germany the origin of the
operation by a free dissection and closure of the parts, for the radical cure of hernia.
His first case was a strangulated hernia of a child two and a half years old, operated
on October 21, 1877. The pillars of the ring were closed by two silk sutures. The
wound became septic with abscess, but the cure was complete two years later. He
refreshed the pillars of the ring, after having resected the sac at its base, which he
* British Medical Journal, November 7, 1874, p. 584.
+ Edinburgh Medical Journal, December, 1880.
| Berlin. klinische Wochenschrift, No. 4, 1881.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 313
tied with a double ligature of stout silk and cut away. Silver-wire sutures were
introduced from within outward through the integuments. A rubber drainage-tube
was used, and the skin carefully closed with a continuous catgut suture. Iodoform
and antiseptic bandages completed the dressing. The wire sutures were generally re-
moved on the twelfth day. Nineteen radical operations were reported upon sixteen
patients. Complete ligation of the neck of the sac was made in nine cases. Suppu-
ration supervened in thirteen.
Schede, * of Hamburg, reported his first case of operation for cure, upon a patient,
suffering from a double reducible inguinal hernia, which in consequence of the large
size of the rings could not be retained by a truss. The operation was performed by
freeing the sac, drawing it down as far as possible, ligating it at the neck, and resect-
ing On one side, a piece of omentum was included in the ligature and removed.
The cure was complete, although the rings were previously large enough to admit
three fingers. He reported in connection a series of eight cases; the primary opera-
tion in all was the obliteration of the sac. The character of the suture was not men-
tioned. He stated that “the difficulty of applying a perfect antiseptic dressing in this
region of the body is very great, on account of atmospheric contamination and the
contact of urine, especially in children.” Wolters + reported from Schede's clinic, in
the Hamburg Hospital, 165 cases, in which there was an adequate history of opera-
tions for the radical cure performed in cases of strangulated and non-strangulated
hernia. In 95, a ligature was placed as high up as possible on the neck of the sac,
and the sac extirpated in congenital cases only partially), and the hernial apertures
sutured. In 17 cases of femoral hernia the sac only was extirpated, and its neck tied
without subsequently introducing sutures. In 15 cases, suture of the femoral ring was
mentioned. In some cases there were slight modifications of procedure; and in 24
the method of operation was not given. In 53 instances, portions of omentum were
ligatured and removed. In 51 cases of strangulated inguinal hernia, the total mortal-
ity was seven ; but only four of these, or eight per cent, were in any way traceable to
the operation itself. One patient, with an enormous scrotal hernia, died from shock-a
rare accident. Three deaths were from peritonitis, and the others were complicated
cases in old people. Of 64 cases of strangulated femoral hernia in which a radical
* Centrablatt für Chirurgie, November, 1877, Max Schede.
+ Remarks on the Radical Cure of Hernia. Sir William Mac Cormac. Vol. xix of the St. Thomas's Hospital
Reports.
43

314
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
operation was performed, four died, two being feeble old women; one death was from
pneumonia, the other from hæmorrhage dependent on a cancer of the stomach. There
were 40 operations on 37 patients affected with reducible inguinal hernia (in three in-
stances a double operation was performed). Two cases proved fatal, one that of a man
of fifty; two died from fatty degeneration of the heart after the wound had healed;
the other, a patient with fatty degeneration of the liver, succumbed to diffuse perito-
nitis, which it is believed had commenced previous to the operation, the symptoms be-
ing mistaken for those of incarceration of the bowel. Of the 10 operations on cases
of femoral hernia all proved successful. In the 50 operations, then, there were but
two deaths; and one of these not being assignable to the operation, the mortality is
only two per cent." His latest report is 387 radical operations, with 72 deaths.*
The interesting monograph of Victor Cuénod gives the work of Professor Socin
in the hospital at Basle, from 1877 to 1881, in operations for the cure of hernia. The
results are so interesting and instructive that I append a brief abstract :
Professor Socin, having carefully disinfected the parts, and the bowel having been
properly emptied by means of mild purgatives, if necessary, proceeded as follows:
“1. Incision of the skin and subjacent tissues as far as the sac.
“ 2. Dissection and isolation of the sac, effected by soft instruments or with the
fingers. If this dissection is not possible, separation of the neck of the sac so as to
be able to constrict it.
" 3. Incision of the sac, and reduction of its contents after freeing the constricted
ring, if it is a strangulated hernia; if necessary, resection of the adherent omentum.
“4. Simple ligature, double, triple, or quadruple, of the neck, carried as high up as
possible, and excision of the sac.
" 5. Suture of the pillars when it is necessary.
“ Finally, the aponeurosis which covers the sac is often brought together with
sutures, the cavity is drained, disinfected, and the edges of the skin are united by
sutures. A Lister dressing, very carefully applied and well compressed, covers the
wound."
M. Socin considered it useless to refresh the edges of the ring, and had not
practiced it upon the cases here reported. It is only rarely, in cases of inguinal hernia,
that he sutured the ring. In one or two cases of crural hernia with a large opening
* Boston Medical and Surgical Journal, May 26, 1892, p. 530.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 315
he found it necessary to bring together the borders of the orifice in order to secure
occlusion.
Finally, in inguinal hernia the presence of the spermatic cord is one of the most
serious obstacles to the perfect success of the operation. It is evident that complete
obliteration of the hernial canal is more difficult, since the surgeon is obliged to
leave in this canal an organ subject to difference in size and frequent movements. In
woman, the presence of the round ligament is of much less importance, and does not
need to be considered from the surgical standpoint. It is owing to these anatomical
conditions that we must attribute the difference in results obtained between inguinal
and femoral hernia. In the first, the passage of the hernia is made through a canal
already formed, which can be only narrowed and not completely obliterated after the
operation; while in the second this passage is made through a simple orifice, the com-
plete occlusion of which is much easier to secure.
Report of M. Socin's cases from 1877 to 1880, which were operated upon in the
hospital at Basle:
“Sur 17 hernies non-incarcérées, il y avait 15 hernies inguinales et 2 crurales; sur
17 hernies incarcérées, il y avait 10 hernies inguinales et 7 crurales.”
Giving as a result:
Sur 17 hernies non-incarcérées, 9 relapses, 8 cures. Sur 17 hernies incarcérées, 3
relapses, 14 cures.”
Or, more exactly :
Sur 15 hernies inguinales non-incarcérées, 9 relapses, 6 cures. Sur 2 hernies cru-
rales non-incarcérées, no relapse, 2 cures. Sur 10 hernies inguinales incarcérées, i
relapse, 9 cures Sur 7 hernies crurales incarcérées, 2 relapses, 5 cures."
This gives as per centum in classes :
“For non-incarcerated hernia, 52.9 per cent relapses, 47.1 per cent cures; for incar-
cerated hernia, 17.6 per cent relapses, 82.3 per cent cures.”
And in varieties :
“Inguinal non-incarcerated, 60 per cent relapses, 40 per cent cures; crural non-
incarcerated, 60 per cent relapses, 100 per cent cures; inguinal incarcerated, 10 per
cent relapses, 90 per cent cures; crural incarcerated, 18.5 per cent relapses, 71 per
cent cures."
These cases had all been heard from as to their condition from nine to forty-three
months after the healing of the wound.

316
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Of the twenty-two cures, eight were males, fourteen females. As to age, as follows:
Patients
cured.
Patients oper-
ated upon.
2
2
.
I
I
2
2
I
.
Age of patients.
One to ten years
Ten to fifteen years
Fifteen to twenty years .
Twenty to thirty years
Thirty to forty years
Forty to fifty years
Fifty to sixty years
Sixty to seventy years
Seventy to eighty years.
3
5
5
3
7
5
II
2
2
I
I
|
22
34
Conclusions :
“1. The result of the so-called radical cure can be considered definite only about
two years after the operation.
“ 2. The chances of success exceeding greatly non-success in children, the radical
operation is indicated with this class always where the hernia can not be retained with
a bandage.
“3. The radical operation is indicated in adults and aged persons in all cases where
a bandage can not be supported, or is not efficacious in its action.
“4. The ablation of the sac and suture of the neck in no way complicates the opera-
tion of kelotomy, but increases, on the contrary, the chances of success of the operation,
and should always be practiced in strangulated hernia.”
In 1889 M. Socin reported seventy-five cases operated upon for radical cure, with
two deaths. These were owing to the desperate condition of the patients, the enor-
mous size of the tumors, and the complications incident to them.
M. Tilanus reported to the Congress held at Amsterdam, in 1879, a statistical paper
upon the antiseptic operations performed for the cure of hernia. He collected reports
of about one hundred cases by different surgeons, with only eleven per cent of cures.
He advised excision of the sac and deep sutures.
One of the most interesting and valuable monographs upon the cure of hernia is
that of J. Lucas Championnière, * of Paris. The author performed his first operation for
*
* Étude sur la cure radicale de la hernie non-étranglée, avec une statistique de cent vingt opérations. Par le Dr.
J. Lucas Championnière.- Journal de Médecine et Chirurgie, 1888.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 317
the radical cure of hernia uncomplicated by strangulation in 1881, under the protection
of the antiseptic method, which at this time was absolutely unknown in France. In
the statistical table of one hundred and twenty operations given, there is much that is
interesting and instructive. Of the entire number, but one case proved fatal, although
it will be seen that every variety of hernia was operated upon, including many of the
most serious and complicated conditions. In some cases the herniæ were of enormous
size, the patient advanced in years and greatly reduced from long suffering. Twice the
bladder was accidentally opened, and once laparotomy was necessitated because of an
omental abscess, all of which the author adduces not alone to show the safety of the
operation, but also to point out the irreproachable security which the antiseptic method
furnishes in the treatment of wounds. While the author mentions a considerable vari-
ety of detail which is necessarily incident to hernial operations, the basic principle is
always the same. Remove as thoroughly as possible the peritoneal sac; restore or re-
move the omentum, and produce a strong cicatrix. In umbilical hernia he uses buried
sutures in layers, and oftentimes re-enforces by deep stay sutures. He urges the opera-
tion in a great majority of the sufferers from umbilical hernia, and does not hesitate to
recommend it in all cases of young women, whether the hernia is large or small, since it
constitutes a life-long infirmity, likely to increase with years. His table includes twen-
ty-five cases of congenital hernia. He preserves the testicle unless it is diseased, re-
stores the tunica vaginalis, and does not consider the operation much more difficult than
the generality of other surgical cases. He emphasizes the advantages derived from the
operation, and states that his results have been extremely satisfactory. His table in-
cludes a number of children, the youngest being only six months old. He prefers to
operate, however, after six or seven years of age, because of the difficulty of retaining
proper antiseptic dressings. He does not consider it advisable to operate, at the same
time upon both sides, if the patient is suffering from a double hernia. The counter-
indications for operation are those common to operations in general. The only fatal
case in his table is one where the operation was undertaken upon a man who had long
been a sufferer from emphysema. The hernia was large, and the operation long and
difficult. Death occurred in thirty-six hours, from pulmonary congestion, without any
abdominal lesion.
“The subjects of diabetes, chronic nephritis, and cardiac complications should be
carefully considered before advising operation. The author does not think the extirpa-
tion of omental masses a serious complication ; on the contrary, he claims originality in
a
а.
a

318
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
advocating the removal of large omental masses for the purpose of rendering greater
security in the results, and believes his experience fully justifies his views. In one ex-
treme instance he removed an enormous amount, weighing eight hundred grammes,
nearly the size of an adult head, with a subsequent good result. The author considers
the operation as one demanding careful dissection, with attention to details, experience
having taught him that, while a few operations have consumed less than forty minutes,
the larger number have taken an hour or more. Patients are usually retained in the
hospital from six weeks to two months after the operation. Where cure has not been
complete, the improvement is almost without exception very great."
The conclusions drawn from the discussion of the paper, and offered by L. S. Riche-
lot, were to the effect that,
"1. In inguinal hernia, as in all others, the resection of the sac is the principal factor
in the radical cure.
“ 2. The operation is not difficult unless there are adhesions with the intestine, or in
cases of old herniæ which have become strangulated.
3. That the resection of the vagino-peritoneal canal is always possible in congeni-
tal hernia with atrophy of the testicle.
“4. That resection of the vagino-peritoneal canal in hydrocele of the cord, when
existing without hernia, should always be performed to prevent the exit of a hernia.
“5. The simple operation, without removal of the testicle, should always be done in
hydrocele and congenital herniæ, just as it is done in acquired hernia.”
Mr. W. Mitchel Banks,* of Liverpool, contributed an article, in 1882, upon the
radical cure of hernia by the removal of the sac, and stitching together the pillars of
the ring. His first reported operation was in January, 1880. In August, 1887, at the
meeting of the British Medical Association, Mr. Banks reported a tabulated list of one
hundred and six cases. + Sixty-eight cases were without strangulation; in thirty-eight,
strangulation was present. His method of operation is as follows: “In inguinal her-
nia, the sac, after being cleanly dissected out, is opened, and all bowel is replaced and
adherent omentum tied and cut away. The sac is then well pulled down, ligatured as
high up in the canal as possible, and removed. Finally, the pillars of the ring are
brought together by two or three silver ligatures, which are left in position. In femoral
* British Medical Journal, 1882, pp. 985-988.
+ Ibid., August 10, 1887, pp. 1259-1261.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 3 19
.
hernia the dissection and removal of the sac constitute the whole operation, and no
attempt is made to close the femoral aperture. In ventral and umbilical herniæ use
is frequently made of the whole or part of the sac, as a kind of plug to stop the aper-
ture, which is generally large, and in which it is seldom possible to adapt any means
of approximating the edges which seem likely to be permanent.”
In the analysis of his tables Mr. Banks stated that “in the sixty-six cases which he
has been able to follow up, forty-four were completely successful from a curative point
of view.” Mr. Banks does not consider the truss such a serious inconvenience, and
would not operate where the rupture could be retained. He also “ advises everybody
.
to wear a light support after operation. ... All parings, scrapings, and freshenings of
the inguinal canal I hold to be utter nonsense, and quite theoretical. When an inguinal
hernia is big enough to warrant operation, there is commonly little canal or ring left.
I have generally found a big hole with a thin-edged margin, which has taken three or
four fingers of an assistant to plug up while the sac was being removed. Then what is
the use of pulling the pillars together by sutures? I do it simply to hold the parts
together temporarily while the wound heals, so as to prevent all danger from cough-
ing or straining, because in very big operations I leave the wounds quite open.” Mr.
Banks would rarely operate in children, having done it only four times in the entire
series.
Mr. Kendal Franks,* of Dublin, first operated in 1882. Reported twenty-four cases
done under strict antiseptic precautions. He wrote: “What I have most frequently
done is to clear the sac from surrounding parts, then open it and pass my finger
through it till I can feel the margins of the internal ring. I then pass the silver wire
first through one pillar of the ring and through one side of the sac; then, passing the
needle through the other pillar of the ring and through the other side of the sac, I
thread it with the same wire and withdraw it. When this suture is fastened it not only
closes the ring, but fixes the sac between its pillars in such a way as to obliterate its
cavity. Two wires are generally used for this purpose. Below the sutures the sac is
excised. ... I always use buried sutures—that is, I endeavor to sew together with cat-
gut the various layers of tissues which have been divided. The skin-wound I bring
together with an oblique suture, so as to leave a slight pucker at the upper angle for
drainage. By so doing a drainage-tube is seldom required, and the first dressing is
.
.
* British Medical Journal, London, December 3, 1887, pp. 1202-1204.

320
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
allowed to remain undisturbed for ten days. I generally find the wound perfectly
healed and the dressings caked and dry. I first close the upper part of the internal
ring, by passing the silver wire straight through the aponeurosis of the external oblique
directly over the internal ring. The needle-point is, of course, protected by a finger
passed through the canal and pressing the abdominal wall forward at this place. The
needle armed with the wire then picks up part of Poupart's ligament, and, having
reached the finger, is carefully made to appear through the canal, when the wire is
caught and the needle withdrawn. The unarmed needle now passes through the exter-
nal oblique aponeurosis, as before, and at a point corresponding to the other side of the
ring, passes through this pillar, and, being brought out through the canal, it is threaded
with the wire and withdrawn. Before this suture is twisted, a second one is passed at
the lower end of the ring in the same manner. This second suture corresponds gen-
erally to about the middle point of the canal. It also passes through the aponeurosis
of the external oblique, immediately in front of the lower part of the ring. The third
suture, which is also generally silver, closes the external ring. This I believe an im-
mense improvement.”
All cases operated on by Mr. Franks easily recovered, and at the time of the report
only four cases were known to have failed, and these were much improved.
In com-
petent hands, where every precaution is taken against avoidable danger, the operation is
believed to be eminently a safe one."
Mr. A. W. Robinson,* of Leeds, England, tabulated twenty-six cases. In all but
two cases, where Wood's operation was performed, the sac was excised after its neck
had been ligatured, the canal being sutured only when very open. Strict Listerism was
followed in every case. He recommended ligature of the sac and suture of the pillars
of the rings.
Mr. Chauncy Puzey,ť of Liverpool, reported twenty-four cases of operation by
the aseptic method; the first was performed in 1881. He emphasized the dissection
of the sac and its ligation as far up as possible, and removal; suture of the pillars
with stout chromicized catgut; he thought wire should not be employed. So far as
known, there had been no failure, and all made rapid recovery.
Mr. Christopher Heath, of London, reported six operative cases, two of extro-
* British Medical Journal, December 17, 1887, p. 1324.
+ Ibid., December 17, 1887, p. 1327.
| Ibid., May 23, 1885, p. 1041.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 32 I
care.
verted bladder; one death. He advised resection of the sac, with deep catgut sutures,
aseptically applied.
Mr. C. B. Keetley,* of London, contributed an interesting article upon the
radical cure of hernia by open injections, and, in summing up, wrote: “I believe
that a thorough operation of combined excision, ligature, and suture will almost
certainly effect a lasting cure. The dangers are often considerable, but they belong
to the operator rather than the operation, and are avoided by care and experience.
The injection method is, at present, uncertain as to result, but it is pre-eminently
simple and safe.”
Mr. F. Treves,t of London, and Mr. G. A. Wright, of Manchester, have presented
most interesting communications upon hernia of the cæcum. Mr. Treves reported
two and Mr. Wright five cases. The operations were given in detail, with a review
of the subject. The sac was tied and resected and the canal closed under antiseptic
.
Mr. A. Rabagliati, # of the Bradford Infirmary, reported at some length the
results of his experience. He advocated the removal of the sac, and stitching the edges
of the peritonæum with fine catgut sutures, as in ovariotomy. The pillars of the
ring were closed by a second line of sutures, and then the skin. The operation
was done under antiseptic precautions. He reported ten successful cases treated
by removal of the sac.
Mr. Arthur E. Barker | recently contributed an interesting paper on radical cure
of non-strangulated hernia. In the entire series of fifty cases there was not a sin-
gle death, although some cases were very troublesome. With the exception of
two the wounds healed by first intention. He writes: “ Having got rid of suppura-
.
tion, almost all other sources of anxiety were readily eliminated after operation.
Shock was not noticed; hæmorrhage was of course absent; nothing was seen of the
accidental wound infections, such as erysipelas, pyæmia, etc. The age of the patients
ranged from three months to seventy years. Three were under six months; two
* British Medical Journal, December 3, 1887, p. 1205.
+ Ibid., February 19, 1887, p. 384.
| Ibid., March 5, 1887, p. 506.
# Ibid., December 3, 1887, p. 1206.
| Medico-Chirurgical Transactions, 1890.-A Study of Fifty Cases of Operation for the Radical Cure of Non-
strangulated Hernia. By Arthur E. Barker, F.R.C. S., Surgeon to University College Hospital.
44

322
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
between six months and one year; thirteen were between one and five years; six
between five and ten; one between ten and twenty; eight between twenty and
thirty; two between thirty and forty; six between forty and fifty; and one over
seventy. Of the entire number, forty were inguinal, of which thirty-one were on the
right side, and in four cases the hernia was double; there were three cases of um-
bilical and two of femoral hernia. Careful aseptic measures were observed." Mr.
Barker has found drainage less and less necessary, until he now closes more often
without drainage. Carbolized interrupted silk sutures are used. Occasionally small
stitch abscesses occur, but these are not considered as cases of suppuration. In six
cases one or more of the deep buried stitches worked their way to the surface at a
period ranging from the thirteenth day to the ninth month, but without giving any
further trouble, Considering that at least two hundred deep stitches must have
been left in the tissues in these fifty cases, the percentage which came away may be
considered small. I think the fault has usually been attributable to using too much
force in tying them on the included tissues, and for this reason I am now content
if the edges of the opening are simply brought firmly together. If this is so, the
percentage of stitches which come away in the next series will probably be smaller.”
Of eleven cases nothing is known; of the remainder, in eight the hernia returned.
Of the remaining thirty, when last seen or heard from, there had been no return.
Trusses are not advised after operation. “In not one of all my own cases have I
ever seen or heard of any ill effects upon the contents of the scrotum. The gauze
dressing is applied, and usually remains undisturbed until the tenth day.” Mr. Barker
dissects the sac carefully to its very base, ties with catgut, and removes it. He
sutures the ring deeply with silk or catgut. In children he finds the dressings must
be frequently changed, on account of the soiling with urine and fæces. He closes
the rings usually with from two to six interrupted silk sutures.
Mr. John Wood, in his later experiences, somewhat modified his method, under
the conviction that antiseptic measures allow of better results. In the discussion that
followed the delivery of Mr. MacCormac's address upon Antiseptic Surgery, Decem-
ber, 1879, Mr. Wood stated: * “In cases of large scrotal hernia, in which trusses are
of no avail, and the sac is much thickened, of great size, and sometimes presenting
constrictions in its substance which are a source of great danger from strangulation,
* Antiseptic Surgery. William MacCormac. London, 1880, p. 74.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE.
323
the spray and the gauze dressing, with the cleanliness and freedom from contamina-
tion, putrefaction, and suppuration which they afford, has enabled me to extend mate-
rially the scope of benefits to be derived from the operation for the cure of hernia.
In such cases I have removed the whole sac, and sometimes coherent omentum,
through an incision in the scrotum two and a half inches long; stitched up the
peritoneal orifice with a continuous suture of strong carbolized catgut, and then I
have drawn together the tendinous sides of the hernial opening with thick silver wire,
to resist the tendency of the intestine to protrude and force through the catgut
suture, which is too weak to support the strain when unaided by such support, and
becomes speedily absorbed. A drainage-tube carried through the bottom of the
wound, and along the wire, enabled me to keep the wound perfectly clean of accu-
mulation and retention of discharges.”
In Mr. Wood's lectures upon Hernia and its Radical Cure, delivered at the Royal
College of Surgeons in 1885, and published in the British Medical Journal, the follow-
ing June, he wrote: “In the case of tendon ligature being used, it is to be braced up
tightly, tied in a well-secured surgeon's knot, cut off close, and buried in the wound,
In the case of tendon being used a drainage-tube should be placed, reaching from
the superficial ring into the scrotal puncture, and the gauze dressing applied in the usual
way, by a double spica bandage, with a piece of jaconet, through which the penis is
passed, placed over all to keep off urine from the absorbent dressing.” In twenty-eight
cases operated on by free dissection and closure of the parts, the sac was tied at the
neck with separate stout catgut and removed; the canal and rings were closed by
sutures of kangaroo, or ox-tendon, or wire. Of the series there were three deaths, but
all were the result of inflammation of the lung in bad subjects.
Mr. Wood's method of suturing is to transfix the sac with a stout tendon, carried
through it by a needle with eye near the point, tie on each side, and cut the sac close.
He closes the femoral ring with the same tendon, and leaves it as a buried suture; uses
here drainage as in the inguinal variety. He reported sixteen operations for strangu-
lated hernia-eight inguinal and eight femoral—with attempt at cure.
“ Seven were
done by ligature of the neck with catgut and entire removal of the sac, with closure of
the canal and rings by wire lacing, and nine by the use of tendon for all these purposes.”
Mr. Wood reported one case of radical cure of umbilical hernia. With respect to the
supposed advantages of the open-dissection method, enabling the surgeon to see the
parts on which he operates, he wrote: “I have myself found that, after the first cut and

324
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
the application of the sponge, the parts became so bleared with blood that I was
obliged to rely mainly upon the aid of the sense of touch before I ventured to pass a
needle through Poupart's ligament, the conjoined tendon, and the pillars of the ring.”
In conclusion, Mr. Wood stated: “It appears indubitable, from the results of the last
twenty years' experience of the radical cure of hernia, that the position of those surgical
writers who have maintained that the radical cure should not be attempted except in
the severest cases is untenable. The operation has given as great relief and exemption
from the minor troubles and worry which make life miserable as any operation asso-
ciated with prolapse, such as hæmorrhoids, and is even more safe." Mr. Wood wrote
me, under date of August 29, 1891, “ My lectures are my last publications on hernia."
Mr. James Hardie, * of Manchester, England, in an article published in 1885, gave
the results of an extended experience of operation by the method of dissection. He
emphasized the liability of the hernia returning, induced by a depression in the peri-
toneal pouch, and recommended the taking of the sutures through the neck of the sac,
so as to include quite a border of the transversalis fascia. This with him is all the more
important, since he leaves the sac, having introduced into the lower end of it a drainage-
tube. He used wire to close the canal.
Mr. Clement Lucas + emphasized the removal of the sac since it is always to be
considered a source of danger. “To rid the patient of this abnormal, overstrained, ill-
nourished, not only useless, but absolutely injurious piece of tissue, should be the aim
of every surgeon when called to operate for strangulation after reducing the bowel. It
is probably the only operation for radical cure that will stand the test of time. I regard
no operation for femoral hernia complete until the sac has been excised, even although
the bowel may have been reduced before the opening of the sac. The same may be
said of acquired congenital hernia. The congenital inguinal presents especial diffi-
culties, as the whole sac can not be excised without sacrificing the testicle; but I
usually excise the funicular portion, and rigid antisepsis is here advisable.” Mr. Lucas
also reported two very interesting cases of cure of large umbilical hernia by the use of
deep-buried catgut sutures; both patients made easy recoveries.
Mr. Thornley Stoker, $ of Dublin, practices the dissection method of operation. He
freely opens the sac, stitches up the neck, and draws together the canal and pillars of
a
* Braithwaite's Retrospect, vol. xcii, p. 122.
+ British Medical Journal, October, 1885.
| British Medical Association meeting, August, 1884.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 325
the ring with chromicized catgut, carbolized silk, or wire, but does not remove the sac.
He considers it risky and unsurgical.
Mr. Alexander, of Liverpool, modifies the operation by tying the neck of the sac
as deeply as possible, and divides below the suture, but does not disturb the sac or
suture the rings. He reported thirty cases operated upon for the radical cure, without
a death.
Prof. Buchanan, of Glasgow, in congenital hernia slits up the sac longitudinally on
each side of the cord. The anterior part is divided transversely and sutured into the
ring as a plug; the lower part is turned down to complete the tunica vaginalis.
Sir William MacCormac,* in an elaborate article upon the radical cure of hernia,
held it as important to ligature the sac high up and remove it, and then close with
sutures. He concluded as follows: “An operation for the radical cure is, I think, per-
missible in a large proportion of cases. It may be regarded as an accepted practice that
in strangulated hernia, whenever the condition of the hernial contents warrants their
return to the abdominal cavity, and the general state of the patient is otherwise satis-
factory, the radical operation should be superadded to that of herniotomy. With refer-
ence to reducible hernia the question is more open. In children, during the first years
of life, a hernia is usually cured by a properly adjusted truss, and this method of treat-
ment should always be carefully tried, the more especially because the operation in
infants is attended by considerable risk, owing to the difficulty in maintaining the
wound aseptic. As the child grows older the chances of closure of the peritoneal
process by means of a truss diminish. Probably after the first six or seven years of
life the prospect of cure by any save operative measures is so small that the attempt
need scarcely be made. The operation is most strongly indicated in cases of irredu-
cible hernia with periodical symptoms of incarceration or impending strangulation—a
condition so especially common in umbilical hernia. It is also desirable in the case of
patients whose occupation is liable to provoke strangulation, or renders the condition
extremely inconvenient, or where social conditions make palliative measures objection-
able. It is also indicated where the hernia, although reducible, can not be so main-
tained by a truss, and in cases which are attended by distressing local symptoms. I
would conclude by saying that in a large proportion of cases of inguinal hernia, espe-
cially those of congenital origin, a radical cure is possible; and that in femoral and
* Vol. xix, St. Thomas's Hospital Reports. Reprint.

326
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
umbilical herniæ of small or moderate size the prospects of cure are good. Even where
an absolute cure is not accomplished a great gain is generally secured in the diminution
of the size of the hernial aperture by which the retention of the hernia within the
abdominal cavity becomes more practicable. Lastly, and most important, the opera-
tion when properly performed is scarcely dangerous to life.”
Mr. John Poland,* of Guy's Hospital, London, in a paper upon the treatment of the
sac in strangulated hernia, reviewed the different methods of treatment and commended
the ligature of the neck and excision. “By it the peritonæum is effectively closed
from hæmorrhage and septic infection, and it holds out a great hope of permanent cure,
not only in restoring the patient to a more normal condition by removing a more or
less open tract along which a portion of the intestine might again descend, this tract
being in fact composed of morbid and useless tissues, but also by producing a radiating
puckering of the peritonæum around the hernial orifice and closing the orifice itself by
dense cicatricial tissue, and thereby tending to prevent yielding again at this spot. We
do away with an indurated thickened mass, which often exists where the sac has been
allowed to remain untouched. ... In cases where the opening is large the pillars of the
ring may be brought together by sutures without adding to the risk of the operation.
.. Ligature without excision has no advantage over ligature with excision.”
Mr. F. T. Heuston † contributed a most interesting paper to the Surgical Section
of the British Medical Association, upon the radical cure of femoral hernia, and re-
ported an illustrative case in a woman of seventy. The cure was easy and complete,
although the sac, besides a loop of intestine, contained a gangrenous Fallopian tube
and the ovary ; both were removed. The sac was tightly twisted and transfixed with
chromicized gut, and excised. The canal and fascia were closed by buried sutures. Mr.
Heuston remarks: “It is sufficiently rare to find the Fallopian tube and ovary within
the hernial sacs, to allow another case being recorded, as I find that in 1871 there were
only thirty-eight cases recorded, namely, twenty-seven inguinal, nine femoral, one sciatic,
and one obturator. Of these, however, seventeen were congenital, all of which were
inguinal, and the ovary alone was usually in the acquired herniæ, while only five of the
cases contained intestine."
Besides the advantage derived from the removal of the sac and closing the perito-
.
* British Medical Journal, December 3, 1887, p. 1201.
+ Ibid., December 3, 1887.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 327
næum by twisting the neck, Mr. Heuston emphasized the importance of closure of the
tissues, “in proper and consecutive order, by hidden sutures, the most important being
the first applied, namely, uniting the fascia transversalis forming the anterior wall
of the femoral canal to the fascia iliaci and anti-psoas layer of the pubic portion
of the fascia lata behind and within.” He used chromicized catgut throughout the
operation, which allows of immediate union, and does not require subsequent
removal.
In the discussion of Mr. Hueston's paper, Mr. Walsham remarked that “he thor-
"
oughly advocated Mr. Banks's method. He used kangaroo-tendon, and believed that,
when it was securely knotted, it was a most reliable ligature, and preferable to both
wire and silk.”
Dr. Ward Cousens observed that “the surgery of hernia had made recently most
rapid advance, especially in the direction of the radical cure in young children. He
had operated on more than fifty cases, and thirty of these were cures; the rest had been
done too recently to express an opinion.” He removed the sac after ligature of the
neck, and closed the edges of the ring and wound with a continuous suture. He advo-
cated silk or wire as more trustworthy than catgut.
Mr. C. B. Ball * reported a method for the cure of hernia by torsion of the sac.
He emphasized the complete separation of the sac from the structures of the cord—a
matter sometimes of no small difficulty. “The peritonæum loosened a little about the
ring, the empty sac is firmly held at its neck by forceps and gradually twisted; gener-
ally four or five turns are sufficient, but the torsion should be continued until it is felt
to be quite tight or rupture seems imminent. Thus held, the twisted neck is tied with
catgut as high as possible and the ends cut off short. Two sutures of strong aseptic
silk are now passed through the skin, at a distance of about an inch from the outer mar-
gin of the wound, through the outer pillar of the ring, through the twisted sac in front
of the catgut suture, and then through the inner pillar of the ring and skin upon the
inside. As these sutures effectually prevent the sac from untwisting, it may now be cut
off in front of them, and a catgut drain is brought out through a separate opening at
the back of the scrotum, and the two sutures closed over lead plates which lie at right
angles to the wound. Superficial sutures are applied if required, and a dry dressing is
held by a fixed silicate-of-potash bandage.” Post-mortem testing shows the perito-
* British Medical Journal, December 10, 1887, p. 1272.

328
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
næum to be thrown into spiral folds radiating in all directions from the ring and ex-
tending about four inches.
Mr. Ball thinks the twisted sac thus transfixed makes a slight projection rather than
depression within the abdominal cavity. He reported twenty-two cases of his own, be-
sides a number, under his observation, done by other surgeons. All recovered. All had
been performed within four years. Three were obliged to wear a truss, from a weaken-
ing of the ring. Mr. Ball deprecated the wearing of a truss, since the pressure of the
pad tends to produce absorption of the plastic effusion in the canal, upon which the
success of the operation so largely depends."
Mr. W. P. Stokes,* of Dublin, advocated the free dissection method; he adopted
the plan of Mr. Ball of twisting the neck of the sac and suturing under aseptic pre-
cautions. He argues, as does Mr. Ball, that the lymph effusion is the factor sought;
that sutures serve but a temporary purpose, and their chief end is to secure an abun-
dant exudation.
No one of the recent contributions upon the cure of hernia has deservedly attracted
a. larger share of attention than the paper of Mr. William Macewen, of Glasgow, pub-
lished in the Annals of Surgery, August, 1886. This was supplemented by a further
contribution t upon the subject to the British Medical Association. Mr. Macewen
stated that “ he was led up to the adoption of his present method by his studies upon
the various methods of the treatment of the sac; and, believing that there was gener-
ally left a depressed pouch or funnel-shaped puckering of the peritonæum at the in-
ternal ring, which receives the wave of impulse of the liquid movement of the intes-
tine, he sought, in the device which characterizes his method, to re-enforce the weak
spot by a new use of the sac.” The steps of the operation are given as follows:
“ 1. Free and elevate the distal extremity of the sac, preserving along with it any adi-
pose tissue that may be adherent to it; when this is done, pull down the sac, and, while
maintaining tension upon it, introduce the index-finger into the inguinal canal, sepa-
rating the sac from the cord and from the parietes of the canal.
“ 2. Insert the index-finger outside the sac till it reaches the internal ring; then
separate with its tip the peritonæum for about half an inch round the whole abdomi-
nal aspects of the circumference of the ring.
* The Practitioner, November, 1887, p. 355.
+ British Medical Journal, December 10, 1887, pp. 1263-1271.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 329
a
“ 3. A stitch is secured firmly to the distal extremity of the sac. The end of the
thread is then passed in a proximal direction several times through the sac, so that,
when pulled upon, the sac becomes folded upon itself like a curtain. The free end
of this stitch, threaded on a hernia-needle, is introduced through the canal to the
abdominal aspect of the fascia transversalis, and there penetrates the anterior abdomi-
nal wall, about an inch above the upper border of the internal ring. The wound in
the skin is pulled upward, so as to allow the point of the needle to project through
the abdominal muscles without penetrating the skin. The thread is relieved from the
extremity of the needle, when the latter is withdrawn. The thread is pulled through
the abdominal wall, and, when traction is made upon it, the sac, wrinkling upon itself,
is thrown into a series of folds, its distal extremity being drawn farthest backward and
upward. An assistant maintains traction upon the stitch until the introduction of the
sutures into the inguinal canal, and when this is completed the end of the stitch is
secured by introducing its free extremity several times through the superficial layers
of the external oblique muscles. A pad of peritonæum is thus placed upon the ab-
dominal side of the internal opening, where, owing to the abdominal aspect of the
circumference of the internal ring having been refreshed, new adhesions may form.
The sac having been returned into the abdomen and secured to the abdominal
circumference of the ring, this aperture is closed in front of it in the following man-
ner: The finger is introduced into the canal and lies between the inner and lower
borders of the internal ring, in front of and above the cord. It makes out the posi-
tion of the epigastric artery, so as to avoid it. The threaded hernia-needle is in-
troduced, and, guided by the index-finger, is made to penetrate the conjoined tendon
in two places: first, from without inward, near the lower border of the conjoined
tendon; then, from within outward, as high up as possible on the inner aspects
of the canal. This double penetration of the conjoined tendon is accomplished by
a single screw-like turn of the instrument. One single thread is then withdrawn
from the point of the needle by the index-finger, and when that is accomplished the
needle, along with the other extremity of the thread, is removed. The conjoined
tendon is therefore penetrated twice by this thread, and a loop left on its abdominal
aspect. Secondly, the other hernia-needle, threaded with the portion of the suture
which comes from the lower border of the conjoined tendon, guided by the index-
finger in the inguinal canal, is introduced from within outward through Poupart's
ligament, which it penetrates at a point on a level with the lower stitch in the con-
45

330
ANATOMY AND SURGICAL TREAMENT OF HERNIA.
c
joined tendon. The needle is then completely freed from the thread and withdrawn.
Thirdly, the needle is now threaded with that portion of the catgut which protrudes
from the upper border of the conjoined tendon, and is introduced from within out-
ward through the transversalis and internal oblique muscles and the aponeurosis of
the external oblique at a level corresponding with that of the upper stitch in the
conjoined tendon. It is then quite freed from the thread and withdrawn. There are
now two free ends of the suture on the outer surface of the external oblique, and
these are continuous with the loop on the abdominal aspect of the conjoined tendon.
To complete the suturing, the two free ends are drawn tightly together and tied in
a reef-knot. This unites firmly the internal ring. The same stitch may be repeated
lower down the canal if thought desirable. The pillars of the external ring may
likewise be brought together. In order to avoid compression of the cord, which
might lead to serious embarrassment and sloughing, or ultimate atrophy of the
testicle, it ought to be examined before tightening the stitch. The cord ought to
lie behind and below the sutures, and be freely movable in the canal. It is advis-
able to introduce all the necessary sutures before tightening any of them. When
this is done they might all be experimentally drawn tight, and maintained so while
the operator's finger is introduced into the canal to ascertain the result. If satis-
factory, they are then tied, beginning with the one at the internal ring, and taking
up in order any others which may have been introduced. In the great majority of
cases the stitch in the internal ring is all that is required. During the operation
the skin is retracted from side to side to bring the parts into view and to enable
the stitches to be fixed subcutaneously. When the retraction is relieved, the skin
falls into its normal position, the wound being opposite to the external ring. The
operation is therefore partly subcutaneous. When the canal has been brought to-
gether, a decalcified chicken-bone drainage-tube is placed with its one extremity next
the external ring, the other projecting just beyond the lower border of the external
wound. A few chromic gut sutures are then introduced along the line of the skin
incision. The wound is dusted with iodoform, also the interstices of the scrotum
and its junction with the thigh. A sublimated wool pad is applied, held in position
by an aseptic bandage."
Mr. Macewen tabulated eighty-one cases, without a death, and with a firm occlusion
obtained before leaving the ward. The material used for sutures, as by far the most
serviceable, he thinks to be catgut, prepared so as to resist the action of the tissues


PLATE LVII.
Fig. 2
Frej 1.
b

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 331
from two to three weeks. The use of decalcified chicken-bone drainage-tubes is
considered by Mr. Macewen as admirably suited for the operation. He wrote me,
under date of September 4, 1891: “I still operate by published method for radical
cure of hernia with permanent results, using no truss. Catgut as previously pre-
pared (with exception of hastening method of preparation) is still used, and for the
last two years nearly exclusively, in my practice, both as ligature and suture. It
answers all my requirements admirably.”
I introduce the following plate, which is of value not only on account of the patho-
logical conditions illustrated, some of which are of exceptional interest, but also be-
cause it exhibits conditions of the peritoneal sac common to most old, large hernia
which would prevent its utilization for any purpose of re-enforcement of the parts as
suggested by Mr. Macewen. These conditions are also well shown in a number of
the preceding illustrations.
PLATE LVII *
Figure 1.
Represents an internal view of an oblique
hernial sac.
a. Femoral artery.
b. Epigastric artery, showing its course, first
below and then to the inner side of the neck of
the sac.
c. Obturator artery.
d. Mouth of the hernial sac.
e. Sac within the scrotum.
f. Testicle.
c. The epigastric artery, taking its course on
the outer side of the mouth of the hernial sac.
d. Mouth of the hernial sac.
e. Pubes.
f. Testis.
Figure 3.
Represents the appearance which an intestine
exhibits under the state of artificial anus.
a. The upper portion of gut.
6. The lower portion of gut.
c. Bougie passed into the artificial anus.
d. Narrow portion of gut connecting the
upper and lower portions.
e. Femoral vessels.
Figure 2.
Represents a direct hernia.
a. Rectus muscle.
b, b. Peritonæum divided to show the epigas-
tric artery
PLATE LVII A.
Figure 4.
Represents the division of the epigastric ar-
tery, in a case of strangulated oblique inguinal
hernia.
a. Spine of the ileum.
b. Pubes.
c. Rectus muscle.
d. Mouth of the hernial sac.
e. Extremities of the divided epigastric ar-
tery.
f. Femoral vessels.
* Cooper, Plate XII, Part I.

332
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Figure 5.
Exhibits intestine strangulated by omentum.
a, a, a. Congenital hernial sac cut open.
b, b. Omentum adhering to the bottom of the
Figure 6.
Shows hernia combined with hydrocele.
a. Abdominal muscles.
6. Hernial sac cut open.
c. Hydrocele behind the hernial sac.
sac.
C. Bougie passed under the constricting band
of omentum.
d. Intestine, girt and strangulated by omen-
tum.
e. Testis.
Figure 7.
Is the section of an intestine in which an arti-
ficial anus had formed after the operation. The
case occurred in the practice of the late Mr. Wes-
ton, and survived the operation four months.
a. Artificial anus with a bougie introduced.
At the meeting of the Congress of Italian Surgeons, held March, 1888, Prof.
Bassini, of Padua, described a new method of cure in inguinal hernia which he had
successfully practiced in one hundred and two cases. His method is quite similar
to my own operation, and in both the chief object in view is the restoration of the
obliquity of the canal. He lays open the canal to the internal ring. The sac is
separated, drawn down, ligated, and resected. The closed peritonæum is returned,
the spermatic cord is pushed aside, and the posterior margin of Poupart's ligament
exposed. The deeper layer is dissected in such a manner that it can be brought in
close apposition to the posterior margin of Poupart's ligament. From the ileo-pubic
tubercle the canal is united posteriorly from five to seven centimetres to the entrance
of the cord into the abdominal cavity. The cord is then replaced and the aponeu-
rosis of the external oblique sutured, an opening being left sufficient only for the
cord without compression. The wound is closed with drainage. The internal opening
and the posterior wall are new-formed, the external ring narrowed. This restores the,
canal to its normal oblique position. The posterior wall, being composed of muscle
and aponeurosis, is permanent, and will not disappear like the cicatricial plug in
Wood's operation. In the author's 102 cases, 95 were reducible and 7 were strangu-
lated; in 98 the hernia was complete oblique, and in 4 complete direct. Professor
Bassini, in an article recently published in Langenbeck's Archiv, records 216 cases
of operation upon reducible inguinal hernia. All recovered but one, in which death
resulted from a pneumonia which commenced after the complete healing of the
wound. The mortality, therefore, he considers nil. In il cases there was some
constitutional disturbance, in the rest none. In 167 cases, or considerably more than
two thirds, the wound had healed in a fortnight.
He was able to obtain the final result in 251 cases operated upon by himself or

PLATE LVII A.
Fig. 4.
Fig. 6.
1
Fig. 7
a


OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE.
333
his colleagues, and found in 108 no return after a period varying from one to four
and a half years. In 131 cases no reappearance had taken place up to periods vary-
ing from a month to two years. In 7 there was relapse, and in 4 the result was
not ascertained.
Anderegg * published a thoughtful article upon the radical cure of hernia by the
removal of the sac and closure of the canal. Of a list of 55 patients where the radi-
cal operation was performed, 38 were reported cured, free from any return. In 71
cases there were i deaths.
Leisrink | reported 188 cases of strangulated hernia operated on, and in the list there
were 33 deaths. He thinks the return of the hernia is less likely to follow the radical
operation when done after strangulation than when performed in reducible cases.
Riesel | advocates the division of the anterior wall of the canal as far as the in-
ternal ring. He narrows the canal by removing a portion of the anterior wall, and
unites by transverse sutures from above downward, so as to close the canal as much
as possible, in the belief that in this way he reforms and restores the obliquity of
the opening. Usually he ties the sac high up and leaves the empty sac below, be-
lieving that it gives further security and protection from return. The superficial
wound he unites over the deeper layer. He claims that by this method of splitting
the canal he can dissect and free the sac to its very base, and in this way obliterate
any pouching of the peritonæum.
Mr. Henry E. Robinson,# Assistant Surgeon at St. Thomas's Hospital, London,
has published recently a tabulated report, with an analysis of all the cases operated
upon for the radical cure of hernia by the surgeons in the hospital, from the begin-
ning of 1879 up to the end of March, 1890. In all the cases the operation was done
for non-strangulation, and not as one of expediency in cases of strangulation, when,
after relief of the strictured contents, the opportunity was taken to effect a perma-
“ Various methods of operation were adopted and cases of varying severity
treated, and we venture to think that the results obtained may be compared favor-
ably with the statistics of any one special operator.
#
nent cure.
* Die moderne Radicaloperation der Unterleibsbrüche, 1885.
† Die Radicaloperation der Hernie. Deutsche. Zeitschrift für Chirurgie, 1886.
1 Otto Riesel. Deutsche med. Wochenschrift, Berlin, 1887, pp. 449-467.
# Sixty-four Cases of Non-strangulated Hernia treated by Radical Cure. By Henry Betham Robinson, B. S. F.
R. C. S.

334
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
2 cases.
* There were 64 cases operated upon; 57 were in males and 7 in females.
Of 57 cases, 56 were inguinal and i umbilical. Of 7 cases, 5 were femoral—2 on
the right side, 3 on the left; 2 were umbilical. Of the inguinal herniæ, (a) 24 were
acquired, (6) 32 were due to defective closure of the processus vaginalis.
“(a) Of the acquired herniæ, 15 were on the right side, 8 on the left, and i double.
" () Of those due to defective closure of the processus vaginalis, 18 were congeni-
tal herniæ, 13 on right and 5 on left; 12 were funicular herniæ, 7 on right and 5
on left; 2 were infantile herniæ, 2 on right and none on left. With acquired ingui-
nal herniæ the favored operation was that advocated by Mr. Mitchell Banks, viz.,
tying the sac up as high as possible, removing it, and then suturing the pillars of
the ring. Of 24 cases, (1) removing the sac and suturing the ring was done in 14
cases; and of these, the pillars were sutured with catgut in 4, wire in I, and
4
with kangaroo-tendon in 3 cases.
3
In 5, the material used is not stated. (2)
5
The sac was removed, but the pillars were not sutured in 5 cases. (3) The sac
was ligatured at its neck and divided, but not removed, and the pillars sutured in
In both, the herniæ were very large, and as the amount of tearing through
of the tissues which would have had to be encountered in the separation of the sac
would have been great, it was not deemed advisable to attempt this. Silk was used
to suture the pillars in one case, and catgut in the other.
“In femoral herniæ the sac in all cases was dissected out and cut away, but in one
case only were the soft parts about the ring sutured. In the cases of umbilical her-
nia the sac was separated and removed, and the ring sutured up.”
Results of the operation : “The present condition was ascertained in 43 of the
60 cases inquired into as to the result. Of the 22 cases of acquired inguinal hernia,
14 answered. Of these, 9 were completely cured, but in 5 cases there was re-
currence.”
Among the cases due to defective closure of the processus vaginalis-
(a) Of the 18 cases of congenital hernia, 14 answered, and “all were cured.”
(6) Of the 11 cases of funicular hernia, 8 answered, and “all were cured.”
(C) Of the 2 cases of infantile hernia neither answered. Of the 5 cases of fem-
oral hernia, all answered. In 3 there was cure, in 2 recurrence.
Of the 64 cases,
4 have been fatal, or 6 per cent.
In Sweden, an “improved ” operation for the radical cure of hernia has for some
time past been practiced by Drs. Svenssen and Erdmann, Surgeons to the Sabbats-

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 335
berg Hospital,* at Stockholm. A ligature is applied to the neck of the hernial sac,
and the sac is cut off below the ligature, the contents being previously examined by
means of an incision into the sac, and returned; or, if only omental, excised together
with the sac. In congenital hernia the upper part of the sac only is removed, and
where the large bowel is included in the hernia and adherent to the sac wall, this,
after being separated from the surrounding tissues, is returned together with the large
intestine, and the divided portions of Poupart's ligament united by sutures. The dress-
ing employed is iodoform and boracic acid, the wounds being washed with sublimate
solution. Since this has been substituted for carbolic gauze, abscesses which used to
occur frequently have become rare. Of the 48 cases thus operated on, none of which
were selected, 38 were permanently cured—at least, no return of the hernia occurred
within six months; and in the cases where a return did take place, which amounted
to 20 per cent, the condition was very much less painful and distressing than it had
been previous to the operation.
Sabbatsberg Hospital has now been opened six and a half years, and during that
time 300 cases of hernia have been admitted, about 200 of these being operated on
with a knife; a milder procedure, consisting of alcoholic injections, being employed in
the earlier cases. Not a single case proved fatal, though some of the herniæ were
very large, some reaching within three or four inches of the knee.
M. Thiriar reported, at the French Congress of Surgeons, held October, 1889,
twelve cures of hernia without accident, following the method of M. L. Champion-
nière. M. Leónté, of Bucharest, reported 7 operations followed by cure. M. Rou-
tier, 14 cases, all cured; M. Segend, 44 operations, without a single death ; M. Riche-
lot, 22 operations, one death, a man of seventy years.
Mr. E. S. Bishop,t of Manchester, England, published an interesting article upon
the radical cure of hernia by a modification of the Macewen method of operation. He
questions the probability of the interior fixation of the pad when the sac is drawn up
like a curtain to form it, and thinks it often fails to protect the interior ring, stating
that "it might either be drawn too high, or tilted slightly to one side, so that the
original cause which slowly extruded the primary sac would produce gradually another
at the unguarded point, slowly pushing aside the block which should protect the whole.”
a
* Medical and Surgical Reporter, Philadelphia, 1886, vol. ix, p. 115.
+ British Medical Journal, April 19, 1890.

336
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
He is careful to separate the sac quite to, but not beyond, the internal ring. A long
suture, armed at both ends with needles, is passed from below upward through each
wall of the sac, in such a way that, when the ends are pulled upon, it is drawn up like a
purse, the central fold being the largest. Having invaginated the sac thus sutured, the
,
needles upon either side are made to pierce the abdominal wall from within outward.
Tension upon both ends of the thread purses up the invaginated sac, which is thus
firmly “ fixed as a rounded boss, exactly over the internal ring; its peritoneal surface
being turned toward the intestine, and its first fold on either side being firmly applied
to the peritonæum immediately within the ring.” The ends of the thread are then tied
firmly but not tightly over the ring, which with the canal is then securely closed with
buried catgut sutures, which are so placed as to draw the superior half of the anterior
wall of the canal and internal pillar of the external ring well over in front of the in-
ferior half and external pillar. A horse-hair drainage is left in the canal, which must
not be so tightly closed as to prevent free movement of the cord lying in it. The su-
perjacent tissues are then united by horse-hair sutures, and the whole dressed aseptically.
The advantages claimed by the author are the accurate intrafolding of the peritoneal
pouch and fixation over the internal ring. This, and the simplicity of surgical detail,
appear to offer marked advantage in the disposition of the sac over the method intro-
duced by Mr. Macewen.
Mr. Herbert W. Allen,* of London, has reported at length 23 cases operated
upon during the last two years : 15 strangulated, with one death owing to complica-
tions, and 8 for radical cure, with one death, an umbilical hernia, size of an adult head,
the contents of which had long been irreducible with adhesions, death occurring on
the second day. He ligatures the neck of the sac and removes it, which he believes
is the most important factor in effecting a cure.
Karewsker advises operation in infants where the use of a truss is not satisfac-
tory. Of 63 cases heretofore operated on, 3 died, 2 from sepsis and 1 from shock.
He believes the cause of infection to be due not so much to the soiling of the
wound as to the retention of the wound secretions due to the complicated attempts at
closure. He advises, after replacing the contents of the hernia, to loosen the sac to
above the internal ring, then twisting and ligating its neck. Skin sutures are inserted,
* London Lancet, October 17, 1891.
+ Report of Bardeleben's Surgical Clinic. - Centralblatt für Chirurgie, 1891, No. 7, p. 139.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 337
9
and the wound tamponed for twenty-four hours, after which a button-hole drain is em-
ployed. Out of 25 cases of hernia under his care, he has performed this opera-
tion nine times. The wound healed, on an average, in ten days. The operations were
done during the past three years, and in none has there been any return. The youngest
case was nine months of age, and the oldest two and a half years.
A. Koehler suggests a new procedure to replace the purse-string suture heretofore
employed, in which the hernial sac is used as a “stopper" "for the hernial opening.
“The sac is completely loosened from the spermatic cord, the peripheral end is removed,
and the balance is slit into three or four strips. These are rolled up separately, with
the surface which presented to the wound (the external surface of the sac) outward,
and each roll is sutured, to prevent unrolling, by means of catgut; finally, all the rolls,
together with the pillars, are sutured together, and the wound is closed by buried su-
tures. In subsequent cases the rolls were not stitched to the pillars, but were crowded
into the abdominal cavity, and the latter sutured over the opening of the ring. The
'stopper' should press against the internal ring, but not press into the inguinal
canal.”
Ferrari advocates a modification of Czerny's operation. After exposure, isola-
tion, and removal of the hernial sac, in addition to suturing the pillars, he splits the
external wall of the inguinal canal to the internal ring, and following this, the entire
extent of the inguinal canal is closed, with the exception, of course, of an opening
for the passage of the spermatic cord. He declares the valve-forming operation of
Macewen and Bassini to be more or less theoretical.
R. W. Parker,t Surgeon to the East London Hospital for Children, recommends
operation for the cure of all cases of congenital hernia over two years of age. He
draws the spermatic cord well out of the way, pulls down the sac as far as possible,
and introduces three or four stitches through its neck, care being taken not to com-
press it too tightly. He closes the pillars of the ring and wound with sutures. He
prefers aseptic silk. “The longer it remains unabsorbed the better, for thus we have
the mechanical help which its presence gives until complete adhesion of the sac walls
has been effected."
In the same journal, Henry O'Neil, of Belfast, advises the operation for radical
* Centralblatt für Chirurgie, 1891, No. 3, p. 62.
+ British Medical Journal, February 7, 1891, pp. 2-9.
46

338
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
cure in children as the rule. He drains with decalcified chicken-bone, uses chromi-
cized catgut sutures, and bandages the dressings on firmly with India-rubber web
bandages. He changes the dressings only when the discharge has stained through
them, or when the temperature rises suddenly above 101'. He advises an opiate for
two or three nights, and gives an anæsthetic during the first and second dressings, to
prevent the child's crying and straining the abdominal walls. “I have had no deaths
.
from this operation. I consider this method only requires to be understood by sur-
geons to be generally adopted; and when the details of the operation are carefully car-
ried out, in suitable cases the results are most satisfactory."
Mr. W. H. Bennett,* Surgeon to St. George's Hospital, London, published an
illustrated description of his method of treatment of the sac for the radical cure of
inguinal hernia. It is a modification of the Macewen method, in that the sac is
divided just below the external ring, and the distal portion is allowed, after bleeding
has ceased, to drop back into the scrotum. A long, straight needle with eye near the
point is inserted about an inch above the margin of the external ring, a little to the
outer side of its middle line, and it transfixes the abdominal wall, impinging upon the
end of the finger in the canal. Thus guided, it is passed down upon the inside of the
loosened sac and made to pierce its outer wall at a point about half an inch from the
cut edge. The needle, having been threaded with a tendon or catgut ligature not less
than twelve inches long, is withdrawn, taking one end of the suture with it. The
needle unthreaded is passed in a similar way half an inch internally to the first puncture
through the sac, threaded with the lower end of the suture, and withdrawn. The open
end of the sac is ligated, and traction upon the deep suture invaginates the inverted sac
within the abdomen. The canal is closed with silk sutures and a drainage-tube applied.
In a somewhat similar way Mr. Bennett advises, under favorable circumstances, the
utilization of a portion of the omentum to serve as a pad over the internal ring. In
umbilical hernia, Mr. Bennett thinks that often the padding of the internal ring with
omentum and suturing to it, are of much importance. The margins of the ring are then
brought together by deep sutures of stout silk or tendon.
Mr. R. Morrison † showed a man, aged forty-seven, who had two undescended testi-
cles, and a troublesome hernia on the left side which had been three times strangulated.
* The Lancet, September 12 and 19, 1891.
+ British Medical Journal, February 6, 1892, p. 277.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE.
339
“On November 21, 1891, operation for radical cure was performed. A thin sac and cord
were tied in one ligature. Two hours after, collapsed, wound and external ring opened
up. Spermatic artery had retracted, a large hæmatocele formed, and peritoneal cavity
full of blood. The spermatic artery was caught and tied, and the abdomen washed out
after median abdominal section. The man was now well, and his hernia radically
cured.”
Among the very recent contributions on the radical cure of hernia is a paper by
Mr. Lawson Tait,* of Birmingham, The Treatment of Hernia by Median Abdominal
Section. In a considerable number of cases of abdominal disease in women, com-
plicated with hernia, Mr. Tait has closed the hernial opening by sutures taken in the
following manner: “Two common glover's sewing-needles armed with one piece of
salmon silk-worm gut are fastened in some convenient needle-holder at a very slight
angle to one another, so that their points completely coincide, and can be made to
enter through one hole in the skin. The left forefinger covers or occupies the inner
aperture of the sac; the needles are made to enter from without, and are then sep-
arated. The outer needle is then made to dip deeply into the external column of
the ring, and the inner needle similarly into the inner column. The needles are then
pulled out through the central incision, and as many sutures as may be thought de-
sirable are inserted in this way. When the insertion of the stitches is completed,
they can be tied from within and cut short. The abdominal wound is then closed
properly, and the operation is over.”
Mr. Tait entered into a long argument to show the advisability of operating in
this way in cases of incarcerated or strangulated hernia, even when the contents are
only omentum, and stated: “My proposal, therefore, is now to apply this method
of proceeding to all cases of hernia in which operation is required, either for the
relief of strangulation, with an operation for the radical cure superadded, as I believe
it always ought to be, or merely for the cure of a chronic hernia." In evidence of
the originality of his method, he quotes from a paper published in the British Medi-
cal Journal in September, 1883: “I have an impression that the radical cure of hernia,
other than umbilical, will by-and-by be undertaken by abdominal section. I am not
sure but that it will be extended to operations for strangulated hernia.” In the first
* Section of Surgery. Annual Meeting of the British Medical Association, July, 1891.-British Medical Journal,
September 26, 1891, p. 687,

340
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
part of Mr. Tait's paper he expresses his good fortune at having learned many im-
portant lessons in the surgical treatment of hernia from an eccentric practitioner of
forty years' experience, practicing upon an unmentioned island, himself so obscure as
to be nameless. This surgeon had had a remarkably large and successful experience
in operating upon the fishermen subject to hernia, and openly expressed his contempt
for the details in the anatomy of hernia, a subject with which Mr. Tait was in full
accord. Had the latter, on the contrary, learned his lesson from one of the greatest
of English surgeons, he would have found that Mr. Brodie * had anticipated and
actually put into practice the method of reduction of a strangulated hernia by median
abdominal section more than sixty years ago.
In the discussion which followed, Mr. C. R. B. Keetley, of London, stated that “in
1883 he reduced the contents of a strangulated umbilical hernia by pulling them back
into the abdominal cavity, previously opened by a small incision in the linea alba.
Soon afterward he attempted the same proceeding in a case of inguinal hernia. It
failed in consequence of adhesions, which he was obliged to open the sac to separate.
Annandale had done this operation ten years before. It could not be of general appli-
cability because of the frequent existence of adhesions and other complications of the
contents of the sac, and it created two potential apertures where there was origi-
nally but one. With regard to the sac itself, Mr. Tait had exaggerated the dangers
and difficulties of dealing with it. After doing much to destroy the old superstitious
fear of the peritonæum in general, did he want to awaken it again with regard to a
small process of it ? ”
Mr. Keetley considered that the essential requirement in order to produce a radi-
cal cure was to bring into direct contact the edges of the hernial apertures in the
fibrous and aponeurotic opening in the abdominal wall. To do this, the sac must
either be removed, reduced, its neck divided, or in some manner got out of the way.
Mr. Jordan Lloyd, of Birmingham, expressed himself as quite content with the
results of herniotomy as at present performed, especially when combined with a pro-
cedure for radical cure; but, good as these results were, they would be even better if
patients were submitted to earlier operations. Mr. Keetley stated “ that he had oper-
ated on a very large number of herniæ, and had not met with a single one which could
have been more easily dealt with by abdominal section. On the other hand, he had
London Medical and Physical Journal, London, 1827.-See this work, p. 172, for report of case.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE.
341
.
encountered many where an abdominal incision would have been both harmful and
useless. He was surprised to hear that Mr. Tait expected to be able to draw the
contents of strangulated herniæ back into the abdomen without division of their con-
stricting structures, particularly the tendinous pillars of the abdominal rings; and he
knew of two cases where unsuccessful attempts had been made to operate in this way,
and where ordinary herniotomy had subsequently to be performed. In a few cases
the combination of abdominal incision and herniotomy might be advantageous, but he
thought that even in these herniotomy should always be the primary procedure, and
not abdominal section, because the former was undoubtedly the less dangerous, and
had the great advantage of allowing the surgeon to learn with promptitude and exact-
ness the nature and condition of the parts with which he had to deal. . .
“ In dealing with strangulated hernia, Mr. Tait's suggestion bristled with dangers,
two of which only need be mentioned: first, that of tearing the softened bowel walls
by traction of the gut; and, secondly, the admission into the general peritoneal cavity
of the highly irritating and almost constantly present fluid contents of the sac.”
Mr. J. Greig Smith, of Bristol, stated “that he would gladly welcome any method
which would render unnecessary the division of the tendinous structures about the
hernial opening. More than once he had known abdominal section performed for
hernia from a mistaken diagnosis. Very recently he had operated for obturator hernia
by abdominal section, and his experience in another case operated upon in this way
two years previously had led him to decide that abdominal section was the best
method of dealing with this rare form of hernia. But, so far as he could see, this
was the only variety of external hernia in which it could be systematically adopted.”
Mr. Bennett May, of Birmingham, stated that “he was present at an operation
where median abdominal section revealed a strangulated hernia as the cause of an
acute obstruction of two days' duration. The herniated structures could not be with-
drawn even after division of the stricture from within, which was accomplished with
difficulty. The ordinary operation had to be done, adhesions separated, and omentum
removed. Any decisive attempt at withdrawal would have pulled away the inflamed
gut. The fact was, the present operation was intrinsically almost free from danger, and
left little to be desired.”
Mr. H. W. Maunsell, of New Zealand, to whose experience Mr. Tait had made refer-
ence, reported that he first performed suprapubic laparotomy for the relief and cure of
a strangulated femoral hernia early in 1887. He believed that in many instances great

342
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
advantages accrued from this method of dealing with hernia. He thought his own
operation had certain distinct advantages over that as described by Mr. Tait. It con-
sists, in femoral hernia, in the introduction of a long and strong curved needle, on a han-
dle with the eye near its point, from without inward through the skin, over the saphe-
nous opening in the upper part of the thigh, piercing the fascia covering the pectineus
muscle, and the lower or posterior border of Gimbernat’s ligament at its attachment to
the pectineal line and near its base or outer free margin, the bowels being protected by
keeping the finger on the point of the needle. The needle should then be carried
through the external abdominal wound, threaded with stout silver wire, and withdrawn.
It is introduced in a similar manner upon the opposite side of the femoral ring,
threaded with the other end of the same wire, and withdrawn. It only remains to twist
it sufficiently tight to compress the parts, and the operation is completed. The mo-
ment the wire was cut the twisted ends retracted out of sight, deep in the tissues of
the groin below Poupart's ligament, and completely occluded the entrance to the crural
canal. In performing this operation one should not be satisfied unless the loop of wire
lay directly across the center of the entrance to the femoral canal. In conclusion, Mr.
Maunsell stated that “ he advocated abdominal section in strangulated femoral, obtura-
tor, umbilical, and diaphragmatic hernia. All other cases (unless associated with ab-
dominal tumors requiring removal) were best treated by direct incision on the sac and
seat of strangulation in the usual way.”
Mr. Ernest Kingcote,* of Salisbury, advocates the utilization of the hernial sac as
an internal pad in the radical cure of hernia. The especial feature of his operation is in
the incision, which is transverse, and well above the internal ring. The advantage of
this is the carrying of the wound quite above the groin, for the better protection in
dressing. The subsequent steps of the operation are conducted quite in the usual way,
the sac being freed about half an inch around the abdominal aspect of the internal
ring, and two stout absorbable catgut sutures are inserted diagonally through the stump
as far inward as the separation from the abdominal wall will allow, and carried loosely
through the pillars of the ring. One or more fine absorbable catgut stitches obliterate
the opening into the abdominal cavity. The stump is then pushed a little inward, and
three or more very stout catgut sutures are introduced through the transversalis fascia,
etc., and the ring closed. The stout diagonal sutures through the stump are now tied
* British Medical Journal, June 28, 1890.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN EUROPE. 343
firmly over the tightly closed-up ring, and the operation is completed in the usual
way.
Under date of January 4, 1892, Mr. Frank Marsh, of Birmingham, wrote me: “I
always advise the operation for the radical cure of hernia, unless constitutional condi-
tions contra-indicate surgical interference. I prefer not to operate on children until they
are over twelve months old. Excluding cases of strangulated hernia, I have never had
a death, nor do I know of one occurring in the experience of my surgical colleagues at
the Queen's Hospital. In the congenital hernia of children, I find it sufficient to ex-
pose and isolate the neck of the sac with the least possible disturbance of the scrotal
tissues, ligating it as high up as possible, cutting through below the ligature, and sutur-
ing the pillars of the ring in the ordinary way. In adults, and especially if the hernia
is an acquired one, Macewen's method has so far given me the best and surest results,
proving effectual in cases of recurrence after the above method. If the sac is very large,
I excise a part, so as not to have too large a pad. During the healing process I con-
sider this pad becomes slowly adherent to the abdominal surface round the internal ring,
and that it materially strengthens the parts.
“In femoral hernia I suture the upper margin of the crural arch to the fascia over the
pectineus muscle, and then carefully approximate the margins of the saphenous open-
ing with sutures. If omentum is adherent to the sac, I am careful to free it from all
attachments, and return or excise it. In a post-mortem after operation for a strangu-
lated hernia, where the omentum was used to block up the opening, the transverse colon
was dragged down and held within an inch of the pubes. I have used catgut prepared
after Sir Joseph Lister's method, and also kangaroo-tendon ; I think I have had the best
I
results with the tendon. I never advise the wearing of a truss after operation. Very
recently I employed your method with the buried tendon sutures in an operation for
hernia in a youth of sixteen, sealing the wound with iodoform collodion ; a pad of wool
and spica bandage were applied over this, but on the third day were omitted as un-
necessary. The simplicity of your method, and the excellent result obtained, have so
favorably impressed me that I intend to employ it in this and other suitable operations.
When better known I believe it will be often used. It is certainly an important ad-
vance over the older methods."

CHAPTER XXV.
OPERATIVE MEASURES INSTITUTED FOR THE CURE OF HERNIA UNDER MODERN METHODS
OF WOUND-TREATMENT (ANTISEPTIC AND ASEPTIC CONDITIONS) IN AMERICA.
It is generally conceded that surgery was both taught and practiced in America,
prior to the late war between the States, with a success quite equal to that in Europe.
The art of surgery, however, was practiced in the great centers of civilization with com-
paratively few—and these unimportant-changes as it had been taught by the great
masters of the previous generations. The active discussions upon wound irritation,
inflammation, suppuration, and dressings, had settled into a very general consensus of
opinion, resulting in large measure in routine methods of treatment,
To the many young American surgeons, engaged for four years in the constant
care of an immense number of gunshot-wounds, the question of wound-treatment as-
sumed an entirely new aspect, and military surgery was advanced to a degree of perfec-
tion hitherto unknown. The reports from the Surgeon-General's office made by one
of my early teachers, Dr. George A. Otis, Surgeon U. S. A., will remain an endur-
ing monument of the genius, skill, and learning of the medical profession of this gen-
eration. The influence of these lessons and experiences, necessarily diffused through
the entire country, crystallized into convictions more or less uniform, until it was gen-
erally believed that little more of vital importance was to be garnered by the profession
which could be of value in the treatment of wounds.
It was probably owing to this wide-spread conviction that the so-called Listerian
doctrine, in the early days of its promulgation, found so few advocates in America. A
large number of our more ambitious young men became post-graduate students in
Germany as the Mecca of scientific medical teaching, and, with comparatively few ex-
ceptions it was not until after the leading surgeons of Germany had adopted the prin-
ciples of antiseptic surgery that they received serious consideration in America. For
this reason slow progress was made in the complete revolution demanded by this sys-
tem of treatment of wounds, and, as a consequent, the favorable consideration of anti-
septic operative measures for the cure of hernia found few advocates in our country.
(344)

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 345
a
a
In a former chapter I have called attention to a number of original devices for the
cure of hernia advanced by American surgeons, notably the injection method, origi-
nated by Dr. Pancoast, of Philadelphia, Dr. Heaton, and later elaborated by Dr. Joseph
H. Warren, of Boston. Dr. Gross, of Philadelphia, as early as 1858 operated for the
cure of hernia in two cases, by dissection of the parts and closure with silver-wire
sutures. Both cases resulted in permanent cure.
In 1870 it was my good fortune to become the pupil of Prof. Lister, in Edinburgh,
and I returned to America thoroughly convinced that the great principles enunci-
ated by him were truly scientific, and that the extraordinary results which he obtained
in surgery were based upon their accurate and painstaking application. Upon the re-
sumption of my surgical practice I inaugurated his methods with scrupulous fidelity of
detail, which I taught in a wide range of clinical demonstrations. The opportunity
soon came of making a definite application of these principles to the cure of hernia.
On the 19th of February, 1871, in consultation with Dr. A. P. Clarke, of Cambridge,
I operated upon a patient, Mrs. M-aged fifty, who had suffered for years from her-
nia. Five days previous she was seized with severe pain in the inguinal region, accom-
panied by vomiting. Long-continued and careful taxis had failed to reduce the hernia,
and for twenty-four hours the vomiting had been stercoraceous, and the patient seemed
in extremis. The hernial tumor was the size of an egg, protruding from the external in-
guinal ring. A careful dissection exposed the sac, which was closely adherent to the
surrounding parts. The constriction was at the internal ring, and was divided with some
difficulty. The hernial contents were reduced, and the sac, unopened, was returned
within the ring. Two stitches of medium-sized catgut were taken directly through the
deeper structures about the ring. The wound was dressed antiseptically, and from Dr.
Clarke's notes, taken at the time, I find that the patient steadily progressed without pain
or accident, and was convalescent in three weeks. The result was a radical cure of the
hernia, although the canal was not closed for this purpose. The opening into the abdo-
men was so large that we feared the escape of the contents, especially as the patient was
afflicted with a severe chronic bronchitis. I only expected the sutures to hold the parts
in situ temporarily. Mrs. M—– died six years after the operation, and was troubled
with the cough during the entire period, but the canal remained firmly closed at death.
She did not wear a truss after the operation.
On March 10, 1871, assisted by Dr. W. W. Wellington, of Cambridge, I operated
upon Mrs. L-, aged forty-five, suffering with strangulated hernia. The hernia was
47

346
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
of some years' standing, usually retained by a truss. It was on the left side, and direct
inguinal in variety. The sac was returned unopened; the canal was closed by three
large-sized catgut sutures, taken deeply through the pillars of the ring, and the wound
carefully dressed antiseptically with Lister's carbolized lac-plaster. When examined the
following June, the cicatrix was linear, and a firm deposit of new tissue could be felt,
marking the site of the buried sutures.
I reported these cases at the meeting of the County Medical Society, October 11,
1871, and published * a paper discussing the subject, November 16, 1871, under
the title, A New Use of Carbolized Catgut Sutures. In closing, I remarked : “ As
far as my observation has extended, this is a new use of the carbolized catgut ligature,
and suggests a still wider field of application. No method of operation for the radical
cure of hernia appears more feasible, is probably attended with less danger, and at the
same time affords a means of closing and strengthening the weakened ring, which
is so desirable, and yet, with all the ingenious devices of surgery, is so difficult to
obtain.”
Although I continued to operate from time to time, as occasion demanded, upon
cases of strangulated hernia, and in every case closed the ring with buried animal su-
tures, it was not until February 4, 1878, that I deliberately attempted the radical cure
of a reducible hernia. This patient I had some time previously (December 2, 1877)
cured of a large, old, irreducible omental hernia of the right side, which had become com-
plicated by the descent of a strangulated loop of intestine. In this instance I dissected
the sac and resected the omentum. I closed the neck of the sac with catgut su-
tures, excised the sac, and carefully closed the ring and structures of the abdominal
wall. A truss retained imperfectly a large direct inguinal hernia of the left side, for
which Mrs. W— besought cure, although seventy years of age. In the operation I
was assisted by Dr. A. L. Norris, of Cambridge, who cheerfully gave his approval.
In this I was the more fortunate, since until that time my advocacy of operative
measures for the cure of hernia in non-strangulated cases had been considered un-
justifiable.
The operation was not difficult, and the result was most satisfactory. On the 17th of
April following, Mrs. W—- died of an aneurismal tumor of the brain. The autopsy
furnished me two excellent specimens of different dates, showing not only the histologi-
* Boston Medical and Surgical Journal, vol. viii, p. 316.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 347
cal changes which ensued about the suturing, but also the condition of the underlying
peritonæum. In the first operation, where the sac had been sutured and resected before
closure of the ring, the peritonæum was perfectly smooth, and without depression at the
former site of the ring. Upon the opposite side, where the sac had been returned un-
opened, there remained a little pouched depression of peritonæum, which taught the ease
of reformation of the hernia. These specimens I presented at the annual meeting of the
American Medical Association in June, and communicated * at considerable length my
views of the operation for the cure of hernia by the buried animal suture.
I gave, in this
paper, the history of the animal suture and its preparation for surgical uses, since few
surgeons at that date, even in England, used catgut for the ligation of vessels, and the
use of the buried animal suture was advocated by none. In a further communication
upon the cure of hernia, read at the International Medical Congress held in London
in 1881, I emphasized the freeing of the sac and its resection, after sewing it across at its
base with a continuous animal suture, and then refreshing the pillars of the ring, and
closing by deep buried double continuous sutures of kangaroo tendon, which are much
to be preferred to catgut. I summarized the advantages of this method of operation as
follows:
“ I. We are enabled to see clearly each and every step of the operation; blind sur-
gery is bad surgery, as a rule.
“II. It is the only method with which I am acquainted by which the hypertrophied
elongated peritoneal pouch, which has been a primal factor of failure hitherto, can be
removed.
“III. Herehy we actually re-enforce as well as occlude the ring. In the weakened,
attenuated condition of the parts, in all old cases, there is no small gain in securing
this effect.
“ IV. Experience has, I think, now demonstrated that this operation may be cata-
logued among those safely advised, and that femoral and umbilical herniæ are no excep-
tions. I would not exclude children from the class to be benefited, for in them the
vital processes are at the best, and when thus cured they are saved from a life-long dis-
ability"
* The Radical Cure of Hernia by the Antiseptic Use of the Carbolized Catgut Ligature. --Transactions of the
American Medical Association, vol. xxix, pp. 295-305, 1878.
+ Transactions of the International Medical Congress, vol. ii, p. 446.

348
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
In May, 1886, at the annual meeting of the American Medical Association, I con-
tributed a paper* entitled The Radical Cure of Hernia, based upon a series of over
thirty consecutive operations, in which I showed that surgical procedures, in my experi-
ence, had been devoid of danger. In conclusion, I recommended the dissection of the
sac to its base, its suture, and excision, the restoration of the obliquity of the canal, and
closure of the parts with the buried tendon suture-
“1. In all cases of operation for strangulation.
“ 2. In all cases where the abdominal contents are imperfectly retained by a truss,
unless the age and condition of the patient prevent.
“ 3. In the large class of children, when the conditions do not promise a spontane-
ous cure.”
Soon after the publication of my early experience in the use of catgut as a bur
suture for the cure of hernia, it was attempted by a number of operators. Dr. David
W. Cheever, of Boston, wrote me in May, 1878, as follows: “I have tried catgut for
the radical cure of hernia, but it was speedily absorbed, and failed.” Dr. J. C. Warren
wrote me about the same date: “I should fear catgut would not hold long enough to
keep the parts in apposition, until union became firm. We have given up its use in
the Massachusetts General Hospital for this reason. The sutures do not hold longer
than four days.” The method of preparation of the catgut was not given. Somewhat
later, Dr. Charles B. Porter, of Boston, reported two cases of hernia operated on, catgut
being used for the closure of the parts, which were followed by cure.
In August, 1886, Dr. John B. Hamilton,t Surgeon-General United States Marine
Hospital Service, read before the Chicago Medical Society a very valuable lecture
upon the cure of hernia. In the discussion of the advantages of the modern operation
of dissecting out the sac and its removal, and closure of the parts under antiseptic pre-
cautions, with a resultant permanent cure, to which he gave his unqualified approval, he
stated: “ Dr. Henry O. Marcy, of Boston, reported, October 11, 1871, cases treated by
this method. Prof. Annandale and Sir William MacCormac give the priority to Dr.
Charles Steele, of Bristol, but Mr. Steele's first case was reported in the British Medical
Journal, November 7, 1874, nearly two years after those of the Boston surgeon. Marcy
and Isidore Israelsohn are undoubtedly the pioneers in this application of antiseptic
* Journal of the American Medical Association, May 28, 1887.
† Ibid., September 4, 1886.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 349
a
surgery.” After a careful review of the dissection method as performed with antiseptic
precautions, he closed as follows: “As no logical reason can be given for a failure to
accept the view that there has been an advance, I perhaps need not say that 'I favor,
in all cases affording even a reasonable prospect of cure, an operation therefor, and
that all cases whatsoever of bubonocele should be operated upon.?”
Dr. T. J. McGillicuddy * reported, in 1887, a case of radical cure of a strangulated
oblique inguinal hernia, with ligature, removal of the sac, and recovery. He closed his
paper with a plea for the removal of the sac and closing with deep, firm sutures.
In an interesting paper by Dr. Thomas H. Burchard, † of New York, upon the
modern treatment of strangulated hernia, the subject of operative measures was care-
fully reviewed. As is well known, he is an advocate for early operation; he prefers
dissection of the sac, suture of the base, and return of the stump, then a careful coapta-
tion of the rings and canal by deep sutures of catgut. He reported one case operated
upon by Macewen's method : “This is the only case in which suppuration of any mate-
rial consequence occurred. Had I ever seen the operation performed, or had I pre-
vious experience with it, I might have secured a better result. As it is, the cicatrix
is very painful, and a hardened mass at the site of the internal ring will scarcely tol-
erate the slightest pressure. I have operated in nine cases of strangulated hernia in
which I have been enabled to carry out the operation in all its details. Eight recov-
ered; one developed delirium tremens, and died the fourth day.”
Dr. Dudley P. Allen, $ of Cleveland, contributed an interesting article upon the
radical cure of hernia, in which he advocated the dissection method under strict anti-
sepsis. He advises extirpation of the sac after suturing at the base with catgut, and
uniting the pillars of the ring with interrupted silk sutures, one end left long; a
drainage-tube is inserted to just outside the united pillars, and superficial interrupted
stitches close the wound. An aseptic state is maintained for a week, when suppura-
tion is allowed, and the silk sutures through the ring are removed as they become
loose. In this way he thinks the plastic repair is more firm and resisting than in
primary union. Reported one case operated upon at two years of age. His first
operation was done in 1885.
* New York Medical Journal, December 31, 1887, p. 737.
+ Ibid., January 21, 1888, pp. 6-15.
| Medical Record, New York, August 11, 1888, pp. 141-143.

350
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
At a meeting of the Suffolk District Medical Society, held November 7, 1888,
Dr. R. Whitman,* of Boston, reported a case of cure of inguinal hernia by Macewen's
method. A long discussion followed, in which a considerable number of surgeons
who had operated for the cure of hernia took part, and the general consensus of
opinion was in favor of the radical disposition of the sac and closure of the canal
with animal sutures.
Dr. H. L. Burrell,+ of Boston, reported eight cases of radical operation for the
cure of hernia. In the manipulation of the sac he had found it advantageous to
distend it with a ball of iodoform gauze. He closed the canal with two or three
interrupted stitches, silk or catgut, and did not use drainage. Closure of the wound
was effected by a continuous catgut suture. Dr. Burrell made emphasis upon aseptic
conditions, and especially in the case of the superimposed dressings; "six gauze pads,
six by eight inches, held in place by careful bandaging, then a piece of mackintosh, with
hole to admit the penis, and over this sterilized sheet wadding ; a cravat gauze band-
age six inches wide, long enough to form a double spica bandage, holds this in place;
over this is another piece of mackintosh, through which the penis protrudes, held in
place by safety-pins." In the same journal, Dr. Hayward W. Cushing reported a
case of femoral hernia in a boy of twelve years, where he operated by adapting the
Macewen method to the conditions found. After freeing the sac, which in this in-
stance was attended with difficulty, he replaced and retained it within the ring, as
advised by Mr. Macewen. Dr. Cushing then closed the femoral ring by suturing Pou-
part's ligament with a “ quilted suture” to the pubic portion of the fascia lata and
the fascia covering the pectineus muscle, the femoral vein protected by a retractor.
The margins of the saphenous opening were then closed by overlapping, after Mac-
ewen's method in inguinal hernia. The result was excellent. Under date of Septem-
ber 7, 1891, Dr. Cushing wrote me: “The patient was last seen in 1889, almost fif-
teen months after the operation, and at that time was well. I have operated on
only one other irreducible femoral hernia since, and the result was equally satisfactory.
The incision above Poupart's ligament I have found of great value while freeing
the sac.”
Dr. Arthur Cabot, of Boston, referred to three cases of femoral hernia, in two of
>
* Boston Medical and Surgical Journal, December 6, 1888.
+ Ibid., December 6, 1888, pp. 551-556.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 351
which he had operated very much as Dr. Cushing. The first of these was a large her-
nia, double-fist size. “The sac was a thick one, and formed quite a large mass. Hav-
ing threaded it in in the way described as 'through and through,' and stitched it well
up inside of the ring, I pulled on the thread and pushed the sac up. I then brought
I
the ring together firmly outside. The patient had a good recovery, and a large, hard
mass filled the whole of that portion of the pelvis where the hernia formerly existed.”
Dr. David W. Cheever gave at some length his own experience, in which he stated
that “the modern method of open dissection gave much better and safer results than
were obtained earlier.” Referring to the difficulties of cure of inguinal hernia in the
male, where a passage for the cord from the abdomen must be kept open, he quoted a
statement of the late Dr. John B. S. Jackson, Boston's most distinguished pathologist :
“ Doctor, you will never get a cure until you can obliterate the serous canal.” “The
wonderful safety of present processes of antisepticism in operating on these structures
I can not speak too highly of, because I saw so much trouble in the old methods by
the throwing out of sutures, suppuration, etc.”
Dr. A. P. Clarke, of Cambridge, referred to Dr. Marcy's experience, and favored his
method of operation. He stated: “I was present and assisted Dr. Marcy in his first
operation, which was in 1871. The patient was one of mine, a female, subject to
asthma, and everything was unpromising. A spray of carbolic acid was used, and the
canal was completely obliterated by the use of the catgut suture. The patient lived
six years, with no return of the rupture, dying of pneumonia.”
Dr. Samuel N. Nelson, of Boston, reported: “I was operated upon by Dr. Marcy
for double inguinal, the right a large scrotal hernia, and after my operation, two years
ago, I tried faithfully to wear a truss, and found it impossible to bear it; and I fail to
see the necessity of it, or any other support. After the buried suture has closed the ring
and united the other layers firmly, the effectiveness of the very simple dressing, which
Dr. Marcy has mentioned, I think ought to be emphasized. When the edges of
the wound have been coapted by the blind stitch, the collodion dressing in itself is
sufficient.”
Dr. Robert Weir,* of New York, treated at some length the subject of the disposi-
tion of the sac after operation. He emphasized the great advance made in modern
surgery in the treatment of strangulated hernia, contrasted the various methods of dis-
* New York Medical Journal, January 21, 1888, pp. 65–68.

352
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
а
a
posal of the sac, and thought, in some cases, the Macewen method advisable. This he
had performed eight times. The preference will be between this method and ligation
with excision of the sac. He uses heavy catgut for sutures. Dr. Weir accepts the
radical operation as a marked improvement in the treatment of hernia, whether free or
strangulated, although he does not consider the operation perfected.
Dr. Charles McBurney,* of New York, in a contribution upon the radical cure of
hernia by the open-wound method, reported in 1888 twenty-seven cases of non-strangu-
lated hernia operated upon by various methods since 1882. One patient died from
shock a few hours after operation, but he was a hard drinker. All the other cases made
easy recoveries. He considered hæmorrhage and sepsis the chief dangers, both pre-
ventable. Under the most careful antisepsis, he opens the entire canal up to the inter-
nal ring, loosens up and ligates the sac as high on its neck as possible; this being done,
he closes the upper and lower angles of the integumental wound, and then packs the
entire canal with gauze and iodoform, allowing it to heal by granulation. He gave
his
reasons as follows : “ The method of closing the sac by ligature is clearly better than
the other plan of cutting it off and closing the communication with the peritoneal cav-
ity by sutures. It is more rapid, it is more even, and the great danger is absolutely
avoided of having the intestines suddenly forced out through the wound by an unex-
pected effort at coughing or vomiting. Two methods of shutting off the sac remain to
be referred to, that of torsion and of Macewen. ... That this method obliterates the sac,
is evident from the brilliant results obtained by Mr. Macewen in a large number of cases;
but I question its superiority in ordinary cases over the carefully applied ligature, and in
larger herniæ it makes no provision at all against the great laxity of peritonæum which
exists in all such cases around the internal orifice of the canal." Dr. McBurney en-
tered into an argument of some length to show why he considered suturing of the
canal a useless undertaking, based upon the conditions and relations of the tendinous
structures which make up the canal. Because of this he has abandoned closure, and
treats the wound by the open method in a manner peculiar to himself. Six or eight
interrupted stitches, on the upper side of the wound, bind into one thick edge the skin,
the external abdominal aponeurosis, including the inner pillars of the ring, the transver-
salis and internal oblique muscles, and conjoined tendon. As many more stitches, on
the lower side of the wound, bind together the skin and Poupart's ligament, including
* New York Medical Journal, January 21, 1888, pp. 58–61.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 353
below the outer pillar of the ring. This insures an open canal, which must slowly fill
by granulation. Iodoform gauze is packed into the wound, and completes the dress-
ing."
Dr. McBurney thinks he obtains double advantage—an antiseptic wound without
drainage, and a firm closure of the walls of the canal by strong cicatricial tissue. On
March 2, 1889, he reported thirty-six cases operated upon, with only one death, and that
attributable to alcoholism. In three cases there was suppuration of the wound, and
in one there was a return, which he attributed to insufficient ligation of the sac. He
had been able to follow up the history of thirty-one of the cases, and the result was
perfect.
The late Dr. John H. Mackie, of New Bedford, wrote me in 1889: “I have oper-
ated nearly two hundred times in strangulated hernia, with a mortality of only ten or
twelve. One case, I think, is a little remarkable. I operated on a man aged eighty-
three, right inguinal hernia, strangulated-recovery perfect; but one year later I oper-
ated on the same man for left strangulated hernia, and he made a good recovery, living
several years. In one case of strangulated femoral hernia, in an elderly woman, the
right ovary was found in the hernial sac.” Dr. Mackie opened the sac, closed the
wound with deep catgut sutures, and used antiseptic dressings.
Dr. A. Vanderveer,* of Albany, reported two cases of strangulated femoral hernia
operated on under antiseptic precautions, where he dissected the sac, ligated at the neck,
and excised it. Wound closed with catgut sutures, horse-hair drain, careful dressing
with bichloride gauze. Second dressing fourth day, drainage removed, and primary
union.
Dr. D. G. Wilcox,t of Buffalo, reported a case of irreducible femoral hernia oper-
ated upon under aseptic precautions. “Epigastric artery was cut and tied. Sac dis-
sected, pulled down, transfixed, and wound closed. Union primary, and recovery rapid.
At three months seems cured. Wears a truss as a precautionary measure.”
Dr. Lewis S. Pilcher, of Brooklyn, in 1889 reported to me two cases of strangulated
hernia where he operated with complete cure on patients eighty-three years of age. .
The first, a male, in whom inguinal hernia had existed many years; the double sac
was dissected, tied high up, and cut off. The wound was filled with iodoform gauze
* Albany Medical Annals, October, 1888.
+ North American Journal of Homeopathy, October, 1888.
48

354
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
and allowed to granulate; recovery slow. The second, a female; old femoral - hernia ;
the adherent omentum was ligatured and resected; also the sac, the stump of which was
pushed within the internal ring, and “the tissues of the canal closely sewed over and
over with catgut superficial sutures. Healing by first intention throughout whole ex-
tent of wound, with quite an appreciable plastic exudate in site of canal.”
Dr. C. H. Mastin, of Mobile, read a most interesting and valuable paper upon the
comparison of the various methods adopted for the cure of hernia, before the American
Surgical Association, May, 1889. He closed the article as follows: “From a compari-
son of all the methods, it is apparent that no fixed rule of proceeding is established; and
although the radical operation is a marked improvement in the treatment of hernia,
whether free or strangulated, we can not consider it perfected, because the methods
hitherto resorted to have not proved radical in results. The operation is ideally cor-
rect, but the question arises whether, with the uncertainty of success, the risk justifies
the operation ; especially is this so if the circumstances of the individual are such that
he can content himself with the use of a properly adjusted truss. I have operated on
thirty-four cases of hernia, with three deaths—all strangulated cases. I should exclude
two of those deaths, because the patients were in extremis when the operations were
done.”
In the discussion which followed, Dr. D. H. Agnew, of Philadelphia, expressed a
preference for Mr. Barker's method of operating, by which the sac is sutured into the
internal ring, and gave his experience of plugging the internal ring with omentum, re-
tained by suturing, recognizing the importance of narrowing this portion of the canal
before closing the pillars of the ring. “I think, first, that in all cases of strangulated
I
hernia we are justified in attempting the radical cure; and, second, in those rebellious
herniæ which can not be controlled by a truss, and which place the lives of the pa-
tients in grcat risk.”
Dr. W. W. Dawson, of Cincinnati, concurred with Dr. Agnew, holding conservative
views, however, upon the question of operation. “When it is merely a question of
æsthetics, or of abridging usefulness, the operation should be approached cautiously.”
Dr. Dawson would not advise the radical operation for children, since a spontaneous
cure may be expected.
Dr. L. M. Tiffany, of Baltimore, stated that “his results were far more satisfac-
tory than formerly; that he believed no operation for strangulated hernia was complete
without the attempt at radical cure.” In non-strangulated cases the question at once

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 355
arises, in determining operation, on the amount of hernia, the inconvenience produced,
and the circumstances of the individual. Where the life-work is interfered with, or the
mode of life necessarily changed because of the rupture, he advised operation in the
belief that, in the large majority of cases, it was not followed with much suffering or
danger. He considered it often the duty of the surgeon to operate also in hernia of
children.
Dr. D. W. Yandell, of Louisville, thought we were just on the threshold of experi-
ence in regard to the methods of operation, and that ten years hence we might arrive
at some definite conclusions. He saw Mr. Macewen operate, and so fell into his way
of doing the operation. “I think that all here will agree that they would not operate
when they can help it, and operate when they are obliged to do so."
Dr. W. W. Keen, of Philadelphia, thought that the profession were surely tending
toward enlarging the bounds of the operation for the cure of hernia, greatly increasing
the number of cases operated upon. “ If the hernia is very large, I should not be dis-
posed to use Macewen's method. Some two years ago I reported a case in which I
used that method in a large labial hernia, operated upon at the Woman's Hospital at
Philadelphia. The sac was very large, and I think I was indiscreet in using this
method. The life of the sac is imperiled by separating it, and if it is large it is almost
certain that a portion of it will slough. Macewen's operation should be limited to her-
nia of moderate dimensions.”
Dr. J. R. Weist, of Richmond, Ind., reported forty-one cases operated upon for
strangulation, in about thirty of which he had attempted the radical cure under various
methods, but in many of the cases there had been a recurrence.
Dr. Mastin, in closing the discussion, stated that “at this date the operation that is
best calculated to offer general satisfaction remains a mooted question, and, until more
accurate experience decides it, the selection of the special operation must remain sub
judice."
At the annual meeting of the New York State Medical Association, held in 1889,
the discussion upon the cure of hernia was given prominence, and elicited much inter-
est.* Dr. Joseph D. Bryant, of New York, introduced the subject by a long and care-
fully written paper of great value. He treated with judicial fairness the various opera-
tive measures that have been advanced for the radical cure of hernia. He accepted the
* Transactions of the New York State Medical Association, 1889, vol. vi, p. 168 +.

356
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
method advised by Mr. Macewen as a representative one, demanding dissection and
suturing. He discussed at some length the disposition of the sac, which is the chief
factorage in the Macewen method, and questioned its advisability. “I am not aware
I
that the occurrence of “bossing” has been actually demonstrated, but I am reliably in-
formed that the reverse of the proposition has been noticed under circumstances calcu-
lated to demonstrate it.” He recommended a disposition of the sac peculiarly his own,
which is at least ingenious, and which I am persuaded to believe may in certain condi-
tions be made available. He draws down the sac after its separation from its surround-
ing parts, and ligatures it at the base; then, making two parallel slits on either side of
the ring, he interweaves it back and forth through the tendinous divisions, and confines
the sac thus disposed of as a vivified, re-enforced retention band of living tissue, by
quilting all the parts together with deep stitches of catgut, leaving room in the lower
angle of the wound for the passage of the cord. He cautions against the use of the
sac in this way if by any reason its vitality has been endangered, and, in a foot-note, re-
ports a case where a sac thus disposed of sloughed, because of too tightly ligaturing at
its base. In order to avoid this, he advises to pass the ligature double and tie in halves
on either side. The utilizing of the sac that it may become, so to speak, a vitalized
suture, holding together and re-enforcing the pillars of the ring, seems to be an ideal
disposition of it. It is, however, open to grave objections, the first of which is that
which had already happened in Dr. Bryant's case-its devitalization. By reference to the
chapter devoted to the formation of the hernial sac, it will be seen that in an old, large
hernia this structure is dependent for its nutrition upon the sources of blood-supply
formed by abundant and oftentimes very vascular adhesions, extending quite into the
scrotum. Not seldom does it happen that the constriction at the neck of the sac, at
the internal ring, has so changed the structures that it is reduced to an imperfectly vas-
cularized, non-elastic band of connective-tissue fibers, compressed together in adherent,
plicated folds, as is a bag by the constriction of tying. This disposition of the parts
alone reduces its nutrition to such a degree that the hernial sac is dependent upon its
acquired blood-supply for its vitalization.
The following plate, from Sir Astley Cooper, is selected as a beautiful illustration of
the changes which supervene in the peritoneal sac in femoral hernia. These pertain in
a greater degree to inguinal hernia, where the sac and contents often assume very much
larger proportions.
In Figure i the hernial sac is small, non-adherent, and well vitalized. It could

PLATE LVIII.

Fig. 2.
Fig. 1.
C
d
e
6
ca
е
f.
X
h
n
o Rume
m
т
n
P.
т
е
g
K
n
I
a
P
q
i
2
o
9
S
a
r
7
m 2
q
Fig.3.
e di
sa
7
Fig. 4.
mf
a
S q 0
с
3
d
с
po
nh
K
N
n
19

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 357
be returned, doubtless, without damage to its vitality, and, when aseptically sutured
at the mouth of the ring, would speedily agglutinate and retain its nutrition.
In Figure 2, on the contrary, the peritoneal sac is externally firmly adherent to
the superficial fascia ; while within, the omental contents are closely fixed to its inner
layer. The constriction at the base had almost altogether cut off its blood-supply
through the plicated folds at the ring. To attempt to utilize the material in a case
like this, which the deformed sac furnishes, folded upon itself and pushed within the
ring, would very likely be followed by the most disastrous consequences.
Figure 4 is worthy of especial study, but not in connection with the present sub-
ject, since it illustrates the anatomical deviation of the obturator artery passing before
and on the inner side of the neck of the sac. This not very rare anatomical disposi-
tion should be kept in mind by the surgeon, since when in this position its division
would not infrequently happen in operation.
PLATE LVIII *
Contains some varieties of crural hernia, viz. : A hernial sac, situated within the sheath of the cru-
ral vessels, which it had not protruded; a large hernia, having the remains of the umbilical artery
placed on the outer part of the mouth of the sac; a hernial sac, which had been contained in part in
the sheath and in part in the common situation; and, lastly, the preparation, with which I was kindly
favored, for the purpose of having an engraving made of it, by the late Dr. Barclay, teacher of anat-
omy in Edinburgh, showing the obturator artery passing before the mouth of the hernial sac.
p. Crural sheath opened and turned back.
9. Hernial sac within the sheath.
Figure 1.
Hernia within the crural sheath.
a. Symphysis pubis.
b. Spine of the ileum.
c. External oblique muscle raised.
d. Internal oblique muscle.
e. Transversalis.
f. Crural arch.
g. Fascia transversalis passing from the cru-
ral arch under the transversalis muscle.
h. Upper abdominal opening.
i. Lower abdominal opening.
k. Spermatic cord passing through both of
these openings.
1. Femoral artery.
m. Femoral vein.
n. Saphæna major vein.
0, 0. Epigastric artery.
Figure 2.
Large hernia, descending more inward than
usual, so as to have the umbilical artery on its
outer side.
a. Pubes.
b. Spine of the ileum.
c. Internal oblique muscle raised.
d. Transversalis muscle raised.
e, e. Linea semilunaris.
f. Rectus muscle.
g. Abdominal ring.
h. Fascia transversalis.
i. Inner part of the same fascia, with the ten-
don of the transversalis upon it.
k, k. Fascia lata.
* Cooper, Plate VIII, Part II.

358
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
m, m. Round ligament passing from the ab-
domen on the fore part of the mouth of the her-
nial sac.
n. Epigastric artery.
0. Remains of umbilical artery.
p. Mouth of the hernial sac, which had the
bladder, much dilated, resting upon it.
9. Superficial fascia and that of the hernia
consolidated into one.
r, r. Hernial sac.
s. Omentum adhering within the sac.
c. Abdominal muscles raised.
d. Aorta.
e. Bifurcation of the aorta.
f. External iliac artery.
g. Iliac artery of the left side.
h, h. Femoral arteries.
i. Arteria profunda.
k. Epigastric artery on the left side, the rec-
tus muscle being drawn down to show it.
1. Inferior cava.
m. External iliac vein.
n, n. Femoral veins.
0. Peritoneum descending to form the her-
nial sac.
Figure 3.
A hernial sac-part within the sheath, and
part in the usual situation.
a. Peritonæum.
6. Hernial sac within the crural sheath,
C. Hernial sac which had protruded the
sheath in the usual manner.
d. Portion of the hernial sac which crossed
the crural artery and vein within the sheath.
P. The hernia.
9. Common trunk of the epigastric and obtu-
rator arteries.
r. Obturator artery passing before and on
the inner side of the neck of the sac, in its course
to the obturator foramen, and situated a little
above the posterior edge of the external oblique
muscle.
s. Epigastric artery.
An engraving of this preparation has been
published in an ingenious Thesis on Crural Her-
nia, by Dr. James Sanders, of Edinburgh, 1805.
Figure 4.
Dr. Barclay's preparation.
a. One of the lumbar vertebræ.
b, b. Spinous processes of the ilia.
When the favorable condition of a hernial sac well nourished at its base exists,
it may be wise to consider the value of its utilization by the novel way proposed.
Should this be determined upon, it is better loosely to sew across it at its base, in order
to minimize its devitalization ; or, rather, I am in the belief that it would be advantage-
ous to split the sac longitudinally into two or more parts, since by thus doing we at least
double the amount of suture material, and, introduced in opposite directions, we can
make a more advantageous disposition of the material used, and secure it safely with-
out suturing it at its base, which in a measure must devitalize it. That it may retain
its vitality, and thereby serve as a re-enforcement of the parts as a deeply implanted
graft, I have no question ; and it is certainly a step in the right direction to use every
possible measure at our disposal, oftentimes for the re-enforcement of the weakened
tissues. It must, however, be very exceptional that the occasion will warrant its utiliza-
tion. In my experience of about two years, since I first knew of Dr. Bryant's method,
I have not met with a single case in which I considered it applicable. At the best, it
re-enforces only the external pillars of the ring, and can affect little the elongation of
the canal, or strengthen its deeper structures.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 359
Dr. Bryant emphasized the dangers resulting from the improper use of taxis, advised
the rigid enforcement of antiseptic principles, and, all things being equal, believed that
the radical cure should be practiced as an addendum to herniotomy. He discussed very
clearly the question of operative treatment if the incarcerated intestine is necrosed, and
advised: “When the condition of the patient permits, intestinal repair should be at-
tempted at once, and the gut returned within the abdominal cavity.” When the con-
striction has occurred in the upper two thirds of the intestine, this rule is to be empha-
sized, even if the immediate result of the operation be somewhat doubtful. When the
conditions do not warrant this, or when the surgeon is not familiar with the details
of intestinal surgery, a temporary artificial anus must be made.
Dr. William T. Bull, of New York,* reviewed the present status of hernial opera-
tions, and added thereto the details of his own very considerable experience, including
the report of 72 operative cases of hernia, with 69 recoveries; the 3 deaths were acci-
dental, and in no way chargeable to the operation. From the 40 cases whose subse-
quent history he was enabled to trace, 20 were operated upon by ligature of the sac, its
excision, and suturing the pillars of the ring. Of these, 12 were cured and 8 were fail-
ures. Exactly the same number of cases were operated upon by the simpler method,
ligature, and excision without suturing, and, curiously, with the same result in all, forty
per cent of failure. The remaining sixty per cent may, as a class, be considered im-
proved. Primary union occurred in 32 cases, and suppuration in 37 cases. He thinks
the suture is not applicable in femoral hernia. He concluded by advising further trial
of the Macewen method. He objected to the so-called open method, as advocated by
Dr. McBurney, as possessing a radical defect, and one that, notwithstanding its able ad-
vocacy, should not be attempted until operations based on sounder principles of surgery
have been thoroughly tried. It certainly is a perversion of our knowledge of the phe-
nomena of reparative processes to assume that the granulative cicatrix is stronger than
that of primary union. There is no other region of the body, or any other operative
wound, where surgeons of experience would act in accordance with this idea. Who
would think seriously of trying to make the umbilicus stronger by cutting out a disk
of all the tissues exterior to the peritonæum, and then trying to get a strong' cica-
trix, by the methods proposed ? It would surely invite the occurrence of hernia.”
Dr. Roswell Park, of Buffalo, stated that “ he had been surprised to read, in a
* Transactions of the New York Medical Association, 1889.

360
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
-
recent monograph, that the radical cure of hernia was regarded as a rare achievement.
He believed firmly in making the attempt to cure every case of hernia radically, be-
cause the cure is radical in a large percentage of the cases, and because, even if suc-
cess be not complete, the patient is always benefited. If the hernia returns, it is not
so severe as at first; men who could not even take exercise because of their hernia are
rendered good working members of society.” Dr. Park wrote me, under date of Oc-
tober 18, 1891, giving a report of 115 cases where he resorted to reduction of the her-
nial contents (unless it were adherent omentum, when he tied it off), ligation of the
neck of the sac high up, with extirpation of the sac (or preservation of its lower part
and closure of canal in congenital cases, to make a new tunica vaginalis), and closure
of the inguinal canal and ring. “For this latter purpose I now use buried silkworm-
gut sutures.
In cases operated on at convenience, 85 in all, I not only have had no
death, but never even a condition which has caused me apprehension. I believe in
thoroughly opening up the inguinal canal, and occasionally I transplant the spermatic
cord, though by no means always. I now resort also to buried catgut sutures in clos-
ing the wound, and seldom put any through the skin.
“ Deliberate Cases.—Males, 68; females, 17. Of these, 6 were operated upon both
sides simultaneously, 8 were umbilical, 3 femoral, 74 inguinal or scrotal. No deaths ;
slight suppuration in 5.
Strangulated Cases.—Males, 19; females, II. Of these, 4 died. Each of these
cases was most unfavorable, from too late operation or some other unavoidable reason."
Dr. Park considers the advantage of the closed method over the open method
to be, that it makes it possible to bring together the edges of the cut fasciæ, thus achiev-
ing on a small scale the same good results as are obtained by the proper closure of large
abdominal wounds.
Dr. William Detmold, of New York, reported an interesting case of femoral her-
nia, published in 1842, upon which he operated in 1837. The operation was then con-
sidered unjustifiable, and surgical assistance was declined him. After division and
reduction, he scarified the upper portion of the canal and packed with lint for sev-
eral weeks. The hernia was cured, and remained so for five years, when the patient
passed from under observation.
Dr. Detmold reported this case at some length, the circumstances of which were
peculiar. He had just commenced the practice of his profession. A young woman,
recently married, was abandoned by her husband because of a considerable large fem-

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 361
a
oral hernia which made a permanent tumor of the groin, he believing it evidence of
syphilitic infection. Dr. Detmold promised the operation, relying upon his old master,
Dr. Willard Parker, for performing the same. This Dr. Parker not only refused to do
himself, but declared the operation absolutely unjustifiable. Without relief, suicide
was determined upon, and therefore, unaided, Dr. Detmold performed the operation.
The young husband, convinced of his error, served faithfully as nurse, and the matri-
monial union thereafter remained one of great happiness. It is believed that this
is the first radical cure of hernia deliberately determined upon by any American sur-
geon.
Dr. H. D. Didama, of Syracuse, advised : If natural tissue can be secured to re-
tain the intestine instead of a cicatrix, it were better to have the natural tissue. If a
variety of suture can be used which is not followed by suppuration and does not re-
quire removal, let us use this variety.” He referred approvingly to the elaborate re-
port which Dr. Marcy had just given of his large experience in the use of the buried
tendon suture for the restoration of the obliquity of the canal and closure with the
same, and stated, “ I have seen Dr. Marcy operate in a number of cases, with the most
satisfactory results."
Under date of February 24, 1892, Dr. George W. Jones, of Cambridge, wrote me
as follows: “In thirty-seven consecutive operations for cure of hernia performed dur-
ing the past six years by your method exclusively, thirty-six have been cured, so far
as I can judge at this time of writing. In no case has the patient's life been jeopard-
ized for a moment by the operation, the primary dressing remaining intact until
healing was complete ; in only one case was this otherwise, when a septic suture was
the cause of suppuration, and the wound healed by granulation.”
At a meeting of the Johns Hopkins Medical Society, November 4, 1889, Dr.
William S. Halsted presented five patients upon whom he had performed his opera-
tion for the cure of inguinal hernia. He described the operation as follows:
“1. The incision begins at the external abdominal ring, and ends one inch or less
(less than one inch in children) to the inner side of the anterior superior spine of
the ileum, on an imaginary line connecting the anterior superior spine of the ilea.
Throughout the entire length of the incision everything superficial to the peritonæum
is cut through.
“ 2. The vas deferens with its vessels is carefully isolated up to the outer termina-
tion of the incision, and held aside.
49

362
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
“ 3. The sac is opened and dissected from the tissues which envelop it.
“4. The abdominal cavity is closed by quilted sutures passed through the perito-
næum at a level higher by one and a half to two inches than that of the so-called neck
of the sac.
“ 5. The vas deferens and its vessels are transplanted to the upper outer angle of
the wound.
“6. Interrupted strong silk sutures passed so as to include everything between the
skin and the peritonæum are used to close the deeper portion of the wound, which is
sewed from the crest of the pubes to the upper outer angle of the incision. The cord
now lies superficial to these sutures and emerges through the abdominal muscles about
one inch to the inner side of the anterior superior spine of the ileum.
“ 7. The skin is united over the cord by interrupted stitches of very fine silk.
These stitches do not perforate the skin, and when tied they become buried. They
are taken from the under side of the skin and made to include only its deeper layers
—the layers which are not occupied by sebaceous follicles.
“ 8. One or two small, short gauze plugs are used as wound-drains.”
Dr. Halsted remarked in this connection that whether or not it were possible or
easy to disinfect absolutely the human skin, he had been much impressed with the fact
that skin sutures not infrequently suppurate, even in wounds sewed by the most care-
ful surgeons in this country and abroad. He thought it advisable, therefore, to test
for a time the subcutaneous buried-skin suture.
The After-treatment.—The gauze plugs are removed at the first subsequent dress-
ing-usually at about the seventh day. The patients are allowed to walk about on the
twenty-first day.
The following is a brief summary of his cases :
CASE 1.—William H. Richardson, colored, aged eight years. Operation, June 13,
1889, for the cure of large, congenital inguinal hernia on the right side. The sac, when
opened, contained cæcum and vermiform appendix; a very short meso-cæcum bound
the sac to its contents.
June 2d.—The wound has healed by first intention, except where the gauze plug
was introduced. Linear cicatrix.
July 4th.- Patient is allowed to get up and walk about.
CASE II.—George Holdorf, German ; blacksmith; aged twenty. Operation, June
17, 1889, for the cure of a moderately large, reducible right inguinal hernia.

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 363
June 18th.—Gauze plug removed.
June 25th.—Patient is discharged for misdemeanor. Wound has healed by first
intention. Linear cicatrix.
CASE III.—John Bleecher, German; blacksmith; aged forty-eight. Operation,
August 16, 1889, for the cure of a large, reducible right inguinal hernia. The neck of
the sac was large enough to admit the tip of the fingers.
August 26th.—Passes urine through wound. Infer that one of the deep sutures
was passed through the wall of the bladder.
September 4th.—Patient passes all his urine through the penis.
September 17th.—Patient is out of bed. The wound is healed, except at its lower
angle.
CASE IV.- Joseph Davis, aged eight years. Operation, October 9, 1889, for the
cure of a small, reducible left inguinal hernia.
October 19th.-Wound has healed by first intention. Linear cicatrix.
November 3d.—Boy is allowed to get up and walk about.
CASE V.–Frank Fisher, aged seven years. Operation, October 12th, for the cure of
a small right inguinal hernia.
October 20th.-Wound has healed by first intention. Linear cicatrix.
November 4th.—Boy is allowed to get up and walk about.
Dr. F. C. Larimore, of Mount Vernon, Ohio, in a recent publication stated “that he
had operated three times for the radical cure of hernia by the use of the buried aseptic
animal suture, after the method of Dr. Marcy, with most excellent results. In the
third case I was completely astonished to note how neatly and accurately the skin
was approximated by the blind continuous suture. No gauze, no cotton, no bandage,
and no truss, will strike every one as laying aside many restraints, and showing sublime
faith in the result of the operation.”
Dr. Nathan Jacobson,* of Syracuse, published an interesting article upon the recent
advance in the radical treatment of hernia. He advocated the splitting of the inguinal
canal in order to expose the internal ring, as first proposed by Riesel. He wrote as
follows: “This plan McBurney and Marcy have both adopted. Schede objects to it,
believing that it is exceptionally bad, and increases the danger of peritonitis. But the
operators mentioned have found no reason for this fear. ... It certainly gives greater
* The Times and Register, August 2, 1890. Reprint.

364
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
exposure of the internal ring, better opportunity for freeing adhesions and separating
the neck, and, as I believe, after operating in this manner, is of great advantage to
the operator. . . . Küster recommends the continuous suture for closing, but Schede
prefers an interrupted suture of No. i catgut. As to the comparative value of these
two methods, perhaps time enough has not elapsed to decide.
“Yet it is most remarkable how wonderfully well Schede and Marcy agree in the
statement of the results of their methods; for, while the latter says in his paper, read
before the American Medical Association last year, that fully ninety per cent are per-
manently cured, as far as he can judge from the histories of those cases of which he has
absolute knowledge, and in no instance does he advise the subsequent wearing of a
truss, Schede's statistics show that, of the one hundred and sixty-five operated upon,
recurrence occurred in but fifteen. It certainly is the best possible indorsement of an
operation to have two operators as widely separated as these, differing in some details,
but striving for the same end, working independently of each other, as I know to be the
case here, reach conclusions so thoroughly alike.”
We have elsewhere quoted favorably and freely from contributions of Dr. William
T. Bull, of New York, giving the results of his special studies upon the operative meas-
ures advised for the cure of hernia. Unfortunately, he has been quoted by those who
hold conservative views upon the question, with the attempt to show that modern surgi-
cal methods for the cure of hernia do not warrant the assumption that very much prog-
ress has been made in methods or results. A careful perusal of his papers does not lead
to such a sweeping conclusion, for he distinctly states that the great majority of the
cases operated upon are vastly improved, if not cured; while he frankly admits that in
the larger number of cases suppuration supervened even in the patients under his own
supervision, and this alone must greatly modify the result. Suppuration should not
ensue, and does not if the wound is maintained aseptic. In none of the cases operated
upon was the effort made to restore the obliquity of the canal, and in only four of the
series, Macewen's method, was it attempted to reinforce and strengthen the weakened
tissues posterior to the spermatic cord. In a contribution published in the New
York Medical Journal, May 30, 1891, Dr. Bull has availed himself of the material
at hand to compile tables in which are arranged, as far as possible, the imperfect
histories which he has obtained of 119 cases where hernia has returned after an opera-
tion of some sort for its relief or cure. Of the whole number, the method of operation
was definitely ascertained in 73 cases, as seen in the following table :

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 365
SUMMARY OF CASES OF HERNIA RELAPSING AFTER OPERATION FOR RADICAL CURE, IN WHICH THE NATURE OF THE
OPERATION HAS BEEN ASCERTAINED FROM HOSPITAL OR PRIVATE RECORDS.
AGES.
HOSPITAL
TREATMENT.
RELAPSES.
TRUSS AFTER
OPERATION.
METHOD OF OPERATION.
NO. OF
CASES.
NATURE.
Eldest.
Youngest.
Average.
Longest.
Shortest.
Average.
Longest.
Shortest.
Average.
No truss.
Truss.
Un-
known.
Heaton's...
wekis
wks. wks. wks.
5 I 4
Wiki
28
wks. wks.
I 247
9
58
yrs.
27
38
5
4
Excision of sac, suture of pil-
lars of external ring.
Czerny's.....
6
mos.
5
381
d.
IO
22
7
31
mos.
15
6
7
I2
3
Excision of sac.
Socin...
mos.
wks. wks.
5 34
4
25
44
..
..
..
18
2
..
2.
Inguinal, 6
Double ing., 2
Double fem., 1
Ing. red., IO
Ing. irred.,
3
Ing. str., 6
70
Double ing. I
Fem. irred., I
Fem. str., I
Ing. irred., I
Ing. str.,
74
Fem. irred., 2
Ing. red.,
10)
Ing. irred., 2
Ing. str., 3 72
Ing. double, 7
Fem.,
2
Double ing., 2
Ing. red.,
49
Ing. str.,
Ing. strang
40
Double ing.
27
Ing. red.
26
wks.
"Open method.”
McBurney's..
24
21
37
mos.
I
42
mos.
8
8
5
yrs.
21
21
2 I
HHNNvWN ON H
Macewen's..
mos.
7
wks. wks.
6
15
4.
32
391
I
..
..
I
..
2
Bryant's ..
Schwalbe's.
Wood's.....
Open wound, suture of omen-
tum in neck..
I
I
I
41
?
6
d.
IO
:::
Nurir
5
5
2
I
I
I
.
.
..
Ing. strang.
2.
68
mos.
2
67
mos,
2
21
2
:
..
Total......
73
A careful study of the table teaches less of value than we could wish. The Heaton
injection method is now so generally abandoned that these cases may be eliminated from
the discussion. Five were by methods now seldom in use, which reduces the number
to 59. Of these, 5 were femoral, leaving 54 cases of inguinal hernia for consideration.
Of these, 10 were reducible hernia, and the operation was undertaken for cure by
Czerny's method, and, singularly, an equal number by the open method, and 4 after
Macewen's method-in all, 24 cases. It is presumable that in these, the operators used
every precaution of which they were masters to induce a permanent cure, and yet Dr.
Bull remarks: “The duration of treatment, practically wound-healing in Czerny's
method, where the pillars of the external ring and the integuments are carefully su-
tured, is almost as great-average seven weeks—as in the open method. This confirms
my own experience in operating, that the wound is a difficult one in which to obtain
absolute primary union, and is an argument in favor of allowing the wound to granu-
late.” Although the table does not show the percentage of primary union, it is an
admitted fact that the supervention of suppuration is one of the most common causes
of failure. One case is noted where relapse occurred in three years and four months
a

366
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
>
after operation without giving any details as to cause. Surely it is a far-fetched deduc-
tion, which the author expresses as follows: “This warrants the statement that future
evidence as to the value of different methods must cover an experience of more than
three years, and the patients who have been without recurrence for a year have no rea-
son to expect to remain so permanently.”
Of the 22 cases of recurrence operated upon after Czerny's method, 12—more than
fifty per cent-wore trusses; a mistaken direction after operation, which undoubtedly,
by the absorption produced under the pressure, often leads in itself to failure. Dr. Bull,
however, thinks otherwise, and states: “I have never seen any evidence of damage to
the repaired structures by the presence of a truss. In the cases operated upon by the
open method (McBurney), where the hernia has returned, the opening in the abdominal
wall is direct, like that of a ventral hernia, which makes the wearing of a truss much
more difficult and painful. In several instances I have seen the peristaltic movements
of the intestines through such a hernial covering, and in two cases an adhesion of the
omentum to this cicatrix made all efforts at coughing or straining painful, while the
truss pressure was almost intolerable. It must be stated that at different periods after
operation, from three to six months, the cicatrix of the open method is to be recog-
nized by its depressed situation and firm, contracted, and dense character. At a later
period it begins to yield in places, or all along its line, and ultimately presents the feat-
ures mentioned above.” Dr. Bull declared that the majority of the above cases were
certainly improved by operation, and stated that these straggling notes do not afford
any valuable evidence as to the comparative reliability of the different methods, but
only emphasize lack of promise to effect a cure.”
In the discussion of Dr. Bull's paper, Dr. Stimson stated that he was “glad to hear
Dr. Bull say that the statistics given were not to be taken as evidences of the propor-
tion of recurrences after any given operation, but that they were only tabulated state-
ments of those cases which had come under observation. These recurrences might,
however, be taken as an indication that no case could be pronounced permanently
cured until after a number of years; but if a case remained cured, say, for four years,
it would hardly be fair to argue that, because it had not gone five years, it was not a
radical cure."
Dr. Stimson stated that he had had “recurrences in a number of cases after opera-
tion, that in a general way he had followed the method advised by Dr. McBurney, and
that possibly his modifications were by no means improvements. Cicatrices left after
a

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 367
a
a
the open operation for hernia were not materially longer or wider than after primary
union, and were a very strong barrier to oppose to a hernia. He believed that a uni-
form cicatrix continuous with all the layers of the abdominal wall on each side formed
an ideal support. He had found the only weak spot to be in the upper angle of the
cicatrix. No operation could make the aponeurosis of the external oblique and the
external ring a better barrier against a hernia than Nature made them, and yet they were
unable to prevent a bubonocele from becoming a complete hernia; consequently, opera-
tions that were limited to create a barrier at this point must fail, if a new hernia began.
The hernia must be arrested at the beginning, if at all; and in the absence of any
means of closing the internal ring, and thus preventing the beginning of a hernia, he
believed that the open method, which rested upon a basis that was radically different
from the others, was the best now at our command. In one case of bubonocele, he
had narrowed the internal ring by drawing down and suturing the edge of the internal
oblique and transversalis muscles, but sufficient time had not yet elapsed to determine
the result."
Dr. J. E. Kelley, in discussing the paper, stated that “Dr. McBurney's operation
was to be mainly recommended because of the consolidation it produced between the
deeper fibrous coverings of the abdominal cavity and the superficial cicatricial tissue.
Unfortunately, union was limited superiorly by the conjoined margin of the muscles,
intact, or divided as they might be in the operation. Here they separated the fibrous
and superficial layers, and, owing to their interposition, these were no longer mutually
supporting. The secondary protrusion forced through or before it the deeper struct-
ure, then made its way under or between the inferior muscular fasciculi, and eventually
overcame the resistance of the superficial tissues, whether they consisted of the normal
structures or the cicatrix.” The ultimate result of the speaker's observations indicated
this as “ an insurmountable defect in McBurney's operation, as, notwithstanding to what
extent the incision might be carried upward, this weakness still existed. In fact, the
higher the incision the greater was the thickness of the muscles between the super-
ficial cicatricial tissue and the fascia transversalis, which latter, in addition, became
weaker as it ascended on the abdominal wall.
“In consideration of this objection, he had attempted another method in his recent
cases, which he termed the “laminated operation,” the principle being to utilize each
layer of the abdominal wall as a vital splint for the lines of incision in the structures
lying superficial to and deeper than it. The axial line of the hernial tumor being re-

368
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
garded as the line of election for the incision in the ordinary operations, he made his
cutaneous incision parallel to it, but about half an inch higher, and separated the lower
margin for a corresponding distance below the line of election, where he divided the
next layer of tissue (in well-developed patients, Camper's, or the superficial fascia), the
upper margin of which incision he treated in a manner similar to the lower one of the
preceding plane, until he reached the level corresponding with the incision in the skin,
where he divided the next fascial covering (Scarpa's, or the deep fascia), thus coming
down to the aponeurosis of the external oblique, which in turn was divided in a line
corresponding to the second incision. It was obvious that, when the structures were
restored, each line of incision was overlapped to the extent of an inch, and if union
was obtained a much firmer wall would result.” Dr. Kelley emphasized the impor-
tance of the closure of the neck of the sac in such a way that a depressed point of the
peritonæum should not be left to invite, through intra-abdominal pressure, a return of
the hernia. He thought Mr. Ball, of Dublin, who twisted the neck of the sac until
the peritoneum became tense, had given the best means yet furnished to obviate this
defect.
Dr. Robert Abbe reported his experience, comprising operative procedures for radi-
cal cure in all classes of cases to the number of about one hundred and fifty. He was
constrained to favor Macewen's method, as yielding the best results, and it had the
merit of applicability to femoral hernia.
In closing the discussion, Dr. Bull said that he had not attempted to bring into
prominence the merits of any method of operating. He himself was undecided as to
the best form of operative procedure, but was inclined to think that simple excision of
the hernial sac after ligating high up, without any attempt to suture the hernial ori-
fice, was as good as any, and this method could be used with equal advantage in
both inguinal and femoral herniæ. He must join issue with Dr. Stimson if he placed
confidence in a method that was supposed to cure by the substitution of a plug of
cicatricial tissue for the normal structures. The cicatrix would eventually yield before
the pressure of the viscera from within.
Statistical tables, as such, I can not help thinking, are quite as often misleading as
instructive, since necessarily nothing can be known of the conditions present; and in
the table upon which Dr. Bull has based his conclusions it will be seen that a classifica-
tion has been made by so-called methods undertaken by a considerable number of
unknown operators, and I am myself surprised that when thus classified the surgical

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 369
a
procedures, as generally undertaken for the cure of hernia, do not show even a larger
number of failures.
I am reminded of the comment made by a very distinguished medical authority, who
stated, “ he considered that the chief value, after all, of statistics lay in the ability to
utilize them in confounding our opponent rather than in the elucidation of truth.”
I have been in doubt if I might not justly be criticised for quoting in extenso
too freely, in this and the preceding chapter, from the recent contributions upon the
subject of hernia and its surgical treatment both in Europe and America. During
the last few months the medical journals in every part of the civilized world contain
more frequent reports of cases operated upon for the purpose of effecting a radical cure
than at any previous period in the history of surgery, although no especial contribution
adds materially to the knowledge or instruction of which we were heretofore possessed.
The general consensus of opinion, however, is that hernia is no longer considered an
opprobrium to the art of surgery; that the operation for its cure in a very wide range
of cases is justifiable; that when done under the precautions generally accepted as advis-
ory, pertaining to all wounds made in aseptic tissues, the operation is eminently a safe
one, the risks being, as we have shown from the experiences collated, when the abdom-
inal contents are not involved, those pertaining to that which is justly considered minor
surgery.
All the operations previously in vogue-of injection, subcutaneous suturing, etc.--
have been practically abandoned ; recognizing a fact which might be rendered in an
axiomatic way, that blind surgery as a rule is bad surgery.
We are almost too near the present field of many of our surgical victories to realize
fully the importance of that which has already been accomplished. In the discussion of
the subject in the preceding pages, which I trust has been approached in a purely judi-
cial spirit, it will be seen that it is not too much to accept as demonstrated that all the
usual varieties of hernia in the female are, as a rule, safely and permanently curable; to
which may be added hernia in the male as usually met with, except in the inguinal
variety. That this is true, should be predicated as expected, since the abdominal open-
ing for the escape of the viscera is entirely abnormal, and its complete closure is within
the easy limit of surgical procedure. As has been elsewhere stated, inguinal hernia in
the male follows the line of an important organ, through a canal which must remain
patent, and the problem assumes an entirely new factorage, since the spermatic cord
must be allowed a free escape without the protrusion of, or pressure by, any of the ab-
50

370
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
a
dominal organs. Although for centuries well understood from the standpoint of its ana-
tomical construction, all the surgical measures of the centuries have necessarily failed of
its reconstruction, since it has not been supposed possible, until within a recent period,
to deal surgically with any of the tissues which make up the posterior wall of the canal
without sacrificing the testicle and the cord. We have seen, in the history of the opera-
tion, that it was well understood that the cure of this variety of hernia could easily be
made permanent by the removal of the spermatic cord; and in the sixteenth and seven-
teenth centuries this was a recognized practice, of which large numbers availed them-
selves, until forbidden by law. It is now generally accepted that the dissection should
be freely made, exposing the spermatic cord to the internal ring, freeing the peritoneal
sac to its very base, treating it as a pathological factor by suture or ligature, and ex-
cision, or utilizing it in order to produce a bulwark to protect the weakened abdominal
wall.
The considerable variety of operations, and the greater number of operators, treat
with the factorage of the problem after the disposition of the sac by the consideration
only of the structures of the abdominal wall external to the inguinal canal. These con-
sist in suturing with a considerable variety of material, and with various methods of
procedure, the parts, for the purpose of re-enforcing and strengthening the tissues. It
was not possible to do more, without the use of sutures that could be left buried in the
tissues. As an indirect hinting of the recognition of the need of this in the preceding
generations, we note the experiences of the punctum aureum and golden stitch of the
seventeenth century, gold, silver, and lead wire having been frequently left buried in the
tissues; and Ambrose Parè distinctly states his purpose to have been the closure of the
internal ring by four times bending the golden wire upon itself to support, but not com-
press, the cord. It was, however, reserved as one of the legitimate deductions of
antiseptic surgery, as has been pointed out in detail in the chapter upon sutures, that
animal sutures could be permanently left to retain and support weakened tissues in any
part of the body.
The methods for the cure of hernia which have been discussed as those of the author
of this book during the last two decades are based upon this fundamental factorage.
The closure of the internal ring from below upward behind the cord, lifted from its bed;
the coaptation and re-enforcement of the transversalis fascia and structures which go to
make up the posterior wall of the inguinal canal, are effected by the use of the buried
animal suture. In this way the exit of the spermatic cord is elevated, the obliquity of


PLATE LIX.
f...
h
1
w
ok
i
.7
d
لرر۔
0
P

OPERATIVE MEASURES UNDER ANTISEPTIC CONDITIONS IN AMERICA. 371
the canal restored, and the intra-abdominal pressure brought to bear at right angles
to it.
I introduce the following plate from Sir Astley Cooper, beautifully illustrating by
a special dissection the transversalis fascia. It will be remembered that Mr. Cooper
was the first to demonstrate the especial strength of this fascia, producing a remark-
able re-enforcement of the parts, especially for the maintenance of the obliquity of
the canal. The peritonæum having been removed, the internal ring appears longer
than otherwise; the cord has been lifted one side, and the vas deferens drawn down,
which deepens also the ring. It is well to remember that the canal is rarely round.
The structures posterior to the cord making up the deeper portion of the canal,
assume an importance, from the surgical standpoint in operations attempted for the
restoration of the obliquity of the canal, not hitherto recognized.
PLATE LIX*
Exhibits an internal view of Poupart's ligament, the origin and course of the fascia, which it
sends upward to unite the transversalis muscle to Poupart's ligament, and the origin and course of
a second fascia which passes over the iliacus internus muscle; also the course of the spermatic cord
through the first of these fasciæ, and the situation and course of the epigastric artery and vein; with
their origin from the iliac artery and vein.
a. Symphysis pubis.
b. Anterior spinous process of the ilium.
c. Articulation of the ilium with the sacrum.
d. Spinous process of the ischium.
e. Foramen ovale.
f. The muscles of the abdomen.
g. The rectus muscle.
h. United tendons of the internal oblique and
transverse muscles passing behind the rectus.
i. Semicircular insertion of Poupart's liga-
ment into the pubis.
k. Tendon of the transversalis which is in-
serted into the pubis behind the abdominal ring,
and which prevents the abdominal ring from be-
ing seen.
1. A tendinous line from which the fasciæ
proceed, which shut up the lower part of the ab-
domen.
m. The anterior fascia, which is separated, to
allow the passage of the spermatic cord. This
fascia begins at 1, and runs upward on the inner
side of the transversalis muscle, and adheres to
the linea semilunaris.
n. The other fascia which passes upon the
iliacus internus muscle, and unites with the inner
part of the crista of the ilium.
0. Iliac artery.
P. Iliac vein.
9. Internal iliac artery.
r. Internal iliac vein.
s. Spermatic artery and vein.
t. Vas deferens.
v. Epigastric artery.
w. Epigastric vein.
[These vessels, passing two inches upward before the
peritonæum, are then continued between the rectus mus-
cle and the tendon behind it.]
* Cooper, Plate II, Part I.

372
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Modifications of the restoration of these parts have been made by Bassini in Italy,
Schede in Germany, and quite recently by Halsted, of Baltimore. The latter advo-
cates in certain conditions the yet more radical plan of making a new canal for the cord
by uniting Poupart's ligament to the conjoined tendon beneath the cord, thus making
an entirely new inguinal canal, covered only by the superficial fascia, adipose tissue
and skin.
As will be seen in the preceding pages, each of these operators report percentages of
cure effected equaled by no other methods. It is very probable that the early future
will teach a safe outcome from the comparative experimental or crucial experiences of
the present, but sufficient has already been determined to outline clearly the surgical
procedures usually to be undertaken for the cure of hernia. It is too much to expect
that by any method cure can be made and maintained absolute. All admit that by
the present more or less accepted measures undertaken for cure, the great majority
of the sufferers are distinctly benefited even when failure of the desired object is
demonstrated. If eight to ten per cent of the whole population of the world are sub-
ject to hernia, showing, however well Nature commenced her work, she made remark-
able failures in the preservation intact of the abdominal supports, it would surely be too
much to expect, however radically cured a hernia might be, that the subject of the
same should never be in danger of its recurrence. And if the hernia should again
return, there is no reason why the individual may not a second time profit by the means
of surgical relief, rather than be relegated to the great army of instrument-bearing
sufferers, incapacitated in a measure from active employment, and at a possible risk
of strangulation and fatal consequences.

CHAPTER XXVI.
CONDITIONS RENDERING SURGICAL PROCEDURES FOR THE CURE OF HERNIA
JUSTIFIABLE.
The advisability of operation in any given case must always be considered as an
independent problem, the factorage of which consists of many individual details.
Judged from my own experience, the operation is permissible and generally to be ad-
vised in a very large proportion of all the sufferers from hernia.
Children.—There is much to be said in favor of operation upon children. It is
admitted that, in a considerable percentage of the very young, hernia results from an
imperfect development of the structures, the inguinal canal being abnormally open.
In this class, if suitable care is exercised, and pressure brought to bear continuously
upon the canal, especially at the internal ring, cure without surgical intervention may
be often rapid and permanent. It should be the aim of the surgeon to effect this by
a carefully adapted support, supplemented by proper attention and care.
The last illustration (Plate LIX) shows the exceptional manner in which Nature
fortifies the internal structures by the tendinous expansion of the transversalis fascia
in its lower portion, by which the internal ring is strengthened and the intra-abdominal
pressure brought to bear at an angle to compress its opening. In children, all the parts
which go to make up the abdominal wall are comparatively delicate, and at the best
the fascia is thin and yielding. We have previously shown* that the foetal structures
during the formative processes of the canal are quite unlike those at the period of
maturity after birth. The peritoneum, which has been carried before the testis, is un-
closed, and is, in its normal development, first shut off only a little above the testicle,
and is slowly narrowed through the upper portion of the canal, leaving the infundib-
ulum process, which in adult life marks a slight depression where the cord enters the
abdomen.
This is subject to considerable variation in healthy adults, and the defective closure
* Congenital Hernia, p. 38.
(373)

374
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
of the peritoneal process is the common cause of inguinal hernia in male infants.
This is exceedingly well shown in the accompanying plate, taken from Cloquet, where
Figure 2 exhibits the infundibulum process as an unclosed pocket, extending into the
scrotum, at the base of which lies the testicle. In Figure i the infundibulum is
abnormally open, although the dissection was upon a healthy adult who was not the
subject of a hernia. The obliquity of the canal, as shown in Figure 3, is such that
the intra-abdominal pressure closes the abnormally large internal ring. A careful study
of the plate teaches the very common cause of incipient hernia, as also the importance
of the even, smooth closure of the neck of the peritoneal sac, which is now generally em-
phasized by operators as of great value, although at the time of Cloquet it was consid-
ered beyond the domain of surgical procedure. Figure 3 also illustrates beautifully the
re-enforcement of the parts by the greatly thickened transversalis fascia, which has
yielded much more than usual obliquely downward and inward on account of the imper-
fect closure of the internal ring. This shortens in a measure the canal, and causes the
intra-abdominal pressure to become deflected toward the line of its opening.
PLATE LX.*
ANTERIOR VIEW OF THE SUPERIOR OPENING OF THE INGUINAL CANAL ON THE RIGHT SIDE.
Figure 1.
M. Prolongation of the peritonæum, which
A. Rectus abdominis.
sometimes extends in front of the spermatic cord.
B. Pyramidalis.
N. Epigastric artery, passing between the
C. Aponeurosis of the obliquus externus
peritoneum and the fascia transversalis.
turned downward upon the thigh.
0. Dotted outline indicating the course of the
D. Internal column of the inguinal ring di- epigastric artery, behind the fascia transversalis.
vided and reflected.
P. Spermatic veins.
E. Remaining fibers of the internal column.
Q. Spermatic artery.
F. Tendon of the rectus continuous with the
R. Vas deferens.
fascia transversalis.
S. Fasciculus of fibers belonging to the ob-
G, G. Fascia transversalis.
liquus externus.
H. Aponeurosis of the obliquus externus con-
Figure 2.
tinuous with the fascia transversalis.
Disposition of the obliquus internus and cre-
I. Funnel-shaped canal formed by the fascia master, in the fætus of seven or eight months.
transversalis, opened anteriorly, in order to bring A. Rectus abdominis.
into view the spermatic vessels which it incloses. B. Aponeurosis of the obliquus externus
K. Proper sheath of the spermatic vessels de- turned downward.
rived from the fascia transversalis.
C. Obliquus internus.
L. Peritoneum covering the posterior surface D. Lower border of the internal oblique be-
of the fascia transversalis.
coming curved, to form the cremaster.
* M. Jules Cloquet, Plate I.

PLATE LX.
Fig.1
M
с
G
Fig.2,
A
D
E.
D
H
G
Fig. 3.
А
E
P
K
H
B
N
M
B
X VT


CONDITIONS RENDERING SURGICAL PROCEDURES JUSTIFIABLE.
375
E. Inverted arches formed by the fibers of this situation internal inguinal hernia takes
the obliquus internus, which constitute the cre- place.
master.
L. Posterior surface of the crural arch.
F. Part of the gubernaculum testis.
M. External iliac artery.
G. External fasciculus of the cremaster.
N. External iliac vein.
H. Internal fasciculus.
0. Epigastric artery. The epigastric vein has
been divided.
Figure 3.
P. Branches of the epigastric artery to rectus
Posterior view of the superior openings of the muscle.
inguinal and femoral canals, on the right side.
Q. Superior opening of the crural canal.
A. Part of the rectus abdominis.
R. Gimbernat's ligament.
B. Posterior surface of the pubes.
S. Concave fibrous fold, forming the exter-
C. Fascia transversalis.
nal angle of the superior opening of the crural
D. Fascia iliaca continuous with the fascia canal and situated opposite to Gimbernat's liga-
transversalis.
ment.
E. Fascia transversalis continuous below with T. Upper part of the obturator foramen.
the tendon of the rectus and with the crural V. Dotted outline indicating the course
arch.
which the obturator artery most frequently takes
F. Superior opening of the inguinal canal, when it arises from the epigastric. Here the ob-
formed by the fascia transversalis.
turator artery would be situated to the outer side
G. Fasciculus of fibers, forming the inner mar- of the sac of a femoral hernia.
gin of the superior opening of the inguinal canal. X. Dotted outline indicating the course of the
H. Spermatic vessels.
obturator artery, when the common trunk which
1. Vas deferens joining the other vessels of furnishes this artery and the epigastric is of consid-
the cord at an acute angle.
erable length. In such a case, the obturator artery
K. Triangular space, bounded externally by descends behind Gimbernat’s ligament, and passes
the epigastric artery; internally by the rectus first above and then on the inner side of the neck
muscle; and inferiorly by the crural arch. In of the sac in femoral hernia.
Accepting the above conditions as the most common cause of inguinal hernia in
male children, it is of comparatively little importance to the surgeon whether the
peritoneal process is open (that is to say, the hernia of the congenital variety) or not.
If closed, the infundibulum process has become dilated into a pouch, which is protruded
with its contents through the canal, often into the scrotum. Recognizing the rapidity
with which the repair processes go on in early life, most surgeons have felt that a per-
manent cure was very probable by the maintenance of continuous pressure upon the
canal, provided that the abdominal contents could be permanently retained—in other
words, that pressure sufficient could be made in a constant way upon the internal ring
so as to cause agglutination of the parts beneath. Nearly all observers of consider-
able experience have witnessed permanent cures by this means.
The great difficulty, however, is in the maintenance of constant pressure upon the
restless little sufferers for a sufficient time for such changes to supervene. As a rule,
when the hernia is slight it is well to attempt such measures, with the expectation that
they may be curative. In order to effect this, the surgeon must be possessed of a thor-

376
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
ough knowledge of the anatomy of the structures involved, and must keep his little
patient under close supervision for a considerable period. The truss must be carefully
fitted, in order to bring the pressure over the exit of the cord from the abdomen—the
internal ring. This is far more difficult in children than in adults, and the maintenance
of such pressure for a length of time is by no means easy. Very commonly even the
family physician relegates this duty to the instrument-maker, with only very general
directions to the mother or attendant. The mechanician, understanding more or less
imperfectly the task assigned to him, is generally governed by the thought only of
retaining the abdominal contents, and to this end applies a pad, usually much too
large, with its bearing upon the pubic bone. This inevitably produces pain, and the
instrument in consequence is soon displaced.
The following plate from Cloquet is a beautiful illustration of the anatomy of the
structures involved, and clearly teaches the importance of the direction in which the
pressure should be applied in order to bring about permanent closure. It is also a fine
demonstration of the transversalis fascia seen upon its anterior surface, which in large
measure makes up the posterior wall of the inguinal canal. These tissues assume an
importance from the surgical standpoint far greater than hitherto considered, since upon
their restoration depends the reforming of the oblique direction of the canal, so fre-
quently emphasized as necessitous for the permanent cure of hernia.
PLATE LXI.*
REPRESENTS THE INGUINAL AND CRURAL CANALS OF THE RIGHT SIDE.
A. Rectus abdominis.
H. Obliquus internus and transversalis mus-
B. Tendon of the rectus, continuous exter- cles divided close to their attachment to the crural
nally with the fascia transversalis.
arch.
C. Aponeurosis of the obliquus externus de- I. Radiating fibers which terminate upon the
tached and turned down upon the thigh.
inside canal of the external oblique, and which,
D. Fascia transversalis.
passing behind the internal column of the inguinal
E. Funnel-shaped prolongation of the fascia ring, are attached to the linea alba.
transversalis around the spermatic vessels to form K. Internal pillar of the inguinal ring at-
their sheath. It has been opened at its upper and tached to the front part of the symphysis
anterior part.
pubis.
F. Proper sheath of the spermatic vessels.
M. Spermatic vessels, surrounded by their
G, G. Fascia transversalis arising from the sheath, and covered by the fibers of the cremaster
posterior border of the aponeurosis of the external muscle.
oblique (crural arch), and with which it forms a N, N. Inverted loops or arches formed by the
deep channel.
fibers of the cremaster muscle.
* Cloquet, Plate II.

PLATE LXI.
A
B
-
M
7.
N
1
7
5
1
1
W
6


CONDITIONS RENDERING SURGICAL PROCEDURES JUSTIFIABLE.
377
0. Internal fasciculus of the cremaster pass- formed by the union of the vena saphena and
ing behind the inner column of the inguinal ring femoral vein.
to be fixed at the pubes.
Z. Point at which the deep and superficial
P. External fasciculus of the cremaster pass- layers of the fascia lata join each other.
ing out of the corresponding part of the inguinal 1. Femoral artery. Ordinarily this artery is
ring
entirely covered by the superficial layer of the
Q. Epigastric artery.
fascia lata, the femoral vein only being seen
R. Dotted lines indicating the course of the through the inferior opening of the crural canal.
epigastric artery behind the fascia transversalis, 2. Femoral vein.
after having crossed the direction of the spermatic 3. Fibro-cellular prolongation from the open-
vessels.
ing of the vena saphena, which descends upon this
S. Testis.
vein and becomes intimately connected with the
U. Superficial layer of the fascia lata, which is fascia superficialis.
fixed to the crural arch and forms the anterior 4. Anterior wall of the crural canal. The
wall of the crural canal.
small apertures in it are represented, which give
W. Vena saphena.
passage to blood vessels and lymphatics.
X. Aperture in the fascia lata which gives 5,5. Fascia lata covering the muscles of the
passage to the vena saphena, and which forms the thigh.
inferior opening of the crural canal.
6. Sartorius muscle.
Y. Strong semilunar edge of the inferior open- 7. Dotted lines indicating the situation of the
ing of the crural canal, which supports the angle sartorius muscle beneath the fascia lata.
Dr. W. B. De Garmo,* of New York, gave in 1888 the results of the mechanical
treatment of hernia in the analysis of one thousand cases in private practice; over one
fourth of the entire number were dismissed as cured-i. e., all remaining so for at least
six months without support; one third improved-i. e., able to wear a lighter truss than
at first, and remaining comfortable. He believed that a large percentage of herniæ
occurring under middle age could be cured by early mechanical treatment. About
twelve per cent of Dr. De Garmo's cases were under five years of age.
Constipation and tight bandaging of the abdomen are common causes of hernia in
infants. Phymosis, with its attendant vesical irritation-frequent and difficult micturi-
tion-causes a straining of the abdominal wall, and thereby produces a yielding of the
imperfectly developed structures about the canal. In the early period of childhood it
is very difficult to fit and retain a truss in position. This is emphasized by the expe-
rience of each additional case, and not seldom is instrument after instrument thrown
aside in despair. Does the medical profession discharge its duty to the public by allow-
ing hernia in childhood to remain uncured? If the farmer has a colt thus affected—and
this is not a rare condition in colts—does he allow the animal to grow up thus disabled ?
The veterinary surgeon does not hesitate to operate for cure under far less favorable
a
* New York Medical Journal, March 3, 1888, pp. 236, 237.
51

378
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
conditions, and with very few failures. If the sufferer is an orphan boy, dependent in
the early future as a bread-winner upon his developing physical powers, is it the duty of
the profession to allow the poor youth to enter the race for life, often for existence,
handicapped at the start? He is unfitted for hard work, can not enter the public serv-
ice, where a physical examination is required, and is debarred from many avenues where
position and success might otherwise be attained. Shall the wealthy parent think
less of the future well-being of his son, when he discusses his physical defects, and
determines, because of his abundant means, that therefore, the necessity of physical
labor not existing, he will permit the heir-apparent to go through life halting and
maimed ?
The English people have an able advocate for early operative measures in Mr. Span-
ton. In his address before the International Medical Congress * he stated: “The num-
ber of cures effected by trusses is infinitesimal, if we may judge from the report of the
London Truss Society, where we find that, of a total of 96,886 persons relieved by
trusses, only 4,387 are stated to have been cured—i. e., 4.53 per cent,
“If it is possible to effect the cure of rupture early in life (thereby eliminating at
once one eighth of the whole number of cases), by an operation which is both safe and
efficient, we are led to inquire, in the words of Sir Spencer Wells, whether it may
not be better to operate even on young children, than to expose them for several years
to the inconvenience of a truss, with the probability that, after all, a radical cure may
not be obtained.' Parents have a certain duty to perform toward their offspring in the
matter of physical defects; and in the performance of this duty it is generally the prov-
ince of the medical adviser to recommend the course to be pursued. Hernia is surely a
source of greater risk to life than club-foot, or hare-lip, or nævus, a crooked limb, or an
anchylosed joint. Yet these are conditions for which an operation, and not infrequently
a fatal one, is recommended; whereas it is thought usually sufficient to palliate hernia
;
by the advice to wear a truss, and allow the dangers and other drawbacks incident to it
to continue uncured. It is time this opinion changed, and I feel convinced that those
who will not be unwilling to see for themselves the advantages of an operation for the
cure of hernia over the uncertain and unsatisfactory treatment with trusses, will, in a
large number of cases, advocate its adoption. Operative measures, in modern days,
* The Cure of Hernia, in Relation to Parents and the Profession, by W. D. Spanton.-Transactions of the Inter-
national Medical Congress, 1881, vol. ii, pp. 448–451.

CONDITIONS RENDERING SURGICAL PROCEDURES JUSTIFIABLE.
379
have not had a fair trial; they have not been carried out on a sufficiently extensive
scale to demonstrate their real value.”
The knowledge and adoption of antiseptic operative measures which have become
general since the date of Mr. Spanton's writing, give yet more force to his earnest plea
in behalf of a large class of helpless sufferers. If by mechanical means we can not effect
a cure, it is our duty to operate. There is little to emphasize about the operation which
does not pertain to adult life. All the tissues are more delicate, they are more vascular,
but on this account admit of the more rapid repair. The sac is usually very thin, and it
may be more troublesome to manipulate than in adults. On the other hand, its surgi-
cal treatment is of less importance. If easy to be separated, let it be treated by dissec-
tion, ligation, or suture at the neck, and removed, as we have already advocated. If
congenital, rather than acquired, it is to be sutured across, in order to complete the
tunica vaginalis testis, and closed upon the cord, continuing the buried suturing so as
to close and increase the obliquity of the canal. Care must be exercised not to press
too closely upon the cord; but when the cord is only pressed upon in an even, continu-
ous approximation of the parts, it is surprising to note, if the wound is aseptic, how little
the scrotum and its contents suffer in their nutrition. Sepsis, and the resulting infective
changes, are the common causes of scrotal oedema, etc., which have usually been as-
cribed to pressure upon the vessels of the cord. If, after the operation, the aseptic state
is maintained, oedema in any degree, or even tenderness of the scrotum, is the decided
exception.
When the internal ring is closed from below upward and the inguinal canal re-
formed, continue the suturing of the tissues in evenly approximated layers until the lips
of the wound are in close juxtaposition, and unite the skin by the use of fine buried
continuous tendon sutures. In this way the tissues are held at complete rest, without
hæmorrhage or separation, and nothing remains to be eliminated as foreign material ;
therefore the drainage-tube, or its equivalent, is avoided.
This is of the first importance, especially in children, since it allows the complete
closure of the wound, which the competent surgeon can make aseptic, and its hermetic
sealing from subsequent infection. This is assured in a dried wound, dusted with iodo-
form and covered with iodoform collodion, into which a few fibers of cotton have been
incorporated. To the surgeon who has labored for years to secure an antiseptic dress-
ing with pads, gauze, bandages, macintosh, antiseptic cotton, or wool, until he made a
little mummy of his patient, only to find, after all his care, that the doubly restless little

380
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
prisoner had generally succeeded in both urinary and fecal defilement of all his protec-
tion, such germ-proof dressing will be welcomed as the near approach to perfection.
The quiet rest in bed, with light diet, loose dejections, the interest and amusement
with toys and games, and the little patient will hardly seem sick. I believe the sta-
tistics of to-day are sufficient to warrant the deduction that operative measures are
almost absolutely devoid of danger, the mortality at the largest not exceeding one
per cent, with not less than seventy-five per cent of permanent cures. I hazard lit-
tle in predicting that a greater familiarity with and knowledge of the details of the
operative measures, with careful attention to asepsis, will make the result of operative
measures undertaken for the cure of hernia in children as favorable as any of the
well-recognized operations advised for the cure of deformities.
Dr. A. P. Gerster,* of New York, advocates the operation in children, by closing
the neck of the sac and packing the wound with iodoform gauze, treating it as an
open wound, allowing it to heal by granulation. This he prefers, since in children
there is so much difficulty in keeping the wound from being infected by the excre-
tions, and because of the deep-seated septic inflammation which results.
The age at which operation is advisable must depend upon the individual condi-
tion, circumstances, surroundings, etc. There is nothing in age per se to debar opera-
tion. The youngest child upon which I have operated was a patient of Dr. S. N.
Nelson, of Revere. The little fellow, otherwise healthy, had at birth a scrotal hernia
of the right side. This was so large and troublesome that I unhesitatingly advised
operation, although the child was only two months old. +
In another case I operated upon a large scrotal hernia in a child sixteen months
old. The following illustration is from a photograph taken at the time of the
operation.
He continued nursing during the few days he was under my care, and scarcely
once cried as if in pain. When dismissed from observation, a few months later, the
cure was complete. I have often operated upon umbilical hernia in children, and never
have I seen any serious symptoms supervene. The youngest patient was a child about
fifteen months old who had been under constant observation during the preceding
summer, and all the various attempts at retention had proved entirely futile. The
* On Strangulated Hernia in Children. A. P. Gerster, M. D.—New York Medical Journal, January 21, 1888, p. 71.
+ See p. 172 for illustration, etc.

CONDITIONS RENDERING SURGICAL PROCEDURES JUSTIFIABLE.
381
omentum was adherent to the sac, probably caused by the pressure of the pad.
Convalescence was rapid, almost painless, and resulted in cure. Umbilical hernia in
childhood, which is not cured after a
few months by the use of properly ad-
justed supports, should unhesitatingly
be subjected to operation
The following is Dr. Nota's * man-
ner of treating umbilical hernia in chil-
dren; his method is a modification of
that recommended by Dessault. The
hernia being reduced and the umbilical
ring closed by the finger, the sac, emp-
tied of its contents, is held firmly by an
assistant. Around the base is thrown
FIG. 26.-Large scrotal hernia of the right side.
a ligature of rubber tubing an eighth
Child sixteen months of age.
of an inch in thickness. Three or four
turns are made with the tubing, held very tense, and as close as possible to the ab-
dominal wall. The two ends of the tube are tied together and the knot is secured
with a ligature of silk. The whole is then covered with a little cotton, and the
children are left entirely free in their movements. After ten or twelve days,
according to the size of the hernia, the sac falls off at the level of the ligature,
leaving a small round opening of perhaps an eighth of an inch in diameter. This
wound is dressed with iodoform and carbolized cotton, and closes in four or five
days, leaving a smooth, regular cicatrix, which prevents any return of the hernia.
Dr. Nota used this method with eighteen children, and effected a perfect cure in
them all.
The following abstract † of a laparotomy, performed upon a child ten hours old, for
congenital umbilical hernia, is of interest, and is probably the youngest patient yet
operated on.
A female child, otherwise healthy, was born with a tumor occupying the larger por-
tion of the anterior abdominal wall. It was covered by the tissues of the cord and
* Gazzetta degli ospitali, November 23, 1890.
+ New York Medical Journal, May 23, 1891, vol. iii, p. 586.—Dr. John R. Hinkson, Blissville, Long Island
city, N. Y.

382
ANATOMY AND SURGICAL TREAMENT OF HERNIA.
the peritoneum, and it contained a large part of the liver and small intestines.
The tumor was elliptical in shape, and projected one inch and a half beyond the
surface of the abdomen, measuring two inches and a half transversely by four
inches in its vertical diameter. It was not pedunculated, and extended from the
ensiform appendix to within one inch and a half of the pubes. The cord was
in the median line at the inferior portion. No vessels were visible, but the liver
could be plainly felt at the upper part of the tumor, which was most prominent.
The covering of the tumor was quite tense and semi-opaque, with a few small
cysts.
The abdomen having been washed with a bichloride solution, an incision was
made in the upper part of the tumor. The adhesions over the right lobe of the
liver were broken up with the finger. The membrane adjacent to the umbilical vein
and the hypogastric arteries were dissected away and the vessels ligated. The mem-
brane was finally removed in connection with the suspensory ligament of the liver ; the
edges of the abdominal wound were pared with scissors, and the abdomen was closed by
interrupted and continuous catgut sutures. The difficulty of the operation was the
want of sufficient material to allow the closure of the abdominal walls. On this account
the operation occupied one hour and a half, anesthesia having been easily maintained
under ether. Three days later, the catgut sutures having failed, under chloroform,
wire was used to reclose the wound. Five days later it was found that these had
cut through, leaving an elliptical opening an inch and a quarter in length near the
middle of the wound. The hare - lip pins were inserted half an inch from the
margin, not passing through the peritonæum, which had closed from the primary
operation. Three days later these had cut through, and all effort at closure was
abandoned, except a supporting bandage. The wound was completely healed on
March 14th, four weeks after the first operation, leaving a scar three inches and a
half in length. The writer reports two similar cases successfully treated—one by
Dr. J. N. Barton, of Philadelphia, a child thirty-three hours old, and another at the
clinic at Klassa, sixty hours after birth.
Inguinal Hernia in Women.—The operation for the radical cure of inguinal hernia
in women should be favorably considered in all cases of hernia occurring in the female
where difficulty of retention or serious inconvenience exists. Age, occupation, social
position, etc., are, as ever in surgery, factors in the problem. Operative measures for the
cure of inguinal hernia are greatly simplified in woman, since the absence of the cord

CONDITIONS RENDERING SURGICAL PROCEDURES JUSTIFIABLE.
383
allows a complete and firm closure of the canal. Although inguinal hernia is far less
common in the female than in the male, the general condition and relation of the parts
are not anatomically very unlike those of the male. The canal through which the round
ligament passes appears to serve no special physiological purpose other than to allow the
fixation of the distal end of the ligament, and thereby supplies to the uterus a support
which, in different positions of that organ, must necessarily vary greatly in length.
The peritonæum is attached to the cord by a loose-meshed connective-tissue sheath
which admits of considerable mobility of the tendon within the canal. It is owing to
this fact that the surgical procedure of shortening the round ligament has been advised
by Mr. Alexander, in order to pull forward the retroverted uterus and hold it in its
normal position."
Inguinal Hernia in Man.-All cases of irreducible and strangulated inguinal her-
nia should be operated upon promptly and thoroughly; also all cases where the truss
imperfectly retains the hernia. We have already noted the large percentage of adult
males who are the subjects of inguinal hernia. Few of this large army of truss-bear-
ing individuals are without daily inconvenience and suffering. They are limited in
their activities, debarred from many of the occupations of life, and are more or less
constantly endangered by accidents incident to the escape of portions of the abdomi-
nal contents into or through the inguinal canal. These dangers are well recognized
by the general public, are appreciated by every practitioner of medicine, and we have
already shown, by reference to the statistics of the general hospitals, that the operations
for the relief of strangulated hernia are followed by a mortality quité equal to that
from the major amputations. If it can be shown that safe surgical measures can be
instituted for the permanent cure of this large class of sufferers, it will be regarded as
one of the most brilliant achievements of the surgical art. It is probable that no class
of sufferers from any single disabling condition is by any means as large, since it is
estimated that in the United States alone there are between three and four millions of
individuals subject to hernia, and the mortality annually resulting therefrom is much
greater than is generally supposed.
The adult sufferers from inguinal hernia who may wisely consider the advisability
of permanent cure should not only include those who have difficulty in retaining the
hernial contents by a truss, but also a large majority of individuals, otherwise in good
* See Plate XLIII, p. 165.
+ See Baxter's tables, pp. 3-6.

384
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
health, who are thereby restrained from the more active vocations in life. It is also
well to remember that the wearing of the truss even in comparatively light cases of
hernia not alone very rarely produces cure, but also that the pressure of the truss upon
the subjacent structures frequently so thins and weakens the abdominal wall, that the
results when operative measures are attempted are often far less satisfactory and per-
manent. The young adult, as a rule, has only to expect a more or less continued
disability, gradually increasing with the years, the cure of which is more certain when
undertaken in the earlier period of life, since the tissues are not only less deformed and
weakened, but possess a greater vitality, giving thereby promise of easy and permanent
reconstruction.
I would not be misleading in the views here presented, or be considered too radical
in my teaching, in advancing the plea for the permanent cure of the large majority of
the sufferers from hernia. I am sure the consensus of opinion, as expressed by the
most careful of modern operators, is that the great majority of males otherwise
healthy, suffering from inguinal hernia, yet within the safe period of life, are privileged
to consider advisedly surgical measures for permanent cure.
Femoral Hernia.—When we remember that a femoral hernia is much more diffi-
cult to retain by a truss, that the canal through which the viscera escape is very firm
and narrow, and consequently the contents are much more likely to become strangu-
lated, there are abundant reasons why this variety of hernia should be especially held
under surgical consideration. I have elsewhere given the opinion of the distinguished
French surgeon M. Championnière, * that all cases of femoral hernia in the female should
be operated upon, the general conditions being favorable. I have also shown that the
cure in this variety is much more certain and permanent. There appears to be no valid
reason why the great majority of all the sufferers from femoral hernia may not be
safely and effectually cured.
Umbilical Hernia.—The writer of a single decade ago who had ventured to advo-
cate the attempt of the cure of umbilical hernia, except in very rare instances, would
have had very little if any support. In the chapter devoted to this variety of hernia, the
conclusions have been reached that surgical measures adapted to the cure of this dis-
abling and oftentimes very dangerous condition are advised in a very considerable per-
centage of this class of sufferers.
* Page 316.

CONDITIONS RENDERING SURGICAL PROCEDURES JUSTIFIABLE.
385
a
The résumé of the subject seems to warrant the conclusion that safety and perma-
nency of cure have been arrived at by a considerable variety of methods in the hands of
a large number of modern operators in all the varieties of hernia. There is still a very
considerable difference of opinion in the selection of the cases or class of cases where
operation for cure is advised.
First, it is generally admitted that every case operated upon for strangulation should
be given the advantages to be derived from the attempt at cure. This, we have seen, so
far as the wound itself is concerned, independent of the condition of the hernial con-
tents, when safety will permit of their return within the abdominal cavity, affords con-
ditions not so very much less favorable for cure than when undertaken primarily for this
purpose, and the resultant cure is generally permanent, with the exception of the cases
of inguinal hernia in the male. These, we have seen, are generally improved when the
cure is not complete, and there can be no question but that, in the hands of a very con-
siderable number of operators, the great majority of even this class of cases remain
cured.
Second, operation is advised in the large majority of the cases of irreducible hernia,
and where great difficulty is experienced in retaining the parts in situ by a truss. Ex-
perience is now sufficiently ample to prove that irreducible or incarcerated hernia may
be surgically treated with remarkable safety under the modern aseptic measures in com-
mon use. The great majority of these cases are rendered irreducible by adhesions
formed between the omentum and portions of the sac, induced by pressure brought
to bear upon them. These may be situated at the ring, or in any part of the peri-
toneal sac or contents. They are usually separated without danger, and, if need be,
very considerable portions of compressed or deformed omentum may be removed with
impunity.
In the rarer conditions, where a loop of intestine has become adherent, delicacy
of manipulation is extremely important. If the adhesions are firm, it is far better to
snip away the adhering part of the sac, or other structure, than to attempt separation
at the line of union. This is rendered still more safe by intrafolding the edges of
the remaining adherent portion by means of a fine suture. Arnaud pointed out, more
than a century and a half ago, that even a small portion of the testicle when adher-
ent might safely be cut away in the separation of the intestine without ultimate in-
jury to either organ.
Third, besides the large numbers of sufferers from hernia that we have discussed
52

386
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
in this chapter, where operation is advised or may be considered permissible, there are
often other reasons which might influence the surgeon to consider favorably opera-
tive procedures for effecting the cure of hernia; such as occupation, the desire to enter
the public service, or a change of residence to localities where surgical aid could not
be obtained in case of strangulation, as, for example, a residence in the remote dis-
tricts of our own country, and in the colonies of India or South America.

CHAPTER XXVII.
OPERATIVE MEASURES ADVISED FOR THE CURE OF HERNIA. -THE ADVANTAGES OF THE
BURIED TENDON SUTURE.
The treatment of operative wounds has from time immemorial been considered
a subject of vital importance in the healing art. Upon the one hand, the philo-
sophic observer holds ever prominent in consideration the so-to-speak factorage of
individual type, the vital, resistant power. On the other hand, the discussion of the
various changes which are observed to take place in wounds under different condi-
tions has engaged a large class of investigators, and seemingly with little profit until
within the present generation. The ever-present material for infection, and its non-
development in a very considerable class of wounds, has been accepted by many as
sufficient evidence for discarding the conclusions arrived at by the earlier advocates
of antiseptic surgery. To many superficial observers it seemed to be clearly proved
that the entire system was untrustworthy and impracticable. Scientific data were cer-
tainly wanting to answer satisfactorily the queries which arose, although in general
the reply was made that the vital, resistant power of the individual was sufficient to
prevent the growth and development of the bacterial infection. Why, when the seed
was vitalized and implanted in a culture medium ample to serve as food, and retained
at equable temperature, did it not develop ?
Our laboratory experiments threw no light upon the question, for here, under the
conditions given, reproduction was a constant factor. The observations of Metschni-
koff upon the power of the leucocyte to surround and destroy, so to speak, to digest
the bacterium under favorable circumstances, are now generally known. These obser-
vations are of interest as a possible explanation of this hitherto unknown quantity in
the problem—the so-called vital resisting power of the tissues, which may vary greatly
in different individuals. It is quite too early to draw general deductions from our
present premises, and declare that in this the entire solution is found, but there is every
reason to believe that this is an important discovery of a power which the organism
brings to rescue it under favorable circumstances from impending danger.
(387)

388
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
The practical deduction is, that we seek to place the wound in such a condition
that the phagocytes of Metschnikoff may be made the active allies of the surgeon.
All this helps also to explain the success which surgeons have obtained by means
which seemed directly opposite in their methods of wound-treatment.
If the so-called phagocytes of Metschnikoff, the familiar leucocytes above men-
tioned, not alone surround but actually eat up their enemies, we have the best of
reasons for understanding why the comparatively few germs in the atmosphere of a
healthy locality are far less dangerous to wounds than was earlier supposed. Again,
too, we see that in the so-called surgically clean wound—that is, a wound where great
care is taken to exclude foreign material, where blood-clots are removed, and the
comparatively uninjured clean-cut surfaces are closely approximated—the reparative
processes go on steadily, and rapid recovery supervenes, although in a strict scientific
sense the wound is not aseptic. In wounds where the surrounding tissue is devital-
ized these favorable conditions are not maintained, and hence the germination of
bacteria goes on much as seen in laboratory culture experiments.
The unbiased student must observe in the recent progress made in wound-treat-
ment a fundamental truth based upon the repeated observations of abundant experi-
ments and facts. This truth consists of three factors:
First, the condition of the patient—the so-called vital, resistant power.
Second, the character and amount of the bacterial infection—the tares introduced
at the seeding of the field.
Third, the local condition of the tissues at the seat of the implantation—the pabu-
lum from which may spring the direful harvest.
Upon this tripod at present rests the scientific basis of modern wound-treatment.
The problem, then, confronting the surgeon is easily subdivided into two chief factors.
The first factor, based upon the accepted premise that the vital organism with which
surgery has to deal in itself in health is free from bacterial infection, protected from
without by a coat of mail, when unbroken impermeable to invasion; and from within,
through its mucous surfaces, by a similar disposition of protective cells; hence all opera-
tive wounds made in such tissues should be, as far as possible, made and maintained
aseptic. The second, when septic, to determine the best measures to be instituted for
the destruction of the infecting organisms.
The ideal of wound-treatment is surely to restore the condition of the parts as
nearly as possible to their primal state.
a

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
389
If this can be assuredly aseptic, then there are no bacteria to remove; if the wound
is surgically clean, with accurate coaptation of the sundered parts, then the vital forces
are sufficient to utilize any resultant exudates, and drainage is not alone superfluous
but harmful. If the leucocytes go promptly to work under such favorable conditions
the first series of the repair processes take place, which ends in a prompt and speedy
restoration. This should be effected under a dressing which will permit of the in-
troduction of no foreign factorage.
Complete closure of an aseptic wound by buried aseptic animal sutures, retained
at rest with a germ-proof dressing, comes nearer to the ideal than any method yet
advised. There is no fear of hæmorrhage in an aseptic wound thus closed. There
is no further danger from infection, and clumsy and expensive antiseptic dressings
are entirely avoided. Little subsequent care is requisite on the part of the surgeon
or attendant, and the patient is relieved of the fear from subsequent suffering in the
removal of sutures, is almost free from pain, and rapid recovery supervenes.
The experience of the centuries teaches that septic wounds, which were the rule
after operation for strangulated hernia, occasionally resulted in a permanent cure.
The cicatrization was slow, the wound closed by granulation, with contraction of the
parts and the long rest in bed that such a wound necessitated, did much to favor
the result. This is noteworthy in a number of the methods formulated in the history
of the operative measures already given. This was especially true of the charpie ball
of M. Petit, which was first soaked in spirits of wine, with which the wound was
packed, and then it was covered over with large compresses of the same material.
Doubtless this kept the wound aseptic, resulting in healthy granulations, with the
safest and most rapid cure possible to the open-wound treatment. I can not ques-
tion that good results followed as a rule, and the contrast of this treatment with the
ordinary suppurating wounds must have been very striking. Rather than wonder at
Petit's enthusiasm, and the adoption of his method for a considerable period, it seems
the more remarkable that it should have fallen into disuse, and to have had substi-
tuted for it far less scientific and satisfactory measures. We see in this a prototype
of a modern method of cure for hernia which is called after its able and enthusiastic
advocate, Dr. Charles McBurney, of New York, who wrote me, under a recent date,
'my experience continues to prove in the highest degree satisfactory; but, owing
to inability to trace the subsequent history of my patients, I am unable to give
statistics as to the percentage of cures, but, so far as I can determine, every

390
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
case of femoral hernia thus treated has remained without relapse." The essen-
tial features of his operation are dissection of the sac to its base, ligation, and
removal. The wound is sutured in a manner to prevent the divided edges from
reuniting. The wound is then stuffed with a dressing of iodoform gauze and left to
granulate. This method has sometimes been called the open-wound method of treat-
ment, to distinguish it from that of suturing and closure in the attempt to secure
primary union. The dissection in either instance remains much the same. The cure
by the so-called open-wound method has also been used in distinction from the sub-
cutaneous suturing, which is for the most part now abandoned. From this has arisen
a confusion of meaning as to the term “open wound"
A very small class of surgeons think the excision of the sac the primal factor,
and all-sufficient to effect a cure. However, it needs little argument to show that,
a
if cure results, it is not from the closure of the peritonæum alone, but rather from
the firm union of the parts which constitute the restored abdominal wall. There are
several objections to this method. It does not allow of the reformation of the
obliquity of the canal. Moreover, a granulating wound, even if aseptic, heals slowly,
and the resultant cicatrix is inelastic, and often painful for a long period.
The subsequent operative procedures are, in my judgment, far more important than
the disposition of the sac. In a former chapter, upon the anatomy of the inguinal
canal, it was demonstrated that it is constructed to course through the abdominal
parietes so obliquely that ordinary pressure from within outward serves to bring its
walls into lateral apposition.
In the following plate from Cloquet, the deep dissection was made so as to
demonstrate the vessels and their relations to the deeper portions of the inguinal
canal. A considerable portion of the fascia transversalis has been cut away on this
account, but Poupart's ligament has been retained, and, although the dissection was
not intended for this purpose, it would be difficult to find a more beautiful demonstra-
tion of the oblique direction of the inguinal canal within which the spermatic cord
finds easy lodgment. This disposition of the parts is the more noteworthy since, in
the normal condition, muscular activity and violent exertion, regardless of the position
of the body, has little or no effect in disturbing the relationship of the parts. Intra-
abdominal pressure only serves to close the lateral walls of the canal, while the
attachment of the cord to the surrounding parts is such that undue strain or tension
is scarcely possible.


PLATE LXII.
A
for
SO
.
.
M
16
99
B
P
H
T
N
K

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
391
PLATE LXII.*
VIEW OF THE DEEPER STRUCTURES, ESPECIALLY SHOWING THE VESSELS AND SPERMATIC CORD
OF THE RIGHT SIDE.
A. Rectus abdominalis.
P. Spine of the pubes, giving insertion to the
B. Pyramidalis.
external or inferior column of the inguinal ring.
C. Tendon of the rectus.
Q. Superior aperture of the crural canal.
D. Portion of the fascia transversalis.
R. Lower border of the aponeurosis of the
E. Aponeurosis of the external oblique mus- external oblique forming the crural arch.
cle.
S. Superficial layer of the fascia lata detached
F. Another portion of the fascia transversalis from the crural arch, and reflected in order to ex-
G. External iliac artery and vein.
hibit the deeper layer of the same aponeurosis,
H, H. Femoral artery.
the crural canal, and the femoral vessels.
I. Femoral vein.
T. Deep layer of the fascia lata forming the
K. Vena saphena uniting with the femoral posterior wall of the crural canal.
vein.
V. The same layer fixed to the crista and su-
L. Epigastric artery. The vein has been di- perior border of the pubes.
vided.
U. Gimbernat’s ligament.
M, M. Spermatic vessels.
W. Sartorius muscle.
N. Vas deferens, forming an angle at its Y. Semilunar edge, which forms the lower
union with the blood-vessels of the testis.
boundary of the inferior aperture of the crural
0. Part of the proper sheath of the spermatic canal.
cord.
Z. Fascia lata covering the Sartorius muscle.
The problem is to reconstruct and narrow the canal. Nature must be our guide
in its solution. The ureter in its entrance into the bladder permits the flow of the
urine in only one direction. The more distended the bladder, the more firmly are the
orifices closed. In like manner intra-abdominal pressure closes the normal inguinal
canal. In both instances the obliquity of the canal is the necessary condition for the
accomplishment of the object desired. Therefore, the most important of all the meas-
ures to be sought in the cure of inguinal hernia is the restoration of the obliquity of
the canal. This can only be effected by a free dissection of the parts, since the restora-
tion must commence at the internal ring. I can not help thinking that to this fact,
rather than the peculiar disposition of the sac, the good results of Mr. Macewen's opera-
tion are due. His method of restoring the canal, so far as suturing the external pillars
of the ring, is excellent.
Where the hernia is of long duration and large, the parts are deformed, and the
criticism of Mr. Banks is correct, that the aponeurosis of the external oblique muscle,
stretched and attenuated, leaves little material for the suturing of the external ring. In
* Cloquet, Plate III.

392
ANATOMY AND SURGICAL TREATMENT OF HERNIA,
these cases the hernia approaches to the form called direct—i. e., the opening appears to
be almost at right angles to the plane of the abdominal wall. It is in this form of
hernia that the cure is especially difficult. The method which I advocate, and have
practiced for many years, has been followed by most excellent results in the hands of a
considerable number of operators. The cord is gently pushed aside, and the internal
ring is narrowed from below and within, upward and outward, leaving only sufficient
space for the cord at its upper and outer border.
This is best effected by the use of the buried double tendon suture, and it is not
nearly as difficult as would at first appear. It will be remembered that the cord emerges
from the internal ring normally by a
small opening through the transversalis
fascia, which is greatly strengthened and
re-enforced by firm connective-tissue bands
throughout the lower portion of its course.
The following figure shows the re-enforc-
ing bands of subperitoneal fascia which
normally strengthens the internal rings,
both inguinal and crural.
Although this fascia has become path-
ologically dilated and deformed in hernia,
it is yet easy, by penetrating it with the
needle at some distance upon either side,
to find a firm fibrous margin for the sup-
port of the sutures. When these are
FIG. 27. -Dissection of internal inguinal and crural rings
drawn together the relaxed tissue is intra-
from internal surface, the peritonæum and fascia be-
folded, and a proliferation of connective-
ing removed : a, external iliac artery; b, epigastric
artery, branch of a; d, deep circumflex iliac, lying tissue cells along the line of suturing
in Hesselbach's triangle ; e, rectus muscle ; f, fascia
transversalis; g, vas deferens or spermatic duct; h, makes a firm support to the posterior
spermatic plexus of veins with artery and nerves;
i, obliterated cord of hypogastric artery; k, lym-
border of the reformed canal. The follow-
phatic glands. At the internal ring may be seen
ing plate, taken from Mr. Cooper's work,
subperitoneal fascia l, enveloping the cord h.
should be studied in conjunction with
Plate XXI; but it is introduced in this connection to show the dilatation and deformity
of the internal ring when the hernia is at all pronounced. At x, although the hernia is
regarded as incipient, the changes which have ensued are so marked that the inner mar-


PLATE LXIII.
Sim

Plate LXIII.
m
r
r
h
g
f
e
m
h
6.
6
.
By
d
d
c
с


FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
393
gin of the internal ring has been depressed for several lines, while at w the mouth of the
large inguinal hernia extends quite toward the symphysis pubis. The obliquity of the
canal has been lost in the deformation. This plate shows clearly the importance of re-
constructing the internal ring, and re-enforcing the weakened tissues which make up the
inferior wall of the canal.
PLATE LXIII *
Is an internal view of the preparation contained in Plate XXI. It exhibits the orifices of the
two herniæ in the abdomen, and shows the change of place which the mouth of the sac undergoes
as it enlarges, by approaching nearer than at its first descent to the symphysis pubis. The origin and
course of the vessels connected with the disease are shown.
a. Situation of the symphysis pubis.
0, 0. Epigastric veins accompanying the epi-
6. Spinous process of the ileum.
gastric arteries.
C, C, C, 6. Abdominal muscles drawn down- 9, 9. Spermatic veins, arising upon the right
ward.
side from the inferior cava; on the left, from the
d, d. The thigh.
emulgent vein.
e, e. The psoas muscle upon each side.
r, r. Emulgent veins, which in part cover the
f. The spine.
emulgent arteries.
8,9. The kidneys.
S, S. Ureters.
h, h. Aorta.
t. Urinary bladder.
i, i. Iliac arteries.
v, v. Vasa deferentia passing to the posterior
k, k. Epigastric arteries, arising from the iliac part of the bladder.
arteries, and passing between the mouths of the x. Incipient inguinal hernia; its mouth seen
hernial sacs and the symphysis pubis, but still midway between the spine of the ileum and sym-
near to the inner side of the mouth of each sac. physis pubis.
1, l. Spermatic arteries, arising from the aorta, W. Mouth of the large inguinal hernia ex-
and passing out of the abdomen behind the her- tended toward the symphysis pubis, and occasion-
nial sacs.
ing an unnatural curve in the epigastric artery.
m, m. Inferior cava.
y, y, y. The peritoneum.
n. Iliac vein.
As I pointed out when discussing the etiology of hernia, the large proportion of
all the cases of hernia are of the inguinal variety, and surgical procedures, to effect a
radical cure, must be especially adapted to this form. I have followed out in detail, in
a previous chapter, the history of operative measures instituted and attempted for this
purpose, through the literature of surgery, since the problem has been for more than
two centuries clearly defined in its varying factorage, and the best minds of the gen-
erations have given unwearied, devoted study to its solution.
The necessary patency of the canal is the one condition more than any other which
has been the reason of failure to effect a radical cure. To constrict and not occlude
*
Cooper, Plate IV, Part I.
53

394
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
the canal, to allow the free escape of the cord with unimpaired circulation and func-
tion, and to retain within the abdomen all besides, are problems the happy solution of
which, by the delicate adjustment of means to ends, is scarcely exceeded in interest in
all surgery.
а.
a
a
For a considerable period in the earlier history of operative measures the resultant
cure was effected by the sacrifice of the testicle and cord and the end attained by this
means was so satisfactory, and such numbers sought relief even at this cost, that it was
after a time forbidden by legal enactment. Open dissections fell into disuse, only to be
revived with the introduction of the principles of antiseptic surgery.
Subcutaneous closure with the wire suture led up in a measure to, and made the way
for, again resorting to the free-dissection method, and closure of the canal and rings, by
suturing in a considerable variety of manner. Success by this method, however, could
not be assured until antiseptic surgery taught the measures necessary to secure the
closure and retention of the wound free from infection.
In the review of the recent literature of surgical procedures which I have given
at length in the previous chapters, there is abundant demonstration that the opera-
tion for the radical cure of hernia can be undertaken with the assurance of success
almost. if not quite equal to that of any of the well-established surgical opera-
tions.
I have incorporated the experiences of the most distinguished surgeons of Europe
and America, as far as I have been able to collate them, and although they are very
far from being complete, and, like all statistical tables, imperfect and unsatisfactory, still
they give a pretty clear idea of the work being done in this field of surgery, and show
the great advance made, not only in the surgical procedures adopted, but also in the
results attained. These experiences include about three thousand operative cases
es; and
while the mortality may seem somewhat large, most of the deaths are explained as
having been the result of either too long delay after strangulation before operation, or
as due to accidental causes rather than to the operation, as pneumonia or feebleness on
account of age. Even when permanent cure has not been effected, it is the decided
exception that the condition of the patient has not been improved; in other words, a
large scrotal hernia has been exchanged for one easily retained by a light truss, an irre-
ducible and incarcerated hernia for one under easy control. The remote results are
not sufficiently defined to tabulate, for the reason that many operators agree that it is
necessary that a hernia should remain for a considerable length of time--one to five

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
395
years—without evidence of return before it should be classified as permanently or radi-
cally cured.
The general consensus of surgical opinion at present emphasizes the factorage of
operative measures in the treatment of inguinal hernia, as: First, the free dissection,
under rigid antiseptic or aseptic precautions, of the structures, making the incision suf-
ficiently large to demonstrate the condition of the parts. Second, the treatment of the
sac. The earlier methods were numerous, and consisted in invagination of the hernial
sac; cauterization of the orifice and the neck of the sac; ligaturing the same; incision of
the sac and subsequent healing of the wound by granulation ; detaching the sac from
its connections and returning it into the abdomen ; excision, suture, and scarification of
the sac; immediate and forcible compression of the sac by bandaging and applying a
truss, and the use of stimulating injections. But, with the revolution in the surgical
treatment of wounds, there were instituted new principles and methods of operative
procedures.
All surgeons now agree as to the importance of the peritoneal pouch as a factor,
but differ widely as to the manner of its disposition. It may be returned to the abdo-
men unopened, and the canal closed with sutures. When this is done, especially if the
hernia is small and the internal ring remains firm, it is probable that it slowly contracts
and becomes greatly diminished in size; very likely it is often consolidated into a puck-
ered mass which remains for a considerable time as an indurated swelling. This may
serve as a wedge to reopen the pillars of the ring, rather than as a buttress of defense.
When a depression remains over the internal ring we have not only a peritoneal pouch,
but also a weakened, slightly open ring. In this condition the wave-like motions of
the intestinal fluid contents impinge into the recess, weakening and dilating the parts,
until, upon some severe strain, there comes to the knowledge of the sufferer a giving
way of the structures—a rupture occurring suddenly.
If the sac is of considerable size, the general opinion, although not accepted by all
surgeons, is that it should first be opened to ascertain its contents, if any, and its rela-
tion to the canal and the rings. The objection urged against it being opened is that it
is continuous into the abdominal cavity, and a peritonitis might be engendered. This
is not, however, considered valid by antiseptic operators.
It is also generally advised to dissect the peritoneal sac quite freely, after opening,
to within the internal ring, and this for the purpose of securely closing its abdominal
orifice. The profession are divided as to the best means of effecting this closure.
a

396
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
The majority of surgeons advocate ligaturing or suturing: some adopt Mr. Ball's
method of twisting the sac and a retaining suture as more likely to obliterate the
peritoneal pouch ; others, more recently, have followed Mr. Macewen, adopting his in-
genious method of puckering the sac into folds and drawing it quite within the ring,
to become attached, and thereby serve as a buttress to deflect the intestinal impulse.
It may rarely happen to the operator, who has opened the abdomen for some other
purpose, to find the complication of hernia. When the section has been made consid-
erably large, as in the removal of a large tumor, the internal abdominal ring is within
reach of the surgeon. Upon reflection, it would naturally occur to any operator that
under these conditions it is better to close the internal ring, and reform the smooth in-
ternal parietal surface from within by means of suturing. My friend Dr. N. Bozeman,
of New York, easily did this at my suggestion in a case of ovariotomy more than ten
years ago.
In Chapter IV, in which the formation of the sac was discussed, it was shown that
the normal peritonæum, within a considerable limit, is elastic; and there can be little
doubt but that, when the sac is freed quite within the ring, it can be safely drawn down
and ligatured or sutured, so that very little, if any, depression upon its inner surface
will exist. I have verified this fact in a number of instances. In one case already
mentioned,* a female upon whom I had operated for the cure of inguinal hernia upon
both sides, death occurred later from rupture of a cerebral vessel. Upon the one side I
had returned the sac, which was about the size of an egg; upon the other side the sac
was much larger, and I had dissected it, and when drawn tense sutured it quite within
the ring, and excised. The autopsy showed, upon the side where the sac had been re-
turned, a slight puckered peritoneal depression, although the closure of the abdominal
wall was firm and unyielding. Upon the other side the peritonæum was firm and
smooth, without depression, and exhibited as the only mark of resection and suturing a
slight adhesion at the site of the obliterated internal ring.
The advantages of Mr. Macewen's buttress are probably more theoretic than real.
The use of the sac sutured and retained as a plug to close the ring has been very gener-
ally abandoned as unsatisfactory. Nearly all operators at present consider the sac, when
large, an abnormal, deleterious portion of useless material to be removed. Utilized as
proposed by Mr. Macewen, if it forms a buttress, as supposed, for receiving the intes-
* See p. 346.

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
397
tinal impulse, may it not be equally inferred that it might act as a wedge to press un-
evenly against the newly formed tissues of the restored canal, and thereby cause harm,
rather than serve as a deflector of the pressure? Although the peritonæum forms a
pouch or pocket surrounding the hernial contents, Nature did not intend it to serve as
a part of the supporting abdominal wall, but rather, by an even, elastic, smooth surface
lining the firm muscular and tendinous structures, to allow the abdominal contents to
glide easily and evenly in every direction. It is very probable that, when the perito-
næum is thus disposed of, its vascularity and nutrition reduced to the minimum,
absorption slowly ensues, and in the end leaves a smooth, even surface. If Mr. Mac-
ewen's disposition of the sac has the advantage, as he believes, in serving as a re-en-
forcement to the parts, it might be inferred that this construction should have entered
into the primal organization of mankind.
The effort of the surgeon should be to restore, as far as possible, the primal condi-
tions. The peritonæum is normally slightly intrafolded at the ring, but loosely at-
tached, and can be quite freely moved by slight traction in all directions, independent
of the other structures which enter into
the construction of the abdominal wall.
Because the internal ring is ovate in-
stead of circular, it is better to inclose
the mouth of the sac in the direction of
its longer diameter, as less likely to
leave folds. This gives, as the result-
ant, a smooth rather than a puckered
peritonæum, in the highest degree vital-
ized and resilient, as freely movable as
possible upon its exterior, loosely at-
tached fascia. In the attempt to effect
this, no method is superior to that
which closes the mouth of the sac with
FIG. 28.-Inguinal hernia, showing the first stitch taken
a continuous seam. However, there is for the closure of the internal ring from below upward,
in order to reform the inguinal canal.
no doubt but that good results follow
any method which closes the mouth of the sac and effects its obliteration.
Having closed the peritoneum so that there shall be no depression at the mouth of
the sac, it will be found, in all herniæ of any considerable size, that the internal ring has
1 XXX

398
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
become greatly enlarged, almost exclusively at the expense of the tissues upon its
lower and inner border. This foreshortens the inguinal canal to such a degree that
its oblique direction is always diminished, and often it becomes the acquired form of
direct inguinal hernia. The tissues which constitute the posterior wall of the canal
are sometimes attenuated, but more generally they are found to have become consid-
erably thickened on both sides of the opening—an apparently fruitless attempt of
Nature to re-enforce and strengthen the structures.
20.01
Tontlich
FIG. 30.
FIG. 29.
FIG. 29.-Inguinal hernia, showing the manner of closure of the internal ring, with the double continuous tendon su-
ture. The needle is rethreaded for withdrawal.
FIG. 30 represents the line of external sutures loosely taken, uniting Poupart's ligament to the conjoined tendon. The
spermatic cord is seen beneath the sutures, escaping externally below the knot.
m
It is manifestly of the first importance to reunite these tissues about the cord at
its exit from the abdominal cavity. This is accomplished without difficulty by lifting
the cord from the inguinal canal * and elevating it at its exit to the upper border of the
internal ring. Having done this, the tissues comprising the posterior wall of the canal
are carefully brought into juxtaposition by a continuous double-tendon suture.
The base or posterior portion of the canal having been re-enforced and elongated
* See Plate LXIV, p. 399.


PLATE LXIV.
Fig.ll.
Fig.l.
a
Martowald

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
399
by the closing from below upward of the internal ring, the cord is replaced, and the
incision which necessarily extended as far as the internal ring is sutured. Usually the
tissues have become much thinned and weakened owing to the stretching of the
parts from within by the pressure of the hernial tumor, and by the wearing of instru-
mental supports to retain it.
Fig. 30 shows the method of uniting Poupart's ligament to the conjoined ten-
don by a row of double sutures, which is an effective way of firmly closing and
reforming the external portion of the inguinal canal.
PLATE LXIV.
tional cases that the tissues can be thus grasped.
Figure 1
When less relaxed they are elevated upon a hook.
Represents the free dissection of an inguinal
hernia.
Figure 2
a. The spermatic cord elevated upon a Represents the introduction of the needle
hook.
threaded with the suture. The loop is left loose,
b. The posterior fold of the relaxed transver- to be pulled through and unthreaded. The needle
salis fascia lifted between the thumb and finger a when unthreaded is to be threaded with the long-
little below the opening of the large internal ring, er opposite end of the suture and withdrawn, car-
ready for the introduction of the needle carrying rying the suture with it, thus completing the first
the suture for the first stitch. It is only in excep-
stitch.
Fig. 31 serves an excellent purpose in demonstrating the structures external to
the transversalis fascia which are to be united beneath the cord by a line of sutures.
The lower border of the transversalis muscle is joined in an even approximation from
above downward to the deep insertion of Poupart's ligament by a double continuous
tendon suture.
A line of external sutures is taken to unite the lower aponeurotic border of the
internal oblique and the external oblique muscles to the thick fascia extending over
and blending into Poupart's ligament. These structures may be included in a single
line of suturing, but the resulting union is often stronger, and larger surfaces are
approximated by suturing in two layers. The tissues to be joined are fairly well
shown in Fig. 32, also from Gray.
By reference to Plate XXX, from Blandin,* it will be seen that by the normal dis-
position of these structures very great strength is obtained, with power of resistance
from direct intra-abdominal pressure. The dissection also shows that which in hernia
* Page 121.

400
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
is usually much more marked than normally—the interblending and intrafolding of
these aponeurotic structures. The restoration of these structures to a normal condition
if often best effected by the folding in upon each other of the borders of the divided
tissues by continuous suturing.
The soft parts external to the muscles and the skin are united, as has been previ-
ously advised, and the line of incision sealed with iodoform collodion.
OBLIQUI
Aponeurose
0-B-LIQUE
Anterior
TRANSVERSALI:S
1QU
RECTUS
Internal
Abdominino
Ring
Poupart
rt's Lig
Ivans
PUT
Conjoined
tendon
Epigastria
Artery
mp3spu sippsion
so ila
Conjained
CREMAS-TER
Fascia
280p
riang
Frid
Sp.Cord
மர
FIL
G
AP2
lata
Symphysis Pubis
covered with Infundib.Fascia
Sp. cord
FIG. 31.
FIG. 32.
Fig. 31.-Inguinal hernia, showing the transversalis fascia and the internal abdominal ring.--GRAY.
FIG. 32.-Inguinal hernia, showing the internal oblique and cremaster muscles and spermatic cord.—GRAY.
In the dissection for the exposure of the parts, it is well to remember that there
is a superficial artery of some size—the external epigastric—which courses across the
parts in the neighborhood of the external ring. This is sometimes of such a consider-
able size that it misleads the inexperienced operator into the belief that the larger epi-
gastric vessel has been severed. It is often unavoidably divided in the operation.
In the reconstruction of the parts, as above outlined, it will be observed that the
spermatic cord is inclosed within a canal restored to its normal size, length, and obliquity.
The superficial tissues and skin are closely and evenly approximated by the buried sutures.
This is the more important, since we are enabled to do away with the drainage-tube,
a


PLATE LXV.
Fig.l.
Fig.11.
Fig.111.
Fig.IV.
Fig. V.
Fig. Vl.
ve
P
-
Fig.VII.
Fig. VIII
Fig. IX.

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
401
never required in any wound where aseptic structures are to be approximated, although
of the greatest value in septic wounds. The avoidance of the drainage-tube renders
available the closure of the wound by a germ-proof dressing, the advantages of which
can hardly be overestimated in the protection of the wound made for the cure of hernia.
The accompanying plate illustrates the author's method of the suturing of wounds,
as well as of the coaptation of the skin by a running buried animal suture.
PLATE LXV.
Diagramatic illustrations teaching the author's method of coapting structures by means of the
double continuous animal sutures.
Figure 1. The needle, having pierced the tissues, has been unthreaded, and is rethreaded with
the opposite end of the suture, ready for withdrawal.
Figure 2. The needle has been withdrawn through the opening made when it pierced the tissues,
carrying the suture with it, thus completing the first stitch, which is shown as a loose loop ready for
tightening
Figure 3. The needle, still threaded with the end of the suture, is ready for its second insertion
which should be about a quarter of an inch from the first.
Figure 4. The needle, having pierced the tissues for the second stitch, is ready to be unthreaded,
and then is to be threaded with the opposite end of the suture, as before, and withdrawn.
Figure 5. The end of the suture which has been carried through with the needle at its second in-
sertion is unthreaded, and the needle, rethreaded with the opposite end of the suture, is ready for with-
drawal, and this will complete the second stitch.
Figure 6 shows several stitches completed and loosely drawn, the better to exhibit the method
of continuous suturing. It will be observed that, when the sutures are drawn more closely, the parts
are evenly coapted and firmly held in position without undue pressure.
Figure 7. This imperfectly illustrates the coaptation of the posterior border of the inguinal canal,
the cord having been held aside by an assistant.
Figure 8 shows the spermatic cord replaced beneath the line of suturing, and two stitches loose-
ly drawn, taken through the superficial structures for the purpose of inclosing them and covering in
the cord. It will be readily observed that this method of suturing is adapted to a great variety of
uses, especially where it is desirable evenly to coapt and inclose divided structures. For a long period
I have used it in a great variety of wounds, especially for uniting in layers the abdominal wall in
laparotomy, and the rejoining of the widely retracted structures in the restoration of the pelvic floor-
perineorrhaphy.
Figure 9 represents the running buried-tendon suture for the coaptation of the skin. The
needle is introduced through the skin at a little distance from one angle of the wound, emerging in
its deeper layer. At a point directly opposite the emergence of the suture the needle is introduced
parallel to the cut surface, only two or three lines from its edge in the deeper layer of the skin, and
is buried in it about a quarter of an inch or less, marking the length of the stitch. This is re-
peated upon the opposite side, the needle again entering exactly opposite its point of emergence, and
thus the suturing is continued the entire length of the wound. When the last stitch is completed, the
needle is carried from within outward through the skin, to emerge at a little distance beyond the limit
of the incision. As each stitch is taken, the tendon may be drawn sufficiently tight to coapt the
edges of the wound, and this is usually sufficient for an even approximation of the parts. There is,
however, an advantage in leaving the distal ends to escape a little beyond the limit of the incision,
since by drawing upon them the tension is made uniform, and the edges of the skin accurately brought
into apposition. It is important that each stitch enters exactly opposite the point of emergence of the
previous one, otherwise the line of approximation will be wavy or puckered. If this is at all pro-
54

402
ANATOMY AND SURGICAL TREAMENT OF HERNIA.
nounced, small portions of the skin will become everted, and the subsequent repair processes greatly
retarded.
In wounds thus sutured, primary union ensues without cicatricial deposit, and some months later
it is often difficult to trace the line of the incision.
Inguinal Hernia in Woman.-Inguinal hernia never assumes in the female the
importance that is attached to it in the male. The peritoneal entrance to the cord is
usually surrounded by firm aponeurotic structures, which, when weakened, can rarely
dilate into a pouch which compares in size or complexity with that of a scrotal hernia.
The problem confronting the surgeon is therefore a simple one, even if the opening
into the abdomen is large and nearly direct. The serious factorage, when such exists,
is in the thin-walled condition of the abdomen, made abnormally so by the dilatation
and weakening of the parts about the ring, often the result of child-bearing and the
faulty pressure of a strong truss.
When the inguinal hernia is small the operation is usually very simple. The sac
is generally thin-walled, and may be disposed of in a variety of ways, which have been
already discussed in the consideration of the various methods advocated for the cure of
hernia. If thin and small, as is generally the condition in children, it is oftentimes
better to twist it carefully upon itself, as a means of freeing it from its attachments and
of " taking up the slack” of the peritoneal pouch about the ring. This done, ligature
or suture it, as seems most advisable. When uncomplicated by an irreducible condition
of contents (adhesion, incarceration, or strangulation), it is admissible in some in-
stances not to open the peritoneal sac, which simplifies somewhat the operation, and
certainly renders it safer in the hands of many operators.
When the peritonæum has been disposed of in a manner to prevent pouching at
the orifice, and the redundant portion cut away, the subsequent operative measures are
not unlike those for any wound made in aseptic tissues. The sides of the wound must
be coapted by that method held in most favorable consideration by the operator. The
wound is comparatively small, and I can not but believe that, by whatever method it
may be rejoined, drainage is positively harmful. The edges of the wound must be
carefully approximated, and the dressing applied so as to prevent subsequent infection.
I have elsewhere emphasized my own method, and given the reasons why a far more
satisfactory result is obtained by the use of the buried-tendon suture and the wound
sealed with iodoform collodion.
When the sac is large and the abdominal wall thinned, the manner of closing the
wound is even of far greater importance. The peritonæum is shut off by a line of su-

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
403
this purpose.
turing, the neck of the sac having been made tense by withdrawing it well from the
wound. I think it is a manifest advantage to open the sac before suturing, not alone
to be assured that a misplaced stitch does not penetrate an abdominal viscus, but when
open the surgeon is much better able to determine the even suturing of the relaxed
peritonæum. The double continuous suture is of great service in accomplishing
Having resected the redundant peritoneal pouch, the subsequent
steps of the operation should be conducted under irrigation, guiding the point of the
needle upon the finger so as not to penetrate the peritonæum; inclose upon either side
a very considerable amount of the attenuated abdominal wall, since joining the pillars
of the canal in this way permits the folding up from either side of quite a portion of
the aponeurotic structures, which thus greatly re-enforces and strengthens the parts.
In some instances I have felt it was a manifest advantage to coapt the thinned
abdominal wall by a so-to-speak flap-splitting method; in other words, to divide the
muscular layers and coapt them so as to invert the deeper structures and evert the
superficial layers, thus greatly thickening the attenuated parts in the same way as
already advised and figured in the discussion of the best method for the re-enforcement
of the structures involved, where similar conditions exist, only in a more marked de-
gree, in large umbilical hernia.* This is not difficult by the double continuous suture,
and it serves also an admirable purpose in strengthening the abdominal wall in inguinal
hernia in the male when it has been weakened under the long-continued pressure of
It is important to remember that the sutures must not be drawn too tightly,
since fixation and retention at rest, and not constriction, are the objects to be at-
tained. I have several times coapted in this way for some inches in length and quite
a finger's breadth upon either side, the attenuated, weakened abdominal wall. When
thus united, it is noteworthy to observe the cell proliferation that occurs along the
line of union, which may be traced for months afterward as a re-enforced, thickened
band along the line of the former opening.
Femoral Hernia.—What has been said in relation to the operation for the per-
manent cure of inguinal hernia, may be emphasized when we take into consideration
the operative measures to be advised in cases of femoral hernia. The relation of
the sac and its contents to the surrounding parts has been fully discussed in the chap-
ter on Femoral Hernia, in which also the greatly increased danger attending this
a truss.
* See chapter upon Umbilical Hernia, p. 190.

404
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
variety was clearly pointed out and the importance of early operative measures em-
phasized. When the ring is sufficiently large to allow the occasional escape of a
loop of intestine, the individual runs a risk of life never to be underestimated. The
retention of the contents by a truss is more difficult than in inguinal hernia, and
when strangulation occurs the danger is much greater, owing to the tense, firm, sharp
border of the ring
Until recently, the radical cure of femoral hernia was rarely if ever taken into con-
sideration. The treatment advised, after the operation for a strangulated femoral her-
nia, was drainage, dressings to prevent the contamination of the wound by infection,
packing with gauze, lint, etc. In this manner permanent cures often resulted from
the cicatricial contraction which followed, but it is only within a short period that
a systematic attempt for the purpose of radical cure has been taken into serious con-
sideration. The ingenious application of Mr. Macewen's method for the closure of
the ring and the narrowing of the canal, as illustrated in the case of Dr. H. W. Cush-
ing, of Boston, has already been described. The disposition of the sac, however, after
his method, is open to more serious objection than in inguinal hernia, leaving, as it
must almost of necessity, a hard, painful swelling slow to disappear.
To one familiar with the anatomy of the parts involved in femoral hernia the
dissection is not difficult, and the introduction of the sutures quite easy. Success is
dependent upon doing away with the sac, and the narrowing of the ring and the
canal to the minimum consistent with the safety of the vessels. When this is
done aseptically, it is surprising to note how closely the vessels can be closed down
upon, without the slightest disturbance of the circulation.
The operation having been determined upon the parts are carefully shaved and dis-
infected, and the incision is made through the skin and external tissues obliquely over
the site of the hernial tumor. The dissection is continued until the femoral ring is
reached. Often difficulty is experienced in seizing upon the hernial sac, since very
commonly the contents of the hernial tumor have previously been restored to the ab-
dominal cavity. When the sac is thin and small it is frequently difficult to isolate it,
and this is of far less importance under these conditions than when large and thick.
It is better, as a rule, to separate it from the surrounding parts quite to within the ring,
and open it to be assured not only that it is empty, but also, by carrying the tip of the
finger quite within its neck, the better to direct the needle while sewing it off at its
base. When closed at its neck, excise the redundant portion and return the sutured

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
405
.
base within the ring. The next step in the operation is the introduction of the needle,
with eye near the point, armed with the suture for the purpose of inclosing the dilated
part of the ring. This is the more delicate procedure in the operation, since puncture
of the femoral vein would be followed by most serious consequences. The vessel in
its sheath is protected by the finger by pressing it gently outward. The needle is in-
serted from below through the falciform process of the fascia lata, care being taken to
avoid the internal saphenous vein, upward through Poupart's ligament; the needle is
unthreaded, rethreaded with the opposite end of the suture, and withdrawn. In this
way the parts lying parallel to the vein are included in a loop-stitch, coapting the
structures closely upon the sheath of the vessels.
A second stitch is taken through the same tissues parallel to the first, about a quar-
ter of an inch nearer to the median line. A third is introduced
through the pubic portion of the fascia lata exterior to the saphe-
nous opening, and the needle is carried through Gimbernat’s liga-
ment in order to fold the strong fascia inward. In this manner the
For
FIG. 33
FIG. 34.
FIG. 33.--Femoral hernia, showing the first stitch taken through the borders of the ring, for the purpose of occluding
it. The needle is to be unthreaded, and threaded with the opposite end, in order to complete the loop or first
stitch.
FIG. 34.--Femoral hernia, showing the second stitch taken for the closing of the ring, by the use of the double continu-
ous tendon suture. The stitches are represented as loosely drawn, in order the better to show the method of
suturing. The needle is passed through the firm pubic fascia and the outer border of the saphenous opening,
and when drawn closely will fold the latter inward.

406
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
ring is closed, and the parts are drawn inward and upward, to become firmly fixed to
Poupart's ligament.
In this way the peritoneal pouch is obliterated and the margins of the ring approxi-
mated. Folding over the fascia carries the saphenous opening quite a little to the inner
side of its former site while the femoral vessels remain undisturbed in their sheath. The
superficial tissues and skin are coapted by buried sutures, and the line of incision is held
firmly at rest with iodoform collodion. This dressing remains undisturbed, and if the
wound is aseptic it will loosen at the expiration of a week or ten days by the exfolia-
tion of the epidermal cells to which it was attached.
It is generally wise to repeat the collodion dressing as a precautionary measure,
although probably not necessary.
Fig. 35 in a diagrammatic way shows the femoral ring closed obliquely from above.
FIG. 35.
FIG. 36.
Fig. 35.—The suturing of the femoral ring completed. The stitches are left loose in order to show the direction
of the sutures.
FIG. 36.—Exhibits the closure of the femoral ring, and the relation of the suture to the femoral canal.
The suture has been carried just internally to the sheath of the femoral vessels, which
are seen slightly compressed in their sheath.
The patient is allowed to sit up at the expiration of a week, care being taken to
protect the parts from undue strain. Permanent cure of femoral hernia does not seem
to be especially difficult when treated in a variety of methods. Both Mr. Macewen
and Dr. McBurney have written me quite recently that they do not know of a single
recurrence among their own cases.
Until the structures become consolidated it is important to avoid active exercise,

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
407
the patient being permitted to undertake only light duties for some months. If the
parts are examined when the tissues are relaxed, a marked exudation will be felt along
the line of the suturing, which does not disappear for weeks. I can not but think the
advice given to wear a light truss for a considerable period is harmful. It interferes
with the processes of consolidation, and causes absorption of the newly formed tissue.
Umbilical and Ventral Hernia.—Little is required to be added to the discussion
already given upon this variety of hernia. Laparotomy is considered in itself by many
surgeons to be attended with so little danger as to be counted almost a minor operation.
This is certainly true in exploratory incisions made under careful aseptic conditions.
The removal of a large umbilical hernial sac when emptied of its contents is scarcely
more than an exploratory laparotomy. In the reducible variety the abdominal contents
are not disturbed, often not even seen. The sac is resected and the parietal walls closed.
When we remember that the intra-abdominal tension is generally much greater than
normal, it is usually wise to pass deep stay sutures, to hold the wound firmly at rest as
in a splint until union is effected. Ventral hernia may be classed with umbilical in the
general direction for operative measures.
Regarding the value of statistics as applied to herniotomy, Mr. Birkett writes : *
“ It is, however, quite clear that we are unable to collect any facts upon which to
institute a safe comparison. Conclusions as to the success of the one practice or the
other, based upon the results of the cases under treatment, in the hospitals, are really
worthless, because the incidents in any two cases of hernia are never precisely alike,
and accuracy as to details, which is absolutely required to arrive at the truth, can not
be obtained.”
The following table, as far as I have been able, has excluded from it all strangulated
cases operated upon, and it clearly teaches at least one fact—the eminent safety of the
operation as undertaken for the radical cure.
The appended table epitomizes briefly the published results of the more prominent
operators given in Chapters XXIV and XXV:
a
2
Czerny...
Schede's clinic..
Socin .....
Championnière..
Banks...
19 operations, no deaths.
165
75
254
106
2
<<
2
. . .
no
* Holmes's System of Surgery, vol. ii, p. 702.

408
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
68 reported cures, 44 known to remain cured.
24 operations, no deaths.
26
Banks....
Franks....
Robinson, A. W.....
Puzey .....
Macewen.
Bassini's clinic.
24
81
66
I
66
60
66
262
(pneumonia).
216 patients operated on.
108, no return from one to four years.
131, no return from one month to two years.
7 relapses, 4 untraced.
55 operations, no deaths.
38 reported cured.
64 operations, 43 traced, 7 of which relapsed, 4 deaths.
.
4
no deaths.
Anderegg
200
I2
7.
14
66
22
I
.
44
(aged seventy years).
(umbilical adhesions).
63
3
number of operations not given, no deaths.
23
I
66
66
Robinson, H. E.....
Sabbatsburg Hospital.
Thiriar..
Léonté
Routier...
Segond..
Richelot.
Allen....
Karewsker...
Treves..
Wright....
Rabagliati ..
Barker...
Wood.....
Alexander
MacCormac...
Ball...
Cousens..
Weir ....
McBurney
Burrell..
Cabot...
Vanderveer
Burchard.
Bull...
10 operations, no deaths.
50
38 traced and 8 relapses, no deaths.
.. 339
7 deaths.
30
number of operations not given, no deaths.
22 operations, no deaths.
50
30 known to remain cured, no deaths.
8
no deaths.
27
8.
66
66
66
66
3
66
66
2
66
Park...
9
72
3
(all accidental).
40 cases traced, 24 cured, 16 relapsed, 40 per cent of failures.
115 operations, 85 reported cured, no deaths.
no deaths.
5
.. I12
78 traced, 4 relapsed.
12 operations, i relapsed, no deaths.
Jones..
Halsted.
Marcy....
36
. .
66
Rickets..
This list gives over three thousand cases operated on with less than one per cent
of deaths, and these are generally explained to have been from causes which the
authors state were accidental, and not due to the operation.
Every surgeon appreciates the difficulty of following the history of operative cases

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
409
through considerable periods of time. No operation has been to me of greater interest
during the last two decades than that for the permanent cure of hernia. A large pro-
portion of my operations have been in the practice of physicians, not hospital cases,
which renders it much more difficult to trace results. I have very recently gone over
my list of hernia operations for the purpose of adducing such evidence as my experi-
ence teaches. The history of many cases is utterly wanting, but the following tabulated
list gives the results of such cases as I have been able to trace :
ADULTS.
66
Inguinal hernia in the male, 38 cases, 3 relapsed, one reoperated on, cured.
female, II no relapses.
Femoral
male,
4
female, 8
Umbilical
Ventral
3
<<
6
66
ܐܐ
CHILDREN.
Inguinal hernia in the male, 5 cases, i relapsed, reoperated on, cured.
Umbilical
female, 3
no relapses.
Total....
78
Of the four recurrent cases, three returned within six months of the time of opera-
tion. Of these, two have been operated on for the second time and remain cured.
Two cases have been reported to me where the abdominal wall weakened, a
bulging of the parts rather than a return of the hernia, and for which a light truss has
been advised.
By reference to the normal anatomical construction of the inguinal canal, it will
be observed that its obliquity is the primal and important factor in the prevention of
hernia. The usual methods recommended for radical cure depend upon the closure
of the internal ring, by ligaturing the neck of the peritoneal sac and the uniting of the
pillars of the ring. This, as will be seen by the accompanying diagram, leaves the
posterior triangle, bounded by the inferior border of the canal, the inferior abdominal
wall, and the peritonæum, unclosed. The internal ring remains large, and the canal is
thereby foreshortened and funnel-shaped—a necessarily imperfect protection from the
return of the hernial protrusion. Mr. Macewen apparently recognized this “ funnel-
shaped depression ” more clearly than any other operator, and, in order the better to
fill this, devised the chief factor peculiar to his operation, the “bossing” with the in-
55

410
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
trafolded sac. By the use of the buried sutures in layers this triangle is completely
restored and the obliquity of the canal is reformed.
-P
a
t
6
с
In résumé.—Emphasis is to be placed upon the following conditions in all the
operations undertaken for the cure of hernia, applied to the different varieties :
Carefully disinfect the hands of the operator and
assistants.
Have in readiness aseptic sponges, towels, instru-
ments, and use nothing which may come in contact
with the wound that has not been sterilized.
Have the parts shaved and disinfected, if possi-
ble, before etherization.
Place the patient upon a table in a good light.
Cover the abdomen and thighs, except about the
region to be operated upon, with light rubber sheet-
ing. Over all place towels wrung from a 1-1,000
mercuric bichloride solution.
Maintain strict asepsis during the operation with
the same care as in laparotomy for any purpose.
d
Conduct the stages of the operation under irri-
gation with a mercuric solution, 1-2,000, until the
last stitch has been taken.
Under exceptional conditions the bleeding may
be stopped, and the wound maintained dry during
FIG. 37. — a, normal internal ring; b,
enlarged internal ring ; c, unclosed
the entire operation.
triangle; d, abdominal wall; h, her-
With the use of irrigation often not a single
nial sac ; Þ, peritoneum ; Þ', re-
sected at site of internal ring; t, sponge is required, and every part of the wound is
triangle, reformed by closure of pill-
clearly within the field of vision during the entire
operation.
The Sac.—The peritoneal sac of the hernia should usually be opened and dissected
free quite within the internal ring-i. e., all the adhesions which the peritoneum has
formed to the ring should be separated. Tension is then made upon the sac, which is
sutured at its base and resected. The tension should be such that when the sac
sected the sutured base will retract quite within the ring.
h-
-
ars of the canal.
re-


PLATE LXVI.
Fig..
Fig.11,
Fig. 111.
-a
-
///
CN
761
>
W
4
.
a
52
C.
--
S-
*
C-
-772
e.
- II
--
Fig VI.
Fig. V.
Fig. IV.
ZUN
Fig. VII.
-
-a
7
As/
i
TV/
-181
C.
63.
sk-
C
63
1s2
-
-
//
l
-
-VIP
-s2
-
m
sr
-

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
411
In inguinal hernia the dissection must be sufficiently large to free the cord to its
exit from the internal ring; the cord is to be raised from the canal and the internal ring
closed upon it from below upward, so as to reconstruct and re-enforce the posterior wall
of the canal. In this way the canal is very considerably elongated, and the transver-
salis fascia is intrafolded and very much thickened. The spermatic cord is restored
within the reformed canal, and the superficial structures are sutured in layers closely
upon, but not so as to impair the circulation and nutrition of, the parts inclosed. In
this manner the length and obliquity of the inguinal canal are restored, and its walls
re-enforced and strengthened even in the largest of old direct herniæ.
The superficial tissues are brought into apposition by a line of continuous buried
tendon sutures, and the skin is coapted by the running parallel buried suture. Join-
,
ing of the structures in this way does away with the necessity of drainage, and permits
the complete closure of the wound. The line of the incision is dried, dusted with iodo-
form, and sealed with iodoform collodion.
PLATE LXVI.
Diagrams showing in inguinal hernia, the author's method of closure of the parts, and restoration
of the obliquity of the canal.
Figure 1
dition of the letter h, which marks the site of the
Shows a commencing hernia ; the internal
hernial protrusion.
ring dilated, the inguinal canal only slightly fore-
Figure 3
shortened, the external ring unchanged. A loop
of the small intestine has found partial lodgment Shows the peritoneal sac sutured evenly
at the internal ring.
across at its base and resected.
The deeper
a. Spermatic artery.
structures forming the posterior wall of the canal
c. Inguinal canal.
have been coapted by a deep double continuous
e. External ring.
tendon suture closing the internal ring quite
i. Internal ring.
upon the elevated cord.
g. Intestine.
a. Spermatic artery.
m. Muscular fasciculus re-enforced by the c. Inguinal canal.
transversalis fascia.
m. Structures posterior to the inguinal canal.
B, p. Peritonæum.
i. Former site of the internal ring.
s. Spermatic cord.
e. Former site of the external ring.
W. Abdominal wall above the inguinal canal. Bp. Peritonæum.
V. Vas deferens.
s. Spermatic cord.
The arrows in each drawing represent the V. Vas deferens.
direction of the internal abdominal pressure.
W. Superior border of the abdominal wall.
1, s, 1. First layer of sutures, including only
Figure 2
the peritonæum.
Represents the hernial tumor slightly pro- 1, s, 2. Second layer of sutures, coapting and
truding through the external inguinal ring. The intrafolding the transversalis fascia, closing and
lettering corresponds with Figure 1, with the ad- elevating the internal ring.

412
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Figure 4.
e. The inferior margin of the external ring
Letters the same as in Figure 3.
scarcely changed from its normal position. It
l, s, 3. Shows the cord replaced in the re-
will be seen that the internal ring has become
constructed inguinal canal by a layer of continuous
dilated in very large measure of necessity from
sutures, which rejoin Poupart's ligament to the
above downward, while the external ring has
conjoined tendon.
yielded in the opposite direction, i. e., from below
upward. It is owing to the giving way of the
.
Figure 5
parts in this reverse order that the canal becomes
enlarged and necessarily foreshortened in propor-
The letters indicate the same structures as in
tion to its dilatation. The arrow represents the
the previous diagrams.
intra-abdominal pressure almost in the direct line
1, s, 4. Shows the lines of sutures taken
of the opening
through the deeper layer of the skin only, thereby
Figure 7
coapting the edges of the external wound, ready
Represents the canal in its normal relation-
for the final dressing of collodion.
ship, where the intra-abdominal pressure is nearly
at right angles to its direction, and necessarily
Figure 6
thereby compresses its walls from within outward.
Represents the canal of an inguinal hernia In this condition there is no possibility of the
foreshortened nearly to the thickness of the ab- wave-like impulse of the intestinal contents im-
dominal wall.
pinging against the opening of the internal ring
i. Indicates the former site of the inferior and acting as a wedge to dilate it. On the contrary,
margin of the internal inguinal ring in its normal the intra-abdominal pressure causes a uniform
condition.
yielding of the abdominal wall in every direction.
The advisability of operative measures in any given variety of hernia is always to be
seriously considered as an independent problem, the solution of which must ever de-
pend upon many individual factors.
There can be little doubt that the surgery of the future will include a large percent-
age of the sufferers from hernia, which the conservative surgeon of to-day relegates to
the truss-bearing army of invalids. Sir William Mac Cormac emphasized the results
of his large experience as follows: *« I would conclude by saying that in a large propor-
tion of cases of inguinal hernia, especially those of congenital origin, a radical cure is
possible; and that in femoral and umbilical hernia of small or moderate size the pros-
pects of cure are good. Even where an absolute cure is not accomplished, a great
gain is generally secured in the diminution of the size of the hernial aperture, by
which the retention of the hernia within the abdominal cavity becomes more practi-
cable. Lastly, and more important, the operation when properly performed is scarcely
dangerous to life.”
Mr. John Wood concluded his lectures as follows : “ It appears to me indubitable,
from the results of the last twenty years' experience of the radical cure of hernia, that
* Loc. cit., p.

FUNDAMENTAL FACTORS IN THE CURE OF HERNIA.
413
the position of those surgical writers who have maintained that the radical cure should
not be attempted except in the severest cases, is untenable. The operation has given
as great relief and exemption from the minor troubles and worry which make life
miserable as any operation associated with prolapse, such as hæmorrhoids, and is even
more safe.”
In 1858 Sir Spencer Wells wrote: “ The relief of a strangulated hernia is justly
regarded as one of the noblest triumphs of operative surgery. The surgeon saves the
life of the patient without removing or deforming any part of his body. But the sur-
geon who cures hernia radically, with certainty and safety, is a greater public benefac-
tor, as he not only relieves large numbers of his fellow-creatures from suffering, but
he averts the danger of a strangulation to which they are continually exposed, in a
greater or less degree, through every period of life.”


INDEX.
Artery or arteries, carotid, tying of, 287.
epigastric, 10, 33, 67, 101, 120, 125, 136, 371, 400.
external iliac, 127, 277, 371.
obturator, 120, 139, 154, 156, 357, 375.
spermatic, 32.
umbilical, 190.
Artificial anus, 227, 238, 246, 252.
Avicenna, 198.
Abbe, Robert, 246, 368.
Abdominal herniæ, classification of, 2, 8.
considerations, general, 1, 7.
frequency, etc., 3, 6, 7, 49.
Abdominal parietes, 2, 9, 12, 27, 35, 48, 53, 97, 233, 290,
390.
Abdominal ring, external, 17, 26, 36, 65, 71, 391.
internal, 23, 26, 33, 41, 67, 370, 392, 395, 411.
Abernethy, John, 286.
Acquired congenital hernia, 35, 38, 46, 191.
Adhesions of sac, etc., 52, 55, 83, 102, 238, 383.
Advisability of early operative measures, 83, 92, 97, 131,
156, 182, 197, 308, 316, 344, 355, 370, 373, 378, 383,
385, 394, 412.
Æginatus, Paul, 198, 259.
Ætius, 286.
Agnew, D. Hayes, femoral hernia, 139, 279, 354.
Albucasis, 198, 260, 283.
Alexander, William, operative measures, 325, 383.
Allen, Dudley P., dissection method, 349.
Allen, H. W., cases of, 336.
Allis's hernia knife, 99.
Ammusat, union of intestine, 243.
Anal rupture, case of, 172.
Anastomosis, lateral, 245.
Anatomy of the groin, 10, 18, 27, 33, 114.
Anatomy of the parts involved in congenital hernia, 38.
diaphragmatic hernia, 213.
femoral hernia, 115.
inguinal hernia, 9, 48, 65.
obturator hernia, 154.
umbilical hernia, 190.
Anderegg, radical cure of hernia, 333.
Animal ligature or ligatures, history of, 285, 299.
Animal suture or sutures, history of, 111, 284, 302, 346.
mode of application, 109, 141, 229, 299, 306, 370, 397,
401, 411.
Annandale, T., 312.
Anterior parietes of the trunk, 21, 25,
Antiseptic surgery, 196, 309, 344, 353, 379, 389, 394.
Anus, artificial, 227, 238, 246, 252.
Aquapendente, F., 242.
Arch, crural, 17, 116.
Arnaud, George, 42, 59, 82, 98, 102, 147, 158, 248, 258,
308, 383, 385.
Bacterial infection, 202, 289, 299, 309, 387.
Ball, C. B., method of operation by, torsion of sac, 327.
Banks, W. Mitchell, method of operation, 318.
Bantock, G. G., case of femoral hernia, 152.
Barker, Arthur E., method of operation, 321.
Barnes, Robert, hernia of ovary, 174.
Barton, J. N., 382.
Bassinni, E., method of operation, 332.
Baxter, J. H., tables of, 3, 7.
Bellinger, John, animal ligatures, 288.
Belmas, use of gold-beater's skin, 269.
Belt, E. O., use of rat-tail sutures, 298.
Benedict, S. C., case of congenital umbilical hernia, 194.
Bennett, W. H., cæcal hernia, cases of, 168, 338.
Bernes, Joseph, animal ligatures, 299.
Bichloride of mercury, 99, 195, 230, 294, 382, 410.
Birkett, John, 78, 92, 107, 154.
Bishop, E. S., method of operation, 335.
Bistoury, Arnaud's probe-pointed, 98.
Le Dran's, 98.
Black, R. S., cæcal hernia, case of, 168.
Bladder, hernia of, 183, 187.
Boinet, A., hernia of ovary, 177.
Bonnet, A. M., hare-lip pin, 269.
Boret, V., catgut sutures, 295.
Bowditch, Henry I., diaphragmatic hernia, 205, 212.
Boyer, Le Baron, umbilical hernia, 191.
Breschet, G., 134.
Briggs, Waldo S., intestinal wounds, 231, 235.
Brodie, B. C., case of anal rupture, 168.
Bröse, use of buried sutures, 301.
Bryant, Joseph D., method of operation, 258, 355.
Bubonocele, 54, 66, 90, 349.
Buchanan, G., congenital hernia, 325.
Bull, William T., method of operation, 359, 364.
Burchard, T. H., cases of, 349.
(415)

416
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Buried animal sutures, use of, 109, III, 141, 203, 223, 230,
284, 299, 302, 306, 344, 347, 365, 389, 392, 398, 411.
Burrel, H. L., gangrenous hernia, 247, 294.
femoral hernia, 350, 365.
Byford, case of hernia of ovary, 179.
Cremaster muscle, 13, 20, 38.
Crochet-hook, Arnaud's, 134.
Croft, John, table of, 6.
Crural arch, 17, 116.
Crural hernia, 115. See (FEMORAL.)
Cruveilhier, foramen ovale, 155.
Cuénod, Victor, report of clinic, 314.
Curling, T. B., gubernaculum testis, 28.
Cushing, H. W., femoral hernia, 350, 404.
Cystocele, 51, 183.
Czerny, V., method of operation, 312, 365.
Cabot, Arthur, case of, 350.
Cæcal hernia, 167.
Camper, Peter, 29, 93, 164, 368.
Canal, femoral, 119, 141, 404.
inguinal, 27, 29, 35, 110, 371, 391, 393, 398.
of Nuck, 28, 35.
obturator, 154, 157.
Cantemir, Demetrius de, 263.
Catgut ligature or ligatures, carbolized, 291, 345.
defects in, 292.
Lister's method of preparation, 293.
Macewen's method of preparation, 295.
Cautery, use of, 197, 259, 260, 268.
Cell proliferation, 291, 392, 403.
Cellular substance of Ruysch, 117.
Celsus, 193, 197, 259, 285.
Chadwick, James R., case of ventral hernia, 209.
Championnière, L., radical cure of hernia, 204, 316.
Charpie ball, Petit's, 389.
Chase, Heber, on trusses, 74.
Chase, H. L., case of, 191.
Cheever, David W., 280, 348, 351.
Chromic gut, use of, 295.
Church, M. E., case of, 161.
Clarke, A. P., cases of, 345, 351.
Classification of hernia, 2.
Claudinus, 260.
Cloquet, Jules, 20, 52, 120, 158, 242, 374, 390,
Closure of internal ring, 110, 141, 203, 282, 329, 370, 379,
391, 397, 402, 409, 411.
Codman, B. C., on trusses, 72.
Coffins, 246.
Collodion iodoform, use of, 110, 112, 142, 204, 307, 351,
379, 400, 406.
Congenital hernia, acquired, 46, 180, 212, 373.
defined, 35, 38.
disposition of sac in, 109, 337, 379.
strangulated, 41, 180.
umbilical, 193, 381.
Congenital hydrocele, 29, 36, 38.
Conjoined tendons, 18, 24, 49, 163.
Connective tissue, subserous, 31.
Continuous double tendon suture, 112, 203, 398, 401, 411.
Cooper, Sir Astley, 15, 41, 57, 68, 72, 78, 97, 104, 117,
123, 163, 185, 200, 212, 287, 371.
Cooper, B., case of, 58, 160.
Coote, Holmes, hernia of ovary, 176.
Cord, spermatic, 16, 27, 32, 66, 120, 370, 390, 398.
Couch, John, 90.
Cousens, Ward, operative measures, 327.
Cribriform fascia, 115, 122.
Darling, W., boundaries of the inguinal canal, 30.
Darrach, W., anatomy of the groin, 10, 18.
Dartos muscle, 13.
Dawson, W. W., operative measures, 354.
De Garmo, W. B., hernia in children, 129, 377.
Deneux, hernia of ovary, 175.
Dent, tendon ligatures, 305.
Desault, umbilical hernia, 198.
Detmold, W., femoral hernia, case of, 360.
Diagnosis, early importance of, 51, 67, 87, 126, 156, 163,
190, 217
Diaphragmatic hernia, anatomical characteristics, 213.
operative measures in, 215.
Didama, H. D., operative measures, 361.
Dilator, Thevenir's two-branched, 134.
Dionis (Pierie), 262.
Direct inguinal hernia, anatomy of, 18, 65.
dissection of, 67.
operative measures advised, 69.
Director, Le Dran's winged, 98.
Disposition of sac, 75, 100, 109, 133, 135, 157, 201, 202,
347, 356, 379, 395, 403, 404, 410.
Doléris, use of buried sutures, 301.
Dorsey, use of animal ligatures, 285.
Dowell, G., subcutaneous suturing, 279.
Drainage in wounds, 110, 300, 379, 389, 402.
Duberger, 242.
Dudley, H. W., tendon ligatures, 298.
Dudley, A. P., ventral hernia, 210.
Dupuytren, B., artificial anus, 86, 132.
Duverney, M., hernia foramen ovale, 158.
Ecchymosis, 86.
Encysted hernia, 46.
hydrocele, 31.
Englisch, Josef, 161, 178.
Ensiform cartilage, 16, 118, 215.
Enterectomy, 232.
Enterocele, 3.
Entero-epiplocele, 158, 222.
Epididymis, 39, 45.
Epigastric artery, danger of wounding, 101, 120, 136, 140,
190, 400.
location of, 33, 66, 68.
Epigastric hernia, 2, 17.

INDEX
417
Epiplocele, 2, 17, 77.
Eve, Paul, animal ligatures, 289.
Excision of hernial sac, 57, 95, 109, 135, 139, 157, 187, 201,
347, 356, 379, 395, 404, 410.
External abdominal ring, 17, 26, 36, 65, 71, 400,
iliac artery, 1o.
oblique muscle, 13, 16, 391, 399.
pubic fascia, io.
spermatic artery, 32.
spermatic fascia, 12.
Falciform process, 115, 405.
Fascia, Camper's, 368.
cribriform, 115, 122.
external spermatic, 12.
iliaca, 117.
lata, 17, 115, 405.
propria, 122, 135.
sub-peritoneal, 392.
transversalis, 22, 118, 371, 376, 399.
Femoral arch, 17, 117.
artery, 120.
canal, closure of, 141, 143, 405.
formation of, 119.
Cooper's measurements of, 124.
Femoral hernia, anatomy of parts involved in, 115, 136.
causes producing, 2, 120.
diagnosis of, 126, 131.
disposition of sac in, 133, 135, 140, 404.
strangulated, 131, 142, 404.
Femoral ligament, 115.
ring, 119, 120, 404, 406.
vein and vessels, 117, 120, 129, 405.
Ferrari, 337
Formation of hernial sac, 51, 97, 191, 219, 337.
Formula for injection, 275.
Foramen ovale, hernia of, 154.
Franks, Kendall, method of operation, 319.
Frith, Charles, case of, 160.
Hab, statistics from, 248.
Haller, A., congenital hernia, 38.
Halsted, W. S., method of operation, 361.
Hamilton, John B., radical cure, 348.
Hardie, James, method of operation, 324.
Hartshorne, parchment ligatures, 286.
Hawkins, Cæsar, hernia of ovary, 175.
Heath, Christopher, case of, 320.
Heaton, George, injection method, 274.
Heister, 98, 117, 193, 198, 242, 262.
Hermann, 246.
Hernia, various kinds of abdominal, 1, 47.
bladder of, 183.
cæcal, 167.
congenital, 35, 57.
crural, 115. (See FEMORAL.)
diaphragmatic, 2, 213.
direct inguinal, 65.
encysted, 31, 46.
epigastric, 2, 17.
femoral, 2, 115, 135, 384, 403.
foramen ovale, 2, 154.
infantile, 46.
inguinal, 9, 20, 39, 71, 78, 382, 395, 402, 411.
internal inguinal, 65.
irreducible inguinal, 51, 78.
ischiatic, 2, 163.
mesenteric, 217.
oblique inguinal, 20, 28.
obturator, 154.
omental, 43, 89, 222.
ovary of, 174.
perineal, 2, 188.
pudendal, 2, 57
reducible inguinal, 51, 71.
retroperitoneal, 217.
scrotal, 47, 53, 78, 187, 380.
strangulated inguinal, 51, 85.
strangulated femoral, 131.
thyroid, 156.
umbilical, 2, 190, 203, 407.
vaginal, 2.
ventral, 2, 207
vesical, 183, 188.
Hernia knife, Allis's and Warren's, 98.
Hernia needle, Dowell's, 279.
Marcy's, 110.
Woods's, 275
Hernial sac, coverings of, 51, 122, 219.
disposition of, 57, 95, 109, 139, 159, 187, 201, 347, 356,
370, 379, 395, 404, 410.
formation of, 47, 51, 97, 154, 191, 215.
pathological changes in, 54, 86, 143.
Herniotomy, instruments, preparation, etc., 98, 100.
Hesselbach, F. K., 29, 40, 65, 122.
Heurnius, 260.
Heuston, F. T., femoral hernia, 326.
Galen, 26, 75.
Garengeot, Jacques, 117, 158, 198.
Gay, George W., gangrenous hernia, 247, 280.
Gay, John, femoral hernia, 118, 132.
Gerdy, P. N., method of operation, 269.
Gerster, A. P., hernia in children, 380.
Gilman, J. H., whale tendons, 296.
Gimbernat's ligament, 17, 116, 137.
Girdlestone, T. M., kangaroo tendons, 297.
Gold wire, use of, 289.
Gouey, M., hernia of ovary, 174.
Green, Nathaniel, water-pad truss, 72, 74.
Gross, Samuel D., congenital umbilical hernia, 194,
345
Gubernaculum testis, development of, 17, 20, 28.
Guthrie, 27, 217.
Guy de Chauliac, 198, 259, 280,
56

418
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Iodoform collodion, use of, 110, 239, 307, 379, 402, 406.
gauze, use of, 239, 247, 380.
Irrigation in wounds, 99, 203, 224, 241, 403, 411.
Ischiatic hernia, 163, 166.
Ishiguro, T., whale tendons, 296.
Israelsohn, Isidore, aseptic surgery, 348.
Hey's femoral ligament, 115, 136.
Hildanus, Fabricius, 75.
Hilton, 160.
Hinkson, J. R., operation on child ten hours old, 381.
Hippocrates, 259.
History of operative measures, 258, 286, 308, 344.
Hogue, William, case of, 193.
Holmes, T. M., tendon sutures, 304.
Holthouse, Carsten, use of seton, 270.
Hood's truss, 76.
Houstoun, use of the cautery, 260.
Hulke, J. W., congenital hernia, 42.
Hunter, John, pathological specimens of, 41, 56, 65, 150,
252.
Hydrocele, congenital, 29, 31, 36, 54.
Jacobson, Nathan, operative measures, 363.
James, F. S., 235.
Jamieson, H. G., animal ligatures, 286.
Jobert, M., reunion of intestine, 242.
Jones, G. W., report of cases, 361.
Kangaroo tendon, use of, in surgery, 297, 306, 398, 401.
Kärte, statistics of, 246.
Karewsker, 336.
Keen, W. W., operative measures, 245, 355.
Keetley, C. B., operative measures, 301, 321, 340.
Kelley, J. E., operative measures, 267, 367.
Kingcote, Ernest, operative measures, 342.
Kingdon, tables of, 6, 129.
Knife, hernia, Allis's, Warren's, 98, 129.
Knight's truss, 75.
Koehler, A., 337.
Küster, Prof., 236, 301, 364.
Iliaca muscle, 28, 32, 109, 119.
Illustrative cases, anal rupture, 172,
accidental hernia, 46, 79, 80.
bladder, hernia of, 184, 187,
bubonocele, 90, 252.
cæcal hernia, 167, 169, 171.
congenital hernia, 46, 380.
diaphragmatic hernia, 215.
direct inguinal hernia, 68.
femoral hernia, 123, 138, 147.
foramen ovale, 155.
irreducible inguinal, 42, 82, 95, 102, 187, 310, 345.
ischiatic hernia, 163, 165.
obturator hernia, 154, 160.
ovary, hernia of, 174, 178, 181.
strangulated intestinal, 59, 90, 243, 248, 258, 345.
umbilical hernia, 191, 193, 204.
uterine inguinal hernia, 177.
ventral, 209, 211,
Indirect inguinal hernia, 47.
irreducible inguinal hernia, 78, 83.
reducible inguinal hernia, 71.
Infantile hernia, 46.
Infundibulum process, 26, 373, 374.
Inguinal hernia, anatomy of parts involved, 9, 19, 54, 376.
complications in, 48, 51, 83, 218, 377.
direct, 65, 398.
indirect reducible, 71.
indirect irreducible, 78.
strangulated, 85.
surgical procedures in, 92, 100, 107, 380, 395, 402.
Internal abdominal ring, 23, 26, 110, 379, 391, 400.
oblique muscle, 17, 18, 399.
Internal inguinal hernia, 65.
Intestine, or intestines, gangrenous, 223.
pathological changes in, 88.
resection of, 229.
method of reunion, author's, 230, 306.
method of reunion, Briggs, 231.
Instrumental supports, 72.
Intra-abdominal pressure, 29, 49, 374, 399, 407.
Lallement, hernia of ovary, 174,
Lanfranc, invagination method, 259.
Langenbeck, C. J. M., 32, 40, 104, 207, 265.
Laparotomy, 91, 157, 172, 207, 217, 240, 339, 381, 407,
Larimore, F. C., method for radical cure, 363.
Latent scalpel, Le Dran's, 198.
Lawrence, William, on ruptures, 32, 53, 131, 165, 186, 198,
265, 303
Lawson, hernia of ovary, 176.
Leblanc, 134.
Le Dran, director, 98.
latent scalpel, 198.
Leisrink, H. W., 333.
Lembert suture, continuous, 224, 241, 247.
interrupted, 229, 241, 245.
Leopold, Dr., case of, 176.
Leucocytes, 387.
Ligament, or ligaments, Gimbernat’s, 17, 116, 132, 137,
141, 405.
Hey's femoral, 115, 136.
Poupart’s, 17, 100, 110, 116, 120, 132, 371, 405.
suspensory, 14.
triangular, 21, 65.
Ligation of arteries, 285, 288, 291, 303.
of hernial sac, 198, 266.
Ligature, or ligatures, animal, 222, 285, 289, 303.
catgut, 291, 292.
silk, 303
tendon, 295, 297, 305.
Linea alba, 12, 18, 211,
Linea semilunaris, 18.

INDEX
419
Lister, Prof. J., antiseptic surgery, 291, 309, 311.
Liston, Robert, case of, 151.
Little, 260.
Lloyd, Jordan, case of, 340.
Lucas, Clement, method of operation, 326.
Lymphatics and nerves, 34.
Nash, G. W., 161.
Nationality, 6.
Necrosis of intestine, 223.
Needle, or needles, hernia, Dowell's, 279,
Marcy's, 110.
Wood's, 275
Nelson, Daniel T., 304.
Nelson, Samuel N., 171, 209, 351, 380.
Nerves and lymphatics, 34.
Neuber, 301.
Neve, E. F., cases of, 209.
Norris, A. L., 346.
Norton, A. E., case of, 187.
Nota, Dr., method of operation in children, 381.
Nuck, canal of, 28, 35.
MacCormac, William, operative measures, 325, 412.
Macewen, William, method of operation, 328.
Mackie, J. H., method of operation, 353.
Makin's statistics, 246.
Malgaigne, 6, 8.
Marcy, Henry O., hernia needle, 110,
buried tendon suture, use of, 109, 141, 203, 230, 306,
346, 384, 398, 401.
method of operation in femoral hernia, 135, 404.
inguinal hernia, 94, 100, 111, 391, 401.
umbilical hernia, 203.
Marion, Horace E., case of, 187.
Marsh, Frank, case of, 343.
Martin, A., catgut sutures, use of, 301.
Martin, H. A., case of, 211.
Mastin, C. H., operative measures, 298, 354.
Matins, statistics of operative measures, 246.
Maunsell, H. W., operative measures, 341.
Maylard, A. E., case of, 179.
May, Bennett, case of, 306.
McBurney, Charles, method of operation, 263, 352,
389.
McCosh's statistics, 246.
McGillicuddy, T. J., cases of, 349.
McGraw, T. A., resection of intestine, 247.
Measurements of inguinal canal, 124.
Membranous funnel, 239.
Mesentery, 48, 241.
Mesenteric hernia, 217.
Mesorchium, 44.
Method of application of the buried tendon suture, III,
141, 203, 223, 230, 284, 299, 306, 344, 365, 389, 392,
401, 411.
Metschnikoff's experiments, 387.
Milliken, S. E., mechanical treatment in hernia, 75,
351.
Moore, E. M., case of, 273.
Morris, drainage, use of, 263.
Morrison, R., 338.
Morton, Thomas, dissections of, 23, 26.
Mudd, H. H., strangulated intestine, 246.
Muscle, or muscles, cremaster, 20.
external oblique, 13, 16, 399.
iliac, 28, 32, 119.
internal oblique, 13, 16, 399.
obliquus internus, 28.
obturator, 157
psoas, 28, 32, 119.
rectus, 18.
transversalis, 21, 66, 399.
Oblique inguinal hernia, 20, 28, 30, 101.
Oblique muscle, external, 16.
internal, 18.
Obliquity of canal, restoration of, 20, 110, 141, 222, 284,
371, 374, 392, 399, 410.
Obré, 160.
Obturator artery, 120, 139, 154, 156, 375.
Obturator hernia, anatomy of, 154.
operative measures for, 157
Oldham, hernia of ovary, 175.
Omental hernia, 43, 89, 222.
Omentum, 49, 96, 102, 122, 197, 202, 222, 302.
Operative measures, early, advisability of, 92, 201, 218,
348, 355, 382, 385.
adults in, 382.
children in, 374.
history of, 258, 308, 344, 374.
importance of, 92, 131, 143, 385.
Operation, or operations, methods of, Barker, 321.
Barsinni, 332
Briggs, 231.
Halsted, 361.
Macewen, 328.
Marcy, 391, 401.
injection method, 273.
invagination method, 270,
seton method, 270.
subcutaneous wire suturing, 275, 394.
use of the buried animal suture, 94, 109, 141, 230, 233,
241, 270, 303, 306, 328, 337, 379, 398, 403, 411.
Otis, George A., 344.
Ovary, hernia of, 174, 182.
cases of, 178, 181.
Owen, 179.
Pacinotti, G., hernia of ovary, 181.
Paletta, 29.
Pancoast, silk ligatures, 272, 303.
Parallel buried suture, 112, 411.
Paré, Ambrose, 198, 261, 289, 370.
Park, Roswell, cases of, 359.

420
ANATOMY AND SURGICAL TREATMENT OF HERNIA.
Ritsch, 242.
Rizzoli, Prof., hernia of ovary, 179, 180.
Robinson, A. W., 320.
Robinson, H. E., 333.
Rorrick's air-pad truss, 74.
Rosset, 259.
Royal stitch or suture, use in hernia, 260, 261.
Ruysch, 117
Pathological specimens, description of, congenital hernia, 41.
deformed sacs, 57.
femoral hernia, 150, 155.
inguinal hernia, 57.
obturator hernia, 162.
strangulated, 104.
strangulated umbilical, 205.
various kinds of, 252, 255.
Pennfield's celluloid truss, 76.
Perineal hernia, 188.
Peritonæum, anatomy of, 51, 52, 56, 214, 230, 356, 373,
397, 402.
depressions in, 35, 204.
Peritoneal pouch or sac, 8, 29, 38, 47, 51, 100, 281, 374,
397, 406, 411.
Petit, J. L., 117, 190, 198, 263, 389.
Phagocytes, 388.
Physick, Prof., animal ligatures, 285.
Pilcher, Lewis S., cases, 353.
Poland, John, 326.
Pollock, tendon ligatures, 305.
Pomcet, case of, 167.
Porter, C. B., case of, 348.
Posterior wall of the inguinal canal, 26, 35, 201, 392, 398.
Pott, Percival, 28, 38, 183, 199, 200, 260.
Potter, W. W., case of, 206.
Poulsen, statistics, 248.
Poupart's ligament, 17, 100, 110, 116, 132, 371, 405.
Processus vaginalis, 28, 35, 40.
Psoas muscle, 28, 32, 119.
Pudendal hernia, 2.
Punctum aureum, use in hernia, 260, 261, 370.
Puzey, Chauncey, cases of, 320.
Pyogenes epidermis albus, 112.
Sac, hernial, coverings of, 35, 45, 51, 86, 122, 219.
disposition of, 57, 94, 109, 139, 187, 201, 370, 392.
formation of, 51, 97, 191.
changes in, 54, 86, 143.
Sänger, operative measures, 204.
Saphenous vein, 115, 122, 126, 405.
Saviard, 198.
Scanzoni, case of uterine inguinal hernia, 177.
Scarpa, A., 13, 42, 66, 156, 185, 189, 200, 226, 239, 265,
368.
Schede, Max, 211, 313.
Schmidt, 246.
Schmucker, 265.
Schroeder, buried sutures, 301.
Scrotal hernia, 47, 53, 78, 187, 380.
Scultetus, 260.
Seeley, hard-rubber truss, 76.
Senn, N. E., decalcified bone plates, 241.
Septum crurale, 120.
Sermecrus, 261.
Seton, use of, 270, 272.
Severinus, use of cautery, 260.
Shephard, T. J., 169.
Silk ligatures or sutures, 241, 303, 304, 307.
Simmons, G. S., tendons from the fox-squirrel, 296.
Skin suture, method of application, III, 112, 204, 379, 396,
411.
Smith, Nathan, animal ligatures, 169, 288.
Socin, Prof., report of clinic, 314.
Spanton, D. W., operation in children, 282, 378.
Spermatic artery, 32.
cord, 16, 27, 32, 66, 120, 370, 392, 398.
Spiral spring truss, 189.
Stagner truss, 76.
Staphylococcus pyogenes albus, 112.
Steele, Charles, 312.
Sterilization of catgut, tendon, etc., 293, 295, 304.
Stimson, 366.
Stoker, Thornley, method of operation, 324.
Stokes, W. P., method of operation, 328.
Storer, H. R., method of operation, 201.
Strangulated femoral hernia, 131.
inguinal hernia, 85.
intestinal hernia, 215.
umbilical hernia, 197.
Subcutaneous wire suture, 146, 275, 394.
Subserous connective tissue, 31.
Supports, instrumental, 76.
Quercus alba, use in hernia, 275.
Rabagliati, A., method of operation, 321.
Radical cure of hernia, 110, 141, 204, 275, 284, 306, 312,
325, 332, 345, 352, 379, 382, 385, 393, 402, 411.
Ramdohr, 242.
Rat-tail sutures, use of, 298.
Reducible inguinal hernia, 71.
Reischet, 246.
Resection of intestine, 229, 233, 240.
Restoration of the obliquity of the inguinal canal, 110, 141,
222, 284, 371, 376, 397, 411.
Résumé, 385, 397, 410.
Retroperitoneal hernia, 217.
Reverdin, catgut, use of, 295.
Rhazes, 285.
Richardson, Maurice H., gangrenous hernia, 245.
Richelot, L. S., operative measures, 318.
Richter, A. D., Riggs's method of operation, 272.
Ring, femoral, 120, 405, 406.
inguinal, 23, 26, 36, 65, 71, 233, 370, 392.
umbilical, 191.

INDEX
421
Surgical measures advised, in adults, 382, 402, 410.
in children, 373.
importance of, 92, 131, 201, 218, 258, 348, 355, 382, 385,
390, 395, 402.
Suspensory ligament, 14.
Suture, or sutures, animal, 81, 112, 202, 284, 293, 304, 307,
346, 370, 397, 401.
intestinal, 230, 293, 306.
Lembert continuous, 224, 295.
Lembert interrupted, 229.
Marcy's “parallel” buried, 112, 229, 411.
Varicosity of femoral vein, 129.
Vas deferens, 28, 32.
Velpeau, 40, 272.
Ventral hernia, 2, 207, 210, 211, 407.
Vesalius, ligation of arteries, 285.
Vesical hernia, 185, 188.
Vessels, external pubic, 1o.
obturator, 156.
spermatic, 27, 32, 66.
Vinson, 156.
Vomitus, character of, 89, 236.
Tables, 6, 129, 407.
Taxis in femoral hernia, 131.
in inguinal hernia, 94.
Tendon suture, or sutures, advantages of, 285, 295, 297,
305, 307, 389.
Testicle, descent of, 28, 38.
removal of, 171, 264, 394.
Thevenir's two-branched dilator, 134.
Thyroid hernia, 154. (See OBTURATOR.)
Thyroidal entero-epiplocele, 158.
Tiffany, L., 354.
Tilanus, 316.
Tincture of cantharides, use of, 272.
Tincture of iodine, use of, 272.
Transversalis fascia, 22, 118, 371, 376, 399.
Treves, F., 169.
Triangle, Scarpa's, 156, 181.
Triangular ligament, 21, 30, 65.
Truss, or trusses, 74, 76, 376, 384.
Tucker, G. R., ligature and suture material, 294.
Tunica vaginalis testis, 28, 40, 47.
Warren, J. Collins, 267, 348.
Warren, J. H., 29, 99, 107, 274.
Warren, J. Mason, vomitus in bronchi, 236.
Wassilieff, A., ischiatic hernia, 165.
Watson, John, ventral hernia, 209, 273.
Weir, Robert, operative measures, 351.
Weist, J. R., operative measures, 355.
Wellington, W. W., 345.
Wells, Sir Spencer, 208, 378, 413.
Werth, buried sutures, 300.
Whale tendon, or tendons, 296.
White, H. C., case of, 241.
Whitman, B., case of, 350.
Whitney, W. F., case of, 187.
Wilcox, D. G., case of, 353.
Williams, John, case of, 178.
Wilson, A. H., case of, 9o.
Winslow, 15.
Wood, pad-truss, 269.
Wood, John, 108, 146, 269, 275, 301, 323, 413.
Wood, Thomas, subcutaneous suturing, 275.
Wolters, 313.
Wounds, drainage in, 110, 300, 379, 389.
infection of, 202, 289, 299, 309, 387.
intestinal, 230, 235, 306.
suturing, 110, 141, 146, 203, 223, 235, 306, 347, 365, 389,
392, 401, 402.
Wutzer, 270.
Wylie, W. Gill, 209.
Wyman, Jeffries, 309.
Umbilical arteries, 190.
Umbilical hernia, acquired, 191.
anatomy of, 54, 190.
radical cure of, 204, 381, 407.
strangulated, 197.
surgical measures, 196, 200, 386, 407.
Vaginal hernia, 2.
Vaginalis processus, 28, 35, 47.
Vanderveer, A., 353.
Yandell, D. W., 355.
THE END.






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