IRREDUCIBLE HERNIA; 
A DISCUSSION. 
BY 
Drs. D. W. Chkever.of Boston 
J. C. Warren/\“ 
G. VV. (xAY, / “ 
H. W. Cushinu, “ “ 
W. Ela, of Cambridge."^ 
C. W. Gali.oxtpk, of Lynn. 
F. H. Thompson, of Fitchburg 
E. W. Chapin, of Springfield. 
Vt the Annual Meeting of the Massachusetts Medicai Society 
June 10, 1890. IRREDUCIBLE HERNIA. 
Dr. C. W. Galloupe, of Lynn :—The great import- 
ance of this subject would not be a sufficient reason, on this 
occasion, for the reiteration of established rules, or. the 
repetition of recorded facts, without the addition of some- 
thing new in principle or interesting in personal observation. 
To most practitioners the subject of old incarcerated hernia 
is not particularly fascinating, and an overgrown suspensory 
bandage, or an esthetic pink abdominal belt would be the 
limit ot their treatment, while their gloomy prognosis tends 
to confirm the discouraged patient still more in his despair 
of relief. But to cure the incarceration and transfer the 
contents of the hernial sac to the abdominal cavitv where 
they can be held by a truss is certainlv a result worth every 
effort. 
The appropriate treatment for any case will depend, of 
course, largely upon the age, health, and social status of 
the patient, but more especially upon the nature of the 
obstacle to reduction. This may be due to adhesions 
tween the sac wall and its contents, so that the gut or the 
omentum becomes anchored in its new location ; adhesive 
bands may form near and across the ring, causing a partial 
obstruction to the return of masses of any size, while not 
preventing the escape of the abdominal contents, which is 
favored by the constant, steady pressure of the abdominal 
walls, and aggravated by the movements of the diaphragm 
in breathing and coughing, while the peristaltic motion 
tends to push the intestine through the ring, after a 
knuckle has been insinuated, in the same manner as it pro- 
pels the feces. This outward pressure is opposed by the 
resistance of the abdominal wall alone. 
Again, the deposit of fat in a piece of extruded omentum 
may increase its size and make it irreducible ; a fibrous or 
glandular growth in the mesentery may do the same. 4 
IRREDUCIBLE HERNIA. 
These processes are more or less chronic in operation, 
but an easily-reduced rupture may at any time quickly be- 
come irreducible through impaction of fecal matter, through 
peritoneal inflammation, or through the congestion and 
swelling of acute strangulation. Other accidental causes 
may prevent reduction :—hydrocele of the sac ; ascites ; 
the growth of abdominal tumors ; a permanent contraction 
of the abdominal cavity which would not allow the return 
of a large hernia of long-standing ; or, in the case of children 
with large congenital herniae, a lack of commensurate 
growth of the abdomen. 
Incarcerated hernia presents, accordingly, many problems 
to the surgeon, and the treatment must vary with the 
prominent features of the case. 
Acute strangulation requires about the same treatment in 
old as in recent hernia, with the exception that palliative 
measures and temporizing are more allowable in the old. 
Inflammation of the hernia demands rest, hot or cold appli- 
cations, opiates, and regulation of diet. Fecal infarction 
call for poulticing, copious enemata of water, oil, glycerine, 
etc., with kneading and judicious administration of purga- 
tives, especially salines. Hydrocele of the sac and ascites 
call for tapping or aspiration, while obstructing tumors 
must be removed or displaced. 
As a preliminary to any active measures the patient 
should be put to bed, with a good hair mattress for his own 
comfort and a high bedstead for the surgeon’s, lying on his 
back as much as possible, with the foot of the bed elevated, 
so that the force of gravity may be utilized to create a con- 
stant pressure of the contents of the sac upon the ring; by 
the same means the sac is emptied of ascitic fluid, and the 
sac wall of oedema. The bowels should be freely opened, 
and the diet restricted so as to prevent large fecal accumu- 
lations, and favor the absorption of fat. In a stout person 
I have found Ebstein’s system of dieting to rapidly reduce 
the fat deposits of the whole body. 
Returning now to our proper subject, old incarcerated 
hernia, the obstacles to reduction are mainly three : gluing 
together of the contents, adhesive band or anchorages, and 
fatty, glandular, or fibrous growths. An accurate diagnosis 
in each case is not always possible, nor is it strictly neces- IRREDUCIBLE HERNIA. 
5 
sary, as the treatment follows the same line. The size of 
the hernia, and the length of time that it has been irreduci- 
ble ought not to deter us from attacking it. The problem 
becomes mainly a mechanical one, and the prognosis will 
depend upon the ingenuity of the surgeon. 
The consideration of a special case will best indicate the 
treatment. 
Case.—My patient is a large-boned, heavy man, 46 
years of age. At the age of 17, while in the act of lifting 
a cask weighing 825 pounds into the rear end of a wagon, 
his foot slipped a little on the snow, and he felt a sudden, 
stinging pain in the left groin. This pain continued, and 
at the end of a week or ten days he noticed a swelling in 
the groin as large as the end of a thimble. He kept con- 
stantly at work, however, until at the end of two years his 
father noticed that he seemed weak and disinclined to lift. 
He then explained the cause of his laziness, and at that 
time examination disclosed a bunch the size of a hen’s egg. 
An iron truss was applied by a country practitioner, 
which was discarded the next day on account of the pain it 
caused. In five years from the date of injury the hernia 
had dropped down into the scrotum, and lie was then fitted 
to a knitted bag, which acted as a suspensory. The rupture 
had increased constantly but slowly up to a year ago, when 
it was about the size of acocoanut. 
At that time he jumped from a horse-car and felt a 
sudden yielding, while the tumor doubled in size in an 
hour’s time. Since then it has steadily increased and has 
prevented him from doing any active work. There has 
been but little pain, but a constant pull and drag that have 
made him an invalid and have led him to indulge freely in 
alcoholic stimulation. 
At the time I first saw him, March 28, 1889, the hernia 
measured 25£ inches in circumference around its base, 30 
inches around its largest part, and its length from pubes 
to perineum was 17 inches. It was of the left inguinal 
variety, but, on account of its size, and the fact that it had 
dissected up the skin from the lower part of the abdomen 
and from the upper part of the thigh, the ring could not be 
felt nor the contents mapped out. He was placed supine 
on a hard bed with the foot elevated ten inches, the bowels 6 
IRREDUCIBLE HERNIA. 
evacuated, and the diet restricted to concentrated and 
digestible foods. At the end of forty-eight hours the 
oedema of the scrotum had subsided sufficiently to disclose 
the nature of the contents of the sac. The upper portion 
contained many coils of gut, while the part nearest the ring 
and below was solid and nodular. Efforts at reduction were 
made and a considerable part of the intestine returned. A 
cotton bandage was then applied in circular turns to form a 
pedicle to the mass, and three sand bags, of three and five 
pounds weight, laid on the top, while a broad sling over 
the shoulders and around the neck held the mass vertical. 
On the fifth day the intestine could be all reduced, and the 
mass measured 21 inches in circumference by 14 in length. 
The residue was omental, the chief obstacle being a hard, 
solid cake four inches in diameter and two inches thick. 
The ring could be easily felt, admitting three fingers. From 
the outset the cotton bandage was applied once or twice 
daily, and after a few days a rubber bandage outside the 
cotton. No attempt was made to exert pressure by bandag- 
ing across the top, as the effect of this was to gradually 
squeeze the mass out under the ring of bandage and cause 
the whole apparatus to slip off. For the same reason the 
sand-bags were of but little value, the chief reliance being 
placed upon daily manipulation to break up the omental 
lumps and dilate the ring, while the tight circular bandage 
caused an internal tension which constantly tended to 
squeeze out the contents of the sac. No pain was felt at 
any time unless the rubber bandage were too tight. If 
applied directly to the skin it would roll up and cut in un- 
comfortably, so that the following plan was adopted : ten 
yards of cotton bandage, two inches wide, were wound 
around close to the abdomen, including the penis and 
testicles, each turn approaching as near as possible to the 
abdominal wall, so as to form a hard constricting collar 
four inches wide ; outside of this was wound the rubber, 
being worn about three hours at a time. 
On April 14th, the seventeenth day of treatment, while 
squeezing the omental cake, it seemed to separate on one 
edge and open out to form a crescentic mass, which was 
insinuated by its smaller end into the ring and by dint of 
steady pressure was wholly reduced, exposing an opening IRREDUCIBLE HERNIA. 
which easily admitted four fingers. A graduated compress 
and spica bandage retained the hernia, and two days later 
the patient was up and around the room with a water-pad 
truss on. Much difficulty was found in getting a truss 
which would retain all the omental masses, but no intestine 
has escaped since the first reduction. The patient was 
attending to his daily work when seen in November, and 
had gained considerably in flesh, while the scrotum had 
shrivelled very greatly and the ring had closed up about 
one-half. May 4, lbSiO, I found the ring contracted so as 
barely to admit two finger-tips, while the scrotum was still 
more shrivelled. He reported that there had been no 
protrusion whatever, although without his truss he has 
walked about his rooms, and on one occasion jumped out of 
bed and ran down stairs in pursuit of a burglar. There is 
now a hard, fibrous mass the size of a hen’s egg, attached 
to the cord about two inches below the ring. This is what 
bothered us at first in the application of the truss, but it is 
now evident that the mass does not belong in the abdomen, 
but is an outgrowth of the spermatic cord. There is no 
escape of abdominal contents, but when he coughs I can 
feel a large, smooth mass press against the ring like a valve. 
The patient now leads a most active life, has gained 20 lbs. 
in weight, and has given up his rum. 
An incarcerated hernia of this size was not a very prom- 
ising case to undertake, more especially as it had proved 
itself unyielding to many physicians during the past thirty 
years ; but having had the privilege of tending a number 
of such cases under Dr. J. Collins Warren in the Massa- 
chusetts General Hospital, I was encouraged to try it by 
the method of treatment proposed by him. 
In considering the mechanics of this treatment we may 
represent the hernia diagrammatically by a rubber bag filled 
with fluid, resting upon a rigid ring of less diameter than 
itself. I he problem is to force the ball through the rino\ 
ihe first aid we have is gravity, obtained by the supine 
position and elevation of the foot of the bed ; next the bags 
of sand or shot, which adapt themselves to the shape of the 
hernia and exert a constant pressure; third, the direct 
pressure of the hands in daily manipulation. In addition 
to these means of direct pressure we have the constrictin0- 
9 ° IRREDUCIBLE HERNIA. 
band, which to my mind is the most important feature. 
If pressure be exerted upon a body of fluid, it is transmitted 
equally in all directions, and with no loss of power except 
from the internal friction of the molecules of the fluid. If a 
cord be bound around a rubber foot-ball with a pressure of 
ten pounds, there will be exerted at every point of the sur- 
face a force often pounds, minus the friction of the fluid, 
which is very trivial. The ring of rubber bandage around 
the hernia exerts a pressure proportionate to its elasticity, 
equally in all directions, but this is opposed by the rigidity 
of the sac wall everywhere except over the ring, where 
there is no obstacle. Consequently a pressure of ten 
pounds by the bandage means a direct downward pressure 
of ten pounds on the ring, minus the friction of the soft and 
easilv-movable contents which obey the same laws as fluids. 
This is the most valuable part of the treatment. This 
pressure would be uncomfortable except for the broad 
bandage of cotton that is first put on to form the pedicle of 
the tumor, but, when so diffused, it is bearable for one hour 
or ten hours according to the tightness of the rubber. This 
can be applied and taken off' by the patient at will, and 
with this pressure I consider the sand bags useless and even 
objectionable. Next to this, the daily manipulation of the 
contents assists by breaking up the internal adhesions and 
dilating the ring. The whole treatment of such a case re- 
quires from two to six weeks of rest in bed, which the 
patient readily becomes accustomed to, and there is but 
little pain from the manipulation, which can and should be 
gentle, even although considerable force is used. If, how- 
ever, it appears that after the greater part has been reduced, 
there still remains a hard mass that does not diminish, I 
should give ether and force it in either by separating its 
substance or tearing the ring,—taking it for granted that 
such a tear would immediately unite. After reduction a 
compress and thorough spica bandage should be worn for a 
few days, then a perfectly fitting truss applied before the 
patient gets out of bed. 
This mode of treatment applies to unbilical as well as 
scrotal herniae, and is in that case more easy of application. 
In conclusion I would say that the safety, comfort, ease 
and notable success of this mode of managing large incar- IRREDUCIBLE HERNIA. 
9 
cerated hernife, deserve from the general practitioner much 
more attention then is at present accorded it. To relieve 
acute obstruction by a skilful though hazardous stroke of 
the knife, is a gratifying act; to relieve a patient of the long- 
endured burden of an old irreducible hernia, together with 
the pain and danger of accidental strangulations, and this by 
a process comparatively painless and free from danger,—to 
do this is equally gratifying to the patient and to the sur- 
geon. 
Dr. J. C. Warren, of Boston :—This is a subject which 
has interested me considerably, and to which I have given 
attention for some years, and therefore I feel authorized to 
make some remarks on this occasion. In the first place, 
a word about the development of irreducible hernia. Ir- 
reducible hernia is very apt to follow the general life his- 
tory which Dr. Galloupe has sketched for it in his case. 
During the most active period of life, from 17 perhaps to 
25 years of age, is the period when irreducible hernia first 
shows itself. For some reason or other, at that time there 
are difficulties in returning the hernia and treatin'; it as an 
ordinary reducible hernia should be treated. I think that 
is what we find in cross-examining the patients with this 
affliction—that, owing to its being omental, perhaps, in 
character, or owing to great carelessness on the part of the 
patients themselves, the hernia has not been returned habi- 
tually into the abdominal cavity. 
Some of these hernias, in their early stages of develop- 
ment, are exceedingly obscure. Many cases that I have 
questioned have stated that the diagnosis was not clear; 
that some surgeons had thought it was varicocele, others 
a hydrocele of the cord, and others a hernia. There 
would be a fullness, a more or less well-developed mass in 
the inguinal region, and an inability to displace it. In one 
case that I have had, an operation for varicocele was done 
by a French surgeon, with the idea of curing the case. 
As the patient advances in life, business pursuits divert 
his mind, and he is unwilling to sacrifice the time which is 
necessary in order to devote himself to the proper amount 
of treatment required for cure. He tries a truss, and the 
truss fails to do its work. He satisfies his conscience by 10 
IRKEDUC1BLE HERNIA. 
wearing the truss part of the time each day, although it is 
doing no good, and probably is doing harm. As he reaches 
the obesity of middle life, the hernia begins to increase in 
diameter, with the fat deposit that is taking place in all 
parts of the body. The force of gravity is a force which is 
constantly acting during the day time to draw the omentum 
or the bowel out of the abdominal cavity, in addition to the 
natural intra-abdominal pressure which always exists. The 
consequence is that when the man has reached the height ot 
his business activity, in middle life, in the forties, he 
is afflicted with a very large, bulky hernia. An irreduci- 
ble hernia cannot last through a period of twenty years 
without becoming also a large hernia. Then we begin to 
have various little complications, as well as big ones. 
Among the little complications is the external irritation 
to which the patient is subjected. An eczema of the scro- 
tum, in a stout individual who is very active, will become 
sometimes so great a source of annoyance as to lay the 
patient up for a considerable portion of the year. That is, 
one patient of mine was obliged to stay in bed for from 24 
to 48 hours each week, in order to allow the congestion of 
the part to be relieved, and the irritation of the skin to sub- 
side, so that he could get about the rest of the week and do 
his work. 
Then of course we have the various complications which 
you are all familiar with in irreducible hernia, viz., the ten- 
dency to become inflamed, the tendency to become incarce- 
rated ; I might add, also, the tendency to become strangu- 
lated, but that is a rare complication of the type of hernia 
which I am describing. A hernia which has reached so 
large a size has a large ring as well as a large sac and large 
contents. The ring is probably suflicientlv large to admit 
from three to four fingers. Is'ow such a ring as that can 
never be constricted sufficiently to stop the circulation in the 
larger vessels which are furnishing the contents with the 
necessary blood supply. Therefore this fact perhaps it is 
well to keep in one’s memory, that strangulation of these 
large hernias is not likely to occur. 1 hey are more liable 
to have what is called incarceration, by which are generally 
understood an obstruction and a local peritonitis, periods of 
inflammation which are accompanied by local pain and ten- irreducible; hernia. 
11 
derness, and perhaps vomiting,—symptoms pretty severe in 
character, but which do not terminate in gangrene of any 
portion of the hernial contents. 
The complications, however, are sufficiently grave to 
make it very important to urge upon the patient some effort 
at relieving himself from so severe an incumbrance. At 
the present time, when antiseptic surgery and abdominal 
surgery have placed us in an attitude towards the forms of 
disease which we were not in you may say even so short a 
time as ten years ago, it may probably suggest itself to 
your mind that the simplest operation would be an incision, 
laying open the sac and dissecting off the adhesions, excis- 
ing the hypertrophied bars of fatty tissue which represents 
the omentum, and returning the bowel and sewing up the 
ring,—the ordinary operation, in other words, for the radi- 
cal cure of hernia. That operation undoubtedly is done, 
and can he done a great deal more frequently in surgical 
practice than we formerly advised. But that operation is 
not adapted to all cases, and is not indicated in quite a 
large number of them. 
In the fi rst place, the patient shrinks from going through 
the ordeal of the operation. In the second place, we can- 
not conscientiously assure the patient that we are going to 
have a radical cure bv that operation, and the probability is 
that in these large hernias, whether they are inguinal 
or umbilical, the majority of them will recur to a greater 
or less extent after a certain length of time. I do not 
mean to decry this operation. I think it is one of the 
great benefits that antiseptic surgery has given us—the 
opportunity of relieving suffering manhood from such a dis- 
agreeable affliction as this one. We can undoubtedly relieve 
the principal symptoms by the operation. We can put the 
patient in such a position that a light truss will enable him 
to go about as comfortably as any individual with a small 
reducible hernia, and I have at present more than one pa- 
tient who reports to me from time to time, with great satis- 
faction, his condition after such an operation as I have 
mentioned. 
But perhaps it is more interesting to the general practi- 
tioner to know about the class of cases in private practice 
which Dr. Galloupe has described in the case which may be 12 
IRREDUCIBLE llEHNIA. 
considered a typical one of the kind in question. The class 
of patient adapted to this particular kind of treatment is in 
the first place the active, busy man, who perhaps dreads the 
operation, fears that he may be laid up a Ions; time, does 
not wish to run the risk of an operation, and will consent to 
treatment without the use of the knife. You know it is a 
much more seductive proposition than the operative mode 
of treatment, to the average man. 
Then we have another class of patients with organic dis- 
ease. One of the first cases of large hernia I had to treat 
had most pronounced Bright’s disease of the kidneys, and it 
would have been manifestly highly improper to perform 
laparotomy on that patient. His weight amounted to 
over three hundred pounds. It would have been fatal, 
undoubtedly, if the radical cure had been attempted. Old 
people and enfeebled individuals are not good subjects for 
abdominal surgery of this kind. Perhaps a simple laparo- 
tomy for ovarian tumor, with a clean incision, with the re- 
laxed abdomen afterward might be followed by the best 
results. We know that it is done successfully, even in 
the aged. Cases have been reported where patients over 
eighty have had ovariotomy performed, and with satisfac- 
tory results. But here we are dealing with a different pro- 
blem. We are pushing something back into the cavity, and 
making the cavity fuller, more distended, than it was before. 
There is always more or less shock after a radical cure of 
hernia, more than after an ordinary laparotomy in the me- 
dian line, and I am inclined to think that feeble and large 
persons, the subjects of organic disease, are not suitable 
for the cutting operation. 
Then again, the treatment is not always applicable, on 
account of the situation of the patient and his surroundings. 
The general practitioner is not prepared for the complica- 
tions of laparotomy. The patient is unable, perhaps, to 
travel, or to reach some hospital where the operation could 
be conveniently done, with all the modern conveniences and 
advantages. Therefore it seems as if the mode of treat- 
ment which has been sketched out already was adapted to a 
very considerable number of cases. 
Now, in regard to the treatment. It is not a new treat- 
ment. Dr. Galloupe has kindly alluded to me as having IRREDUCIBLE HERNIA. 
13 
taught him some points about this mode of treating irredu- 
cible hernias. Dr. Samuel Cabot, and others of his con- 
temporaries, undertook this method of reducing large and 
irreducible hernias, over thirty years ago, when I was a 
medical student, and the method, if I am not mistaken, was 
derived from the French surgeons ; and it was here that the 
elastic bandage was first used as a therapeutic agent. 
The hernia, which we will assume for the time being is a 
scrotal disease, was caught up by the hand around its pedi- 
cle, and formed into a pediculated mass. The bandage was 
then wound around the neck of this pediculated tumor. If 
we wind a bandage around the scrotum with hernial con- 
tents, the moment we have the bandage wound around we 
find that it collapses and that its contents have disappeared, 
not into the abdominal cavity, but rather into the loose fatty 
and cellular tissue of the perineum or abdominal wall, es- 
caping of course from the grasp of the bandage. It will 
escape wherever the pressure is relieved. If there is an 
absence of resistance just around the outside of the ring, 
we lose the effect of this mode of pressure. Dr. Galloupe 
supplied this pressure by first winding a linen or cotton 
bandage around the tumor, and making thereby a pedicle. 
That is the technical expression—first make the pedicle. 
He made a cylindrical collar of cotton, which opened at one 
end into the hernia, at the other end through the ring into 
the abdominal cavity. 
The old French method was to grasp the hernial sac, 
make a pedicle, and then take one or two very tight turns 
just above the hand, so as to make a pedicle ; then, when 
that was once made, continue winding the turns over the 
sac itself, in order to force it back. But the moment you 
have taken one or two other turns around the bandage, it 
requires a good deal of courage to leave the bandage there, 
for it must be so tight, in order to hold the part, that it is 
practically a tourniquet, and the whole tissue turns such a 
color that it requires a good deal of courage, as I say, to 
leave it on there sufficiently long. Of course, venous 
congestion is relieved by continuing the pressure all over 
the fundus of the tumor with the wound bandage. That 
being held in position for several hours will materially di- 
minish the size of the tumor and sometimes will force it 14 
IRREDUCIBLE HERNIA. 
back into the abdominal cavity. In order to got up a 
firm pressure, which would avoid the danger of mortifica- 
tion of the part, I devised a bag, some years ago, for a 
particular case. While it was being prepared, the patient 
was going through the line of treatment that has been 
sketched. The foot of the bed was raised, so that the force 
of gravity would act from without inward. The scrotum 
was held up and weights applied, so as to give a moderate 
pressure. After that treatment, pursued for several weeks, 
the tumor diminished about two-thirds in size. There was 
left a large ball of fatty tissue, which represented the omen- 
tal part of the tumor, to be disposed of. The bag was 
made in tbe shape of a balloon, with an opening about 
three inches in diameter. It was made of two layers, the 
inner one being a soft flexible one, and the outer an inflexi- 
ble one. Being blown up between the layers, the flexible 
one produced pressure on all sides. This bag was put on 
like an ordinary rubber bag capable of inflation with air. 
After it had been strapped down firmly and held to the ring 
by a large number of figure-of-eight turns in all directions, 
so that it was buried up with bandages, the pressure was 
brought to bear by blowing it up with air or water. The 
pressure was left on for fifteen hours, and when it was taken 
off the hernia had been reduced. The hernia was about the 
size of that pitcher [a medium-sized one] originally, having 
lasted twenty years, and had resisted the efforts of a large 
number of surgeons. The patient was a victim of Bright’s 
disease. lie was comfortable for the remainder of his life, 
which lasted seven or eight years after the treatment, and 
he died of Bright’s disease. The hernia was kept back by 
an ingenious strap truss, which he devised himself. I have 
since then reduced a number of cases in that way, and then 
succeeded afterward in retaining the hernias. 
There are a certain number of hernias which have very 
large openings, and which after reduction come out again. 
They cannot be held back by any apparatus. The patient 
is unable to use the amount of ingenuity and brain work 
which is necessary to apply and keep in position a truss, or 
there are inherent difficulties in the problem. In these 
cases I am content with using a very large, stout, jean-cloth 
suspensory bandage, and with that form of apparatus the 15 
IRREDUCIBLE HERNIA. 
hernia will be made so much snugger and more manage- 
able and smaller that patients are as a rule satisfied with it. 
I have an old man, over eighty years of age, who uses such 
a support, and has used it for ten years, with very satis- 
factory results. lie would never have been able to wear 
any kind of truss, he was too old for a radical cure, and 
this seemed to be the best method of treating his case. 
Dr. G. W. Gay, of Boston :—In preparing1 the few re- 
marks I have to offer upon this subject, I have assumed 
that it was particularly desirable to bring forward our ex- 
perience in treating cases of old irreducible ruptures, such as 
heretofore have been accustomed to roam about from hospital 
to dispensary, or from one physician to another, until falling 
into the hands of some enterprising man having plenty 
of time and an abiding faith in antiseptics, they have been 
subjected to a thorough and prolonged, if not a very suc- 
cessful method of treatment. In other words, the duration 
of the affection is an element, and an important one, in the 
classification of the cases which come under our consideration 
to-day. 
In numerous instances, though the rupture has existed for 
months or even years, yet it has been irreducible only a few 
days. The symptoms of strangulation are not yet developed, 
but from the tenseness of the tumor and the discomfort of 
the patient, they may come on at any moment. The ad- 
hesions of the contents of the sac in these cases being com- 
paratively slight, the treatment is more simple and the 
results are more favorable than in the next class. 
The greater number of old irreducible hernias are brought 
to the surgeon’s notice by reason of a recent strangulation 
either of the original contents of the sac, or of fresh ac- 
quisitions to the same. In many instances an irreducible 
omental hernia gives very little trouble, until a knuckle of 
intestine comes down and gets entangled in the meshes of 
the omentum, when symptoms are pretty sure to declare 
themselves in a very short time. In looking over the 
records of the Boston City Hospital for the past ten years, 
I find that the majority of cases of irreducible hernia come 
under these two classes : the recently descended, but not 
strangulated, and the descent of bowel behind the omentum. 16 
IRREDUCIBLE HERNIA 
A third and rarer class of cases are those large, unwieldy, 
unmanageable ruptures of long standing, which have here- 
tofore been the bane of the out-surgeon, and a no very 
welcome guest to the visiting surgeon of our hospitals. 
They are bundensome from their size, as well as from the 
colicky pains and various discomforts to which they give 
rise. No sort of truss or other appliance is very satis- 
factory in preventing their slow and sure increase in bulk 
and weight. They may be composed of bowel, or of 
omentum, or of both together. The adhesions are apt to 
be very firm and unyielding, the parts out of all natural 
proportions, and the different structures enlarged, thickened, 
and changed in various ways. lie who undertakes to re- 
lieve these cases by operation, should make up his mind to 
a long, tedious, and oftentimes puzzling dissection, and not 
allow himself to be surprised if he is unable to accomplish 
as much as he would like. These operations require 
patience, perseverance, and a strong back. 
A brief resum6 of a few of the cases treated by the sur- 
geons of the City Hospital during the past ten years may 
be permitted at this time. 
I. —A woman, 48 years of age, had an irreducible 
omental hernia of one year’s duration. Five days before 
coming under Dr. Cheever’s care a small knuckle of in- 
testine came down, causing pain, but no other symptoms of 
strangulation. Herniotomy. Omentum firmly adherent 
to sac ; cut off even with ring. Discharged in seven weeks 
wearing a truss. Five years later this patient was admitted 
to the hospital again, with symptoms of strangulation in 
the old hernia. It was reduced under ether by taxis, and 
as she was found to be suffering from chronic nephritis 
nothing further was attempted. 
II. —A young woman of 17 had an irreducible femoral 
hernia, the size of an egg, for one year. Operation by Dr. 
Gay. Omentum cut off. Well in five weeks, and wearing 
a truss. Has been under observation over four years, and 
is now wearing a truss. The rupture lias never returned. 
Ill .—A man, aged 33, had an inguinal, omental hernia, 
of moderate size, for fourteen years. Irreducible for some 
time, not definitely known to patient. Herniotomy by Dr. 
Gay. Able to leave the hospital in seven weeks wearing a 17 
IRREDUCIBLE HERNIA. 
truss. Was free from rupture a year and a half later, but 
did not dare to leave off the truss. These two cases are 
reasonable cures. 
IV. —Direct inguinal hernia in a man aged 21 years. 
Irreducible for several years. Operation by Dr. Cheever. 
Omentum removed. Recovered in a month. No truss 
worn on leaving the hospital. 
V. —A woman, aged 52, had an omental femoral hernia 
for eight months, size of a lemon. Irreducible four days ; 
no signs of strangulation. Herniotomy by Dr. Gay. 
Omentum ligated and cut off. Recovered in a month, but 
could not wear a truss. 
VI. —Dr. Gay operated upon a woman 52 years of age 
for an irreducible omental femoral hernia of eight years’ 
duration, in October, 1880. As is very often found in those 
old omental ruptures, a knuckle of bowel had come down 
and become entangled in the meshes of the omentum the 
day before the operation. There were no signs of stran- 
gulation. The bowel was returned, and the ring was 
plugged with the stump of the severed omentum. Wound 
healed in six weeks. 
VII. —A man with an irreducible inguinal hernia of two 
© 
years’ duration, after being treated for a month by com- 
pression and position, was operated upon by Dr. Burrell. 
Omentum firmly adherent to sac. Patient died in three 
days, and the autopsy revealed fatty kidneys. 
VIII. —Two days before entrance, Mr. M.’s hernia (in- 
guinal) came down ; taxis failed to reduce it. Dr. Homans 
did the "minor” operation successfully (sac not opened). 
Patient discharged well in three weeks. A few months 
later he returned to the hospital and was operated upon for 
strangulation at the site of the former operation. Feces 
escaped from the wound a few days during convalescence. 
The wound was nearly healed in three weeks, when he left 
the hospital. 
The two following cases occurred in Dr. Cheever’s private 
practice. 
IX. —A man, aged 68, had a femoral rupture irreducible 
for years, size of a small egg. Sudden strangulation ; 
herniotomy. Intestine and omentum in sac. Former re- 
turned ; latter adherent, dissected off and cut away. Stitches 18 
IRREDUCIBLE HERNIA. 
of boiled silk slowly ulcerated out in two months. Wound 
then healed ; tissues firmly contracted. Patient wears a 
truss, and is comfortable. A good result. 
X. —Man, aged (52, scrotal hernia size of a large fist, 
irreducible for years, steadily increasing in size, and attracts 
patient’s attention constantly by the discomfort. Operation. 
Large amount of omentum and eight inches of bowel, both 
firmly adherent to sac, and to each other. All dissected up 
and freed, but reduction was impossible until the inguinal 
canal had been slit up an inch and a half, when the whole 
was returned with much difficulty, due apparently to the 
want of room in the abdominal cavity. Wound closed with 
four boiled silk sutures. Usual antiseptic precautions. 
Abscess on the sixth day followed by sinus. Slow extru- 
sion of stitches for period of four months. Wound is now 
nearly healed, but it is to be observed that during all this 
time the hernia has been solidly held in place by the heavy 
cicatrix. No impulse, and no truss. Patient goes about. 
The result obtained in this last case is the same as is 
sought by Dr. McBurney in his operation, namely, a closure 
of the canal and rings by a large solid mass of cicatricial 
tissue. 
XI. —Nearly a year ago Dr. Cheever operated upon a 
woman, aged 49, who had an umbilical hernia the size of a 
cocoanut. It had existed 17 years, and had been irre- 
ducible several weeks. Patient confined to a sitting or 
recumbent position for 8 or 10 months, as nothing retained 
the rupture without producing excoriations and inflam- 
mation of the deeper tissues. 
The entire sac was removed by long elliptical incisions. 
Bowel dark colored. Omentum adherent to ring, which 
admitted three fingers. Contents of sac returned, and 
wound closed with one catgut, three button (wire), and 
several superficial silk sutures. 
The patient suffered great pain after the operation, which 
was only relieved by removing the deep wire sutures. 
She sat up in three weeks, and left the hospital in a 
month. She is now wearing a belt; follows her vocation 
as a cook, and is very comfortable. 
An old woman was brought to the hospital a few weeks 
since with a moderate sized hernia in the umbilical region. IRREDUCIBLE HERNIA. 
19 
It was gangrenous, covered with blebs, and the patient was 
in a partial collapse. She had been ill at least three days, 
but had had the rupture for years. A very little ether was 
given ; sac opened by Dr. Gay ; bowel adherent to ring ; 
latter cut open an inch and a half; healthy portion of 
proximal intestine stitched to ring ; artificial anus made of 
the gangrenous portion, which included about ten inches. 
Patient rallied well from operation, and was very com- 
fortable for the remainder of her life. She died in about 
two months of starvation, due to limited area of bowel sur- 
face from which absorption could take place. Resection 
and suturing the bowel would undoubtedly have ended 
fatally upon the operating table. 
In another case of a large irreducible, scrotal enterocele 
of long standing, I undertook to do an operation. Symp- 
toms of strangulation had subsided, and gangrene had 
supervened. The patient suddenly developed oedema of 
lu ngs while taking the ether ; his bronchial tubes became 
filled with mucus and serum, and he died before the opera- 
tion was fairly begun. A cessation of the symptoms of 
strangulation, that is, pain and vomiting, with persistence 
of the tumor, means collapse ; and I have never seen any 
treatment do good under these circumstances. Operation 
is always fatal, so far as I know. 
An old man was admitted to the hospital some years ago 
with an enormous scrotal hernia, which was gangrenous, 
and had been irreducible for a long time. An opening was 
made directly into the sphacelated portion, with a view of 
giving exit to the pent-up gases and other offensive mat- 
ters. The condition of the patient forbade any further 
efforts for his relief. lie lingered several days, and died 
from exhaustion. 
It will be noticed that in a majority of the above cases 
the irreducible portion of the hernia was omentum. Sud- 
den strangulation was often due to the descent of bowel 
behind or alongside of this structure. The frequency of 
the occurrence forms a strong argument in favor of sur- 
gical interference in these irreducible ruptures. They are 
treacherous affections, and besides being the source of much 
discomfort from their size, weight, bearing down sensa- 
tions, and colicky pains, are liable at any time, and with- 20 
IIIUEDUCIBLE HERNIA. 
out warning, to become obstructed, inflamed, or stran- 
gulated, often leading to fatal results. Previous to the 
introduction of antiseptic methods of treating wounds, the 
results of operative measures were not very encouraging. 
As the danger of opening the peritoneum has been very 
greatly diminished by recent modes of wound treatment, 
one need not feel that hesitancy in attacking these cases 
that formerly existed. While experience does not justify 
us in promising perfect cures in a majority of cases, yet 
much good may be accomplished by a judicious resort to 
surgical measures. The tumor may be removed ; adhesions 
severed ; displaced organs restored to their normal position ; 
various sorts of pain and discomfort gotten rid of; and the 
patient’s mind relieved of a great and constantly increasing 
burden. And, finally, by being enabled to wear a truss 
or other support, he may thus exchange a life of invalidism 
and suffering, for that of usefulness and comparative comfort. 
Dr. H. W. Cushing, of Boston :—My part in this dis- 
cussion is to present the operative side of the question. Lhe 
object to be attained is a complete and permanent relief from 
the affection, to place the patient in a position where he will 
be permanently independent. I think I can best describe 
this method by reading the description of an individual op- 
eration. 
The patient was a boy aged 12, the victim of an irreduci- 
ble hernia of four years’ duration. 1 he operation was 
commenced by a straight incision, extending from Poupart’s 
ligament over the crural ring to just below the saphenous 
opening. The sac was exposed and found to contain omen- 
tum, which manipulation failed to separate from its adhesions 
to the edge of the saphenous opening. The sac was then 
explored from above. In order to do this the upper end of 
the incision was prolonged outwards, parallel to and one 
half an inch above Poupart’s ligament, making the total 
length of the wound three inches. By dissecting through 
the subjacent tissues, the sac was exposed as it entered the 
crural ring. It could then be freed from within outward by 
gentle traction, manipulation and dissection, and, after divi- 
sion of the adhesions to the saphenous opening, became 
easily reducible. I would especially recommend this opera- IRREDUCIBLE HERNIA. 
21 
ting wound, i. e., the method of exposing the hernia from 
above and below the crural opening, as giving a much better 
idea of the exact condition of the anatomical relation of the 
parts, and the ease with which, if possible, these adhesions 
are relieved. The sac was now opened with the scissors 
and the scalpel, and the omental adhesions of the inner sur- 
face were divided with considerable difficulty, the omental 
mass, measuring two inches by one and one half, was then 
ligated, and the stump pushed back into the cavity. A 
continuous suture closed the sac, which was then folded 
on itself, and fixed within the abdomen. The suture 
affecting this reduction passed through the crural ring, 
up through the transversalis fascia, the conjoined tendon 
and aponeurosis of the external oblique. The crural ring 
was next closed by suturing Poupart’s ligament with a 
quilted suture. The femoral vein was protected with the 
retractor. When secured, the opening had apparently be- 
come impervious. The enfolded sac formed a pad which 
was firmly fixed against the internal opening of the canal. 
The pubic and iliac portions of the fascia lata were next 
sutured in a manner similar to that by which Macewen 
causes the external pillar to overlap the conjoined tendon iti 
the inguinal operation. The operating wound was then 
closed. No drainage. Aseptic dressing. The patient re- 
mained in bed two weeks, his condition being practically 
normal during the time. Dressed on the twelfth day. A 
narrow red line alone marked the seat of the operation. 
Complete union by first intention. An indurated mass 
could be felt just above Poupart’s ligament. No tender- 
ness. There has been no subsequent treatment. Operation 
May 14, 1888. The patient, an active restless boy, has 
been without any apparatus or support since that time. In 
the opportunities which 1 have had to carry out the details 
described, the result has been corresponding to the case re- 
ported. 
Dr. Walter Ela, of Cambridge:—The irreducibility 
of a hernia may depend : 
(1) On its bulk, 
(«) from the presence in the intestines of flatus, 
fluid, or feces, or, IKREDUCIiiLE HERNIA 
(6) from the enlargement of the omentum or mes- 
entery from the deposition of fat, or, 
(c) from fibroid or other organic change, the neck 
of the sac being narrowed by atrophy and the seat 
of an hour-glass contraction, there being, in other 
words, a mass disproportioned to its orifice, and 
doubling up when pressure is applied. 
(2) On more or less firm and extensive adhesions of 
the sac to its contents, or, 
(а) of the latter to each other, or, 
(б) bv fibrous bands traversing the sac, associated 
with changes in the shape of the sac or omen- 
tum, or, 
(c) when the hernia is csecal, when the naturally 
adherent peritoneum is dragged down and be- 
comes fixed to the tissues into which it is pro- 
truded. 
(3) On some fresh descent of omentum or bowel, as 
when the latter is caught between folds of the 
omentum. 
(4) On spasmodic muscular contraction which influ- 
ences the size of the abdominal rings under the 
influence of irritation ; or, induration of the neck 
of the sac itself, or of the parts around. 
(5) It may moreover be irreducible from other causes 
than those inherent in the rupture itself by being 
forced from the abdominal cavity by constant 
pressure, as by the presence of ascites. When 
the fluid is withdrawn, the hernia may be re- 
duced. A large old rupture may be too bulky 
for the now contracted abdominal cavity. 
In most cases the prime cause of this condition of irredu- 
cibility is attributable to the neglect of proper treatment of 
a reducible hernia by the use of a truss. When inflamma- 
tion is set up a hernia may become irreducible in a very few 
days from adhesions. 
An irreducible hernia may be partly reduced, the intestine 
being the part which slips back into the abdominal cavity, 
and the omentum, which cannot be returned. 
Irreducible hernia, always a source of anxiety and danger, 
may produce many inconveniences by its size and weight, IRREDUCIBLE HERNIA. 
23 
which are aggravated by corpulency or pregnancy. It al- 
ways has a tendency to increase in size if left to itself. 
Even if small, the patient may have a sensation of weak- 
ness in the part, and dragging pains in the abdomen. 
The objective symptoms if the tumor is large are self-evi- 
dent ; the subjective ones are dyspeptic, as flatulence, 
nausea, constipation from irregular peristaltic action, per- 
haps attacks of vomiting, and colic. The tumor is greatly 
exposed to external injury, and is in constant danger of 
obstruction and strangulation. 
The first symptoms of these are, general distress, 
vomiting (in later stages stercoraceous), arrested peristaltic 
action of the bowels, want of impulse on coughing, heat, 
swelling, and pain in and about the tumor. 
Unless these symptoms subside or are relieved, we 
will have gangrene, and fecal fistula if not collapse, and 
death. 
The severity of the symptoms is in proportion to the 
distance of the strangulated intestine from the stomach, the 
nearer the rectum the less distressing the vomiting. 
The medical treatment of a simple irreducible hernia 
should consist of regulating the diet, bowels and exercise. 
If impaction of feces seems to be an element in the case, 
copious laxative enemata, aided by the topical application of 
hot fomentations, with the patient in a recumbent position, 
will at times aid taxis to a successful issue. 
If the hernia is strangulated, however, do not give 
purgatives, but opium, ice to suck, hot fomentations (or in 
the early stage ice if more agreeable), and time, but too 
much time must not be lost in the pernicious plan of tem- 
porizing by mild means. Administering medicines does 
not check the vomiting, but too often the means, at the suit- 
able moment which will more likely arrest it, is rejected. 
The palliative plan of treatment of an irreducible hernia, 
if quiescent and accompanied by no special symptoms, by 
applying a well fitting binder or bandage with buckles, or 
a bag truss, or one with a boss, or one with a hollow pad 
to receive and support the rupture, may be sufficient to pre- 
vent its increase and to relieve the patient, whose physical 
condition or age forbids, in addition, anything further than 
regulating the diet, bowels or exercise. IRREDUCIBLE HERNIA. 
A certain amount of truss pressure is borne on the omen- 
tum, and it tends to promote absorption of that already 
adherent, or to cause a more complete blocking up of the 
hernial canal. The patient’s feelings must be our guide in 
continuing this. 
If a knuckle of intestine slips down also, there may be 
unusual pain and inability to wear the truss comfortably, 
and great care must be taken against this. 
It is important, and sometimes very difficult, to decide 
whether the irreducible hernia is composed of omentum, 
intestine or both, especially if the bowel is strangulated, 
and often the bowel may be reduced while the omentum is 
irreducible and adherent, but the latter is of less conse- 
quence. 
It is to be supposed that taxis has been employed before 
terming the hernia an irreducible one, and supposing the 
attempt has been unsuccessful, even under an anaesthetic, 
and it is desired to make a further attempt at reduction, the 
following plan is sometimes successful, provided we have 
the cooperation of the patient, who should be fairly vigorous, 
and the canal of whose hernia is not reduced to a mere ring. 
Long-continued, supine rest in bed, the foot of which is 
elevated to get inward traction. The patient’s knees should 
be flexed to relax the abdominal muscles. Hot fomentations, 
or the application of ice (which should not be employed if 
symptoms of strangulation have existed 24 hours, as it 
occasions the delay of more important means), are at times 
grateful and efficacious. The application of sand or shot 
bags, weights, or elastic pressure to the tumor (which should 
be supported if pendant) is often beneficial with the other 
means. This may relieve the congested blood-vessels, and 
the tension of the sac may be lessened, by pressing the 
serous effusion it may contain into the peritoneal cavity. 
This old method of recumbency and pressure often does 
well, especially if accompanied by a low diet so as to favor 
the absorption of fat. 
Irreducible ruptures have disappeared spontaneously in 
the course of a long illness. Dr. F. H. Hamilton has re- 
ported many cases in which the mechanical effect of posture 
and gravitation was to reduce the hernia by inward traction, 
and more recently Dr. J. Collins Warren has successfully IRREDUCIBLE HERNIA. 
employed the same means combined with pressure in several 
cases. If reduction is accomplished (and it is more likely 
to succeed in the non-adherent omental variety), it is better 
than hazarding the life of the patient by a doubtfully success- 
ful operation, and if successful, the complaint is very liable 
to return as in Dr. Warren’s reported cases of attempted 
radical cure. 
Sometimes, moreover, the reduction of an old, irreduci- 
ble hernia is a source of great discomfort to the patient, and 
the reproduction of the protrusion is desirable to obtain 
relief. 
If the irreducible hernia is strangulated, or the sufferings 
or desirability justify the risk, and other and safer means 
fail, and the symptoms are urgent, the propriety of opera- 
tion (which is unsuccessful as far as my experience goes) 
must be entertained. 
Long delay and violent taxis before operation may be 
even more fatal than strangulation itself. If taxis is used 
it should be with gentleness and great care, especially if 
the strangulation dates more than 36 hours. So, the sooner 
after strangulation, if reduction has been fully tried and 
failed, the operation be performed, the better. 
Often death results not from the operation, but because 
it was not performed at the right time, and the longer the 
hernia remains strangulated, the less the chances of re- 
covery. 
I have seen death follow in four cases which were re- 
duced by taxis. The return of a small part of inflamed 
sloughing intestine is the dangerous thing which may set up 
peritonitis. 
If the omentum cannot be reduced, it may be left in the 
sac, cut off, or a ligature tied around it. Of course the 
first or the last methods are to be preferred. 
Numerous cases are recorded in which a portion of the 
omentum, in large and unwieldy hernias, has been stran- 
gulated by ligature, or in a gangrenous state removed alto- 
gether, without producing symptoms. 
If on operation there are tough adhesions, interfering with 
them is attended with great risk of tearing the bowel. It 
is safer than that, to enlarge the mouth of the sac, and re- 
duce as much of the protrusion as possible, allowing the 
balance to remain in the sac relieved from constriction. IRREDUCIBLE HERNIA. 
Experience and the recorded results of all methods of 
operation for the radical cure of hernia, and those irreducible 
in particular, leave much to be desired. Dr. \Yr. T. Hull’s 
report of 134 cases is particularly interesting. 
Dr. H. W. Cushing reports a successful case in a boy. 
Mr. John Wood has seen several cases where adhesions of 
the omentum at the deep ring have effected a complete occlu- 
sion and produced a radical cure. As a rule, if the hernia 
is irreducible no attempt should be made to effect a radical 
cure. 
To illustrate what I have said, I will mention the follow- 
ing typical cases, most of which I have had to do with : 
M. R., a fat woman, has had an umbilical hernia for 
years, and it is now irreducible. The tumor, which is prob- 
ably intestinal and omental, is painful, and she has been 
vomiting for 12 hours. I saw the case in consultation, 
attempts having been made at reduction. Under ether I 
reduced the hernia mainly by squeezing together the skin 
over the tumor, exerting diffuse pressure on the hernial 
contents. A well fitting band with buckles was more 
efficacious than a truss pad in retaining the mass within 
the abdomen. 
A. J., a man of 72 years, has had a hernia for 40 years, 
which has been irreducible for the last 15 years. It was 
apparently a direct, inguinal one, and as large as a peck 
measure. Except for its size and weight it has not in- 
commoded him. His penis was obscured in the voluminous 
hernia. He wmre a cloth bag for support, and died recently 
from an affection in no way connected with the hernia. 
A similar case has recently been related to me, where a 
double inguinal, irreducible hernia had existed for years and 
years. The man never did anything for it and never wore 
a support, as it was not a source of great annoyance. He 
never had strangulation, and died of an affection of the 
kidneys and bladder. 
An interesting case was that of an irreducible umbilical 
hernia, as large as five fists, which followed the operation of 
ovariotomy in a woman of 38 years. It wuis adherent to 
the skin and was partly omental. A well fitting swathe IRREDUCIBLE HERNIA. 
27 
alone gave relief. No attempt at taxis was made, as it was 
not a source of great annoyance. 
The case is reported to me of a woman who had an irre- 
ducible, unbilical hernia probably omental, which was 
formerly reducible. She wore a flat shield held in place by 
adhesive plaster and a band. She had an attack which 
simulated strangulation, viz.,—distress, vomiting and pain, 
which subsided on rest, hot fomentations and opium. She 
had no other attack for three years, when the above symp- 
toms were repeated accompanied by colic. The mass could 
not be reduced, and she died not operated on with the 
symptoms of strangulated hernia. 
F. A. M., a man of 72 years, entered the Cambridge 
Hospital nine months ago for a double inguinal hernia. 
He had had it for 30 years, the right one being larger since 
a fall 18 months ago. It now measures inches in cir- 
cumference. It has always been reducible until now. 
Taxis is unavailing. He has pain, and tenderness over the 
tumor and gurgling in it. No nausea nor vomiting, liest 
in bed, hernia supported by a swathe and hot compresses. 
After a few days, the symptoms and size subsided some- 
what, and in two weeks he was discharged relieved. It 
has not incommoded him since, and he pursues his occupa- 
tion as harness-maker, wearing a bag support. 
A man of 70 years, having a strangulated, irreducible 
hernia, had passed no feces for six days. The principal and 
important symptom was vomiting, which also had lasted for 
six days. 
Mr. Jonathan Hutchinson made a slight attempt at 
moderate taxis under an anaesthetic, but from the duration 
and hardness of the swelling said he would not be reluctant 
to open the sac. The hernia was reduced and no untoward 
symptoms followed, and five days later he had a natural 
movement of the bowels. 
A. F., male, 89 years of age, was seen at the Cambridge 
Hospital with a strangulated inguinal hernia formerly 
omental, but now secondarily intestinal. Always easily re- 
ducible until six months ago, when, having nausea and 
vomiting, under ether it was apparently completely reduced. 
A few days later something came down, and has been IRREDUCIBLE HERNIA 
down since, but it caused him no pain. When seen at the 
present attack the tumor was large, tense, very tender, no 
vomiting, no great pain but some would come at consider- 
able intervals. Vomiting came on attended with more 
pain, tumor more tense and tender. Aspiration with no 
result. All thought taxis useless. Operation showed 
omentum adherent to sac, and a small knuckle of intestine 
driven behind the omentum was adherent at the neck of 
the sac. The intestine was returned. The omental adhe- 
sions were separated and the omentum tied high up in three 
parts and excised. Walls of the sac were brought to- 
gether and drainage tubes inserted, one inside and the other 
outside the sac, and the wound closed. 
He died in three days, failing gradually. 
A woman of 52 years with a large, irreducible umbilical 
hernia, strangulated for 12 hours, had vomiting; tumor 
tense and hard. 
On incising the sac a pint of fluid came away. Gut and 
mesentery were black. The ring was nicked in four places 
and gut returned. Then several pails of water were re- 
moved from the abdomen (ascites). 
A fenestrated rubber tube was inserted and cotton and 
band applied. Eight days after the patient died with 
symptoms of peritonitis, which came on only 12 hours be- 
fore death. The autopsy showed gangrenous gut but not 
perforated. The cause of the ascites was malignant disease 
of an ovary. 
All the cases of irreducible hernia that I have seen oper- 
ated on have been strangulated and have died. Operative 
procedure is very dangerous in this class. It is very diffi- 
cult in some cases to decide what to do, and it must be left 
to the best judgment of the attending physician, and even 
then according to the best rules he may fail. 
Dr. F. II. Thompson, of Fitchburg:—It happens that 
my experience in this special department of surgery, 
irreducible hernia, has been quite limited. In fact, I can 
recall two cases only that I think will be of interest. 
One of them was an enormous umbilical hernia, irreducible, 
which became strangulated and afterward gangrenous, and IRREDUCIBLE HERNIA. 
29 
is interesting as representing perhaps the formation of an 
unnatural anus by nature, and is a case that was reported 
by Dr. Richardson, at a meeting of the surgical association, 
two years ago. The other case, on which I operated last 
Sunday, was an old inguinal hernia in a woman of fifty, of 
six years’ standing. The history is incomplete. The case 
is doing well, and I shall report it later. 
Dr. F. W. Citapin, of Springfield :—I would like to 
report a case occurring in my own practice, although I know 
it may not at first appear to have anything to do with this 
subject, but which the autopsy proved to illustrate one of 
the dangers in the treatment of incarcerated hernia. I was 
called one morning to see an old patient of mine, a man 
about fifty years of age, who had had a hernia twenty-three 
years. About twelve years ago the hernia was strangula- 
ted, and was then reduced. On the morning on which I 
was called the summons was urgent, and I was told that 
Mr. C. had got his rupture down and could not get it back. 
I expected to find a strangulated hernia. When I reached 
the house I made an examination and found that the hernia 
was not protruding, but that he had pain in the abdomen in 
the region of the ring, and had just vomited. He told me 
he had been out in the yard, exercising in the garden, and 
lifted something and probably strained himself. I noticed 
that the left testicle, the hernia being on the left side, was 
drawn up close to the ring. 
I told him to keep quiet, gave him morphine, and waited 
developments. This was on Tuesday. He continued to 
vomit during the day, and went on without any movement 
from the bowels (he had had one that morning), and con- 
tinued to vomit occasionally, but not severely, and did not 
develop any fever. The tenderness at the ring diminished, 
and he did not seem to have much shock. However, I be- 
gan to feel anxious, and called in counsel on the next night, 
3fi hours afterward. The testicle had remained close to the 
ring, and the symptoms of obstruction continued. At that 
time the vomiting had assumed a slightly fecal odor. We 
thought that perhaps there was fecal impaction, and used 
large injections of sweet oil. We continued this during the 
next day, and finally, Friday night (the case having begun 30 
IRREDUCIBLE HERNIA. 
on Tuesday), he had a very copious dejection of fecal mat- 
ter which filled the vessel once and a half. On Saturday 
morning he seemed almost well. The testicle had begun to 
descend, the hernia protruded—he had a large ring—and it 
went in and out with the greatest facility. 1 felt as if the 
case was all right and was bound to get well. 
In the afternoon of Saturday he began to vomit again 
persistently, and the vomiting became stercoraceous. 
Thinking there was still further impaction, I introduced my 
hand and arm into the rectum, passing my hand up as far 
as possible, even to my elbow. I think I passed beyond the 
sigmoid flexure, examining in all directions, but I could find 
nothing. When the question of laparotomy was considered, 
we thought that he would die in the operation, and nothing 
was done. The man died on Wednesday, eight days from 
the time he was taken sick. 
The autopsy revealed an old incarcerated hernia, which 
had been reduced in the sac and had become strangulated 
inside, a little neck of intestine having been forced into it 
in addition to what was already there, and the constriction 
consisted apparently of the peritoneum and the transversa- 
1 is fascia, the hernia protruding through the ring with the 
greatest ease, and at the same time being strangulated. All 
this time he had almost no fever and almost no tenderness. 
In another case which I have recently had, of femoral 
hernia, and on which I operated, the hernia had been down 
about thirty-six hours. The patient was a woman of about 
35. The symptoms of strangulation were not very urgent, 
except the time, but after using taxis I felt something slip 
back suddenly, and believed that it was all right, and yet 
what was left was of such a size that I thought it could not 
have been all returned. I was unable to make any further 
impression on it, and decided to operate. On cutting down 
I found a cyst in the sac wall, as large as a horsechestnut. 
I opened the sac and found it was empty. After I had re- 
duced the intestine, the cyst of course could not be reduced. 
These cases, although perhaps not strictly connected with 
the subject, may be interesting. 
Dr. J. Collins Warren :—There are several points 
which have presented themselves to me in the papers of IRREDUCIBLE HERNIA. 
31 
these gentlemen. In the first place, I would not like 
the impression left upon their minds that I would not 
favor operation for hernia. What I meant to say was, 
that a certain class of cases, perhaps less numerous now 
than I should have regarded them ten years ago, could 
be treated with advantage without operation. I think it is 
valuable for the general practitioner to be aware of this fact, 
that it is within the power of every physician, whether he is 
a specialist in this department of medicine or not, to treat a 
certain number of these cases and give his patients great 
satisfaction. No especial apparatus is required. All that 
is necessary is to persuade the patient to go to bed and stay 
there for from two to eight weeks on his back, with the bed 
tipped up, with pressure from sand-bags or shot-bags, or 
from bandages. In that way he can reduce the hernia down 
to one-third of its original size, and then, if he does not 
wish to try the method that Dr. Galloupe and myself spoke 
of, he can give his patient ether and can push back through 
the ring the few remaining nodules of omentum which have 
not already been reduced. Some kind of truss will be satis- 
factory, without operation. 
There are, however, of course, a large number of cases 
of irreducible hernia which can now be treated much more 
satisfactorily by the operation for radical cure, even though 
the patients do not stay cured ; even though they are unable 
to do without some form of apparatus, still they are in a 
very different condition from what they were before. They 
are like the average man with a reducible hernia; they go 
about, and do what everybody else does. I would not be 
considered as saying that the radical cure is not a radical 
cure. We have not perfected the operation yet. It is not, 
in the majority of cases, 1 think, a radical cure. There is 
a large number, and an increasingly large number, of cases 
where the radical cure does probably take place, but the 
group of cases which Dr. Ela alluded to, those that Dr. 
Bull reported (and perhaps there is no more skilful operator 
than he), shows that there is a very large number of cases 
where radical cure does not take place. When we can all 
carry out great care and great nicety, such as Dr. Cushing 
used in his operations, perhaps we shall get more satisfac- 
tory results. There is a good deal, of course, that can be 32 
IRREDUCIBLE HERNIA. 
said upon this subject, but that is hardly the topic of discus- 
sion this afternoon. I merely wish to place myself in proper 
position upon that point. 
There is another point to which I would like to refer 
again, and that is the statement that I made that large irre- 
ducible hernias did not become strangulated. You have 
since heard mention of several cases of strangulation. But 
these are not exactly what I meant by large irreducible her- 
nias. I mean the largest variety, where four fingers can be 
put into the ring. In such cases I think you will find that 
authorities state, and certainly it is my experience, that 
strangulation is exceedingly rare. It is more likely to occur 
in large umbilical hernias, I think, than in large scrotal 
hernias. Perhaps some sudden addition of intestine to the 
contents may bring on strangulation. Certainly in umbili- 
cal hernias of considerable size I have seen strangulation. 
Dr. C. W. Galloupe :—I would like to add, in refer- 
ence to what Dr. Warren just said, that I have seen a 
patient, a large woman, weighing 300, with an enormous 
umbilical hernia. It has been three times strangulated. I 
worked over it a quarter of an hour, and it became smaller. 
It increased suddenly, and yet the new accession had been 
reduced rapidly, and everything was all right. 1 have not 
been able to get a sand-bag on it yet, as I want to do. It 
remains about the same size, except that the accessions occur 
and disappear again. 
One statement that I made I should like to explain a little. 
In speaking of manipulation of these tumors being necessa- 
rily gentle, I do not mean that a good deal of force should 
not be used, because it can be used. After the strangula- 
tion is reduced, the bowels being mostly out of the way, 
and the chief obstacle being adhesions, a great deal of force 
can be used. I have seen Dr. Warren use a great deal of 
force with the best results, and in these cases 1 do not see 
why the time should not be shortened very much indeed, 
—instead of giving it two to eight weeks, giving two weeks, 
then administering ether and applying a great deal of force. 
But this should be applied gently. Gentle force does no 
harm at all in these cases. 
The case that Dr. Chapin reported, there being a cyst in IRREDUCIBLE HERNIA. 
33 
the case of hernia, was somewhat parallel to that which I 
reported, where there was a fibrous growth some two inches 
beneath the ring. I could reduce that, but it would pop 
out after the patient was about. That case of Dr. Chapin 
I believe would lead us to think that we need not be too 
particular about returning every part of the hernia, if the 
essential part is returned. 
Dr. H. W. Cushing :—I do not think that the method 
by operation has received the proper amount of attention. 
There is a large number of cases in which operative treat- 
ment, properly carried out, according to the methods which 
we have now at our disposal, is decidedly advantageous, es- 
pecially in the case of children and young adults. It 
enables the patient to select the most comfortable time for 
such a procedure, and have it done under the most favor- 
able circumstances. It is quite a different state of affairs that 
we get when the hernia becomes strangulated, for then the 
operation has to be performed under the most disadvan- 
tageous conditions. The advantages which are obtained are 
very great, especially where the patients are either children 
or young adults. If the operation is successful, they are 
rendered practically independent of apparatus the rest of 
their lives. Then, if the operation is unsuccessful, so 
far as a radical cure goes, the patients are placed where they 
are much more comfortable, and can be much more efficiently 
treated by apparatus. If the early operative treatment 
were to be adopted, I think these extreme cases which are 
to-day coming up would cease to appear. 1 would not de- 
fend a system of reckless surgery, but I think that many of 
these cases would be placed in circumstances where they 
could be much more satisfactorily treated than if allowed to 
continue untreated surgically. 
The Chairman, Dr. D. W. Cheever, of Boston :—The 
case of Dr. Chapin, which was a very interesting one of 
strangulation of the sac, will be found depicted and described 
in Astley Cooper’s great folio, and he recognized, I re- 
member, as one of the distinct perils, that, although we 
may have cut up the external structures and think we have 
relieved the strangulation, there is still liable to be a pinch 34 
IRREDUCIBLE HERNIA. 
in a certain number of cases, high up in the sac itself, and 
hence the rule that the finger should be passed into the 
abdominal cavity and freely pushed about, to be quite sure 
that no nipple, so to speak, of intestine, remains, which is 
not perfectly free from adhesions. 
With regard to the size which these hernias sometimes 
attain, it is interesting to recall the case, considered classical, 
of Gibbon the historian, the pyloric orifice of whose stomach 
was outside the external abdominal ring, and all the stages 
of his alimentation were carried on in a bag between his 
legs. That again is a good illustration of the fact that 
when a hernia becomes large enough it ceases to be very 
dangerous. The application of the bag is very comfortable 
in a good many cases. I have had several such. I have 
one still under observation which 1 have been knowing to 
for between fifteen and twenty years. The patient gets 
about and leads a fairly active life. lie has had no great 
discomfort, and has reduced his hernia considerably by the 
aid of a small bag which is trussed up in various directions 
by three or four straps of elastic webbing. In that way he 
can adjust the pressure, and gets on comfortably. In 
another case of a large hernia, where, on account of the 
obesity and age of the patient, and impelled also by the 
comfort with which this other man had gotten on, I advised 
a similar bag, the result was not so good. His history 
was interesting as illustrating the danger of these cases. 
He went on a journey, and was returning on the night train. 
The train stopped for a few moments at one of the stations 
where refreshments are taken with lightning rapidity. 
While he was eating, the train started, and he ran to catch 
it. He succeeded in catching hold of the rail, and at the 
same time felt a severe pain and an additional increase in 
his hernia. He got into his berth and rode all night in 
agony. Then he went a little farther to reach his own 
home. He developed symptoms of strangulation, gangrene, 
and died while he was being operated upon to relieve the 
strangulation. 
These are two cases which are typical—one perfectly 
comfortable on account of the care which the man takes, 
the other dangerous on .account of the want of care which 
o 
the man took at that moment. That seems to me to prove IRREDUCIBLE HERNIA. 
35 
that these cases are never very safe. The measures of 
treatment, according to the papers we have heard read, seem 
three. One is to carry the hernia in a bag. The second is 
compression, which certainly is very successful and perfectly 
safe, and depends for its success, apparently, upon the 
patience of the victim of the hernia, who is willing to lie in 
bed, and the perseverance of the surgeon. The third is 
operation. 
Now of course we shall all agree that the majority of 
these hernias, in the laboring classes, where they exist most 
frequently, do not present themselves to the surgeon until 
they have stoppage. Patients go about with them ; they 
work with them ; they do not mind a little difficulty, a 
slight attack of pain, but when they present themselves to 
the surgeon or the hospital it is because they have already 
strangulation. In these cases we have no opportunity 
except to operate. The cases that have been read show that 
the percentage of recoveries from operation is very large. 
Few die. Those who do, die because the bowel is already 
sphacelated by pressure. Almost all of them recover, and 
they recover with the opening closed up temporarily, if not 
permanently. They can work, and, if they are not cured, 
at any rate they are relieved so that they are perfectly safe. 
It was thought, in bringing this subject forward, that the 
subject of irreducible hernia would elicit just that class of 
papers which it has brought out, and which I think are 
very valuable. We all know what to do for strangulated 
hernia ; everybody knows the symptoms, and no one hesi- 
tates to use the knife, but it is this class on the border line, 
which are not severe enough to demand operation, to which 
various modes of treatment may be applied. 
With reference to two of the cases mentioned, which Dr. 
Gay reported, where the sutures came out, I contrast them 
with the case of Dr. Cushing where such an admirable re- 
sult was gotten after prolonged sewing up of the various 
tissues, and I cannot help thinking that the age of the 
patient has something to do with the result. My patients 
being 62 and 68 years of age, their powers of resistance 
were small. I cannot think the cutting out of the sutures 
was due to the material used, because the same silk, pre- 
pared in the same way, was used in two other cases, and 36 
IRREDUCIBLE HERNIA. 
remained permanently in position for a period of many 
months. I think the age of the patient is a great factor in 
the chance of permanent recovery. I, too, was very much 
impressed by the statement of Dr. Bull, in which he gave 
over sixty per cent, of relapses in 134 cases, operated on 
in four different ways.