The Cure of Inguinal Hernia 
in the Male. 
Read at the Forty-second Annual Meeting of the Ohio State 
Medical Society, at Cleveland, Ohio, May 19, 1897. 
By HENRY O. MARCY, A.M., M.D., LL.D. 
Of Boston, U. S. A. 
Surgeon to the Cambridge Hospital for Women ; late President of 
the American Medical Association; President of the Section of 
Genecology, Ninth International Medical Congress; late 
President of the American Academy of Medicine ; Mem- 
ber of the British Medical Association ; Member of 
the Massachusetts Medical Society ; Member of 
the Boston Gynecologic Society; Corre- 
sponding Member of theMedico-Chirur- 
gical Society of Bologna, Italy; 
late Surgeon U. S. A., etc. 
NORWALK OHIO: 
The Laning Printing Company. 
1897. THE CURE OF INGUINAL HERNIA IN THE MALE* 
BY 
Henry O. Marcy, A. M., M. D., L,L,. D., 
Boston, Mass. 
Mr. President: My thanks, sir, are due to you 
for your complimentary introduction, since I must confess 
that I accepted your invitation to deliver the annual 
address upon surgery with more than usual pleasure. This 
in part because the subject was of your selection, and pre- 
sumably grew out of an early correspondence upon hernia 
and the knowledge of your own wide experience as an 
operator, you being among the first, if not the first of the 
surgeons of Ohio to effect the cure of hernia in the male. 
Another and a personal reason is the fact, that the larger 
share of my family have been citizens of Ohio, my grand- 
father, Thomas Marcy, having been one of the early settlers 
of the Western Reserve, having made eighteen round jour- 
neys from Massachusetts with his four-horse canvass-covered 
wagon in the enthusiastic settlement of the town of Free- 
dom, Portage county. 
Therefore, accept the congratulations of a foster son upon 
the high position which the members of the medical profes- 
sion of Ohio have taken, not alone in the councils of our 
nation, but also in the great brotherhood of the profession. 
We limit the subject of our discussion this evening to 
the cure of hernia in the male, since this is confessedly by 
far the more difficult variety of hernia in which to effect a 
cure, because, no matter what means are employed, it is es- 
sential that we permit the passage of the uninjured cord 
* Illustrated by stereoptican views. 4 
through the abdominal wall. The student of the history 
of surgery finds that the surgeon of an earlier period made 
comparatively easy the permanent cure of hernia, by the 
sacrifice of the testicle and the permanent removal of the 
vas defere?is with its attendant vessels, but in that period 
of surgical development an uninfected wound was a rare 
accident, and the suppurative processes, incident to wound 
repair, made the plastic reconstruction of the abdominal 
wall an impossibility. 
It was reserved as one of the triumphs of antiseptic sur- 
gery to make possible the cure of hernia in the male by 
the reconstruction of the parts to their normal condition. 
To this end certain factors are necessary. First, an open 
and free dissection of the parts, the wound made and main- 
tained aseptic. 
Second, the reconstruction of the inguinal canal to its 
normal obliquity and the re-enforcement of its posterior 
wall, in order that the intra-abdominal pressure may be 
brought to bear upon it in a way to coaptate and close its 
walls, instead of acting as a wedge to dilate the canal by 
the escape of a portion of the abdominal contents through it. 
For the making and maintaining of a wound in an aseptic 
condition,, surgery will be indebted for all time to the im- 
mortal Lister, and I take much pleasure in expressing my 
special indebtedness to the great master, as his first Ameri- 
can pupil. Based upon his demonstrations that arteries 
might be ligated in continuity with sterilized cat-gut, it 
seemed to me a reasonable corollary that undivitalized 
tissues might be safely coaptated by the use of buried 
sutures, to be left undisturbed in closed wounds, and this 
has been my contribution to surgery. These were first 
used for the purpose of affecting the cure of hernia and pub- 
lished by me in 1870. 
The methods best adopted for this purpose will be referred 
to later, and since all good surgery is necessarily based upon 
an intimate knowledge of the anatomy of the parts with 5 
which the surgeon has to deal, I shall now call your 
attention to the photographic reproductions upon the 
screen of as large a number of the splendid demonstrations 
of the great masters of a former generation as the time at 
my disposal will permit. In passing, I would emphasize 
that very except:onal piece of bookmaking at the begin- 
ning of our century, Sir Astley Cooper’s work upon Hernia, 
his expenditure upon the illustrations of which alone cost 
five thousand pounds sterling. 
The excellent artistic perfection of the illustrations in 
Scarpa’s great work upon Hernia, first published in 1812, is 
even superior to that of the great London surgeon, while 
Bourgery’s surgical atlas is likely long to maintain su- 
premacy, since the original drawings were, not alone like 
its predecessors, produced by great artists, but each one of 
his plates were carefully and painstakingly colored by 
hand. This extraordinary work was published at twenty - 
five hundred francs per'copy, and to-day is obtained only 
with the greatest of difficulty. 
I take pleasure in expressing my thanks to Mr. Appleton 
of D. Appleton & Co., publishers, for his generosity, which 
has made possible the faithful reproduction of these and 
many other valuable plates, and for placing the same at 
comparatively small cost at the service of the surgeon of to- 
day. 
I think you will agree with" me that the analytical exam- 
ination of these plates demonstrates the fact, that singu- 
larly enough, has scarcely been pointed out by any, that 
the inguinal canal traverses the abdominal wall in a direc- 
tion so oblique ihat the intra-abdominal pressure is exerted 
at nearly a right angle to its axis, and that in its normal 
development, the greater the intra-abdominal pressure pro- 
duced by the most violent exertion, the more closely is the 
canal closed upon itself by the lateral compression of its 
walls. This will be readily observed by the study of ath- 
letes in the performance of their extraordinary feats of 6 
muscular exertion, where the abdominal muscles are ac- 
tively brought into use. 
My attention was first directed to it by the study of the 
valvular closure of the ureter at its entrance into the blad- 
der. The obliquity of its passage through the bladder- 
wall being such that the more distended the viscus, the 
more firmly is the canal closed in order to prevent the re- 
flux of the urine. 
We are indebted to Sir Astley Cooper for having pointed 
out that normally there exists a very decided reenforce- 
ment, or thickening of the transversalis fascia, which is 
the chief element of strength in the posterior wall of the 
inguinal canal. This, normally, should continue quite 
up to or beyond the internal ring, the opening of which 
is strengthened by bands of circular fibers. Sometimes 
muscular fascicjtli of the transversalis extend below the 
internal ring and when this takes place it might be said 
that the internal ring of the canal is formed by an opening 
through the transversalis muscle. These muscular fibers 
are unimportant except as a study of the developmental 
processes, but the exceptional thickening of the connective 
tissue which normally pertains is the especial reason why 
the obliquity of the canal is maintained. This has been 
called the fascia Cooperi in honor of the great surgeon. 
I have shown you the magnificent illustrations of W. 
Darrach, M. D., published in Philadelphia in 1880. He 
was an enthusiastic pupil of Cooper and made his dissec- 
tions and measurement after the methods of this great 
master. You will also note that the fine dissections of 
Blondin clearly demonstrate the oblique course of the canal 
without any hint whatever of its physiologic importance. 
In this connection I invite your attention to the plates of 
Cloquet, who is said to have made five hundred dissections 
of hernial subjects. From him we have the naming of the 
structures about the internal ring as seen from within, 
called the infundibular process. This is designated as 7 
normal anatomy, but, in reality, no such process exists in 
the normal development and can only be made so to appear 
by pulling upon *he cord, when a depression will take place 
from undue tension of the lower border of the internal ring. 
In the normal condition the connective tissue attachment 
of the cord to the internal ring and peritoneum is such as 
to permit an easy play of the cord through the ring, and, 
when this alone exists, the peritoneum presents a smooth, 
even surface without depression over the site of the internal 
ring. But here it will be remembered the constituents of 
the cord which passes from the testicle to the internal ring 
separate at a wide angle, the vas deferens alone descending 
to the seminal vesicle at the base of the bladder. 
By far the more common cause of inguinal hernia is 
found in the imperfect development of the structures mak- 
ing up the internal ring, and this consists almost entirely 
of a depression of the lower border of the ring and lack of 
resisting power in its posterior wall. 
It is certainly impossible to produce an indirect inguinal 
hernia, following the line of the canal without there first 
having been a very decided weakening of the lower portion 
of the internal ring. When this has taken place, the intra- 
abdominal pressure commences to act as a wedge, and every 
special effort of the abdominal muscles produces a decided 
hydrostatic impulse which, little by little, opens still farther 
the inguinal canal. Although a sense of weakness and dis- 
comfort is often felt, as a rule, the subject does not ap- 
preciate his condition, until the external ring gives way as 
a result of some sudden muscular effort, and this has given 
to hernia the name of rupture, signifying a sudden yielding 
of the retaining structures. 
I have presumed to occupy this much of the time in 
the emphasis of the normal conditions, since it is evident 
that, in the proper sense of the definition, the cure of hernia 
must be the restoration to, and maintainance of the struc 
tures in their normal condition, which I contend, means the- 8 
reconstruction and reenforcement of the posterior wall of the 
inguinal canal as its first and most important factor. It is 
not, as many have accepted, simply making a new canal for 
the passage of the cord, or again reducing the same in size 
so that the cord may be permitted to escape through a 
smaller opening. 
When this portion of the canal has been reconstructed, 
the remainder of the problem is reduced to simple terms, to 
wit, the closure of the external structures, after the cord 
has been replaced, and the reformation of the external ring- 
Operators form the new canal in a variety of methods, and 
this constitutes in a large degree the hernia operations named 
after different surgeons. The custom of thus recognizing 
the value of the services of contributors to our art is most 
satisfactory and pleasing, especially so, since the only reward 
given to merit for such service is complimentary. 
However, names are confusing unless the conditions in- 
dicated thereby are kept clearly in mind. I have, from the 
beginning, contended that, in normal anatomy, the surgeon 
will ever find his safest guide, and departures therefrom are 
defective and dangerous. One extreme of reconstruction, 
which may be considered the swing of the pendulum from 
early conservatism, is the forming of the internal ring as 
high up as possible and placing all the strong structures of 
the abdominal wall behind the cord, covering it in with only 
fatty tissues subjacent to the skin. This in effect, makes a 
short, direct opening through the abdominal wall, so far as 
its important resisting structures are concerned. With- 
out taking into consideration the impairment of the 
function of the testicle, owing to the unnatural relation of 
its efferent canal, a danger far more than hypothetical, 
there is left, as a result of the operative interference, an 
opening, more or less large, directly in line with the intra- 
abdominal pressure. This not seldom is the site of a re- 
current direct hernia, the abdominal contents usually 9 
escaping above the cord. I have several times operated 
for the cure of such a recurrent hernia. 
In quite a number of the illustrations projected for our 
study, it is clearly demonstrated that the structures exter- 
nal to, and opposite the internal ring are of a very strong, 
unyielding character, made up as they are of the conjoined 
tendon and Poupart’s ligament firmly united each to the 
other by the inter-columnar fascia. These structures but- 
tress from without very firmly the internal ring and neces- 
sarily reflect the intra-abdominal force obliquely downward 
along the line of the canal. When the internal ring is of 
normal dimensions, the intra-abdominal pressure forces it 
against these strong unyielding structures and produces a 
firm valvular closing of the sides of the inguinal canal, and 
in the reconstruction of the structures for the cure of 
hernia, it is of the utmost importance that these parts are 
restored to their normal integrity. 
I know that even the most accomplished surgeons pres- 
ent will pardon the emphasis which I have made in the 
foregoing analysis of the normal structures which make up 
the inguinal canal, the more so, especially since the surgi- 
cal authorities have treated this part of the subject as of 
little importance. 
In the discussion of the cure of hernia, naturally the 
first question which arises is, when to operate ? 
Early in my experience there were very few surgeons 
who gave their approval to my opinions and with emphasis 
declared that operative interference should be limited only 
to cases of strangulated hernia, and that here it might be 
permissible to institute measures for the cure of the hernia. 
Indeed, it was with great difficulty that I secured the pres- 
ence of a physician to witness my first operation, in 1870, 
deliberately undertaken for the cure of a reducible hernia. 
Little by little, confidence grew in the safety of the new 
surgical measures, and it was deemed permissible to operate 
upon hernia, where the retention of the abdominal contents 10 
was difficult or uncertain. When it was clearly demon- 
strated that the operative wTound could be safely closed 
without drainage, and that the iodoform collodion seal was 
a protection from subsequent infection, the list was en- 
larged to make it advisable to operate upon children, until 
now a very considerable, although minor portion of the 
profession, deem it permissible, if not wise, to operate 
upon any of the great truss-bearing army of invalids who 
are otherwise in a fair condition of health. 
My own experience has gradually produced the convic- 
tion that, as a rule, it becomes the duty of the competent 
surgeon to advise the larger number of hernial subjects to 
avail themselves of the present safe and almost certain 
means of cure. 
First, because every man affected with hernia is liable at 
any time to a possible and immediate danger to his life. 
The strangulation of a loop( of intestine, escaping through 
the inguinal canal has from time immemorial been consid- 
ered as a condition of the greatest danger. 
The statistics of our large hospitals show a greater mor- 
tality in this class of operations than in that of almost any 
other, not from the operation per se as was too often earlier 
supposed, but from the conditions which demand operative 
interference. 
That this danger is a common one every practitioner 
present will testify from his own too abundant experience. 
Statistics are now ample to show that the operation 
undertaken for the cure of hernia, when the abdominal 
contents are not involved, should be almost entirely devoid 
of danger. 
In my own experince, now in my four hundredth series, 
I have not seen a case which seemed to approach the dan- 
ger line where the intestine was not involved. In my 
recent wrork upon hernia, I have collected over three thou- 
sand operative cases, with a mortality of less than one per 11 
cent., and even here the fatality is ascribed to other and 
accidental causes. 
That hernia may be permanently cured the testimony 
of experience is now ample. My own statistics give a 
permanency of over ninety per cent., and some of these 
cases have been under observation for many years. That 
this widespread infirmity is owing to something more than 
accidental causes is adduced from the fact that in the 
United States alone there are estimated lobe between three 
and four millions of sufferers from hernia. This great 
truss-bearing army of invalids appeal to our sympathy for 
aid, and it is in their interest especially that I plead with you 
to qualify yourselves to furnish the means of relief. 
The details of the operation in a general way may be 
outlined as follows: It is taken for granted that this, as 
every other surgical operation, must be conducted under 
the most careful modern asep ic precautions. The parts 
having been shaven and disinfected, the incision is made in 
the line of the canal and of sufficient length to permit of a 
free and easy manipulation of the parts involved. The cord 
is carefully separated from its attachments and carried 
toward the median line, where it is gently held as most 
convenient by an assistant. The hernial sac is opened, 
and its contents examined, and returned to the abdominal 
cavity. If adhesions have formed these are carefully sepa- 
rated. Not very rarely an omental mass, which has long 
been retained, constituting an utireducible hernia, is wisely 
removed. If so, its pedicle must be sutured across with 
much care. It is my usual custom to do this in two lines 
of double continuous suture. The advantage of this lies in 
the fact that the pedicle is subdivided into as many parts as 
may seem desirable, while a second line of suturing renders 
hemorrhage less liable and permits the occlusion of the ves- 
sels with less violence to the constricted structures. The 
importances of preserving the enclosed structures undevital- 
ized is of the first importance although a strict asepsis has 12 
been maintained. It is much wiser to return the incarcer- 
ated omentum, unless its deformation is very considerable, 
or that its many bleeding points cause it to be a source of 
troublesome hemorrhage. 
In strangulated cases this condition of the incarcerated 
intestine may demand special operative measures, discus- 
sion of which cannot be entered upon at this time. 
The sac, if of any considerable size, is to be dissected 
to its very base, and separated from its attachments quite 
within the ring. Tension is gently made upon it by an 
assistant, while it is sutured in the long axis of the wound, 
and then the sac is resected. The suture is greatly to be 
preferred to the ligature in that it closes the peritoneum in 
an even seam, without the possibility of slipping from the 
enclosing suture. 
The elasticity of this peritoneum is quite sufficient to 
cause it to retract without depression. The structures 
which make up the posterior wall of the canal are now re- 
formed by enclosing from side to side the attenuated trans- 
versalis fascia, until the sutures are carried from below up- 
ward as far as the judgment warrants, reforming the 
internal ring by coaptation of the tissues under the cord 
upon its posterior border. In large, old hernise these tis- 
sues are often so atrophied and weakened that it is wrise to 
split the conjoined tendon and Poupart’s ligament, enclosing 
their posterior portions to strengthen and reform the 
posterior wall of the canal. When this has been 
effected, the cord is replaced and the firm aponeurotic 
structures of the oblique muscle are carefully sutured 
from above downwards, the last stitches forming the exter- 
nal ring. A layer of skin sutures, also buried, completes 
the operation. The wound is thoroughly dried, the edges 
of the skin are carefully adjusted and held in apposition by 
a protective layer of iodoform collodion, reinforced by a 
few fibers of absorbent cotton. 13 
It is many years since I have used drainage of any kind. 
The patient is kept in the recumbent position only so far 
as is necessary to give physiologic rest to the parts in- 
volved. This should be maintained for about three weeks. 
No truss is subsequently applied and light work is permit- 
ted at an early date, only insisting that the patient must be 
careful in exercise for a number of months, since I believe 
that the full resisting force of the structures returns very 
slowly. 
In children it is the exception to remove the sac, often- 
times it is not necessary to open it, although I believe the 
rule is a good one in order to be sure that the sac is empty, 
and that is often ascertained only by an examination of the 
interior of the sac. 
The suture material to be employed is important. For a 
considerable period I used sterilized cat-gut, then the ten- 
dons obtained from the deer, caribou, and moose, but since 
1882 I have used exclusively the tendons taken from the 
tail of the Kangaroo. These latter furnish almost an ideal 
suture material, are strong, smooth, and even, and are ob- 
tained .of any size which may be desired. They should be 
taken from the freshly-killed animal, quickly sun-dried and 
kept dry until prepared for use. In this way they have 
never been subjected to processes of decomposition and, as 
a consequent are not likely to have been invaded by bacteria. 
Their preparation consists in soaking them in a 1-1000 
solution of bichloride of mercury until softened, so as to be 
easily manipulated, separated, and selected. They are then 
dried on an aseptic towel, soaked in a solution of for- 
mal, after which they are chromicised (a sort of tanning pro- 
cess for the fixation of the cement substance), and are ready 
for use. Hike cat-gut they may be preserved in a very con- 
siderable variety of media; bichloride alchohol, boiled in 
alcohol or kummel. However, these processes injure the 
structure of the tendon materially and, on this account, I 
still prefer the boiled linseed oil and carbolic acid, as first 14 
recommended by Lord Lister. When preserved in this, 
excluded from the air to prevent the oil drying upon the 
tendons, the suture material improves with age and I pre- 
fer not to use the tendon until it has been six months thus 
preserved. The carbolic oil is not a germicide and should 
be kept carefully closed from any source of infection. Wet 
tendons must not be put in the oil, but carefully dried first 
covered in an aseptic towel, since the water forms an emul- 
sion with the oil which will soon soften and ruin them. In 
preparation for an operation the tendon is transferred from 
the oil to a warm solution of 1-1000 bichloride of mercury, 
in which it is to remain for half an hour before using. In 
this way it becomes supple and is applied more easily. 
When first taken from the oil it is much too hard and stiff 
for easy manipulation. Cat-gut is the connective tissue 
sheath of the intestine of the sheep, and no matter how 
prepared it is necessarily defective from its inherent con- 
struction. 
While I would again emphasize that the one object to be 
attained in the cure of hernia is the reconstruction and re- 
enforcement of the inguinal canal to its normal obliquity, 
the especial means by which this is effected may vary 
greatly and yet the results be satisfactory. Silk, silk-worm 
gut, silver wire, cat-gut, all may be used as suture material, 
and may be applied by various methods, and the inclosing 
structures may vary in a considerable degree, and yet the 
resultant cure be effected. I believe in the use of as few 
and simple instruments as possible, and consequently have 
added to the list only with reluctance. 
The advantage, however, is considerable in the use of a 
needle with the eye near the point by which the suture is 
introduced under the parts to be enclosed. It is threaded, 
carried through the parts, unthreaded, rethreaded with the 
opposite end and withdrawn. In this manner, a double, 
or two lines of continuous suturing are applied, quite after 15 
the way in which the shoemaker sews with awl and waxed 
end. 
It is to be remembered, however, that coaptation and 
not constriction is sought with a minimum of violence to 
the sutured structures. With an Hagedorn needle the 
tissues may be coaptated by introducing the needle from 
side to side, parallel to the long axis of the wound, each 
stitch entering directly opposite the emergence of the pre- 
ceding one. In this way the tissues are neatly intrafolded 
and held in even coaptation. With ease and rapidity the 
reconstruction of the parts to their normal conditon is effect- 
ed. With a very fine suture, the stitches being taken 
through the deeper layer of the skin only, the edges are 
coaptated by a buried suture without wavy lines or pucker- 
ing. 
The collodion seal renders subsequent infection im- 
possible and aids in a measure in holding the structures 
in a state of physiologic rest. The addition of idodoform 
in solution is of value in its inhibiting power upon the de- 
velopments of the M. pyogenes a/bus. Bandages of any sort 
are worse than useless. 
kittle by little the buried animal suture is encapsuled by 
leucocytes and invaded by them. These in turn are trans- 
posed into connective-tissue cells and pari passu, as the 
suture is absorbed, a living band of connective tissue is 
formed. This process may extend over a period of from 
four to six months.. 
In closing let me thank you for the attention which you 
have given me. A subject of such importance and extent 
has necessarily been treated all too briefly with many 
omissions of important details. For the sake of brevity I 
have laid myself open to the criticism of being dogmatic. 
I have necessarily been obliged to omit entirely the his- 
tory of operative measures, undertaken for the cure of 
hernia, which in itself is of exceptional interest and would 
compass an entire evening if briefly told. 16 
During the last quarter of a century, with unwearied en- 
thusiasm, I have endeavored to teach the lesson which to- 
night I have here presented. In many of its essentials 
more recently the credit has been given to Bassini of Italy, 
whose first operations were undertaken long after my re- 
peated publications upon the subject. I am not without 
personal ambition and it is with the largest pleasure that 
I not alone invite criticism, but ask that whatever of merit 
has accrued to our art by my own unwearied labors may 
be accorded to American surgery.