INGUINAL HERNIA IN THE MALE. 
BY 
HENRY O. MARCY, A.M., M.E., LL.D., 
MASS. 
LATE PRESIDENT OF THE AMERICAN MEDICAL ASSOCIATION, SURGEON TO THE 
HOSPITAL FOR WOMEN, CAMBRIDGE, ETC. 
READ BEFORE 
THE SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION, 
AT LOUISVILLE, NOVEMBER, 1892. Q')r. 
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■ ''/Ir.i/fn. THE CURE OF INGUINAL HERNIA IN THE 
MALE. 
By Henry 0. Marcy, M.D., 
Boston, Mass. 
Until recently the cure of inguinal hernia in the male has 
been considered at the best accidental, and when apparently 
effected, generally doubtful, and it is still taught that the 
hernia is liable to return. 
The great majority of surgeons look upon an attempt at 
cure as ill-advised, and believe that operative measures are not 
to be undertaken except in cases of strangulation. 
There is abundant reason for such conclusions, when judged 
from the earlier history of surgical procedures as attempted 
for cure. It is impossible in the limit assigned me to consider 
at all exhaustively this most interesting subject. Three cen- 
turies ago the problem was mastered by the surgeons of 
Europe, but only by the sacrifice of the testicle and the 
removal of the cord. In this way the abdominal opening was 
closed and the resulting cicatrix was unyielding. The de- 
mand for relief from this burdensome complaint was, however, 
so great, even at this sacrifice, braving the suffering from 
surgery without anaesthetics and with the slow healing of a 
dangerous suppurating wound, that the operation was forbid- 
den by royal edict, lest the nation should suffer from the 
lessening of the reproductive power of the race. 
It is necessary to revert briefly to the anatomy of the parts 
involved, in order to note the method by which Nature per- 
mits the passage of the cord through the abdominal wall 
without pressure, and retains without inconvenience or suffer- 2 
CURE OF INGUINAL HERNIA IN THE MALE. 
ing the abdominal organs. This passage is normally lined 
with peritoneum, loosely attached to the abdominal wall with- 
out, and to the cord within, the canal. This peritoneum, 
owing largely to its loose attachment, presents a slight infundi- 
buliform depression at the site of the internal ring, but never 
more than to permit a very limited movement of the cord 
within the canal. The canal itself traverses the abdominal 
wall obliquely from without inward, in such a direction that the 
intra-abdominal pressure, radiating from a centre represented 
by the promontory of the sacrum, is distributed equally along 
the line of the canal, compressing its walls laterally. The 
disposition of the canal is not unlike that of the ureter in its 
entrance into the bladder, the intra-vesicular pressure, closing 
yet the more firmly the ureter at its orifice. The pathological 
changes incident to acquired hernia present, as the first fac- 
tors, a bulging of the infundibulum of the peritoneum about 
the cord and a depression of the lower border of the internal 
ring. Thus is produced a change, at first slight, of the direc- 
tion of the intestinal wave impulse which acts at times as a 
wedge to open yet more the ring. Little by little the axis 
of the canal changes, until at length the intra-abdominal 
pressure is in the line of the opening instead of at right 
angles to it. 
These changes, which culminate in a well-pronounced hernia, 
more or less direct, have long been recognized, but the re- 
construction of the canal to its normal conditions was of 
necessity impossible, until aseptic surgery established the 
methods of primary repair of the tissues upon a scientific 
basis. The most important factor, as I shall presently demon- 
strate, is the closure of the deep structures by means of the 
buried animal suture. 
The essential considerations for the cure of hernia are : 
First. Strict aseptic conditions. These pertain alike to all 
modern surgical procedures, and need not be recapitulated to 
this audience. 
Second. A free dissection. This is necessary in order to 
lay bare the internal ring, to permit of the enucleation of the HENRY O. MARCY. 
3 
peritoneal sac and the separation and elevation of the cord 
out of the wound. The external epigastric artery often 
courses in the line of the incision. It is not seldom that the 
size of this vessel is such that the operator fears he has 
wounded the larger vessel. 
Third. The disposition of the sac. The separation of the 
sac to its very base before removal is to be recommended as 
the rule. There are times, however, when it is not easy to 
free the peritoneal pouch, owing to adhesions to the surround- 
ing tissues, and in large, old, irreducible hernia, a more or 
less intimate fusion of the contents to the inner wall of the 
sac. 
It is generally better to open the sac before ligating or sew- 
ing through its neck, since, by so doing, the condition at the 
internal ring is assured, and by such knowledge the operator 
is often profited, even when the sac is completely empty. Not 
seldom the omentum is adherent at the internal ring, and even 
a constricted loop of intestine may escape observation when 
it is attempted to resect the sac unopened. Freed to quite 
within the ring, tension is to be made upon the sac, and then 
the sutures are applied in the line of the long diameter of the 
internal ring, and the sac is resected near its base and excised. 
The retraction should be sufficient to carry the resected peri- 
toneum quite within the ring. 
Mr. Macewen and his followers who recognize the (neces- 
sarily) from within outward funnel-shaped opening of the 
inguinal ring after operation, make the attempt to utilize the 
freed sac, in whole or in part, by puckering it up into a mass 
and with it embossing the internal ring, more or less filling 
the open space, otherwise left to invite a lodgment of the 
abdominal contents and wedge open the canal, causing a return 
of the hernia. Having demonstrated the feasibility of recon- 
structing the obliquity of the canal, it needs no argument to 
show the greater value of such a procedure over the substitution 
of plugging the opening with pathological tissues. 
Fourth. The posterior border of the inguinal canal. Hav- 
ing freed the cord to its point of entrance within the 4 
CURE OF INGUINAL HERNIA IN TIIE MALE. 
abdominal cavity, and lifted it to one side, we are prepared to 
study the structures which may be utilized in the re-formation 
of the internal ring and the posterior border of the canal. 
Sir Astley Cooper was the first to emphasize the remarkable 
development of the transversalis fascia, which is here usually 
found to consist normally of a thick layer of connective-tissue 
fibres. 
In large hernia the lower border of the internal ring has 
often fallen quite on a line with that of the external ring— 
direct hernia—but it will usually be observed even where ab- 
normal pressure of the truss has produced absorption, that 
Nature made a distinct effort to fortify the parts, and that 
the lower margin of the ring and the transversalis fascia have 
become markedly thickened. These structures are to be 
utilized in the re-formation of the posterior wall of the canal. 
Upon the lower and outer border this fascia blends with the 
posterior edge of Poupart’s ligament, while upon the upper 
and inner border it unites with the lower edge of the trans- 
versalis muscle and conjoined tendon. Often the finger may 
be introduced into the internal ring to aid in the guidance of 
the needle, which is made to traverse from side to side the 
relaxed fascia and evenly intra-fold it with a layer of double 
continuous tendon sutures. These are carried from below 
upward until the internal ring is closed upon the spermatic 
cord at its exit from the abdominal cavity. One unaccus- 
tomed to the operation will be surprised to note the amount 
of tissue that maybe thus intra-folded to form the posterior 
border of the canal. 
If, however, for any reason the structures seem to be insuf- 
ficient, it is easy to unite the deeper edge of Poupart’s liga- 
ment to the lower border of the transversalis muscle, and thus 
strengthen the parts. This is usually recommended by Prof. 
Bassini, and upon this, in large measure, his method of opera- 
tion is based. 
Halsted, of Baltimore, has gone one step farther, and but- 
tresses the posterior wall of the canal by uniting all the muscles 
beneath the cord, forming an entirely new canal external to HENRY 0. MARCY. 
5 
them. These operators carry the methods which I have 
long used and taught, to extremes which I have found 
rarely necessary, very likely in large measure because, by my 
method of using the deep double continuous suture, I am 
enabled to coaptate a thick layer of firm resisting structures 
and re-form the posterior portion of the inguinal canal much 
more closely after the pattern of normal construction. 
Once satisfied that the coaptated structures are sufficient, 
the cord is replaced and the uniting of the external structures is 
conducted in the same manner, with a layer of deep double ten- 
don sutures joining the divided muscular wall of the abdomen 
and bringing into close apposition Poupart’s ligament with 
the conjoined tendon quite upon the cord, until the external 
ring is reconstructed. It is surprising to note the little interfer- 
ence which follows upon the close approximation of the struc- 
tures upon the cord the entire length of the canal, as evinced 
by back-pain, swelling of the testicle, or even oedema of the 
scrotum. 
The structures external to the muscles are best approxi- 
mated by one or more layers of single continuous sutures 
taken by means of a Hagedorn needle introduced from side 
to side. The skin is closed in a similar manner with a con- 
tinuous buried tendon suture. The needle, straight or curved, 
is best held in the fingers, and is carried through the deep 
layer of the skin, entering upon the other side of the 
wound just opposite the point of emergence of the last stitch. 
This is important, otherwise the wound assumes a wavy look, 
owing to a puckering of the skin, as tension is made upon the 
suture. 
This I have termed “ the parallel suture” since the needle is 
carried through the skin exactly parallel to the line of inci- 
sion. It will be noted, however, that when the points of 
entrance and emergence of the needle are exactly opposite 
the suture lies in the wound transversely, and if, for the 
purpose of demonstration, the wound is allowed to remain 
only partially closed, the suture lies in parallel lines, like the 6 
CURE OF INGUINAL HERNIA IN THE MALE 
rounds of a ladder, and at right angles to the long axis of the 
wound. 
I believe it is generally safer to conduct the entire opera- 
tion under irrigation with a weak sublimate solution, and often 
not a sponge is needed. It is better to remove shreddy tissue, if 
much tearing of the parts has occurred, since it is most im- 
portant to join well vitalized structures in order that primary 
union may supervene. I think it is also wise to dust the parts 
with iodoform before sealing the wound with collodion. 
It is well worth while to take the time and trouble to dry the 
wound, and to coaptate evenly the edges of the skin, sealing, 
if need be, only a part of the wound at a time. This is best 
effected by spreading evenly a few fibres of absorbent cotton 
upon a smooth surface, and moistening with iodoform collo- 
dion. This, gently laid upon the approximated edges of the 
wound, soon dries and makes a germ-proof dressing, holding, 
as in a splint, the tissues in a firm, sure grasp. The treat- 
ment of wounds in this way is of sufficient importance to be 
emphasized, since primary union almost always supervenes, 
without suppuration, pain, or inflammation. 
Aseptic animal sutures, aseptically applied in an aseptic 
wound, aseptically maintained. This is the sine qua non 
without which more or less of failure must ensue. Other- 
wise buried sutures are not to be commended in any wound, 
and must ever be a source of danger. The advantages ot 
the above method of operation and closure of the structures 
for cure of hernia are obvious. First. By no other means 
than deep closure of the parts by the use of sutures to be left 
in the wound, and not to be subsequently removed—buried 
sutures—can the posterior border of the inguinal canal be 
restored, the parts strengthened and reinforced, or even the 
neck of the sac closed, and the redundant tissue removed. To 
accomplish such a purpose the use of silver wire or silkwonn- 
gut is not to be considered, since, by general consent, these 
sutures must act as irritants, and usually are a source of much 
annoyance and suffering until they are finally eliminated 
us foreign bodies. Silk is used by many operators for this HENRY 0. MARCY. 
purpose, but abundant clinical and experimental studies Lave 
demonstrated that silk at the best is encapsuled, never ab- 
sorbed. It may, after months of suffering, be thrown off by 
suppurative processes. 
A wound that is closed aseptically in layers with the tendon 
suture leaves no pockets to become distended with blood or 
serum, and hence the drainage-tube is not required. In asep- 
tic wounds the drainage-tube is ever to be considered as a 
foreign body, positively harmful, since it separates tissues 
which should be in contact, and, if long maintained, this por- 
tion of a wound must be restored by secondary processes. 
During its retention it is ever a positive source of danger from 
infection, which must be guarded against by the most careful 
of antiseptic dressings. This is most difficult in the region of 
the groin, and the large proportion of suppurating wounds 
following operations for hernia, in the hands of our best 
operators, shows the great risk from an open wound in this 
portion of the body. The complete closure of the skin by a 
line of buried animal sutures has been my daily practice for 
years, and was decided upon in order to prevent stitch abscesses 
long before the beautiful demonstrations showing their cause 
to be from the introduction with the suture of the micrococcus 
pyogenes albus, the normal habitant of the healthy skin, aid- 
ing in the destruction and proliferation of the dying and dead 
epithelium. 
The iodoform collodion seal is useful in two ways : First, 
it holds in fixation at rest the divided edges of the skin which 
should be carefully approximated; secondly, it prevents the 
possibility of subsequent infection. An aseptic wound thus 
protected must remain aseptic, and, when the tissues are well 
vitalized, union is always primary. If the skin is in close 
approximation, the union is linear, and often after a few 
months can scarcely be detected. 
In many wounds in other parts of the body this is of great 
value, especially facial wounds in the female. It is interest- 
ing to note briefly the repair-processes which supervene in 
such a wound. Histological investigations upon animals 8 
CURE OF INGUINAL HERNIA IN TIIE MALE. 
show that the tendon or animal suture is little by little 
invaded by leucocytes which are abundantly proliferated to 
surround the material. Gradually, dependent upon age, 
activity of developmental processes, vitality of structures, 
etc., this proliferated material is transformed into connective- 
tissue cells, until the suture is, in large measure, replaced by 
a band of living tissue. This is important in most wounds, 
but is perhaps never of greater value than in hernia, where 
the resistant power of the structures has long been defective. 
An aseptic wound thus closed is rarely painful, oedematous, 
or even tender to gentle touch. The new proliferated mate- 
rial can be easily felt for a considerable period, and is perhaps 
at its maximum from four to six weeks after the operation. 
For many reasons the tendon suture is greatly to be pre- 
ferred to catgut, a subject of extreme interest and of the first 
importance, but cau receive here only reference. The kan- 
garoo tendon has met with the unqualified approval of nearly 
every operator who has used it, and is now in the market in 
quantity and price so that it comes within the reach of every 
surgeon. Time does not permit an analytical comparison of 
the different methods of operation. I have recently treated this 
subject in extenso.1 The operation is eminently a safe one. 
In a table which I have recently collated of over three thou- 
sand cases, the mortality is less than one per cent., and is 
usually explained as having been from causes which the 
authors state were accidental, and were not due to the opera- 
tion. In numbers Bassini’s clinic leads the list, 262 opera- 
tions and only one death, due to pneumonia ; Championniere 
reports 254 cases operated upon, 2 deaths; Sehede’s clinic, 
165 operations, 2 deaths; Banks, 106 operations, no deaths; 
Park, 115 operations, 85 reported cured ; Marcy, 115 opera- 
tions, no deaths, 78 traced, 4 relapses. The experience of the 
late celebrated John Wood, of London, covering years of 
1 Anatomy and Surgical Treatment of Hernia. By Henry 0. Marcy, A.M., 
M.D.,LL.D., Boston. Quarto, with 66 full-sized illustrations; 8 colored, 37 
woodcuts. D. Appleton & Co., 1892. HENRY 0. MARCY. 
9 
labor before the period of antiseptic regime, gave only seven 
deaths in 339 operations. 
By estimate, between three and four millions of the people 
living in the United States are subject to this usually life-long 
progressive disability; and, if the demonstration is complete, 
that the risk of life is less than one per cent, from the operative 
procedures instituted for cure, and that scarcely more than ten 
per cent, are subject to relapses, and these almost invariably 
in a state improved by the operation, the plea is a very strong 
one to consider favorably the advisability of operation in a 
very large majority of all the sufferers from hernia. 
We are all painfully familiar with the dangers of strangu- 
lation in neglected hernia and the large percentage of mortality 
which results therefrom. It seems to me a duty, resting 
heavily not only upon all surgeons, but upon every physician 
residing where he cannot easily obtain surgical assistance, that 
he make himself familiar with all the details of the operation 
for hernia, its relief when strangulated, its cure when trouble- 
some, and thus fit himself for the discharge of a solemn obli- 
gation which may at any moment of his professional experi- 
ence be freighted with the issues of life or death.