[Read before the Philadelphia Academy of Surgery, February 4, 1895.] 
ON A MODIFICATION OF THE “INVAGINATION” 
METHOD OF OPERATING FOR THE RADICAL 
CURE OF HERNIA. 
By JOHN H. PACKARD, M.D. 
Surgeon to the Pennsylvania Hospital ana to the St. Joseph's Hospital. 
I think it can hardly be necessary to enter into any argument 
as to the desirableness of effecting the radical cure of hernia in 
every case where it is possible. My own experience is that 
there is great difficulty in getting trusses properly fitted, as well 
as in having them properly applied by the patients. Yet a 
truss badly made or wrongly put on may be worse than useless; 
it may cause suffering, and even danger to life. 
A radical cure can be accomplished in only one way: by 
doing away with the sac as such; by obliterating the tube of 
peritoneum, like a glove-finger, through which the descent of 
bowel or of omentum takes place. This is the object aimed at 
in all the proposed procedures, which are very many. Sedillot, 
in the edition of his Mcdecine Operatoire published in 1855, enu- 
merated twenty-five, and his list was not then complete. The 
number has been very largely increased since that time, and 
especially, of course, since by the introduction and general 
adoption of antiseptic methods, the dangers of such interference 
have been in great measure set aside. Modern surgeons have 
suggested and put in practice much bolder modes of dealing 
with the problem than could formerly have been employed. 
By some, as Banks and McBurney, the sac is ligated and cut 
off as high up as possible. Barker cuts it off at the external 
ring and carries the stump up to be sutured into the internal 
ring. Ball twists it up and applies an intercolumnar suture. 
McEwen and Bishop crumple it up by means of “ drawing- 
string” sutures. Bassini’s and Halsted’s plans are to make a new 
canal and a new ring ; Landerer makes a plastic operation, trans- 
planting one of the columns of the external ring. Kocher car- 
ries the sac away from its position, angulating it twice, bringing it 
out through an artificial opening in the tendon of the external 
oblique muscle, and then twisting it. 
I do not propose to discuss these various methods, but venture 
to suggest another plan by which the hernial canal can be 
closed, I believe securely and permanently, and the object ac- 
complished in a simple way. 
I think it may be laid down as a sound rule of surgery, that 
in all operations there should be as little sacrifice and as little disturbance of the parts as possible, consistently with the attain- 
ment of the desired end. 
A recent writer says that there are two requisites for an 
operation for the radical cure of hernia. u I. Complete elimi- 
nation of the peritoneal funnel, of which no trace must be left 
in the canal. 2. The firmest union of the rent in the fibrous 
layers of the abdominal wall that can be obtained.” He then 
states that “a proper operation requires the hernial canal to be 
laid open throughout its whole length up to the level of the in- 
ternal ring, and the neck of the sac and the peritoneum beyond 
the internal ring to be completely loosened and dissected free 
for some distance beyond. Thereafter the walls of the canal 
must be accurately sutured and brought in the closest possible 
apposition.” In other words, he would first lay open the 
abdominal wall, and then close the rent as firmly as possible. 
But would it not be better to avoid making the rent unless it is 
absolutely necessary to do so ? 
I think we can do away with the sac as such without any 
destruction of its tissues, not eliminating it or laying it open, 
but simply making use of it, converting part of it into a solid 
plug, and fastening it into the canal at its inner end, sacrificing 
nothing. Such invagination of the isolated sac is the essential 
principle of the procedure which I wish now to describe. 
It will be remembered that there were in vogue many years 
ago a number of invagination methods. Of these perhaps the 
best known was that devised by Gerdy, but modified by Wiitzer, 
and generally attributed to him. All these methods consisted 
in pushing up the sac along with a considerable amount of the 
surrounding tissue; and my belief is that to the want of isola- 
tion of the sac, and the consequent drag upon it, many failures 
in cases at first promising should be attributed. 
Some successes were, however, attained. I operated in 1863, 
by a method substantially that of Wiitzer, upon a young man 
who was desirous of entering the U. S. Navy, but was prevented 
by the fact that he had a right inguino-scrotal hernia. He 
afterward gained his appointment, and three years later was 
doing duty as a third assistant engineer, the rupture giving him 
no trouble. Two other cases, on which I operated in the same 
way at about the same time, passed out of my observation before 
the results could be determined. And the risks and uncertain- 
ties of all such procedures were then so great that it seemed 
imprudent to undertake them unless in exceptional instances. 
I have already said that the method which I wish now to 
describe consists essentially in the invagination of the isolated 
sac. No one feature of it, I believe, is entirely new; but as a 
whole it has not to my knowledge been proposed by anyone 
else. 
I expose the hernia by a curved incision, describing a semi- 
circular flap of ample size. (See Fig. 1.) This I do also in operat- ing for strangulated hernia, as it carries the cicatrix away from 
the seat of trouble, which is afterward covered in by sound 
skin. (I have several times noticed, however, that in the final 
healing the scar is drawn over so as to form a straight line 
between its two extremities.) 
Fig. 1. 
Fig. 2. 
Fig. 3. 
The sac being laid bare, is isolated from the external ring 
down to its tip. Sometimes it is better to empty it during this 
process, which may often be accomplished by tearing with the 
fingers. Bassini’s advice, to begin the isolation at the ring and 
to proceed downward, is, I think, generally to be followed. 
In order to secure control of the empty sac I now pass a silk 
thread through its wall at either side; the two ends of each are 
left long, and caught in haemostatic forceps. 
With the forefinger of the left hand the tip of the sac is now 
inverted and pushed up as far as the internal ring, or as near it 
as possible. (See Fig. 2.) 
Next a slightly curved needle, with an eye near the point, 
and armed with a thoroughly sterilized silk thread, is passed up 
along the finger as a guide, to be pushed out at one side of the 
tip through the tendon of the external oblique muscle. One 
end of the thread being caught, the needle is withdrawn slightly, 
and again pushed through the tendon at the other side of the 
tip. The other end of the silk thread is now detached from 
the needle, which is wholly withdrawn, and the two ends, left 
slack, are caught together in a haemostatic forceps. 
Now, by means of the two lateral threads, and by grasping in 
the fingers, the doubled sac is drawn down carefully, and with 
a small'curved needle a fine silk suture is passed through it 
from side to side from below upward as far as possible, and then 
from above downward, so that its two ends, when drawn tight, 
will crumple up the sac into a solid mass. (See Fig. 3.) These 
ends are tied and cut off short. 
The lateral threads are now removed, and the other silk thread is drawn up tight, pulling the plug formed of the sac into place 
at the internal ring; its two ends are tied on the outer surface 
of the tendon of the external oblique, and cut off short. The 
skin-flap is laid over in place again, the wound closed by sutures, 
and the ordinary antiseptic dressings applied. 
Until the wound is completely healed the patient is kept in 
bed. I have not put a truss on any of the patients recently sub- 
jected to this operation, but have cautioned them against making 
any muscular effort likely to bring undue stress upon the parts 
until time enough has elapsed for their consolidation. 
As to the ultimate results of this operation I have no cases of 
sufficient duration to enable me to speak positively. A man, 
aged twenty-two years, operated on October 24th, is present for 
your examination this evening; he does full work as an orderly 
at the Pennsylvania Hospital without either truss or discomfort. 
To my disappointment, a boy, aged twelve years, operated on 
December 12th, has failed to be here; there is no sign of yield- 
ing of the plug, though he is running about as heedlessly as 
any boy of his age. A man, aged forty-nine years, operated on 
at the same time, seems also to be completely relieved. On 
January 10th I operated on a man aged fifty-four years, at St. 
Joseph’s Hospital; he has since had a severe bronchitis, but his 
hernia seems entirely controlled, and he is now going about 
freely. Another man, aged thirty-two years, in the Pennsyl- 
vania Hospital, operated on January 7th, is still under treatment. 
Of four other cases, including the first one, operated on in 
September, 1890, I will not speak, as they passed completely 
out of my knowledge too early for the results to be determined. 
I am well aware that my array of cases is very small, but the 
first two above mentioned and the fourth afforded pretty severe 
tests of the efficiency of the closure of the canal. I offer the 
method as one which seems to me sound in principle and prom- 
ising well; moreover, in case of its failure, the parts are in 
condition for the repetition of this procedure or for the adop- 
tion of any other that may commend itself. 
Of course, there must be an exercise of judgment as to the 
suitableness of any mode of operation in any given case. I 
think there would be difficulty in adopting the one now described 
in cases of congenital hernia; and whenever for any reason the 
sac must be extensively opened it would have to be carefully 
sutured before invaginating it. And I believe that it might not 
answer well if the canal and internal ring were very wide.