Reprinted from the 
University Medical Magazine, 
June, 1889. 
THE RADICAL CURE OF HERNIA. 
A REPORT OF FOUR SUCCESSFUL CASES, 
WITH REMARKS. 
J. William White, M.D., 
Professor of Clinical Surgery, University of Pennsylvania; Surgeon to the 
University, Philadelphia, and German Hospitals. Reprinted from the 
University Medicae Magazine, 
June, 1889. 
ORIGINAL ARTICLES. 
CHE RADICAL CURE OF HERNIA-A REPORT OF 
FOUR SUCCESSFUL CASES, WITH REMARKS.1 
J. William White, M.D., 
Professor of Clinical Surgery, University of Pennsylvania ; Surgeon to the 
University, Philadelphia, and German Hospitals. 
Ftjza Myers, sixty-three years of age, white, a native of Germany, and by occupa- 
tion a domestic, was admitted to my ward in the Philadelphia Hospital, on the nth of last 
December, with the following history : For nine years she had had a swelling in the neigh- 
borhood of the left groin, which had occasionally disappeared, but now' and then became 
tender and painful. About four hours before admission she had been seized with a severe 
pain in the region of the swelling which increased, and which, when I saw her at 2 o'clock, 
A.M., was referred chiefly to the umbilicus. At this time there was frequent vomiting, 
fecal in color, but not in odor ; a temperature of 97.2, and a pulse of 56; a hard tumor about 
the size of a walnut, quite movable, and feeling through the thick layers of subcutaneous 
fat which covered it like an enlarged lymphatic gland, was observable at or about the level 
of Poupart's ligament on the left side. Manipulation of this swelling excited vomiting ; 
an enema given a short time previously had brought away a considerable quantity of fecal 
matter, and she had had a large spontaneous natural stool a few minutes before I saw her. 
Taxis having failed to produce any effect, she was etherized, and the superincumbent 
layers of tissue divided, the tumor proving to be a femoral hernia containing a very small 
but very tense knuckle of gut with a little omentum. The constriction which was at the 
femoral ring was divided, and the gut, which rapidly assumed a natural appearance, was 
returned. The omentum, which was partially adherent to the neck of the sac, was dissected 
loose and tied off, a portion being removed. The sac itself was then carefully freed with 
the finger from its adhesions to the edges of the femoral ring, was drawn gently down- 
1 Read before the College of Physicians, April, 1889. 2 
WHITE, THE RADICAL CURE OF HERNIA. 
wards for a short distance and encircled with a stout cat-gut ligature which was tied tightly 
around the neck, the ends being left long. One of these ends was then threaded through 
a stout curved needle which wras carried from within outward through the inner margin of 
the ring-Gimbernat's ligament-and the soft parts above it exclusive of the skin ; the other 
end wras carried through the outer edge of the ring in the same manner, the femoral vein 
being protected by the tip of the finger; these ends were then tightly knotted and cut off. 
An investigation with the finger then showed that the stump of the sac completely filled 
and occluded the ring. The pubic and iliac portions of the fascia lata were next closely 
brought together by interrupted sutures as were the soft parts above them, and a few cat-gut 
strands were laid through the deep portions of the wound which was then irrigated and 
dressed antiseptically. The case ran an aseptic course, union by first intention being ob- 
tained without a drop of pus. The highest temperature was 99.2. The bowels were moved 
on the fourth day by a small dose of Rochelle salts ; the patient was kept in bed for six 
weeks, but has ever since been up and about in the condition in which you now see her. 
I desire to call attention in the clinical history of this case to the fact that 
with some general symptoms pointing to strangulation, she yet had local con- 
ditions that both to sight and touch seemed to favor the view that the swelling 
was due to lymphadenitis, and that at the same time she had one large evacua- 
tion produced by enema, and another which was spontaneous. Such a combi- 
nation of circumstances might easily lead to a mistaken diagnosis, and con- 
stantly does lead to the postponement of operation, or to the failure on the part 
of the general practitioner to seek surgical aid until valuable lives have been lost. 
I have recently called attention to these and other minor difficulties in the 
diagnosis of hernias, and merely wish now to emphasize the practical point 
that operation and not delay should be considered as indicated whenever there 
is reasonable ground for even a suspicion of strangulation. 
Jacob Vetz, forty-nine years of age, was admitted to my w'ard in the Philadelphia 
Hospital on January 25th, 1889, with a left femoral hernia of moderate size which had given 
him much inconvenience by its occasional irreducibility, which was alwrays accompanied 
by great pain and by symptoms of impending strangulation. Trusses had not been suc- 
cessful in retaining it, and the patient pressed earnestly for relief by operation. On the 
28th of January, having previously been put on a restricted diet and having had moderate pur- 
gation by salines, he was etherized, ami the following operation performed :- 
The sac of the hernia was exposed by a longitudinal incision inclining slightly inwards 
at its lower end and extending from Poupart's ligament to a little below the inferior edge of 
the saphenous opening. The sac when exposed was found to be very adherent to the edges 
of the saphenous opening and to contain adherent omentum. It was opened by an incision 
corresponding to that through the skin and fascia, the knuckle of gut which it contained 
was easily reduced, and the omentum carefully separated and tied off, the stump being re- 
turned and left free within the abdominal cavity. The opening in the sac was closed by a 
continuous cat-gut suture, and the sac itself was then with considerable difficulty separated 
from the edges of the opening and from its adhesions to the femoral vein and to the mar- 
gins of the ring, the tip of the index finger being swept around just within the ring 
so as gently to loosen the sac through its entire circumference. A cat-gut thread was 
passed through the fundus of the sac, and then alternately from side to side until the neck 
was reached, after which by drawing upon it the sac was doubled upon itself. It was then 
pushed gently into the femoral ring and was held in place by carrying the ends of the same 
suture through Poupart's ligament above, and through the pubic portion of the fascia lata 
below. It was then tightly knotted fixing the sac as a plug in the femoral ring and com- 
pletely closing the latter at the same time by bringing together the ligament above and the 
ascia below. It having been ascertained by the finger that the femoral ring was in this WHITE, THE RADICAL CURE OF HERNIA. 
3 
manner absolutely occluded, a suture was next passed through the pubic portion of the 
fascia forming the internal margin of the saphenous opening in such a way as to leave two 
long ends external, the loop of the suture being on the under surface of the fascia ; these 
ends were then carried from below upwards and from within outwards through the iliac 
portion of the fascia forming the external margin of the saphenous opening, and were then 
drawn upon tightly and firmly knotted. The opening was thus closed in the same valvular 
manner as that employed by Macewen in the inguinal operation by which he causes the 
external pillar of the ring to overlap the conjoined tendon. A few cat-gut strands were 
then laid in the wound for drainage and the soft parts closed by interrupted sutures. 
The case ran an aseptic course with the exception of a small stitch abscess which dis- 
charged itself along the track provided for drainage leaving a little sinus that soon healed. 
There was no suppuration or other disturbance of the deep portion of the wound. The 
highest temperature was 99.3. The patient was kept in bed for six weeks since which time 
he has been up walking about the hospital in the condition in which you now see him. 
The method adopted in this latter case is a modification of that of Macewen 
as employed in the inguinal variety of hernia, and has been principally 
described and practised by Dr. H. W. Cushing, of Boston. The details of the 
operation for the radical cure of femoral hernia are not given satisfactorily, so 
far as I know, in any, even of the more recent, systematic works on operative 
surgery. Jacobson says : " Omental femoral hernia should be operated on when 
there is the least difficulty in fitting or unwillingness to wear a truss, the sac 
being always ligatured and taken away. The same course should be followed 
in all cases of strangulated femoral hernia when the condition of the patient 
admits it." He gives no description whatever of the operation. Stephen 
Smith describes a method for which he does not give his authority, which con- 
sists in transfixing the sac together with the pubic portion of the fascia lata 
and then Poupart's ligament in such a manner as to encircle with a wire suture 
the tissues in the neighborhood of the femoral ring. The method seems to me 
complicated, but I have had no opportunity of trying it, and the description is 
far from satisfactory. Barker briefly describes a method which is practically 
that which I employed in the case of the woman before you. 
The questions still in dispute in regard to inguinal hernia are equally unset- 
tled as to the femoral variety. Is it better to make a plug of the whole sac by 
folding it upon itself, or to avoid the sometimes tedious separation of the fundus 
by ligating and dividing the sac just below its neck, using the stump to occlude 
the ring ? We have here an example of each method, and thus far with equally 
good results. Is it better to open the sac, or when possible to reduce its con- 
tents and treat the sac without opening it ? It would seem safer to open it in 
cases of strangulation for the purpose of satisfying one's self as to the condition 
of its contents, and it is certainly absolutely necessary to open it when per- 
forming an operation for the radical cure of hernia, if, as in this instance, there 
is adherent gut or omentum. In other classes of cases it may be considered an 
open question. Should the temporary use of a truss follow the operation for 
radical cure ? There is much to be said on both sides of this question, but my 
own feeling is that a compress and spica bandage give all that is needed in the 
way of moderate evenly distributed support, while avoiding the risk of produ- 
cing absorption of the newly formed cicatricial tissue, which is inseparable from 
the more concentrated pressure of a truss. 4 
WHITE, THE RADICAL CURE OF HERNIA. 
The next case which I have to present is that of C. B., a man of twenty years of 
age, who was admitted to the German Hospital on the evening of May 5th, 1888, suffering 
with strangulated oblique, complete inguinal hernia of the right side. With the exception 
of the knuckle of gut which it contained, the scrotum on this side was empty, and it ap- 
peared that when the hernia was reduced the right testicle could be felt in the inguinal 
canal. It frequently gave him great pain and distress, and the hernia was very difficult to 
retain on account of the presence of the testicle, the truss exciting swelling and inflamma- 
tion ; for the same reason the attacks of strangulation had been frequent. On this occa- 
sion the pain was agonizing and unbearable, and both the patient and his family, who ac- 
companied him, agreed that the prevention of other recurrences was worth any risk. 
Herniotomy being performed in the usual manner, the small, immature testicle was dis- 
covered lying in the inguinal canal near the external abdominal ring and held in place by 
bands of recent inflammatory lymph. The sac, i. e., the tunica vaginalis, contained a large 
quantity of fluid and ten or fifteen inches of much congested intestine. The stricture, 
which was at the internal ring, was divided and the gut easily reduced. On account of the 
history which the patient had given, and for the reasons stated above, the cord was then 
ligated as high as possible, the stump returned to the abdomen, and the remaining portion, 
together with the testicle, removed. This allowed the upper portion of the sac to be pulled 
strongly down and ligated, after which the remainder was easily dissected out with the 
finger, as in cases of castration. Cat-gut drainage was used, and the wound brought 
together, the superimposed layers in each wall of the wound being first stitched to each 
other, and the whole wound approximated afterward. Union by first intention under one 
dressing followed, and the patient was left with a firm cicatrix, and at the present time, 
eleven months after the operation, is without the slightest remains of the hernial tumor, 
although he has been actively following his trade of paper-hanger. 
In these hernias in which the vaginal process of the peritoneum does not 
close and the hernia therefore lies in contact with and includes a testicle, the 
problem of effecting a radical cure is manifestly complicated. The ordinary 
plans are inapplicable as the sac of a hernia which surrounds a cord and tes- 
ticle can neither be folded up after Macewen's plan nor ligated and excised. It 
is directed under these circumstances to divide the sac in the middle, and then 
close up the lower part by a few stitches, so that it may form a tunica vaginalis. 
The upper portion is then to be sealed up posteriorly, allowing the cord to 
escape behind it, after which it is closed up by stitching, and may then be 
treated by any of the ordinary methods. It has always seemed to me that this 
must necessarily leave a weak point in the neighborhood of the cord, and that 
the effacement of the hernial pouch must be more or less incomplete. For these 
reasons, where in a congenital hernia there is a retained and atrophied testicle, 
it is better to sacrifice the latter organ as in the case I have just shown. 
I had expected to present a fourth case of hernia to you this evening, but 
have been unable to secure the attendance of the patient. The case was one 
of scrotal hernia, the operation was performed in March, 1888, and the result 
was as good as in any of these cases, though all the conditions at the time of 
operation were most unfavorable. Still another case, a large labial hernia in a 
young woman is now under treatment, the patient having completely recovered 
from the operation, but still keeping the recumbent position as a precaution 
against recurrence. 
We have here, however, three excellent illustrations of the possibilities of 
the radical cure of widely different hernial conditions. The operation is one 
which is now accepted by the vast majority of surgeons all over the world as WHITE, THE RADICAL CURE OF HERNIA. 
5 
entirely proper in all cases of herniotomy for strangulation. Conservative sur- 
geons are not yet clear as to its advisability in those cases of hernia which pre- 
sent no threatening symptoms, and in which the palliative treatment by trusses 
seems effective. It may be stated, however, without fear of contradiction, that 
it is steadily gaining ground in the favor of the profession. The excellent sta- 
tistics shown by careful operators everywhere have done much to popularize 
the procedure, and a few of those who are most cautious are now beginning to 
include in the list of cases in which the operation for radical cure is justifiable 
all those in which trusses act imperfectly, give rise to pain or irritation, or are 
especially unpleasant to the patient. It would seem that its early adoption as a 
systematic operation in the majority of cases is probable, the chances of success 
being favorable in direct proportion to the youth of the patient, the smallness of 
the hernia, and the shortness of its duration. And yet there are many impor- 
tant questions still unsettled which very properly exercise a restraining influence 
upon the profession. It may not be unprofitable briefly to enumerate a few of 
them :- 
First, Is the " radical cure" all that its name implies, or should we with- 
hold our final judgment for a time, until greater numbers of cases have been 
observed for longer periods ? Certainly the proportion of relapses, taking all 
the reported cases up to the present time, is sufficiently large to prevent a con- 
scientious surgeon from absolutely assuring the patient of a " cure," that is of 
the re-establishment of such a condition of the abdominal wall that no truss or 
other artificial support will be required. With the possible exception of Mr. 
Macewen, nearly every operator who has recorded an extensive series of cases 
has also recorded a return of the hernia in a certain number of them, and it is 
fair to suppose that the proportion of these cases of relapse will increase as time 
goes on and as the cicatrices of the operative wounds are exposed to further 
and longer continued pressure. It is equally fair, however, to note that the 
evidence is even now sufficient to justify the belief that in the majority of cases 
a permanent cure is obtainable, though we have as yet no data which will war- 
rant a more positive statement. It does not seem to me an improvement in 
terms to adopt the one suggested by M. Trelat, who believes that some form of 
support is required for a long time, if not permanently, after all of these opera- 
tions. He rejects for that reason the term "radical cure," and substitutes 
surgical cure' ' (cure chirurgicale'') as more accurate. It would appear, how- 
ever, that the doubt, if doubt there be, relates to the substantive "cure" rather 
than to its qualifying adjective. Mr. Banks, after operating more than one hun- 
dred times, and with excellent results, also rejects the term radical cure, for 
the reason that the subject of hernia is a person with a naturally weak and yield- 
ing canal or ring, who after operation will, at the best, still have a weak condi- 
tion of the abdominal wall in the hernial region. Even if this were admitted 
to be true (and it is by no means demonstrated), it would be merely an admis- 
sion of our inability to remove the predisposition to hernia, not of our failure 
to cure the hernia itself. The question is obviously one which only time can 
settle. The lack of conclusive evidence at present is due to several causes : a. 
The comparative newness of the operation and consequently of all the figures 6 
WHITE, THE RADICAL CURE OF HERNIA. 
relating thereto ; b. The multiplicity of methods which have been employed, 
necessitating the separate study of each series of cases and rendering all deduc- 
tions from the whole number manifestly inaccurate and misleading ; c. The 
frequent failure to take into account, even in the statistics of individual opera- 
tors, the social position and the subsequent occupation of the patient, factors of 
prime importance in determining the liability to relapse ; d. The vagueness of 
the terms often used in describing the resulting condition-" a slight bulging," 
''a trifling fulness," "partially successful," "benefited," etc., being among 
the expressions frequently employed. I do not mean to say that these are not 
as precise and accurate as the circumstances would permit, but I do say that, 
taking into consideration the natural tendency of each operator to look with 
leniency upon his own results, we should probably be safe in including such 
cases among the " failures" rather than in any doubtful group. 
Second. What is the mortality after the operation ? Here again we must 
be content for the present with the very general statements that in competent 
hands but few patients die as a result of the operation, and that those who do 
almost invariably succumb to some form of septic infection. And yet selecting 
almost at random from published statistics of Bnglish and French surgeons of 
the first rank (Banks, Barker, Socin, Tucas-Championniere et al.,) I find 
that there were io deaths among 242 non-strangulated cases. It is evident 
that we must not base our opinion as to the general advisability of this opera- 
tion upon the reports of one operator who like Macewen can publish a series of 
nearly 100 cases with no deaths and no serious complications, but that we must 
take the average results obtained by the best men throughout the world. I 
know, for example, of one unreported case, fatal from septicaemia, which was 
operated upon by one of the most distinguished of British surgeons and teach- 
ers, and taken charge of by a highly competent surgeon here, who, however, 
describes the operation as " perfectly safe and justifiable," and makes no reser- 
vation. Others point to the number of deaths which annually occur from stran- 
gulation as in itself justification for general, and almost indiscriminate operation. 
This argument will have more weight when our first question is satisfactorily 
answered, and we know what proportion of hernias we can reasonably expect 
to cure. While that is still sub judice, and while the mortality from the opera- 
tion itself in non-strangulated cases is still indeterminate, we cannot base any 
logical conclusions upon the asserted fatality of hernia in general. Neither 
should it be forgotten that such fatality is largely among patients with untreat- 
ed and neglected hernias. The question which the practical surgeon has now 
to decide almost daily is not whether it is better to operate than to let a patient 
go without treatment, or with a badly fitting truss, or with an irreducible and 
frequently inflamed or incarcerated hernia, or even with an irritable hernia 
and a very tender easily excoriated skin making the best truss unbearable. I 
have already stated that in my judgment the great majority of conservative sur- 
geons approve of the operation for radical cure, under these circumstances as 
well as in the presence of actual strangulation. The question which presents 
the greatest difficulty relates to those cases of hernia to whom a truss is an an- 
noyance ; to those cases in which it is claimed, but not demonstrated, that a truss WHITE, THE RADICAL CURE OF HERNIA. 
7 
cannot be worn ; to those cases by whom the hernia is regarded as a blemish, 
and who for that reason insist upon an " operation de complaisance." It is here 
that the conscientious surgeon will hesitate while asking himself whether on 
the one hand the probability of cure is sufficiently great, and on the other, the 
risks of operation are sufficiently small to justify interference. I am inclined 
to subscribe to two statements of Mr. Keetley's, which bear upon this question : 
" Among reducible hernias, rebelliousness to treatment by truss is one of the 
rarest indications for operation. In plain language it is usually an indica- 
tion of incapacity in the instrument makers and inexperience in the sur- 
geon and further : " I believe operations involving mechanical interference 
with the sac and canal to be safe enough in the hands of a few surgeons, 
but only a few. If I suffered from hernia myself I would not let any one try 
his prentice hand on the sac of my own hernia and the walls of its canal." 
Third. Operation having been decided upon in any given case what is the 
preferable method ? The final answer to this question must, like the others, 
await the testimony of time and larger experience. At present I can but ex- 
press my individual opinion, based on my own experience, in which I have tried 
a variety of operations, and on my observation of the cases of others. It seems 
to me that in complete oblique inguinal hernias the choice at present lies 
between the operations of Macewen and Barker, in both of which especial atten- 
tion is paid to the internal ring, which is filled in the one case by the folded sac, 
entire and unopened, and in the other by the stump of the excised or divided 
sac, the pillars being brought together differently, but in both cases effectually. 
The details of these procedures have been so often published that it is not neces- 
sary to repeat them. The operations which, like Socin's, ignore the rings, and 
which are limited to the treatment of the sac, do not seem to me to be philosoph- 
ical. Minor modifications, such as the manner of suturing the canal, or its 
open treatment as suggested by McBurney, or the attempt to secure broad fleshy 
surfaces for apposition by first stitching together the layers of abdominal struc- 
tures in each wall of the wound, as suggested by myself, are worthy of consid- 
eration, but cannot be considered as of chief importance. 
In direct hernias the same choice as to treatment of the sac exists, with 
but little if any difference as to the treatment of the external ring. In femoral 
hernias I know of no better method than the one I have described in this paper. 
In umbilical and in ventral hernias operation has thus far been especially unsat- 
isfactory, and statistics are exceedingly meagre, but the same general principle 
as to choice of method prevails, the sac may be retained and used as a buttress, 
or excised, the latter method being probably preferable. 
In conclusion it is perhaps safe to make a few general statements in regard 
to this subject, if it be distinctly remembered that, in some important respects, 
they are to be regarded merely as an individual expression of views liable to 
frequent change or revision as new evidence is presented, and based on facts 
which for want of space cannot be presented in this paper. 
1. In all operations for strangulated hernia when the age and condition 
of the patient permits, an attempt at securing a radical cure should be made. 
2. Among non-strangulated hernias the following may be considered 8 
WHITE, THE RADICAL CURE OF HERNIA. 
as especially justifying operation ; those which are irreducible with adherent 
omentum frequently incarcerated or inflamed ; rebellious to the use of a truss ; 
so large or so painful as to render work impossible ; distinct at four years of 
age, especially among the poor and ignorant where proper attention to the use 
of a truss cannot be secured.1 
3. In quite young children a radical cure may be hoped for from the 
use of a truss or support. 
4. In adults it should never lightly be assumed that a truss cannot 
effectually and persistently retain the hernia, making an intelligent and 
obedient patient practically both comfortable and safe. In the majority of cases 
this may certainly be taken as a starting point from which to consider the pro- 
priety of operation. 
5. Whatever method is chosen absolute asepsis is an essential for 
success and safety. While the former may be attained in suppurative cases, the 
latter is undoubtedly imperilled, nearly all the fatal cases which have been re- 
ported having been attended by the formation of pus. 2 
6. Sufficient data have not been gathered together to enable us to judge 
finally as to certain minor points, such as the treatment of the sac and rings and 
?anal, the use of a truss, etc., nor even of the much more important questions of 
mortality and permanency of cure, wide differences of opinion still existing 
among prominent surgeons as to all these matters. 
1 Jacobson. This is not meant to be an exhaustive list of cases requiring or justifying operation. 
2 This is only worthy of special mention because suppuration has been claimed by several surgeons to 
be really an advantage, a most dangerous and misleading doctrine which from the risks of pus decomposi- 
tion would vastly increase the dangers of this as well as all other operative wounds.