Aavaan tvnoiivn 3nid_ „^D„ I ~CW..^ NATIONAL LIBRARY OF MEDICINE NLM DD13iim b c«irr ur mrtrn-iTVc WUTUNAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR o Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn aNiDiaaw do Aavaan tvnoiivn aNiDiaaw do &RARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR i o xavagn ivnoiivn aiMiDiaaw do Aavaan ivnoiivn gNiDiaaw do Aavaan ivnoiivn 3NiDia3w do -a 9 /4fcF- s BRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR < * > o AHvaan tvnoiivn 3nidici3w do Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn snidiqsw do BRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR J * KWky -° VW7 I- o Aavaan tvnoiivn snidiosw do Aavaan tvnoiivn 3nidiq3w do Aavaan tvnoiivn snidiqsw do BRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIB 13 £±y o^ o Aavaan tvnoiivn snidiqsw jo Aavaan tvnoiivn 3nij- NLM001391416 I j^y I NE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 4: V 5 I VN I gNioiaaw do Aavaan tvnoiivn NE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE > I I / VN 3NIDI03W dO Aavaail IVNOIIVN 3NIDI03W dO Aavaflll IVNOIIVN SNiDiasw do Aavaan tvnoiivn NE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE iH 3NIDIQ3W dO Aava8IT TVNOIIVN 3NIDIQ3W dO AavaaiT TVNOIIVN 3NIDIQ3W dO Aavaan TVNOIIVN -a c 0 ME NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE n 3NIDIQ3W do Aavaan tvnoiivn snidiosw do Aavaan tvnoiivn IE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE •4 s, ----"""V 'yn"n«" „ 3wi-,iagw do Aavaan tvnoiivn aNiDiaaw do Aavaan tvnoiivn S^ i ^€ Sfcff,-\ /^^s IN PREPARATION. Pg the $ame Author. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. One Volume. Octavo. Fully Illustrated. AS THE CONDITION OF THIS VOLUME WOULD NOT PERMIT SEWING, IT WAS TREATED WITH A STRONG, DURABLE ADHESIVE ESPECIALLY APPLIED TO ASSURE HARD WEAR AND USE. Practical Treatise ON HERNIA. BY JOSEPH H. WARREN, M.D., MEMBER AMERICAN MEDICAL ASSOCIATION; BRITISH MEDICAL ASSOCIATION: MASSACHUSETTS MEDICAL SOCIETY ; FORMERLY SURGEON AND MEDICAL DIRECTOR U.S.A.; ETC., ETC. SectmB anD IfobtscH ISUttton. FULLY ILLUSTRATED. BOSTON: JAMES R. OSGOOD AND COMPANY. LONDON: SAMPSON LOW, MARSTON, SEARLE, AND RIVINGTON. 1882. All rights qf translation reserved by the author. Wr Copyright, 1880, 1881, By Joseph H. Warren. University Press: John Wilson and Son, Cambridoe. TO the HONORABLE STUDENT AND REGULAR PRACTITIONER OF MEDICAL ART IN AMERICA AND IN EUROPE This Work is Respectfully Dedicated §2 % ^ut^or. PREFACE TO THE SECOND EDITION, The manner in which the First Edition of this work has been received by the profession is very pleasing to the author. The danger is that he who writes concerning a single operation will be considered an enthusiast. I trust, however, that the intrinsic value of this volume will be evidence that I have approached my subject in the spirit, not of an enthusiast, but of a searcher after truth. I have at all times endeavored to be liberal and impartial in my views and presentations of the various methods that have been employed for the relief and cure of hernia. The Introduction to the former edition has been entirely omitted, as has also the Appendix, giving urinary instruments of the author. To the original manuscript, a new Introduction and six wholly new and carefully written chapters have been added: Chapter I., Causation of Hernia; Chapter X., Eecent Operations for Hernia; Chapter XL, Artificial Anus and Wounds of the Intestines; Chapter XIIL, Hydrocele and Varicocele; Chapter XIV., Observations on Hernia; and Chap- ter XV., Resume* and Clinical Reports. For the benefit of critics, the author would say that if stereo- type plates of the book had not been already cast, many of ^e additions, which must now be massed together into one chapter, could more appropriately have been introduced in the body of the text. For the benefit of readers, it may, however, be said vi PREFACE TO THE SECOND EDITION. that full and convenient references have been made throughout the book to these additions, so that no confusion of thought will result. Many new illustrations have been added by the heliotype process, besides three beautiful anatomical plates, two of them reproduced from Bourgery, and the third from Blandin. The Index has been revised and enlarged, while the Bibliography' has been more than doubled, — the author having given much care in London to the collection of the literature upon the subject. In addition to all this, what was previously published has been carefully revised, much of it rewritten, and many typo- graphical errors corrected which were previously unavoidable. The microscope has revealed to me nothing that is new in the pathology of plastic lymph in the hernial rings. While the mere specialist may possibly think the Treatise too condensed in places, and the more general reader too minute in its details, the author has endeavored to take a happy medium, striving, however, to be practical rather than merely theoretical. Thanking the regular profession once more for their kind words of cheer and encouragement, he presents and dedicates to them this volume, which he trusts will be found a thoroughly comprehensive and practical Text-book on Hernia. 51 Union Park, Boston, Mass., U. S. A., July, 1881. » PREFACE. It has been the author's desire in placing the present work before the medical profession to do so in as concise a form as possible. There seemed to me great need for a work like the one now issued, giving a short sketch of the various opera- tions for the cure of Hernia that are most worthy of mention, in order that the busy practitioner could refer to them without wading through whole volumes. Much labour has been bestowed upon the little monograph, and very many authors consulted. I have striven, with the time at my command, to make a trustworthy work of reference on Hernia, although it is far from being as perfect or as extended as I should like. It will be found to contain much that is original with the author (the result of the study of Hernia for many years), and never before given to the pro- fession in a printed form. Besides this will be found a condensation of many operations from the French, German, and English. A short Bibliography is given to indicate some of the work that has been devoted in previous years to the subject under consideration. I am under many obligations to my very kind and generous friends in the profession, both in my own country and in others, viii PREFACE. who by encouraging and cheering words have done much to aid me in accomplishing my task. I am under the most par- ticular obligations to my son, Charles Everett Warren, A.B., Student in Medicine, and to my nephew, Willard Everett Smith, A.B., Student in Medicine, for the very great amount of labour and assistance they have rendered me in translating from the French and German, and in compiling these pages. Had it not been for their great interest and assistance I could not at such short notice have prepared the work. To Messrs. Geo. Tiemaim and Co., of New York, I am indebted for great assistance in the perfection of my various instruments, as well as for the loan of several electrotypes. Messrs. Codman, Shurtleff, and Co., of Boston, also supplied several electrotypes, and Dr. Codman has furnished me with an article on trusses. I am also under obligations to Messrs. Weiss and Son, London, who so readily conceived my ideas in regard to a lithopaxy tube, and other instruments of great beauty and finish. In conclusion, I would gratefully acknowledge the favour received from Prof. G. Dowell of Texas, and Dr. H. 0. Marcy of Cambridge, Mass., whose operations are inserted in the body of the work. I would express great obligation to Sir Henry Thompson for the favour which he showed me in allowing me to witness his operation for lithopaxy a number of times, and in explain- ing his operation and instruments to me; also I am grateful to Thomas Bryant for his great kindness to me in allowing me to use illustrations from his work, and for affording me PREFACE. ix an opportunity to operate on Hernise before a number of surgeons at Guy's Hospital. And also to my very kind friends Dr. Brown Se"quard of the College of France, who recommended me to the Academy of Medicine; to Dr. Alphonse Guery, Surgeon to H6tel Dieu, who very kindly presented me, and explained my instruments more fully at the Academy ; and to Dr. Blum, Surgeon to the Hospital Beaujon, who kindly assisted me in my demon- stration of the operation for Hernia and other operations with the new instruments of my devising. CONTENTS. PAGE Introduction..............., xiii CHAPTER I. Hernia: Causation.............. 4 CHAPTER II. Hernle : Kinds and Frequency.........37 CHAPTER III. Anatomy: Descriptive and Surgical.......48 CHAPTER IV. Strangulated Hernia.............So CHAPTER V. Operations for Hernia............93 CHAPTER VI. Author's Operation by Injection........134 CHAPTER VII. General Remarks..............17o CHAPTER vm. Treatment of Strangulated Hernia : Taxis .... 208 XII CONTENTS. CHAPTER IX. PAGE Kelotomy or Herniotomy...........217 CHAPTER X. Recent Operations for Hernia.........243 CHAPTER XI. Artificial Anus, and Wounds of the Intestines . . 303 CHAPTER XII. Trusses . ................312 CHAPTER XIII. Hydrocele and Varicocele...........324 CHAPTER XIV. Observations on Hernia............341 CHAPTER XV. Resume and Clinical Reports.........379 Bibliography................405 Index...................421 HERNIA. INTRODUCTION. " I believe the time is coming when most cases of reducible hernia will be radically cured by the surgeons, if not of this generation certainly of the next." — Sir T. Spencer "Wells. While it is right and fitting that in a Practical Treatise on Hernia we should consider all the various methods and devices that have been suggested for its relief and cure, sufficiently at least to give the student and general practitioner an idea of the field open for more minute study, if any are interested in looking at the subject in its historical aspect, I do not consider it neces- sary for me at this period of general information and intelli- gence to develop to their full extent all the operations that have been performed, but will give more special attention to those that seem more worthy of commendation. " Look not mournfully into the past. It comes not back again. Wisely improve the present. It is thine. Go forth to meet the shadowy future without fear and with a manly heart." It is altogether probable that from the very earliest times mankind has been afflicted with hernia, even before the dawn of history had given us any records. Many of the ancient operations for the cure of this affection have come down to us from the early surgeons ; but it does not tax the ingenuity to any great extent to suppose that the wandering nomadic tribes xiv INTRODUCTION. of the East, as well as the more noble and civilized builders of the Egyptian pyramids, were conversant both with the disease and methods of its cure. Since every day brings to light new evidences of the culture and civilization of Egypt, it is no great stretch of the imagination to suppose that the Oriental surgeons knew of a subcutaneous injection of some stimulating and astrin- gent fluid into the hernial rings. We know beyond a doubt that from the most remote ends of the inhabited earth patients flocked to the Egyptian surgeons to be healed; and we know that in their process of embalming they showed no want of proper anatomical knowledge, and that they made no little use of the astringent properties of tannin in the abdomen in the preservation of their dead. Whether our suppositions in regard to their knowledge of in- jection be true or not, we do not know. We do know that, during the ages of darkness in Europe, surgical knowledge and the treatment of hernia were kept alive by the ancient Arabs who in olden times were remarkable for their scientific attain- ments. It is altogether probable also that the ancient Israelites, the chosen people of God, were acquainted with hernia and its cause, prevention, and treatment; and if, as we shall see further on, phimosis be a great cause of hernia in children, may it not be that the law of circumcision was divinely given, as well for the prevention of hernia, as for the preservation of cleanliness and the prevention of syphilis and urinary diseases, which, by causing stricture and obstruction, produce straining and con- sequently hernia?. That syphilis and gonorrhoea, as well as phimosis, do have a marked influence upon hernia and its treatment, we all know from our professional experience. I have frequently observed that persons who have had extensive suppurations from lues veneria are more liable to have bad and complicated forms of hernia than more healthy persons, because the abundant for- INTRODUCTION. xv mation of pus had caused a loosening and weakening of the tissues of the groin. Since the Orientals hated the spilling of blood in their surgical treatments, they made, use of poultices and plasters of astringent substances, whether tannin or pome- granate ; and it may be that the records will sometime show that they also employed astringents internally for the relief of an affection that must have afflicted them. The nineteenth century has witnessed a revolution in medical and surgical science. It has seen ether and chloroform giving comfort to both patient and operator, so that operations can now be performed which before our time would never have been dreamed of. It has seen wonderful advances made in the treat- ment of diseases of the eye, ear, and throat, in the diagnosis of affections of the chest, and in the removal of fluids from the body. Why, it was only in 1856 that I performed the opera- tion of paracentesis thoracis with a thumb lancet and a female catheter. This, I think, was one of the very earliest operations of this kind in this country; yet to-day it is of every-day occurrence in our practice. It has seen surgery made safe by the use of antiseptic precautions ; and I thought, while recently assisting a brother physician to remove the entire uterus and ovaries from a suffering woman, that the conservative surgery of the future will save many precious lives for usefulness that our fathers would have given up for lost. We may, therefore, with perfect truth and confidence say that our profession has ever been, and is to-day, fully as progressive in its advance toward scientific perfection as any other branch of art and science. Let us hail, then, with joyful gladness, all scientific measures that offer to relieve suffering or to save life ; and what grander field than hernia is offered for this work! By endeavoring to relieve the sufferings that this scourge entails upon mankind, we shall take no undue praise to ourselves, but we may safely xvi INTRODUCTION. claim the satisfaction of performing well our duty both to our patients and our profession, and shall preserve in all its sanctity the ever-binding .oath of Hippocrates to preserve life and never to destroy it. Let " Droit et Royal" be our motto, and " Ycrite clans la Science " our greatest desire in the practice of our art. Like many other diseases which the profession has pronounced incurable, it has been the fate of hernia to fall into the hands of unscrupulous men, who in every age have obtained a spurious reputation for curing a disease concerning which it is not in some cases easy to decide whether it can be cured or not; — a disease which is not to be distinguished, except by experienced surgeons, from many others which are easily curable. In both ways the public have been deceived repeatedly, and professional men are naturally placed in an attitude of suspicion toward all such attempts to remove the stigma of impotence which in too many instances is fixed upon their art. In these latter days of attention to the social sciences, we justly consider the physical qualities of races and their deteriora- tion to be of paramount importance. Habits of active exertion and muscular training are encouraged with a view to military, scientific, mercantile, and colonizing pursuits. Doubtless the frequency of hernia, great as it already is, will be thereby in- creased until these habits have invigorated more than one generation and impressed its influence upon their descendants. Thus has arisen an increasing demand for something to be done for hernioe, leading to the revival of attempts to cure this pre- vailing deformity, although most of them in the past have proved futile. Hernia, especially inguinal, is a very common disease, more particularly in those classes of men who are the backbone and support of nations; namely, the laboring, military, and naval classes. The disease renders them incapable, for the most part totally, of the effective performance of their duties, and may INTRODUCTION. XVII place their lives in jeopardy under circumstances in which their greatest efforts are required and surgical help not available. This result has been found by experience not to be effectually guarded against by the use of trusses, which often fail just when most needed or cause so much trouble and expense that they are discontinued as unprofitable. Before we can obtain a proper light from statistics on this subject, we must compare the total number of deaths from attempted radical cure with those from strangulation and other fatal consequences of hernia, and the proportions of each to the total number of hernia?. This alone will show whether society at large is a gainer by the many radical cures that have been proposed. It is a question generally asked of the surgeon by the patient, " Is the operation a safe and certain one " ? The answer will vary somewhat with the experience and more probably with the individual character of the surgeon. The most reasonable defini- tion of a safe operation seems to be, " an operation which has no peculiar dangers arising from the situation of the parts or the method of procedure, and which is not subject more than others to those accidental diseases which may occasionally follow any interference whatever with the surface of the body, such as erysipelas, tetanus, and pyaemia. " Xext, — is the proportion of success to failure such as to offer to the patient chances of cure which will overbalance the dangers and inconveniences of a hernia treated by a truss more or less efficient ? In estimating this, it must be borne in mind that in almost all of the cases called unsuccessful the patient is in a better condition than before the operation, inasmuch as a truss is rendered effective which had previously failed in keeping up the hernia. In none of the cases has the condition of the patient been rendered worse." * * Wood, on Rupture. CHAPTER I. Causation of Hernia. In the following consideration of hernia, we shall discuss minutely the Causation of Hernia in fcetal and infantile life, and devote a few more general remarks to its causation in adults. I have deemed this the better arrangement, since the consideration of the former variety of hernia rests upon an exact anatomical and physiological knowledge, and upon conditions which affect both infants and adults, while the causation of the latter variety is more problematical and rests upon many and varied inherited predispositions, as well as upon conditions and habits of life which differ with the individual. I shall, for these purposes, beg leave to extract freely from many different authors, selecting from each such portions as I shall judge will present to the reader and student the very best and most recent views upon the subjects in question. I wish in this place to acknowledge my very great indebtedness to the writings of Scarpa, Birkett, and John Wood, both for many suggestions and quotations. Congenital Inguinal Hernia.—As an introduction to the proper understanding of this subject, the following extracts from a paper by Allan Burns, of Glasgow, published in " Munroe's Outlines of Anatomy," are very valuable : In the foetus or new-born male, we find that the tendon of the external oblique muscle at its anterior and inferior part separates into two pillars, which leave between them an irregular opening through which CAUSATION OF HERNIA. 5 the cord passes. Both pillars inclining toward the crest of the pubes, one is -completely lost, the other in part implanted. That fold which passes below the cord is completely implanted into the tough ligament which covers the tubercle of the pubes. The other pillar, when it reaches the pubes, separates into two bands; the posterior or deeper is inserted along the lower pillar into the tubercle of the pubes, and extends even to the opposite side. The other, and by far the most important band, winds obliquely inward, then bending backward between the penis and the cord, is at last incorporated with the fascia of the triceps, covering the heads of the triceps, the gracilis, and flexor muscles of the leg. In some cases it can be traced much further and reaches even to the tendon of the gluteus maximus, to which it is attached. The slip from the upper pillar of the canal is always inseparably joined to the fascia covering the cremaster ; indeed it may perhaps most properly be described as a part of Camper's fascia, i.e., the cremasteric sheath attached to the rinor. " I thought," says Burns, " that this structure had not been noticed by any author, but I find that it has not escaped that indefati- gable anatomist, Camper." This part of the canal merits peculiar attention, for whoever is ignorant of the position and connection of the production of the upper pillar of the ring can possess only a very confused notion of its action in disease. When we have examined, in the very young subject the struc- ture of the external orifice through which the cord passes, we have seen all that is most worthy of notice; for in the very early part of life, the inguinal canal is not formed. I have never Observed the cord in any obvious degree oblique in its course. In an infant at birth, it runs in a straight line from the psoas muscle to the bottom of the scrotum, and passes through a mere aperture. When, however, we take a subject even a month old, we find there is a very apparent obliquity in the course of the cord. If we examine subjects of different ages, we find that 6 HERNIA. the older they become until they arrive near the age of puberty, so much the longer does the inguinal canal become. It may be worth while to inquire how the canal comes to be formed, and what changes take place in the neighboring parts. I have already said that the upper and lower openings of the fcetal ring are opposite to each other, and so very little distinct the one from the other that there is hardly a calculable space between them. The ring is placed just in contact with the tubercle of the pubes. The lower outlet in the foetus is there- fore in the same spot which it is afterwards to occupy in the adult. In proportion therefore as the foetal ring is changed into the adult canal, it is the internal orifice which changes its posi- tion. It is the upper opening which ascends toward the spine of the ilium. From this we may very readily understand that it is the gradual extension of the transversalis fascia in this direction which encloses the cord in the canal. A very simple contrivance gives a very clear idea of the man- ner in which the inguinal canal is formed. Let any one take two slips of paper of the same length, and cut two small holes in the centre of each. Let him then lay these holes opposite each other, and pass through them a quill or pencil case. When he has done this, he has a very good plan of the state of the parts about the groin in the foetus. If he now holds the papers opposite him, and then pulls to one side the one nearest to him, he will find that by so doing he comes to lay the quill between the pieces of paper in the same way that the spermatic cord, by the extension upward and outward of the internal orifice of the ring, comes to be lodged in the long canal. He will also see that the length of the canal must vary according to the greater or less extension of its posterior side. On pages 56 and 69 of this present work it will be seen that the author has expressly stated that the inguinal and femoral canals are not properly canals unless distended by a hernia. In a normal state they are simply flattened passages. CAUSATION OF HERNIA. / It is this close apposition of the tissues that first led the author to consider the feasibility of producing union of all these parts by exciting a certain amount of inflammation and the exudation of plastic lymph. If we bear in mind this anatomical relation, we can readily see the practicability and propriety of the operation of injecting into these parts some stimulating fluid which may excite and bring about this desired object. The careful anatomist sees that in proportion to the degree in which the posterior side of the canal overlaps the anterior, so must the length of the canal vary. He will thus understand why in- guinal hernia is much more frequent in young than in old sub- jects, why it is often cured spontaneously in the former and seldom in the latter, and why in the one it is a more dangerous affliction than in the other. In the advanced stage of hernia, the parts are brought into precisely the same state they were in when the disease began. In a congenital hernia, or in the common inguinal hernia taking place in a very young child, the sac passes through a mere aper- ture ; then we see that in time, owing to changes which this opening undergoes, the gut is lodged in a canal, so-called. This continues until the tumor becomes large, when the posterior side of the canal, owing to the pressure, is slowly absorbed, and again the upper and lower orifices are brought opposite to each other, so that the hernia resembles, in its appearance and course, the incipient tumor. If this view of the anatomy be a correct one, we see that by preventing the descent of the intestines, and by returning the sac, we bid fair to cure the disease by allowing the extension of the posterior side of the canal along the cord to take place. In the very young child, there is no security against hernia, except what arises from the cord filling the aperture through which it passes. This is generally sufficient, for the infant is exposed to few of the exciting causes of the disease. In later 8 HERNIA. life, nature has wisely provided that, in proportion to the danger, the security should be increased. The posterior side of the canal overlaps, every day more and more, the anterior side ; con- sequently, when the canal is completed, any pressure against the posterior side, tending to produce hernia, has the effect of laying that side more firmly in contact with the cord, and of forcing the latter steadily against the anterior side, where the fibres of the transversalis and internal oblique muscles react upon it. Thus a most perfect valve is formed, and, when the posterior side of the canal is fully extended, it is impossible that inguinal hernia can take place except by violence. When hernia has once taken place, the very objects which formerly had a tendency to prevent the descent of the intestines are now so far changed in their action that they present obstacles to their replacement. In the congenital form of hernia, the sac is formed of that portion of the peritoneum formed by the descent of the testicle. The passage of the testis through the inguinal canal usually takes place about the eighth month of intra-uterine life. Under conditions retarding the rate of development, this transit may be delayed until after birth, and may be observed to occur at any period during the first few years. Cases are not uncommon in which this descent is retarded until the period of puberty has passed. In such instances, the gland is almost always retained permanently within the abdo- men by adhesions to the colon or parietes, and is usually more or less atrophied. (See page 15.) Sometimes it is arrested in the inguinal canal itself, and is not infrequently mistaken for a hernia. The differential diagnosis may be found in the table on page 81. The impulse given to the gland, upon coughing under these circumstances, results from the presence of a portion of intestinal omentum in a cul-de-sac of the peritoneum, arrested in its developments into the tunica vaginalis in the male, and into the canal of Nuck in the female. CAUSATION OF HERNIA. 9 Certain writers have supposed that the gubernaculum testis possesses the power and has the function of drawing down the testis through the inguinal canal. This gubernaculum attains its full development between the fifth and sixth months; it is a conical-shaped cord attached, above to the lower end of the epididymis, and below to the lower portion of the scrotum. It is placed behind the peritoneum, lying upon the front of the psoas muscle, and completely fills the inguinal canal. According to Mr. Curling, in his " Practical Treatise on the Diseases of the Testis," the gubernaculum, as well as the muscular fibres of the cremaster which surround it, divides below into three processes. The external and broadest process is connected with Poupart's ligament in the inguinal canal, the middle process descends along the inguinal canal to the bottom of the scrotum, where it joins the dartos, the internal one is firmly attached to the os pubis and sheath of the rectus muscle. Up to the fifth month the testis is situated in the lumbar region, covered in front and at the sides by peritoneum, and supported by a fold of that membrane called the mesorchium. Between the fifth and sixth months, the testis descends into the iliac fossa, the gubernaculum at the same time becoming shortened. During the seventh month, it enters the internal abdominal ring, a small pouch of peritoneum (processus vaginalis) preceding the testis in its course through the canal. By the end of the eighth month, the testis has descended into the scrotum, carrying down with it a lengthened pouch of peritoneum. Just before birth, the upper part of the pouch usually becomes closed, shutting it off from the peritoneal cavity. Mr. Curling believes that the descent of the testis is effected by means of the muscular fibres of the gubernaculum; those fibres which proceed from Poupart's ligament and from the ob- liquus internus are said to guide the organ into the inguinal canal, those attached to the pubis draw it below the external 10 HERNIA. abdominal ring, and those attached to the bottom of the scrotum complete its descent. Although there can be but little doubt that the main cause of the formation of congenital hernia consists in the retardation and want of vigor of developmental changes, which seal up the inguinal rings and the canal after the testis has accomplished its transit, still there is great doubt that the descent of the testis above described is accomplished by the forcible retraction of the muscular fibres of the gubernaculum. More probably, the descent is by a simple growth taking place in different parts and in different directions at successive periods of foetal life. The gubernaculum in the human subject, therefore, has no proper function as an organ, but is merely the anatomical vestige or analogue of a corresponding muscle in certain of the lower animals, where it has really an important function to perform. In the rabbit, for instance, the serous pouch of peritoneum, which preceded the descent of the testis, remains in communica- tion with the peritoneal cavity even into adult life, so that the testis may be alternately drawn downward into the scrotum or retracted into the abdomen by the action of the gubernaculum and the cremaster muscle. Guthrie believes that the testis ascends or descends, as the case may be, at the proper period, for the same reason that a child is usually born at nine months in preference to any other period of uterine gestation, which is, as Avicenna says, by the will of God. The office of the gubernaculum appears to be therefore rather to keep a passage open, which might, if it were not occupied in this manner, be closed, than to operate upon the testis by any contraction of its substance. This view is still further strengthened by the anatomical fact, mentioned even by Curling, that the gubernaculum diminishes in size as the testis approaches the bottom of the scrotum. This diminution is not, however, in the muscular fibres, as we might suppose it would CAUSATION OF HERNIA. 11 be if their function had ceased, but is owing to a change in the disposition of the cellular elements of the structure. As the testis passes through the transversalis muscle, it may carry down with it any fibres which lie in its way; when this occurs, the transversalis is found to be united at this part to the internal oblique. The fibres thus brought down assist in the formation of the cremaster muscle, which is nothing more than a certain portion of the lower edge of the internal oblique, caught by the testis and carried before it, Curling to the contrary notwith- standing. See page 61. When the testis is retained in the abdomen, it is not because of a lack of an opening in the trans- versalis or internal oblique muscles, but for some reason which has not yet been sufficiently explained, as the person usually suffers from a hernial protrusion because the parts are less de- fended than usual by the natural structures. If at the period of birth the testis has but just escaped from the canal, or still lies lodged above the external ring, the cries and struggles of the infant, during its first inspiratory movements, will force down a portion of the intestines into the canal. The continual recurrence of this protrusion will prevent the proper closure of the openings. As a rule, the later the descent of the testis through the rings, the larger and the less disposed to close is the hernial opening which results. In many individuals not ruptured in childhood, a late descent of the gland leaves a patu- lous condition of the external ring which greatly predisposes to the subsequent formation of a hernia;' since the only resistance in such cases is a limited extent of adhesion at the upper part of the canal and internal ring. It is generally associated also with a feebleness and deficiency of the lower fibres of the in- ternal oblique. I have at present, under my professional care, a patient neither of whose testes has ever descended. He is a physician fifty years of age, and the father of four children. He has 12 HERNIA. double inguinal congenital hernia, oblique on the right side, and direct on the left. The former descends into the scrotum, lying beneath and back of the testis, which can be felt in the external ring. The condition is the same on the left side, except that the hernia does not descend into the scrotum. The rings upon both sides are enormously enlarged. It is remarkable in this case that the testes will endure without pain pressure suffi- cient to allow a double truss to sustain the hernial, and that they can also be freely handled. When, however, the patient is amorous and excited, the truss causes such extreme pain and almost faintness that, on account of the exhaustion, he has to abstain from such exciting influences. A similar formative deficiency in some of these cases may possibly account also for the non-descent of the testis. The peritoneum is usually lax and loose, and plentifully bestowed upon the superior false ligament of the bladder, which rises more than usual out of the pelvis when distended, and is broader in proportion to its depth. Upon dissection it is usually found that the peritoneum is thinned to its utmost extent by the gradual filling up and dilatation of its areolar meshes by a de- posit of fat. In the omentum particularly, it may be entirely perforated in many places so as to assume a cribriform appear- ance. In these cases the fat, which is the more temporary tissue, may have been more quickly absorbed by illness or star- vation than the containing tissues are able to contract and follow it. The inguinal and other hernial openings are left patulous, and the weakened and yielding peritoneum quickly contributes a thin sac to the rapidly forming hernia which results. It follows from this description that congenital hernia must necessarily be of the oblique variety, in its relation to the in- ternal ring and epigastric artery, and that a true direct hernia is rarely seen in the child. The student who bears in mind what has been previously said CAUSATION OF HERNIA, 13 in regard to the inguinal canal, and the relative position of the rings to each other in the foetus and young child, will not by this statement be misled into the idea that congenital hernia in the child takes such an oblique course as external or oblique hernia in the adult. He will, however, readily see the vicious- ness of the term "oblique inguinal" hernia, the confusion and misunderstanding caused by it, and the worse than confusion caused by the misnomer " indirect," as sometimes applied to the same variety. In long-continued and neglected cases, as I have further emphasized on pages 7, 73, and 180, the internal and external openings are often closely applied to each other and the oblique hernia becomes in its treatment and the difficulty of its management like a direct hernia. In early foetal life, and in many cases for a month or so after birth, the tubular process of the peritoneum, which I have spoken of, extends into the scrotum, lying in front of the sper- matic cord and testis arid extending from the internal inguinal ring to the lowest end of that gland. Before birth or soon after, this vaginal process of the peritoneum becomes divided into two portions, — the superior or funicular process, and the inferior or vaginal process. Under normal conditions the inferior, or vagi- nal process peculiar to the' testis, remains throughout life as a closed serous sac, and the superior canal or vaginal covering peculiar to the spermatic cord, the funicular process, is entirely obliterated, and its superior abdominal orifice permanently closed. The time at which the closure of this ventral orifice takes place and the obliteration of the canal is completed is not fully deter- mined. The first stage in the obliteration begins at the upper part from the internal inguinal ring, at least on one side. The second stage is marked by a union of the walls of the vaginal sheatli as far as the superior end of the testis. The third stage is accomplished when the canal is entirely or partially closed, and when the serous membrane is converted into connective 14 HERNIA. tissue. In the fourth stage, this strip of connective tissue be- comes thinner and at last disappears. In the majority of new-born infants, some portion of this vagi- nal canal still remains. In twenty-one cases, Seiler found four in which it was open on both sides, five in which it was open on the right side, and four on the left. In fifty-three new-born infants, Camper found twenty-three open on both sides, eleven on the right, and six on the left. Schreger found in thirteen infants that the canal was open in eight on both sides. Paletta gives the rule, that the complete closure of the vaginal canal takes place from the twentieth to the thirtieth day after birth. Hernia into the Vaginal Process of the Peritoneum. — AYhen the intestines escape into this open canal, the hernia of infancy exists, and the serous sheath is converted into a hernial sac. Haller, in 1749, was the first to call the attention of pathologists to this fact. John Hunter and Percival Pott confirmed his ob- servations. Haller called the variety in which the intestines and testis touch each other, or are contained in the same sac, a " congenital hernia," which name is still applied to it. Birkett, however, considers the term inappropriate, since " the hernia does not exist either during intra-uterine life or at birth." As, however, a congenital malformation allows the descent of a hernia soon after birth, Malgaigne calls it the "hernia of in- fancy." Birkett still, however, prefers the term, "hernia into the vaginal process of the peritoneum." See Fig. 10. Other illus- trations of the same abdominal imperfection may be found in Camper's " Icones Herniarum," John Hunter's " Med. Comm," and in Palmer's edition of the " Works of J. Hunter." Pott wrote nearly a hundred years ago that " ruptures of this kind are said to be very rare, but from what I have observed both in the living and the dead I am inclined to believe that they happen much oftener to adults than they are suspected to;" while Scarpa says, " It is impossible to turn the bottom of the CAUSATION OF HERNIA. 15 hernial sac upwards in congenital hernia, as may be done in common hernia, leaving the spermatic vessels with the testicle in their situation; for it is not possible in congenital hernia to raise and invert the bottom of the vaginal coat forming the her- nial sac without raising at the same time and turning upwards the testicle and spermatic vessels which are inserted into it. Upon which point I cannot mention but with horror the injury which, from a want of this knowledge, was practised on the celebrated physician Zimmermann, from the false persuasion under which the surgeon labored, of being able to raise up the bottom of the vaginal coat without removing the spermatic vessels from their situation, and to tie it at its neck in order to prevent the return of the hernia, according to an erroneous and already antiquated opinion." It is probable, according to Scarpa, that the descent of the caecum into the scrotum sometimes takes place in preference to that of the small intestine. This may arise from an excessive laxity of the union of the caecum with the peritoneum, and a weakness of the aponeurosis of the external oblique. If the hernia be congenital, it was probably occasioned by the adhesion of the testis to the caecum before the descent of the former into the scrotum. Wrisberg has several times demonstrated a fascia binding the testis partly to the mesentery of the vermiform appendix, partly to the caecum, and partly to the ileum. Hernia into the Funicular Portion of the Vaginal Process. — When an annular constriction of the walls of this vaginal pro- cess takes place between the external abdominal ring and the testis, the hernia lies in the superior portion before spoken of, and is called " hernia into the funicular portion of the vaginal process." (See Figs. 11 and 12.) Instances of this constricted condition of the sac of an oblique hernia are recorded by Pott, Wrisberg, Le Cat, Scarpa, Pelletan, Sir Astley Cooper, and Law- rence. 16 HERNIA. Acquired Congenital Form. — The " acquired congenital fornl of hernia" "encysted hernia of Sir Astley Cooper" or the "infan- tile hernia of Hey" (see Fig. 13) are synonymous terms for a variety of oblique hernia which also depends upon an abnormal state of this vaginal process. In this variety the ventral orifice of the sheath is closed, but the canal persists from that point to the testis. The parietal peritoneum is slowly pushed into this sheath, so that, as Hey says, " the tunica vaginalis is continued up to the abdominal ring and encloses the hernial sac." From its name, one might infer that this hernia is always developed in infancy; such, however, is not the fact. Hey's case was an in- fant fifteen months old, and Cooper's case was about thirty-one years old. The variety is very rare. Acquired Hernial Sac. — The more common form of hernia is where the viscera have been protruded into the acquired her- nial sac, which is, however, distinct from the testis or closed vaginal process of peritoneum. (Fig. 14.) Pott believed that " common ruptures, or those in a common sac, are generally gradually formed; that is, they are first inguinal and by degrees become scrotal; but the congenital are seldom if ever remem- bered by the patient to have been in the groin only." The great importance of a knowledge of the anatomical differences between these two kinds of hernial sacs is especially demon- strated in their surgical treatment. Birkett says: " When the surgeons of the last century dis- covered that a hernia could pass into the vaginal process of the peritoneum and there be in contact with the testicle, they ap- pear to have been content, and without further research to have assumed this variety to" be the only form of hernia dependent for its origin upon non-closure of the ventral orifice of this canal or upon defective obliteration of the upper part of the vaginal process of the peritoneum." We now know that the testis may be wholly shut off from CAUSATION OF HERNIA. 17 every protruding viscus, but that there may yet remain the upper portion of the vaginal process in open communication with the abdomen at the internal ring. Into this caecal or funicular portion of the process, a hernia may protrude and be quite as much congenital as the variety ordinarily characterized by that term. Malgaigne was the first surgeon to point out this variety, its origin and its anatomical relations. There may be two expla- nations of its occurrence; either the parietal peritoneum was suddenly pushed down, or else the serous canal existed con- tinuous with the peritoneal cavity. The latter seems to be the more correct view. In this connection I beg leave to insert, as one of the most recent theories of the causation of hernia, the following essay by Samuel Osborn, F.Pt.C.S., upon " Phimosis as a cause of hernia in infants " : — " Having, in my capacity as surgeon to the Surgical Appliance Society, to examine many cases of hernia and apply some hun- dreds of trusses in the course of the year, the frequency of phi- mosis in combination with rupture in infants has struck me repeatedly. More especially of late, as I have had no less than ten cases within the last month. The phimosis in all these cases, I am certain, was the undoubted cause of the rupture, and may be thus explained. " After the descent of the testicle into the scrotum has been accomplished, the vaginal process of peritoneum, through which it descended, begins to close and become converted into a fibro- cellular cord. But the testicles having but lately descended (the left coming down between the seventh and eighth months of foetal life, and the right between the eighth and ninth months) the uniting medium is but yet young; and, not being sufficiently organized, is easily broken down by any strain thrown upon it. " Phimosis occasions that strain from the impediment which it offers to the outflow of urine; for the mechanism of ordinary 18 HERNIA. micturition is effected by the contraction of the muscular coats of the bladder and urethra; but in cases of obstruction to the outflow of the urine, extraordinary force is called into action, and this is effected by the contraction of the abdominal walls pressing upon the bladder, whilst the diaphragm is also, at the same time, in a state of tension. By this means pressure is exerted over the whole of the abdominal wall; and tire aper- tures by which the testicles have descended to the scrotum being always the weakest points of the ''abdominal surface, they natu- rally give way under the strain thrown upon them. In other words, the child, straining to pass his urine, forces the abdomi- nal contents downwards upon the weak points at the inguinal canals, and rupture on one or both sides results. « " I would go even still further than this, and say that the canal which has been the last to close, or in other words, that side on which the testicle was the last to descend, is the side on which we usually have the rupture occurring; and knowing that the right testicle is generally the last to descend, we naturally find that hernia in infants is also most frequently observed on this side. That the rupture occurs on the side on which the testicle was the last to descend, is only what one would suppose; for the uniting medium, which is effecting a closure of the canal on this side, is not in so advanced a condition of organization as on the other side, where the testicle has taken its place prior to the other. " It is thus easily seen how a single truss frequently produces a double rupture. The cause of the obstruction to the outflow of urine is still present in the phimosis; and, one inguinal canal being guarded by the single truss, the abdomen gives way at its next weakest point, namely, the other inguinal canal, and a double rupture is the consequence. Such a result mioht have been prevented by early circumcision. The hernia in these cases is generally scrotal, or, if not, it soon becomes so by the wed^e-like CAUSATION OF HERNIA. 19 projection of the intestines; and, whether it be congenital or infantile in variety, depends upon the amount of the funicular- process of peritoneum which has become converted into fibro- cellular tissue, or which has been broken down by the aforesaid propulsion of intestine. " The operation of circumcision as performed upon young children, and which was done in all of the cases of which I previously spoke, is both easy of performance and effective in its results; easy of performance, because no sutures are ever required, children bear pain well, and the parts are usually well in a week or ten days; it is effective in its results, because the hernia then stands every chance of being effectually cured by the application of a truss, the exciting cause having been re- moved ; and at all events a double rupture is prevented by its early adoption. Occasionally difficulty arises in the operation when the rupture is very large; for the penis, buried by the projection of the rupture, is represented in such cases by a but- ton-hole aperture, and the operation is then more easily effected if the rupture be commanded by a double inguinal truss during its performance. In conclusion, I would suggest that, whenever an elongated or contracted prepuce is present in infants, the sooner circumcision is performed the better; thereby the more serious complaint of rupture would be prevented." Umbilical Hernia. — Umbilical hernia, properly so called, is a disease of infancy. It rarely occurs in the adult, and when- ever it does occur we may say either that the beginning of the disease had passed unobserved in infancy or else that it had occurred in the linea alba either above or below the aponeurotic umbilical ring or on one or the other side of it; rarely, as is shown on page 39, through the ring. It is not until the fourth month of foetal life that the abdomi- nal muscles assume a fibrous form from the umbilicus to the pubes; but the centre of their union in the linea alba becomes 20 HERNIA. depressed and is the part of the aponeurosis that is least resist- ant to pressure. A small fossa like a funnel is formed in the umbilical ring on the side of the abdominal cavity by compress- ing the centre of the umbilicus with the point of the finger and at the same time drawing the cord gently outwards. Two months after the cicatrization of the umbilicus, this fossa is no longer presented; but, on the other hand, a small tubercle which resists pressure and to which the peritoneum very firmly ad- heres. In process of time the cicatrix of the integuments deep- ens and comes in contact with the aponeurotic umbilical ring, which is likewise plugged in the centre by the three umbilical ligaments and by the urachus; " these ligaments form a triangle, the apex of which is fixed in the cicatrix of the integument, the base in the liver, in the two ilio lumbar regions and in the fun- dus of the bladder." This triangle acts as an elastic bridle to prevent the viscera from protruding through the ring. The margin of the ring also is thickened and elastic. From all these circumstances, it is easy to see that the danger of the formation of umbilical hernia diminishes as the foetus approaches maturity and as the infant increases in age; unless, indeed, external con- ditions interfere. This variety of hernia, like all other varieties, may be either Congenital or Adventitious. The congenital form is found in the embryo, in the immature foetus, and in the fcetus at full term. (See page 49.) The hernial sac contains sometimes a knuckle of small intestine, sometimes a prominence formed by the liver, and sometimes even the spleen or portion of the large intestine. Foetuses born with this disease survive in general only a short time, both because they are affected with spina bifida and other abnormalities and because the viscera protruded have formed adhesions and cannot be completely reduced. The principal cause of this congenital disease is probably owing to the slow CAUSATION OF HERNIA.' 21 and incomplete development and closure of the abdominal muscles. (See Fig. I).1 Besides the intestine, there is a very well authenticated case by Cabrolius that even the urinary bladder, when there has been an obstruction to the outflow of the urine, has been raised so high in the abdomen as to form a hernia through Fig. I. — Congenital Umbilical Hernia. the umbilical ring and afterward to open externally in a urinary fistula. The urethra was closed by a membrane. The girl hav- ing reached the age of eighteen, the umbilicus protruding about four inches, an incision was made into the membrane, the urine took its natural course, the fistula closed and the tumor disap- peared. Probably the protruded viscus had no peritoneal cov- ering. A similar case occurred in a lady patient of mine from Deer Isle, Maine, in 1878. From her umbilical hernia she menstruated and micturated. The treatment was to dilate the urethra and the os uteri, both of which seemed to be spasmodi- cally closed as if by a stricture. Menstruation from the fistu- lous opening in the hernia had followed the birth of a child; previous to that time urine and pus only had been discharged. After six months' treatment, the urine and menses resumed their natural course; the fistulous opening was nearly closed by gran- 1 See Rare Forms of Umbilical Hernia in the Fetus, by James K. Chadwiek. Reprint from Vol. I. Gynecological Transactions. Boston, lS7t>. 22 HERNIA. ulation, but the hernia still remained. It should be stated that I was able repeatedly to pass an ordinary uterine probe through the fistula into either the uterus or bladder. Closure was brought about by the application of perchloride of mercury on the end of the probe. Adventitious umbilical hernia in children is the result of the combination of several unfavorable circumstances. First, we may mention as a cause, the slowness of the contraction of the aponeurotic umbilical ring; difficult labor; the weak cohesion of the divided extremities of the vessels of the cord with the cicatrix of the umbilicus and the aponeurotic margin of the ring, together with the weakness of the integuments composing the umbilical cicatrix; and the permanent tumescence of the abdomen for some time after birth. When these circumstances exist, the continual cries and struggles of the infant are suffi- cient to protrude the viscera from the umbilicus as the weakest part of the abdomen. The division of umbilical hernia into the true umbilical and into the hernia of the linea alba is not without its value. The latter increases more slowly than the former, and is more likely from its smallness to pass unobserved, especially in very fat persons. It is more common above than below the umbilicus, because, as Scarpa thinks, the linea alba from the ensiform car- tilage to the umbilicus is naturally broader and less resistant than from the umbilicus to the pubes, since the recti muscles as they descend constantly converge towards each other. The treatment also is more difficult and less satisfactory than in true umbilical hernia, probably because the aponeurotic ring has a natural tendency to contract, while contraction is not easily obtained in the fissure in the weakened aponeuroses forming the linea alba. Hernia in the Adult. — Having considered the formation of hernia in foetal life, we will next consider some of the causes of CAUSATION OF HERNIA. 23 hernia in more adult life. Three theories have been offered to account for this complaint; and as the adoption of one or the other of them may influence our judgment as to the curability of the disease, we will briefly notice them. First; the theory which has received the support of Warton, Morgagni, Brendel, Richter, Benevoli, Possius, and which is now held by some surgeons, is that the immediate cause, especially of inguinal hernia, is an abnormal elongation of the mesentery permitting such movement of the bowels as to allow their protrusion through the openings in the groin under abnormal circum- stances. The assumption is that a mesentery of proper length would not allow any protrusion of the intestines through an opening in the abdominal wall. Without recapitulating the arguments opposed to this opinion from the able hands of Scarpa (Traitc pratique des Hernies) and of Samuel Cooper (Surg. Diet.), some facts may be mentioned which any anatomist may observe, and which tend to support the conclusion of the first-named surgeon, that the necessary elongation of the mesentery does not precede the displacement of the intestine, but is more probably simultaneous with it, and that both the elongation and the displacement are dependent upon a common cause. When the bowels are distended with food or air the whole front wall of the abdomen is projected forward. There being no vacuum and action and reaction being equal, the pressure is equally distributed over the whole of the containing parietes. The mesentery is stretched to its utmost. If the sides be sound and equally resisting, the whole of the abdominal wall yields equally to the pressure and no hernia occurs; but, if one part be weak while another is resisting, that part yields to the pressure and a hernia results. The culminating point of the pressure is produced by the action of the recti and other abdominal muscles antagonizing the downward pressure of the abdomen and the 24 HERNIA. inspiratory action of the lungs. The most likely, as well as the most frequent place for the abdominal walls to yield before such pressure, is in the aponeurotic structures at the side of the recti muscles, especially when the internal abdominal ring is not sufficiently strong. Often, however, the umbilical opening, which is nearer the point of attachment of the mesentery than the openings in the groin, yields, and this is especially the case in children. In other cases the obturatum foramen, the vagina, or the sciatic notch are found to be the weak parts, although they are much further removed than the groin from the root of the mesentery. These facts lead to the induction that the hernia is dependent rather upon the weakened abdominal parietes than upon an elongated mesentery. There is, moreover, a great variety in the position of the at- tachment of the mesentery to the spine. It is thus very com- mon to find a great part of the small intestines lying in the cavity of the true pelvis between the bladder and rectum. The same result may also be brought about by hypertrophy of the liver, stomach, or spleen; yet hernia is by no means the necessary or frequent accompaniment of these conditions, because the abdominal walls may be everywhere equally resistant and strong enough to retain the viscera. If then the mesentery be long enough to allow the small intestines to lie in the true pelvis, it is surely long enough to allow them to protrude at the groin if the parietes be weak. Again, the direction of the mesentery is toward the left side of the abdominal cavity, and the small intestines lie chiefly in the left lumbar, iliac, and hypogastric regions. If the supposi- tion in question were true, hernia should be more common on the left than on the right side, whereas precisely the opposite is the case (see page 47). But perhaps the most conclusive argument is to be drawn CAUSATION OF HERNIA. 25 from the fact that we find hernia most common, not in subjects who have elongated mesenteries, but in those in whom the abdominal parietes are deficient or insufficient, and that it is an indisputable fact that hernise have been cured by strengthen- ing these containing parietes. If hernia were primarily and principally due to an abnormal elongation of the mesentery, any attempt to cure it, by occluding the opening and strengthen- ing the wall, must be either useless or result in a protrusion in some other weakened part. Second; — the theory that the chief cause 'of a hernial pro- trusion is to be found in a deficiency in some part of the walls containing the intestines. What the precise structure of the retaining power is, is a matter upon which there is a difference of opinion. Some suppose that the parietal peritoneal layer is the most powerful agent in retaining the intestines. At the internal abdominal ring there are evident traces of a cicatrix closing the Vaginal process and the canal of Nuck. This must evidently offer considerable resistance to a protrusion. The sense of something giving way, which is often one of the first experiences in the occurrence of a hernia, is probably due to the yielding of this resistance, together with the forcible dilatation of the internal ring. Although weakness and laxity of the peritoneum, together with a general laxity in the abdominal muscles, may predispose to the formation of a hernia, yet it can hardly be maintained that this is the chief cause of hernia, since hernia frequently occurs where no such laxity exists. The chief cause of rupture, according to this theory, consists in the inefficiency of the tendinous or muscular walls to resist pressure from within. The cause of inguinal hernia lies in the failure of the valvular action of the walls of the canal, as we have previously shown; of femoral, in the inefficiency of the cribriform fascia, which is protruded to form the fascia propria of the hernia. 26 HERNIA. Third; —the theory that the causation of hernia is to be found in an increased pressure caused by the viscera. This increased pressure may be termed the exciting cause, while the diminished resistance of the abdominal walls is the predisposing cause of hernia. The action.of the respiratory muscles is the principal source of pressure upon the viscera. The diaphragm, by its contraction, pushes the contents of the abdomen against the relaxed abdominal walls; these subsequently contract and push the viscera against the relaxed diaphragm. When these movements of diaphragm and abdominal muscles are alternate, the viscera can easily sustain the pressure and compression. When, however, these same muscles act simul- taneously, as during the forcible expulsion of the contents of the uterus, rectum, or bladder, or when they are firmly fixed to enable the person to perform any great exertion, the viscera sus- tain a much greater compression, and consequently react much more violently upon the abdominal muscles. The strength of the walls, and the pressure of the viscera are so admirably adapted to each other in their normal state, that, with ordinary respiration and with the ordinary contraction of the abdominal muscles, the viscera do not protrude. When, however, the walls are abnormally weakened or the action of the muscles excessive, the resisting power of the former is often overcome, and a hernia is produced. When the viscera are once displaced, if the weakest point of the abdominal walls is at the groin, their further dis- placement is very rapid, owing both to gravity and the action of the diaphragm and abdominal muscles. The predisposing causes of hernia are of three kinds : — First: Whatever tends to diminish the resistance of the abdominal walls, such as a weakened constitution, laxity of the fibrous tissues, congenital enlargement of the canal, ascites, pregnancy, old age, etc. Poverty and hard work thus favor the production of hernia. Men, who have larger abdominal rings than women, CAUSATION OF HERNIA. 27 are the more liable to inguinal hernia; while women who have a deeper and wider femoral arch than men, and usually smaller muscles over the space, are relatively more subject to femoral hernia. Second: Whatever increases the volume, weight, or mobility of the contained parts ; such as hypertrophy of the viscera from whatever cause, deposition of fat in the omentum, etc. Third : The existence at birth, and persistence, afterward, of a canal composed of a prolongation of the peritoneum. This has already been considered on page 13 under congenital hernia. The exciting causes of hernia are : — First: Wounds or lacera- tions of the abdominal walls. Second: The weakening or destruction of the same parts by inflammation. Deep-seated abscesses about the hip-joint, groin, and perinaeum, may also undermine and weaken their adjacent tissues. The aetiology of ischiatic and pudendal hernia, together with some other varieties, will thus be easily understood. Third: What- ever diminishes the capacity of the abdominal cavity, the viscera remaining of their normal size. Under this head may be in- cluded the tight lacing of corsets, the wearing of tight pantaloons or a strap around the waist, as is the custom among many laborers. Fourth: The gradual expulsion of the parietal peritoneal mem- brane at weak parts of the abdominal walls. This protrusion is produced by whatever calls into play the violent simultaneous action of the diaphragm and the abdominal muscles. This action, which constitutes the act of straining, plays an important part in the production of hernia, even when the containing parietes possess their usual strength. It is most strikingly exemplified in lifting heavy weights, leaping, singing, especially in deep tones, and in playing on wind instruments ; in the powerful and irregular acts of excessive coition, vomit- ing, coughing, horseback riding, and some military exercises ; in certain diseases, as calculus, constipation, asthma; in exces- 28 HERNIA. sive exertions immediately after a full meal, or during the state of pregnancy, in the exertions attending difficult parturition, and in the forcible attempts to evacuate the rectum or bladder made by persons afflicted with stricture, enlarged prostrate, stone in the bladder, and constipation. Straining is also produced by haemorrhoids, or piles, by fis- sures of the anus, and by fistula in ano. Spondylitis, and curvature of the spine from whatever cause, may also produce a protrusion of viscera at weak or weakened portions of the abdominal parietes. Hernia may however be produced, not only by these diseases themselves, but also by the very methods of their treatment. Prof. John T Hodgen, of St. Louis, recognizing this fact, criticised, at the Richmond meet- ing of the American Medical Association, the plaster casts applied by Dr. Lewis A. Sayre for curvature of the spine. He believes that they "have a tendency to cause hernia and deprecates their use in such cases."1 Certain concussions, for example, those from railroad accidents and collisions, Mill also be found to be a fruitful source of hernia. In this connection, the essay upon phimosis as a cause of hernia in infants, on page 17, will be interesting for the reader to peruse again. Generally, several causes act concurrently in the production of hernia. Some authors have gone so far as to assert that a hernia cannot be produced in a person who is not predisposed to it. This would seem to merit some consideration, when we reflect upon the cases cited by different authors and met in our own practice, where a hernia, being retained, was followed by a second, and sometimes by even a third or fourth, in other weakened parts. Consistently, however, to support the opinion that exertion is the most frequent cause of hernia, it must be shown that exer- tion is the primary as well as the proximate cause. If a person during some extraordinary exertion suddenly experienced "Teat 1 See p. 266. CAUSATION OF HERNIA. 29 pain in the groin, and was sensible that something unusual had occurred; if on examination a protrusion of the viscera was found, but the parietes in a firm state and the ring so constrict- ing the protrusion as to occasion some difficulty in replacing the tumor ; and if, when replaced, it did not again immediately protrude, a fair argument would be that up to the time of the accident there was no predisposition to hernia, but that over- exertion was the sole cause. On the contrary, suppose a person sensible of a hernia dur- ing great exertion, but the parts found to be in a relaxed state, the protrusion, not constricted by the ring but readily reducible, and when reduced disposed to reprotrude immediately, — in fact the resistance of the parietes diminished; how can it be ascer- tained whether in such a case exertion or predisposition was the remote cause ? That extraordinary exertion is often a cause of hernia, no one who has had any experience with the complaint can doubt, and that it will facilitate the descent of the viscera, when a predis- position exists, is also certain. Still, it is a well-known fact that indolence and sedentary habits encourage such a predisposition, and I do firmly believe that if an impartial investigation were made, the complaint would be found quite as common among those who lead sedentary lives as among those of more active habits. Persons of sedentary habits are not only more liable to the predisposing causes in a greater degree, but they are also equally liable to many of the exciting causes. The wear and tear of a working man's constitution is often erroneously attributed to the quantity of exertion employed in gaining a subsistence. A little inquiry and observation will correct this notion and enable us to find other and much more probable causes, among which intemperance stands pre-eminent. The frequent draughts of ale and beer, to say nothing of stronger liquors, to which most working men are accustomed, are of 30 HERNIA. themselves sufficient to account for most of their ailments. Those men whose work is what is termed heavy find a ready excuse for such indulgences; they foolishly imagine, or pretend to imagine, that all these potations are necessary to support their strength, while the artificial thirst thus created by habit is, they contend, the call of nature. The natural vitality of the body, which is so powerful an auxiliary to the vis medicatrix, is therefore turned to no other account than partially to resist the effects of this inseparable intimacy between the cup and the mouth. The thousands who are employed in manufactories, some exposed to fever temperature, some to the noxious effects of impure air, some to unwholesome employments, some only half fed, and almost all packed into rooms ill-ventilated, and living in the same unhealthy manner, furnish abundant evidence of causes for debility without referring to excessive labor. An eminent physician has said that ere long cases of hernia would become comparatively rare because machinery would be univer- sally substituted for manual labor. We know that within the past fifty years machinery has been most extensively introduced, and therefore less manual labor required; yet hernia has not become less frequent, but on the contrary much more frequent. This is shown by the extraordinarily increased demand for trusses, according to the statistics given by various truss socie- ties and manufacturers. Lawrence has said that our inferiority in muscular develop- ment arises, not from organic deficiency, but from want of exercise. Civilized man is ignorant of his own powers. He is not sensible how much he is weakened by effeminacy, nor to what extent he might recover his native powers by the habitual and vigorous exercise of his frame. Labor braces muscular fibre by promoting full circulation and healthy perspiration. It is true that labor carried to excess produces fatigue; but rest CAUSATION OF HERNIA. 31 and conservative power restore strength again, and it is reasona- ble to suppose that this restorative power is not denied to the parts in the neighborhood of herniae. The amount of exertion necessary to cause fatigue must, of course, depend upon habit and constitution, but, at all events, it is quite certain that the less we exercise ourselves, the sooner we are fatigued. " The first physicians by debauch were made ; Excess began, and sloth sustains the trade : By chase our long-lived fathers earned their food, Toil strung the nerves and purified the blood, But we, their sons, a pamper'd race of men, Are dwindled down to three score years and ten ; Better to hunt in fields for health unbought, Than fee the doctor for a nauseous draught; The wise for cure on exercise depend — God never made his work for man to mend." Drydex. If then sedentary habits occasion great relaxation, the parts in the groin will necessarily become more flaccid, and we may expect to find the rings larger, their margins weakened, and, in all probability, an abnormal laxity of the peritoneum. Such a condition of the parts is a positive predisposition to hernia, and it requires only some exciting cause, to which all are liable, to force the viscera out of the abdomen. On the contrary, if the result of exertion shall be strength of muscle and tension of fibre, the parts in the groin will be capable of offering consider- able resistance; supposing, of course, no malformation to exist. " In the development of inguinal hernia," says Wood, " there are at least three different conditions of individual peculiarities." In one class of cases, the muscular system is well developed. The cremaster is powerful, the hips are narrow, the inguinal canal and Poupart's ligament short, and the genital organs small. The hernia is frequently direct, sometimes separating the fibres of the outer pillar. The sac is small in diameter, but when 32 HERNIA. scrotal, much elongated and with a flask-shaped neck; the fundus is apt to become pyriform and, if irreducible, to simulate a hydrocele. The subjects of such herniae are able-bodied men, soldiers, sailors, or laborers. Their hernia occurs suddenly with a sense of something giving way, and is often accompanied with pain and sickness. These cases are liable to that violent form of strangulation which depends upon a spasmodic contraction of the internal oblique across the neck of the sac. The second class of cases has a greater development of the fibrous and fascial structures, with less development and power of muscle. Such persons are wiry and sinewy, so called, and often have a loose and shambling gait. The pelvis is large and the inguinal canal and Poupart's ligament consequently long. The muscular portions of the abdominal muscles are small in proportion to the extent and thickness of their aponeuroses. The total effect of this arrangement of the muscles and aponeu- roses is to depress the abdomen in the median line and to produce extensive projections towards the iliac wings. The genitals are usually large and loose, with a pendulous scrotum indicating an abundance of fasciae and a feeble de- velopment of the muscular fibres of the dartos. The tendons are thick but inelastic, and apt to be weakened by rheumatic changes or fatty degeneration, especially after middle life. The pillars of the external ring are thick, but lose themselves in the thick coverings of the hernial sac, so that their edges are less evident to the touch. The hernia is usually of the oblique variety, and of slow formation. It is noticeable that a thick gristly ring is apt to form in the substance of the sac at its neck, while thickened bands of the deeper fascia may also cause a strangulation. This variety of hernia is a favorable one for the radical cure. The third class of cases retains many of the foetal peculiarities, CAUSATION OF HERNIA. 33 and is generally of congenital or infantile origin, the viscera protruding from imperfect abdominal muscular development. The patient is usually fat, and the inguinal rings very patulous and capable of easy dilatation. The pillars of the external ring are small and thin, and are not so easily made out as in the former cases, being gradually lost in the coverings of the sac. They are weak and easily torn. The inguinal canal is short and wide ; the internal ring large and its edges not easily dis- tinguished. For a further description of them, see page 14. Femoral Hernia.—A few special words upon this variety seem to be necessary. Before the age of twenty, this hernia is extremely rare. Sir Astley Cooper saw only three cases, aged seven, eleven, and nineteen respectively." M. Malgaigne, during five years of service at the Bureau Central, did not see a single case affected before the age of twenty. It is universally ad- mitted to be more frequent in females than in males (page 44), and on the right than on the left side. There should, how- ever, be one exception to this general statement. Malgaigne asserted that inguinal herniae in females are the more numerous. He admits that femoral hernia is most frequently the subject of operation in women, but this, he says, proves only that femoral is more liable than inguinal to strangulation. See, however, page 43. He therefore established a more accurate method of diagnosis, which may be found on page 342. The greater predisposition to femoral hernia in the female may be attributed to the fact that the muscles filling and covering the femoral arch are smaller in them than in men, and because the arch itself is wider and deeper from the wider expan- sion of the iliac wings. In the male, the arch, being smaller, is compactly filled by the psoas and iliacus muscles, and by the vessels and nerves passing to the thigh. It is also protected by the strong union of the transversalis and iliac fasciae. The shrinkage of these muscles in advanced age leaves the femoral 34 HERNIA. arch less occupied, and when added to the general muscular and fibrous relaxation predisposes to the formation of femoral hernia. Hence is readily explained the greater frequency of this kind of hernia in old persons of both sexes. The direction of the crural ring being very nearly upward and downward, the weight of the abdominal viscera, and the pressure* exerted upon them by the abdominal muscles, com- bine in their effect to push upon the peritoneum and septum crurale which cover the ring above. When, therefore, the ring and canal are wide, as we have said they are in the female, the action of any exciting cause will tend to produce a femoral hernia. It will be found also that in those males who are the subjects of femoral hernia the pelvic wings are broad and spread- ing as in the female, and that, moreover, the muscular develop- ment is less than is normal to the sex. Among the exciting causes of this variety of hernia may be included, not only all the exciting causes that we considered on page 27, such as lacerations, inflammations, compression of vis- cera, and straining, but also the more especial exciting causes, as dropsy, tumors, accumulation of peritoneal fat, the violent ab- dominal exertions attending child-birth, and the general relaxa- tion of the abdominal walls after pregnancy. The influence of pregnancy and child-birth upon the produc- tion of femoral hernia is so marked that it is rare to see this variety except in women who have borne children. In males, abdominal distention or accumulation of fat acts chiefly upon the inguinal rings, both because they are kept open by the spermatic cord and because the increased pressure acts upon Poupart's ligament from above. Femoral hernia has, however, been known to co-exist with inguinal. Malgaigne has noticed such a complication; Lawrence mentions a preparation in St. Bartholomew's Hospital, " exhibiting an oblique inguinal and a femoral hernia on each side in a male subject;" while Teale CAUSATION OF HERNIA. 35 cites a case of a patient admitted into the Leeds Infirmary " with two inguinal and two femoral herniae." The first occurrence of a femoral hernia is due to the yielding of the peritoneum, and to the loosening of its connections at the upper margin of the crural sheath. A pouch is then formed at the expense of the neighboring folds or false ligaments of the bladder. This then presses upon the thin septum crurale, until finally the cribriform fascia is stretched, the saphenous opening dilated, and the fundus of the tumor emerges under the integu- ments of the thigh. If these tissues be resistant, the hernia may remain for some time like a bubonocele and cause no visible tumefaction, being concealed by Poupart's ligament and the fal- ciform process. When, however, the integuments have yielded so that the hernia has protruded beyond the crural canal, the tumor gradu- ally expands into a globular form, while the neck remains of nearly its original size; it has been known to extend half-way down the thigh. Serous cysts are occasionally developed in its vicinity, from the closure of the neck of an old hernial sac and from a new protrusion taking place by its side. For the differential diagnosis of femoral hernia, see Table No. 2, page 79, and also page 341. Effects of Hernia. On the other hand, whatever be the individual physical pecu- liarities, we may naturally expect to see certain constant effects, when once there has formed a hernial protrusion. In a small and recent hernia that can be easily reduced, the protruded vis- cera seldom exhibit any change of structure; when, however, the hernia has attained great size, has long existed, and has become irreducible, they are frequently found congested, opaque, indurated, or hypertrophied. The coverings of the sac may also undergo pathological modifications (see page 74), while the 36 HERNIA. mesentery contained in the sac may be thickened, loaded with fat, and filled with congested and varicose vessels. Under the distending influence of a protruded mass, the hernial apertures, which at first are somewhat oval, gradually become enlarged, and assume a more circular form. This enlargement is generally effected by the elongation and separation of the aponeurotic fibres composing the pillars of the rings. We have already, seen (page 7) that the apertures are sometimes displaced in old herniae, so that the internal and external rings finally lie in close apposition, as they did in the foetal state. Scarpa has noticed another displacement of the tendinous fibres of the ex- ternal ring in large scrotal herniae. " The superior pillar is forced so much upward and forward that the neighboring tendinous bands are made to approach each other, and are thus gathered together at the upper part of the ring, so as to give to it a degree of thickness and hardness much greater than it naturally pos- sesses." Finally, the effects of a hernia may be constitutional. The functions of the alimentary canal may be disturbed, causing nausea, flatulence, indigestion, and constipation. When the omen- tum has been protruded, there may result an injurious traction upon the stomach and colon, painful, dragging sensations, and not infrequently colic. Hence it is not uncommon to see per- sons afflicted with hernia become emaciated, and show weariness, exhaustion, and even suffering, from comparatively slight exer- tions. " In fact, the healthy performance of the nutritive proc- esses is so much interfered with as to render them insufficient to compensate for the waste constantly taking place in the tissues." CHAPTER II. Hernia : Kinds and Frequency. kinds of hernle. The varieties of Herniae as generally described derive their • names from the time of life at which the hernial sac is formed, from the region of the body which is affected, from the viscus composing the protrusion, or from the condition in which their contents are formed. As regards the time of life at which Herniae may be found, we recognise Congenital, occurring either at time of birth or immediately thereafter; with its variety, the Infantile or Encysted Hernia ; the former relating to the complete openness of the vaginal sheath of the tunica vaginalis, and the latter, the encysted, to the closure of the sheath at the abdominal parietes leaving a cavity below inclosed by the tunica vaginalis ; Accidental, from whatever cause, whether undue exertion or severe injuries; and Herniae as the result of weakness of the abdominal tissues. Herniae named from the region of the body in which they occur may be Cerebral.—This term is applied to several different forms ; one form may be due to a defect in the cranial ossification, another to a congenital deficiency of both cranium and integuments resulting in the speedy death of the infant, while a third form is seen as a result of the operation of trephining. 88 HERNIA. Diaphragmatic or Phrenic.—These are somewhat iare, often congenital, and when strangulated are beyond operative means of relief. The part of the diaphragm where the fibres are especially weak and deficient is "between the sides of the muscular slip from the ensiform appendix and the cartilages oi the adjoining ribs." * Umbilical, Exomphalos, Omphalocele, or Ruptured Navel.—These are more frequent in infants. When in adults they are more common in females than in males and in obese than in spare persons.2 They protrude through the opening left 1 They are of three kinds:—1st, where the muscular fibres of the • diaphragm lose tone, so that the abdominal viscera are pressed into the thorax; 2ndly, where there is a congenital defect in the fibres; ancP thirdly, where the hernial tumour protrudes through one of the natural openings in the diaphragm which have been stretched. 2 To illustrate some of the remarkable displacements in the thoracic and abdominal cavities that may result from this variety of Hernia, I make the following quotation from the Proceedings of the St. Louis Med. Society of a rather unique case. The report was made by Dr. Stevens :— HERNIA OF THE TRANSVERSE COLON. " I report this case from notes taken at the time of my observations. I was called by Dr. John Laughton to make the dissection in an examination of the body of Police-officer Holton. Besides Dr. Laughton, who had been the attending physician, there were present Dr. Thompson and Prof. Ellsworth Smith. About a year before death, and while in the perform- ance of his official duty, Holton received a stab, made with a pocket knife. The wound was on the left side between the eighth and ninth ribs and about four inches from the sternum. The wound healed readily and with- out any alarming complications. After a few days, just at the site of the wound, there appeared a soft reducible tumour, about the size of half a hen-egg but causing no inconvenience. He returned to his occupation and continued to perform his duties for several months; in fact, till within a few days of the time of his death. The death was caused by enteritis and was not attributed to the lesion mentioned. In the long interval between the time of the injury and his death the case excited considerable interest and there was a wide difference of opinion as to the nature of the tumour, the majority believing it to be a Hernia of the lung ; only one or two, as the sequel demonstrated, formed a correct diagnosis, viz : A Hernia of the transverse colon. " Upon opening the cavity of the chest a most remarkable displacement HERNLE: KINDS AND FREQUENCY. 30 by the umbilical vessels of the foetus.1 The visci found most fre- quently protruding are the epiploon or omentum, the jejunum, the arch of the colon and sometimes the stomach. The tumour is usually round, readily reducible and not very liable to strangu- lation. In the foetus the opening left by the umbilical vessels is perfectly patent but in the adult the aperture is so firmly closed that it is stronger than the linea alba itself. The linea alba however shows even in the normal state weak places around the vessels as well as various orifices in the tendinous parietes for small cutaneous blood-vessels. When from any unusual strain, as from pregnancy, these openings have yielded and of thoracic and abdominal viscera was apparent. The stomach with its greater curvature upwards, was the first object in view; the left half, at least, of the transverse colon was above tlie plane of the diaphragm ; the heart was found backward from its normal position, and the lung diminished by at least four-fifths of its usual dimensions driven to the extreme upper part of the cavity, and presenting more the appearance of a spleen than of a lung. It was wholly impervious to air. The right lung seemed to have expanded and have forced the mediastinum to the left of its normal location. The diaphragm of that side seemed to have almost disappeared; only a vestige remained showing its marginal attachment. You will readily form an idea of the enormous distension that had taken place in order to admit the passage upward of nearly the whole of the stomach and a large section of the colon. " This then was the state of things as revealed by the autopsy. Our conclusions were as follows: That the knife first passed through the in- tegument and intercostal structures, entering the pleural cavity during the act of expiration, the lung escaped injury ; the blade then passed through the diaphragm without wounding any viscus beneath; that at first, a small section of either the colon or the stomach entered the opening in the diaphragm, and then by slow advances, so slow in fact as not to bo perceptible to the individual himself, and so slow that the natural functions of the various organs implicated had ample time to conform their com- pensatory or other actions to the gradually changing relations. Probably it took weeks or months to work out the entire revolution. " A rather interesting fact was mentioned by the attending physician, that the patient frequently vomited during his illness. Of course this must have been performed solely by the contraction of the muscular fibres of the stomach and without the action of the diaphragm and abdominal muscles." . i See p. 19. 40 HERNIA. become enlarged in adults, the protrusion of the viscus may be and often is called umbilical because near the umbilicus. Thyroid.—In this variety the protrusion of the abdominal viscera comes through the thyroid or obturatum foramen. Ischiatic.—Protrusion through the sacro-sciatic notch. Vaginal.—When the tumour descends along or into the vagina. Perinceal—When the protrusion is through a laceration of the perineum of the male. It is the counterpart of the vaginal in the female. Lumbar.—Of this variety a very few rare cases have been reported. by Petit and Cloquet. The intestine is protruded through the posterior muscles immediately above the pelvis. In the anterior region of the abdomen we have Inguinal and Femoral, the former protruding above and the latter below Poupart's ligament. Of Inguinal Hernia there are two varieties. External or Oblique.—Called external because the neck of the sac lies on the outer or iliac side of the epigastric artery. The intestine emerges through the internal abdominal ring, pushing before it a pouch of peritoneum, and then lies in the inguinal canal. " Pursuing the oblique direction of this canal, it emerges at the external abdominal ring, and enters the scrotum, into which it descends. The mouth of the hernial sac is situated to the outer side of the internal epigastric artery, whilst its neck and body are usually in front of the structures composing the spermatic cord. But in rare cases these organs are divided; sometimes the blood-vessels pass over the tumour, the vas deferens behind it, and vice versa; or they are attached to the sides of the tumour. The relative positions of the hernial tumour and testicle differ. The variable site of this latter organ depends upon congenital defect, and hence in some cases the testis cannot be distinguished from the tumour produced by the hernia. , HERNLE : KINDS AND FREQUENCY. 41 However, in the majority of cases the testicle is situated at the posterior and inferior regions of the scrotum; more rarely, it may be detected at the front of the fundus of the tumour. An endeavour should always be made to ascertain the site of this organ, in every case of Inguinal Hernia, and under all circum- stances." 1 Internal or Direct.—Not so common a form as the oblique. It pushes through some part of the abdominal wall internal to the epigastric artery, i.e. on the pubic side of it, and passes directly through the abdominal parietes and external ring. " The mouth of the sac is close to the outer border of the pubic attachment of the rectus muscle, the posterior surface of which may be more easily felt when the Hernia is reduced than in the oblique variety." "The finger enters the abdominal cavity much more readily in the direct furm of Inguinal Hernia than in the oblique. In its passage from" the abdomen ifc traverses merely that small portion of the inguinal canal which lies immediately behind the external inguinal ring, and those structures which form that part of the floor of that canal are either pushed before the Hernia, or they are lacerated when the hernial sac escapes through the opening so formed. Those structures are the conjoined tendons of the internal oblique and transversalis muscles and the pubic portion of the internal abdominal fascia. The spermatic cord and round ligament are not attached to the hernial sac until it has reached the external abdominal ring. When it has passed that point, they lie to its outer side, and are usually less identified with its tissues than in the oblique variety." 2 A rare anatomical variation is when the tumours pass not through the true external abdominal ring but through a division of the fibres of the external abdominal muscle near the ring. Bubonocele.—When an indirect or oblique Inguinal Hernia i Beckitt. 2 Ibid. 42 HERNIA. is incomplete, i.e. not fully formed or protruded, it is called a Bubonocele, probably from its resemblance to an inflamed lymphatic gland in the groin (bubo).1 Scrotal or Oscheocele and Pudendal.—When a complete Inguinal Hernia passes through the external ring and escapes into the scrotum it is called Scrotal, when into the labia majora, Pudendal. Ventral.—When it escapes through some part of the ab- dominal walls usually strong and muscular it is called Ventral Hernia. Ventro-Inguinal.—When a Ventral Hernia slips into the inguinal canal it is called Ventro-Inguinal. Femoral, Crural or Merocele.—This form of Hernia was not accurately differentiated from Inguinal until the middle of the seventeenth century, and its exact anatomical relations were not properly understood or described for many years after.1 It pro- trudes through the femoral or crural ring, the upper opening of the crural canal in the angle formed by Gimbernat's and Poupart's ligaments, and emerges fiom the saphenous opening of the fascia lata in the upper and inner side of the thigh, the femoral veins lying on the outer side of the ring, and the epigastric artery crossing the upper and outer angle of the ring. It is more common in females than in males. As regards the contents of the sac or the viscus composing the protrusion, if it be intestine, usually the small intestine and more particularly the ileum, we have an Enterocele, if omentum we have an Epiplocele, while a combination of the two is called Entero-EpiploceU. Rarer forms of hernial tumours from the abdomen are Gastrocele,2Hepatocele,3and Cystocele,4protrusions of stomach, liver, and bladder. The terms applied to the pathological conditions in which we 1 It has passed through the internal ring but not the external, therefore it lies in the inguinal canal. HERNLE: KINDS AND FREQUENCY. 43 find Herniae are Reducible when the protrusions can be readily returned to the abdomen. Irreducible, a generic term to signify a Hernia that cannot be returned either because of adjoining adhesions, incarceration, strangulation, thickening of coverings or deposit of fat.5 Incarcerated, when the Hernia has become temporarily irre- ducible because of a constriction in the intestines which prevents passage of faeces.6 Strangulated, when the Hernia is irreducible because of a constriction which prevents not only passage of faeces but also circulation of blood in the tumour. This circulation may be impaired " by muscular spasm, oedema or the sudden forcing of additional contents into the sac." For the relief of this form of hernia, the operation of herniotomy or kelotomy must be employed.7 FREQUENCY OF HERNIA. The frequency of the occurrence of Hernia varies in different kinds of herniae according to kind, sex, age, population, occupa- tion, walls of the abdomen, social state and the nationality. 1. Relative frequency of the different Kinds.—The In- guinal and Femoral are the most frequent, and after them comes Umbilical, while all the others can be considered as very rare. Out of the 93,355 Herniae forming the total of the statistics published in 1855 by Bryant, we find 46,551 simple Inguinal to 7,452 Femoral without distinction of sex, being 1 Femoral to 6j24 Inguinal. Of 30,575 double Herniae there were 28,503 Inguinal and 1,972 Femoral which gives the relation of 1 double Femoral Hernia to 14'25 double In- guinal. The sum of these figures gives 75,054 simple and double Inguinal to 10,425 simple and double Femoral, being 1 Femoral to 7*19 Inguinal. These figures may not form an absolute rule, but still the result of 93,355 cases ought 44 HERNIA. to be some guide to the relative occurrence of these kinds of Herniae.8 2. Relative frequency according to Sex.—J. Cloquet states the relation of this occurrence as 2 males to 1 female. According to Malgaigne it is 4 males to 1 female. The tables prepared by the Truss Society of London give still different results, being 5 males to 1 female. According to Kingdon this last proportion is too great, leaving the relation given by Cloquet as nearer the truth. As regards the relative occur- rence of Inguinal and Femoral Herniae in the two sexes the Truss Society in 1855 claim about 1 Femoral in the male to, 75 Inguinal, but in the Report for 1863 give 1 Femoral to 32 Inguinal. It is so hard to understand such a difference in these figures that only a general idea must be drawn from them. According to the same Report of 1855 the relation in the female is 1 Inguinal to 4*6 Femoral, while according to Malgaigne Inguinal are even more numerous than Femoral in the female, although proportionally less than in the male. In the Report of 1863 the proportion was not quite 1 Inguinal to TQ4 Femoral in the female, figures which seem a priori much more reasonable. As regards Umbilical Herniae, they are more frequently found in the female than in the male. 3. Frequency according to Age.—In 300 Herniae examined by Malgaigne 26 occurred between the ages of 10—20 45 „ • „ „ 20—30 66 „ „ „ 30—40 163 „ „ „ 40—80 300 4. Frequency in Relation to Population.—According to the same authority above cited— HEHNLE: KINDS AND FRKQUENCY. 45 Before 1 year there is From 1— 2 „ 9__ 3 » - ° M „ 5—13 „ From 30—35 „ „ 35-40 „ At 50 „ 60—70 „ „ 70-75 „ He estimates the proportion of the whole population of France which is ruptured to be 1 out of every 13 males, and 1 out of every 52 females, or taking both sexes together 1 out of every 20 5 individuals. 5. Frequency according to Occupation.—In a general way we may say that the more difficult the occupation the more liable are those engaged in it to suffer from Herniae. Here as in all other tables of a similar nature, figures can be only approximately valuable and must not be relied upon as absolute. The following table I believe to be as nearly accurate as can possibly be. Hernia in every 21 individuals. » 29 >» >l 37 tt » 77 » tt 32 >> 1} 21 i* >) 17 •i >) 9 »> )) 6 » >» 4 tt 3 46 HERNIA. Report of Kingdon (Truss Society). According to Census of 1851. 1S59. i860. 1S61. Farm labourers .... 171 173 Farmers.... 776 503 734 Boot and Shoemakers S8 53 12 Carpenters and Joiners 173 178 99 Tailors . 20 33 28 House servants (male) 101 176 131 Workers in Silk 63 71 53 Blacksmiths . . . 48 51 63 Masons and Paviors — 18 — Poiteis and Gardeners , 478 410 351 Gardeners 65 119 114 Bookmakers . — — 49 Butchers 53 52 52 Painters and Plumbers 33 45 50 Breadmakers . 35 69 52 Carters . 73 87 82 Commercial Brokers 29 30 65 C'erks . — — 41 Boatmen — 44 35 Sawyers . . . 35 34 29 Pedl irs . 33 57 37 Wheelwrights . 10 — 18 Engineers 2(i 51 42 Coopers . 20 32 23 We can, however, go further than this and investigate the influence of position during work. This question has been especially discussed in regard to Inguinal Herniae, and the question that has arisen is, " Are various attitudes capable of modifying the diameter of the Internal Abdominal Ring and of the Inguinal Canal ?" Here again, all that is best known on the subject rests upon the authority of Malgaigne, who is content to say that occupations requiring the adduction and flexion of the thighs expose the bowels to displacement much more than the occupations allowing a normal position of the body. Thompson and Richet on the other hand, think that adduction of the thighs will relax the external ring, it being impossible to modify the dimensions of the internal HERNLE: KINDS AND FREQUENCY. 47 ring by special attitudes. If this be really so, the effect of position will be to modify not the causation of Hernia but only the development when the Hernia has once been formed. 6. Frequency according to the Side of the Body.— Herniae as a rule are more frequent on the right side than on the left, and that in the proportion of 7 to 4 or 5. The reason for this has been variously expressed. Schinkius thought it due to the larger lobe of the liver being upon the right side, Martin to the inclination of the mesentery, Cloquet to the predominance of those who are right-handed in their actions over those who are left-handed. This seems by far the best and most plausible way of accounting for the fact, since we observe that in all movements of the right side the diaphragm forces the abdominal viscera downward, forward, and to the right side. Malgaigne as usual doubts the state- ment, and by figures seeks to show that Herniae in right- hauded persons are more frequently on the left side than on the right. Thus of 313 Inguinal Herniae 40 were double, and of the 273 remaining, 171 were right and 102 left, while of the 273, 1 out of every 11 was left-handed. 7. Frequency according to Race of Men.—As regards the race most frequently afflicted with this abdominal weak- ness, it has been found that inhabitants of warm climates are more often " ruptured " than those of temperate and cold reoions. Then of course we can make the general statement O that the hard toiling nations are more like to be " ruptured " than those who lead a more moderate life. This will as well apply to the different orders of men in the same nationality, and when thus much has been said, we can say no more that could be of the least authority or practical value. CHAPTER III. Anatomy : Descriptive and Surgical. anatomy of hernia : descriptive and surgical. Of all these varieties, the kinds most commonly met are the Umbilical, the two varieties of Inguinal and the Femoral; to these we will now more particularly confine our attention, defining minutely the anatomy, coverings and symptoms, their several variations under unusual conditions, differentiating diag- nostically between them individually, and also between them and the other abnormal conditions of the abdominal region likely to be confounded with Herniae. For this purpose I have, besides consulting other authors, made many extracts from Gray, Anderson, Lawrence, Beckitt and Ranney, to whom I wish to give due credit for their labours, researches and writings.1 SURGICAL ANATOMY OF UMBILICAL HERNIA. This protrusion is directly through the abdominal parietes at the navel, or umbilicus, or its immediate vicinity. Passing from without inwards we meet the integument, superficial fascia, the aponeurosis formed by the union of the oblique and transversalis 1 Descriptive Anatomy. By Henry Gray.—System of Surgical Anatomy. By William Anderson. New York, 1822.—.4 Treatise on Ruptures. By W. Lawrence. Philadelphia, IW3.—A System of Surgery. Edited by T. Holmes. Vol. IV.—Surgical Diagnosis. By Ambrose L. Ranney. New York, 1879. — The Essentials of Anatomy. By William Darling and Aiubroso L. Rnnney. New York, 1880. ANATOMY: DESCRIPTIVE AND SURGICAL. 49 muscles, the fascia transversalis, a layer of sub-peritoneal cellular tissue often containing fat and a pouch of the parietal layer of peritoneum, forming the hernial sac. These coverings being of more importance in Inguinal Hernia will be there more fully described. In Umbilical Herniae these coverings may become so inseparably united and thinned that they appear as one and allow the contents of the sac to be seen from the surface. Other variations in the coverings have reference to the method of for- mation of the sac. If it be suddenly produced, not only may the tendon of the external oblique be wanting but also the superficial fascia and the fat. If the tumour be formed before the separation of the umbilical cord, it passes directly through the umbilicus into the substance of the cord and gains from it a peculiar covering. No blood-vessels, unless it be superficial vessels or abnormal veins, as seen by Manec, Meniere and Velpeau, are situated nea*r a Hernia in this region. The contents of an Umbilical Hernia are usually both omentum and intestine, entero-epiplocele. Other viscera besides the large and small intestine may be inclosed by the sac, as for example the stomach or uterus. The firm margin of the umbilical ring forms an unyield- ing ring around the neck of the sac which is itself thicker at this point than over the body of the sac. As the tumour increases in size it does not extend uniformly over the abdo- minal surface but downwards towards the symphysis pubis more than in any other direction. It may be sessile with an immense base, or pyriform, and suspended by a peduncle or stalk. In the Foetus, umbilical Hernia is always in consequence of a defective development in the abdominal walls, as I have already said, and is often associated with other malformations such as hare-lip or club foot. It has a covering formed by the union of the peritoneum and the envelope of the umbilical cord. If the £ 50 HERNIA. tumour be large, death often takes place from peritonitis a few days after birth. In the child, umbilical protrusions occur usually after some violent muscular exertion, as coughing or crying, are small and Flo. 1.—Umbilical Hernia. The three most common forms of Hernia, named in the order of their occurrence in the female am Umbilical Femoral and Inguinal. Oblique Inguinal, or Pudendal in the female is v.rv fine'y shown on the nyht side of the figure. Umbilical as well as Kemoral on the left side speak for themse'ves. The fibres and fascia transversalis in the Umbilical ro -ion are verv we'l drawn, mid show the appearance of a Hernia in that stage of its formation when the intestine ha* already passed the internal ring and commenced to protrude fro-u the external surf ice. conical and almost always contain only intestine and not omentum. In the adult I have already said this variety of Hernia is not ANATOMY: DESCRIPTIVE AND SURGICAL. 51 strictly umbilical, but only so-called by convention and for con- venience of classification. The tumour is globular or pyriform, and in corpulent persons tends to insinuate itself into the adipose tissue downwards towards the pubes. Thus it may for years exist unsuspected because concealed in this way. In such a state too there is great danger of strangulation and fatal results. Such Herniae more frequently exist in fleshy women who have borne many children, than in men. Certain symptoms are characteristic. The tumour at first is small, soft and ovoid. It readily reduces by pressure, when a distinct sharp outline of the umbilical ring can be felt by the finger. On removing the finger the skin either remains creased in folds or it gradually distends until the tumour re-appears. On coughing a distinct impulse in the tumour is felt by the finger. In adults, who have Umbilical Hernia, any tenderness of the abdomen, constipation or nausea should be carefully watched as giving symptoms of possible strangulation. (For diagnosis from Ventral Hernia see Table on p. 80.) SURGICAL ANATOMY OP THE ABDOMINAL REGION RELATING TO INGUINAL HERNIA.1 The superficial fascia of the abdominal region is of two layers, between which are the superficial vessels and nerves and the inguinal lymphatic glands. It was first described by Camper. The superficial layer is thick and areolar, and contains adipose tissue. The deep layer is thin, aponeurotic and strong. It adheres in the middle line to the linea alba, and below to Pou- part's ligament and the fascia lata, although it does not increase the strength of the abdominal ring. Between them are the superficial epigastric, circumflex iliac and external pudic arteries and veins, terminations of the ilio-hypogastric and ilio-inguinal nerves and the upper group of the inguinal lymphatics. i See p. 160. E 2 52 HERNIA. These cutaneous arteries all arise from the femoral, about half an inch below Poupart's ligament. The superficial epigastric passes through the saphenous opening, crosses Poupart's liga- ment midway between the spine of the ilium and pubes, and ascends nearly as high as the umbilicus, anastomosing with the deep epigastric from the external iliac and with the internal mammary from the subclavian. It supplies the integument and fascia. Its vein enters the internal or long saphenous. The superficial circumflex iliac runs parallel with Poupart's ligament out to the crest of the ilium. The superficial external padic passes inward across the spermatic cord to supply chiefly the integument of the penis and scrotum of the male and of the labia of the female. The ilio-inguinal nerve pierces the transversalis and internal oblique muscles, and escaping at the external abdominal ring accompanies the spermatic cord to the scrotum and thigh. The aponeurosis of the external oblique muscle lies beneath the fasciae. It is thin and strong with fibres running down- ward and forward. The lower edge of the aponeurosis, thickened and stretched like an arch between the anterior superior spinous process of the ilium and the spine of the pubes, is called Fallopius' or Poupart's Ligament, and under Femoral Hernia will be spoken of as the femoral or crural arch. It is narrow behind and increases in breadth towards the front. On the superior surface is a concavity for the spermatic cord. The reflection of this ligament backwards and inwards to the ilio- pectineal line is called Gimbernat's ligament, which is about an inch in length although larger in the male than in the female and almost horizontal in the erect position. It is triangular in shape; its outer margin or base, concave and sharp, being in contact with the crural sheath and blended with the pubic portion of the fascia lata; its apex joining the spine of the pubes. A reflection of this ligament extending behind «5SiS I \ PLATE A. STUDY OF THE INGUINAL CANAL. By BOURGERY. [As a curiosity of language, the descriptions of these three plates will be given in the words of the original translation.] Details of the inferior extremity of the Great Oblique and Transversal, and their relations with the Groins and origin of the Thighs. Left side of the Subject: Great Oblique, whose aponeurosis is half open, and thrown back to shew the interior of the inguinal canal, the cremaster being re- moved. The circumference of'the ring is preserved in form of a stay. The thigh represents the upper extremity of the superficial muscles. Right, side: Femoral transversal and aponeurosis. Explanation of the Plates. The explanation refers to two plates which have been combined. A, A. Anterior and superior iliac spines. B, B. Pubic spines. LEFT SIDE. 1. Inferior extremity of the great oblique. 2, 2. Its aponeurosis. 3, 3. Shreds of the aponeurosis, inverted, to show the inguinal canal. 5. Origin of Poupart's ligament. 6. Cut of the small bands, from whence the external pillar proceeds. 7. External pillar, implanted upon the spine of the pubis. 8. Small band, from whence the internal pillar proceeds. 9. Internal pillar. Between the two pillars is the inguinal ring. 10. Internal inguinal ligament. 11. Extremity of the internal pillar of the right side. 12. First band of insertion to the pubis, separated from the internal pillar by the arcade of passage to the ilio-scrotal nerve. 13. Extremity of the aponeurosis which closes the ring, preserved in form of a stay. HIGHT SIDE. 1 4. Origin of Poupart's ligament in the iliac spinal. 15. Aponeurosis, thrown back upon the thigh. 16. Its tie, forming the external pillar. 17. Aponeurosis of the little oblique, in front of the great right. 18. L"ft side: Last ties of this muscle in the gutter of Poupart's ligament. The arcade which it forms is raised up by a hook, to let the transversal be seen. 19. Right side: Extremity of the fibres of the little oblique inverted within, to let the aponeurosis of the transversal be seen. 20. Idem. Transversal. 21. Idem. Last ties of this muscle in the gutter of Poupart's ligament. 22, 22. Summit of the arcade which it forms above the internal orifice of the inguinal canal. 23. Aponeurosis of the transversal. 24. Inferior tie of the pubis. It is the same aponeurosis which is seen through the orifice of the left inguinal ring. 25, 25. Of the sides: Thick edge of the fascia-transversalis, which limits the superior orifice of the inguinal canal outside, and then unites itself with the gut- ter of Poupart's ligament. 26, 26. Idem. Very fine portion of the same fascia, which forms the internal edge of the orifice. Behind a fibro-cellulous sheet are seen the epigastric vessels which ascjnd parallelly to the internal edge. 26, 27. Idem. Ellipsoidal internal orifice of the inguinal canal. 28. Right side: Superficial aponeurotic leaf, applied upon the crural vessels. 29. Mem. Section of the internal sapheneous vein, which crosses the femoral aponeurosis (inferior crural ring), in order to through itself into the femoral vein. 30. Left side : Sartor muscle. 31. Fascia-lata. 34. Anterior right. 32. Keflected mass of the psoas and iliac. 35. First abductor. 33. Pectine. 36. Penis. ANATOMY : DESCRIPTIVE AND SURGICAL. 53 the internal pillar of the external abdominal ring to the linea alba is called the triangular ligament. In the middle line of the body, the fibres of this aponeurosis join with the fibres from the aponeurosis of the corresponding muscle on the opposite side to form a thickened line from the ensiform cartilage to the pubes, the linea alba, formed by the union of the aponeurosis of the oblique and transversalis muscles. About an inch and a half from the pubes the thickened fibres of the aponeurosis separate to form the pillars or columns of the external abdominal ring. The internal or superior pillar is broad, thin and flat, and attached to the upper edge of the pubes near the symphysis. It interlaces with fibres from the opposite side. The external or inferior pillar is narrower, thicker and stronger, is inserted into the spine of the pubes, and is curved around the spermatic cord to form the groove above mentioned. The separation of these tendinous pillars leaves a triangular opening over the pubes, called the external or abdominal ring. The pubes forms the base of the triangle and the tendinous columns the sides. At the apex are some curved fibres, inter- columnar fibres, which increase the strength of the aponeurosis, and are more developed in the male than in the female. Through this triangular opening passes the spermatic cord in the male and the round ligament of the uterus in the female. Over the outer surface of the cord and testis is prolonged a thin fascia, the intercolumnar or external spermatic fascia, attached to the pillars of the ring. The abdominal ring, or more properly triangular aperture, is directed upward and outward. "When distended by a Hernia it assumes more of a circular form, so that then the appellation of ring is much more appropriate. Its size and form vary; sometimes it is rounded, and closely em- braces the cord or round ligament, sometimes elongated, and sometimes square. It is usually about an inch in it3 long diameter from pubes to internal angle, and about one half inch 54 HERNIA. transversely between the columns. It is larger and stronger in the male than in the female. The fascia of the obliquns internus muscle along the middle line over the rectus for the upper two-thirds of its extent is divided into tuo layers, of which the outer is blended with the fascia of the obliquus externus, while the inner is blended with the transversalis fascia. In the lower third all this expansion of Fio. 2.—Inguinal Hernia. This figure shows the various coverings ; 1, skin, superficial fascia; 3. intercolumnar fascia; 4, en master muscles, hifundilm ifmin fascia, subserous ce.lulur tissue; 2, sac, epigastric artery with veins on either side of it. fascia? passes in front of the rectus. The fibres of the internal oblique from the upper half of Poupart's ligament arch down- ward and inward across the spermatic cord, to be inserted with the tendons from the transversalis as the conjoined tendon into the crest of the pubes and pectineal line for half an inch. It lies behind, and so closes Gimbernat's ligament, and the ex- ternal abdominal ring, and strengthens the ring towards the abdomen. Sometimes it is insufficient to resist the pressure ANATOMY : DESCRIPTIVE AND SURGICAL. 55 from within, and is protruded as one of the coverings of direct inguinal Hernia. The Fascia Transversalis lies between the inner surface of the transversalis muscle and the peritoneum, and closes the ring of the external oblique toward the muscle ; otherwise there would be a direct opening into the abdomen behind the ring. Thick and dense in the inguinal region, it becomes thin and cellular as it ascends toward the diaphragm. The internal abdominal ring is an oval opening, running upwards and downwards, much larger in the male than in the female, situated in the transversalis fascia "midway between the anterior superior spine of the ilium and the spine of the pubes, and about half an inch above Poupart's ligament." The following description of this ring is taken from Sir Astley Cooper, who first noticed the fascia in which it occurs. The edges of this ring " are indistinct on account of its cellular connections with the cord ; when these are separated, the fascia of which it is famed will be found to consist of two portions : the outer strong layer, connected to Poupart's ligament, winds in a semi-lunar form around the outer side of the cord and bounds the aperture by a distinct margin, from which a thin process may be traced passing down upon the cord. The inner portion which is found behind the cord is attached to, but less strongly connected with, the inner half of the crural arch, and may be readily separated from it by passing the handle of a knife between it and the arch. It ascends between the tendon of the transversalis, with which it is immediately blended, passes around the inner side of the cord, and joins with the outer portion of the fascia above the cord, being at length firmly fixed in the pubes; the inner margin of the ring is less defined than the outer, the fascia transversalis being doubled inwards towards the peritoneum to which it is firmly attached. Thus, then, it appears that the internal ring is not a circumscribed 56 HERNIA. aperture like the external abdominal ring, but is formed by the separation of two portions of fascia, which have different attachments and distributions at the crural arch; the outer portion terminating in Poupart's ligament while the inner portion will be found to descend behind it, to form the anterior part of the sheath that envelopes the femoral vessels. The strength of this fascia varies in different subjects; but in all cases of inguinal Hernia it acquires considerable strength and thickness especially at its inner edge; and if these ports had been formed without such a provision, the bowels would, in the erect posture, be always capable of passing under the edge of the transversalis muscle, and no person would be free from inguinal Hernia.1" The opening then in the abdominal parietes for the passage of the spermatic cord is not a simple aperture, but an oblique canal, the abdominal or Inguinal Canal, although it is not properly a canal unless distended by a Hernia. In its normal state it is merely a flattened passage. The crural arch running from the anterior superior spine of the ilium io the spine of the pubes, and forming a channel in which lie the psoas and iliacus muscles, with the femoral vessels, gives attachment to the internal oblique and transversalis muscles, and contains in its lower half the spermatic cord or the round ligament. The external oblique presents in the lower and inner parts of its aponeurosis above the pubes the triangular opening called the external ring, but now more properly the lower or external opening of the inguinal canal. This space between the tendinous columns of the ring is closed behind by the insertion of the internal oblique into the pubes. Hesselbach has accordingly called it the " crural surface of the anterior inguinal ring." It is the only place where the internal is left uncovered by the external oblique muscle. The corresponding surface on the posterior or abdominal side 1 Cooper on Hernia, part I. p. 6, ed. 2. * ANATOMY: DESCRIPTIVE AND SURGICAL. 57 of the canal is a triangular space bounded on the inner side by the outer edge of the rectus abdominis, on the lower by the pubes, or as usually given by, Poupart's ligament, and on the outer by the femoral and epigastric vessels. This has been called the "triangular inguinal surface," or Hesselbach's Triangle. It is the weakest part of the abdominal parietes, being covered only by the transversalis fascia and the conjoined tendon. The inguinal canal is bounded posteriorly, or on the abdominal aspect, by the transversalis fascia, in which is the opening of the internal abdominal ring, higher and more external than the external ring, and about an inch and a half distant from it. Besides the superficial epigastric artery coming off from the femoral, the surgeon must pay particular attention to the deep epigastric from the external iliac. It arises immediately above the crural arch in a loose cellular structure. Concealed at first by the crural arch, it lies behind the obliquus internus and transversalis, and is covered by the spermatic cord just before the cord enters the inguinal canal. It ascends obliquely inward between the transversalis fascia and peritoneum to the outer margin and posterior surface of the rectus, running "along the lower and inner edge of the internal abdominal ring, in general, precisely along the inner margins, but sometimes rather nearer to the pubes, passing at the distance of nearly an inch from the upper extremity of the ring of the external oblique." It lies behind the inguinal canal and immediately above the femoral ring. It is accompanied by two veins, the larger of which is always found upon the inner side. They unite into a single vein before they terminate in the external iliac vein. Several small branches of the artery ought to be known to the operating surgeon, the cremasteric, which accompanies the spermatic cord, the pubic, which runs across Poupart's ligament and then descends to the inner side of the femoral ring and the muscular branches. 58 HERNIA. Fio. 3. Superficial dissection of inguinal and cniral regions. Below the groove up.™ front of thigh is seen the triangular depression forming the lower part oi groin. Tins is desciibetl in connection with Femoral Hernia. Above the pubis may be felt Ihe opening,in the deep parts,of the superficial abdominal ring through which the spermatic cord escapes to testicle. Beneath the skm of groin and fascia superfici.lis are two layers, between whi.h are found the superficial vessels and lymphatics. The layer below this i« made up of elastic areolar tissue, and fat, closely attached to Poupart's liga- ment at spine of pubis and crest of ilium, g. Crossing the groin are SL°en three blood-vessels turned obliquely inwards and upwards from common Wral artery. Outer one, superficial circumflex iliac, passes up to superior iliac spine d. The middle one, superficial epigastric, supplying glands and integuments of g.oin to umbilicus, e. Inner one, /, superficial external pubic, enters fascia lata near the pubis, crossing beneath spermatic cord to scrotum and root of penis. The external pubic is liable to be divided in cure of Inguinal Hernia ; if a dull bistoury be used in making the division, hemorrhage is less liable to occur, unless the vessel is very much enlarged winch is the case sometimes in old and large ruptures ° ' The abdominal wall is made up of layers of° muscular'and aponeurotic tissue below the iliac crests. The external oblique is very stroiur nnd the fibivs curve downwards and inwards towards median line and pubis, formin- with other tendons a vertical line, and by union with opposite side line" alba ANATOMY: DESCRIPTIVE AND SURGICAL. 59 Externally towards thigh, fibres growing thicker and oblique, running in with fascia lata, and uniting with deeper fascia form crural arch or ligament of Poupart, g. This band of fibres is attached to, and forms an arch between anterior superior iliac spine and spine of pubis. It has a slight convexity downward, outward, and backward so as to form the hollow of the groin. The fibres of the aponeurosis are bound together by tough areolar tissue which can be traced downward into the intercolumnar fascia, h. Through various 'sized openings in this fascia pass vessels and nerves into abdominal wall. One of these larger openings is the external ring, i. There are considerable variations in the point of origin of the artery. It may arise " from any part of the external iliac between Poupart's liagment and two inches and a half above it, or it may arise below this liagment from the femoral or from the deep femoral." The measurements of these parts vary so in the two sexes that the subjoined tables by Sir Astley Cooper, from the measure- ments of well-developed persons, will be of especial value. Although the distances will be somewhat different according as the person be large or small, the relative proportions will be the same. From symphysis pubis to anterior superior spine of ilium . to tuberosity of pubes . to inner margin of the lower open- ing of the abdominal canal to inner edge of the upper opening to middle of iliac artery to iliac vein..... to origin of epigastric artery . to course of epigastric artery on inner side of upper opaning to middle of the lunated edge of fascia lata .... From the anterior edge of the crural arch to the saphena major vein .... From symphysis pubis to middle of crural ring The transversalis muscle and fascia with the epigastric vessels which form the anterior boundary of the abdomen are lined behind by the peritoneum, which presents a well-marked depression or pouch. A thin fibrous prolongation extends for Male. Female. inches. inches. H 6 H 11 i 1 3 n H 3§ 2| n 3 3i 2| n- n 3^ i H 2* 2^ HERNIA. Fm. 4.—Rule. This sliding and revolving rule will be found very handy in taking these anatomical measure- ments. This was loaned to me by T. Bryant, Surgeon at Guy's Hospital. ANATOMY: DESCRIPTIVE AND SURGICAL. 61 a short distance over the front of the spermatic cord, and is the remains of the pouch of peritoneum which in the foetus accom- panies the descent of the cord and testis into the scrotum, and which soon after birth begins to be obliterated. (See page 13). The spermatic vessels situated behind the peritoneum descend over the psoas and iliacus internus muscles connected to them by loose cellular tissue, and at the divisions of the transversalis fascia are joined by the vas deferens at an acute angle. This union forms the spermatic cord, composed there- fore of arteries, veins, lymphatics, nerves, and vas deferens invested by its proper coverings. Making a sudden bend up- ward, it enters the inguinal canal through the inner abdominal ring, and running obliquely downward and inward in the in- guinal canal between the transversalis fascia and the aponeurosis of the external oblique, emerges at the external abdominal ring. It then descends nearly vertically into the scrotum, lying on the outer pillar of the external ring so as to cover its insertion into the pubes. In its passage through the inguinal canal the cord is strengthened by the cremaster muscle, which consists of scattered bundles of pale reddish fibres derived from the internal oblique during the descent of the testis. They form around the cord and testis a series of inverted arches or loops, rather difficult to dissect. As to their insertion, M. Cloquet says, " the lower fibres of the internal oblique, traversing the external angle of the ring in front of the cord, ascend again immediately, to be fixed to the pubes behind the external pillar of the ring, forming loops of small extent, with their concavity directed upward." These parts forming the cord are joined together by a cellular structure which Scarpa thus describes :— " The soft cellular texture which envelopes the spermatic vessels behind the great bag of the peritoneum, and accom- panies them under the fleshy edge of the transversus muscle 62 HERNIA. passing with them through the separation of the lower fibres of the obliquus internus and along the inguinal canal into the groin and scrotum, continues to surround them as far as the part where they terminate in the testicle. This cellular investment, Fia. 5. Deep dissection of inguinal canal and abdominal wall, a, external oblique thrown back over Poupart's ligament ; b, internal oblique ; c, transversalis muscle ; d, conjoined tendon ; c, rectus muscle ; /, transversalis fascia ; g, triangular aponeurosis formed by a layer of fibrous tissue passing across linea alba from aponeurosis of external oblique of opposite side. These fibres pass outward and downward to pubic symphysis, crest and spine, or even to pectineal line, where they are implanted with those of the conjoined tendon ; h, muscular fibres of the cremaster. The fascia transversalis, uniting at the groin with fibres of the tendon of the transversalis muscle, is closely connected with Poupart's ligament, iliac fascia and conjoined tendon. Here it forms the oval opening of the internal ab- dominal ring and gives off over the cord, the funnel-shaped investment called the fascia propria or infundibularis, i. ANATOMY: DESCRIPTIVE AND SURGICAL. 63 being a continuation of that which connects the great bag of the peritoneum to the muscular and aponeurotic parietes of the abdomen, becomes thicker and more copious as it approaches the part where the vessels pass out of the inguinal ring, and after that passage it is enclosed together with the vessels and the tunica vaginalis testis in the muscular and aponeurotic sheath formed by the cremaster, which extends to the bottom of the scrotum. If we make a small opening into the upper part of the sheath and impel air through it, the cellular texture is im- mediately distended, and the cord is swelled into the form of a cylinder extending from the groin into the scrotum as far as the attachment of the vessels to the testicle, where a circular groove or depression is seen marking the boundary between the cellular substance of the cord and the tunica vaginalis testis. While the part is thus artificially distended we may carefully slit up the sheath of the cremaster and expose the investment of the cord, which is then seen as a vesicular spongy tissue with large and long cells capable of extension without tearing. The spermatic vessels .are seen running through it separate from each other, and near them is that prolongation of the peritoneum which constitutes in the infant the neck of the tunica vaginalis testis. The diffused hydrocele of the spermatic cord affords another proof how easily this cellular texture may become dis- tended. The cellular sheatli of the spermatic cord, which con- stitutes an investment of tolerably close texture, is connected to the margins of the opening of the transversalis, and again to the external abdominal ring. The cremaster muscle contributes further to fix and support the cord in its passage through the abdominal parietes, while it provides for the necessary move- ments of the testicle." To recapitulate: of inguinal Hernia the great majority of cases are of the external or oblique variety. The viscera pro- trude " through the opening left between the two portions of the * 64 HERNIA. fascia transversalis and under the margin of the internal oblique and transversalis muscles: that is, at the point where the tunica vaginalis communicates with the abdomen in the foetus, and where the spermatic cord passes out in the adult." The mouth of the sac is at the upper or inner opening of the Fig. 6. Dissection from the peritoneal surface of the parts affected by an oblique rupture ; peritoneum, its fascia and the transversalis fascia are removed. The sac is cut off at its neck in the deep ring. The epigastric artery is seen below the neck, but has been removed a>t the inner side to show conjoined tendon, h. inguinal canal, and is therefore midway between the anterior superior spine of the ilium and the spine of the pubes. The normal distance between the internal and external rino-s is O rarely seen in Hernise of long standing; in fact the normal distance is rarely preserved in any complete inguinal Hernia The spermatic cord is placed behind the hernial sac. After the ANATOMY : DESCRIPTIVE AND SURGICAL. 65 Hernia has escaped beyond the external ring, however, many variations in the relations of the cord to the sac may be pre- sented. It may be found at the sides or even on the anterior surface, or, as often happens, the vas deferens and the spermatic vessels, owing to the great pressure following the distension, may Fig. 7. Dissection of Inguinal and Crural Hernia from internal surface, the peritoneum and fascia being removed, a, external iliac artery; b, epigastric artery, branch of a ; d, deep circumflex iliac, lying in Hesselbach's triangle ; e, rec- tus muscle ; /, fascia transversalis ; g, vas deferens or spermatic duct ; h, spermatic plexus of veins with artery and nerves ; i, obliterated cord of hypogastric artery ; k, lymphatic glands. At the internal ring may be seen subperitoneal fascia, I, enveloping the cord, h. separate, the former on the inner side of the tumour and the latter on the outer. An internal or direct inguinal Hernia pro- trudes through the fascia transversalis at Hesselbach's triangle and then through the external abdominal ring. Such a Hernia F 66 HERNIA. according to Cooper, takes place "if this tendon is unnaturally weak ; or if from malformation it does not exist at all; or from violence has been broken." The spermatic cord lies usually on the outer side of the sac, although it may lie behind it as in the external or oblique variety. The epigastric artery is pretty constant in its relation to the Hernia, that is, in its normal state about three-quarters of an inch from the upper and outer extremity of the external ring, although Hesselbach records a case in which he found the epigastric so near the symphysis pubis that had a direct Hernia taken place the artery would have been upon the inside of the mouth of the sac. The inguinal canal has the following boundaries, which have been taken from Darling :— {Skin. Superficial fascia (2 layers'). External oblique (entire length). Internal oblique (outer third). ' Conjoined tendon of internal oblique and transversalis. t> i« j /c . x \J Transversalis fascia. Behind (5 structures) Triangular ligament. Sub-peritoneal tissue and fat. I Peritoneum. Above (2 structures) ( Fibres 2 £ 3 o 3 £ Pressure . outward and i?~ backward. Pulsation of deep epigas-tric artery concealed. Direct Inguinal Hernia. Globular. Seldom scrotal and usually small. P. Flat. Hard when it is epiplocele. Empty. Outside of the neck as a rule. g -o Pressure £ directly backward. Epigastric often felt pul-sating outside the neck. Scrotal Hernia. Smooth and regular. Flask-shaped. Scrotum. Weight: light. Sudden. P. Usually resonant. A. Gurgling. Soft and doughy. Present in majority of cases. Usually tilled. Concealed & displaced by neck of sac. Occasional embarrass-ment. Pressure back-ward & outward unless strangu-lated, incarcer-atedor irreducible Seldom painful unless inflamed or strangulated. Sarcocele. Often nodular and irregu ar in outline. Testicle. Weight: heavy. Grows slowly as a rule. P Dull or flat. A. Negative. Hard and resistant. No impulse. Empty. Surrounds the cord Never afTected. Irreducible. Frequently painful. Scrotal Hernia. F ask-shaped. Opaque. Scrotum. Weight: lLht. Develops suddenly trom above downward. P. Resonant. Soft and doughy. Fluctuation absent. Filledexcept when direct Hernia enter scrotum. Usually con-cealed by neck of sac. Neither con-cealed nor displaced. May bo embarrassed Usually reducible. Aspiration negative. Hydrocele of Testicle. Pyriform or ovoid. Trans! uceut. Tunica vaginalis. Testis. Develops slowly from below upwards. P. Dull or flat. Hard, tense. and elastic. Fluctuation wed marked. Empty. Never affected. Never reducible. Fluid withdrawn by aspiration or tapping. Scrota] Hernia. Smooth and regularin outline Colour: normal Scrotum on either side. Weight: light. Develops suddenly. P. Usually resonant. Smooth on surface. C. I. Usually present. F. Absent. Usually tilled. Concealed and displaced. May be embarrassed Reducible by taxis only. Effect of heat: negative. Return of tumour pre-vented by pressure at external ring. Variocele. Knotty and irregular. Colour: bluish. Most frequent on left side. .Around spermatic cord. Develops gradually. P. Dull. Feels like a bag of worms. C. I None. F. May exist if vessels are large Uninvolved. Not affected. Never affected. Often reduces spontaneously when position favours increased venous return. Etlect ol heat: tumour in-creases. Tumour returns in standing position in spite of pressure at the ring. Scrotal Hernia. Flask-shaped, unli'SS due to direct Hernia. Colour: nonnal. Scrotum. Weight: light. Tunica vaginalis. Testis. Weight: heavy. Develops suddenly from above downward. P. Usually resonant. A. burgling. Soft and doughy. F. Never present. Usually tilled. Concealed and displaced. May be embarrassed Usually reducible. No constitutional symp-toms except when strangulated or severely inflamed. Hematocele of Testicle. Pyriform. Integument is ecehymotic. Suddenly if of trmtmatic origin: slowly if sponta-neous Grows from below upward. P. Dull or flat. A. Negative. Soft at first but hard after coagulation occurs. F. Always present until coagu'ation occurs. Empty. Not affected. Never affected. Irreducible. Pallor: Great prostration often present from loss of blood. 1 No. 2] Location. Weight, Size. Advent and dc\elopiuent. Percussion and Auscultation. Cough Impulse and Fluctuation. Bowel. Reduction. Addenda. Femoral Hernia Often felt deep in groin. Movements restricted. Usually due to some severe niuscu'ar effort. P. Resonant. A. Gurgling. C 1. Present on flexion and adduction of thigh with body bent forward. F. Never present. Often embarrassed. Reduced by pressure downwards, backwards, and upwards. Tumour always solitary. Rare in the male sex. Enlarged gland. Always superficial. Great mobility. Scrofulous diathesis. P. Flat. A Negative. C. I. None. F. Often detected. No embarrassment. Irreducible. Tumour seldom so'itary. Equally frequent in both sexes. Femoral Hernia. Neck of sac lies internal to femoral artery. Usually due to severe muscular effort. P. Resonant. F. None. Intestinal derangement often present. On pressure downwards. backward, and upward. Distinct and sudden disappearance with gurgling. Pain frequently absent. Tumour remains reduced in recumbent position. Psoas abscess. Neck of saoext final to femoral artery. History : Spinal disease or pelvic affection. P. Dull or flat. F. Often occurs if tumour is superficial. Bowel acts normally. Disappears gradually on direct pressure. No gurgling. Pain in back or loins always precedes development. Tumour returns after removal of pressure. Femoral Hernia Directed obliquely across the thigh. Usually small Severe muscular effort. P. Resonant Often exists. C. I. Present on flexion and adduction of thigh with body bent forward. Often embarrassed. By pressure downward. backward, and upward with a sudden slip and gurgle. Tumour usually hard and tense ; may be doughy. Skin of normal colour. Return of ri duction prevented by pressure over femoral ring whin patient is standing. He.it has no effect on size. Varix of saphenous vein. Lies in longitudinal axis of limb. Variable in size. History and increased size of veins b low crural ring. P. F at. 0.1. Often absent but may exist. No embarrassment. Reduction gradual by direct, pressure in recumbent position. No gurgle. Soft and indistinctly fluctuating, often discoloured. Tumour returns when patient stands in spite of pressure at femoral ring Increased by heat. Femoral Hernia Sma'l and well-d, fined in outline. Advent sudden. P. Resonant. May exist. C 1 Often detected with thigh flexed and adducted and body bent forward Intestinal embarrassment not infrequent Usually reducible. Tumour often hard. Symptoms in common. Tumour in upper part of the thigh, ,, inside of femoral vesse.s, „ external to pubic spine, ,, below ., „ Tumour always doughy. Lipoma of femoral canal. Not well-defined in outline May be large. Develops slowly. P. Dull. C I. Never present. Bowels not affected. Irreducible. Femoral Hernia. Neck below Poupirt's ligament. Usua ly small and round. Spermatic cord. Internal to and in front of neck of sac. P. Frequently dull. Femoral pulsation. Felt external to neck when finger is in the canal. Spine of pubes. Internal to neck of sac. By pressure downward, backward, and upward. Tumour if elongated lies obliquely across the thigh and never enters scrotum and labia. Inguinal Hernia. Neck above Poupart's ligament. Often very large and flask-shaped. External and behind neck of sac. P. Resonant. Finger in the Femoral canal detects no pulsation. External to neck of sac. Indirect : By pressure outward and backward. Direct : By pressure directly backward. Tumour if elongated is often scrotal In situation. No. 3.] Location. Advent and Development. Reduction. Age. Neck of tumour and appearance. Palpation. Navel. Ventral Hernia. Most frequent between ltee.ti nmsiles of abdomen. Naer congenital. History : Traumat-ism, abscess or weakening of abdominal walls. Often somewhat difficult May occur at any age. Edges of pregellt m& ln Neck Is well-denned. abZn'nal walls nolraa>, can be felt. position; Uuibi'ical Hernia. Bulging at the navel. Navel therefore absnt. Often congenital. Hisiory of trau-matism or abscess selnvm present. Effected by mere pressure. Most frequent in infants. No apparent neck, but only a bulging at the navel. Usually spherical. No unnatural | Absent : opening can be 1 tumour sup-deticUd. [plies its place. i Thyroid Hernia. In the thigh near the. inferior commissure of vulva. Seldom found in male SeX. Sudden. a *§ K Occurrence. In the old and emaciated neck is felt. from outside the body In obscure cases a vaginal or rectal exploration is necessary. Symptoms in common. Often impossible to detect when small. Sudden advent. Resonant percussion. Redueibi ity. Cougli iinpu'se as a rule. Possible, intestinal embar-rassment. Perineal Hernia. Perineum above rectum. In botli sexes Rare but easily detected. Not discernible unless protrusion is ex-tensive and involves perineum. Origin easy to decide if tumour is pronounced. Diaphragmatic Hernia. Passing through diaphragm. Sudden advent of protrusion into the t hoi ax known to the patient. Mail possibly be reduced by manipulation and position. Percussion. Auscultation. Bowel. Thirst. I'eritonitis. Tympanitic or localized dulness low down in inuliustinum or thorax if hernia is superficial. Gurgling.' Embarrassment may exist. Maybe Symptoms rapid extreme. " u,,""u':« .-'•nrrrn atfd. Extreme thirst is Never produced absent. Mi diastinal Tumours. High up in the thorax. No marked or sudden symptoms until the size creates pressure. Irreducible. Localized dulness. Negative. If aneurism exists a bruit is heard. Unaffected. Congenital Hernia. Inguinal canal distended and involved. Occurrence sudden. May suddenly increase when onco developed. When fluid portion is reduced it revea.s a concealed testicle, which also reduces with gurgle and peculiar sensation ot sickness. Age. Shape. Pedicle. Fluctuation. Trans-lueency. Inguinal canal. Usually in infants. Subsequent attacks may occur in adults. Globular. Marked. Usua ly fluctuating at vpper part. May be trans.ucent. Either distended or invohed. Hydrocele. Inguinal canal empty. Always developed s.owly and gradua ly. Irreducible. Any age. Not necessari 1 y associated with previous attack. Pyrifonn. 1 None. Marked at ail points. Always translucent. Empty. Congenital Hernia. May occur any-where but here we consider only the scrotal variety. When in scrotum, is formed before the tunica vaginalis closes after descent of testicle. After reduction of fluid and intestinal portion the testicle appears. This is also redueib'e with gurgling and pain. Age. Fluctuation. Translucent. Never attacks adults unless a previous attack has existed in infancy. Exists at upper part of tumour from presence of peritoneal fluid. Translucent at upper portion. 1nf;tflti'e Occurs after c'osure Ticilnction of tumour Most common in infan s. but Absent. O). nque. — No. 4.] Location. Advent and Development. and Auscul-tation. Pa'pation. Cough Im-pulse and fluctuation. Bowel. Pain. Reduction. Addenda. Incomplete Inguinal Hernia. limits of inguinal canal. Outlines often indistinct. History of muscular strain usually present. P. Frequently resonant. A. Gurgling. Usually soft. C I. Often detected. F. Absent. May be embarrassed. Generally painless. Possibly and often easy. (Edema absent. Constitu-tional symptoms absent unless sac be. strangulated or inflamed. Bubo. beyond the limits of the cause. Outline usually clearly defined. Venereal origin often detected. Pt Dull. A. Negative. Hard at onset. C. I. Usually absent. F. Present if suppuration occurs. Unaffected. Generally painful. Impossible. CEdema present. Frequent constitutional symptoms. Bubonocele. 15 B a o £•= B P. Fr< quently resonant.. A. Gurgling. Usually soft. B o S j II d May be embarrassed. Generally painless. Reduction with a gurgle. - Vomiting. Scrotum normal and both testicles present. Undescended Testicle. P. Dull or flat. A. Negative. Hard like a gland. Unaffected. Ver;/ painful. Pressure causes characteristic sensation of sickness. ' May be impossible. '.No gurgle. Vomiting. Scrotum imperfect on side corresponding to ttunuur and testicle wanting. Inguinal Hernia. Felt only in inguinal region. Developed sttdrfrnl// after strain or injury. P. Usually resonant. Usually soft. CI. Frequent. F. IS one. May be asso-ciated with obstinate constipation. Usually painless. Pressure may effect reduction. wniuiip absent unless In ruin be strangulated or inflamed Not sensitive unless strangu atcd or inflamed. Impacted Faeces. Felt at the side as well as in inguinal region. Developed slowly with colic pans and no apparent causation. P. Flat. Hard and nodulated. C 1. Absent. F. Present. A Iwnys associated with obstinate Constipation Painful. Localized pressure causes-indentation. Vomiting usually present. Always tender on pre ssure in ad\aneed stages. Inguinal Hernia. Frequently scrotal and generally • diffused. Sudden and from above downward. P. Resonant, as a rule. A. Gurg.ing. Soft as a rule. Opaque. CI. Frequent. F. None. Often embarrassed. Usually painlcs. Reduces with a gurgle. Movements < f testicle have no ell'.ct Reduction remains while recumbent position is maintained. Hydrocele of Cord. Circumscribed in limits. Slow unless produced by vio'ence. Occurs Irom above downward. P. Dull. A. Negative. Tense Often -translucent. C. I. Absent. F. Present. Never embarrassed. Usual'y painless. Vunllii Irrcducib'e. 11 reduced, mo gurgle. Movement of ti sticle trans-mits an impulse to the tumour. Return of reduction irrespective of position. Enterocele. In all forms of herniae. Advent sudden, with acute pain. P. Usually resonant. Soft, com-pressive, elastic. CI. Distinct. May be embarrassed. Frequently absent Sudden return with gurgling. Epiplocele. Rare in Femoral. Advent s'owor, with dull pain. P. Flat. Doughy, harder, in-elastic, and lobulatcd. C I. Lus distinct. Unembarrassed unless we have Entero-epip'occle. More painful. Reduced slowly in a lump with no gurgling. » 82 HERNIA. The following diagrams illustrating the different forms of Hernia with some of the complications, are taken from my distinguished friend Thomas Bryant's highly esteemed work on Surgery, by his according me free permission for the use of this work. The same permission is granted by my no less distinguished friend Mr. J. Wood. In all these diagrams the thick black line represents the parietes covering the hernial sac; the thin line the peritoneum and hernial sac; the small body at the bottom of the sac the Fio. 10. Ro. 11. Fio. 12. Fio. 10.—This diagram Illustrates the tubular vaginal process of peritoneum open down to the testicle, into which a hernia may descend. When the descent occurs at birth the hernia is called "congenital;" when at a later period of life the "congenital form," iiirkett's "hernia into the vaginal process of peritoneum." or Malgaigne's "hernia of infancy." Fia. 11.—The same process of peritoneum open ball-way down the cord, into which a hernia may descend at birth or at a later period. Birkett's " hernia into the funicular portion of the vaginal process of the peritoneum." Fio. 12. —The same process undergoing natural contraction above the testicle, explaining the hour-glass contraction met with in the congenital form of scrotal hernia as well as in hydrocele. Fio. 13. Fio. 14. Fio. 15. Fio. 13.—Diagram showing the formation of the "acquired congenital form of hernia," the "encysted of Sir A. Cooper," "the infantile of Hey," the acquired hernial sac being pushed into the open tunica vaginalis which encloses it. Fio. 14.—Diagram illustrating the formation of the "acquired" hernial sac, distinct from tho testicle or vaginal process of peritoneum which has closed. Fio. 15. — illustrates the neck of the hernial sac pushed back beneath the abdominal parietes with the strangulated bowel. See Figs. 19 and 'M. ANATOMY: DESCRIPTIVE AND SURGICAL. 83 Fio. 16 Fio. 17. Fio. 18. Fio 16. _ Shows the space in the subperitoneal connective tissue into which intestine may be pushed through a rupture in the neck of the hernial sac, the intestine being still strangulated by the neck. See Fig. 21. . Fio. 17. — Diagram showing how the neck of the vaginal process may be so stretched into a sac placed between the tissues of the abdominal walls, either upwards or downwards, between the skin and muscles, — muscles themselves or between the muscles and the internal abdominal fascia, — forming the intra-parietal, inter-muscular or interstitial sac, hernia en bissac of the French, " additional" sac of Birkett. See Fig. 22. , , . .^, ,, Fig. 18. — Diagram illustrating the reduction of the sac of a femoral hernia en masse with the strangulated intestine. First variety of displaced hernia. Fio. 18. Fla- *■ Drawing illustrating the second varieties of displaced hernia. Fia. 19. A A portion of abdominal muscles, with the peritoneal lining. B. The strangulated fold of intestine. 5* TIig t6Sticl6 The dark lines at the neck of the sac represent the duplicature of the peritoneum, which being unfolded formed a sac for containing the intestine when reduced. Fio. 20. A Peritoneum lining the abdominal parietes. .... . ., „„„.„„»:« Si The tumour formed when the strangulated intestine was pushed through the spermatic canal into the sac formed by peritoneum in the inside. C. The superior portion of tiie intestine. D. The inferior. E. The scrotal hernial sac. F. The testicle, with the vaginal coat opened, bee also *ig. is. G 2 84 UEJiNIA. Fig. 21.—Third variety. Interstitial hernia, with ruptured neck of hernial sac. See also Fig 16. Fio. 22.—Drawing illustrating the fourth variety or intra-parietai form of displaced hernia A. Peritoneum lining the aDdominal muscles (B). C Intra-parietal sac witu strangulated bowel. D. Scrotal hernial sac \eading down to testicle (T). E. Director passed from the congenital scrotal sac through the internal ring. In the drawing the strangulated bowel has been introduced to make the description clearer. See also Fig. 17. CHAPTER IV. Strangulated Hernia. A Hernia is said to be strangulated when not only the passage of faeces is impeded by the constriction, but also the circulation of the blood. The varieties of Hernia in which strangulation is most violent and severe are the femoral and incomplete in- guinal, since they are small and therefore apt to be overlooked. A large and long standing Hernia is more liable to strangula- tion than a large and recent one, but a small recent Hernia is still more liable to strangulation than one of longer standing. Sir Astley Cooper says," A small Hernia is more easily strangu- lated than a large one, the pressure on the contents being more violent and the symptoms much more urgent, as the stricture acts with much more effect upon a single knuckle in stopping its circulation, than when the contents of a Hernia are large and Voluminous." On the other hand it must be borne in mind that of Hernias of the same size, an old one is more liable to strangu- lation than a recent one, although in the latter the symptoms are more dangerous and likely to be attended with mortification of the intestine. Is this condition of strangulation solely the result of a mechanical constriction, or is it partly the result of some pathological change set up in the intestine before protrusion ? Birkett feels justified from the symptoms preceding the con- striction, " in attributing the strangulated state of a Hernia to 86 HERNIA. a predisposing cause, commencing in a morbid state of the alimentary canal generally; at least in some cases." The patients have usually complained for some time of a disordered or relaxed state of the bowels, and it is also found that the entire mucous surface of the small intestines secretes more than a normal amount of their fluid, and that the intestines are greatly distended and congested. Erichsen on the other hand gives a slightly different aetiology of the Hernia. He thinks it induced by the constriction to which the intestines are subjected, producing stagnation of blood and inflammation of the congested part. The stricture is most commonly outside the neck of the sac in the tendinous structures surrounding it, although sometimes at the neck itself, and more rarely around the body of the sac, thus giving a Hernia shaped like an hour-glass. It takes place suddenly and usually in consequence of some violent muscular exertion.13 1. What is the condition of a Strangulated Hernia ? 2. What changes take place in it ? 8. What are the symptoms excited in the constitution, and the morbid conditions in the abdomen ? 1. The first condition of strangulation is that the blood is impeded, and next that it is arrested. The tissues of the bowel become swollen, they are solid and leathery, their colour dark purple often mottled with red. This inflammation causes a flow of lymph into the intestines giving then a rough and villous appearance. When the bowels have been some hours strangulated their tissues become soft, the serous surface has lost all its normal characteristics, it is black and adhesive, gangrene has now set in. This state usually comes on within twenty-four hours, although it may come on in a very few hours or may be delayed for forty-eight hours. The intestine becomes firmly fixed to STRANGULATED HERNIA. 87 the mouth of the sac by adhesions, the omentum becomes dark purple, and there is usually a large quantity of turbid serum in the sac. If the strangulation is unrelieved, gangrene of the skin may take place, and the fa?oal matter may be discharged through the disintegrated tissues. Such a state is somewhat rare, and it is often the case that there is no external evidence that gangrene has attacked the intestines. 2. As a result of the gangrenous inflammation an artificial anus may be formed in two ways; one in which only a hole is corroded through the alimentary canal without interfering with its continuity, the other " due to an ulceration of all the coats of the bowel even to the mesentery," and therefore "interfering with the continuity of the bowel.1 The coverings of the hernial sac undergo pathological modifications due to ecchymoses, inflammations,11 oedema &c. The tumour may become very sensitive and excruciatingly painful; it may also become swollen, from infiltration of serum, tense and regular in outline. " The discoloured parts become cold and insensible, and more and more dark except at their borders which are dusky red ; a thin, brownish, stinking fluid issues from the exposed integu- ments ; gas is evolved from similar fluids decomposing in the deeper-seated tissues, and its bubbles crepitate as we press them ;.■... At the borders of the dying and dead tissues, if the mortification be still extending, these changes are gradually lost; the colours fade into the dusky red of the inflamed but still living parts; and the tint of these parts may afford the earliest and best sign of the progress toward death or the return to a more perfect life. Their becoming more dark and dull, with a browner red, is the sure precursor of their death; their brightening and assuming a more florid hue is as sure a sign that they are more actively alive."2 1 See Chapter XL 2 Paget, Surgical Diagnosis. 88 HERNIA. Another appearance of mortified parts, characteristic of a class, is presented after they have been strangulated. I have mentioned the difference which in these cases depends on'whether the strangulations have been suddenly complete, or have been gradually made perfect. In the former case the slough is very quickly formed, and may be ash-coloured, gray, or whitish, and apt to shrivel and become dry before its separation. In the latter case as best exemplified in Strangulated Hernia, the blood vessels become gradually more and more full, and the blood grows darker till the walls of the intestine, passing through the deepest tints of blood colour and of crimson, become com- pletely black. Commonly by partial extravasation of blood and by inflammatory exudation they become also thick, firm, and leathery, a condition which materially adds to the difficulty of reducing the Hernia, but which is generally an evidence that the tissues are not dead; for when they are dead they become not only duller to the eye, but softer, more flaccid and yielding, and easily torn like the rotten tissue of other mortified parts. The canal which was before cylindrical may now collapse ; and now commonly the odour of the intestinal contents penetrates its walls. I have said the serum might be turbid. It also becomes brownish yellow with the odour of faeces and before burst- ing though the walk of the intestine may infiltrate, its tissues or coverings. 3. One of the first and main symptoms of strangulation is nausea in the morning after rising from bed, with vomiting due to a nervous irritation upon the viscera. As soon as the strangula- tion has taken place the patient feels restless and uneasy, a feeling of tightness is felt as though a band were bound around the body. In general, the symptoms are those of obstruction. Around the seat of constriction there is acute pain, often increasing so as to resemble the severe pains of peritonitis.14 As a STRANGULATED HERNIA 8? • result of the stoppage of peristaltic movements, complete con- stipation, severe and continuous vomiting together with violent retching, first ejecting the contents of the stomach and then faecal matter, and colic pains ensue. When the symptoms of peritonitis have appeared, the pulse is quick and hard, the mouth dry, surface of body hot and head racked with pain. The countenance assumes the peculiar shrunken aspect called by the name of Hippocrates, the extremities are cold, the mind is clouded with delirium, and when gangrene has set in hiccough comes on with a sudden cessation of pain. This symptom of hiccoughing is regarded as an especially unfavourable symptom. The period at which death takes place varies from three to five days, being earlier in small and recent than in large and long standing Hernia?. It is worthy of notice that strangulated omental Hernia has symptoms resembling strangulated intestinal Hernia, only they are less severe; they lead however to the same result—fatal peritonitis. As in reducible so in strangulated Hernia there is need of a differential diagnosis. It may be confused with ilius but may be distinguished from it because in general the patient can tell the state of his bowels, there will be the history to help us and if we are to deal with a Hernia we can always with more or less search find a tumour. It may be confused with an obstructed irreducible Hernia but distinguished from it because the latter is not tender to touch and has no peritonitis. Although there may be constipation there is no vomiting as there is in strangulated. From an inflamed irreducible Hernia, because in it there is no vomiting and because the constipation is not entire,liquid faeces usually passing. From general peritonitis conjoined with Hernia, because in it the peritonitis is not confined to the region of the sac, because 90 HERNIA. what little vomiting there is does not bring up faecal matter and because the constipation is not entire. With double Hernia, one may be strangulated and the other not; the strangulated one will be the more tender about the neck of the sac, and thus we can determine in which the con- striction lies. Displaced Hernice. — There are four varieties. The first ap- plies only to femoral herniae, the other three only to inguinal. First. The strangulated hernia with its sac may be bodily reduced within the abdominal ring and behind the abdominal parietes. This is the true reduction en bloc or en masse of French writers and of Luke. See Fig. 18. Cases are rare. Second. The neck of the sac becomes detached from the in- ternal ring and pushed upwards beneath the abdominal walls, so that the intestine is strangulated by the orifice of the sac. See Figs. 15, 19, and 20. The two latter drawings are the origi- nal ones of Sir Charles Bell, and first appeared in the Medical Gazette in 1828. A clinical report upon such a case may be found on p. 352. Third. This is an interstitial form with a ruptured or lacerated • neck of the hernial sac. " The delicate serous membrane of the sac is rent or torn, and the hernia makes its escape through the aperture into the subserous connective tissue, as the effect of forcible or long sustained compression of the hernial tumor. Its course outside the peritoneal sac is advanced by continued pres- sure, and, detaching the connections of the neighboring peri- toneum, it forms for itself a pouch between that serous membrane and the internal abdominal fascia." See Figs. 16 and 21. This form is more common in the congenital variety of hernial sac, and occurs at the posterior part of the neck. According to Birkett, the indications of the accident are as follows: The tumor becomes flaccid, and therefore smaller. The bulk of the tumor slowly diminishes as the pressure is continued, STRANGULATION OF HERNIA. 91 until at last very little, if anything, can be felt; but still the surgeon has failed to experience that sudden jerk so characteristic of the escape of the hernia from the gripe of the mouth of the sac. After the effects of the chloroform have passed away, all the symptoms of strangulated bowel recur, and perhaps with increased force. Even the tumor itself may reappear and recede on the application of slight pressure. When such a condition is found, the hernial sac must be exposed and opened. It may appear empty, and the finger may enter the cavity through a well-defined abnormal aperture, which may be mistaken for the internal ring and the cavity of the abdomen. This would, how- ever, lead to a fatal error, and one which would surely com- promise the life of the patient. Two orifices will be found; one dipping into the artificial sac, the other dipping into the abdomi- nal cavity. If the bowel does not come forth spontaneously, an effort must be made to draw it out, and then the true mouth of the sac will be discovered by passing the finger upward along the anterior surface of the mesentery. The protrusion is firmly constricted by the orifice of the her- nial sac. This constriction must therefore be cut, "after which operation the exercise of great care and caution is needed to prevent the entrance of the hernia once more into the abnormal space outside the peritoneal cavity. As the salvation of life depends upon the return of the protrusion through the natural orifice of the sac, considerable freedom in the use of the knife is justifiable." An interesting case, reported March 8, 1881, by Dr. E. Mason, of New York, will well illustrate this form of hernia, and may be found on p. 352. Fourth. This consists of an intermuscular or interstitial or intraparietal sac, with a herniated neck, and is almost always associated with a congenital form of hernia. The sac is usually found between the abdominal muscles and abdominal fascia, although sometimes between the external oblique and the skin. 92 HERNIA. See Figs. 17 and 22. Anatomically, it consists of two parts; that which passes along the inguinal canal into the scrotum, and that which is lodged in the wall of the abdomen. Scarpa and Fano have recorded cases. See also on p. 354 a case reported by Dr. Shrady, February 4, 1881. When the hernia is strangulated by the ventral orifice of the sac, and when it occupies the scrotal division, it may, unless very great care is used, be pushed by taxis into the other side, so that the tumor disappearing, the surgeon thinks the hernia reduced. The symp- toms, however, very quickly show that this is not the case. Birkett offers the following explanation for many of these cases. " The tissues of the scrotum are very loose, and readily change their position. Both the spermatic cord between the external abdominal ring and the hernial sac attached to the an- terior surface of the spermatic cord vary in length. When the hernia occupies the sac, the latter extends lower than when it is empty. Now let its mouth and neck be detached from the internal abdominal ring, and the hernia, still strangulated by the margins of the orifice, be pushed inside the abdominal walls. The fundus of the sac attached to the tissues of the scrotum is not on this account severed from these connections, but merely ascends toward the inguinal canal, and lies partially within it, with its walls in close contact, which, being rather thin, are not recognizable." All these forms of displacement are indicated by the disap- pearance of the tumor without the characteristic jerk, and by the persistence of the symptoms. The treatment in all is the same as that described under the third form. CHAPTER V. Operations for Hernia. "The radical cure of Hernia would be too important a triumph for surgery and a resource too deeply interesting to humanity to permit that we should not endeavour to improve it still more and to modify its pro- cesses and to make renewed efforts for the purpose of attaining this result. For myself I cannot cease to entertain the idea that in the experimental spirit of our age we may succeed in obtaining a remedy of this description which shall be of real efficacy."—Veli'Eau, Operative Surgery. In this brief and necessarily imperfect sketch of the various operations that have been or are now used for the relief and cure of Hernia, I have thought it best to insert without material alterations a paper prepared by me and read before the Vermont State Medical Society, June 15, 1880. With this brief explan- ation I trust the reader will kindly pardon any peculiarities of expression that may have crept into an essay intended to be delivered in an assembled meeting of medical gentlemen. As many of you are aware, I have written of late much upon the radical cure of Hernia, which has been received by the medical press and profession with no little interest. I therefore take the present opportunity to say that I do not • like the term radical when applied to this or any other surgical operation. To me it sounds unprofessional, contrary to all my ideas of professional propriety and detrimental to the fair name of medical and surgical science. I know that some of the most honoured men that have brightened the pages of surgical litera- 94 HERNIA. ture or that have taught in our universities of medicine have thus denominated many of the operations that have been devised for the treatment of Hernia. The term has been more extensively used, however, by those who are not of the regular profession and whose ideas of professional etiquette are not models for us to pattern after. I can but think then that in our present progress of the healing art, it would be out of harmony with the advancing march of improvement to retain the cognomen longer. If I have heretofore used the term radical it has been only to convey to the general profession a more distinct idea of the nature and possibilities of my operation. I now will gladly join hands with you of the profession in erasing from our vocabulary wherever we possibly can the word 'Eadical Cure/ and I feel confident that under the less pretentious phrase, ' Cure of Hernia/ we shall accomplish just as successful results as with the more ambitious cognomen in general use.18 In presenting to your notice the various mechanical cures for Hernia, such as external compression, the application of sutures, of metals, catgut or silken cords, the insertion of goldbeaters' skin, the invagination of the external abdominal covering or any other device, whether herniotomy, tendinous irritation, or the actual cautery, I would have you take into consideration the re- marks of our distinguished and learned fellow and one of Boston's adopted sons and renowned operators as well as teachers in surgery. His remarks at our last February meeting of the Suffolk District Medical Society were that it was a well established fact and a true principle of surgery that all the operations that had, to his knowledge, been performed for Hernia had sooner or later, with hardly an exception, given way in a few days or years where a cure had been attempted by sutures or pins for the relief of the sufferer. There never were truer words uttered by any surgeon ancient or modern than these of Dr. D. W. Cheever, OPERATIONS FOR HERNIA. 95 whose name shines brightly in the annals of our society and upon the pages of surgery. Words like these are comparable to the utterances of a Webster in constitutional law, and I take great pleasure in recording them. Well may the state of his nativity take pride in claiming such sons in medicine and law. But while his remarks, as well as those of Dr. Henry H. Smith, in his Principles and Practice of Surgery, are true of all previous operations for the relief and cure of Hernia, still we must remember that in all these operations a different irritation and a different amount of effusion is produced from that produced in the operation by injection now under consideration, and that by their methods of operation either the surrounding tissues are directly excited to absorb the lymph that has been effused or else they produce suppuration which is always fatal to the adhesive formation of lymph tissue whether this lymph is pro- duced on muscles or on tendons.1 Even if by this new method of injection for cure there should be a tendency in the newly formed tissues to melt away, the process will be so gradual and will take place from such a superabundance of tissue (as has been fully borne out by experience) that nature will have sufficient opportunity to reassert her power and form afterwards out of the effused plasto-lymph as strong a tissue to say the least as ever originally existed around the rings. May we not hope then, with your generous efforts as well as those of the profession at large, to perfect this operation and present to the world a glorious exception to all the previous operations ? Who would not lend a helping hand to give this priceless gift to our fellow-men ? If I perform this or any other operation I wish, as any medical gentleman would, to do it well; but because I wish all this it is not necessary that I should make a specialty of curing Hernia only, nor need I feel inclined to follow the i See p. 206. 96 HERNIA. example heretofore set by some to keep all of my doings in this operation from the light of the profession. My whole pro- fessional life, and all that is manly in my nature, revolts against pursuing any operation in the art of surgery or medicine in secret and apart from my professional associates.for the purpose of selfish aggrandisement or personal gains. I do not believe in an idea of specialists in our noble, grand, old profession. The gentlemen who generally follow one idea and branch as a specialty are apt to become circumscribed in all of their professional reasoning and acts: if the specialty is that of the diseases of women, all their ideas of the suffering and illness of the fair sex are centred in the uterus and its appendages; if the diseases of the eye, great opacity to every other ailment of the body. He who follows the treatment of the insane finds all insane except those who recover under his treatment. If Sir Henry Thompson removes stone from the bladder by a peculiar process of his own discovery, and does it successfully, he does not think it necessary that he should be interested only in the operation of lithophaxy; or because Henry J. Bigelow may have thought to improve the tube of Thompson, and to establish the toleration of the bladder to undergo prolonged operations, he does not operate for removal of stone only. No, gentlemen ; those doing one operation exclusively, even if they do arrive at great perfection in it, lose their enlarged views on others that may be quite of as much importance as the single operation they perforin. This is the reason we find Graefe, and Agnew, or Williams, operators of distinction on the eye, taking as much interest in other surgical operations or in any improvement in medicine or hygiene as in their own depart- ment. By this study and interest do they not have better perceptions of all that pertains to all professional advancement ? You will also find Spencer Wells of England, Thomas and Barker of New York, and Brown Scquard of Paris, takin^ the OPERATIONS FOR HERNIA. 97 same interest in other branches as in that branch which they have so worthily developed and perfected by their study. In speaking thus, I would, not have you think that I do not fully appreciate those who may have made a special study of any special branch of medical and surgical science, and that I intend to infer that we should not call such men to our aid and refer to them in any difficult operation requiring their peculiar operative skill. I do not, as is quite apparent, expect to do all the operations for the cure of Hernia, or overcome all the strictures of the urethra, or pass all the catheters of vermicular point into the human bladder. No, I give freely my instruments and my method of performing these various operations and I feel confident that in them all will succeed quite as well as I have or even better. In this may I not look for your full approval and support ? What has been called a Radical Cure ? A cure has been considered radical when the tendons, muscles, and fascia form- ing the barriers to the protrusion of the bowels are restored to a normal firmness and power of resistance. Such a cure is tested by the firmness of the rings and the absence of inconvenience and tenderness when the patient has returned to his usuai avocations. Hernia was formerly considered an immoral disease, and ever since the days of Hippocrates, Galen, and Celsus there have been constantly proposed new and pretended cures for this terrible affliction ; yet it would be manifestly unjust to condemn all cures indiscriminately simply because they were new and because they laid claim to a complete cure. Many of them are, however, so thoroughly empirical and absurd that the barest mention of them will be sufficient. The more scientific methods employed have been either to plug up the orifice by articles which will fuse with the surrounding tissues, or to produce such an inflammation of the parts as will provoke adhesions of the enlarged opening, and hence a contraction. Some of these 9S HERNIA. methods are plausible, others probable, while others may justly lay the claim to fairly successful results.16 Among operations long ago obsolete, may be mentioned the 1 ccrat de brique' of Fabricius, the vinegar bags of Verduc, the remedy of the Prior of Cabriere, which was an astringent plaster over the hernia and milk given internally, the method of A. Pare, which consisted of a cataplasm of iron filings with internal administration of diamond, Arnaud's decoction of dog- grass and laurel, the application of ammonium carbonate, as recommended by Belmas, &c.17 Compression.—Among the advocates of this well-known palliative remedy are Celsus, Theodoras Aetius, de Salicet, Norsia, Blegny, Trecourt, Petit, Juville, &c. Fournier, Beau- mont, and Duplat favoured the use of compression combined with the application of astringents, while in Germany some went so far as to recommend pressure to such an extent as even to form gangrene. Position.—This is too laborious a cure to be at all prac- tical or practicable, yet Eavin, Eiviere, de Hilden, Eeneaume, Aniaud, Fedran, Hey, and Rieck have soberly advocated a horizontal position in bed for six months with topical com- pression and astringents, together with low diet, blood-letting, and purging as insuring a prospect of recovery. Passing such unscientific procedures, we now come to methods of cure which rightly deserve the name of surgical operations. Some, to be sure, are more dangerous than others, while many, although now abandoned in their original form, have recently been revived in methods based upon them, but improved in various ways. These operations will include cauterization, incision, excision, ligature, suture, castration, scarification, dila- tation by organic plugs, acupuncture and closure of the rings either by wires or by injection. Cauterization.—This operation of layiug bare the hernia. OPERATIONS FOR HERNIA. 99 raising up the internal envelope without opening it, and cau- terizing the ring with a red-hot iron is spoken of by Avicenna. Franco wa,s in the habit of laying open the sac and touching the neck v/ith a button cautery. Among the cauteries that have been used we may mention sulphuric acid, muriate of antimony, potash, essence of euphorbium, ranunculus, &c. The object sought was to obtain an eschar around the neck and thus to cause a suppuration sufficient to produce new tissue. The cautery was applied by two methods, one directly to the hernial coats, the other indirectly from the interior of the sac. In the former method there is the serious inconvenience of not penetrating deep enough to accomplish our result, or if we do succeed in cauterizing the right parts, of injuring at the same time some important and vital organ, while in the latter the danger of injuring the viscera by the cautery is avoided by pushing them out of the way.18 " Incision.—This has been so popular a method that it was not until the latter part of the last century that it was aban- doned.19 The hernial coverings, together with the sac, were first divided as in strangulated Hernia. The viscera having then been reduced the opening was closed by suture. But the results wrere fatal almost immediately; and while Arnaud, Lieutaud, and Le Blanc favoured the operation, Acrel, Eichter, Sharp, Abernethy and others as strongly condemned it as formidable and dangerous. Just here it might be well to say that G. W. Hinman, of Deny, Vermont, recently reported one cure by opening the sac and brushing the inside with tincture of iodine, an operation which has in it some reasonable hopes of success. Excision.—This consists in dissecting and removing the sac, and involves such exceedingly great and almost inevitable danger of peritonitis, that although practised by Bertrandi, Lanfranc, Arnaud, Schmucker, Langenbeck and others of more H 100 HERNIA. recent date, it is painful even to think of it. After this was done away came the method of cutting down upon the sac and introducing a ligature which prevented haemorrhage and did not expose, although it might involve, the peritoneum. Ligature.—Some have applied the ligature directly upon the sac by cutting down upon the parts; others apply it to the superficial integument.1 Celsus speaks of those who placed the integument between two pieces of wood and pinched it so as to produce gangrene, while Saviard and Desault constricted the hernial envelopes so as to produce its mortification. It is recorded of Guy de Chauliac that in 1360 he laid bare the sac and then applied a ligature around its neck. Although this may be an operation to be preferred above cauterization, yet as it is essentially painful and dangerous in its liability to injure the peritoneum, it seems strange that in recent days it should be revived. An attempt was, however, made in 1872 in Paris and Lyons, by M. Martin, to rescue it from oblivion, and within the last thirty years by J. C. Nott, of Mobile, Alabama, who binds the columns together by a leaden ligature, at the same time compressing the sac, but taking care not to constrict or involve the spermatic cord. Suture.—Closely allied to the preceding method is the method of suture which is applicable especially to inguinal Hernia in males, and as it involves only the external ring, can be applied only to the direct kind of inguinal. Some accomplish the suture after a tedious dissection, but Thomas Wood of Cin- cinnati, Ohio, in 1851 passed a suture through both columns of the ring and bound them together by adhesive inflammation, 1 This cure is especially applicable to young subjects. Although censured by Sabatier, Scarpa, and Sir A. Cooper, as producing convulsions and inflammation in children, it has been successfully used by Uesault and Dupuytren. For an improved cure by ligating with carbolized catgut see p. 114 for Lister's antiseptic method. OPERATIONS FOR HERNIA. 101 taking care not to compress the sac.1 The new tissue formed however in these cases has not been found sufficient to prevent the return of the Hernia. 1 Essentially the same method has been used by G. Dowell, of Texas, who about 1859 performed the operation in the following manner:—The double spear-pointed needle (Fig. 23) being threaded with silver wire at one end, a portion of the skin and cellular tissue was pinched up over the hernia and the needle inserted and pulled through until the threaded point reached the superior tendon of the external ring. The sac was now in- vaginated and the needle passed through both superior and inferior tendons Fio. 23.—Dowell's Needles. of the ring. A second ligature was applied in the same way and both tied over a piece of cork, drawing the edges of the two tendons together. Another method by ligature is that recently devised by Octavius White, of New York, and soon to be given to the profession. The point A ia invaginated into the ring. The needles are then pushed out through the Fie. 24. integument and a ligature tied over the two handles and knobs C and Df these handles being turned over, as shown by the dotted lines. The needles are then withdrawn and the instrument, weighing less than an ounce, is left in place for some days. H 2 102 HERNIA. S. E. Beckwith, of Cleveland, Ohio, also reports a process (May, 1872,) for the cure of recent inguinal and umbilical Herniae by a hare-lip suture. Castration.—Some of the operators by excision, ligature and crowding up of the sac, finding the operation too tedious enveloped the cord and sac by the same thread; from this originated castration as a method of cure. This was long ago interdicted by law, even by Constantine, although in very recent years many have boasted of the number of cases thus operated upon in secret. It is not only dangerous to life, unnecessary and barbarous, but it offers no hopes of a radical cure.20 Gilded Point.—To prevent the loss of the testicle, this operation was invented. It was used by Buchwall, in Denmark, and by Berault and A. Pard, in France. It is practically the same as castration, although theoretically it avoided compressing the cord, compressing only the sac. Royal Suture.—This ancient process consisted in dissecting the sac and sewing it up without involving the cord. It is nothing more or less than suture applied to scrotal Herniae, and was fancifully called Royal by Fabricius because it saved the lives of subjects who if cured might protect the king in his royalty. After taking this cursory and synoptic view of the ancient operations, what surprises us most is not that the operations of excision, incision and exposure of the sac and ligature of the same were practised in ages gone by, but that they should be revived with all their suffering and danger by modern operators when safer and better means of cure lie near at hand. Scarification.—In this operation Le Blanc took advantage of the method of dilatation of the ring used for strangulated Hernia. It is, after all, only a variety of the incision method already OPERATIONS FOE HERNIA. 103 mentioned and is open to the same dangers, although it is true that the effusion of lymph thus produced favours the con- solidation of the tissues and not their relaxation as Petit has claimed. Alphonse Guerin, the tenotomist, scarified sub- cutaneously, and compressed the abraded surfaces with the pressure of a truss. The operation, though plausible, is nearly useless, although Heaton sometimes resorted to it when supple- mented by his injection of quercus alba. Organic Plugs—Of this method there are five varieties:2J 1. Plug of the Epiploon. 2 Pluino- with the testicle or the sac. ~* DO O 3. Plug of integuments. 4. Plug with the invaginated skin. 5. The two methods of Belmas. 1. This applies to cases where we are dealing with an entero- epiplocele; the epiploon or omentum may be inserted into the rings and compel them to contract so that the Hernia will not reappear; Cooper, A. II. Stephens, of New York, Velpeau and Goyrand have in this way been successful in cures. The process is in some respects a natural one, but still has two inconveniences: it seems applicable only to strangulated Hernia and is liable to produce colic and traction upon the stomach. Besides it is not uniformly successful. 2. The obstruction of the ring by the testicle is a useless operation advocated by Moinichen and Scultetus. Garengeot and SLffen claim to have accomplished the same result by dissecting the sac and inserting it into the rings. 3. Jameson, of Baltimore, reported in 1828 one solitary case of a crural Hernia upon a lady, cured in the following way. He cut down to the ring, cut from the neighbouring integuments near the ilio-pubic ligament a strip two inches long and ten 104 HERNIA. lines wide, which he succeeded, he says, in engrafting into the ring. Although painful, complicated, and somewhat dangerous, it has every reason in its favour theoretically, in small femoral Hernias. Practically, however, the fact of this reported cure is vitiated by the circumstance that there was no professional witness of the operation. His only follower was Eedfern Davies, of Birmingham, England, whose instrument (Fig. 25) and operation seem to be a complicated modification of Wurtzer's. He also was successful in his case. Fio. 25.—Redfern David's Instrument. 4. This is the method of M. Gerdy and Signoroni performed in 1837, and modified by M. Leroy. Velpeau reports one successful operation in his practice. Gerdy reports about sixty cases, some of which failed utterly after a time. The adhesions formed are in fact too slight and tender ever to consolidate, and although it may not involve serious injury to the epigastric artery still it may produce dangerous and even fatal inflammation and peritonitis. It is principally adapted to the inguinal form. A fold of skin is pushed as far as possible up the sac, and held by two interrupted sutures introduced one third of an inch from each other by a curved double-threaded needle through the covering tissues, the ends being tied over a bougie. The cuticle of this pouch is then destroyed by ammonia, which OPERATIONS FOR HERNIA. 105 causes the inflammation that is supposed to work the cure. The suppuration produces adhesion about the eighth day, when the threads are removed. But when the threads were removed the plug often came out and with it the hernia came down. Gerdy used the finger for invagination, while Signoroni used a piece of catheter. It not only often failed of good lesults, but was also frequently fatal, as Thierry has shown. The principles of the operation have in a modified form done some service in the hands of other operators, «.^.,Wurtzer and others.22 D. Hayes Agnew, of Philadelphia, used an instrument (Fig. 2G) like a bivalve speculum, with which to invaginate the plug, and then embraced the base of the plug with a silver wire, which Fio. 26 — Agnew's Instrument. could be removed after 10—14 days. This operation is no longer performed. Belmas' Method. 1820.—The original operation consisted in the introduction and attachment of a small pouch of gold- beaters' skin to the upper part of the sac. The plastic material poured forth by the irritation produced by the presence of the foreign body spreads, involves this foreign body and forms the nucleus of an insurmountable barrier to the protrusion of the viscera. The operation was first tried upon dogs and with success. The first human subject operated on was easily cured by Belmas. He then induced M. Dupuytren to undertake the operation. This was upon a boy of fourteen, whose life was in 106 HERNIA. danger for ten days in consequence of the operation, but who was radically cured after two months, not only of a congenital hernia, but also of a hydrocele. Five cases in all were operated upon. Velpeau, who assisted in the last one, thinks the operation safe in itself, but provocative of remote dangerous symptoms. Belmas now modified his operation and deposited in the sac strips of gelatine or goldbeaters' skin, instead of pouches. These strips were introduced by a canula which can be separated into two halves within the hernial sac. This second method is pro- nounced by Velpeau as even less beneficial than that of Gerdy and is now entirely abandoned. Fig. 27.—Wurtzer's Instrument Acupuncture.—A more simple method of cure was introduced by Bonnet, of Lyons, in 1836. It is called acupuncture, and consists in perforating the scrotum and sac near the rings with several pins, which are allowed to remain until they produce ulceration of the skin. M. Mayor of Lausanne, used a seton instead of a pin; but whatever the modification, the method is useless since the whole canal is left open and the sac only imperfectly agglutinated.23 In 1838, Wurtzer, of Bonn, Germany, invented an instrument (Fig. 27) which carries out Gerdy's method of invagination simply OPERATIONS FOR HERNIA. 107 and safely. His instrument consists of three pieces — a wooden (or, as now used, hard rubber) cylinder, a long curved needle and a concave wooden cover to produce adhesions. The cylinder is three inches long and three eighths to three fourths inches in diameter, according to the size of the Hernia, of a flattened shape, perfectly smooth and rcunded upon the free end, a short distance from which is the orifice for the exit of the curved needle which runs through the cylinder, and is attached to the movable handle. The cover is to compress the folds of integu- ment during the operation and likewise has a hole in it for the needle. The protruded parts having been returned, the integument is pushed up the canal with the forefinger of the left hand, the cylinder is introduced into the cul-de-sac thus made, the finger at the same time being withdrawn. When the end of the cylinder is in the internal ring, the needle is pushed through the sac, canal, and integument. The handle is then removed and the rest of the instrument allowred to remain in position 6 or 8 days. The puncture made by the needle sup- purates by the fourth day, the bowels are not allowed to move, rest is enforced, with a plain diet, and then a truss is worn for six months or more. Dr. Otto Weber, of Bonn, says, however, that of fourteen cases operated on by Wurtzer, not one was cured, for the rings are not closed and the plug gradually with- draws. The failure is not due to peritonitis, but rather to the insufficient character of cellular or lymphoid tissue poured forth by the suppuration. Such tissue from its very nature never can be permanent, and is entirely different in this respect from that produced by irritation of the tendons by injection. This operation has been followed by Mosmer, by Eothmund, in Munich, Sigmund in Vienna, and by Spencer Wells in 1854, in the United States. Professor Armsby, of Albany, New York, has modified the operation by allowing a thread, which is occasionally moved to 108 HERNIA. produce inflammation, instead of a needle, to remain in the hernial sac and internal ring so as to cause the necessary sup- puration. Dr. J. W. Piggs, of New York, in March, 1858, also advocated the use of a seton, but on a larger scale, and reported several successful cures. Still another modification is that of Dr. Hachenberg, of Day- ton, Ohio, who used an ivory ball threaded by a double thread to produce the suppuration. Since, however, the operations of Thomas Wood, Dowell, Wurtzer, and Gerdy, with all their various modifications, do not involve the internal, but only the external ring, they are not applicable to the oblique Hernias, whatever little may be Fra. 28.—J. Wood's Operation. said of their probable or possible value in the relief of the direct variety. Operation of Wood, of King's College Hospital, London. This operation consists of the * compression and closure of the tendinous sides of the hernial canal throughout its entire length' (Fig 28). It differs from the older operations by being entirely subcutaneous, and by puncturing the sac only by a small valvular opening. The hernia being reduced, an incision through the scrotum is made by a tenotomy knife sufficient to introduce the forefinger and a needle. The fascia is then detached from the skin for the space of two square inches, and invaginated into the canal. The needle is now passed through OPERATIONS FOR HERNIA. 109 the conjoined tendon, upwards and inwards through the internal pillar of the external ring. A wire about two feet long is introduced into the needle and drawn out through the scrotal aperture, one end projecting from the puncture above. Then with the finger placed behind the exterual pillar, this pillar and Poupart's ligament are raised from the deeper structures. The needle is now passed below the internal ring and through Poupart's ligament to emerge at the puncture already made in the skin and the wire drawn back into the scrotal puncture. The sac is pinched up and the cord slipped back from it as in taking up varicose veins. The end of the inner wire is now hooked to the needle and drawn back across the sac. Both ends of the wire are then twisted together into the incision so as to twist the inclosed sac likewise while traction upon the loop invaginates the sac up into the canal. This loop is then joined to the two ends of the wire in an arch beneath which is a stout pad of lint. After 10 or 15 days the wire may be withdrawn. It is reported that 65 to 70 per cent, of the cases thus operated upon have been cured, although many of them have returned to their original state after the lapse of several years."1 Operation of Dowell. — I here place my friend Dr. Dowell's operation, which he has very kindly written out for me, to in- sert in this work in his own words. Melrose, Mass, July 11 th 1880. " De. J. H. Warren : "Dear Sir, " Inclosed herewith I give you a synopsis of my subcutaneous ligature for the radical cure of Herniae. I com- menced the investigation of the cure more particularly in 1858, and continued these investigations until in 1850, 10th Sept. in the night and in bed, thinking over an operation with Wuitzer's instrument I was going to perform next morning, I I See p. 243. 110 HERNIA. planned the entire operation as I now perform it with slight modifications as to the needle and other details which I will give you as briefly as I can. I started well with the idea to cure Hernia; we must adopt some method by which we can restore the natural supports to the abdomen. That in operating for Strangulated Hernia it was often the case that within from one to two days the adhesions became so great that it was im- possible to separate them without cutting, showing that to get adhesions it was not necessary to fasten the surfaces brought in contact, that single contact with slight pressure would cause all peritoneal surfaces to unite. " The next question was how could we best do this, and at last I projected and had made in 1866 by Messrs. George Tiemann and Co., New York, the needle shown in Fig. 23, p. 101, with an eye in each end, which I have changed since only by adding an eye at one end. The needle is made first with a groove from eye to eye, or rather from point to point to keep it from bending or breaking. The needle is from four to six inches long. At first I had it only three inches and the eye in the centre, but I found this too short, and the eye in the centre prevented the reversing of the needle which acts as a weaver's shuttle. " Operation. —I prepare my patient by having his bowels moved several hours before the operation and the urine voided before going on the operating table. The parts are then shaved of all hair and three lines made with a pencil or ink, one immediately over the centre of the tumour; two about one or two inches on the sides of the first. Thus:— Fio.». OPERATIONS FOR HERNIA. Ill For left inguinal the needle is then threaded with some strong thread, I usually use wrapping twine used in the drug- stores. I thread only one eye and twist the thread hard and use it. I ha\e from one to seven silver wire ligatures ready, and after putting all the threads in I think necessary I replace them with the silver wire. Thus prepared, the patient is put under ether or chloroform. I now take the unthreaded end in my right-hand finger and thumb while I pick up the skin and cellular tissues with my left hand to remove it from the sac and tendons. I then put the threaded point below my left-hand finger and thumb and run it through the elevated portion of the skin and cellular tissue until the unthreaded end rests on the tendons just under the line on the right or left as the case may be. At this stage, still holding the needle, the Hernia is invaginated and the left index finger is put in to guide the needle under the tendons and from one side to the other until I bring out the unthreaded end in the line on the other side. I then pull on the unthreaded end until it gets loose above the tendons and then push back the threaded end to where I first started and the two ends of the ligature cross each other and are finally tied over a roll of adhesive plaster which I now mostly use. A bougie or piece of wood or cork will answer, it being fastened simply as a quill-suture; but the adhesive plaster is soft and fits well, and I believe is the best thing I have used. I begin to put the ligatures in at the upper point of the rupture and continue them down until I have put in a sufficient number to close the rupture, using from one to seven according to the size of the opening. The ligatures have been left in from three to eight and some, in first case, fifteen days. The ligatures before tying are simply pulled up so as to close the wound, or bring its edges in contact with slight pressure ; if they are made too tight they will cause suppuration, and perhaps a failure, as all my failures suppurated and as I 112 HERNIA. think by pulling the ligatures too tight. The ligatures are re- moved when I think I have produced sufficient inflammation to cause complete union, and this must be judged according to the case, but if no tendency to too much swelling leave them to seventh day at least. The bowels should again be moved before the ligatures are removed and a compressing bandage applied. Patient ought to keep quiet in bed for at least a week and avoid straining, coughing, laughing or anything that will press on the ring. I, last summer (1879), invented what I call my buggy spring truss to apply after these operations, to support the parts while they are tender and in all cases where the patient is only relieved. The spring is made rather thin and not very Fio. SO.—Dowell's Buggy Spring Truss. strong; and two extra springs are put on over the main spring as the springs are fitted in a buggy (sec Fig. 30). The whole is covered with soft leather, and adjusted over the rupture making only very light pressure while the springs prevent continuous pressure; but when there is a tendency to protrusion they become very strong and will not allow any protrusion sufficient to rerupture. This truss will be beneficial in the subcutaneous injection method as practised by yourself at the present. With the two methods subcutaneous ligature (by my operation) and subcutaneous injection as practised by your- self, with the aid of this truss. I sincerely believe all cases can be cured and without danger. The result of my operation OPERATIONS FOR HERNIA. 113 so far as I can learn is about as follows : one hundred and three cases treated by myself; twenty-four cases partially relieved, two cases reported as made worse, one child died in seven days after operation, with congestion of the brain, but no doubt the chloroform and operation had something to do with the development of the fever which was of the malarial form of congestion of the brain. Cures seventy-six. So far as I know all these remain well, some have had partial return of the Hernia and wore trusses. Several were operated on twice and failed both times; I know no particular reason for the failures except the ligatures were put in too tight. The ligatures should be carefully cut just under the knot and at one side of the knot. If cut on the side or the knot cut off, when the quill is removed the ligatures become buried and cannot be removed, and have suppurated and caused a great deal of pain, and in almost every case a failure. This is a little thing, but is one of the most important in the whole operation. When the patient suffers any pain I give full doses of morphia and apply cold cloths or astringent washes with morphia over the ligatures. Where there is no pain I simply put a piece of lint over the ligatures and saturate it with collodion. "The operation above has been performed about two hundred times by different operators. Drs. Wilkerson and Trueheart, of Galveston, Texas; Drs. Worthington and Bibb, of Austin, Texas; Dr. Powell, of Florence, Texas; Dr. Kuskin, of Groes- beck, Texas; Drs. Allis and Hunter, of Philadelphia; Dr. Johnson, of Kichmond, and many others. Their exact statistics are not at hand, but I believe they have had equal or even better success than myself, as I included in my list all the cases operated on in my experiments to perfect the operation. My greatest fear was of general peritonitis, but this has not hap- pened in any case of mine. Some ask, do you inclose the spermatic cord in the ligatures ? No, never ; it is ke^t below the 114 HERNIA. ligatures by the invaginating finger. The subcutaneous injec- tion is specially useful in Hernias of small size and recent date, while the subcutaneous ligature is suitable to large Hernias and of long standing, and, as I believe, contains the only principles of success in Hernias large and of long standing. " Yours most respectfully, " Greensville Dowell, M. D." Antiseptic Use of the Carbolised Catgut Ligature. —With. the consent of the author, Dr. Henry 0. Marcy, of Cambridge, Mass., I reprint from the Transactions of the American Medical Association, 1878, the following essay : —- "October 11, 1871, I, read a paper before the Middlesex County Medical Society, which was afterwards published in the Boston Medical and Surgical Journal, November 16, 1871, page 315, entitled'A New Use of Carbolised Catgut Ligatures.' I there reported the two following cases, operated on for Stran- gulated Hernia. "Case I. 'On the 19th of last February I was called in consultation by Dr. A. P. Clarke, of Cambridge, to see Mrs. M., aged sixty, who had for years suffered from Hernia. Five days previously she had been seized with severe pain in the inguinal region, accompanied with vomiting, and had been confined to her bed since that time. "' Long-continued and careful taxis had failed to reduce the hernia; and for twenty-four hours the vomiting had been ster- coraceous, and the patient seemed in extremis. The hernial tumour was the size of an egg, protruding from the external inguinal ring. A careful dissection exposed the sac, which was closely adherent to the surrounding parts. The constriction was in the ring, bounded below by Poupart's ligament, and above by the transversalis fascia and conjoined tendon. "' The stricture was divided in the usual way, with the OPERATIONS FOR HERNIA. 115 hernial knife carefully introduced upon the finger. This was accomplished with some difficulty, owing to the constriction of the ring. The sac, unopened, was then pushed up with its contents into the abdominal cavity, and two stitches of medium- sized catgut ligature were taken directly through the walls of the ring. The wound was dressed antiseptically, and from Dr. Clarke's notes, taken at the time, I find that the patient com- plained of no pain, steadily progressed without accident, and was discharged, convalescent, March 12th, three weeks after the operation. "' The wound did not close entirely by first intention, but a careful daily examination showed no trace of the ligatures, and an abundant deposition of new tissue could be felt in the line of the opening about the walls of the ring. The result was a radical cure of the hernia, and a firm, hardened deposit may still be felt marking the closure. The ligatures were first suggested to my mind, because the patient suffered severely from an asthmatic cough, and it was at least desirable to secure a temporary strengthening of the weakened ring.' " She died six years after the operation, and was troubled with the cough during the entire period, but had no return of the hernia. " Case II. ' Mrs. L., aged forty-five, had been very much reduced by excessive menorrhagia, and upon March 10, 1871, my attention was called to an old, direct inguinal hernia of the left side, usually supported by a truss, which had come down the night previously and defied the patient's efforts to replace. After two attempts to reduce the hernia under ether had failed, assisted by Dr. W. W. Wellington, of Cambridge, I operated as in the first instance, dividing the constricting ring and replacing the sac and its contents unopened. Three carbolised ligatures were applied through the walls of the ring, and the wound was carefully dressed with carbolised lac plaster. "' As in the first case, there was complete absence of pain, I 2 116 HERNIA. the wound united without suppuration, there was an abundant deposit of new material about the ring, and when last examined in June, the cicatrix was linear, but a, firm, hard deposit of new tissue could be felt marking the site of the sutures. "'On the 7th of April my attention was called to the wound by the patient, who felt a slight uneasiness, and I discovered a small swelling in the cicatrix about the size of a bean; this, upon being opened, discharged a drop or two of pale, serous looking fluid, which microscopic examination proved free from pus cells, but it contained a few shreds of connective tissue, which appeared to be minute portions of one of the ligatures. The cure is radical, and in neither case has the patient used a truss since the operation.' " I then say, as far as my observation has extended, this is a new use of the carbolised catgut ligatures, and suggests a still wider field for application. No method of operation for radical cure of Hernia appears more feasible, is probably attended with less danger, and at the same time affords a means of closing and strengthening the weakened ring, which is so desirable, and yet, with all the ingenious devices of surgery, is so difficult to obtain. As perhaps might have been expected, the article attracted very little attention, written by a young man fresh from his European studies and an ardent admirer of Professor Lister, whose views at the time, I believe, were not accepted by a single surgeon in the Boston district. " In these days of improved means for the reduction of Hernia, by the use of ether, by aspiration, and by rest with the hips higher than the shoulders, with the ice-bag applied locally, the surgeon in private practice is called upon to operate for the relief of Strangulated Hernia much less frequently than formerly. As far as I remember, I have operated for Strangulated Hernia only four times since the publication of this paper, and these OPERATIONS FOR HERNIA. 117 cases were treated substantially as those above given. The last case, inasmuch as it affords the opportunity of showing the result anatomically, merits a careful study, and causes me to bring the subject to your attention now. " Mrs. W., aged seventy, had been for many years an invalid from double inguinal Hernia, the right side being of such pro- portions that, after many endeavours to retain it by a truss, this appliance had been thrown aside as useless On the left side was an irreducible omental hernia, at times complicated by the escape of a loop of the intestine through the ring. Nausea and vomiting had persisted for thirty-six hours before the operation. "As usual, antiseptic precautions were used, with carbolised spray and careful dressings. After slightly enlarging the ring, the intestine was easily reduced, but the omental portion, the size of a small orange, presented a number of bleeding points upon its being unravelled, and was adherent to the walls of the ring. Because of this, the whole mass was tied with catgut and removed, the ling was carefully closed with catgut sutures of a large size, No. 2, I think, five in number. The wound healed by first intention throughout. Temperature never exceeded 99° F. " The patient suffered no pain, and made a perfect recovery. She was allowed to get up in two weeks, and never wore a truss. She was so much pleased with her happy escape from danger and her complete cure that she besought the privilege of being operated upon for the radical cure of the right side. I tried again a series of trusses, but to no avail, and after careful reflection consented to perform the operation. This took place February 4, 1878. The abdominal wall was thin, the ring extremely large, and its pillars were attenuated. The sac was readily returned unopened, and sutures were used as upon the other side, perhaps eight in number. I included in my stitches 118 HERNIA. as much tissue as possible, but at the close of the operation felt the cure less satisfactory because there was so little material to fill in and support the weakened ring. " The union was entirely by first intention, leaving, as before, a linear cicatrix which never suppurated. There was no eleva- tion of temperature, and the patient made a rapid recovery. During the first week there was considerable swelling of the tissues about the ring; these parts were slightly tender upon pressure; and, what I believe to have been the thickened returned sac could be felt through the attenuated relaxed abdominal walls. The patient was kept in bed three weeks; but upon being permitted to get up it could be easily seen the cure was not complete, for there was impulse on coughing and a slight protrusion through the ring. She was fitted with a light truss, which easily retained the hernia, and was allowed to go about the house. She died suddenly, April 17, 1878, and the autopsy revealed an aneurism of the internal carotid of the right side, which had given rise to scarcely any symptom, except a gradual loss of vision of the right eye, but its existence had not been suspected. "The specimen here presented shows the walls of the ring much thicker than before the operation, and its calibre dimi- nished perhaps two-thirds. A light truss would probably have been sufficient easily to hold the parts in their proper relations. " The use of animal ligatures in surgery is by no means new. In all probability catgut, the form of animal thread or ligature which has been most frequently used in modern times, was employed as surgical sutures eight or nine hundred years ago. The celebrated Arabic writer, Rhezieus, who practised in Bagdad about a.d. 900, speaks of stitching up wounds of the abdomen with a thread made of the string of a lute or harp; and another Arabic author, Albucasis, who lived a century or two later, OPERATIONS FOR HERNIA. 119 alludes in the same class of injuries to stitching a wounded bowel with a fine thread made of the twisted intestine of an animal. The strings of the ancient Egyptian harp, and hence probably of the Arabic, were made of catgut. Homer, in the Odyssey, speaks of the strings of the old Greek harp as made of the twisted intestine of the sheep. " To Dr. Physick, of Philadelphia, is undoubtedly due the honour of having first introduced animal ligatures into surgical practice. His ligatures were made of chamois leather. Silk may be considered an animal product, but however used, even when carbolised and inclosed in a wound which readily heals by first intention, the softened fibres usually act as an irritant, and are later discharged by the processes of suppuration Animal tissues made but indifferent ligatures; and were practically long since abandoned. They were soft, slippery upon being immersed in water, and were by no means strong. " To Professor Joseph Lister we are indebted for a most im- portant modification of the catgut ligature. In his enthusiastic devotion to his new ideas of the possible repair of tissue, he had observed that, under antiseptic dressings, clots of blood and large pieces of dead skin and other tissues had disappeared without suppuration; therefore he inferred that small pieces of animal texture, if applied antiseptically, would be similarly disposed of. To make cutgut antiseptic, he immersed it, as prepared for the violin, in a strong watery solution of carbolic acid, and noticing the changes which followed in its texture, after considerable variety of experiments, he gave us the ligatures as at present used. They are prepared by immersion of the gut in a mixture of five parts of fixed oil, olive or linseed, to one part of the crystallized acid, liquefied by the addition of live per cent, of water. After a few weeks' suspension in this fluid, the catgut becomes translucent, firm, hard, but moderately pliable, makes a strong knot, and upon immersion in water or 120 HERNIA. the fluids of the body, it undergoes no immediate change, and for days together the knots retain a firm hold. "To show the importance of the proper preparation of the ligature, I quote from Professor Lister's original paper, published in the Lancet, April, 1869 : ' But for the sake of surgeons who may wish to prepare it for themselves, it is necessary to mention, in order to avoid disappointment, that the essence of the process is the action of an emulsion of water and oil upon the animal tissue. The same effect is produced upon the gut, though more slowly, by an emulsion formed by shaking up simple olive oil and water, as by one which contains carbolic acid. "' On the other hand, an oily solution of carbolic acid without water has no effect upon the gut beyond making it antiseptic, and if water be added only in the small proportion which the acid enables the oil to dissolve, though the gut is rendered supple, and acquires a dark tint from the colouring matter of the oil, it will be found, even after steeping for months in such a solution, that when transferred to water it swells up and becomes soft, opaque, and slippery, as if it had not been sub- jected to any preparation. How it is that an emulsion produces this remarkable change in the molecular constitution of the tissue I do not profess to understand. I was at first inclined to regard it as a closer aggregation of the particles, brought about by a kind of slow dying of the moistened gut in the oil, as the watery particles precipitate to the bottom of the vessel; but, not to mention other circumstances opposed to this view, the oil remains turbid for a very long time, the finer particles of water being extremely slow in precipitating, and if, after the lapse of weeks, a piece of dry unprepared gut is suspended in it, the thread is soon rendered soft and opaque by the very liquid in which gut which has-been longer immersed is growing constantly firmer and more transparent. "' It is necessary that the gut be kept suspended so as not to OPERATIONS FOR HERNIA. 121 touch the bottom of the vessel, for any parts dipping into the layer of precipitated water would fail to undergo the change desired. "' The vessel containing the emulsiou should be kept undis- turbed, for if the water is shaken up with the oil the process is retarded. An elevated temperature, of about 100° F., seems for a while to promote the change, but ultimately leaves the gut in an unsatisfactory state compared with that obtained at an ordinary temperature; and conversely, some portions of gut which I have prepared in a room without a fire, in cold weather, at a temperature of about 46°, were in one week already in a trustworthy condition for surgical purposes. Hence the gut should be prepared in as cool a place as possible. The longer it is kept in emulsion the better the gut becomes. I once feared that in time it might grow too rigid for convenience, and possibly brittle also ; but experience shows that this is not the case. "' When removed from the emulsion it soon dries in the air, but retains a considerable portion of its carbolic acid for several hours, so that no apprehension need be entertained of loss of its antiseptic property from exposure during the performance of an operation. In course of time it loses all the carbolic acid also, but retains permanently its altered molecular condition. If thus kept dry, as may prove the most convenient for the manufacturer on a large scale, it must be steeped thoroughly in some antiseptic lotion before its use. And for the surgeon the most convenient way will probably be to keep it always in the antiseptic emulsion, so as to be ready for use whenever it is required.' " Dr. D. W. Cheever, of Boston, writes me under date of May 14, 1878: ' I tried catgut for a radical cure of Hernia, but it was speedily absorbed and failed.' He is unable to give me particulars with regard to the use of the ligatures. 122 HERNIA. " Dr. J. C. Warren wrote me a few day since : ' I should fear that they would not hold long enough to keep the parts in apposition until union becomes firm. We have given up their use at the Massachusetts General Hospital for this reason : they do not hold longer than four days.' " I believe there are distinct limits to the usefulness of the catgut ligature, and if our profession early learns to know what these limits are, not only may the lives of our patients be less endangered, but an aid to surgery which now promises much of good will be rescued from wholesale condemnation acd oblivion. In plastic operations, especially of mucous tissues, I would never think of using catgut ligatures. "In wounds exposed to the air, or liable to suppuration, where the ligatures are soaked in fluid secretions, I am well aware the catgut knot is liable to become loose; but in the antiseptic ligation of vessels, or the closure of deep-seated tissues, it is far superior to any other. Here, when properly applied, it is open to few of the objections made. Owing to the firm character of the material, circulation of the inclosed part is more liable to be impeded than with silk ligatures, and hence care should be exercised; but within the limits here assigned, an experience of eight years justifies their use. " Judging from my own observation I am inclined to believe the ligature properly, that is antisepticaliy, used is not absorbed at all, but is changed particle by particle, being in this way not revitalised but replaced by living tissue, thus producing a rein- forced band of new connective tissue in place of the ligature itself. " The specimens here shown I think demonstrate this. The one last operated on, February 5th, death taking place April 17th, namely, sixty-eight days after the operation, shows un- mistakable thickening of the connective tissue about the ring; and there are yet seen, although preserved in a bichromate of OPERATIONS FOR HERNIA. 123 potassa solution, hence less distinctly than at the autopsy, traces of the ligatures. These are of a darker colour than the sur- rounding parts, retain imperfectly the shape of the ligature, and are of considerably greater density and firmness. Under the microscope they show only wavy bundles of connective tissue. In the older specimen operated on December 2d, after the lapse of four or five months, you can no longer trace constricting fibres in the shape of circumscribed bands, but you will find a firm reinforcement of the parts by connective tissue which certainly includes the walls of the ring, and hence we infer it is developed about, or transformed from the ligatures them- selves. This quite accords with Mr. Lister's experiments in the ligature of arteries. " From the article previously mentioned I quote as follows ' Thirty days after the operation, the animal, a calf, which had continued in perfect health, was killed, and the parts removed for examination. On dissection I was struck with the entire absence of inflammatory thickening in the vicinity of the vessels, the cellular tissue being of perfectly normal softness and laxity. On exposing the artery itself, however, I was at first much surprised to see the ligatures still there, to all ap- pearance as large as ever. But from my other experiments, it might have been anticipated that the ligatures of peritoneum and catgut placed on the calf's carotid would, after the expira- tion of a month, be found transformed into bands of living tissue. Such was in truth the case, as was apparent on closer examination. " Mr. Fleming published in 1876, in the Lancet, a series of observations upon the 'behaviour of carbolised catgut inserted among the living tissues,' and gives his results confirmatory of such change. 'A softening takes place from without in, the catgut breaking down and becoming infiltrated with cells. The mass into which it has been converted begins to metamorphose and is soon permeated with blood channels, and ultimately may 124 HERNIA. be described as a cast of the catgut in a kind of granulation tissue, freely supplied with blood-vessels, which in many of my sections are easily injected.' These views should not seem exceptional, when we remember many well-known facts, for example, that the revivifying of skin dead at least by separation for a considerable period, as in that from an amputated limb, goes on so uniformly that transplantation of it upon granulating surfaces, and these not best fitted for its growth, has now become a daily practice in surgery. " Even the epithelial cells removed by a considerable distance from the circulation, and already dead, thus live again, and multiply so rapidly as to be of practical use in the repair of large denuded surfaces. The periosteum, as Oilier and others have shown in their experiments, may be also transplanted, and not only live but become an active factor in the reproduction of bone ; and teeth have been removed, filled, and replaced, actually transplanted to other locations, and regained their lost relation- ship of nutrition. "The spurs of the cock, as observed by Baronius, when transplanted to the comb, not only live, but remarkably increase in size, and when ingrafted into the ears of oxen, as is practised in Mexico, they attain a size truly wonderful. " Mantegazza described and figured one of these spurs, which in its dry state weighed nearly one pound (396 grammes), was twenty-four centimetres in height, and twenty centimetres in width. "If such wonderful activity of reproduction and growth are shown by these tissues, there would appear to be no reason why the cells of the fibrous tissues might not also undergo changes in nutrition equally remarkable, of which practical advantage may be taken. " This is not the place, nor have we the time for a careful review of the history of the various devices suggested for OPERATIONS FOR HERNIA. 125 the radical cure of Hernia. For centuries this has been a prolific field for charlatans and for quacks of every description. Hernia-curers roamed over Europe a century ago, practising castration and various reckless and dangerous devices, at the cost of many lives, and, it is needless to say, with the performance of few cures. " Within the present century many of the best surgeons have given this subject careful study, and some of the most ingenious of surgical devices have been brought into requisition. Nearly all of them have sought to accomplish a cure by one of two ways : either by producing adhesive inflammation and oblitera- tion of the sac, or by producing closure of the ring. Monsieur Bonnet inclosed the cord between pins fastened to rolls of linen. Gerdy plugged the ring with invaginated skin held by stitches, and afterwards with the object of correcting the tendency of the invaginated skin to be withdrawn, cut it free, and ended with a plastic operation, by raising a flap from below. This method was often successful in his hands, but its complication and dangers prevented its general adoption. " Belmas invented an instrument, consisting of acanula with stylets. Through the passage in the canula threads of gelatine were to be introduced and be ultimately absorbed, after having produced the requisite adhesive inflammation. Then he applied a truss. "The operations of Velpeau, Wiitzer, and Wood are better known. Mr. Wood operated about two hundred times, with the result of three deaths and about seventy-five per. cent, of reported cures. Acupuncture, a revival of the punctum aureum of the ancients, as practised by Dr. Pancoast of Phila- delphia, though unsuccessful as a means of cure, suggested to him, as well as to Dr. Young of Tennessee, the use of subcuta- neous injections of iodine or cantharides into the sac. A number of successful cases thus operated upon are reported. 126 HERNIA. " This method was practised for many years as a secret cure by Dr. Heaton of Boston, with reported success. Recently he has published a monograph upon Hernia, in which he gives a de- tailed account of his treatment and experience. He reports a large number of cures, and claims that his method is devoid of danger. It consists of a fluid extract of white oak bark injected with a hypodermic syringe into the sac.1 This method has been tried with moderately successful results at the Boston City Hospital. By means of it, a considerable amount of thickening and narrowing of the ring is certainly produced. " In 1858 Dr. Gross, in two cases, cut down upon the ring and brought together its walls with silver sutures. A cure followed in both cases. In 1871 Dr. Van Best reported three cases operated on for radical cure by a subcutaneous sewing of the ring with salmon gut. Two of these cases were successful. " Dr. G. Dowell, professor of surgery in Texas Medical College, published a treatise on Hernia in 1877. and describes a new method for its radical cure. He there reports sixty-eight cases with sixty permanent cures, and at the date of this publication, he informs me the number of his operations exceeds one hun- dred. By a needle of peculiar construction he subcutaneously sews the pillars of the ring with silver wire. The testimony of such an indefatigable student, with his very large experience and remarkable results, is of the greatest value.2 " Mr. Charles Steele, of Bristol, reported in the British Medical Journal, November 7, 1874, a successful case of radical cure of Hernia, which was operated on precisely as were my own cases. The patient was a boy of eight. The surgeon used two stitches 1 The operation has often been thus misunderstood. The needle was not an ordinary hypodermic syringe but had a blunt needle with two orifices near the end, so that the fluid might be thrown at right-angles upon the rings and not into tlie sac.—J. H. W. 2 Dr. D. informs me, July 3rd, 1880, that he succeeds in 75 per cent, of his cases.—J. II. W. OPERATIONS FOR HERNIA. 127 of catgut antiseptically, and union followed by first intention. After six months the hernia returned, and the operation was repeated. A truss was applied for safety. A perfect cure was effected, in the judgment of the operator, a year later. " Nearly all the late writers on surgery, such as Bryant and Erichsen, deprecate any attempt to secure the radical cure of Hernia, except in severe cases; and Mr. Bryant regards the supposed elongation of the mesenteric ligament as a probable cause of the imperfect results obtained by various operators, but he supports his proposition neither by theory nor by fact. If the operation which I have proposed is done properly, with antiseptic caie, I believe that to a great extent it is devoid of danger. In a series of papers upon Strangulated Hernia, based upon one hundred operations performed by himself, published in the British Medical Journal for 1872, Sir James Paget, in advocating the replacing of the sac unopened, if possible, says: ' The structures divided externally to the sac are insignificant; and it might be difficult to name an operation less endangering either life or health than this would be. The peritoneum is not wounded; the intestine or omentum is not touched or exposed to the air; the wound may be small; any haemorrhage may be easily stayed and must be all external. Thus the wound is favourable to speedy healing, and erysipelas, or any other mischief, is not likely to extend to the peritoneum.' " I would not appear over sanguine in the suggestion of any new method for the radical cure of Hernia. I am perfectly aware that this has ever been one of the most troublesome and unsatisfactory problems in surgery ; and my experience has been too limited to prove little except possibilities. " However, I must claim a favourable consideration, on a legi- timate field, for the use of the carbolised catgut ligature, at least in all cases of Strangulated Hernia where the wound can be closed. This method does not add to the dangers of the 128 HERNIA. operation, and is probably followed by a cure. In comparing the operation with that usually recommended, of subcutaneously stitching the ring with sutures of any material, it seems appa- rent that to cut down upon and expose the ring gives a much better opportunity of carefully closing it, refreshing its borders, and thus avoids injury to the spermatic cord, while it does not increase the danger of the patient."l Injection. — This method marks an epoch by itself in the history of the radical cure of Hernia. Velpeau is, without doubt, the first who ever injected for the radical cure, and says that " sensible like other practitioners of the want of a radical cure for Inguinal Hernia, and convinced, moreover, for a long time that we were wrong in abandoning indiscriminately all the trials which had this object in view, I also have endeavoured to arrive at it by a special method. The process which I have proposed is the same as that which is employed for the radical cure of hydrocele." In the early part of 1835 he had already conceived the idea of applying injections to the cure of Hernia, and in February and July, 1837, he performed successfully and without difficulty, the operation upon Herniae with an iodine injection, first, however, cutting down upon the parts, but at the same time being very careful not to allow any of the injecting fluid to penetrate the peritoneal cavity. The injection was administered with "the canula of the trochar guided upon a blunt-pointed probe." We find also that my esteemed and honoured countryman, the late Dr. Pancnast of Philadelphia, cured thirteen patients in 1836, and that later my beloved friend, the late Dr. J. Mason Warren of Boston, injected sulphuric ether with success. In 1846, Dr. W. H. Roberts of Alabama made his first hypodermic injection for Hernia with oil of cloves. His idea of this opera- tion had been derived from a Dr. Woogencraft, as I am informed by Surgeon Billings of the U. S. Army. i See p. 270. OPERATIONS FOR HERNIA. 129 But the honours of the true hypodermic injection without any preliminary incision, I think, after much caieful research in the literature of surgery, belong to the late Dr. George Heaton of Boston, who, " after eight years of discouraging experiment, discovered a process which I call the method of ten- dinous irritation^ by the injection of a solution of quercus alba. Since he performed successful cures by his new method as early as 1840', and experimented as he tells us eight years previous to this, we are carried back to the year 1832, when he first conceived his operation. His first operations were with Dr. Jaynes of St. Louis.24 In this brief sketch I have endeavoured to be impartial in my honour to the various operations, whether they are hypodermic or not. I would cast no reflections upon any one, nor at the same time endeavour to lessen whatever credit I think may justly belong to Heaton for bringing the operation to a full fruition and success. Previous operators have relied upon suppuration to produce their cures; Heaton tried to avoid it. In this is the element of his success, but as will be hereafter seen, I soon after taking up the operation, abandoned the simple fluid extract of oak bark which Heaton had used, and produced by a more stimulating preparation a much more abundant effusion of plasto-lymph. That, however, Heaton did by his simple injection, effect wonderful cures, can be doubted by none. The following is a fair example of his success. A soldier by the name of Pitcher was ruptured in the femoral region at the battle of Big Bethel, and was discharged in the latter part of May from the United States service for physical disability caused by said rupture. Dr. Heaton operated upon him in June, and after the operation the man again enlisted as a soldier in the following September, and served his three years without sickness or return of his rupture. You who have been 1 Heaton on Rupture. See, however, page 380 of present work. K 130 HE UN I A. with me in the United States service know that a soldier must be badly ruptured to be discharged from the army, and I will not weary you with more lengthy details. I examined this ■man in March, 1880, and he is still fully cured. That Heaton also failed in some of his cases is also true. This all must expect, for one of the cardinal principles in sur- gery is that wounds will not always heal by the first or best intention, and that we never can certainly foretell the results of our best endeavours. Upon this point I will speak more at length further on. Here I trust I may be pardoned for inserting a clinical lecture delivered by Dr. William F. Jauney, at the Philadelphia Hospital in January, 1880. " Gentlemen :—I have the opportunity to-day of exhibiting to you a few cases of Inguinal Hernia, and by the consent of one of the patients who wished to be cured, I shall perform the operation of irritating the abdominal rings according to the Heatonian method, which method has been brought before the profession by Dr. Joseph H. Warren of Boston, in many articles in different medical journals and essays read before medical societies. I am not certain that Dr. Heaton deserves the credit of being the originator of the operation, but rather inclined to believe that to Professor Joseph Pancoast, Emeritus Professor of Anatomy, of the Jefferson Medical College, belongs the honour of being the first to attempt to cure Hernia by subcutaneous injection of an irritant into the inguinal canal. The records of the Philadelphia Hospital disclose the fact that Professor Pan- coast, in 1836, injected into the inguinal canal and hernial sac Lugol's solution of iodine in thirteen cases of Inguinal Hernia, and that they were all cured of the hernia, and were retained on the farm attached to the hospital, and worked as farm labourers for some time. Some worked as long as one year after the opera- tion without wearing a truss ; and in no case did the hernia OPERATIONS FOR HERNIA. 131 return. It is with just pride that we claim this operation as a Philadelphia operation, and for a more detailed description of it I refer you to Pancoast's work on operative surgery. " Heaton's claim I think will be recognised as a very slight modification of Professor Pancoast's, except that he used a con- centrated extract of quercus alba, instead of Lugol's solution of iodine. The success of Professor Pancoast's cases did not make it a recognised operation by the surgeons of the country, but to Dr. Warren, of Boston, is justly due the credit and honour of making this operation an assured method of curing Hernia. In some cases the Hernia may return, but from my experience in this method I am well satisfied that fully seventy-five per cent. of all Hernias operated on in this way can be perfectly cured. Dr. Warren's position to this operation will be similar to that of the late Dr. Atlee to the operation of ovariotomy. These operations are two of the grandest achievements of surgery in the nine- teenth century, and both by American surgeons. This patient that I show you has had right Inguinal Hernia for eighteen years, is a sailor by occupation, and is fifty years old. He was admitted to this hospital for medical treatment, and was trans- ferred to the surgical wards, in order to have his hernia cured. I shall now use an instrument for this operation which was made for me by Mr. Gemrig, of this city, in April, 1869. It consists of a screw syringe so graduated, that when filled and ready for use, one quarter turn of the wheel will expel two drops of the fluid from the terminal end of the trocar. The trocar is a modification of Fitch's ovarian trocar. It consists of a hollow tube, that fits on the nipple of the syringe, and is about three inches in length, with a small orifice one-twentieth of an inch from the distal end ; over this is a sheath or tube with a terminal point, similar to the cutting point of a hypodermic needle; this tube or sheath is somewhat shorter than the hollow probe attached to the syringe, and is fastened to the hollow probe K 2 132 HERNIA. by a bayonet joint. The patient is now placed on the table, his hips slightly raised and the instrument properly armed with a concentrated aqueous extract of quercus alba. The cutting sheath is unlocked, and the point pushed forward, so as to extend about one-fourth of an inch beyond the distal end of the hollow probe, thereby closing the orifice for the exit of the irritant. This operation, not being a painful one, we will not give the patient ether. Taking the instrument in the right hand, with the left index finger I invaginate the tissue of the upper part of the scrotum, and insert my finger into the external ring. I find that the hernia and sac have been reduced with my left index finger in the external ring in front of the cord, and pressing upon the outer portions of the pillars. I now insert the cutting point along my finger, and the pillars of the ring ; then with my right index finger and thumb I gently unlock the cutting sheath, and push the hollow probe into the inguinal canal, thereby, as you observe, retracting the cutting edge along the hollow probe. I now have the probe in the inguinal canal, and as it is a per- fectly smooth probe it can do no injury to the cord or adjacent parts of the canal. I now gently push it up to the internal ring, and by one quarter turn of the wheel I deposit two drops of the irritant on the internal ring, and with the end of the probe I rub it around the edges of the ring. I also move it to another part of the ring and emit two more drops, and gently rub it around this part of the ring. I have now applied six drops of the irritant to the internal ring. I withdraw the in- strument, and apply in the same way the irritant to the external ring; having now applied ten drops to the external ring, I pull out the instrument, and apply a pad over the parts, and a bandage. You observe that this patient has not complained of pain. He will be placed in the ward, and kept in a reclining position for the period of two weeks. " February 6th—I have now the pleasure of showing you the OPERATIONS FOR HERNIA. 133 patient operated on in January for the cure of hernia. You notice that he walks around the amphitheatre without any sign of Hernia. We will test the cure, by having him stand upon this table and then jumping down; now by running up and down the steps, all of which has no effect upon the hernial rings. I think you may consider this man cured, but we will keep him under observation for some time yet. " May.—No sign of return of Hernia." Dr. Janney now says that hereafter in all his operations he shall in place of his syringe above described use my new instrument (to be described later on), as more effective, less dangerous, and in every way far preferable to any yet devised CHAPTER VI. Author's Operation by Injection.—I. General Remarks. II. Author's Modifications of the Injection Method. III. Author's Operation. From what I have thus far said it will be seen that all of the operations, from that of Chauliac to that of Wood, are severe, and likely to be attended with great danger of life, if not absolute loss of it. It is no wonder then that Bryant and others should in their surgeries express great dread of the many so-called radical cures, and doubt their expediency and their value. No such arguments can be used against the operation that I recommend, as no fatal results have ever occurred in any of the operations performed by the various surgeons who have attempted them. Nor are such results at all likely to occur unless the operator unwarrantably interferes with the work of nature set up by the injection, unless he makes the injection in the most bungling and careless manner, or unless he uses some im- proper instrument, such as a scarf or lancet-pointed needle, as some few have proposed to use. The use of all such instruments has been severely deprecated for reasons which will appear later. As regards the objection that is often made that all such operations which concern the peritoneum are dangerous I can- not do better than quote Dr. Davenport, editor of Heaton on Rupture: " Although allusion has been frequently nu de to the AUTHOR'S OPERATION BY INJECTION. 135 necessity of much caution in practising this method for the cure of rupture, in order to avoid inflammation, the risk in this respect is in reality a very slight one. In the first place, the profession have laboured for years under a groundless fear of abdominal inflammation, because they have confounded inflamma- tion of the parietal wall of the abdomen, which is generally easily controlled, and can scarcely be called dangerous, with deep-seated peritoneal inflammation of the abdominal contents. In the second place, as a matter of fact and experience, no inflammation does occur if the operation be performed with even a reasonable amount of skill. No surgeon after the ex- perience of a few cases will be deterred from trying the operation because of apprehension of this danger, unless per- chance he wishes blindly to adhere to his preconceived ideas, and rest content with the unsatisfactory and evasive practice of treating rupture by ordering a truss. Such advice is often almost like recommending a man with a broken leg merely to get a crutch." By this the reader must not understand too much. We do not mean to say that inflammation is not excited by our injection, but that peritoneal inflammation is not set up. The inflammation that we excite is local in its nature, and rarely extends beyond the crest of the ileum. Upon this point Professor Wood says : " On reading over the opinions of modern writers on Hernia one cannot but be struck with the importance they attach to the supposed dangers of meddling with the peritoneum and its offsets. Around this theory are grouped most of the objections to operative inter- ferences. The theory alluded to seems to have been deduced from experience of operations performed upon this membrane in a state of disease or inflammation, or operations exposing it extensively to external influences. Hundreds of operations in- volving the healthy peritoneum, both upon Herniae and under other circumstances without bad results, have been overlooked 136 HERNIA. or ignored. This prejudice is, I believe, at the bottom of most of the objections, as it formerly prevailed against early operation in cases of Strangulated Hernia. In the latter cases it seems to have generally given way, rendering it more easy to be dealt with in the former class. In a general way, inflammation of a parietal portion of the peritoneum has been confounded with that of the visceral layer or general inflammation of the cavity near the important nervous centres. A secluded portion has been invested with the attributes of the whole, a logical error not uncommon." To illustrate this matter by practical cases I insert the following paper upon the toleration of the peritoneum to resist injuries. This has been a theme of great interest, from very earliest times to the present, the older writers often feeling very timid in their tieatment of any injury or wound, small or great, that should occur to the peritoneum, and giving almost always un- favourable prognostications, even in the slightest and most trivial injury to this membrane. In many cases, however, the more ancient mode of combating inflammation of all kinds, and par- ticularly of this membrane, did prove fatal, no matter how assiduously the antiphlogistic treatment, internal and external, was applied. We are taught, however, by more modern surgery, that by the application of water and by the internal use of opium and veratrum viride, under proper hygienic rules, serious injuries of this membrane are not only combated, but brought to a more favourable issue. This has been illustrated in our civil contest, and other late wars. The great tolerance of the membrane has been still further illustrated by that honoured son of Kentucky, Dr. McDowell, and by Drs. Atlee, of Philadelphia, Peaslee, of New Hampshire, Spencer Wells, of England, and other ovariotomists, as well as by Dr. Heaton, in his numerous injections for the AUTHOR'S OPERATION BY INJECTION. 137 radical cure of Hernia. I have heard from Dr. Heaton's own lips that—and so we are led to infer from his published work— he frequently punctured the peritoneum, both in the umbilical and inguinal, region. To illustrate this tolerance more fully, I would here relate a few instances of the many injuries to this membrane that 1 have known :— In my earliest years Mr.----called upon me. He had had the misfortune to receive a wound from a large rat-tail file, which struck him about three inches above the symphysis pubis. It punctured the superficial integuments and the bladder near its fundus. Here, it is true, we had a favourable portion of the peritoneum wounded, as regards subsequent inflammation. Although the man had acute cystitis from the injury, still, after the wound had discharged pus and urine for some time, he made a good recovery, without any peritonitis. Another patient, in the year 1856, while in the delirium of fever, jumped from an attic window into the door yard, upon a stump covered with dry roots. As he fell he was impaled through the perineum to the rectum, and the walls of the abdomen were pierced in several places, just above the base of the bladder and the crest of the ileum, on the right side of the linea alba, by those small, dry rootlets, which were jagged and rough, and varied in size from a goose quill to half an inch in diameter. Yet from all this serious injury, suffering as he was at the same time with typhoid fever, he made a good and successful recovery, suffering, however, for some months, from paralysis of the neck of the bladder. Still further to illustrate, I will mention Mr. H., a case occur- ring in my practice on Christmas Eve, 1857. He was suffering from a wounded abdomen, which had been torn from the pubic 138 HERNIA. symphysis to nearly the ensiform cartilage, by a dull jack-knife used for the cutting of tobacco. From this wound most of the small intestines had escaped to the floor of a room covered with coal dust and the dSbris of a midnight carousal. After ether- ising my disembowelled patient, I passed the intestines through my hands, bathing off, with warm olive oil, the filth adhering to them, and closed the frightful wound by deep sutures and adhesive plaster. Over the abdomen I laid a cloth covering of cotton wool, and upon this placed a bladder filled with ice, which was frequently renewed. I placed the man in bed, ad- ministered thirty drops of laudanum and an injection to the rectum, and gave, I must confess, a most unfavourable prognosis. To my surprise, I found on my first dressing, forty-eight hours afterwards, that the wound had healed by the first intention, with no peritonitis or other intestinal or abdominal in- flammation. I may conclude these illustrations by mentioning a very remarkable case of rupture of the uterus, while in labour, and the escape of the child through the rent into the abdominal cavity. This resulted from a contracted pelvis. The woman had gone her full term, and the child, a large one, was extracted through the ruptured organ, a wound being made sufficiently large to admit the hand and arm of the gentleman with me, Dr. Benjamin dishing, of Boston, so that I could feel his fingers and hand at the ensiform cartilage. You may judge of my surprise, when, on the following morning, entering the patient's room with my autopsy case under my arm, I found, not the fine subject for study which I had anticipated (but was happily dis- appointed in), but the patient sitting up in bed eating a bowl of gruel, and in the most cordial manner saluting me with the compliments of the opening day. This case was detailed at the time in the Boston Medical and Surgiccd Journal. Suffice it to say that she made a rapid recovery, without AUTHOR'S OPERATION BY INJECTION 139 peritonitis, and in about the usual time as if she never had suffered from a ruptured uterus. I therefore feel more confident at the present time, after the experience I have had, that if in any way, by accident, or in injecting, for cure, the hernial rings, whether in umbilical, inguinal or femoral, I pierce this membrane, unfavourable results will not necessarily occur. As yet I have never had a fatal result in any of the cases where I was led to suppose that I might have punctured the membrane. I would not, nor would I advise any one to puncture the peritoneum, however, if it can possibly be avoided. I am a firm believer, as you may infer from reading these cases, in the application of cold water or ice, either in rubber bags or in bladders. I have never seen a case of peritonitis, arising from any injury, that was not followed by favourable results if these means were used to allay the inflammation, and I have yet to see a case requiring the application of poultices or hot fomentations to bring about such favourable results. These applications of poultices for abdominal inflammations involving the bowels, peritoneum, and the uterus, have been, I believe, the bane of surgical treatment by ancient physicians, and by some physicians of the present day. They are unne- cessary, unless there has been an open wound and suppuration, and even in these cases a large majority, I think, would be better cured by the applications of cold, either dry or moist. I can conceive that there may be some exceptions to the universal use of these cold applications, and in these cases hot stupes of terebinth and opium combined with chloroform might be useful, as, for example, in the puerperal diseases of women, involving the uterus and its appendages, and attended with great tympanitis, and also in the tympanitic condition of enteric and "astric fever. Still I think it will be found that in very many of these cases the water or ice bags will be of the greatest 140 HERNIA. benefit in a successful treatment of all these inflammatory actions. At least I have so found it in my practice, and I more- over prefer the ice in a bladder to that in a rubber bag, because the tissues of the body take more kindly to an animal tissue than to a smooth, clammy, rubber surface.25 Every surgeon who has had much to do with operations and wounds in the abdominal muscles and integuments, particularly in the inguinal and pelvic regions, must be struck with the vast amount of sero-plastic lymph poured out from any injury or wound of these parts. Even in the application of a blister to this portion of the body it will be noticed that we have a far greater amount of serum poured out than we do when one is placed upon almost any other part of the body. In the injections into the hernial rings, for the cure of rupture, we take advantage of this, and in some cases we may have a full occlusion of the hernial rings, even after we have partially divided some of the muscles and ligaments for the release of the strangulated intestine, and we obtain a far more favourable result than perhaps might be reasonably expected from so severe an operation. This takes place from the adventitious tissue formed by the serous lymph, and from the cicatricial contraction of the wounded muscles; hence any irritation of these fibres, fascia lata, &c, by means of astringent fluids injected upon them, will be found to produce a free effusion of this lymph, which soon becomes organised, and unites the oblique, internal and external, transversalis and transversalis fascia, and so forth, fully together. The greater the amount of serous effusion, the more sure are .we of obtaining this desirable result in the radical cure of Hernia.26 I have become so familiar with this condition and abundant effusion, that I can usually judge whether I shall get an oc- clusion and union of the parts of the hernial rings in my operation for the cure of rupture, in the course of forty-eight AUTHOR'S OPERATION BY INJECTION. 141 hours. After I have operated, should the effusion be slight, I do not anticipate a very satisfactory result, but, on the contrary, if it be abundant, I look, and generally not in vain, for a most favourable and permanent cure of the Hernia. author's modifications of the injection method. Having advanced thus far in our subject, I will, before describing the exact modus operandi of my improved operations, give a brief account of the way in which I was led to improve the instrument and fluid used by Dr. Heaton, with some re- marks upon the proper and improper instruments used in the operation. I began operating for the cure of Hernia soon after the death of Dr. Heaton. The first patient was Mr. G-----, aged twenty-three, with double direct Inguinal Hernia. I was assisted by Dr. Wm. Emery, of Boston, who was his physician at the time of the operation. The hernial ring on the right side had become dilated to the extent of about one and a quarter inches in diameter by the protrusion of the hernial sac and intestine. The hernia on this side had existed for over two years, and the tumour formed by the hernial protrusion was about the size of a goose-egg. The Hernia upon the left side had existed for about a year and a half, was about one inch in diameter, while the hernial protrusion was about one-half the size of the one on the right side. These herniae being at times very painful, and almost impossible to be retained with the ordinary truss during the patient's daily labour, it was thought best to perform the Heatonian operation for hernia, which was done in the following manner. With the old in- strument of Dr. Heaton, I injected on the right side about twenty minims of the fluid extract of quercus alba, which had been evaDorated to the consistency of glycerine, and united 142 HERNIA. with an eighth of a grain of morphine; on the left side about fifteen drops. In about six hours after the injection the patient began to grow feverish and restless ; pulse running to about ninety, tem- perature about one hundred. This condition continued for about three days, when it began gradually to subside. The urine was passed naturally, and a natural passage of the bowels took place on the sixth day. There was some swelling and redness over the hernial ring, extending up over the abdomen obliquely to the crest of the ilium. Dr. Emery attended the case, I seeing the patient occasionally. He administered one-eighth of a grain of morphine at bed-time to secure rest, and cold water was constantly applied over the seat of operation by means of a compress. A rapid and successful recovery took place, with a perfect cure of the Herniae, and on the twenty-third day of Fio. SI.—Heaton's Instrument, with Davenport's Needle. July the patient came to my office, wdien a temporary truss was ordered. This he was to wear for several months until we should conclude that the tissues had gained sufficient strength for him to dispense with it. It will be seen from the nature of the case that I here felt obliged to use a much larger quantity of the extract of quercus alba than is recommended by the late Dr. Heaton in his work on the cure of rupture. The instrument, Fig. 31, too, with which he performed his operations, I found very much worn from constant use in his practice for the last thirty years, and very unfit for the purpose for which it was designed, since great manipulation was required to exclude the air from the barrel of the syringe, because of the loose and worn packing. The needle was pierced for the exit of the fluid with two small AUTHOR'S OPERATION BY INJECTION. 143 holes about, one-fourth of an inch from its point. In order, therefore, to apply the mixture thoroughly to all the circum- ference of the ring, internal and external, it was necessary to twist the needle around during the injection. The fact is, however, that this method of operating caused a very unequal distribution of the fluids upon the parts, and much pain and needless suffering to the patient. I examined also the needle devised by Dr. Davenport, editor of Heaton on Rupture, and found his likewise had but two openings, with what I consider a very dangerous point, it being lancet-shaped, and liable to pierce the pubic and branches of the epigastric arteries, together with other vessels. It thus had not even the merits of Dr. Heaton's old needle,1 which was in shape not unlike a bradawl at its point, and which, because not very sharp, easily glanced by any vessels it might meet in its passage through the integuments. Accordingly, in my next case I had a needle made for me and pierced with four holes, the first two much nearer the point of the needle than in the old instrument. This new needle, I found, worked very much better, distributing the fluid more equally upon the internal and external ling, together with less turning of the needle in the integuments and consequently much less pain in the operation. With this needle, as I had improved it, I continued to perform several operations with much better success than with the needle devised by Dr. Heaton. Still when I came to operate for a very large double inguinal hernia, one direct and the other oblique, the distance through the integuments being greatly increased by adipose deposit, I found there was still a great amount of pain which I thought unnecessary, produced by the instrument—since, being rather blunt at the point, it met with considerable resistance in penetrating the tissues. 1 See Fig. of Heaton's case, p. 370. 144 HERNIA. When I came to make a second injection, which was necessary on the left side of this hernia, since the first injection did not succeed in causing the adventitious tissue to be thrown out so as fully to close the ring, I found much greater resistance in the in- teguments than before, they having become more firmly consoli- dated from the effect of the oak bark. The operation thus caused considerable pain, although no more than most patients could endure without etherisation. I next turned my attention to find some means of penetrating the tissue into the hernial ring with less pain, and for this purpose devised a new instrument, Fig. 32. It consists of a glass barrel inclosed in silver, through whose fenestrated openings the fluid Fio. 32.—My First instrument, with Revolving Needle. can be seen and the presence of air-bubbles detected. The number of minims is also plainly indicated on the engraved glass barrel, so that we can measure the exact number of drops injected in any given operation. It has two semicircular handles on the lower end for holding the instrument conveniently and firmly during the operation. If we next examine the needle or beak, we shall see that it is hollow, about one and three-quarter inches long, and that throughout its whole length it partakes of a spiral twist, so that it will, of necessity, revolve as it enters the tissue, and by such revolving penetrate the skin and other integuments much more readily than is possible with a straight, bluntly-pointed instru- ment. We can readily illustrate this by passing the improved AUTHOR'S OPERATION BY INJECTION. 145 needle through a piece of parchment, and then by performing a similar operation with a straight needle pointed like a brad-awl. The ease with which the fine needle penetrates, compared with the resistance which the other meets, proves conclusively that the former instrument must do its work with much less pain than the latter. The secret of this is that with the straight needle we get constant friction and bearing on the entire length of the needle during the whole operation, whereas with the spiral form of the needle the friction and pressure are on but a small portion of the body of the instrument at any one time, and are thus reduced to the minimum. Then, again, it is to be observed that the needle, instead of being round, is of a flat, oval shape, and makes a wound of the same form. In this way there is a more ready coaptation of the wounded tissue than would be possible with a round puncture. The needle is pierced with ten openings upon its sides, wdiich causes a more free and equal distribution of the fluid ejected. The difference between this and the hypodermic needle, which I shall speak of later on, is that, instead of the direct terminal uses of the fluid, we have it spread at right angles to the needle, and therefore gain a better distribution upon the hernial rings, internal and external, at the same time avoiding the applica- tion of the fluid to the peritoneum which we wish to irritate as little as possible. With the hypodermic syringe, however, the principal flow of the fluid would be upon the peritoneum, and not upon the parts intended to receive it, thus making the operation, in view of the small amount of fluid recommended, of limited and doubtful success. If we examine the attachment of this needle to the barrel of the syringe, we shall see that the needle is held in place by a coupling and collar, which allows it to revolve while on its passage through the integuments. The head of the needle within this collar is rounded something 146 HERNIA. like the smaller end of an egg and on its bearings is in contact with a diamond or other hard stone which is concaved to fit accurately the convexity of the needle. In this way we avoid almost entirely the friction which would, if metal met metal, prevent the free revolution of the needle; and at the same time we render the joint sufficiently tight to prevent all leakage of the fluid as it passes from the chamber of the instrument into the needle. Some improper instruments having been used in this opera- tion I have to make the following general and important criticisms upon all sharp-pointed needles, like that on Fitch's trocar which has been used for the purpose, or like that devised by Dr. Janney of Philadelphia, previously described. I do not wish to be considered an opposer of any other gentleman; on the contrary, nothing pleases me so much as to have others do this operation successfully. When, however, they attempt to do it, I do hope that they will select a proper and safe instrument to work with. If any one can devise a better instrument than has been devised, I, for one, should be happy to have him do it, and shall be happy to use it. But I hope they will be sure that it is safe, and that it gives honour to the good name of the operation, before they make it public as an improvement on both Dr. Heaton's instrument and my own, which are already in successful use. Therefore, as the only living man whom Dr. Heaton ever personally taught the opera- tion as it was performed by him, I protest, in the name of humanity, against the use of any sharp, or angular-pointed needle in the operation, and I emphatically warn the profession to expect many unfavourable and even dangerous results from the use of such instruments; results which probably might have been a successful cure had proper instruments been used. Lest the profession should consider me over cautious in this matter I will refer to an incident during a recent visit I made AUTHOR'S OPERATION BY INJECTION. 147 to New York. Dr. Post desired me to go to the Presbyterian Hospital to see a patient he had operated upon for Hernia, but in whom he had not ventured to make the injection from the surface, for fear of injuring the arteries and other vessels. He had therefore first cut down upon the rings with the scalpel, freely, and then injected. He was in dread of these sharp- pointed instruments, but thought my new-pointed instrument avoided the difficulty. If this skilful and veteran surgeon, famous for his successful operations, dreaded and did not dare use a sharp-pointed instrument, how much more should the mere tyro in surgery avoid their use ? It is impossible to'be too cautious in this region so rich in surgical anatomy. In addition to this it should be stated that in my method of performing the operation, instead of applying the fluid to the internal hernial ring first, as in Dr. Heaton's operation, I reverse the process and do this last; for as soon as my needle has pene- trated the tissues, I immediately begin to eject the fluid upon the external ring and its surrounding parts, and so continue until I reach the internal ring. After sufficiently bathing the latter with the fluid I withdraw the instrument, still continuing to eject.1 In performing in this manner we complete the operation in one half the time employed by Dr. Heaton, and, comparatively speaking, with an absence of pain. At the same time we en- tirely avoid the sweeping motion of the needle described in Dr. Heaton's treatise, a process which I consider very much endan- gers the wounding or irritation of the muscular fibres and blood- vessels composing the rings. Furthermore, the tissues being less likely to be serrated or irritated with my needle than with his, there is much less tendency to the formation of abscesses from such irritation than in the old operation. I find, too, that the extract of oak bark employed by Dr. i See pp. 170, 388. L 2 148 HERNIA. Heaton is not well held in solution, being liable to much sed- iment, the powder forming granulations which do not readily pass through the syringe, and which, if ejected, form a consider- able irritation, and therefore a great tendency to abscesses. A better and safer formula is to evaporate the fluid extract of oak to about the consistency of glycerine, add sufficient absolute alcohol to reduce it about one half, and then add about one half a dram of sulphuric ether to the half ounce of fluid. To this mixture I also add about two grains of sulphate of morphia, thus making one of the most perfect injecting fluids that I have thus far been able by numerous experiments to devise, combin- ing the astringent effect of Dr. Heaton's extract of quercus alba, together with that of the German method of using alcohol alone, and producing the most favorable results in this operation of injecting the hernial rings for the radical cure.2,7 The use of an ordinary hypodermic syringe would be, I con- sider, an operation attended with much danger, not only from the liability of penetrating a portion of the pubic and epigastric arteries, but also because the instrument would be a poor and feeble one for thorough and successful operations on Hernia, since it is well known that the needle has to act in some degree as a staff and guide in slightly lifting up, as it were, the integT uments, which are often thick and supplemented by excessive adipose tissue. I hardly need call the attention of any surgeon of prominence who keeps well up in the anatomy of these parts to the great danger of wounding the epigastric and pubic arteries, and other blood-vessels and nerves, by a sharp lancet or angular-pointed instrument. The cautious surgeon well knows that his patient might easily receive a dangerous wound here and bleed to death, perhaps, before it be discovered and secured. Hence, after what is known and has been said on the subject, a hypo- dermic syringe, or any thin and sharp-pointed instrument, will PLATE C. INGUINAL AND CRURAL CANAL. (Seen Outwardly.) From BLANDIN. Explanation of the Plate. A. Portion of the thigh. — B. Penis. — C. The testicles. — D. Hair of the pubis. — E, E. Portion of the anterior abdominal enclosure (costo-iliac region). — F. Anterior and superior iliac spine.—G. Eight muscle in its sheath.— H. Pyramidal muscle equally in its sheath. ■— I. Aponeurosis of the great oblique. — J. Hook which lifts up a portion of the aponeurosis of the great oblique, detached over the crural arcade, where it forms the anterior enclosure of the inguinal canal. — K, K. Crural arcade. — L. Inguinal ring crossed by the testicular cordon, and sending from its circumference a fibrous expansion upon the cordon. — M. Fibrous expansion detached from the circumference of the inguinal ring. — N. Internal or superior pilaster of the ring. — 0. Ex- ternal or inferior pilaster of the ring. — P. Place where the crural arcade con- tinues with all the thickness of the fascia lata aponeurosis. — (}. Place where the crural arcade adhered only to the superficial leaf of the fascia lata aponeurosis leaf, which here has been detached and overturned outside. — R. Sinus, open in the upper part, which the crural arcade forms in continuing backwards and above, with the fascia transversalis sinus which constitutes the inguinal canal. — SS. Fascia transversalis aponeurosis, which forms the posterior enclosure of the in- guinal passage, in a place where of the three muscles of the abdomen only the external oblique one is found. — T. Place where the fascia transversalis aponeu- rosis rises from the external edge of the right muscle. —VVV. Inferior edge con- founded and horizontally directed from the small oblique and transversal muscle. — V,V, V,V. Muscular handles of the cremastereous muscle formed by an emana- tion upon the cordon of the inferior edge of the small oblique and transversal muscles. — X. Testicular cordon, in the middle of which are seen the rlexuosities of the testicular veins.—Y. Ileo-scrotal nerve of the lumber plexus.—Z,Z, Z. The adipous skin and tissue of the abdominal enclosure, turned down. — &. Fascia superficialis aponeurosis. — a. Cordon knotted upon the fascia superficialis aponeu- rosis, detached from the abdominal enclosure, and overturned upon the thigh and hip. _ b, b,b. Tegumentary vessels of the abdomen. — e. Genital external super- ficial vessels. — d, d. Anterior enclosure of the crural canal, cut and overturned from inside to outside in order to show the crural canal. — e. Large lymphatic ganglion, placed before the crural canal. — f,f. Openings of the anterior enclosure of the crural canal, which are crossed by lymphatic vessels. — g. External enclo- sure of the crural canal, formed by the deep leaf of the lata fascia, supported upon the psoas and iliac muscles. — h. Opening made to the external enclosure of the crural canal, in order to show the crural nerve placed immediately outside of it, in the sheath of the psoas. — i. Femoral artery, placed outside of the vein of the same name. — j. Femoral vein placed within the artery. — i. Internal sapheneous vein.—m. Inferior opening of the crural canal, crossed by the internal saphe- neous vein. — n. Fibrous falciform bunch, placed at the confluence of the saphe- neous and femoral veins. AUTHOR'S OPERATION BY INJECTION. 149 appear extremely dangerous to most successful surgeons. I should suppose there was hardly a single maker of surgical instruments who would be a party to the manufacture of any such dangerous instruments, and much less that there was any surgeon who would attempt to use such foul implements on any human being. Indeed, one of the many reasons why Dr. Heaton preferred a needle like a bradawl, with a round and somewhat blunted point, was that it would easily and safely glide off the coats of the vessels. In my instrument I further guarded against danger by a round and blunt-pointed needle, which would revolve in penetrating the tissues. In this way there is still less danger of wounds or unnecessary irritation than in Dr. Heaton's method of sweeping the needle around, so as to distribute the fluid equally upon all the parts. With my instrument the fluid is simply and completely distributed around the rings and canal during the act of entering and withdrawing the instrument, and there is no possible danger of injury to the parts during the operation. There has been some misunderstanding too about the manner in which the injection should be given. From an ordinary hypodermic syringe the fluid will be injected straight forward, while Dr. Heaton strove to force his fluid in a spray at right- angles to the needle. This is an essential point in the operation, since it is the hernial rings and not the hernial sac that we desire to irritate.28 Although it is high time that this operation should be better understood, still a thorough comprehension will neither lessen our great esteem for the more formal surgical operation for Strangulated Hernia, as now performed by all modern surgeons, nor will it be less essential for all practical surgeons thoroughly to understand this latter operation. So long, however, as thousands upon thousands are ruptured 150 HERNIA. with reducible Herniie, which have heretofore required all the ingenuity of mechanical art to support and retain within the abdominal cavity by bands of iron and steel, elastic fabrics, bone and ivory thereby endangering life by their liability to become strangulated, and often abruptly terminating existence by the strangulated intestines becoming sphacelated and gangrenous, before relief can be obtained by the surgeon's knife, or the more gentle operation of taxis ; so long as this is the case, the dis- covery of a permanent cure seems a most wonderful blessing for mankind. Should I ever be disappointed in the success of this operation for the relief and cure -of rupture, I should be the first to acknowledge it. Allow me to add, I know of no operation in the annals of surgery that requires a more delicate touch, and finer manipula- tion in all its details, or a steadier and firmer hand in the operator, not even excepting the fine and graceful operation of cataract on the eye. What operation demands more care than passing a sharp-pointed instrument through the living tissue into the hernial ring, among numerous tissues, vessels. nerves, and surrounded by the peritoneal membrane ? I know of no operation more simple and painless, or that brings forth such rich results in relief, comfort, and almost certain cure in nearly every case when performed by a skilful operator, than this one for the cure of rupture. But when awkwardly and indifferently performed by one deficient in the anatomical and surgical knowledge proper for the undertaking of the operation, I know of no operation so fraught with danger to human life, and one so barren in results, and therefore disappointing to both physician and patient. In regard to the duration of the after treatment, my experi- ence has been, and it was the experience of Dr. Heaton, that the effusion of plasto-lymph around the parts is not sufficiently AUTHOR'S OPERATION BY INJECTION. 151 organised in five or ten days after the operation into adherent and fibrous tissue, to bear any strain at all upon them. They would at once separate and give way. Dr. Heaton caused his cases to remain at rest at least ten or twelve days. That we know from his experience, and I can say the same has been the case in my experience. Finally, I wish to add a word of caution and advice to those who may have to do with this operation. Should the patient get up too soon after being operated upon, or make any undue exercise or exertions before the parts have acquired sufficient union, consolidation, and firmness, they will very readily be- come separated, and of course let the Hernia escape again; or, should there be union in the parts sufficient even to retain the Hernia within the abdominal rings, yet a secondary swelling may again appear in the track of the first swelling and inflammation which usually attends the primary operation. This secondary swelling, more particularly if it follows after we have made two or three injections, which are often found necessary fully to close the hernial rings, will appear in any form of Inguinal Hernia very prominent over the seat of the injected parts, not unlike an inverted common saucer in size and appear- ance, extending along the oblique to the crest of the ilium, and will assume a dark maroon colour. If we now examine it, it will appear to the touch as though fluid or pus were present. This is not, however, the case; it is only a slight effusion and exudation of plasmatic serum, together with some mingling with the discoloration produced by the extract of oak injected. If now we cut freely down, exposing these parts to view, we see that the tannin in the mixture injected has united with the ex- udation, causing the appearance of the tannate of albumen. This will show itself by the striated, shroudy, and granulated sub- stance resembling dry blood when moistened again. If we should now constantly apply compresses of cold water and 152 HERNIA. allow the patient to remain in bed, on his back, this redness and swelling will generally, in the course of two weeks, entirely disappear. Such cases, when fully over all inflammatory attacks, will be found to be stronger in the hernial rings than those which had only the primary inflammation following the injection, because this secondary inflammation more fully unites the parts inflamed by thickening an additional deposit of organised lymph over the seat of the operation. But we should not be misled by this inflammation and proceed at once to open this large swelling, as we thereby very greatly endanger the result of the primary operation for the relief of the rupture, and put the patient's life in great and needless danger. We should patiently wait, and after a sufficient time, it will, if it be an abscess, converge, in the course of ten or twelve days, to about the size of a Seckel pear, and something like it in shape and appearance. Then, and not until then, we should proceed to open the swelling, and even then we should first be able to feel the fluctuation of the pus through the thinned wTalls of the abscess. And if still in doubt, from our diagnosis, wdiether it be.an abscess or not, we should, before opening, pass into the swelling one of the finest needles of the aspirator. Cold water is the best dressing, and all through the treatment, from the very beginning to the perfect recovery to the normal condition of the inflamed parts, neither lotions nor ointments are required. Now, sometimes when we discharge a patient after this opera- tion, he is commanded to wear a truss or bandage, not to lift or jump either from the cars or any other height, and to be very careful about any violent exercise whatever; all of which he promises to do. But the person so dismissed, cured to all appearances, will possibly feel so mighty and proud in his re- covery that, although he may for a time follow the instructions, AUTHOR'S OPERATION BY INJECTION. 153 he will some fine morning cough, perhaps, and force the abdo- minal parts down in order to see how strong he is in this region; or taking a peculiar delight now in examining what previous to the operation was so repulsive, he will try to lift a heavy weight, pull a hand-cart if he takes a notion, or see how high he can reach. From these self examinations he may feel satisfied that he is perfectly cured, and yet, in the very acts in the time of his unusual exertions, he has started and opened the adhesions formed in the hernial rino-, and in the end his state will be nearly as bad as before ; for upon the least yielding of these new adhesions the peritoneum and intestines will insinuate them- selves through the most minute opening, and act like a wedge in forcing the parts asunder. Had he been more cautious in following explicit directions, and waited a year or two before making violent exertions, he would never have had to bear a return of his rupture. Should a return of his Hernia unfortunately take place, another opera- tion and injection will generally effect even a firmer closing of the rings than the first operation did, because of a decidedly greater condensation and stronger cohesion of the parts treated. But I am assured that he never again, in his joy, will experiment to see how perfectly he is cured. Sometimes, after the hernial rings are closed, as Dr. Heaton says in his work, and as I myself have seen, portions of the hernial sac, particularly in cases of long standing, are fastened down in the folds of the rings and surrounding parts, after the operation for cure has been successfully applied, and this may lead the patient—nay, even the physician—to think that the hernia has not been in reality cured. If, however, as I have already said, the rupture remains closed for a year or so, the cure may be looked upon as certainly a permanent one. Suppose, however, that this hernial sac can be passed readily 154 HERNIA. through the hernial rings, then a very slight amount of the injection will close the parts efficiently, leaving the patient much strengthened by the operation. I wish to call attention again and especially to the fact, that although this operation is generally successful upon its first performance, yet it has sometimes to be repeated several times before we get a full and strong occlusion of the rings, particularly in hernias of large and long standing. If, after we have once operated and have succeeded in partly closing the opening, we find we have not done it so as fully to effect a permanent cure, we must, after the lapse of eight or ten days, repeat the ope- ration, and continue so to do until we have entirely closed the parts beyond danger of opening. Thus, by perseverance, and thus only, we shall in the end be delighted and rewarded by the perfect cure of almost every case we undertake. Even after the patient has returned to his usual occupations, and has seemed, both to himself and the operator, cured, upon the slightest indication of the return of his troubles he should at once present himself for examination, and, if necessary, an- other operation. Indeed, not only in this operation, but in all others in surgery that may be presented to me for treatment, I could not positively, and under all circumstancess, warrant a permanent cure any mere than if I performed ovariotomy or the amputation of a limb, for it is well known that from some unforeseen circumstances in the operation, or in the conduct of the patient submitted, success may not always and with certainty follow a good and legitimate attempt at relief. author's operation. With all due deference to the many and honoured operators for the cure of Hernia, I now give my improved operation, with a description of my new instrument and injecting fluid. While AUTHOR'S OPERATION BY INJECTION. 155 I make no claim to originality beyond whatever originality is required to perfect and bring to a scientific development what before, in a crude and imperfect form had worked many good results, I am encouraged to present whatever I have done because of the very general interest shown by the profession in my own country and in other countries, in what I have already given them in the medical journals. My method of performing and presenting the operation would seem to be more acceptable to the better and greater part of the profession than previous operations, if I can judge by the letters of congratulation I receive from distinguished surgeons of this and other countries, fully approving the operation as safer and freer from all follow- ing complications than any operation heretofore proposed. Thus far I have not had a single fatal case, and the worst case I have had was an old congenital hernia cited in the report of interesting cases (see p. 192, operations 3, 4, 5) read before the Suffolk District Medical Society. The operation is here given with some slight increase of matter, being nearly as read before the British Medical Asso- ciation at Cambridge, 12th August, 1880; and presented before the Academie de Mddecine, 31st August, 1880. It gives me great pleasure to have the honour of addressing you at this, the annual meeting of your venerable Associa- tion, on the treatment of Hernia by a new method, by means of an instrument and injecting fluid of my own devising. As many of you are aware, I have written considerably on this subject, and by means of the various medical journals, the so-called radical cure of rupture has been circulated through the medical profession, and caused no little interest. But I do not like the term " radical" as applied to this or any other operation, for it is not euphonious, and is distasteful to the true surgeon, sounding as it does of charlatanism. It sounds un- professional to all preconceived ideas of medical and surgical 156 HERNIA. science, and in my humble opinion it should not be so much as named among us in speaking of this or any other operation. Let us in speaking of this operation call it by its true name, an operation for Hernia by injecting the hernial rings. I am aware that some of the most honoured men that have brightened the pages of surgical literature or taught in our Universities have applied the term radical to the operation for Hernia, but notwithstanding this I would take exception to the time-honoured precedent, and in accordance with the present spirit of medical and surgical art, call this operation by its true name, trusting that we shall be quite as successful in curing and relieving our patients as we should under the irre- gular name of radical cure. In all my future papers and work upon Hernia I will join hands with the profession and erase the objectionable word, and will speak of treating and curing rup- tures by this method as we do of any operation devised for the cure of any affection. I would here take the liberty of expressing at this time my most sincere thanks to the distinguished profession of London, New York, and Boston, as well as to the profession generally in my own couutry and Europe, for their kind criticisms and consideration of me in presenting my imperfect papers on Hernia, which are given while engaged with many cares incident to an active professional life. In presenting this paper, I wish to say here that in giving my new instruments and method to the profession I do not wish to detract any credit from the late Dr. George Heaton, of Boston, nor underestimate his valuable work on rupture, nor the great labor and pains of his late co-editor, the refined and scholarly Dr. Davenport. On the contrary, I look up to Dr. Heaton, not only as my former master and instructor in this operation, but as one from whom I gained all my inspiration for my present and future AUTHOR'S OPERATION BY INJECTION. 157 efforts in developing and demonstrating this, as yet, as I feel, imperfect operation on Hernia. To Dr. George Heaton will always belong the honour of first injecting the hernial rings with fluid extract of oak bark, Quercus alba, for the radical cure of rupture, if he was not the first to inject hypodermically. I am, as will be seen, working over the field of operation of Hernia, trying to perfect and improve any deficiencies which I find in the treatment by injections, and it will be my greatest desire to be candid and truthful in all that I do and present to my medical brethren; and may I not hope with their kind Assistance to accomplish much in this operation, which does not as yet seem to be fully understood by the profession or appreciated as it properly should be?30 The following is a short description of new syringe and instrument for injecting the hernial rings in the cure of Hernia.29 Fro. 33 The instrument which I show you consists of a barrel, A, holding about sixty minims. This barrel is of glass, accurately fitted within a cylinder of silver, which is fenestrated with two openings to present a view of the barrel and its contents. The barrel is graduated, each degree indicating ten minims. The piston B works by a spring c, very tightly, within this tube, so as to exclude all air possible. The lower end D of the piston is slightly concaved. At the bottom of the interior of the glass barrel there is a ring e, one-eighth of an inch in thickness, made of soft rubber, for an air chamber, with a hole in its centre for the exit of the fluid. 158 HERNIA. On the lower exterior end of the barrel will be seen a convenient semi-circular handle, with the concave side rough- ened to give a firm hold for the finger and thumb of the operator. A valve is situated just below the bottom of the barrel and rubber chamber, and is opened and shut by pressure on the lever c. We thus have perfect management, both of the amount of the fluid to be injected and of the time when it shall be injected. Below this valve is a diamond, or other hard stone, concaved to fit exactly the convex head of the needle which plays upon it. The needles are flatfish, oval in shape, and are twisted throughout their entire length. They are of three sizes. No. 1 is one and a quarter inch in length, size two and a half American scale; No. 2 is one and three-eighths in length, size two and three-quarters American scale; No. 3 is one and a half inch in length, and size three. It should be remembered that, from their peculiar form and twist, they make an incision only about one-half the size of round needles which measure the same on the scale. The twist of the needles also varies. No. 1 is twisted to revolve once in penetrating one-fourth of an inch, No. 2 once in penetrating one-half an inch, and No. 3 once in penetrating three-quarters of an inch. I use No. 1 in operations on umbilical Hernia and other Herniae where the tissues are thin. It is therefore small, and has a quick twist because it is necessary that the needle in penetrating should make a full revolution, so as to distribute the fluid on the parts to be irritated by the injection. No. 2 is for use in operating on the majority of small and recent Hernise. No. 3 is for use on large and long-standing ruptures, where the needle must traverse tissue generally much thicker than in the other cases mentioned, and often surrounded by adipose deposit. The needle has a round shank, playing through a collar, which is AUTHOR'S OPERATION BY INJECTION. 159 attached by a screw thread to the neck of the barrel. This needle does not bore in passing, but turns round in a spiral manner as it advances, and the same can be said of all the other instruments to be hereafter described, except the aspirating needle, which is twisted in through the tissues by slight pressure and revolving it at the same time.1 I have said that there was a rubber cushion at the bottom of the glass tube. This cushion remedies the defect common to hypodermic as well as all other syringes, for it forms an air chamber which arrests the passage out of any air that may be in the barrel, and there is always more or less which would be injected with the fluid. It also acts very effectually in stopping the farther action of the piston after all the fluid has been injected. The method of using the instrument is as follows. With the valve closed, the needle is inserted in the fluid to be used. The valve is now opened by slight pressure upon the lever. The pressure being continued, the piston can be retracted, and the barrel will be consequently filled with the fluid. The valve is then allowed to close, and the instrument is charged for use. Having selected the most suitable point over the rings to be injected, we now thrust the needle slowly and gently, but at the same time firmly, through the integuments. During this act the needle revolves because of its twisted form. As soon as it has passed through the integuments, pressure is made upon the spring, which opens the valve, and allows the fluid in the barrel (o flow as slowly and in such quantities as the operator may in any given case think necessary. The quantity used can, of course, always be known by the engraved scale on the barrel. 1 See First Edition. 160 HERNIA. ANATOMY OF FEMORAL AMD INGUINAL HEKNIA.1 The real and essential anatomy of the parts where our seat of operation lies, we find to be the following: Fig. 31. Bh°75n anat0I™al relation and coverings of Oblique Hernia. 5, transversalis fascia; c peritoneum ; a, muscles, internal oblique transversa^ and ev X, m V'' *'> eXr6ma *teSi™«rt«. These illustSnswerd™ under Mr. Cooper's directions from my friend Mr. John Wood's L,-l^ Rupture, who very kindly permitted me'to make use of them L tlulw^k The inguinal or spermatic canal begins at the internal ab- dominal ring, its length being about one and a half inches. It 1 See p. 51. AUTHOR'S OPERATION BY INJECTION. 1G1 serves for passage of the spermatic cord in the male and the round ligament with its vessels in the female. Its boundaries are: In front —Tendon of external oblique muscle, lower border of internal oblique and a small portion of the cremaster muscle. Behind.—Fascia transversalis, conjoined tendon of internal oblique and transversalis muscles, and the triangular fascia. Above.—Arched border of transversalis muscle. Below.—Poupart's ligament. This inguinal canal is of great surgical importance on account of its being the channel through which inguinal Hernia escapes from the abdomen. Inguinal Hernias are of two kinds, oblique and direct. The former enters the inguinal canal through the internal abdominal ring, passing obliquely along the canal and through the external ring to descend into the scrotum. Direct inguinal Hernia escapes from the abdomen at Hesselbach's triangle and passes through the external ring. Hesselbach's triangle is situated at the lower part of the abdominal wall on either side. Its boundaries are: Externally.—Epigastric artery. Internally.—Outer margin of rectus. Below.—Poupart's ligament. The following are the coverings of the two varieties of inguinal Hernia, commencing at the surface: Oblique. 1. Skin. 2. Superficial fascia. 3. Intercolumnar fascia. 4. Cremaster muscles. 5. Fascia transversalis. 6. Sub-serous cellular tissue. 7. Peritoneum. Direct. 1. Skin. 2. Superficial fascia. 3. Intercolumnar fascia. 4. Conjoined tendon of internal oblique and transversalis muscles. 5. Fascia transversalis. 6. Sub-serous cellular tissue. 7. Peritoneum. M 162 HERNIA. FEMORAL HERNIA.1 The crural or femoral canal is a funnel-shaped interval which exists within the femoral sheath between its inner walls and the femoral vein, and is the space into which the sac of femoral hernia is protruded. It is limited above by the crural or femoral Fio. 85.—Femoral Hernia. For description of plate, see Fig. 52. ring and is lost below by the adhesion of the sheath to the coats of the vessels. In the normal state, the canal is occupied by loose cellular tissue and numerous lymphatic vessels, which per- forate the cribriform fascia covering the saphenous opening in the 1 See p. 66. AUTHOR'S OPERATION BY INJECTION. 163 fascia lata and the walls of the sheath, to reach a lymphatic gland situated at the crural ring. This gland is retained in its position by a thin layer of sub-serous cellular tissue—septum crurale— which together with the peritoneum separates the canal from the abdominal cavity. The crural ring is,the point where femoral Hernia leaves the abdomen, and is the most frequent seat of strangulation. Its boundaries are :— In front.—Poupart's ligament. Behind.—Ileo-pectineal line, and body of pubic bone. Externally.—Femoral vein. Internally.—The sharp margin of Gimbernat's ligament. The coverings of femoral Hernia commencing at the surface are: 1. Skin. 2. Superficial fascia. 3. Cribriform fascia. 4. Femoral sheath or fascia propria. 5. Septum crurale or sub-serous cellular tissue. 6. Peritoneum. THE POSITION FOR OPERATION IN THE CURE OF HERNIA BY SUBCUTANEOUS INJECTIONS. I have often done this operation on a table made of white wood, for the sake of lightness, about six feet long and one foot wide. It is supported by three pairs of legs, which at the foot are two feet four inches high, and at the head two feet high, while the central ones are nineteen inches high. These legs diverge from the middle line of table to give the greatest possible stability. There are four leaves attached to the top of the table, two on either side; that is, each leaf is about three feet long and six inches wide. The two leaves at the head of the table are spread open for the patient to lie upon, while the two at the foot are allowed to hang at the sides of the table. On these latter M 2 164 HERNIA. leaves is placed a foot-rest for the patient, so that his limbs may be in a proper position for a convenient operation. These leaves, as well as the legs, are hinged to fold up, and are properly braced to be held in position during the operation. The table has in its centre, and about three feet from the lower end, an oval opening six inches in diameter, around which the surface has been bevelled to fit accurately the patient's sacrum and hips. The table being first covered with sheets or blankets, or, if necessary, a rubber cloth, the patient is laid upon it with the head upon the lower end of the table. In this position the spine partakes of the curvature of the table top, the pelvis and hips being elevated. If desired, a small pillow can be laid under the head so as not to elevate the shoulders unduly. The patient is now in position for the operation in umbilical, inguinal, and femoral Hernia; a position clearly the most favourable for the entire relaxation of the spinal, abdominal, and limb muscles. The Herniae may now be returned within the abdominal cavity, where they will remain on account of the position of the patient, and can be at once operated upon. This table can also be used in the treatment of uterine diseases and for operations on the anus, by placing a staff at the foot of the highest end of the inclined top on which to suspend a fountain syringe, bucket, or other vessel. The patient will be found to lie on this table in the very best possible position for the treatment of such cases on account of the concavity of the table from head to foot, and the circular orifice will allow all overflow to escape, thus keeping the patient clean and dry. I now prefer and use the Goodwin invalid bedstead in my operations in place of this table, as I find it better adapted and much more convenient while operating, and the patient is not obliged to be moved afterwards till able to be up again, and AUTHOR'S OPERATION BY INJECTION. 165 the desired elevation can be obtained, as the foot and head can be lowered or raised to any height and firmly remain so long as we wish by the means of a canvas bottom that is pierced with a hole, so that the bed-pan can be used without any trouble for all the calls of nature. OPERATION FOR INGUINAL HERNIA The patient is first placed upon this table, or, if the table be not at hand, upon a bed, in which case the hips should be elevated by a pillow, whilst the head and shoulders should be allowed to fall somewhat lower in order to produce a slight curvature of the spine and a relaxation of the abdominal muscles. If a bed is used, the legs of the patient should now be drawn up, but if the table is used, this same position is gained by the foot rest below the surface of the table. The patient being thus in a relaxed yet firm position, we seek the Hernia to be operated upon, and, after reducing the protruded intestinal sac and omentum by taxis, we pass the left middle finger up the spermatic canal until we come to the inguinal ring. The end of this middle finger, being slightly raised as above mentioned, is felt by the forefinger, which also helps us to indi- cate the exact point, and is a guide to insert the point of the instrument. Having ascertained that the ring is well open and free from attachments or adhesions to the returned sac, we begin to insert the needle at the lower portion of the ring, where we feel its edges through the abdominal parietes.1 The needle should always enter this lower portion of the ring, as in passing obliquely upwards and backwards it is less likely to wound either column of the internal ring. Great care should i All the sac that can be put back free from adhesions must be returned If it is firmly bound down the injecting fluids should be freely distributed around it as thoroughly as possible. 166 HERNIA. be taken in inserting it through the integuments and superficial fascia, so as not to wound the external pillar, but to enter the Fia 36 —The three most common forms ot Hernia, in the order of their occurrence in the male, are (1) Oblique Inguinal; (2) Direct Inguinal; (3) FemoraL' canal at once. The needle then should never be passed in a perpendicular direction, as there is thus danger of wound- 1 The artist has drawn the instrument too nearly horizontal, so that it appears as if it were entering the right groin. The instrument should lie across the thumb of the left hand between the first and second joints, making an angle of about forty degrees when the needle first enters. After passing the superficial integuments the instrument should be de- pressed so that the needle may pass freely into the rings along the superior surface of the spermatic cord, taking care not to wound the cord. AUTHOR'S OPERATION BY INJECTION. 167 ing the spermatic cord, but it should receive the necessary obliquity as soon as we feel that it has passed through the in- teguments. We can diagnose the position of the needle when first entering, by passing the left fore or little finger up with the invaginated scrotum upon it. When we have passed the needle through the integuments, we begin to open the valve and slowly push the needle in the direction already indicated. As the needle is thus inserted, it revolves and injects the fluid in sufficient quantities to cover well the external and internal rings.1 The needle is now slowly withdrawn, still injecting fluid in its back- ward motion. As soon as the needle is withdrawn, pressure is made with the end of the fingers over the wound and rings for five or ten minutes, until the smarting and throbbing pain subsides. Now a pad about three by four inches and three-quarters in thickness is made by folding a linen napkin once or more. This pad should be immersed in cold water and applied, gentle pres- sure being at the same time constantly exerted until the bandage, which should be double and three or four inches wide, is passed round the body and firmly secured by pinning. In double Hernia this bandage should be kept from slipping upward by two perineal bands beginning at the crests of the ileum and pinned near the symphisis pubis in front.30 The patient is now placed in bed with his legs side by side and should remain upon his back in this position for from twenty-four to forty-eight hours. He should not be allowed to rise in voiding urine or attending to other calls of nature but the bed-pan should be used for such natural calls. i In most cases ten to twenty-five drops will be sufficient. It will be remembered by those present at my operation, August 19th, 1880, at Guy's Hospital, where the ring was very large, as demonstrated by Mr. Bryant and Mr. Smith of the Seamen's Hospital, that I was obliged to use thirty drops. 168 HERNIA. OPERATION FOR FEMORAL HERNIA. Same position of the patient as above. Having ascertained by diagnosis whether the Hernia be femoral or inguinal, that is, having found the relation the Hernia bears to Poupart's liga- ment (femoral Herniae lying below this ligament and inguinal Herniae above), and having selected the position of the saphenous opening to wdiich we are easily guided, if the femoral Hernia has emerged from the femoral canal, the operation is performed in a manner similar to that in inguinal Hernia. This saphenous opening we can usually locate by pressure in the thigh below Poupart's ligament and about three-quarters of ?io. 37.—Femoral Hernia as usually seen in female. an inch to the inner side of the femoral artery. Over it usually lies a lymphatic gland, which is much enlarged if a truss has been worn. In most cases the sharp edges of the falciform process or fascia lata may be found thickened and hypertrophied from friction. This results from the action of the truss upon the Hernia, and forms our landmark, for its curve is peculiar and not readily mistakable in making our definition. For similar operation see Heaton on Rupture. The Hernia having now been reduced and the forefinger pressed against the outer edge of the falciform process, the AUTHOR'S OPERATION BY INJECTION. 169 needle of the instrument is inserted into the canal just above the saphenous vein and on the inner side of the femoral vein which is held to one side by the finger, care being taken not to forget the femoral vein that often lies posterior to the hernial membrane. The needle thus enters the femoral canal external to the hernial membrane. The irritation applied to the crural ring should be slight, as femoral Hernia will not require so much of an irritant as an inguinal one of nearly the same size. The pad and bandage are applied similarly to those in inguinal Hernia, only run the Spica bandage as seen in Fig. 38. Fio. SS.-Splca Bandage. Of all Hernia?, femoral are the most difficult to cure by this operation, especially in females, as they require the utmost skill and care on the part of the operator, because of the extreme length of the ligaments which make up the crural ring, and because of the immediate relation of the femoral veins and arteries, and because in large and long standing Hernias the sac is often ramified by branches of larrp veins and arteries, together with lymphatics. 170 HERNIA. OPERATION FOR UMBILICAL HERNIA. From the ease of diagnosis this will not require any lengthy description. The patient is placed upon his back as in femoral Hernia, except that the feet may be slightly elevated. The finest needle which revolves once in going one-half of an inch, is selected and passed to the centre. As soon as it has penetrated the integuments, we deliver the injection with some force upon the edges of the ring by throwing the valve wide open. Care should be taken in this operation not to puncture the peritoneum. Wheret the integuments are very thin and the Hernia small, as in children, the hernial rings should be seized with a pair of dressing forceps and elevated while the needle is passing through them. In extreme and old Hernias of this kind, two or even three points may be selected for injecting the irritant. This is necessary in cases of extreme size, in order that the liquid may bathe the edges of this enlarged umbilical ring. The bandage and pressure is the same as in the other cases mentioned. In addition to these usual injections into the hernial rings, I have found when the opening in the rings has been very large, the following plan of reinforcing the ordinary effects of our operation to be of great value. While withdrawing my needle after the primary injection, I allow sufficient fluid to escape into the superficial parts to create a more or less permanent swelling over the rings. This has a tendency to form a large tumefaction over the seat of operation, and acts not only as an additional support, but also as a compress just where we most need and desire pressure. This contracted thickening of the tissues will remain in this state for months, and adds much to the success of the operation. One might think at first, from this swelling, that we were dealing with an abscess produced by our injection, but this is AUTHOR'S OPERATION BY INJECTION. 171 not so. On the other hand, we often do get small superficial abscesses similar to those following the hypodermic injection of morphine or ergot; but these are of short duration, seldom larger than a pea, and after ten to fifteen days may be pricked. They will exude their contents—usually a mixture of bloody serum mingled with our injecting fluid—and in a short time will readily heal. This modification of our usual operation is especially effective when the patient is very spare and thin over and in the vicinity of the hernial protrusion, when we are dealing with either inguinal or femoral Hern'se. From this it will be evident that in all cases of umbilical Hernias it will always be best to inject the superficial tissues, because the integumentary coverings are so thin and require so much the more the additional cicatricial thickening. If upon the day following the operation of injection we find there has not resulted a sufficient flow of lymph, we can readily excite a greater flow by pressing the ends of the fingers into the external ring, pushing all the external integuments down upon the internal ring, and when our fingers are in this position, by rubbing and twisting the integuments between them with more or less force. This rubbing should never be repeated after the first day succeeding the operation; and in consequence of its necessity, we should warn our patient that he must remain at rest a day or two longer than if the rubbing had not been made. Heaton, to supplement his injection, was in the habit of serrating the columns of the internal ring with the point of his needle. We should, however, remember that if this manoeuvre be carried to too great an extent, the result might be that inflammation would set in rather than the effusion of lymph, that we might seriously injure the peritoneum, or that we might cut some important vessel from which a severe, if not fatal haemorrhage might take place. It is not a procedure that I 172 HERNIA. should recommend any one to adopt, as with my more stimu- lating injecting fluid, and the after operation of rubbing, I can with more safety and surety obtain far better results. At the risk of repetition I will, at this point, institute a comparison between the effects produced by the old fluid of Heaton and the new mixture of my own. The application of a mustard paste to the surface of the skin wdll excite a great amount of irritation, and what might have been called, by older writers, a dry and local inflammation. If in place of the mus- tard we apply a blistering plaster of cantharides, we shall get a greater amount of lymph effusion with far less soreness, tender- ness, and inflammation of the surrounding tissues. From this I intend the inference to be drawn that mere soreness and tenderness of the rings is no criterion that the operation of injecting the hernial rings has been successful in occluding the hernial opening. On the other hand, the success of the operation depends entirely upon the effusion of lymph sufficient to produce new tissue in the rings. Of the amount of this effusion we can judge by the soft and fluctuating appearance of the swelling over the seat of our operation, feeling like fluid beneath the folds of a thick rubber bag. AFTER TREATMENT. From six to eight hours after the injection, an increase of temperature, a slight increase of pulse and a feverish condition showing a slight constitutional disturbance will set in and con- tinue usually from three to four days, when it will be found gradually to subside. The patient should have a light liquid diet, and, unless otherwise indicated, should have cold water constantly applied by means of a compress, from be Page 148. heaton's formula. R Fl. Ext. Querci Albae........ § J Solid Ext. Querci Aibae.......gr. xtv Morphl. sulph...........gr. ij M. Sig. Inject 8 to 10 drops. The following formulas I have devised, and find to be the very best for injection : — formula a. For infants and children, whether the hernia be accidental or congenital: — R Fl. Ext. Querci Albae........ S O Reduced by distillation to....... §j Alcohol 70%...........3it Ether, sulph. ............ 3 i Morph. sulph...........gr. ss M. Sig. Inject 8 to 10 drops. FORMULA B. For old and long-standing hernas in adults, whether congenital or acquired, I used the following in my first operations: — R Fl. Ext. Querci Albae........ § fv Reduced by distillation to....... S j Alcohol 90%........... 3m Ether, sulph............ 3 lj Morph. sulph...........gr. ij M. Sig. Inject 10 to 25 drops. FORMULA C. The very best formula, however, which I have ever used is the following. It is the one I now recommend for most cases in the adult person. 372 HERNIA. R Fl. Ext. Querci Albae........ §vt Reduced by distillation to...... § D Alcohol 90%............ SSs Ether, sulph............ 3ij Morph. sulph...........gr. tv Tr. Veratri Viridis......... 3 ij M. Sig. Inject 15 to 20 drops iu small and recent herniae, but 25 to 50 drops in large or old herniae. Of this irritating mixture, we can use a much larger amount than of any other I have ever used, and with more impunity. I have often, during the past year, injected large doses without forming any local suppurations or abscesses. In one case I had a very slight superficial irritation of the size of a pea, such as we often see after the hypodermic injection of fluid extract of ergot. The greatest advantage, however, in the formula is that we get a very marked reduction of pulse and temperature, which often comes on so suddenly that we have to apply a bottle of hot water to the patient's feet. This reduction may last as long as forty-eight hours, thus giving us a decided advantage during the very period in which we most desire to keep down the tempera- ture, and allowing us to gain a more decided local effect of our irritant. It will be readily seen also that nearly all, if not quite all, of the ingredients used are antiseptic in their action ; so that we may claim, in addition to the simplicity and all the other advantages of the subcutaneous method of treating hernia, the peculiar advantages of the antiseptic methods that have been mentioned. 88 Pages 149 and 205. operation by injection. The operation by injection, as described in many text-books of surgery — even the most recent, — has been thus strangely misunderstood. See also page 367. By injecting the hernial rings, the effect is very different from what it would be if the OBSERVATIONS AND OPERATIONS. 373 irritant were introduced into the neck of the sac. In the latter, it would simply act upon opposing serous surfaces and produce an effusion of serum or sero-purulent matter. A portion of such effusion, it is true, might consist of lymph, and cause the opposing surfaces of the sac to unite by adhesions with more or less apparent organization. The persistency of such a result, however, would be very uncertain, and it could scarcely termi- nate in a trustworthy cure of the hernia. For if these adhesions should not soon diminish or disappear by absorption, the protru- sion, if it could not re-enter the old sac, would sooner or later force down a new one through the still undiminished or even gaping fibrous opening. This was long ago pointed out also by Lawrence in his able treatise On Ruptures. On the other hand, the lymph produced by the injection into the rings " has a natural tendency to organize into tissue similar to that which gave it birth, thus thickening by interstitial formation the whole series of fascias, contracting the rings both directly and indirectly." See also pages 129 and 381. 29 Page 157. my new instrument. Being desirous of having a lighter and less complicated instrument for performing the oper- ation of subcutaneous injection, I have devised the instrument here figured. This was made for me by Messrs. Codman & Shurtleff, of Bos- ton, and by Milliken & Down, of London. It is equally as effective as the one figured and de- scribed on page 157, and is not a quarter part Fio. 81. 374 HERNIA. as expensive. In general appearance it is similar to my first syringe (figured on page 144). It has a valve by which we can control the fluid; the head of the needle revolves on a ruby, and a spiral spring upon the piston within the barrel forces the plunger down upon the fluid, ejecting it through the valve. A screw on the piston, similar to that seen on the common hypo- dermic syringe, regulates, with great certainty, the number of drops of fluid we wish to use. This is my latest device, and it is very much lighter, and more fully under control of the operator, than any of my previous instruments. so Page 167. BANDAGES. To facilitate the operation still more, I would present to your attention the following remarks upon bandages, since bandages and compressing pads are a very important factor in obtaining our satisfactory results. It will be found that a strong elastic bandage, or, still better, one of pure rubber, will be of very great advantage in maintaining perfect compression of the parts dur- ing all of the treatment. Such a bandage does not slacken by stretching, as does ordinary cotton or linen cloth. It should not be drawn very tight for the first four or five days. After this time, if the swelling and inflammation be not too great, the bandage may be tightened so as to compress a little more severely, but not enough to give rise to much pain or discomfort. We should always remember that pressure is of the greatest importance in obtaining a successful issue in many operations, and particularly in this operation under consideration. Nothing can equal this rubber bandage for obtaining a firm, but gentle, pressure. This bandage, when pure rubber, should be 6 or 8 feet lone, and 3 or 3 \ inches wide, and of the thickness usually in use. OBSERVATIONS AND OPERATIONS. 375 It can have a tape attached to one end, sufficient in length to pass around the body and be tied above the symphysis pubis in a bow knot. Before applying the bandage I usually apply a thin piece of coarse cotton or linen cloth next the parts, to absorb perspiration and give a more agreeable sensation than the clammy rubber would give. In adjusting this rubber bandage we can, by passing the fingers beneath it, judge the amount of pressure proper to apply. This same equal pressure can be constantly maintained, as we pass the bandage around the body twice or thrice. The elastic webbing is too thick and bungling to be adjusted well, so that I have abandoned its use in these operations. I prefer that the perineal bandage should be made of cotton flannel, as it is much softer than linen. Those who prefer linen, however, will find that a little cotton rolled within it will make it far easier to the patient. The head of this bandage should be fastened over the tro- chanter and brought not too spirally around the hip, and fastened by passing it under the rubber bandage, and bringing the end over to make a loop, that can be pinned in front by the ordinary safety pins. It should not be drawn so tight as to narrow or contract the rubber bandage. A linen napkin, folded so as to be about three or four inches wide and forming a compress about one half an inch in thickness, will be found to make a satisfac- tory compress. 31 Page 210. Another method has been devised and successfully applied to irreducible hernias by my distinguished friend J. Collins Warren, editor of the Boston Medical and Surgical Journal, Instructor of Surgery at the Harvard Medical School and Surgeon at the Massachusetts General Hospital. His plan is to use a "rubber water bag externally inelastic, but containing an elastic lining 376 HERNIA. inclosing a space to which water or air could be admitted by a tube." To this a stout T bandage is sewed to secure it in the scrotum. When once buckled in place, the bag is pressed firmly down upon the pillars of the ring by thick wooden pads. Water may now be forced in at any desired pressure, and con- tinued for any length of time. It is indeed a great improvement over the simple rubber bandage devised by Maisonneuve. If uniformly successful, it will give us a fair prospect of relieving many cases hitherto incurable, except by the more serious opera- tions of herniotomy, because, manifestly, if hernias hitherto irre- ducible may be reduced, they will then be subject to the same conditions of treatment as the reducible. 33 Page 217. M. Seutin, the eminent surgeon of Brussels, made some ex- periments in 1856 to establish the superiority of tearing either the inguinal or crural ring, over the operation of incising the same for the reduction of strangulated hernia. He made experi- ments on the cadaver, and had several succesful cases in prac- tice. He places, first, great reliance on graduated taxis, continued with due precautions, for a considerable period; when this fails, he endeavors to hook his index finger around the margin of the ring by passing it between the tumor and the abdomen; by using a certain amount of force he then causes the fibres of the external oblique to give way and tear to an extent sufficient for the reduction of the hernia. The method is a good one in many cases. The operation for strangulated hernia has been known only since the time of Rousset. Maupasius seems to have been the first to demonstrate its advantages. Aymar and Formi, however, had recourse to it with success in the sixteenth and seventeenth centuries. Up to that period kelotomy had not been performed except for the radical cure of hernia. Fig. 82 —Author's Herniotomy Cape. 1. Golding Bird's Torsion Forceps. 2. Scalpel. 3. Author's Herniotomy Knife 4. Author's Aspirating Needlj. 5. Scissors. 34 Page 221. Giinz, Camper, Louis, Hevermann, Callisen, Bell, and Wilmer paid little attention to the epigastric artery, and said that the fears of surgeons of wounding it in dividing the inguinal ring were vain and ill-founded. Upon this point Bertrandi says, " I can affirm that I have opened the bodies of men who have died a few hours after this operation (speaking of the incision of an incarcerated inguinal hernia), although performed with great facility, dexterity, and quickness, so that the operators thought highly of themselves on that account; and they were quite astonished, and could not comprehend the cause of so unex- pected deaths; but their astonishment ceased when they saw the abdomen full of blood discharged from this artery {epigastric) wounded." On the other hand, surgeons were not ignorant, even before 378 HERNIA. the time of Arnaud, that the incision of Poupart's ligament, to free femoral hernia in the male from strangulation, was a very dangerous operation. They supposed, however, that the danger here was also in injuring the epigastric artery, but Arnaud was the first to point out the important " fact that in the male the spermatic cord passing over the neck of the hernial sac in a semicircular manner, and running immediately behind the mar- gin of the ligament, was much more exposed to the injury than the epigastric artery in either sex." CHAPTER XV. Resume and Clinical Reports. We said in the first edition of this work that we could not then in all truth and candor give so systematic and conclusive results of our operation as we could desire, but hoped to do so in some future edition. From the very many successful cures that have since occurred, both in the author's practice and in the practice of many most trustworthy and conservative gentle- men in the profession, we are confident and happy in saying that we can now give even more favorable reports than we then anticipated even with our most buoyant expectations. If any, however, should prefer some other operative measure rather than the painless subcutaneous injection, he will, I think, find it clearly described in the- preceding pages. I am fully convinced that the grand and essential reason why the injection method succeeds so uniformly in attaining a per- manent cure of hernia, while all other methods have more or less failures, is that it gives us local inflammation about the rings and canal, but no tendency to suppuration. Suppuration, as I have already said, weakens the surrounding- tissues and pre- vents their consolidation. This weakening influence is also seen in the tendency that abscesses in the groin have to produce a relaxation of the fibres about the rings, and consequently a hernia. The reader will remember that in my first two or three cases I did have slight suppurations, and said at the time that 380 HERNIA. I feared the result of the operation would, on that account, not * be a successful one; but from the time that I have used my new combination of fluids, I have had not even incipient signs of suppuration, and therefore I have had uniform success. Just so far as an operation for hernia tends to produce sup- puration, just so far will it be ineffectual in attaining a cure. On the other hand, let inflammation without suppuration be set up, and we shall produce a contraction and consolidation of tissue. The principle of this theory may perhaps be illustrated by the consequences of a burn or scald upon the skin. Wherever the injury has been so severe as to produce suppuration, we do not get a contraction and distortion, but only a deep and smooth cicatrix. Where, on the other hand, we do not have abun- dant suppuration, but only a serous exudation, we get the con- tractions and distortions that require much surgical skill to remove successfully. The same principle, in another phase, is seen in tenotomy; when we have not thoroughly and completely divided the tendons and fascias covering the muscles, we shall be sadly disappointed in the results of our operation, for instead of relieving the traction we have increased it, because we have irritated, and hence inflamed the fibrous structures. The oper- ation for strabismus often fails, too, for the very same reason, — failure to divide the fascias of the muscles. It will thus be made evident that I maintain that the oper- ation for hernia by injection is successful not because it pro- duces tendinous irritation simply, but because it produces both tendinous irritation and local inflammation without suppuration. This is an important distinction, both as regards the theory and also as regards the practical success and permanence of the oper- ation. All other methods have accepted and expected suppura- tion as an accompaniment of the operative procedure, and have not been disappointed when they obtained it. This method avoids suppuration, as it would every other unfavorable complication. RESUME AND CLINICAL REPORTS. 381 Other methods cannot avoid suppuration; this method can and does avoid it, when properly performed, and with the proper fluids. The value of the various antiseptic methods and ligatures in treating hernial protrusions is, then, simply that they make an attempt, however successful, to avoid suppurative inflamma- tion. As regards the fluids that have been used for injection, it may be said that it is altogether probable that many have failed be- cause they were absorbed before they had produced the inflam- mation necessary to produce consolidation. Some have supposed that the chief value of Quercus Alba lay in its power of pro- ducing contraction of the tissues by virtue of its astringent properties. Probably oak bark is specific in its action, but it acts chiefly, not by contracting tissues and blood vessels, although it may do this in a measure, but by refusing to be absorbed readily, and by remaining in the tissues until the stimulation and irritation set up by it, the alcohol, and the ether shall have produced an inflammation that shall compel the tissues to consolidate. This is readily proved by the fact I have often mentioned, that when I have injected the superficial integuments around the rings, the dark appearance and consolidated structure will remain for months, and even years. It also offers an additional reason for " reinforcing " these tissues as I do, to sustain the rings, and act as a constant compress. This specific action is the reason why this operation does not have recidive more frequently. For the benefit of any who wish to perform this operation, the following concluding observations are given. In small hernias or bubonoceles occurring in patients from four to twenty years of age, who otherwise enjoy good health, an injection of iodine, sulphuric ether, alcohol, oak bark, or, as one surgeon writes me, of sulphate of zinc — fifteen grains to the ounce of water — will generally effect a cure, if all the directions 3S2 HERNIA. I have given are carefully followed out in every particular. In very large hernias, or those of long standing, the cure will be more difficult of accomplishment, and we cannot expect a per- manent cure so confidently as in the simpler cases of small and recent hernias. The cure can be accomplished only by impress- ing upon both the patient and ourselves that the action of any fluid we may elect is only the primary step in the operation; remembering that with a stimulating fluid we are hastening, with some degree of certainty, what might take place more slowly under the wearing of a proper truss. See page 321. These large and old hernias may require several injections before we effect a cure. The injections should be repeated once in three to six or eight months, or upon the least signs of any weakening of the parts. As soon after the operation as possible a good truss of steel, or an elastic bandage with proper pads, should be applied. This should be worn constantly while in the upright position. The patient should wear a truss, and remain under our observation for a year or more, and be carefully exam- ined from time to time, so that successive irritation and inflam- mation of the parts may be made, if necessary, either by gentle pressure or by a new injection if needed. If we treat our cases with judgment, taking all possible care and pains, we shall by perseverance be rewarded with the cure of many unpromising cases; but if, according to the method of one operator, we inject only a little fluid, use only a cloth bandage and discharge the patient as cured after a few days have elapsed, we shall be most certainly disappointed. I feel warranted in saying from my experience, that if our operation be successful in keeping up the hernia for a period of six months, we may have great hopes that adhesions have formed so firm and solid that they will, as is shown on page 199, continue to grow more firm and consoli- dated. As I have already said upon page 175,1 have exercised «reat RESUME AND CLINICAL REPORTS. 3S3 care in the selection of my patients; I have not endeavored to see how many cases I could operate upon, but I have all the time been careful to see both how much can be done in the way of effecting a permanent and trustworthy cure of hernia, and how much we can reasonably expect of the method of sub- cutaneous injection in effecting this desired cure. I have there- fore rejected many cases which might possibly have been cured, but upon whom I thought the operation of injection would not be markedly successful. I have done this for three reasons: because some of the patients were aged or in poor health; be- cause others had been ruptured so many years that even with our improved method, mentioned below, we could hardly hope for success; and, finally, because some of the patients did not seem sufficiently intelligent to appreciate the importance of the after-treatment, and the fact that the greater part of our success really depended upon them in obeying our instructions most implicitly. On page 180, I have said that I hoped at some future time to develop a method of operation which should give us a better success in the case of old and large rings which have become fused into one, and which produce little exudation of plastic lymph. I have fulfilled my expectations much better than I then could even hope. In the first place, I can inject much more of my new injecting fluid (see page 372), on account of the tincture of veratrum viride that is in it, while by the strong rubber compress (mentioned under Bandages, page 374) I can keep the parts in close apposition, for a time varying from three to thirty days, until adhesions take place sufficient to bind the fibres of the rings together. In the second place, to persons of great obesity, and to those who have hernias not easily retained, I apply a piece of elastic rubber tubing, some five or six feet long, just below the hips, after the method of Esmarch in his bloodless operations. After tying it tight around the groin, I 384 HERNIA. roll it over the abdomen, pressing upward thereby all loose tissue, together wTith the peritoneum and hernial protrusion, so that they are out of harm's way during the operation. I have found this arrangement convenient both to the patient and to the operator, and it has enabled me to undertake cases with con- fidence that I should previously have rejected or accepted only with hesitation. I have said already many times, and I now finally repeat, that we cannot foretell with certainty what success may attend our efforts to effect a cure; we can only wait upon and assist nature. If, then, we ourselves can only hope, but cannot know what will be the result, it is very unprofessional, and savors of the charlatan, to assure any single one of our patients that we can certainly cure them. On the other hand, it is likewise as unreasonable that patients should expect us to give such posi- tive assurances. No surgeon, even in the operations that have been performed from time, I was about to say, immemorial, would venture to say more than that some operation seemed to be necessary for the patient's happiness, or even life, and that this or that opera- tion in the surgeon's candid opinion was the best one to be em- ployed. Yet in the cure of hernia, patients seem to expect us to " warrant a certain cure without failure;" and, stranger still, physicians of good standing can be found who will not only promise such a cure, but who seem to praise faintly an operation which will not allow of such rash assurances. All of my patients, at least, clearly understand before I operate upon them that this is my position, and that I will never in any case of operative surgery, no matter what it be, guarantee a cure. That, however, I have the greatest confidence in the operation and its value the following cases will show; according to their record, it has been found by actual calculation that 92 per cent of all operated upon have resulted in positive and permanent RESUME AND CLINICAL REPORTS. 385 cures. Out of about one hundred and fifty-six cases reported and well authenticated, there have been only twelve failures. It will be seen that I report only cases of genuine hernia, and that there is no mistake about their character, kind, and severity; so that we may with confidence know just how much reliance to place upon the operation. In my first twenty-nine cases I have already said I had some failures, and on page 199 I have attributed these partial failures to both the imperfect instrument and the crude injecting fluid. In my last cases, out of more than the same number, I have not had a single failure, — unless, possibly, in the case of a physician, upon whom I operated for a very severe case of oblique inguinal hernia, and who was suffering at the time from general debility and dyspepsia. The case was a success at the time of opera- tion, but no very great length of time has since elapsed, so I cannot yet be confident of a permanent cure. In a treatise on hernia like the present one, I cannot think of giving, or even attempting to give, the names of all who are now operating by the injection method, nor a full record of the cases operated on. From the reports I have from the instrument makers, that " they are hard pressed to manufacture my instru- ments fast enough to fill the orders for them," I should judge, however, that the number of medical gentlemen who are now employing the method is no small one, to say the least. Many of them have corresponded with me, and with some of them I am personally acquainted. I mention especially Drs. C. P. Bancroft, of Boston, Mass., W. A. Byrd, of Quincy, 111., H. I. Jones, of Scran ton, Pa., H. S. Greeno, of Kansas City, Missouri, and W. H. Heath, of Buffalo, New York, and know that they have operated successfully by the subcutaneous method. I shall therefore give only a few characteristic cases, first from the practice of Dr. H. S. Greeno, of Kansas City, Missouri, then a few reported by Dr. W. H. Heath, Assistant Surgeon United 386 HERNIA. States Marine Service, attached to the Hospital at Buffalo, N. Y., and shall conclude the list by a few of my own which are deemed the more interesting, taken not in order but at random. CLINICAL REPORT OF CASES OPERATED ON FOR THE CURE OF HERNIA BY THE METHOD OF SUBCUTANE- OUS INJECTION. CASES REPORTED BY DR. H. S. GREENO, OF KANSAS CITY, MO. Mr. J. R. R., Fort Smith, Ark., aged twenty-seven, November 20th, 1879, right inguinal oblique hernia, eleven years' standing; left inguinal oblique, fifteen months' standing. Unable to retain the bowel on right side with truss, and complained of much pain and suffering. Operated November 22d, on right side, with Dr. Heaton's instrument and simple extract of Quercus alba, with usual dressing. December 3d, dressing removed; ex- amination indicated cure. Then operated on the left side, Decem- ber 12th. Removed dressing; found left side solid. In a few days there was a slight protrusion of bowel through internal ring of right side. The patient being unable to remain longer, I in- troduced a few drops of the solution directly into the internal ring. On the third day applied a double elastic spring truss and the patient left for his home, being instructed not to remove the truss for sixty days. Six months after he reported himself cured, having abandoned the truss. Case 5. — J. B., Buffalo, Ark., aged sixty-two, direct inguinal hernia, which he was unable to retain with a truss ; complained of much pain at times. Operated December 15th, 1879. Result partly successful. Operated the second time January 10th, obtaining a perfect cure. Case 9.—Wm. McA., Independence, Mo., age seventv- three, double oblique inguinal hernia, right. side, twenty-one years; left side twelve years. Had worn truss continuously for RESUME AND CLINICAL REPORTS. 387 twenty-one years. . Operated, March 24th, on right side, using fluid as improved by Joseph H. Warren in his work on Hernia, and applied rubber bandage with compress. Usual symptoms followed; third day fever entirely subsided. On the tenth day operated on the left side. Fever and increase of temperature much less than after first operation. On the twenty-first day after first operation, removed the bandage. Had the patient stand up and cough, and let him walk about as much as he felt able. Found a very slight tumor on internal ring on right side. Applied a double elastic spring truss to be worn a month. I did not deem it necessary to operate the second time, trusting to the continuous wearing of the truss to complete a cure. At the present time the patient is perfectly cured of both hernias. Case 11. — J. W. J., Kansas City, Mo., brought to me his little daughter, aged eleven, having right inguinal hernia of six years' standing. Operated March 26th, 1880 ; cure perfect. Case 14. — Mr. C, Kansas City, Mo., aged forty, left oblique inguinal hernia, eleven years' standing. The hernial opening was very large, and the protrusion could not be retained with a truss. Operated with Dr. Warren's instrument and fluid, sub- stituting for the bandage a double elastic spring truss, after re- moving the wooden pads, and supplying their places with muslin folded to many thicknesses. This I found more convenient than a bandage. The elastic belt, broad front pad, and perfectly adjustable thigh straps have proved all that may be desired as a dressing, and is worn with as much comfort after the operation as any truss or bandage I have been able to procure. Case 15. — Mr. E., Kansas, aged twenty-five, umbilical hernia of recent standing; operated April 15th, 1880. Case 16. —Mrs. B., Fort Smith, Ark., aged fifty-six, left fem- oral hernia, six years' standing. A large and irreducible tumor, which I diagnosed as omental, and which, after several trials, I 388 HERNIA succeeded in reducing. I then operated for radical cure, with satisfactory results. Case 17. —Mr. McD., Kansas City, Mo., aged thirty-six, oblique inguinal hernia of right side of sixteen years' standing. Operated April 24th, 1881 ; successful. Case 18. — Mr. C, Iowa, aged thirty-two, left inguinal hernia, twelve years' standing. Operated May 2d, 1880. On the twelfth day patient returned home cured. Case 20. — Dr. W., Kansas City, Mo., right inguinal hernia, nine years' standing. Operated May 20th, 1880, obtaining a cure. Case 30. — Mr. C. S., Kansas City, Mo., child, four and a half years old, congenital scrotal hernia right side. Operated August 23d ; cure complete. Wears no truss. Case 31. — Mr. D., Kansas City, Mo., boy, eleven years old, direct inguinal hernia on right side. Bowel had descended into scrotum; parts were swollen, and I had much trouble in return- ing the hernia. Operated August 24th. Case 33. — Mr. McQ., Ottona, Kansas, aged forty, right ob- lique inguinal hernia ; operated August 25th, 1880. Patient returned home on the fifth day, refusing to remain longer. The inflammation was very slight, and there was no fever. This case was not cured, owing to the very slight disturbance produced by the operation and the patient's refusal to comply with my instructions. Case 34. — Mrs. D., Kansas, right oblique inguinal hernia, twelve years' standing. Patient had an excess of adipose tissue. Opening quite large and hernia retained with much difficulty. Operated August 28th. Eight days after, in spite of all I could do to the contrary, my patient would return to her home, some two hundred miles from the city. I expressed my fears that the cure might not be complete without another operation. She promised to return after a few months if the operation did not prove suc- cessful. Several months after, I received a letter from her RESUME AND CLINICAL REPORTS. 389 claiming that she was not cured, and censuring me quite severely for not having made a cure. Such failures will occur in every surgeon's practice, but cannot be attributed to any fault in the operation or operator. Case 36. — Mr. W., Kansas City, Mo., aged fifty-two, right oblique inguinal hernia. Operated August 28th, 1880 ; cure perfect. Case 40. — F. S. H., Lawrence, Kansas, aged twenty-eight, direct inguinal hernia on right side, rings very large and could not be retained with a truss ; bowel descended into scrotum, and was a source of great annoyance. After a second operation, the patient was discharged cured. Case 51. — Air. E. T. P., Kansas City, aged fifty-six, inguinal hernia of fifteen years' standing. Operated January 3d, 1881, ob- taining a permanent cure. Case 53. — Mr. B., Lawrence, Kansas, son, four and'a half years old, congenital hernia of left side. Injected dilute extract of quercus alba ; this operation failed. Six weeks after, 1 injected a stronger solution, using more care in the after treatment. From present indications I have no doubt as to the cure. Case 85. — Mr. H. H., Ellis, Kansas, aged fifty-six, double inguinal hernia, right side, sixteen years ; left side, eight years. Twelve years before, the bowel on the right side descended into scrotum, since which it has been impossible to retain it with any appliance. Bowel remained almost constantly in the scrotum. The tumor was as large as a new-born infant's head. When reclining, the hernia could be reduced with much difficulty ; but on resuming an erect position, the bowel would, to use the language of my patient, " shoot out" in spite of all efforts to retain it. The left side was not quite so bad. His condition was truly deplorable. He suffered much pain, and experienced a dragging sensation upon the stomach, spleen, and diaphragm. After moving the bowels freely with oil the day previous, I 390 HERNIA. operated May 22d, 1881. I found the sac on the right side ad- herent, and it was impossible to reduce it by any amount of manipulation. There was much thickening of the walls of the sac, so in this case it was quite out of the question to pass a needle into the rings without penetrating the sac. Either the knife must be used and the sac must be dissected away and returned within the cavity of the abdomen, or the irritant be deposited within the walls of the sac. The patient was deter- mined to submit to an operation, life to him being intolerable in his present condition. I therefore disregarded the sac, and passed the needle through it as near the upper margin of the ring as possible, depositing at least thirty drops of the irritant within the ring, taking care that the fluid should be well dis- tributed. Used wet compress and usual dressing. The inflam- mation was greater than in any other previous case, and the fever continued until the fourth day before declining. By the sixth day fever was absent and inflammation rapidly subsided. On the twelfth day, removed dressing; patient stood up and walked around, there being no protrusion of bowel. I then operated on left side. Sac was readily reduced. Had no trouble in introducing the needle; injected fifteen drops of fluid. Eight days after, and twenty days after first operation, removed the dressing and found the parts solid. Coughing and straining had no effect on the hernias on either side. On the twenty-fifth day, patient returned home perfectly cured and much elated. Case 86. — Mr. J. W. H., Baldwin City, Kansas, aged nine- teen, direct hernia on left side; twenty-four years old. Had varicocele and could not wear a truss. Operated May 27th, 1881. Inflammation quite severe, with much soreness. Pulse 110, but declined on third day. Case discharged cured on the tenth day. Mrs. B., Texas, aged fifty-two, irreducible femoral hernia on right side, had been irreducible for six years ; wore a truss with RESUME" AND CLINICAL REPORTS. 391 great inconvenience, and more or less pain. The tumor was about the size of a small hen's egg; it was impossible to reduce it by taxis, although I made several efforts at different times, and I concluded to operate with the knife. Contents of the tumor were omental. I was obliged to remove a portion of this before I could return it into the cavity of the abdomen. I followed Dr. Heaton's suggestion of not ligating the neck of the protruding mass before removing it. The hemorrhage was slight and easily controlled by compress. This case gave me but little trouble, and the recovery was perfect, although at one time I had fears of secondary hemorrhage, and fully made up my mind that should I ever again amputate a portion of the omentum I should first ligate the neck. Six months after the patient returned home, she wrote me that she was perfectly cured. To sum up my cases, I submit the following, which is really as near the facts as it has been possible for me to obtain knowl- edge. Some of my cases have failed to answer letters of inquiry addressed to them, which I take as a very good indication that they are satisfied with their treatment, or I should hear from them. Total number of cases operated on . . 97 Cases reported cured.......91—93.81 Failures...........6— 6.19 100. Number reported who have abandoned the use of trusses.......56 The failures were of my first cases, and were mainly from my neglect in carrying out details and giving proper attention to after treatment. I have had no failures lately, and do not now expect any in the future, as I confine myself to Dr. Warren's improved instrument and more stimulating fluid. 392 HERNIA. CASES REPORTED BY DR. W. H. HEATH, OF BUFFALO, N. Y., ASSISTANT SURGEON, UNITED STATES MARINE HOSPITAL SER- VICE. Case 1. — The irritant wTas deposited by accident in the areolar tissue around the cord, which from pressure of the her- nia had been spread out and displaced almost beyond recogni- tion. This accident resulted in the formation of an indurated mass, occupying the site of the cord, and apparently very indo- lent ; later it became larger with fluctuation, and was tapped, yielding two ounces of clear fluid. A second enlargement oc- curred, and pus was found and withdrawn. At this period, the mass was very tender and disposed to inflame, but did not; the patient left soon after with this indurated mass (about the size of an egg) occupying that region, and resumed his work as a laborer. He was a stupid, middle-aged Irishman, that had been sent to me, and had Bright's disease, which fact I was not informed of until afterwards. Singular to say, the hernia has not since de- scended, the mass evidently blocking the way, in part at least. Case 2. — G. P., aged thirty-two years, native of France, was admitted with acute bronchitis. An oblique reducible inguinal hernia was discerned of some seventeen years' duration. He consented to an operation reluctantly, and the result was a fail- ure. The ring was comparatively large and patulous, and should have had a second wetting with the fluid ; but he would not give his consent. He contributed nothing himself to aid in a successful issue in the way of lying on his back, and keeping quiet, and prognosticated in advance, that it was impossible to cure him ; and he did n't care, etc. I think this had something to do with the result. Case 3.— E. C, sixty-one years, native of Canada, with a double reducible inguinal hernia of twenty-three years' standing, came in to have one side operated upon, and, if successful, would return RESUME AND CLINICAL REPORTS. 393 in the fall to have the other side operated upon. Left hospital apparently cured, and promised to let me know by mail if it descended again. I have not heard from him since. He was under my observation eight weeks, having been detained in the hospital with neuralgia and some abdominal trouble. Dr. Heath says, " I think it requires more care than would at first appear, and is one of the most rational of the many methods advised. I am firmly of the opinion that it is a step in the rioht direction." Simple as it all appears, it requires considerable care and dexterity; the cord, which must be pushed aside, may be dis- placed and in part overlie the sac, which may itself be irredu- cible. The direction of the canal and position of internal ring changed, the possibility of transfixing one of the pillars, wound- ing the cord, or entering the abdominal cavity, are all to be remembered and avoided. The attention to every detail in oper- ating, adjusting the compress and bandage, and the after-care are so important as to largely determine the result in most cases. An hour or so, therefore, in the dissecting-room, with a long needle, would not be misspent, but would aid to familiarize a beginner with the points most important to find, or as far as possible, to avoid. This method I have resorted to twelve times with one failure (I believe due entirely to a nurse's carelessness), and one acci- dent where I deposited the irritant in the areolar tissue of the cord, which from pressure of the liernia had been spread out and displaced, almost beyond recognition. Nine of the cases I con- sider permanently cured, and two are yet under observation in my wards. All the cases were of the oblique reducible inguinal variety, eight of five years' standing, one of seventeen years', one of twelve years', two over ten years'. In no case did I observe a single bad symptom, elevation of temperature, or pulse rate, and but little, if any, of what may 394 HERNIA. properly be termed suffering; and, with the exception mentioned, every case left my hands, after keeping them as long as I could, apparently cured. I say "apparently cured," because the standing argument against the permanency of the result at once is raised; and I cannot say positively, beyond peradventure, that they are permanently cured, for they are beyond my observation now. Two of the men I had the good fortune to see and examine some six months after, and in both the inguinal canal was closed per- fectly, and the protrusion had never appeared since leaving the hospital. One of them had subjected his case to a pretty severe test, having worked as coal-heaver on a southern steamer ever since. I do not recall what kind of work the other had been engaged in; but, as he was an ordinary sailor, I do not doubt the radical cure was strongly tested. CASES REPORTED BY THE AUTHOR. Case . — Mr. M., aged twenty-eight, direct inguinal hernia on right side for five years. Could not bear a truss on account of the tenderness of the parts. Operated October, 1879, using fifteen drops of Formula B. For six or eight hours after the in- jection, he had fever and increase of temperature to 99, pulse 80. This subsided to normal on the following day. The parts oper- ated on were considerably swollen, and for three days compresses of cold water were applied externally and one eighth of a grain of morphia given internally once every six hours. On the eighth day, an active cathartic was administered. The opening, which before would admit the ends of two fingers, was now fully oc- cluded. Several medical gentlemen saw the case both before and after operation. July, 1881, he is still free from hernia, and can go without his truss. Case . — Mr. J., aged thirty, oblique inguinal hernia on right side extending into scrotum. It had existed for six years. The opening in the rings was one inch by three quarters of an RESUME AND CLINICAL REPORTS. 395 inch. Operated on him December, 1879, with fifteen drops of Formula B. The inflammation was sharp, and extended up as high as the crest of the ileum. There was some increase of tem- perature for about four days, but on the seventh day the bowels were moved by a laxative and a truss applied. On the twelfth day he was discharged, cured of his hernia. I have no report from the patient himself, but have heard elsewhere that he is still free from his hernia. Case . — Mr. M. J., aged sixty, large oblique inguinal hernia on right side extending into scrotum. It had become strangulated. It came on while stepping down from the side- walk, and the first noticeable symptom was pain and smarting in the umbilical region, together with considerable nausea. As he had been suffering for some time from indigestion, he did not think very much of it at the time. But the pain began to grow in- tense, the action of the heart became feeble, and beads of cold sweat stood upon his neck and forehead. I succeeded, in De- cember, 1879, after considerable difficulty, in reducing the pro- trusion by taxis, and on the following day the tenderness and swelling of testicle had so .far abated that I operated by the sub- cutaneous method, injecting ten to fifteen drops of Formula C. There was but little increase of temperature after the operation, but a smart local inflammation around the cord and rings. His extremities felt so cold that hot applications were made to them. In three weeks' time he returned to his office, wearing a com- press, which he afterward changed for a light truss. After wearing this for a few months he abandoned it, and is now with- out any support. Case . — Mr. M., aged thirty-two, oblique inguinal hernia on right side of five years' duration, caused by rowing. Protru- sion very slight. Operated March, 1880, injecting fifteen drops of Formula B. Fever very slight, and continuing three days; temperature 99, accompanied by active inflammation about the 396 HERNIA. rings. The opening in the external ring was three quarters of an inch by five eighths of an inch. It was an irritable hernia, the truss by its pressure causing pain and tenderness through all the parts, so that it could not be worn conveniently. On the fifth day, the bowels were moved by a mild laxative. On the tenth day, he was discharged, wearing a compress and bandage. He wore a truss for six months, but has been able to go without truss or support of any kind for about a year, with no signs of return of hernia. Case . — Mr. H., aged thirty-two, direct inguinal hernia on left side, caused by exertions as a fireman. Operated by the subcutaneous method April 8th, 1880. Protrusion very large and prominent. Opening in rings, three quarters of an inch by one inch, running to a sharp point at both ends, or diamond-shaped with greatest diameter longitudinally. Injected twenty drops of Formula B. We had an abundant effusion of plastic lymph and a perfect occlusion of the rings. He suffered but little general fever, and hardly any increase of temperature, but had an intense soreness about the rings, and a prominent swelling, which began on the second day and lasted until the sixth. On the seventh, a mild laxative moved the bowels, and on the tenth day, he was discharged cured, wearing a truss of very gentle pressure. He wore it for eight months, and since then has been without any support. Case . — Mr. D., aged forty, double inguinal hernia, oblique on left side and direct on the right. Been ruptured fifteen years. The ring on left side was one inch by three quarters of an inch. The right ring was one half inch by five eighths. Pro- trusion when in erect position was very slight on right side, but large on the left side. Operated October, 1880, assisted by Drs. H. 0. Marcy and Bancroft of Boston, and my Assistant, Willard E. Smith, Medical Student. I used Formula B, which contained a little less ether and alcohol and a little more of the Fl. Ext. of RESUME AND CLINICAL REPORTS. 397 Oak Bark. On the seventh day, the bowels were moved by in- jection ; the swelling and inflammation, which was active on both sides, had fully subsided; on the twelfth day he was al- lowed to rise from bed and be "about the house," wearing a bandage and compress. Both rings were perfectly occluded and the hernias well retained. On the fifteenth day, a small super- ficial abscess, like that seen after the injection of ergot, appeared on the right side. This did not extend deeper than the super- ficial integuments. It was thought to be caused by too severe pressure of the perineal band, and it annoyed him for two or three weeks by discharging a sero-sanguineous fluid. A light double truss was then ordered, and he resumed his occupation as a finisher of microscopes. On June 30th, 1881, I examined him. He is free from hernias, and can go without his truss. Case . — Mrs. T., aged thirty-five, large femoral hernia on right side. It had been strangulated some six weeks previous to the time when I saw her. Her physician was Dr. A. L. Nor- ris, of Cambridge, Mass., who had succeeded in reducing it by taxis after great efforts. He was assisted by Dr. D. M. Edgerly, of the same city. I operated by subcutaneous method in Jan- uary, 1881, using from fifteen to twenty drops of Formula C. I was assisted by Drs. Norris and Edgerly, and by Dr. E. L. White, of Somerville. The temperature never rose to 100, as I was informed by Dr. Norris, under whose care I had left her. The injection set up in the femoral canal an active inflammation, which lasted for about a week. On the fifteenth day from the time of operating she was discharged, perfectly cured of her hernia, and was ordered to wear an elastic bandage with a sole- leather pad in front, shaped like an abdominal supporter. This apparatus was devised by a gentleman who himself has suffered from hernia. I have found it very effective to apply after these operations, while the parts are sensitive, and do not bear well the compression of an ordinary spring truss. It has the addi- 398 HERNIA. tional advantage that it can be worn night and day without dis- comfort. On July 6th, 1881, I examined her in company with Dr. Norris, and found that she still remained free from her hernia. I would say that Dr. Norris caused the patient to cough, and bear down, and make other efforts, which satisfied us of the perfect retention and cure of the hernia. Owing to her excessively large and broad hips, I thought it would be safe for her to continue to wear the support until autumn, when she could abandon it. Case . — Mrs. E., aged fifty-five, ruptured at childbirth, thirty-three years ago. Very large umbilical hernia. The size of the opening was two inches by an inch and a quarter, and was of a long oval shape; the lower portion extended down into the rectus muscle. The umbilical dimple had entirely disap- peared on account of the enormous protrusion, which in the erect position was nearly as large as the head of a child a year old. Operated by the subcutaneous method February, 1881, assisted by my son, C. Everett Warren. I used nearly a drachm of Formula C. I made my puncture just to one side of the centre of the umbilical cicatrix and below it, sweeping- my needle around and distributing my fluid well on the outer edge of the umbilical ring. For the first forty-eight hours the temperature and pulse were normal. At the time of operation the pulse had been reduced from 70 to 55, and it was found necessary to apply hot applica- tions to the feet. On the third, fourth, fifth, and sixth days the pulse stood at 80, and the temperature at 99. She had a pretty smart local inflammation, and complained of considerable pain in the back, owing, probably, to the constrained position of lyino- upon it. There was very great curvature of the dorsal and lumbar portion of the spine, so that a large pillow could be in- serted under the small of her back easily; thus her abdomen was thrown forward and presented a very prominent appearance. RESUME AND CLINICAL REPORTS. 399 She was very large, and weighed about one hundred and eighty pounds. She continued restless after the second night; morphine was given, but this producing nausea, we then gave her bromide of potassium, which seemed to be sufficient to produce the desired rest and sleep. On the eighth day the bowels were moved by a slight laxative, and the patient was allowed to sit up in bed and to lie on her side. The local swelling and inflammation extended in a circu- lar direction, with a radius of seven or eight inches. Compresses of cold water were applied, and on the tenth day the swelling- had so far subsided that we could pass a rubber band three inches wide twice around her body, giving us an equal pressure. This compress was continued for four or five days. It was applied over the linen bandage which had already been put on. At the expiration of this time, sufficient exudation had taken place, and the vast umbilical ring was found to be fully occluded and the former hernial protrusion entirely retained. This exu- dation and inflammation caused a thickening of the integuments, which lasted for three or four weeks. As it gradually shrunk and contracted, the original umbilical cicatrix again made its appearance, and she has to-day as perfect an umbilical dimple as she had when a babe. She is now (July 1, 1881) able to go without any truss or bandage, and I, together with her, feel as confident that she is as perfectly free from her hernia as she was before her rupture. Entertaining such confidence, she is to spend her summer among the White Mountains, going without any support whatever. She regrets very much that she did not have a photograph of the hernia taken, to show the contrast between her condition then and her normal condition now. It will be seen that this protrusion was one of the largest of this variety that we meet. I fully expected to have to inject several times before attaining the desired result, but by taking great pains and care at the time of operating, by distributing the 400 HERNIA. fluid as equally as possible all around the ring, I succeeded be- yond my expectations in making a radical and complete cure by a single injection. Case . — Mr. H., aged thirty-five, oblique inguinal hernia on left side of two or three years' standing. Operated in April, 1881, with the assistance of Dr. B. 0. Kinnear, of Boston, and Mr. Cox, medical student. I injected of Formula C, twenty drops. The hernial opening was very long and irregular oval, one inch by one half inch, the pillars on the outer side seem- ingly torn. For the first four days he had slight increase of pulse and temperature, the latter being 98.5, and never extend- ing over 99. On the fifth and sixth days a swelling of two fingers' breadth over the external oblique, extended from the seat of operation up to the crest of the ileum. This swelling gradually subsided, leaving a hard, cord-like feeling, which diminished slowly, but which will remain for a number of months or even years. It will give him no trouble, but will be of great assist- ance in closing the rings and retaining the hernia. I presume it was caused at the time of operation by a small stream from the instrument escaping upon the surface of the muscle as I withdrew my instrument. I can account for it in no other way. There was no other complication, and the case made a remarkably rapid recovery. So perfect was this, that, with the support of the elastic truss which I have before mentioned, he visited Cape Breton Island, and told me that he went over mountains and valleys, and waded through streams. After returning home, he lifted seven hundred pounds in weight in the office of the doctor who had assisted me, and then called upon me to show that the operation was a perfect success, and that he was cured from hernia. When we consider that all this was done within the brief space of one month after the time of my operation, it seems almost like a fairy tale, and would be hard to believe, if it were not well RESUME AND CLINICAL REPORTS. 401 authenticated by the physician in whose office he lifted the weight. I myself had some reasonable doubts that such a thing could be possible, but on asking the physician found that the feat had really been performed. I think the reader will agree with me in assuring the man that he is permanently cured of his hernia. Case . — Dr. H., aged fifty-nine, oblique inguinal hernia on right side. Has existed more than two years. The hernia was prevented from descending into the scrotum with great diffi- culty and by means of a truss. Operated by the subcutaneous injection in April, 1881, using Formula C, assisted by Drs. Daniel Chaplin and son, of Bridgewater, Mass. The operation was not very painful, Dr. H. said, but the smarting of the injected fluid was " liquid fire for a minute or two." This soon subsided, leaving a throbbing sensation in the parts, which gradually passed away. The opening at the ring was about an inch and a half long by five eighths wide, and was long and irregularly oval. He had little constitutional disturbance except a rapid reduction of the action of the heart, and cold extremities to which hot bottles were applied. He was slightly feverish for four or five days, with considerable tenderness about the parts operated upon. The greatest suffering was from the constrained position of lying on his back and from considerable flatus of the bowels. For the latter he ate freely of "ginger snaps," with sufficient morphine at night to cause rest. He was able to be up on the eighth or ninth day, with a perfect retention of the hernia. An elastic truss was applied, which he is still wearing. Case . — Mr. W., aged twenty-one, oblique inguinal hernia on right side. Patient sent to me by Dr. G. W. Bullard, 01 Vermont. Operated June, 1881, using of Formula C, about ten or twelve drops. The sensation of smarting was very sharp for four or five minutes. The temperature never rose to 100, nor the pulse above 88. The local inflammation and soreness 402 HERNIA. were considerable; they were increased by my reinforcement of the external integuments, which left a prominent swelling at the time of his discharge, some twelve days after the operation. The rings were occluded and the hernia well retained. He was ordered to wear a truss for six months. One thing I notice in hernia of short duration is, that the smarting from the injected fluid is more intense, and that the amount of fluid necessary is smaller than in cases of longer standing. Case . — Mr. L., aged twenty-three, direct inguinal hernia for five years. Operated June, 1881, by injecting twelve to fifteen drops of Formula C. He passed through the usual phases, with the exception that his attendant, Dr. Stevens, of North Cambridge, was obliged to draw his urine for two days. On July 1, 1881, I found the rings firmly united, and the hernia retained. BIBLIOGRAPHY. « BIBLIOGRAPHY OF HERNIA. A. Abeknethy, J. J. Inguinal Hernia. Amer. Journal Med. Sciences. Vol. XL, p. 31. 1832. Acret, G. S. Treatise on Hernia. London, 1835. Agnew, D. Hayes. Surgery. Last Edition. Albers, J. F. H. Pathologische Anat. Albinus. Tab. Muscul. Anderson, TV. System of Surg. Anat. 1822. Arnaud. On Hernias. 1748. Mem. de Cliir. Paris, 1743. Observations sur plusieurs Hernies. Atlee, W. F. Case of Strangulated Hernia. Amer. Journal Med. Sciences. Vol. XXXVIL, N. S., p. 275. 1859. B- Balfour. New Mode of Taxis in Med. and Phys. Journal. November, 1824. Bell, B. System of Surgery. Vol. I. Bell, C. Surgical Observations. Part II. London, 1816. Benevoli. Dissertazioni Cliir. Tomo I. Bernard, Claude. Medecirte Operatoire. 1866. Bertrandi. Traite des Operations. Tomes I. et II. Bicliat, X. Anat. Generale. Paris, 1830. Bigelow, II. J. Inguinal Hernia (injection). Boston Med. and Surg. Jour- nal. Vol. XLIII., p. 339. 1S50. Billard, C. De la Membrane Muqueuse Gastro-Intestinal. Paris, 1825. Birkett, John. In Holmes's Surgery. 2d Ed. Vol. IV. Blackmail, G. A. Wurtzer's Operation. Amer. Journal Med. Sciences. Vol. XXXIV., N. S., p. 292. 1857- 406 HERNIA. Blackman, G. P. Reduction of Strangulated Hernia "en masse." Amer. Journal Med. Sciences, Vol. XIL, N. S., p. 336, 1846; N. Y. Journal of Med., Vol. V., p. 367, 1850. Blasius, Ernst. Akiurgische Abbildungen. Berlin, 1844. Blegny. L'Art de guerir des Hernies. Paris, 1676. Boch, C. E. Anat. des Menschen. Berlin, 1871. Boehmer. De Herniis Abdominalibus. 1780. Bonnet. De la Cure Radicale des Hernies. Paris, 1839. Bose. Animadvers. de Hern. Inguin. Bourgeryet Jacob. Traite Complet de l'Anatomie del'Homme. Paris, 1830. Braithwaite's Retrospect. Brendelius. De Herniarum Natalibus. Breschet, G. Considerations sur la Hernie Femorale. Brugnone. Dissert, de Test, in Foetu posit. Briininghausen, H. J. Unterrich iiber die Briiche, etc. Wurzburg, 1S11. Bryant, Henry. Boylston Prize Essay. 1847. Bryant, Thomas. Analysis of 126 Cases of Hernia followed by Death. Guy's Reports, 1856. Vol. II. Clinical Surgery. Part III, Practice of Surgery. Vol I. Butcher, Rich. G. Oper. and Conserv. Surgery. C. Callender, Geo. W. Anatomy of Femoral Hernia. London, 1863. Campbell, H. F. Strangulated Ventral Hernia. Southern Med. and Surg. Journal. Vol. XIII., N. S., p. 131. 1857. Camper. Demon. Anat. Path. 1760. Camper. Icones Herniarum. Carroll, T. Vaginal Rectocele and Vaginal Hernia. Western Lancet. Vol. XVII., p. 321. 1S56. Chadwick, James R. Rare Forms of Umbilical Hernia in the Fetus. Re- print from Vol. I. Gynecological Transactions. Boston, 1876. Chancellor, C. TV. Diaphragmatic Hernia. Amer. Journal Med. Sciences. Vol. XXX., N. S., p. 404. 1855. Chase, Heber. Treatise on the Radical Cure of Hernia by Instruments. Phil, 1836. Final Report of the Com. of the Phil. Med. Soc. on the Construction of Instruments, etc. Phil., 1837. Cheever, D. W. Clin. Lect. in Bost. Med. and Surg. Journal. July, 1866. Chopart. Traite des Malad. Chir. Tome I. Chopart et Desault. Parisian Surg. Journal. Clark, J. C. Strangulated Crural Hernia. Western Lancet. Vol. XIL, p. 613. 1852. BIBLIOGRAPHY. 407 Cloquet, J. Recherclies Anatomiques sur les Hermes. 1S17. Colles, A. Treatise on Surgical Anatomy. Part I. Cooper, Astley. The Anatomy and Surgical Treatment of Abdominal Hernia. Anatomical and Surgical Treatment of Inguinal and Congenital Hernia. Folio. London, 1804. The Anatomical and Surgical Treatment of Crural and Umbilical Hernia. 1807. Cooper, Sam. Surgical Dictionary. 8th Ed. Curling. T. B. Practical Treatise on Diseases of Testis. London, 1S43. Czerny, V. Beitrage zur operativen Chirurgie. Stuttgart, 1878. D. Da Costa, J. M. Medical Diagnosis. Darling, W. Essentials of Anat. 1880. Darrah, William E. Drawings of the Anatomy of the Groin. Folio. Phil., 1830. Delorme, R. Diet, de Med. XV. Demaux, De. L'Evolution du Sac Hernaire. Ann. de la Chir. Francaise etrangere. 1842. Tome V. Desault. ffiuvres Chir. Par Bicliat. Tome II. Traite des Malad. Chirurg. Tome I. Dieffenbach's Opei*ative Chirurgie. Band II., p. 621. Dionis. Cours d'Operations. 1777. Divoux. Disp. de Hernia Vesicae. 1732. Dowell, G. On Hernia. Dufour, W. Treatise on Hernia. 1819. Dupuytren. Clin. Chir. Tome I. Consid. et Obs. Anat. sur la Hernie Fern. E. Edin. Med. and Surg. Journal. Vol. III., p. 240 : Vol. IX., p. 159. Elder, G. Notes on Three Successful Cases of Herniotomy. London Lancet, 1S78, 11, 657. Erichsen's Surgery. Edited by Brinton. F. Fahnestock, P. Strangulated Umbilical Hernia. Amer. Journal Med. Sci- ence. Vol. XVII., p. 368. 1835. Fielitz. Ein Darm- und Xctzbauchbruch. Fletcher, R. Medico-Chir. Notes and Illus. London, 1S31. 408 HERNIA. Folsom, N. L. Strangulated Umbilical Hernia. Boston Med. and Surg. Journal. Vol. XLIX., p. 317. 1853. Franco, P. Traite des Hernies, etc. Lyons, 1561. Fried, G. A. De Foetus Intestinis. 1760. G. Gant. Science and Practice of Surgery. Garengeot. Oper. Chir. Tome I. Sur plusieurs Hernies Siugulieres. Mem. de l'Acad. de Chir. 1743. Tomes I. et II. Gay, John. On Hernia. 1848. Geoghegan, Edw. Commentary on Ruptures. 1810. Gerdy. Cure Radicale de la Hernie par Invagination. Gerdy, P. N. Remarques et Observations sur les Hernies. Arch. Gen. de Med. 1836. 2 Serie. Tome X. Gibson, W. Institutes and Practice of Surgery. Gibson, C. B. Strangulated Scrotal Hernia. Stethoscope. Vol. II., p. 139. 1852. Gimbemat. Account of a New Method of Operating for Femoral Hernia. Trans, from Spanish by Beddoes, 1795. Germ, trans., 1817. Goldschmidt. Practische Erfahrungen iiber die Behaudlung und Heilung der Unterleibs-Briiche. Gooch. Chirurgical Works. Vol. II. Goursaiid. Sur la Difference des Causes de l'Etranglement des Hernies. Mem. de l'Acad. de Cliir. Tome IV. Goyrand. Sur les Hernies des Enfants. Presse Med., 1837. Cliuique Chir., Paris, 1871. Gray, Henry. Anat. Descrip. and Surg. Gross, S. D. System of Surgery. Vol. II. Guerin, Alphonse. Elem. de Chir. 1864. Guerin, J. Cure Radicale des Heruies par la Methode sous-cntanee. Ann. de Cliir. Francaise et Etrangere. Paris, 1812. Tome V. Gunthris. Lehre v. d. Blutigen Operationen. Guntz, J. G. Observationes Anatomicse-Chirurgicse de Herniis. Libellus. Leipsic, 1744. Prolusio Invitatoria in qua de Entero-Epiplocele agebat. Leipsic, 1746. Guthrie, G. J. On Inguinal and Femoral Hernias. London, 1833. Guy's Hospital Reports. 1842, Vol. VII.; 1856; 1861; 1841, Vol. VI., p. 232. BIBLIOGRAPHY. 409 H. Hahn, J. Strangulated Femoral. Phil. Med. Museum. Vol. IV., p. 26. 1808. Haller. Disput. Chir. Tome III. Opera Minora. Opuscula Patholog. Hamilton, F. H. Case of Hernia. Boston Med. and Surg. Journal. Vol. XXV., p. 57. 1841. Ilammen. De Herniis. Sugd., 1581. Hancock, Henry. Operation for Strang. Hernia. London, 1850. Hancock, H. Remarks on Hernia and Diseases simulating it. London Med. Times, 1878, 11, 514; 543 ; 597. Harris, S. D. Strangulated Hernia. Charleston Med. Journal. Vol. VII., p. 19. 1852. Heath. Lancet. 1857. Vol. II., p. 109. Heaton, George. The Cure of Rupture. Edited by J. Henry Davenport. Boston, 1877. Heaton, G. Strangulated Femoral Hernia. Boston Med. and Surg. Journal. Vol. XXX., p. 35. 1844. Heister. Instit. Chirurg. et de Hernia Incarcerata Suppurata non semper Lethali. Hesselbach, F. C. Disquisitiones Anatomico-pathologicse de Ortu et Pro- gressu Herniarum Inguinalium et Cruralium. Wiirzburg, 1S16. The original edition was published in 1806. Beschreibung und Abbildung eines neuen Instrumentes zur sichern En- deckung und Stillung einer beidem Bruchschnitte entstandenen ge- fahrlichen Blutung. 1815. Die sicherste Art der Briichschnittes in der Leiste. 1S19. Ueber den Ursprung und das Fortschreiten der Leisten- und Schenkel- briiche. Wiirzburg, 1814. Heverman. Chir. Operat. Band I. Hevin. Pathol, et Therap. Hewett, P. Med. Chir. Trans. 1844. Hewson, T. S. Strangulated Umbilical Hernia. Amer. Med. Record. VoL XL, p. 106. 1827. Hey and Leeds. Infantile Hernia. Hey's Practical Observations. 3d Ed. Hildanus, F. Cent. 5, Obs. 54. Disputationes Chir. De Herniis Congenitis. 1749. Herniarum Adnotationes. 1755. 410 HERNIA. Hilton. Med.-Chir. Trans. Vol. XXXL, p. 323. History of the Rebellion, United States of America. Surgical Vol. Part II. Hitchcock, A. Strangulated Hernias. Boston Med. and Surg. Journal. Vol. XLV., p. 89. 1851. Hoin. Essai sur les Hernies rares et peu Connues. 1767. Holmes, Timothy. System of Surgery. Vol. IV. Howship's Practical Remarks on the Discrimination and Appearances of Sur- gical Disease. 1840. Huestis, J. W. Strangulated Umbilical Hernia. Amer. Journal Med. Sci- ences. Vol. XVI., p. 380. 1835. Huette, Ch. Medecine Operatoire. 1866. Hull, G. A. Nature of Hernias. N. Y. Med. and Phys. Journal. Vol. IV., p. 435. 1825. Hunter, John. Works edited by Palmer. Hunter, W. Med. Comment. 1762. Hutchinson. London Hospital Report. 1865. J. Jacob et Bourgery. Traite Complet de I'Anatomie de I'Homme. Paris, 1830. Jalade-Lafond. Considerations sur les Hernies Abdominales, sur les Ban- dages. Paris, 1832. Memoire sur une Nouvelle Espece de Bandage a Pelote Medicamenteuse pour la Cure Radicale des Hernies. Paris, 1836. James. On Hernia. 1S59. Jameson, H. G. Strangulated Inguinal Hernia. Maryland Tied. Recorder. Vol. III., p. 54. 1832. John, J. G. F. De Insolita Calculi Ingentis per Scrotum Exclusione. Wit- tenburg, 1750. Jones, J. S. Radical Cure of Inguinal Hernia. Boston Med. and Surg. Journal. Vol. XLVIIL, p. 510. 1S53. Jouille. Traite des Hernies. K. Kempf, M. Operation for Radical Cure of Right Reduc. Inguin. Hernia. Louisville Med. News. 1878. Vol. VI., pp. 215, 217. Key, Aston. On Hernia. 1833. Kingdon. Mechanism and Causes of Hernia. Med. Chir. Trans. 1864. Vol. XLVII. Kirschbaum. De Hernia Ventriculi. 1749. Knox, Robert. The Ligaments. Edin., 1834. Kok, P. S. De Herniis. 1872. BIBLIOGRAPHY. 411 L. Labrey, D. J. Observations sur les Hernies accompagnees d'autres Maladies Graves. Journ. Compl. der Diet, des Sci. Med. Paris, 1819. Tome V. La Faye. Cours d'Operations de Dionis. 1777. Lafond. Considerations sur les Hernies Abdominales. 1821. Lane, R. Case of Herniae. Amer. Journal Med. Science. Vol. XXV., N. S., p. 560. 1858. Langenbeck, C. J. M. Commeutarius de Structura Peritonei, Testiculorum Tunicis, eorumque ex Abdomiue in Scrotum Descensu ad illustrandam Herniarum Indolem, 1817. Bibl. fur die Chir. Band IV. Neu Bibl. Band II. 1819. Langier. Diet, de Med. En 30 Vols. Paris, 1837. Tome XV. Larrey. Mem. de Chir. Mil. Tome IV. Lassus. Pathologie Chir. Tome I. 1809. Med. Oper. Tome I. Lawrence, W. On Ruptures. 3d Ed. Le Blanc. Nouvelle Methode d'operer les Hernies, avec un Essai sur les Hernies. Par M. Hoiu. 1767. Le Dran. Traite des Operations de Chir. Observations de Chir. Obs. 57. Leonard. W. T. Radical Cure Inguinal Hernia (Truss). N. 0. Med. and Surg. Journal. Vol. XV., p. 378. 185S. Le Quin. Le Chirurgien Herniaire. Paris, 1697. Levret. Obs. sur la Hernie de la Vessie. In Mem. de l'Acad. de Chir. Tome II. Lionet. De l'Origine des Hernies. Littre, Observation sur nue Nouvelle Espece de Hernie. Mem. de l'Acad. des Sciences. 1700. Sur une Hernie Rare. Same Work. 1714. Lobstein. Dissert, de Hern. Congen. Louis, Reflexions sur l'Operation de la Hernie. Mem. de l'Acad. de Chir. Tome IV Luke. Medical Gazette. Vol. 1. Cases of Strangulated Hernia reduced en masse. Medico-Chirurgical 'Trans. Vol. XXIV., XXVL, and XXXI. M. Mabbox. Strangulated Hernia. Rev. de Mim. De Med. mil. Par. 1878. XXXIV. 461-467. Major, F. Scarification of Inguinal Canal. Western Lancet. Vol. XVII., p. 321. 1855. 412 HERNIA. Malachgeiger. Kelegraphia sive Descriptio Herniarum cum earundem Cura- tionibus, tarn Medicis quam Chirurgicis. 1631. Malgaigne. Legons de Clinique sur les Hernies. 1841. March, A. Strangulated and Reducible Herniae. Western Lancet. Vol. XIII., p. 373. 1852. Marshall, Henry. Contribution to Statistics of Hernia among Recruits for the British and Conscripts for the French Army. Edin. Med. and Surg. Journal. 1838. Mauchart. De Hern. Incarc. In Halleri Disp. Chir. Tome III. McPheeters, W. M. Peritonitis simulating Strangulated Hernia. St. Louis Med. and Surg. Journal. Vol. XV., p. 366. 1857. Meckel. Tractatus de Morb. Hern. Congenita. Medical-Chirurgical Trans. 1859. Medical Observations and Inquiries. Mery. Mem. de l'Acad. des Sciences. Paris, 1701. Mondierre. Memoir in Archiv. gen. Sept., 1834. Monro, A. Crural Hernia, 1803. Morbid Anat. of Human Gullet, Stomach, and Intestines. Edin., 1811. Anat. and Chir. Works. Monroe, Alex. Outlines of Anat. 1813. Monteggia. Iustituz. Chir. Tome III. Moore, E. B. Strangulated Inguinal Hernia. Boston Med. and Surg. Journal. Vol. XLVII., p. 525. 1853. Moreau. Sur les Suites d'une Hernie Operee. Mem. de l'Acad. de Chir. Tome III. Morgagni. De Sed. et Caus. Morb. Epis. 43, art. 13. Morton, Thomas. Surg. Anat. of Perinaeum. London, 1838. Muscroft, S. C. Strangulated Femoral Hernia. Western Lancet. Vol. XVIII., p. 637. 1857. N. Naphey's Surgical Therapeutics. Neale, R. Medical Digest. A Book of Bibliographical Reference. Nekton. Elemens de Path. Chir. Tome IV. Nessi. Instituz. Chir. Tome II. Neubaver. Dissert, de Epiploo-Oscheocele. Nott, J. C Radical Cure of Hernia. ' N. 0. Med. and Surg. Journal. Vol. XVI., p. 474. 1859. Radical Cure of Hernia by Leaden Ligature. Amer. Journal Med. Sciences. Vol. XIV., N. S., p. 402. 1847. Nuck. Obs. de Chir. Tome II. Nuttall. British Med. Journal, p. 566. 1857. BIBLIOGRAPHY. 413 0. Obre. Med. Chir. Trans. XXXIV., p. 233. Officinal Alcohol as a Stimulant. Med. and Surg. Reporter. Aug. 9, 1879. Orth, J. Pathol. Anatomy. P. Paget, J. Surg. Pathology. Paletta. Memor. de 1' Instituto. Tomo II., part 1. Nova Gubernaculi Testis Descriptio. Parise. Mem. de la Soc. de. Chir. de Paris. 1851. Mem. sur deux Varieties Nouvelles de Hernies. Parker, W. Strangulated Femoral Hernia. N. Y. Journal Med. Vol. XV., N. S„ p. 152. 1S55. Parrish, J. Strangulated Hernia. Eclectic Repertory and Analytical Review. Vol. I., p. 98. 1811. Pelletan. Clinique Chir. Tome III. Petit, J. L. Chirurgische Wahrnehmungen. Vol. II. CEuvres Posthumes. Tome II. Traite des Mai. Chir. Tome II. Petit, P. (le jeune.) Sur les Hernies de la Vessie et de l'Estomac. In Acad. de Chir. Tome IV. Peyronie. Observations, etc., sur la Cure des Hernies avec Gangrene. Mem. de l'Acad. de Chirurg. Tome I. Pfannius, M. G. De Entero-Oscheocele antiqua. 1748. Pipelet. Remarques sur les Signes Illusoires des Hermes Epiploiques. Post, A. C. Congenital Hernia. N. Y. Medico-Chirurgical Bulletin. Vol. I., p. 19. 1832. Pott's Works. By Earle. Vol. II. and III. Pouteau. ffiuvres Posthumes. Tome III. Q. Quain. Jones Anat. Plates. 2 vols. R. Radical Operation einer Kindskopfgrossen freien rechtsseitigen Leisten- Hernie. Prager Med. Wochenschrift. 1S7S, 111, 434. Ramsey, A. L. Essentials of Anat. 1880. Surgical Diagnosis. 1880. Ravin, F. P. Memoire sur la Theorie et la Cure Radicale des Hernies. Arch. Gen. de Med. 1831. Tome XXVII. 414 HERNIA. Richardson, F. G. Inguinal Entero-Epiplocele. N. O. Med. and Surg. Journal. Vol. XV., p. 683. 1859. Richerand. Diet, des Sci. Med. En 60 Vols. 1827. Tome XXI. Richet. Archives Generales de Medecine. 1856. Tome VIII. Richter, A. G. De Hernia Incarcerata. Gottingen. 1777. Traite des Hernies, trad, de 1'Allemand. Par J. C. Rougement. Bonn. 1784. Richter, E. Zur Lehre von der Unterleibsbruchen. Riege, C. Ueber die Aetiologie der Leisten- und Schenkelbriiche. Berlin, 1878. Rindneisch. Patliolog. Histology. Riolanus. Anthrograph. Lib. LXXI. Roberts, W. H. Injection Oil of Cloves or Tinct. Canth. Souther. Med. and Surg. Journal. Vol. IX., p. 133. 1853. Strangulated Hernia. Southern Med. and Surg. Journal. Vol. VIII., p. 533. 1852. Robertson, F. M. Strangulated Inguinal Hernia. Amer. Journal Med. Sci- ences. Vol. XXIX., N. S., p. 127. 1S55. Roeser. Archives f. phys. Heilkunde. Rokitansky, C. Path. Anatomy. Ronstan. De quelques Modes de Guerisons Naturelles, etc. Journal de Chir. de Malgaigne. Paris, 1843. Tome I. Rossius. Acta Nat. Cur. Rudtorffer, F. X. Abhandlung iiber die einfachste und sicherste Operations- methode eingesperrter Leisten- und Schenkelbriiche. 2 Bande. Wrien. 1808. S. Sabatier, Medecine Operatoire. Tome I. Saltzmann. Disp. de Vesicae Urinaria; Hernia. 1712. Sandifort. Observ. Anat. Pathol. 1777. Icones Herniae Inguin. Congen. 1781. Sanson, L: J. Diet, de Med. et de Chir. Pratiques. Paris, 1833. Tome IX. Scarpa, Antonio. Neue Abhandlungen, u. s. w. Sull' Ernie Memoire Anatomico-Chirurgiche, 1819. Trans, into French. By Cayol, 1812. " English. By Wishart. Edin. 1814. Schindler. De Herniis Observ. Schmidtmann. Von einem geheilten Magenbruch. Scbmucker. Chir. Wahrnehmungen. 1774, 1789. Vermischte Chir. Schriften. BIBLIOGRAPHY. 415 Schreger, B. G. Versiiche Chir. Tome I. Versiiche zur Vervollkommung der Herniotomie. Niirnberg, 1818. Schwalbe of Germany used Ethylic Alcohol. See No. 61,1879, of the Allgem. Med. Central Zeitung, Berlin. Seiler, B. G. Observatioues nonnullse Testiculorum ex Abdomine in Scrotum descensu et Partium Genitalium Anomalis. 1817. Sharp, E. S. Operations and Critical Inquiry. Sherrill, H. Strangulated Inguinal Hernia. N. Y. Medico-Chirurgical Bul- letin. Vol. I., p. 20. 1832. Skey, F. C. Operative Surgery. Simon, F. Guerison Radicale des Hernies, 1841. Smith, Henry H. Surgery. Vol. II. Smith, Nathan R. Surg. Anat. of Arteries. 1835. Smith, Stephen. Operative Surgery. Snead, N. Cases of Hernia. Transylvania Journal of Med. Vol. II., p. 525. 1829. Soemmering, fiber die Ursache der Briiche am Bauchen und Becken, ausser der Nabel und Leistengegend. 1811. Solly. S. Surgical Experiences. Spanton, W. D. Immediate Cure of Inguinal Hernia. 1881. Stanley. Trans, of the Path. Soc. Vol. III., p. 94. Stephens, Henry. On Obstructed Hernia. 1829. Stevenson, S. Three Cases of Hernia Reduced by Unusual Methods. Med. and Surg. Reporter. 1S78. XXXIX., 373. Stewart, F. C. Knife for Strangulated Hernia. Amer. Journal Tied. Science. Vol. V., N. S. p. 497. 1843. Stone, W. Observations on Herniae. N. O. Med. and Surg. Journal. Vol. XV., p. 79. IS5 8. Strangulated Hernia relieved by stretching the Abdominal Rings. Med. and Surg. Reporter, Oct. 18, 1879. Strangulated Hernia treated by New Method. Med. and Surg. Reporter, Oct. 25, 1879. Sue. Traite des Bandages. Paris, 1746. Sully. Surgical Operations. Syme, J. Fascia of Groin in Edin. Med. Journal. No. 81. T. Tatjsig, W. Strangulated Inguinal Hernia. St. Louis. Med. and Surg. Jour- nal. Vol. XIL, p. 404. 1854. Teale, J. P. Practical Treatise on Abdorn. Hernia. London, 1846. Tebay. Med. Times and Gaz. Vol. II., p. 270. 1852. 416 HERNIA. Tenon. Acad, des Sciences. 1764. Thierry. Des Diverses Methodes Operatoires pour la Cure Radicale de Her- nies. 1841. Thurmeissen. De Hernia Ventriculi. 1777. Tivy, W. J. Successful Case of Wood's Operation. Brit. M. J. 1878. 11, 559. Todd, C. H. In Dublin Hosp. Rep. Vol. 1. Trask, J. D. Strangulated Inguinal Hernia. Amer. Journal Med. Sciences. Vol. XVIIL, N. S., p. 90. 1849. Travers, B. Injuries of Intestines. 1812. Triistedt, F. L. De Extensione in Solvendis Herniis Cruralibus Incarceratis prae Incisione Praestantia. 1816. V. Van Btjren, W. H. Strangulated Scrotal Hernia. N. Y. Journal Med. Vol. X., N. S., p. 56. 1853. Rep. N. Y. Path. Soc. 1853. Velpeau. Edited by Mott. Vol. III. Verdier, P. L. Recherches sur la Hernie de la Vessie. In Mem. de l'Acad. de Chir. Tome II. Traite Pratique des Hernies. Paris, 1840. Vesalins. De H. C. Fab. Lib. V. Vidal. Pres. Med. Tome I. W. Wagner. Manual of General Pathology. Walther. De Hernia Crurali. 1820. Nova Acta Erud. 1738. Ward. On Strangulated Hernia. 1854. Warren, J. C. Strangulated Crural Hernia. Communications Mass. Med. Soc. No. II., part 2, p. 44. 1790. Wrarren, J. M. Surgical Observations. Warton. Adenograph. Cap. 11. Watson, J. Radical Cure of Reducible Hernia (injection Tinct. Canth.). N. Y. Journal Tied. Vol. IX., N. S., p. 290. 1852. Weber, J. E. Radical Cure of Inguinal Hernia (Wutzer). N. Y. Journal Med. Vol. XIL, N. S., p. 30. 1854. Wheelwright, J. Hernia through a Laceration of Diaphragm. In Med. Chir. Trans. Vol. VI. Wilmer. Prac. Obs. on Herniae. London, 1788. Wilson, Erasmus. Anat. Plates. 2 vols. Wishart. Treatise on Hernia. BIBLIOGRAPHY. 417 Wood, John. On Rupture. 1863. Application of Trusses to Hernia. London, 1878. Wood, T. Strangulated Hernia. Western Lancet. Vol. XL, p. 417. 1850. Hernia. Western Lancet. Vol. XIL, p. 273. 1851. Wrisberg. Comment. Reg. Societ. Gottingen, 1778. A FEW OF THE OPERATORS ON HERNIA. Obsolete Topical Applications. Fabricius de Aquapendente. Lanfranc. Verduc. The Prior of Cabriere. Babynet. Mile. Devaux. A. Pare. Arnaud. Belmas. Compression. Celsus. Galen. Leonidas of Alexandria. Theodorus Aetius. De Salicet. Norsia. Blegny. Trecourt. Petit. Rareton. Juville. Fournier. Beaumont. Duplat. Position. Ravin. Riviere. De Hilden. Reneaume. Arnaud. Fedran. Hey. Rieck. Cauterization. Aetius. John, son of Serapion. Avicenna. Franco. Albucasis. Roger. Brunnes. Guy de Chauliac. Petrus de Bonanti. Jean de Crepatis. Andre de Montpelher. Pierre d'Orliat. Little John. . Maget. Gauthier. Monro. Incision. Arnaud. Lieutaud. Le Blanc. Bertrand. Excision. Paulus. Celsus. Bertrandi. Lanfranc. Arnaud. 418 HERNIA. Schmucker. Langenbeck. Ligature. Celsus. Saviard. Desault. Dupuytren. Guy de Chauliac. Martin. Nott. John Wood of King's College Hospital, London. Sir W. Fergusson. Erichsen. T. Bryant. W. D. Spanton. Carbolized Catgut Ligature. Chas. Steele. Joseph Lister. H. 0. Marcy. Annandale. Czerny. Suture. Celsus. Thomas Wood of Cincinnati. G. Dowell. Octavius White. S. R. Beckwith. Castration. This operation was mostly in the hands of quacks. Gilded Point. Buchwall. Berault. A. Pare. Royal Suture. Fabricius de Aquapendente. Scarification. Le Blanc. Guerin. Organic Plugs. Sir A. Cooper Velpeau. .Goyrand. A. H. Stephens. Moinichen. Scultetus. Garengeot. Graefe. Jameson. Redfern Davies. Gerdy. Signoroni. Leroy. D. Hayes Agnew. Belmas. Dupuytren. Acupuncture. Bonnet. Mayor. Wurtzer. Mosmer. Rothmund. Sigmund. Spencer Wells. Armsby. Riggs. Hachenburg. Malgaigne. Injection. Joseph Pancoast. Desault. Velpean. W. H. Roberts. Woogencraft. Bowman. Geo. Heaton. Schwalbe. J. Mason Warren. Jos. H. Warren. Wm. Janney. H. S. Greeno. W. H. Heath. And many others. INDEX. > INDEX. A. Abdomen, remarkable cure of wounded, 137. Abdominal supporter, 319. Accidental Herniae, 37. Acquired Congenital Hernia, 16. " Hernial sac, 16. Action of Quercus alba, 381. Acupuncture as a cure, 107. Adhesions, 75. Adjustment of truss, 320. Adult, Hernia in, 22. Adventitious umbilical hernia, 20. After treatment of hernia, 172. Age as affecting Hernia, 44. " most suitable for injection, 177, 181. Agnew's instrument, 105. " method of cure, 105. Allis' herniotome, 220. Amussat's operation in artificial anus, 304. Anatomical measurements, sliding and revolving rule for taking, 60. Anatomy of Hernia, 4, 48. " " Femoral, 66, 160. " " Inguinal, 51, 160. " " " Strangulated, 48 et seq., 86. " " Umbilical, 48. Ancient prescription, 362. Animal ligatures in surgery, 119. Antiseptic carbolized catgut ligature, operations by the use of, 114, 270, 274. Antiseptic ligature of neck of sac, 270. " treatment of'hernia, 114, 270, 274. Anus artificial, 232, 303. Arch, Femoral, 33, 69. Arteries, — Danger of wounding, 146, 148, 221, 377. Deep Epigastric, 57. Femoral, 69. Arteries, — Superficial Epigastric, 66. " Circumflex Iliac, 66. Superficial External Pudic, ' 66. Artificial anus, 232, 303. Aspirating needle for Strangulated Her- nia, 216, 377. Author's Anatomical Truss, 321. " Formulae for injection, 371. " Herniotomy Case, 221, 239,377. " Instruments for Hernia, 142, 144, 157. " Modification of Injection, 141, 154. " " Kelotomy, 238. " New Instrument, 157, 373. " operation for Hernia, 134, 154, 163, 165, 167, 168, 170. " operation for Hernia Femoral, 168. " operation for Hernia Inguinal, 165. " operation for Hernia Umbilical, 170. " operation for Varicocele, 339. " Treatment after operations, 172. B. Ball and Socket truss, 318. Bandages, 167, 169, 374. Belmas' method of cure, 105. Bernard on operations for Strangulated Hernia, 225. Bibliography, 403. Birkett on Strangulated Hernia, 208. Bonnet's method of cure, 106, 365. Breschet's operation for varicocele, 337. Bryant's Surgery, Diagrams from, 82, 84. Bubo, 42. 422 INDEX. Bubonocele, 41. Buggy Spring truss, 112. Burn's ligament, 68. C. Callisen's operation in artificial anus, 303. Camper's Fascia, 5. Canal, Crural or Femoral, 69, 72. " Inguinal, 5, 56, 66. " of Nuck, 8. Carbolized catgut as ligatures, 118. Cases. On observing, 174. " Record of interesting, 186, 386. Castration for hernia, 102, 364. Catgut as a ligature for hernia, 114, 270, 274. Causes of failure by injection, 183, 379. " Hernia, 4, 17, 22, 25, 26, 28, 31, 34, 266. " " Hydrocele, 327. " " success by injection, 134, 141, 163, 177, 202, 379. " " Varicocele, 335. Cauterization for Hernia, 98, 360, 363. Cerebral Hernia, 37. Chad wick, James R., on umbilical her- nia in foetus, 21. Circumcision for Hernia, 18. Clinical Reports. Author's, 394. Greeno's, 386. Heath's, 392. Cloquet on Hernia, 71. Codman, Benj. S., on trusses, 315. Colon, Hernia of transverse, 38 note. Common Hydrocele, 324. Compression for Hernia, 98. Concluding observations, 381. Conclusions of Czerny's " radical cure," . 300. Congenital Hernia, 4, 8, 14, 20, 37,181. " Hydrocele, 327. " Inguinal Hernia, 4, 8, 12. " Umbilical Hernia in foetus, 20. Conjoined tendon, 54. Constitutional effects of hernia, 36. Cooper, Sir Astley, bis hernia knife, 220 ; opinions on hernia, 16, 55, 59, 71, 74, 85, 346. Cord, Hydrocele of, 327. Cornil and Ranvier on fibro-plastic lymph, 368. Coverings, — Femoral Hernia, 74, 350. Inguinal " 74, 350. Cremaster muscle, 61. Cribriform fascia, 67. rural. See Femoral. urative treatment of hydrocele, 329. ures of Hernia. — Acupuncture, 107. Annandale's, 270. Antiseptic, 114, 270, 274. Author's, 134, 141, 154. Castration, 102, 364. Cauterization, 98, 360, 363. Circumcision, 18. Compression, 98. Czerny's, 274. Dilation bv organic plugs, 103. Dowell's, 109. Excision, 99, 359. Gilded point, 103, 244. Graefe's, 364. Incision, 99, 364. Injection, 128, 134, 206, 372. Ligature, 100, 114, 270, 274, 359. Position, 98. Royal Suture, 102. Scarification, 102. Spanton's, 243. Suture, 100, 359. Wood's, John, 108, 245. " Thomas, 100. Wurtzer's, 104, 365. Cures of Hydrocele. — Excision, 331. Incision, 330. Injection, 331. Seton, 330. Theories of, 333-335. Cures, percentage of, 1S2, 384, 391. Curling on descent of testis, 9. Cystocele, 42, 344. Czerny's " radical cure," 274. " " Conclusions of, 300. " " Summary of, 297. D. Danger of wounding epigastric artery, 146, 148, 221, 377. Davenport's instrument, 143. Davies' Redfern instrument, 104. Deep crural arch, 69. " epigastric artery, 66. " Fascia, 67. Definition of safe operation, xvii. Demonstrators' knife, 340. Descent of testicle, 8-12. Development of hernia, 31-33. Diagnosis between Femoral and Inguinal hernia, 341. Diagnostic Tables, 78-81. Diagrams illustrating the different kinds of hernia, 82. Diaphragmatic or Phrenic hernia, 37. IND1 Diffused Hydrocele, 328. Direct Inguinal hernia, 41. Directors for strangulated hernia, 220. Displaced hernia, 90-92. Do well's Buggv Spring truss, 112. method of cure, 101, 109. needles, 101. Dupuytren's operation in artificial anus, 307. E. Effects of hernia, 35. '' muscular exertion on causation of hernia, 30. Elongation of mesentery as cause of her- nia, 23. Empty hernial sacs with symptoms of strangulation, 348. Encysted or Infantile hernia, 16, 37. " Hydrocele, 327. Enterocele, 42. Entero-epiplocele, 42. Enterotomy, 308. Eperon, 306. Epigastric Artery, — Danger of wounding, 146, 148, 221, 377. Deep, 57. Superficial, 66. Epiplocele, 42. Excision as a cure, 99, 359. Exciting causes of hernia, 27, 34. Exertion as a cause of hernia, 27-31. Exomphalos, 38. External Abdominal ring, 56. " Inguinal hernia, 40. " oblique muscle, 52. " spermatic fascia, 53. F. Fabiiicius ab Aquapendente on hernia, 362. Failure, causes of, of injection for hernia, 183, 379. Falciform process, 68. Fallopius ligament, 52. Fascia, —• Camper's, 5. Cribriform, 67. Deep or Fascia Lata, 67 Intercolumnar or External Sperma- tic, 53. Internal oblique, 54. Propria, 71. Superficial, 66. Transversalis, 11, 55, 61. Femoral and Inguinal hernia, Diagnosis between, 341. EX. 423 Femoral Arch, 33, 69. Canal, 69, 72. Hernia, 33, 42, 168, 212, 341. " " Anatomy of, 48, 66. " " Kelotomy in, 233. " Rare form of, 212. " Symptoms of, 51, 75. " ligament, 68. " ring, 34. " rupture, Gav's figures for, 234. Fibro-plastic lymph, 140, 368. First operator by Injection, 129, 302. Foetus, hernia in the, 21, 49. Formation of hernial sac, 72. Formulae, — Author's, 371. Heaton's, 371. French truss, double and single, 317. Frequency of hernia according to Afjn, 44. Kind, 43. Nationality, 47. Occupation, 45. Population, 44, 345. Sex, 44. Side of body, 18, 47. Funicular process, 13. " " Hernia into, 15. G. GagnebE's operation for varicocele, 338. Gangrene in strangulated hernia, 86. Gastrocele, 42, 344. Gay's operation for femoral rupture, 234. General remarks, 175. Gerdy's method of cure for hernia, 104. Gilded point as a cure for hernia, 103, 244. Gimbernat's ligament, 52. Golding Bird's torsion forceps, 377. Graefe's operation for hernia, 364. Gubernaculum testis, 9. Guthrie on descent of testis, 10. Guy's Hospital, Author's operation at, 167. H. Heaton's instruments, 142, 368. Hepatocele, 42, 344. Hernia, — Best age for injecting, 177, 181. Causation of, 4, 17, 22, 31. Cures of. See Cures. Development of, 31. Directors, 220.1 Effects of, 33. Fabricius ab Aquapendente on, 362. 424 INDEX. Hernia, — Frequency of different kinds, 43 ; according to age, 44 ; occupation, 45 ; population, 44, 345 ; race, 47 ; sex, 44 ; side of body, 18, 47. In adults, 22. Kinds of, best treated, 177. Knife, — Allis's, 220. Author's, 221, 239, 377. Cooper's, 220. Hinge's, 220. Levi's, 220. Peter's, 220. Stewart's, 220. Of transverse colon, 38. Operations for, 18, 93, 359. Operators on, 417. Percentage of cures by injection, 182, 384, 391. Reduction en bloc or en masse, 90. " by taxis, 209. Urinary bladder in, 21. Hernia, various kinds of, — Accidental, 37. Acquired Congenital, 16. Adventitious Umbilical, 20. Bubonocele, 41. Cerebral, 37. Congenital, 4, 8, 12, 14, 18, 37, 131. Crural, 42, 232. Diaphragmatic, 38. Displaced, 90. Encysted or Infantile, 16, 37. Enterocele, 42. Entero-epiplocele, 42. Epiplocele, 42. Exomphalos, 38. Femoral, 33, 42, 66, 162, 168. Incarcerated, 43, 345. Indirect, 13. Infantile or Encysted, 16, 37. Inguinal, — External, 13, 40, 77, 165. Internal, 41, 165. Intermuscular, interparietal, or in- terstitial, 91, 352, 354. into Funicular process, 15. '" Vaginal " 14. Irreducible, 43, 345. Ischiatic, 40. Lumbar, 40. Merocele, 42. Oblique, 40. Of infancy, 14. " linea alba, 22. " tunica vaginalis, 8, 13. " transverse colon, 38. Omphalocele, 38. Oscheocele, 42. Perineal, 40. Hernia, various kinds of, — Pudenda], 42. Reducible, 43, 75. Scrotal, 42. Strangulated, 43, 85, 208, 345, 381. Thyroid, 40. True Umbilical, 22. Umbilical, 19, 38, 48, 170, 233. Vaginal, 40. Ventral, 42. Ventro-inguinal, 42. Hernial sac, — Acquired, 16. Congenital Umbilical, 20. Consequence of fluid in, 76. Coverings of, 74, 350. Empty with symptoms of strangula- tion, 348. Formation and nature of, 72. Inflammation of, 75, 87, 88, 348, 351. in strangulated hernia, 86, 226, 227. Herniotomes, kinds of, 220. Herniotomy. See Kelotomy. Hesselbach's triangle, 57. Hey's ligament, 68. Hinge's hernia director, 220. History of operations, 186, 359. Hodgen, Prof. John T., on Sayre's treat- ment as a cause of hernia, 28. See also 266. Hospital, Guy's, Author's operation at, 167. Huette on strangulated hernia, 225. Hydrocele, — Causation of, 324. Common, 324. Curative treatment of, 329. Cures, — Excision, 331. Incision, 330. Injection, 331. Seton, 330. Theories of, 333. Diagnosis of, 326. Diffused, 328. Encysted, 327. Of Cord, 327. " Tunica vaginalis, 324. Operations for, 328. Palliative treatment of, 328. Hypodermic syringes, objections to, 145. I. Ilio-inguinal nerve, 52. Incarcerated hernia, 43, 345. Incision as a cure, 99, 364. Increased visceral pressure as a cause of hernia, 26. INDEX. 425 Inefficiency of parietes as a cause of hernia, 25. Infantile or Encysted hernia, 16, 37. Inflammation of hernial sac, 75, 87, 88, 348, 351. '' Maisonneuve's treatment of, 368. " treatment of, 136,139, 311, 368. Inguinal canal, 5, 56, 66. " hernia, 40. " " Anatomy of, 51. Inguinal hernia, External, 13, 40, 77, 1&5. " " Indirect, 13. " " Internal, 41, 165. " " Symptoms of, 51. " and Femoral hernia, diagnosis between, 341. Injection as a cure for hernia, 7, 134. " as modified by author, 141,163. " causes of failure by, 183. " " " success by, 7, 134. " first operator by, 129, 302. " operation by, 149, 206, 372. Instrument. — Agnew's, 105. Allis's herniotome, 220. Author's, 144, 157, 216, 239, 373. Cooper's liernia knife, 220. Davenport's, 143. Davies' Redferu, 104. Dowell's, 101. Heaton's, 142, 370. Hernia director, 220. Hinge's " 220. Janney's, 132. Levi's director, 220. Peter's " 220. Stewart's hernia knife, 220. Wurtzer's, 106. Intemperance as a cause of hernia, 29. Intercolumnar Fascia, 53. Intermuscular, interparietal, or intersti- tial hernia, 91, 352, 354. Internal abdominal ring, 6, 55. " oblique fascia, 54. Intestines, wounds of, 310. Introduction, xiii. Irreducible hernia, 43, 345. Ischiatic hernia, 40. Jameson's cure, 103. Janney on Injection, 130. " Instrument, 132. K. Kelotomy, 217-242. Author's modification of, 238. " new knife for, 239. Bernard's and Huette's method of, 225 et seq. Gay's method of, 234. in Crural, 232. " Femoral, 222. " Inguinal, 217. " Umbilical, 233. Incision of sac in, 226, 227. Instruments for, 220 et seq. Key's method of, 223. Malgaigne's method for, 230. Multiple division in, 230. New knife for, 239, 377. Petit's method of, 222. Reduction in, 231, 376. Without opening sac, 221. Kinds of hernia, 37, 43. " as affecting occurrence, 43. " best treated, 177. Kingdon's Tables of Hernia, 46. Knife, new herniotomy, 239, 377. Life, time of, at which hernia occurs, 37. Ligaments, — Burn's, Hey's, or Femoral, 68. Gimbernat's, 52. Poupart's, 52. Triangular, 53. Ligation as a cure in varicocele. Intermediate, 338. Subcutaneous, 338. Ligature, — animal, in surgery, 119. as a cure for hernia, 98, 114, 270, 274, 359. ' Dowell's subcutaneous, 112. of neck of hernial sac, 270. surgical operations without, 240. Linea alba, hernia of, 22. Lister's carbolized catgut, 120. Littre's operations in artificial anus, 303. Lumbar hernia, 40. M. Maisonneuve's treatment of inflamma- tion, 368. Malgaigne's diagnosis between Femoral and Inguinal hernia, 342. Malgaigne's operation for varicocele, 338. Marcy, H. O., Antiseptic treatment of hernia, 114. Measurements of the abdomen by Sir Astley Cooper, 59. 426 INDEX. Merocele, 42. Mesorchium, 9. Muscles, — Cremaster, 61. External oblique, 52. N. Navel, ruptured, 38. Nationality as affecting hernia, 47. Neck of sac, antiseptic ligature of, 114, 270, 274. Needle, — aspirating, 216, 377. Dowell's, 101. Nerves, — Anterior Crural, 56. Genito " 52, 56. Ilio-inguinal, 52, 67. 0. Oak bark, action of, in hernia, 381. Oblique inguinal hernia, 13, 40. Obliteration of vaginal process, 13. Observing cases, 174. Occupation as affecting hernia, 45. Occupations most favorable for opera- tions for hernia, 177. Omentum, treatment of, 165, 232. Omphalocele, 38. Operations for artificial anus, 303. " Hernia, 91, 165, 168,170, 189,359,364. See also Cures. " Hydrocele, 328. " " Varicocele, 336. " Wounds of Intestines, 310. Operators on hernia, 417. Organic plugs as a cure for hernia, 103, 245. Oscheocele, 42. Ossified tunica vaginalis, 346. P. Paget, Sir James, on strangulated her- nia, 87, 127. Palliative treatment of hydrocele, 328. Pancoast's operation for varicocele, 339. Pathology, — After injection, 140, 150, 379. Cornil and Ranvier on fibro-plastic lymph, 368. Gangrene in sac coverings, 87. " ." strangulated hernia, 86. Patients, on the selection of, for treat- ment for hernia, 175. Percentage of cures by injection for her- nia, 182, 384, 391. Perineal hernia, 40. Peritoneum, — Davenport on, 134. Funicular process of, 13. in hernia, 346. John Wood on, 135. Nature of the, 74. Toleration of, illustrated, 136. Vaginal process of, 13. Peritonitis, efficacy of cold water or ice in cases of, 136, 139, 368. Persons in whom injections best succeed, 176, 177, 181. Peter's hernia director, 220. Petit's operation of kelotomy, 222. Phimosis a cause of hernia, 17. Phrenic or Diaphragmatic hernia, 38. Pillars of external ring, 4, 53. Plaster jacket a cause of hernia, 28, 266. Plugs, organic, as a cure for hernia, 103. Population as affecting hernia, 44. Position, — as a cure, 98. in author's operation, 163. " taxis, 209. of truss, 314, 320. Poultices injurious in abdominal inflam- mations, 139. Poupart's ligament, 52. Predisposing causes of hernia, 26, 33. Prescription, quack, 362. Process, — Burns', 68. Falciform, 68. Processus vaginalis, 9. Proper position of truss in Inguinal hernia, 314, 320. Proper position of truss in Umbilical hernia, 314. Pudendal hernia, 42. Q- Qfack prescription, 362. Quackery in treatment of hernia, 102, 125, 364. Quercus alba. Action of in hernia, 381. R. Race of men, frequency of hernia ac- cording to, 47. Rachet truss, 317. Radical cure, 7, 93, 97, 125, 128, 155. Raynaud's operation for varicocele, 338. Record of interesting cases, 186, 386. Reducible hernia, 43. " symptoms of, 75. Reduction in strangulated hernia, 209, 231, 376. INDEX. 427 Reduction of hernia, en bloc or en masse, 90, 352. Reports, Clinical, 386. Resume, 379. Kicord's operation for varicocele, 339. Rigaud's " " " 337. Rings, — External inguinal, 53, 56. Femoral or crural, 34, 70. Internal inguinal, 5, 55. Royal suture as a cure for hernia, 102. Ruptured navel, 38. s. Sac, acquired hernial, 16. congenital umbilical, 20. consequence of fluid in, 76. coverings of hernial, 74, 350. formation and nature of, 72. inflammation of hernial, 75, 87, 88, 348, 351. in strangulated hernia, 86, 226, 227. Saphenous opening, 67. Sayre's treatment as a cause of hernia, 28, 266. Scarification as a cure for hernia, 102. Scarpa, — cellular structure described by, 61. on texture of peritoneum, 74. opinions on various points, 15, 22, 23. triangle, 61. Schmalkalden's operation in artificial anus, 307. Scrotal hernia, 42. Sedentary habits a cause of hernia, 30. Sex as affecting hernia, 44. Side of body as affecting hernia, 47. Smith, WillardE., viii., 396. Spanton, W. D., immediate cure of hernia, 243. Specialists, 94. Spermatic cord, 5, 61. " " relation of, to sac, 61, 66. Spica bandage, 169. Spiral spring truss, 316. Stewart's hernia knife, 220. Stranguated hernia, 43, 85, 208, 345, 351. " " Birkett on, 208. " " operations for, 91. " " reduction of, 209. " " reduction of, bv J. C. Warren, 375. " " symptoms simu- lating, 348. " " taxis in, 209. " " treatment of, 225. Strangulation, symptoms of, 88, 351. Subcutaneous ligature for cure of her- nia, 109. Success of injection for hernia depend- ing upon age of patient, 178. " kind of hernia, 177. " selection of patients, 175. " treatment, 172. 183, 379. Summary of Czerny's "radical cure," 297. Superficial circumflex iliac, 66. " epigastric, 66. " external pudic, 66. Suppuration as cause of failure of injec- tion for hernia, 379. Surgery, animal ligatures in, 119. Surgical operations without ligatures illustrated, 240. Suture as a cure for hernia, 100, 359. Symptoms, — of reducible hernia, 75. of strangulated hernia, 85. of umbilical hernia, 48. simulating strangulation, 348. Syringe for injecting hernia, 157, 373. " objection to hypodermic, 145. T. Tables of Diagnosis, 78-81. Taxis and position for, 209. Tendon, conjoined, 54. Testicle, 8, 15. Theories of cure of hydrocele, 333-335. Theory of cause of varicocele, 335. Thyroid hernia, 40. Toleration of peritoneum, illustrated, 136. Trades in which hernia is most fre- quent, 46. Transversalis fascia, 11, 55, 61. Transverse colon, Hernia of, 38. . Treatment after operation for hernia, 172. " of inflammation, 136, 139, 311, 367. " " omentum, 165, 232. " " strangulated hernia as given by Bernard and Huette, 225. Triangles, — Hesselbach's, 57. Scarpa's, 61. Triangular ligament, 53. True umbilical hernia, 22. Trusses, — Abdominal supporter, 319. Adjustment of, 320. Anatomical, 321. Ball and Socket, 318. Codman, Benj. S., concerning, 315. Dowell's Buggy Spring, 112. 428 INDEX. French, double and single, 317. Proper position in inguinal liernia, 314, 320. " " in umbilical hernia, 314. Rachet, 317. Spiral spring pad, 316. Umbilical, 318. Tunica vaginalis, 8. Hernia of, 8, 13. " " Hydrocele of, 324. " " ossified, 346. U. Umbilical, Adventitious hernia, 20. " Anatomy of, hernia, 48. " belt, child's and adult's, 319. Hernia, 19, 38, 48, 170. " " in adult, 50. "in child, 50. " " in foetus, 19, 49. " " symptoms of, 51. true, 22. " " truss, 318. Umbilicus, Pain at, in strangulated hernia, 351. Uterus, remarkable rupture of, 138. V. Vaginal Hernia, 40. " Hernia into, 14. " process, 13. Varicocele, — Causes of, 335. Operations for, 336. Author's, 339. Breschet's, 337. Gagnebe's, 338. T. . J Immediate, 338. Ligation j subcubtaneous, 336. Malgaigne's, 338. Pancoast's, 339. Ricord's, 339. Rigaud's, 337. Velpeau's, 337. Vidal de Cassis', 339. Theory of, 335. Velpeau's operation for varicocele, 337. Ventral hernia, 42, 80. Ventro-inguinal hernia, 42. Vidal de Cassis' operation for varicocele, 339. w. Warren, C. Everett, Demonstrator's knife, 340. " J. Collins, operation for stran- gulated hernia, 375. White's ligature for hernia, 101. Wood, John, — method of cure, 108, 245. on the peritoneum, 135. Wood, Thomas, — method of cure, 100. Wounds of the intestines, 310. Wurtzer's cure for hernia, 106. University Press: John Wilson & Son, CamDridge. llECOMMENDATIONS AND REVIEWS AUTHOR'S LABORS AND STUDIES IN DEVELOPING THE SUBJECT OF HERNIA. NOTICES OF FIRST EDITION. 53 Upper Brook Street, Grosvenor Square, Feb. 7, 1SS1. Dear Dr. Warren, — I have to thank you for your book, which I have carefully gone over, and I can see that you have bestowed much time and work in its preparation. I only hope you may have pointed out a way for us to work in and radically cure hernia. I am now looking up the case of mine you operated upon at Guy's, and as soon as I can find time I will report the case in full in the London Lancet. Your herniotome and rotary wedge needles and catheters I like much. With kind regards, believe me, sincerely yours, Thomas Bryant, F.R.C.S. 58 Beacon Street, Boston. My dear Dr. Warren, — I have to thank you for your kindness in presenting me a copy of your very interesting work on Hernia, which I have already glanced over, and anticipate reading with much interest. I am, yours very truly, John C. Warren, M.D. I would sincerely thank you for the service you have done to the profession in openly, clearly, and fully making known and describing an innovation in surgery of considerable value, but which had by others been so long and so shamefully kept a mystery and a "secret." Yours very truly, Henry A. Martin, M.D. 27 Dudley Street, Boston, Mass., Jan. 21, 1881. 4 NOTICES OF FIRST EDITION. 35 Wimpole Street, W., Jan. 31, 1881. Dear Dr. Warren, — On my return from Rome, I find your com- prehensive monograph on Hernia. I must at once, without delay, send you my best acknowledgments for the kind and too flattering position you have accorded to me in connection therewith. Be assured I highly appreciate it. I see the work is fully illustrated, and enters on your experience and views relative to your system of applying injection. This I hope to devote some early leisure to investigate. I shall be interested in seeing and in trying your new instrument (the Thompson American catheter). I am always surrounded by strangers and visitors, and shall be happy to give it a trial. Meantime, with best wishes, believe me, yours very truly, Henry Thompson, F.E.C.S. In addition to these, letters of commendation have been received from Prof. S. D. Gross, M.D., LL.D., D.C.L., from Prof. C. E. Brown-Sequard, M.D., LL.D., and from many others. Pages 5-8 lacking PRESS NOTICES OF FIRST EDITION. 9 its basis is the generation of an amount of inflammatory disturbance at the hernial seat sufficient to close the opening with plastic adhe- sions. This is the key to its successful practice, and it is not only evident that this prerequisite varies in every case, but also that a large amount of time, ingenuity, and experiment must have been expended in order to meet it favorably in any case, thus giving adequate reason for the unsatisfactory results that were obtained in the early history of the operation. Some space is also devoted to a discussion of kelotomy, and import- ant suggestions are made for the modification and improvement of this operation. A full bibliography of hernia completes the work. It is a valuable and interesting production, and we express the hope that it may find its way into the library of every practitioner in the land. From Peoria Medical Monthly. The method of subcutaneous injection has given a larger percentage of cures than any other. It is safe, for no fatal results have yet occurred from it; and we think that, from the exact and lucid descrip- tion and explanation given by Dr. Warren, any man of good ana- tomical knowledge and surgical experience may make it successfully. At any rate, we hope this book may bring it fully and prominently before the profession, that it may be carefully tested, and its merits decided upon. We can confidently recommend this work to our readers as one of the most interesting and instructive ever brought to our notice. From Buffalo Medical and Surgical Journal. The author has improved the operation, and perfected and invented new instruments. The operation deserves more attention than has heretofore been granted it. From Michigan Medical News. While this book contains a general consideration of the whole sub- ject of hernia, its anatomy, and the various operations for its relief, — its distinctive feature is the consideration of the operation for radical cure of reducible hernia by subcutaneous injection. This operation is 10 PRESS NOTICES OF FIRST EDITION. based on advanced ideas regarding the susceptibility of the peritoneum to wounds. The liability to peritonitis after wounds of the perito- neum is net so great as was formerly supposed. To those desiring a full consideration of this important procedure in the treatment of hernia we commend this book. Dr. Warren has identified himself very closely with the operation, and has, by his successful performances of it, both in this country and in Europe, won for himself the right to speak authoritatively regarding it. From Philadelphia Medical Bulletin. This work sheds a remarkable degree of light upon the history of the various operations performed for the cure of hernia, the great bug- bear of surgeons of the past and present. In regard to the operation as now improved and performed by Dr. Jos. H. Warren for some years past, and in numerous cases with brilliant results, we think the very- highest honor is due for his untiring energy in striving to perfect an operation which had fulfilled so much, and which, as now practised by him, must prove an unqualified boon to the profession, as it already has to those who were suffering from hernia, and who have passed from his skilful hands cured. The work contains a valuable instructive table on the differential diagnosis of hernia. The author's description of the several forms of hernia, inguinal, oblique and direct, femoral, umbilical, ventral, &c, evinces the fine anatomist and skilled surgeon. The work is amply illustrated with fine wood-cuts and diagrams of clinical cases and instruments used, of which among the latter promi- nently stands forth the syringe, devised and used by the author in making subcutaneous injections for the perfect cure of hernia. Also, valuable chapters on the performance of herniotomy and on the appli- cation of trusses. This effort on the part of the author to arouse fully the attention of surgeons throughout the land to this great achievement will, no doubt, command that thoughtful consideration and following which it so eminently merits. From Southern Medical Record, Atlanta, Ga. The difficult subject of hernia is here treated in .an able and lucid manner, and the new suggestions and new instruments presented will PRESS NOTICES OF FIRST EDITION. 11 give to the work especial interest. The practitioner, and especially the surgeon, will find it a most useful and valuable addition to the medical library. From New England Medical Gazette. Dr. Warren has made many contributions to medical journals, has invented several new instruments for facilitating it, and has com- pounded a fluid for injection which he considers superior to Dr. Heaton's Quercus alba. His book is elaborate, introducing, besides this special operation, a great deal of general information on hernias. He has produced a very interesting as well as valuable book, which we hope will have a large sale, and spread the knowledge of this beautiful operation. From North Carolina Medical Journal. We have read this book with great interest. It should be carefully read, as it has peculiar merits, among others a marked degree of individuality. We trust this operation may have a fair trial. From Nashville Journal of Medicine and Surgery. This admirable work is au exposition of the treatment of hernia by subcutaneous injections and concise descriptions of all the operations for the radical cure of hernia. The plan is simple, devoid of danger, and generally successful. It is certainly worthy of trial, and we hope that in a few years it will be established as a generally accepted sur- gical procedure. The book is well written, well illustrated, and well published. From Medical Journal, Edinburgh, Scotland. In this book Dr. Warren has favored the profession with an account of his method of treating hernia by injecting a stimulating fluid into the tissues which immediately surround the apertures, and so promot- ing closure by the effusion of plastic lymph. The operation consists of several stages, — first, the complete return of the hernia; next, the insertion of a fine hypodermic needle (which is blunt-pointed to prevent injury of important structures), from which 12 PRESS NOTICES OF FIRST EDITION. a few drops of an irritating fluid is injected into the cellular tissue at the internal and external ring, and also along the canal (in oblique inguinal liernia). As a result of this operation inflammation is set up (as in the case of an injected hydrocele), which lasts for some days, during which time the patient is kept in bed, and cold applied over the inflamed and swollen part. To give the irritated textures oppor- tunity to become agglutinated, the patient must be kept in bed for a fortnight or three weeks. We recommend this operation to practical surgeons for a fair trial. We found our recommendation mainly on an anatomical fact which Dr. Warren points out, and which, though it is not new to any one, is apt to be forgotten by surgeons, from the manner in which they are accustomed to speak of the hernial openings as "rings." The fact is this, that these so-called rings are not rings at all, but have their walls in contact (generally), except when they are separated by the hernial protrusion. It seems natural enough, when we remember this fact, that if we can irritate these tissues in such a manner as to make their opposing surfaces become covered with plastic lymph, their subsequent fusion together is merely a question of rest and time. 3NiDia3w jo Aavaan tvnoiivn 3nidici3w jo kwxM**vxxM*v™»¥,wj\*w»XJv„www-\vNO\Lvu 3fc NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 1 M^ IF ^~~ SNiDiasw jo Aavaan ivnoiivn snidiosw jo Aavaan tvnoiivn snidiqsw jo Aavaan tvnoiivn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 5 v'jy^p ? p_ aNiDiasw jo Aavaan tvnoiivn snidiqsw jo Aavaan tvnoiivn snidiqsw jo Aavaan tvnoiivn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE aNiDiasw jo Aavaan tvnoiivn snidiosw jo Aavaan ivnoiivn snidiosw jo Aavaan tvnoiivn □ £ is* / t < ^JK £ i£* / % c -va^ =s -a a NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN 3NiDia3w do Aavaan tvnoiivn aNiDiaaw jo Aavaan tvnoiivn snidiosw jo Aavaan tvnouv NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICI 3NIOIQ3W JO AavaaiT TVNOIIVN 3NIDIQ3W JO AaVl1v-|v-|v IV IV IV IV IV IV IV IV IV IV TV TV TV TVNOI1 ifln tvnoiivn snidiosw jo Aavaan tvnoiivn snidiosw 3= ,,vf^ $1 3W JO A ? ^V K /\ "^ SJT) • iiS 1 j ""....."."........."......|^t \L LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL ^v.. ✓ % x vyyv y -i /-/%■»/ / > x y&Kr\ / -I rT^sy 3w jo Aavaan tvnoiivn 3Nidio3w jo Aavaan tvnoiivn snidiosw jo Aavaan tvnoiivn snidiosw AL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL sw jo Aavaan tvnoiivn snidiosw jo Aavaan ivnoiivn snidiosw jo Aavaan ivnoiivn snidiosw 1 AL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL iw jo Aavaan tvnoiivn snidiosw jo Aavaan tvnoiivn snidiosw jo Aavaan tvnoiivn snidiosw \ * r%3/\ t /TOED S ~sbr?>> £ iS* / -1 ^ ~^K s iS* / % < ^r^ » TJ 0 M. LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL iw jo Aavaan ivnoiivn snidiosw jo Aavaan tvnoiivn snidiosw jo Aavaan tvnoiivn snidiosw ^?;f \ \ & L LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL wop n i.-vV\ P /V an tvnoiivn 3NIDI03W jo Aavaan TVNOIIVN SNID'03W NLM001391416