1 LIBRARY OF CONGk 
 Shelf 'MZA 
 
 T'MTED STATES OF AMERICA. 
 
HERNIA, 
 
 STRANGULATED AND REDUCIBLE. 
 
 WITH CURE BY SUBCUTANEOUS INJECTIONS, TOGETHER 
 
 WITH SUGCESTED AND IMPROVED METHODS FOR 
 
 KELOTOMY. ALSO AN APPENDIX GIVING A 
 
 SHORT ACCOUNT OF VARIOUS NEW 
 
 SURGICAL INSTRUMENTS. 
 
 BY 
 
 JOSEPH H. WARREN, M. D. 
 
 MEMBER OF AMERICAN MED. ASS'N., AND DELEGATE TO FOREIGN COUN- 
 TRIES FOR l88o AND l88l ; MEMBER MASS MED. SOC. ; HON. MEM. 
 OTSEGO CO. MED. SOC. OF N. Y. ; FORMERLY MEM. BOSTON 
 GYNAECOLOGICAL SOC. ; MEM. BOSTON NAT. HIST. 
 SOC. FORMERLY SURGEON AND MEDICAL 
 DIRECTOR, U. S. A. ETC., ETC. 
 
 WITH ILL US TEA TIONS. 
 
 /^^ c ?N 
 
 BOSTON: 
 
 CHARLES N. THOMAS. 215 TREMONT ST. 
 
 LONDON : 
 
 SAMPSON LOW, MARSTON, SEARLE, AND RIVINGTON. 
 
 1881. 
 / / 
 
 All rights of translation reserved by the author. 
 
 
Copyright by 
 JOSEPH H. WARREN. 
 
 1880. 
 
 Press cf E. K. Dunbar & Co., 299 Washington St.. Boston. 
 
Qrimtwn. 
 
 This work h most respectfully dedicated to Joseph Pancoast, 
 M.D., LL.D., the distinguished Emeritus Professor of Anatomy and 
 Surgery in Jefferson College, Philadelphia, to whom belongs the honor 
 of discovering the subcutaneous method of curing Hernia, and of 
 being the first successful operator, as proved by the ?nost careful 
 researches. 
 
 And to Sir Henry Thompson, M.D., F.R.S., etc., who is 
 world renowned for his contributions to scientific medieine ; for his 
 operations for removing stojie from the bladder, and for other difficult 
 surgical manipulations upon the u? i nary organs ; as a token of esteem 
 for his great kindness and friendship towards the Author. 
 
 And to the late distinguished Prof. John Collins Warren, 
 M.D., LL.D., etc., who will always be known as the'EXACT teacher 
 of Anatomy aud Surgery in Harvard Medical School, and as the 
 father of New England Surgery, in memory of his wise counsel and 
 many kind words, which did much to advance the Author in the 
 pathway oj pi'ofessional success. 
 
•/;/. 
 
 if 
 
 w PREFACE. q 
 
 IT lias 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 aa 
 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. Tiemann 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. D. 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 by explain- 
 ing his operation and instruments to me ; also 1 am grateful 
 to Thomas Bryant for his great kindness to me in allowing 
 me to use illustrations from his work, and for arTordincr me 
 
PREFACE. ix 
 
 an opportunity to operate on Hernias before a number of 
 
 surgeons at Guy's Hospital. 
 
 And also to my very kind friends Dr. Brown Sdquard of 
 the College of France, who recommended me to the Academy 
 of Medicine ; to Dr. Alphonse Guery, Surgeon to Hotel Dieu, 
 who very kindly presented me, and explained my instruments 
 more fully at the Academy ; and to Dr. Blum, Surgeon to 
 the Hospital Bcaujon, who kindly assisted me in my demon- 
 stration of the operation for Hernia and other operations 
 with the new instruments of my devising. 
 
PREFACE TO AMERICAN EDITION. 
 
 My labors and efforts in developing the operations contained 
 in this book, for the subcutaneous method of curing Hernia, as 
 in perfecting the various instruments for the Uterus and Urinary 
 organs, have been so well and flatteringly received in Europe, 
 where no few compliments and praise was conferred upon the 
 author in public and ni private, as well as by personal letters, that 
 I am, after such endorsement and recognition, greatly encouraged 
 to present to the American profession my studies in this direction. 
 
 I present not only my own method of operating, but also the 
 operations and observations of others, endeavoring to give them 
 in as concise a form a possible, and to award credit wherever 
 there seemed to be merit. It will, I think, be seen that I have 
 not attempted to advocate my own peculiar views to the exclusion 
 of other surgeons, but to present all fairly for the reader's con- 
 sideration. I am now making a study of the pathological and 
 microscopical appearances produced in connective tissue by the 
 various fluids that have been used for injection as a cure of 
 Hernia. 
 
 I thank the profession for having received so liberally my 
 previous writings upon the subject of Hernia. It will give me 
 pleasure to demonstrate, when opportunity presents, not only my 
 method of operating for Hernia, but, also, for the removal of 
 stones from the bladder by new and improved instuments, which, 
 I think, I can show greatly facilitate the operation, besides giving 
 greater safety and ease to the patient than has hitherto been 
 possible. At no distant day I hope to lay before the profession 
 my labors in this very interesting branch of surgery. 
 
 Since the publication of this book in London, I have received 
 information that warrants me in giving the credit of the discovery 
 of the subcutaneous method of curing Hernia to the operator, to 
 whom. I think, the profession will join with me in agreeing that 
 it legitimately belongs. See Dedication and Appendix. 
 
 JOSEPH H. WARREN, M D. 
 
 51 Union Park, 
 
 Boston, Mass 
 
CONTENTS. 
 
 TAOV 
 
 INTRODUCTION . ~. 1 
 
 CHAPTER I. 
 
 HERNLE, KINDS AND FREQUENCY ••••••••37 
 
 CHAPTER II. 
 
 ANATOMY : DESCRIPTIVE AND SURGICAL • • • • 4S 
 
 CHAPTER III. 
 
 •STRANGULATED HERNIA * « . . • 85 
 
 CHAPTER IV. 
 
 OPERATIONS FOR HERNIA ..«••••• •••91 
 
 CHAPTER V. 
 author's operation by INJECTION « • • • • . 134 
 
 CHAPTER VI. 
 general remart:s 175 
 
xii CONTENTS. 
 
 CHAPTER VII. 
 
 FAGE 
 
 TREATMENT OF STRANGULATED HERNIA— TAXIS ••. 208 
 
 CHAPTER VIII. 
 
 KELOTOMY OR HERNIOTOMY .......••••••••. 217 
 
 CHAPTER IX. 
 
 TRUSSES • ••••••••••••• 243 
 
 BIBLIOGRAPHY ...♦.♦.♦... # . • • • . »f. 253 
 
 APPENDIX : giving urinary instruments of author . •T«T« • • 2p 5 
 INDEX 275 
 
HERNIA. 
 
 INTEODUCTIOK 
 
 In presenting to the profession this operation for the en re of 
 Hernia by injection, I am well aware that I shall meet with 
 some rebuffs and prejudice. This has always been the history 
 of every new or important surgical operation ; and in some 
 aspects it is well that it is as it is. We have only to recall the 
 history of ovariotomy to substantiate this statement most fully. 
 When McDowell performed his first successful operation he was 
 looked upon by the profession as rash and inconsiderate in the 
 extreme to propose such a preposterous idea as the removal 
 of the ovaries. If we refer to the earlier operators and 
 writers on ophthalmology, we find that no suggestion for the 
 removal of cataract was well received at first, and that it has 
 been only by perseverance and success, obtained by a conscious 
 honesty and sincerity that the operation was all that was claimed 
 for it, that every similar improvement in surgical art has been 
 attained. The same can be said of the operation of removing 
 stones from the bladder, of which Sir Henry Thompson has be- 
 come a world renowned authority. If such has been the history 
 of our art, how can any one hope to present to notice anything 
 new and not expect to run the gauntlet of professional criticism 
 and opposition ? It is in full knowledge of all these prejudices and 
 
 B 
 
2 HERNIA. 
 
 the severe criticism to be met, that I, after mature consideration 
 and reflection, now make my best endeavours amid the cares of 
 a general practice to present to the medical profession an 
 operation which I esteem worthy of most careful study and 
 its confident adoption. If by ovariotomy thousands are 
 yearly relieved to the prolongation of their lives, by the 
 operation which I present millions can be not only relieved 
 but cured. 
 
 " Droit et Royal/' our family motto, rightly expresses my 
 spirit of truthfulness and candour in freely offering to the 
 profession this operation, with all my instruments, to the end 
 that if my humble endeavours to aid the advance of scientific 
 medicine and surgery shall be of any avail, all may redound to 
 the glory and credit of the profession, and not to the selfish 
 aggrandizement of any individual. 
 
 Soon after the proper test had been made of the efficacy of 
 the operation for Hernia by injection, Dr. Geo. Heaton, leaving 
 the West, came to Boston and began the practice of medicine 
 in that city, celebrated for the high attainments of its pro- 
 fessional men of all arts as well as for the special high order 
 of all the thinking men who have prominence in any range 
 of life. Flushed with youthful pride at what lie naturally 
 and justly thought to be a complete revolution of practice upon 
 this great human malady, Dr. Heaton moved immediately to 
 bring out his operation more fairly to the medical profession. 
 There are those who will no -doubt remember that he was 
 not much more than courteously received in his first advances 
 to the gentlemen of the profession. The operation that he 
 described was so simple, so painless in comparison with the 
 older methods, and so perfectly and concisely stated, that the 
 practitioners were loth to believe that an operation so trifling 
 should be so effective as he described it. Those whom he had 
 invited to attend and witness his operation did not consider 
 
INTRODUCTION. 3 
 
 it worthy of their attention, and with some coolness of manner 
 did not hesitate to show such feeling ; this too, in spite of the 
 fact that it had already become known that the discoverer had 
 effected cures on a number of patients. Not disconcerted, 
 Dr. Heaton went to London, taking with him the secret of his 
 invention, determined, in view of the treatment he had received, 
 to give it to the old world, and let it reach the new, if it did, 
 without either his assistance or his favour in any degree beyond 
 his own practice. Sir William Fergusson became deeply in- 
 terested in the operation. The London profession received him 
 •with great cordiality. He was, immediately at the topmost 
 round of professional skill, and his fame began to spread. 
 He soon became Fellow of the Boyal ChirurgicaJ Society 
 of London, ot the Westminster and London Medical Societies, 
 and later of the Parisian Medical Society of France. 
 
 Upon his return to his native country the same prejudice 
 he had first met awaited him. This was heightened by the 
 anomalous position he had resolved to occupy in the profession. 
 Although a regularly accepted member of the Massachusetts 
 Medical Society, he resolved to practise his operation as a secret, 
 both in principle and details known only to himself. Although 
 I shared with the rest of the profession in this opposition to 
 the method he took of keeping the operation to himself, if there 
 was any good in it for the amelioration of human sufferings, 
 still I have since had reason to believe that much injustice 
 has been done to his motives. He was young when first he 
 came to Boston, he did not fully appreciate the conservativeness 
 of New England life, he was sensitive in his nature, and he 
 keenly felt the slight put upon him, at that time an unknown 
 operator. Instead, however, of excusing these fancied wrongs, 
 he nourished them so that they gained renewed acuteness as 
 the years went by. Finally he reached such a state of rebellion 
 and self-confidence that he would never acknowledge he had 
 
 b 2 
 
4 HERNIA. 
 
 a failure, although many of us knew that his success, grand 
 as it was, was not by any means perfect. 1 
 
 The principles of this operation given to the profession in 
 Heaton's work on Eupture, I at the death of the discoverer 
 assumed. I, now conscious of the imperfections of manner in 
 which I present it, offer this operation as I have scientifically 
 improved it for your favourable acceptance. If all as many 
 as see fit to adopt the method of operation will keep faithful 
 records of their results in a spirit of fairness, we may hope, 
 if circumstances warrant, to produce in some future edition 
 of this work more systematic and conclusive results than we 
 can in a spirit of truth do now. 
 
 With this distinct understanding, that I do not wish to 
 exaggerate, to deceive, or to be deceived, I beg you to receive 
 and to weigh well whatever I shall say upon the method of 
 subcutaneous injection into the hernial rings for the cure of 
 Hernia, trusting that if there still remain theoretical doubts 
 in the minds of any, time and experience will clear them 
 away. 
 
 I hasten the more to present this work upon Hernia to the 
 profession, because I am painfully aware that many who have 
 heard the method of subcutaneous injection have held such 
 wofully mistaken ideas as to the nature and results of the 
 operation, to say nothing of the culpable mistakes in regard 
 to the manner of performing it. 
 
 Although not wishing to be understood as defending Dr. 
 George Ileaton in his position towards the profession, and the 
 Hon. Committee of the American Medical Association that was 
 
 1 How perfect it was we had no means of knowing, yet many of us 
 were all the time conversant with the fact that we had patients under cur 
 care that apparently had been cured by Dr. Heaton. I myself knew of 
 many of his successful cases before I became personally acquainted with 
 the operator. 
 
INTRODUCTION. 5 
 
 sent to him, yet in justice to the deceased, and to give the 
 grounds of justification which he took, I will here reprint his 
 Review of the Report of the Committee that waited upon 
 him from the Association to ascertain his method of operation. 
 This will be of interest to the profession in Europe, and 
 especially to the younger members, as it gives a short history 
 of Dr. Heaton and of his operation of subcutaneous injection 
 for the cure of hernia : — 
 
 " A Committee appointed by the American Medical Asso- 
 ciation, to investigate the subject of the permanent cure of 
 reducible hernia, having made a report on the same, wherein 
 they come to certain conclusions, which a long and extensive 
 experience in the treatment of hernia has conviuced me to be 
 unsustained by facts, and make a certain statement in regard 
 to me which is not true, basing thereon some reflections alike 
 unwarrantable and unworthy of honourable men, I am induced 
 to submit the following review of the Report to the considera- 
 tion of the profession. 
 
 " Before considering the subject matter of the report, I will 
 notice briefly the particular portion which the Committee have 
 seen fit to devote to me. 
 
 " In speaking of certain communications received by them 
 from various sources, they say : 
 
 "'The writer of the fourth letter, George Heaton, M.D., of 
 Boston, has devoted himself pretty extensively to the treatment 
 of reducible hernia, and had given notice to that effect, 
 from time to time, for some years, in medical and other 
 publications 
 
 " ' The Committee, therefore, sent him not only a copy of the 
 questions luhich thy had addressed to the profession at large, but 
 they also wrote him a private note, couched in the most respect- 
 ful terms. To this he made a courteous reply, but, at the same 
 
6 HERNIA. 
 
 time, declined giving the information sought for. Not content 
 with this, he caused the note addressed to him, and his answer, 
 to be printed in several newspapers, which has, in our opinion, 
 given him a notoriety, wherever the transaction is known, of a 
 very unenviable character. 
 
 " ' It is certainly an unusual course for a member of our pro- 
 fession to conceal from his brethren any method of treatment 
 which he may regard as more valuable than those in common 
 use; and it is clearly one which cannot be too strongly re- 
 probated by all honourable and high-minded men. 
 
 " In this, there are two sources of complaint — the publication 
 of their letter to me, with my reply, and my refusal to make 
 them the medium of communicating my discovery to the world. 
 The latter point I will discuss anon. I will only say of it 
 now, that I feel myself fully competent, and imagine I have 
 the right, to make known any discoveries that I may make, 
 without the aid of any other man or committee of men, at such 
 time, and in such way, as may be convenient to me. 
 
 " The statement of the Committee, in regard to the publication 
 of our correspondence, grossly misrepresents the whole matter, 
 and conveys a totally wrong impression. 
 
 "I will state the case briefly, and let the profession draw their 
 own inferences. 
 
 " The Committee assert that they sent me, in the first place 
 o. copy of the questions which they addressed to the profession 
 at large. 
 
 "Whether such a copy was sent to any or every other member 
 of the profession, and if so, at what time, I know not. Nothing 
 of the kind was ever sent to me ; and it was not until after 
 I had rendered doubtful, by my reply to their note, whether 
 I should communicate my discovery through them, or not, that 
 these questions were published in the Boston daily journals, 
 addressed to the profession and public at large. The only 
 
INTRODUCTION. -J 
 
 communication I ever received from the Committee, was the 
 following : 
 
 "'Boston, Oct. 30th, 1851. 
 
 "'Dear Sir: — The undei signed are a Committee of the 
 American Medical Association, to prepare a report on the 
 "Kadical Cure of Hernia." Being aware that you have given 
 much attention to this interesting branch of surgery, and learning 
 that your method of treatment has been attended with a great 
 degree of success, they are desirous of ascertaining from you 
 what is the precise mode you adopt, and what has been the 
 general result. 
 
 " ' They trust that you will readily communicate such informa- 
 tion as may aid them in the performance of the duty assigned 
 them by the Association, and a compliance with their wishes 
 at your earliest convenience will be gratefully felt and ac- 
 knowledge^ by your friends and humble servants, 
 
 'Geo. Hayward, j 
 
 "'Geo. Heaton, M.D/ 
 
 "'J. Mason Warren, > Committee, 
 "'S. Parkman. ) 
 
 " Although I was unable to see the propriety of a request on 
 the part of those who did not profess to know anything of any 
 practical value of a subject, to obtain from one the results 
 which patience, perseverance, and years of hard study had 
 afforded him on the same subject, merely that they might be 
 the medium of heralding his discoveries to the profession, and 
 considered their supposition, that I would readily accede to 
 their request, as an hypothesis which neither they nor any 
 other reasonable man ought to entertain, I still concluded, 
 considering the very courteous manner of the Committee, to 
 give their request due consideration. After having done so, 
 I submitted to them the following reply, some two weeks or 
 more after I received their note. 
 
6 , HERNIA. 
 
 "'Boston, Nov. 17th, 1851. 
 No. 2, Exeter Place. 
 
 "'Gentlemen: — Your note of the 30th nit., requesting me 
 to communicate to you the precise mode I adopt for the radical 
 cure of reducible hernia, in order to assist you in making out 
 a report, in compliance with the wishes of the American Medical 
 Association, was duly received. 
 
 "'I at once took the matter into consideration, and determined 
 to comply with your polite request. Upon more mature 
 reflection, however, I found that it would be very difficult, if 
 not impossible, for me to do so, and at the same time do 
 justice to myself and the subject, in the limited time allowed me. 
 
 " ' I have devoted, as you are aware, many years to the careful 
 investigation of this important branch of surgery, and have, I 
 am happy to say, discovered a safe and certain method of 
 curing a complaint which has so long baffled the skill of our 
 profession. 
 
 " ' But, knowing that so many surgeons of eminence have so 
 far convinced themselves of their ability to cure the disease, 
 that they have actually published to the world their particular 
 modes of operation — no one of which, however, has outlived 
 its author — and, on the contrary, knowing that many, by pre- 
 maturely thrusting their supposed discoveries upon the profession, 
 have not only brought upon themselves censure, but even 
 ridicule, — I determined, even long after I had satisfied myself, 
 and verified my theory, by hundreds of successful cases, that 
 it should be subjected to the more convincing test of time, 
 and consequently delayed publishing it to the profession. 
 
 " ' After long deliberation I decided that I would either publish 
 the matter through a paper, or more at length in a volume, and 
 finally had determined to follow the latter course. 
 
 " ' If I shall determine to publish, as preliminary to my work, 
 a paper on the subject, I shall be most happy, gentlemen, to 
 
INTRODUCTION. 9 
 
 make you the medium of communication. In the meantime, 
 hoping that you will excuse the delay I have shown in replying 
 to your note, and thanking you for your kind recognition of 
 my claims, I am your friend and humble servant, 
 
 '"GEOEGE HEATOK 
 
 "'Geo. Hayward. M.D., "} ~ . ±± . . ,,,. 7 . , 
 
 ,. , „ 'I Committee American Medical 
 
 "'J. Mason Warren. M.D., V . x . , 
 
 Association. 
 
 "<S. Parkman, M.D. 
 
 \ 
 
 f| It was after I sent them this reply, that certain questions 
 appeared in the daily journals, addressed, seemingly, to the 
 medical profession, but virtually, like everything else in a 
 public journal, to the public at large. 
 
 " The Committee, all Boston men, knew well, and the public 
 knew well, that I had been attending for some ten or twelve 
 years to the radical cure of hernia, and also as the Committee 
 admit, that my method had been attended with a great degree 
 of success. 
 
 u After having requested me, then, to make to them an expose 
 of my peculiar mode of treatment, and having obtained what 
 they deemed to be my refusal to do so, with my reasons 
 assigned, (which they have, however, carefully, and most in- 
 excusably, kept out of their report), they appealed through 
 the daily press to the public. 
 
 " Now what, I ask, would be the inference which any man 
 unacquainted with the whole truth of the matter, would draw 
 from reading an appeal from eminent phj^sicians, through the 
 columns of a newspaper, desiring to be furnished with data, — 
 if any such there were, — bearing on the radical cure of hernia ? 
 Manifestly, that there was no cure for hernia known. 
 
 " Should I, then, suffer so false an impression to be spread 
 abroad, when I had professed, for years, to cure hernia? When 
 
10 HERNIA. 
 
 the public, or a large portion of it, at least, had understood 
 that I did ? When the medical profession throughout the 
 country, and some of its leading members in Europe, under- 
 stood it ? When the very members of this Committee not only 
 knew it, but knew of its great success ? 
 
 " Did the Committee suppose, when they published those 
 questions, calculated to brand me, in the eyes of those who 
 read them, as an imposter, and all my pretensions, for ten 
 years, as quackery, that I would neglect to notice them, merely 
 to gratify an unwillingness on their part, to have what they 
 pretended to be their honest sentiments made known ? That 
 I would disregard my own welfare, and that of those dependent 
 on me, merely for fear of some imaginary breach of the laws 
 of etiquette? If they did, they must have supposed me to 
 be destitute of the very common and necessary instinct of 
 self-defence, or, at all events, to be a very different person 
 from what I am. I can assure them, that had their note been 
 of a private nature, as it in reality was not, it would have 
 been given to the public under like circumstances. 
 
 " The note contained, as I supposed, their honest sentiments ; 
 and, although containing nothing of a private nature, as any 
 one may see by referring to it, would still have been cheerfully 
 kept private, had not their course afterwards obliged me to 
 publish it as a matter of self-defence. It was the only means 
 I could adopt to destroy effectually the false, and to me fatal 
 impression, which their appeal was calculated to produce. If 
 they did not mean what they said in their note, — if it was 
 only an ingenious trap to catch an unsuspecting victim, they 
 may have reason to regret its publication ; but not to charge 
 me with any breach of professional or other etiquette. I repel 
 any such imputation as an ill-disguised sophism to conceal 
 a more ill-disguised feeling. 
 
 <c As to the opinion of the Committee, that the transaction, 
 
INTRODUCTION. 11 
 
 wherever known, has given me a notoriety of a most unenviable 
 character. I must beg leave to differ from them entirely. 
 
 "As far as I can judge, from conversation with distin- 
 guished members of the profession, and from communications 
 received from all parts of the country, immediately after the 
 publication of those letters, the notoriety which accrued to 
 me was eminently of an enviable character ; if, by envy 
 we are to understand (as the Committee seems to) the desire 
 on the part of one person to come into the condition of 
 another. 
 
 " The majority of the profession, and the public generally, 
 probably neither cared nor thought anything of the letters 
 themselves, or of the circumstances of their publication, any 
 further than as they were the vehicle of conveying the announce 
 ment, that a new and valuable discovery had been made in 
 surgery. The notoriety in question, seemed to me to be 
 precisely that which would attach to any author of a discovery 
 which had been confirmed by scientific men. 
 
 " It was such, for example, as accrued to the discoverer of the 
 anaesthetic power of sulphuric ether, after its value had been 
 attested by this Committee and others, at the Massachusetts 
 General Hospital. And the opinion of the Committee on the 
 particular mode in which this discovery was made known to 
 the world, is of as little interest or consequence to the profession 
 and the public, as the almost endless discussion known as 
 the ' Ether controversy.' 
 
 " The welfare of mankind being of so much more consequence 
 than the laws of etiquette, men do not stop to inquire whether 
 these latter have been fully observed in making a valuable 
 discovery known. 
 
 " An engineer announces that he has discovered a mode of 
 substituting heated air for steam, in the propulsion of machineiy. 
 It is immaterial to the public whether the gentleman consulted 
 
12 HERNIA. 
 
 his fellow engineers and mechanics, or not, so long as it has 
 faith in the genuineness of his discovery. 
 
 "The opinion of the Committee, on this point, I deem to 
 be false ; and, whether false or true, of no value whatever, and 
 totally out of place in a report purporting to treat of the radical 
 cure of hernia. The relevancy of the laws of etiquette to 
 the approximation of the pillars of the abdominal ring, the 
 true point to be discussed in such a report, I have yet to learn. 
 
 " The Committee assert that ' it is an unusual course for a 
 member of our profession to conceal from his brethren any 
 method of treatment which he may regard as more valuable 
 than those in common use.' 
 
 " Without being the apologist or defender of selfishness, as 
 exhibited by the medical or any other profession, I doubt the 
 truth of the assertion as a general one. It is an adage, almost 
 an axiom, that every physician makes his own theory and 
 practice. 
 
 " The evident and immediate consequence of this is, that there 
 are as many different modes of treating diseases in general (there 
 are exceptions of course) as there are physicians. Another fact, 
 with which we are all acquainted, and which has always been 
 the standing reproach of the profession, is -the jealousy, almost 
 proverbial, which exists among its members. The origin of this 
 feeling is not, it is true, to be charged upon physicians them- 
 selves, but probably to that disposition or desire on the part of 
 patients or their friends, in critical or difficult cases, to change 
 their medical attendants. The effect of it is, to induce them to 
 study out more carefully than they otherwise might, successful 
 modes of treating disease ; and while they would not withhold 
 from the profession or public the matured results of their careful 
 experience, they do not feel called upon to pause from their 
 labours at the command of every tyro, until he shall be in- 
 structed equally with themselves. Physicians, generally, do 
 
INTRODUCTION. 13 
 
 not fling this as a reproach at each other, but consider it a merit 
 rather. Complaints, if they ever do come, emanate from those 
 who, having become independent of their profession, have time 
 to instruct' in their peculiar ethics, their less fortunate brethren, 
 since they are not likely to be called upon to act up to them. 
 The ' high-minded and honourable men ' of whom the Committee 
 make mention, I have too often found to be those, who, by an 
 illustrious name handed down through a long line of ancestry, 
 or by a competency of the means of subsistence, which has 
 come to them over the same royal road,* are independent of the 
 labours to which other men are subject, and can, from their 
 position of leisure, launch their darts at their more laborious 
 brethren with impunity. So far from fearing to lose the esteem 
 of such men, I am quite willing to be the object of their 
 reprobation. 
 
 " I do not wish to be understood as basing the defence of my 
 position on any ground of expediency, but, as the Committee 
 have taken the liberty to decide summarily certain points which 
 are, at least, open for discussion, I have presumed to differ from 
 them. 
 
 " In my course, I profess to have followed no authority or 
 precedent whatever, but to have been governed by my own idea 
 of right, and the course I have taken is so in accordance with 
 my own convictions of duty, that nothing would have induced 
 me to swerve from it. 
 
 " There is another fact, of which, however insignificant in it- 
 self, as it involves a point of etiquette, the profession may as 
 well be informed. 
 
 " The Association, as I am told by one who was present, ap- 
 pointed the Chairman of this Committee alone, giving him the 
 privilege of selecting two others as associates. Now one would 
 suppose, a friori, that in such a case, if there was one particular 
 member of the profession whom the chairman knew to have 
 
14 HERNIA. 
 
 devoted more time than anyone else to hernia — whose mode 
 of treatment, practised daily for years, he knew had been at- 
 tended with great success, — he would, out of mere regard for 
 professional courtesy, have selected this individual as an as- 
 sociate, instead of choosing one who, however otherwise 
 distinguished as a surgeon, knew nothing more of the matter 
 in question than he himself knew, and then, having completed 
 his body corporate, turn deliberately to the individual whom 
 he acknowledged to be the depositary of all the facts of any 
 value not already known, and request him (very politely indeed) 
 to make an expose of his 'precise mode' of treatment, and a 
 general history thereof, in order, forsooth, that these three 
 individuals might have the privilege of communicating it to 
 mankind. 
 
 " Verily, the Committee must either have regarded me as 
 totally incapacitated for communicating my discoveries to the 
 world, or as too modest to make them known without the aid 
 of an interpreter, to neither of which hypotheses, I must 
 say, do I plead guilty. 
 
 " The charge of a want of philanthropy on my part, (which I 
 conceive to be the essence of what the Committee recommend to 
 the reprobation of honourable and high-minded men,) from their 
 own admission, is reflected directly back on themselves. 
 
 " They admit, without any qualification, that they have learned 
 of the great success of my operation in the treatment of hernia, 
 and yet not one of the Committee, that I am aware of, ever 
 sent or even recommended a patient to me. 
 
 " Whenever patients of theirs have consulted me, it has been 
 of their own accord, or at the suggestion of some friend ; never 
 by the advice of the physicians themselves in the outset. 
 
 " In cases where they have informed their physicians before- 
 hand, that they were about to place themselves under my care, 
 the former have, indeed, condescended to assure them (as the 
 
INTRODUCTION. 15 
 
 patients themselves have informed me) that ' Dr. Heaton has 
 had much experience in the treatment of hernia, and they 
 would undoubtedly be safe in his hands.' 
 
 " Most of my patients from out of town have been sent to me 
 by their physicians. In a majority of cases, these physicians 
 have had no more to rely on than the mere announcement 
 through a medical journal, that I treated hernia ; yet, on the 
 bare peradventure that I might cure it, hundreds have been thus 
 recommended to my care. 
 
 " If the Committee were aware, as they assert they were, of my 
 great success in treating hernia, it certainly would have been 
 the truest philanthropy on their part (according to any plausible 
 definition of the word philanthropy) to recommend the afflicted 
 to one ' in whose hands, from his long experience in the 
 treatment of hernia, they would undoubtedly be safe.' 
 
 " I will give a brief history of my experience in the treatment 
 of hernia, — of the encouragement and discouragement with 
 which I have been favoured by sundry of my professional 
 brethren, and let those who are ignorant of the matter draw 
 their own conclusions as to who is in the right and who in 
 the wrong. 
 
 " As the Committee have much to say of the operation by 
 injection, the value of which, in my opinion, they exaggerate 
 entirely, and the origin of which, whether accidentally or in- 
 tentionally, they attribute to the wrong source, I will give the 
 true account of the origin and value of this operation ; from 
 which, I will premise, two conclusions will be obvious, at 
 variance with those to which the Committee seem to have come. 
 
 " First, that Dr. Pancoast is not the originator of the operation 
 by injection ; that I performed it, and described it to' my friend 
 Dr. Mott, of New York ; and, moreover, that Dr. Jayne, of 
 Illinois, had invented an instrument for performing said 
 
16 HERNIA. 
 
 operation, and secured letters patent on the same some two years 
 before Dr. Pancoast, according to his own account, made any 
 experiments with it. Secondly, that the subcutaneous operation 
 by injection of the hernial sac, is neither a simple nor advisable 
 operation ; that, although successful in many cases, if rightly 
 performed, the difficulty of performing it without bad 
 consequences ought to condemn it entirely. 
 
 " My attention, with that of Dr. Hart, of Alton, Illinois, was 
 first directed more particularly to the operation by injection of 
 the sac, for the radical cure of hernia, by Dr. Jayne, who had 
 invented an instrument for performing such an operation, and 
 before coming to us, had, in the year 1840, secured a patent on 
 the same. 
 
 " Having at that time under our care several cases of re- 
 ducible hernia among the convicts in the Penitentiary at Alton, 
 we immediately set about testing the value of the operation on 
 the persons of these, and also on that of some of the blacks at 
 St. Louis. The operation consisted in injection of the sac sub- 
 cutaneously with an irritating fluid, by means of the instrument 
 before mentioned. In the selection of a fluid for the purpose, 
 Dr. Jayne gave the preference to some one of the essential oils, 
 using now and then tincture of cantharides. In my first 
 operations I used also the essential oils, but soon abandoned 
 them for ""the tincture of iodine. I believe, therefore, that I 
 performed the operation of injection with iodine, of which so 
 much has been said, before any other man. 
 
 " Before our experiments, the operation of injection by the 
 subcutaneous method had never been performed either in this 
 country or in Europe. At least no report had been made of 
 any such operation, and there is no reason to suppose that it 
 Lad ever been undertaken. 
 
 " With the success of these experiments we were much elated, 
 and felt that the desideratum for the radical cure of hernia had 
 
INTRODUCTION. 17 
 
 at length been discovered. Subsequently, in November, 1841, 
 I communicated the result of the operation to Dr. Valentine 
 Mott, of New York. He expressed himself highly pleased 
 with it, and made a complimentary allusion to it in his lectures 
 before the University. 
 
 "In the spring of 1842 I came to Boston, where I had 
 concluded to remain, and make the treatment of hernia a 
 speciality. Having obtained an introduction to the leading 
 members of the profession in Boston, and particularly to the 
 surgeons of the Massachusetts General Hospital, I informed 
 these latter of my intention, and offered to operate in their 
 presence, on any case or cases which they would furnish me, 
 and let them see the result, knowing well that such cases were 
 continually coming under the notice of physicians, and were 
 probably always to be found in the hospital. No notice was 
 taken of this offer ; no cases were furnished me. 
 
 "Although I considered that I was under no obligation to 
 those who had shown such entire want of what I believed to 
 be common courtesy, I still, some six months after this, when 
 I had, through the kindness of a medical friend, obtained 
 several cases of reducible hernia, addressed the surgeons to 
 whom I had made my original proposal, and other members of 
 the profession, a polite note, inviting them to be present and 
 witness me operate for the radical cure of hernia. Most of 
 those invited were present, and witnessed the operation. I 
 felt then that I had done my part, that T had cleared myself, 
 at all events, of the liability to a charge of a want of profes- 
 sional courtesy ; and from that day to the present I have taken 
 an entirely independent course. 
 
 " Feeling that these men, not only by the total w T ant of en- 
 couragement, but the complete discouragement which I had 
 received from them, had forfeited all right to expect any 
 further advances from me, I resolved to rely entirely on my 
 
 c 
 
18 HERNIA. 
 
 own individual effort for success, and in spite of the frowning, 
 discountenancing, nay, the very direct opposition which the 
 would-be leaders of the profession here have shown me, I have 
 so relied to this day, and thank fortune that I have leaned on 
 no broken reed. 
 
 " So much for my course, on which the Committee have seen 
 fit to reflect so severely. I will only say in addition, that such 
 reflections ill come from the very ones from whose want of 
 courtesy and good feeling the course which they reprobate was 
 entered upon. 
 
 "The operation by injection, in many cases so satisfactory 
 and apparently so permanent, in others was not so. Frequently 
 it required to be repeated several times on the same individual, 
 and in all cases the utmost care was required in its perform- 
 ance to avoid troublesome consequences, as, I understood, those 
 of the Committee who undertook it found out. 
 
 " Becoming dissatisfied with this operation, and having al- 
 ready, in the course of my investigations, tested every principle 
 of any degree of plausibility which had been suggested or relied 
 upon by operators in times past, for the cure of hernia, with no 
 satisfactory results, I felt that the only hope of a permanent 
 cure in all or in a majority of cases of hernia, lay in some modus 
 operandi, the effect of which should be an approximation of the 
 pillars of the abdominal ring, or a closure of the tendinous 
 openings. For a long time, therefore, I conducted all my re- 
 searches with a view of getting at some principle which would 
 enable me to accomplish this. 
 
 " These researches, in which of necessity I was obliged to 
 rely almost entirely on theory alone, did conduct me, I am 
 happy to say, to precisely such a principle ; a principle on 
 which I have based a mode of treatment and operation which 
 closes effectually and permanently the various openings through 
 which hernial protusions take place. Not only, indeed, does it 
 
INTRODUCTION. 19 
 
 do this, but in those cases where, from a general weakness re- 
 sulting from the extreme delicacy of the textures connected 
 with hernia, or a thinness, as it were, of the parieles abdomi- 
 nales, there is a positive predisposition to the complaint, I have 
 found that it rendered the part firmer and better ab 1 - resist 
 pressure than in its original condition. 
 
 "In such cases, where there has been a recurrence of hernia, 
 I have almost invariably found it occurring at some other 
 opening. Thus, when I have cured a person of oblique ingui- 
 nal hernia, and he has afterwards, from a fall or violent strain, 
 brought it on anew, it has proved, almost without exception, to 
 be direct inguinal hernia. 
 
 " The Committee are aware, and every physician who knows 
 the anatomy of the parts thoroughly must be aware,, that any 
 operation for the radical cure of hernia must be, at the best, a 
 delicate operation, and an operation which an unskilful or un- 
 practised hand would undertake with no little hazard. » And 
 yet it might be an operation, the apparent simplicity of which 
 would strike any one ignorant of the complicated anatomy of 
 hernia, the vital organs and vessels involved therein. The 
 history of the attempts at the cure of hernia furnishes, we all 
 know, a series of catastrophes perhaps unequalled in the annals 
 of any other branch of surgery. 
 
 " Such is the frequency of the complaint, the alarming condi- 
 tion which it so often assumes, and to which it is always liable, 
 and the readiness with which men submit to any operation 
 likely to cure it, that it has always furnished a broad and 
 fruitful field for the labours of quackery and imposition. 
 
 " Suppose, then, an operation against which scepticism, from 
 a high quarter, has already directed its attacks, should be 
 announced to the world, the apparent simplicity of which were 
 its obvious characteristic. What, according to the reason and 
 experience of every physician, would be its probable destiny 1 
 
 c 2 
 
20 HERNIA. 
 
 It would be undertaken by surgeons of every grade of capacity, 
 by quacks of every grade of villany. With the more skilful 
 and more experienced of the former, it would probably be at- 
 tended with success. With those of less experience and manual 
 skill, it would undoubtedly be condemned, not from its own 
 deficiency, but simply from their inability to perform it. 
 
 " The attempts of the latter class would, in a majority of 
 cases, prove most unfortunate, if not fatal to those who might 
 fall into their hands. All the evil results would be attributed 
 not to their true cause, the fact of a man's undertaking what 
 he is not competent to perform, but unquestionably to the 
 operation itself. 
 
 " That this is not all theory I think I have letters in my 
 possession to prove. I have been applied to from various parts 
 of the country, through letters, by non-professional men, de- 
 siring to obtain from me, by payment or otherwise, my mode 
 of operation ; and by persons whose very letters show their 
 entire ignorance of hernia, and their utter incompetency to 
 undertake so difficult a branch of surgery as a profession. 
 
 " It is this class of reckless experimenters who would eagerly 
 seize an operation apparently simple, which promised to cure a 
 complaint so universally prevalent as hernia, and whose efforts 
 would, in a very short time, condemn both the operation and 
 its author to inglorious oblivion. 
 
 " I am not so destitute of foresight as to run any such risk 
 in making haste to publish a discovery of mine. Although 
 satisfied early of the value of my operation, I determined not 
 to give it to the world until its success should have placed it 
 beyond the reach of cavil or scepticism. Such was the ground 
 I took in my letter to the Committee, and such is the ground 
 on which I defend myself from the unjust and dishonourable 
 reflections in their report. 
 
 " But, setting aside all apologies and extenuations, how the 
 
INTRODUCTION. 21 
 
 Committee can so ignore the indisputable right which every 
 man has to make known a discovery he may have made in 
 science, at such time and in such way as he may see fit, is 
 beyond my comprehension. It is a right which, if we have 
 any rights as individuals, is so evident, that any man or any 
 society that shall attempt or pretend to override it, certainly 
 lays itself open to the charge of an unwarrantable assumption 
 of authority. 
 
 " The Committee have presumed not to form an opinion only 
 — which of itself would be of no consequence, — but, on the 
 ground of that opinion, to base certain reflections for the public 
 ear, when the very premises on which alone a correct opinion 
 may be formed are entirely unknown to them. 
 
 " A man may, for the very best of reasons, keep a certain 
 discovery for a time to himself. It may be necessary both for 
 his own safety and that of the discovery itself. Xay, the case 
 is supposable, and even probable, where it may be the part of 
 the highest philanthropy for him to do so. 
 
 " A surgeon, for example, from long experience in performing 
 a very delicate operation, for an ever-varying and always com- 
 plicated complaint, may have so disciplined his sense of touch, 
 and have acquired such delicacy of manipulation, that he can 
 detect those peculiarities, whether anatomical or abnormal, a 
 knowledge of which is absolutely essential to the successful 
 treatment of the complaint, and adapt his mode of treatment 
 to the Protean phases it may assume. This faculty, acquired 
 only by long experience, he knows he cannot communicate to 
 another ; yet on it the success of his operation mainly depends. 
 The mere description of the operation he may give to any one ; 
 but in the hands of other men it is very sure tc prove unsuc- 
 cessful. In this want of success he of course must- share, until 
 finally the operation is condemned, merely because other men 
 lack the ability to perform it. 
 
22 HERN I A. 
 
 " Yet, according to the Committee's theory of condemnation, 
 the very course on the part of the surgeon which would secure 
 to humanity the benefit of such an operation, is not merely to 
 be found fault with, but actually held up to the reproach of all 
 honourable and high-minded men. 
 
 "The absurdity of such a judgment, on the part of sensible 
 men, is to me so manifest, that I deem it almost an insult to 
 common sense to expose it ; and had they seen fit, in their 
 report, to have stated their own private opinion in regard to my 
 course, although it must have been entirely without foundation, 
 it might have remained on record undisturbed; but as they 
 have gone still further, and founded on this baseless opinion 
 certain reflections derogatory to my character, I cannot refrain 
 from holding up so dishonourable, if not libellous an attack, as 
 eminently worthy the reprobation of every true gentleman in 
 the profession and community. I find nothing generous, 
 nothing manly in such an attack. Indeed, what [ have done 
 to merit it I cannot divine. I am not aware that I ever inten- 
 tionally insulted any one of the Committee. If my course has 
 not been such as comes up to their idea of philanthropy, they 
 may in their hearts pity my want of humanity, but never, while 
 I am not doing evil to my fellow men, upbraid me publicly, I 
 flatter myself, however, that I feel quite as tenderly for those 
 suffering in mind or body, as they do. I think I might descend 
 to the same acts of charity and self-sacrifice. In the faculty of 
 deliberately attacking a fellow physician who is pursuing the 
 even tenor of his course, and perchance doing good in an 
 humble way, without interfering in the least with others — of 
 attempting to undermine the refutation which years of steady 
 industry may have afforded him — I yield the palm most wil- 
 lingly to the Committee, and trust they may find quiet repose 
 on such laurels. I must inform them, however, that denuncia- 
 tion founded on mere surmise, from however lofty a source it 
 
INTRODUCTION. 23 
 
 may emanate, and however well it may answer as an apology 
 for the meagreness of a report, is not likely to be digested as 
 truth by the generality of men of sense and honour. 
 
 " After expressing their acknowledgment to the few physicians 
 who have furnished them with the results of their experience 
 in the treatment of hernia, they assert that they have not 
 obtained all, in this way, which the Association had a right to 
 expect. Just how extensive may have been the expectations of 
 the Association, in fact, just whom the Committee mean by the 
 Association, it is not easy to tell. 
 
 " I understand the Ainerican Medical Association to include 
 all regular physicians in the country. A majority of these, pro- 
 bably, had no expectation whatever in regard to any of the 
 reports of the various committees. 
 
 " Those who might have had any in regard to that of the Com- 
 mittee on hernia, imagined, I presume, that this Committee 
 themselves had something extraordinary which they were 
 anxious to divulge, and were not to furnish a report of various 
 unsuccessful attempts to cure hernia, already made known to 
 the profession over and over again, by their authors and others 
 treating on hernia, and without exception abandoned as failures. 
 That surgeons of high standing should presume to rill out the 
 pages of a report with an exposition of operations of such 
 notorious worthlessness and barbarity as those of cauterization, 
 ligature, suture, invagination, &c, was more than the Associa- 
 tion had reason to expect or desire. It certainly was to be 
 hoped, for the honour and welfare of the medical profession 
 that such operations, already expounded and exploded ad 
 satietatem one would suppose, might never again, be dragged out 
 from their obscurity, and paraded before the profession and 
 public to increase a prejudice, already sufficiently strong, 
 against physicians, but might be permitted to rest in peace, as 
 sad monuments of the rashness and complete disregard of life of 
 
24 HERNIA. 
 
 which scientific men may be guilty. Had any troubled them- 
 selves to think of the matter beforehand, they would, of course, 
 have seen that had a particular individual anything really new 
 and valuable in regard to the treatment of hernia, he would be 
 far more likely to make it known per se when he saw fit, than 
 to take advantage of even so distinguished a medium of 
 communication as this Committee furnished. 
 
 "The interest created among physicians in general by their 
 appeal, seems to have been by no means commensurate with 
 the Committee's expectations. From the entire medical pro- 
 fession throughout the country, (exclusive, I suppose, of the 
 Canadas and Mexico,) seven only have thought it worth while to 
 furnish them with communications, the value of which may be 
 inferred from the fact, that the sweeping conclusions at the 
 close of their report condemn them without mercy or apology. 
 
 " Their language seems to imply that, in their opinion, many 
 physicians have kept back valuable information which they had 
 a right to expect ; and 1 only wonder, considering the particular 
 notice they have taken of one individual for his inexcusable 
 reserve, that they did not condense their indignation against all 
 these other imaginary delinquents into, at least, one general 
 sentence of condemnation. 
 
 "At the close of their report are three conclusions, which 
 seem to contain the sum and substance of their efforts to 
 perform the duty assigned them by the Association. 
 
 " As I presume I have had more experience in the treatment 
 of hernia than the Committee and all those whose communica- 
 tions they give in their report together — having, as far as I can 
 learn from the published accounts of their experience, treated 
 and cured a hundred cases where they have attempted one — I 
 shall take the liberty to examine these conclusions critically. 
 
 " They are as follows : 
 
 1. "' There is no surgical operation at present known which 
 
INTRODUCTION. 25 
 
 can be relied on, with confidence, to produce in all instances, ot 
 eVen in a large proportion of cases, a radical cure of reducible 
 hernia.' 
 
 " This conclusion I, of course, affirm to be false in toto. I 
 assert that there is a surgical operation which can be relied on 
 with confidence, to produce a radical cure of hernia,, not only in 
 a large proportion of cases, but in all cases which one could 
 reasonably expect to be cured; and I am ready to prove the 
 assertion by referring the sceptical to five hundred cases, 1 or 
 more, if they choose, including those of almost every degree of 
 severity, exhibiting the complaint in nearly every form, which, 
 it seems to me, it is possible for it to assume, and as it occurs 
 in those of every age, from the infant of nine months to the 
 adult of seventy years, — treated and radically cured by this 
 operation. 
 
 2. " ' That they regard the operation of injection by the subcu- 
 taneous method, as the safest and best. This will, probably, in 
 some cases produce a permanent cure, and in many others will 
 afford great relief.' 
 
 " As this conclusion is entirely empirical, I suppose the one 
 who has had the most extensive experience with the operation 
 may be permitted to decide upon its merits. As to its being the 
 safest and best, I will only say that I think it neither safe nor 
 well for the Committee to recommend it in any such terms. 
 Certain it is, that in the hands of inexpert operators it is very 
 far from being a safe operation ; in the hands of none, whether 
 expert or not, is it the best. The second portion of this conclu- 
 sion is of no consequence. The same might be said, with equal 
 truth, of the obsolete operations of cauterization, invagination, 
 the royal stitch, and various other barbarities which the humanity 
 of modern surgeons has condemned. ISTo one doubts that in 
 some cases they did produce permanent cures, while in many 
 1 I have given a few examples of these as an appendix to this Review. 
 
26 HERNIA. 
 
 other cases, the relief afforded by them was certainly permanent 
 and final as to all troubles of the body. • 
 
 3. " ' That compression, when properly employed, is, in the 
 present state of our knowledge, the most likely means of 
 effecting a radical cure in the greatest number of cases.' 
 
 " As to compression as a curative agent, twelve years' expe- 
 rience in the treatment of Hernia has led me to a different con- 
 clusion entirely. As a remedial agent, as an agent essential to 
 the safety of those afflicted with Hernia, before they are radi- 
 cally cured, I do not wish to detract from its value. That now 
 and then persons are cured by means of compression, is not to 
 be denied. But as a curative agent in general, it is not to be 
 relied on at all. 
 
 " I have known, and so have the Committee, in all probability, 
 the most favourable cases to have received almost perfect com- 
 pression, from well-constructed trusses, and that, too, for a 
 period sometimes of twenty years, without having their aspect 
 changed, unless for the worse, in the slightest degree. 
 
 " There are some other points in the report deserving criti- 
 cism, and some not connected with it, which I may have occa- 
 sion to notice at a future time. In what I have said, I may 
 have shown feeling, perhaps too much. My apology is, that I 
 have had to defend what I know 7 in my heart to be an honourable 
 course, against an uncalled for and unjust attack, which would 
 represent it only as dishonourable, but as worthy the reproach 
 of honourable men. Engaged in defence of character, I have 
 spoken decidedly. I have no disposition to offer insult, and 
 cannot brook it, come whence it may. For condemning mis- 
 statements, misrepresentation, and pernicious opinions, by 
 whomsoever made or entertained, I offer no apology. 
 
 " Taking the report as a whole, as it has failed to add to our 
 knowledge a single new fact or principle from which future 
 good is likely to be derived, while, as a review of various 
 
APPENDIX. 27 
 
 obsolete operations, its place was more than supplied by a similar 
 review by Dr. Bryant, of which it seems to be little more than 
 a mere transcript ; and, moreover, as they have seen fit to make 
 it the vehicle of an un gentlemanly attack upon a private indi- 
 vidual, for not complying with an arbitrary request — an indi- 
 vidual, too, towards whom one of the Committee, at least, had 
 not shown even common courtesy — it is certainly unworthy the 
 character of the Association for which it was prepared. 
 
 APPENDIX. 
 
 " I have here subjoined skeleton reports of a few cases, taken 
 at random from my journal. It will be readily seen by those 
 conversant with Hernia, that these exhibit the complaint in its 
 most aggravated form, and are those which serve as tests of the 
 value of any operation for its radical cure. In all or nearly 
 all of them, the Hernia could not be retained with any truss • 
 the patient suffered great pain at times, and constant incon- 
 venience ; in many, a bad varicocele or enlargement of the 
 spermatic veins accompanied the Hernia; while in others, these 
 two complaints were combined with hydrocele. The time I 
 have required patients, in such cases, to remain under my care, 
 has been ordinarily from two to three weeks. 
 
 '• The impression, which I find to be quite general, that my 
 mode of treating Hernia requires a formidable surgical opera- 
 tion, I would here state to be entirely wrong. The operation 
 which I perform is wholly subcutaneous, and is done with 
 a delicate instrument adapted to the purpose, the wound froni 
 which cannot be discerned six hours after the operation. 
 
 " Mr. K. D. C, of Marlboro', Vt., aged 22 years, consulted 
 me February 28th, 1847, for a direct Inguinal Hernia, of about 
 one year's standing. The Hernia had got to be of great size, 
 had descended into the scrotum, which it filled up. He waa 
 
28 HERNIA. 
 
 unable to retain it with any truss, and had in consequence 
 been obliged to give up business in a great measure. I operated 
 for its radical cure, February 23th. He remained under my 
 care one week. It has never made its appearance since the 
 operation. 
 
 " Mr. J. C, of Fall River, Mass., aged 35 years, very fleshy, 
 had a very large oblique Inguinal Hernia, which he had found 
 it impossible to keep up with a truss. May 15th, .1847, I 
 operated for the cure of the same. Cure complete. 
 
 " Mr. J. B., Boston, aged about 24 years, had had for six years 
 an oblique Inguinal Hernia of the right side. The opening 
 through which the protrusion took place, I found so large as 
 to admit three fingers readily. I performed my operation for 
 its radical cure, May 20th, 1847. There has been no appearance 
 of the Hernia since. 
 
 " Mr. A. M., Gloucester, Mass., aged 27 years, consulted me 
 for a Hernia and Varicocele, both of over ten years' standing, 
 and very troublesome, rendering it difficult and sometimes 
 impossible for him to attend to his business. May 21st, I 
 operated on the Hernia ; May 24th, on the Varicocele. He 
 remained under my care two weeks. Both complaints were 
 radically cured. 
 
 " Mr. D. G. A., of Prospect, Me., seafaring man, placed 
 himself under my care for the cure of an oblique Inguinal 
 Hernia, of six years' standing, June, 1847. The Hernia had 
 attained the size of a large hen's egg, and was partially 
 irreducible. I operated for the radical cure of the same, 
 June 1st. The last time I heard from, him, two years afterwards, 
 he was entirely well. 
 
 "Mr. P., of Providence, aged about 54 years, consulted me 
 in July, 1 847, for an Inguinal Hernia of the right side, of 
 sixteen years' standing. It was very large, and he had been 
 unable to find any truss to retain it. For several years he had 
 allowed it to remain down constantly. After a few days' 
 preparatory treatment, I operated for its radical cure, July 10th. 
 He left me cured, and has remained so. 
 
 " Mr. D., of Boston, aged 26 years, had suffered much for 
 several years, from a double Inguinal Hernia. Although he 
 
APPENDIX. 29 
 
 had worn a strong double truss, he had, at times, found it 
 ineffectual for retaining the Hernia. It had several times 
 become partially strangulated, causing excessive pain, and 
 threatening his life. I operated for its radical cure, July 28th, 
 1847. He remained under my care two weeks, and left cured. 
 
 "Mr. H., of Bridgewater, Mass., aged about 35 years, had 
 been troubled for seventeen years with an oblique Inguinal 
 Hernia of the right side. When it descended it became very 
 painful. It was accompanied with a hydrocele of the spermatic 
 cord. He came under my care in November, 1847. Left 
 cured, and there has been no appearance of the Hernia since. 
 
 " Mr. J. S., Gloucester, Mass., aged about 40 years, consulted 
 me for a direct Inguinal Hernia of the right side, of long 
 standing. The protruded mass was very large, consisting, I 
 found on examination, of both bowel and omentum, the latter 
 being about equal in size to a hen's egi>-, and irreducible. I 
 found the adhesions so strong, that it was impossible to reduce 
 it by taxis. I therefore out down and removed the irreducible 
 mass of omentum. Afterwards I operated for a radical cure, 
 January 10th, 1848. He has had no trouble since. 
 
 " Mr. H., of Boston, aged about 28 years, had been troubled 
 from boyhood with oblique Inguinal Hernia of the right side. 
 I operated for a radical cure of the same, March 31st, 1848. 
 Hernia lias never appeared since. 
 
 " Mr. F. B. ; of Concord, Mass. , consulted me, January, 1848, 
 for an oblique Inguinal Hernia of the right side, and a Femoral 
 Hernia on the same side, the latter being of unusual size. 
 They were of tour years' standing, had descended freely, and 
 he was unable to prevent the descent with a truss. Much of 
 the time he had been unable to work with any comfort. 
 January 20th, I operated on both. A radical cure was 
 effected. 
 
 " Mr. J. S., Valley Falls, E. I., came to me with an Inguinal 
 Hernia on the right side, of fourteen years' standing. It had 
 for a long time caused him great pain in the back and loins. 
 Accompanying the Hernia was a small Hydrocele, and a 
 Varicocele of the left side. He was a good deal broken down. 
 October 5th, 1847, I operated for the cure of the Hernia; a 
 
30 IIEKNIA. 
 
 day or two afterwards for the radical care of the Vatic iccfe 
 and Hydrocele. Patient remained at my Infirmary three 
 weeks. A permanent cure was effected of the three complaints, 
 followed by a great improvement in the general health. 
 
 " Mr. D. H. , of Essex, Mass., aged 18 years, was ruptured 
 and otherwise badly injured by a fall from the cars. Admitted 
 to my Infirmary. March 10th, 1848, previous to which he had 
 been confined to his bed six months. Simultaneously with 
 the Hernia, Varicocele appeared on the left side. March 1 0th, 
 I operated on the Hernia : shortly afterwards on the Varicocele. 
 April 5th, he left cured, and has had no trouble from either 
 complaint since. He is now in California. 
 
 " Mr. H. B. G., of Boston, consulted me for an oblique 
 Inguinal Hernia of the right side, of lame size. The hernial 
 opening was very large, so that a truss would not retain the 
 protrusion. It descended readily beneath the truss, causing 
 great inconvenience. I operated for its radical cure, March 6th, 
 1848. It has never appeared since. 
 
 "Mr. J. J., of South Boston, aged 40 years, had had an 
 Inguinal Hernia on the left side for two years. The opening 
 was very large, and the Hernia could not be kept up with a 
 truss, but descended into the scrotum. I operated on it, March 
 18th, 184S. Cure was permanent. 
 
 " Mr. A. J. W., of Boston, aged 27, placed himself under 
 mv care for the treatment of Inguinal Hernia of the right side 
 March 24th, 1848. The hernial opening w r as large, and the 
 protrusion not retainable by a truss. Operated, March 24th, 
 and effected a radical cure. 
 
 "Mr. W, of New Orleans, 35 years of age, had had an 
 Inguinal Hernia of many years' standing, accompanied with 
 Varicocele. He came to my Infirmary, 20th July, 1848. Left 
 August 7th, cured of both complaints. 
 
 " H. E., of Charlestown, 9 years old, had a direct Inguinal 
 Hernia of five years' standing. Trusses had been tried, and 
 as usual, to no purpose. Difficulty grew worse. Truss had 
 caused much soreness of the parts. I operated on him, January 
 4th, 1849, and effected a radical cure of the Hernia, 
 
 "Mr. M. A., of Essex, Mass., aced 61 years, accustomed to 
 
APPENDIX. 31 
 
 hard work, had an oblique Inguinal Hernia of the right side, 
 of five or six year-;' standing. Admitted to Infirmary, February 
 26th, 1847. Left cured, and lias had no trouble since. 
 
 "Mr. W., of Brooklyn, Mass., age 68 years, consulted me 
 for an oblique Inguinal Hernia of the right side, of rive years' 
 standing. He had found it impossible to retain it with a truss. 
 May 17, 1849, I operated for its radical cure. Hernia never 
 appeared afterwards. 
 
 " Mr. J. A., of Fall Eiver, aged about 27 years. Admitted to 
 my Infirmary, May 14, 1850. Had an oblique Inguinal Hernia 
 of the right side, of several years' standing ; also a Varicocele 
 of the left side. May 14th, I operated on the Hernia ; May 
 31st, on the Varicocele. A complete cure of both was effected. 
 This patient had tried the best trusses without any relief, but 
 rather an aggravation of his difficulties. 
 
 " Mr. F., of Boston, about 30 years of age, came to me in June, 
 1849, with a very large direct Hernia, which he had never been 
 able to keep up with a truss. June 6th, admitted to my 
 Infirmary, and operated on. Left in a short time, radically 
 cured. 
 
 " Mr. M. F., of Portsmouth, N. H., aged about 23 years. Ad- 
 mitted to Infirmary, June, 1850. Had a very large direct 
 Hernia of the right side, accompanied with Varicocele of the 
 left side. June 14th, I operated on the Hernia; within a week, 
 on the Varicocele- — effecting a complete cure of both. 
 
 "Mr. G. B., of Jamaica Plains, Mass., about 22 years of age. 
 Admitted to Infirmary, Sept. 9th, 1850. Had a large Inguinal 
 Rupture of the left side, which he had tried in vain to retain 
 with a truss. Operated for its radical cure, Sept. 9th. Hernia 
 never reappeared. 
 
 " Mr. K., of Kennebunk, Me., aged about 27 years, very fleshy. 
 Admitted to Infirmary, Oct. 22nd, 1850. Had a very large 
 direct Inguinal Rupture of long standing, which he had been 
 unable to keep up with a truss. Patient called on me a few 
 days since to show that he was completely cured. 
 
 " Mr. M., of Fall River, Mass., aged about 46. Admitted to 
 Infirmary, November, 1850. Had an oblique Inguinal Rupture 
 of the size of a hen's egg. It was of several years' standing, 
 
32 HERNIA. 
 
 and could not be kept up by a truss. Radical cure readily 
 effected. • 
 
 " Mr. S., of Salem, aged 55, very fleshy. Admitted to In- 
 firmary, December 9th, 1850. Had two very large Inguinal 
 Euptures which would descend in spite of the strongest truss. 
 Operated, December 9th, for a radical cure, which was effected. 
 
 " Mr. G. P., of Salem, aged about 37 years. Came to Infirmary, 
 December, 1850. Had had for many years a direct Inguinal 
 Hernia, accompanied with a Hydrocele. A radical cure of both 
 complaints was effected. 
 
 CASES OF IEKEDTJCIBLE HERNIA. 
 
 "During the month of June, 1844, Mr. D., aged 41 years, of 
 thin habit of body, consulted me for a Femoral Hernia on both 
 sides. That on the right was about the size of a butternut, and 
 had been irreducible twenty years. He had worn a scoop truss 
 a part of the time, and had been a great sufferer. This, to my 
 surprise, I was able to reduce by taxis, continued for about half 
 an hour. I immediately operated on it for a radical cure. The 
 Hernia on the left side had not been irreducible so long as the 
 other, but I found it impossible to reduce it by taxis, and there- 
 fore cut down and removed a portion of the contents of the tumor, 
 which proved to be omentum, and which had increased to such 
 an extent that it was impossible to return it. The patient was 
 radically cured of both Hernias. 
 
 " Mr. M., aged 55, very fleshy, weighing over three hundred 
 pounds. Came to me in December, 1845, with an Umbilical 
 Hernia of twenty years' standing, which had not been returned 
 to its proper place during the whole time, and was considered 
 irreducible. On the 22nd of December I made my first attempt 
 to reduce it by taxis. The next day I made another trial, and 
 so on for the several succeeding days, working on it for some 
 half an hour or more once or twice in twenty-four hours, until, 
 on the 27th, I succeeded in reducing it completely. A radical 
 cure was then easily effected. 
 
 " September, 1846, Miss H, aged 35, of spare habit, came 
 under my care with an omental Femoral Hernia, of two years' 
 
INTRODUCTION. 33 
 
 standing. The omentum had been irreducible from six to 
 eight months. During this time she had been able to do but 
 little work, — had suffered much from attacks of colic, which 
 could with difficulty be relieved. Finding it impossible to 
 effect the reduction by external pressure, I performed the opera- 
 tion usually done in strangulated Hernia. I found strong 
 adhesions existing between the sac and omentum. These I 
 found it difficult to break up, as is almost always the case in 
 Femoral Hernia. This being done, and a slight enlargement 
 of the ring having been made, the reduction was readily 
 effected. A radical cure followed this operation. 
 
 " July, 1847, Mrs. K., aged about 43, of spare habit, came to 
 consult me for two Inguinal Hernias. The one on the right side 
 had been irreducible from three to four years. The protrusion 
 was about the size of an English walnut. I found it impossible 
 to reduce it by taxis, and therefore operated with the knife. 
 The operation was successful, and was followed by a radical cure. 
 
 "Mrs. K., about 45 years of age, of robust person, consulted 
 me, May, 1847, for an omental Inguinal Hernia of the left side, 
 of sixteen years' standing. For nine years it had been irre- 
 ducible. She had been under the care of eminent surgeons, 
 without, however, obtaining relief. At their suggestion she had 
 worn a scoop truss, which seemed to afford little or no relief. 
 During a part of the time she had been unable to walk, and 
 finally had become much broken down in health by her suffer- 
 ings. I found, on examination, that there was much water in 
 the sac, and probably for that reason no adhesions of any con- 
 sequence. I therefore concluded to perform a subcutaneous 
 operation. This 1 did, and upon enlarging the ring, the pro- 
 truded mass readily slipped back into the abdomen. I after- 
 wards operated on this, and on a reducible Femoral Hernia of 
 the other side, for a radical cure. 
 
 "Capt. S., aged 40 years, came under my care in January, 
 1848. He had an omental Intestinal Hernia, which had 
 descended into the scrotum. The omental portion had been 
 irreducible for five years. This I removed. Patient suffered 
 little inconvenience from the operation, and I soon after operated 
 successfully for the radical cure of the Intestinal Hernia. 
 
 D 
 
34 HERNIA. 
 
 " Mrs. H., aged 88, somewhat corpulent, came to me in May, 
 1848, with a very large Inguinal Rupture on the right side, and 
 an irreducible Femoral Rupture on the left side. Her sufferings, 
 she informed me, had been very great, sometimes almost in- 
 tolerable. Finding it impossible to reduce the tumor on the 
 left side, I cut down upon it. Finding the contents to be 
 omentum entirely, I removed that portion which could not be 
 returned, and restored the remainder to the abdominal cavity. 
 The patient soon recovered from this operation, so that I was 
 enabled to operate on this side as well as on the Hernia of the 
 right side, for a radical cure, winch proved entirely successful, 
 restoring the patient to health, and freedom from the severe 
 pain with which she had so long been afflicted. 
 
 "Mr. K.. of Acton, Mass., aged 54 Admitted to Infirmary, 
 Nov., 1848. Mad an irreducible omental Femoral Hernia of 
 several years' standing. It was very painful, and obliged him 
 to give up work. Being unable to reduce it by taxis, I removed 
 the protruded mass, and afterwards operated with success for a 
 radical cure. 
 
 " Capt. R., aged 55, of spare habit, came to me in the month 
 of November, 1850, with an irreducible Femoral Hernia on the 
 left side, of seven years' standing. I found, on cutting down, 
 that it contained omentum only. Having been out for a long 
 time, it had become considerably enlarged, and was not fit to 
 be returned ; I therefore removed it. The patient very soon 
 recovered from the operation, and was radically cured. 
 
 "Mrs. 13.. aged about 25, consulted me in June, 1841, for an 
 irreducible Femoral Hernia, of thirteen years' standing. She 
 had suffered much at different times from attacks of colic. 1 
 tried in vain to effect the reduction by taxis, and therefore 
 resorted to the operation. I found very strong adhesions exist- 
 in-, and was obliged to enlarge the ring considerably, in order 
 to effect the reduction. No inconvenience was experienced 
 from the operati n. and the patient soon recovered. 
 
 " Mr. C, aged suxrat 24 years, .came to me wi:h an irreducible 
 Omental Hernia of recent occurrence. It was very painful, so 
 much so that he had been unable to wear a truss, or any kind 
 of support, and most of the time had not been able to walk. 
 
INTRODUCTION. 35 
 
 The soreness was so great that I could not try the taxis to any 
 extent ; I therefore cut down upon it, and returned it, the 
 patient suffering little inconvenience from the operation. A 
 cure was effected in this case, and the patient restored to health. 
 "Miss V., aged about 35, consulted me, December, 1851, for 
 an irreducible Femoral Hernia, of ten years' standing. She 
 had suffered much, at times, from partial strangulation, to which 
 she was almost constantly subject. Protracted vomiting or 
 retching occurring at frequent intervals, and sometimes con- 
 tinuing for two or three days, had rendered existence oftentimes 
 a burden to her. I endeavoured to reduce the protrusion by 
 taxis, but without success, and finally was obliged to resort to 
 the operation that I usually perform in such cases. I found 
 the Hernia to consist of omentum, a portion of which I had 
 to remove. I afterwards operated successfully for its radical 
 cure." 
 
 It will be seen in his reply that he promised to give his 
 operation to the profession, and this promise lie fulfilled to the 
 letter. He always held Ins word sacred and after handing me 
 this little pamphlet said in answer hi my oft repeated request, 
 that he would publish his operation as soon as he could find 
 a suitable editor. This work he entrusted to Dr. Davenport, 
 but as the author was advanced in years, the result was far 
 from satisfactory or perfect. Had he lived longer I know that 
 another edition would have been issued with many corrections, 
 and much more extensive than the first. Had Dr. Heat on 
 published his operation ten or fifteen years before, a much fuller 
 account and a more perfect work would have been the result. 
 
 In the present work I have tried to correct any wrong im- 
 pression the profession may have drawn from his little volume, 
 have added to and improved the same as much as I could by 
 explaining more fully all the details of the operation, adding 
 also the results of my study and experience in this as well as 
 in other branches of surgery, in which my practice has been by 
 
 D 2 
 
3G HERNIA. 
 
 no means small or limited. I have been enabled to accomplish 
 much in this direction from intimate acquaintance with Dr. 
 Heaton for many years, and have been brought into much closer 
 relation, as his physician, than would otherwise be possible. I 
 have repeatedly gone over the operation, discussing all of the 
 details of the operation both before and after the publication of 
 his work. 
 
 Should any fail to succeed in this operation after a careful 
 study of this work, let them not imagine that some secret has 
 been withheld, for I have written with full knowledge of Dr. 
 Heaton s methods of treatment, and have given all that he knew 
 upon the subject, which it is possible to convey through the 
 press. It is true I cannot convey his fine sense of touch and 
 delicate manipulation, any more than I can by writing convey 
 to you my own, but I have done all that I can do to give you 
 a full knowledge for a successful operation. How well I have 
 succeeded I leave to your judgment and approval. 
 
 Joseph H. Warren. 
 
 15, New Cavendish Street, London, 
 August, 1880. 
 
 Eeports of cases, suggestions, and other communications 
 relating to the subject would be gratefully received and duly 
 acknowledged. 
 
 J. H.W. 
 
CHAPTEE I. 
 Heenle : Kinds and Frequency. 
 
 kinds of heenle. 
 
 The varieties of Hernias 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 Hernias 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 Hernias as the result of weakness of the 
 abdominal tissues. 
 
 Hernias 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. 
 
38 HERNIA. 
 
 Diaphragmatic or Phrenic. — These are somewhat rare, 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 of 
 the adjoining ribs." 1 
 
 Umbilical, ExonipJialos, 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 ; and 
 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. 1' 
 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. 39 
 
 by the umbilical vessels of the fcetus. 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 fcetus 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 coion was above the 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 
 perceptibje to the individual himself, and so s.ow 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." 
 
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. 
 
 Ischiadic. — Protrusion through the sacro-sciatic notch. 
 
 Vaginal. — When the tumour descends along or into the 
 vagina. 
 
 Perinatal — When the protrusion is through a laceration of 
 the perineum of the male. It is the counterpart of the va_ 
 in the female. 
 
 Lumbar. — Of this variety a very few rare cases have been 
 reported by Petit and Coquet. The intestine is protruded 
 through the posterior muscles immediately above the pelvis. 
 
 In the antt i jgion 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 ax: 
 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 ] sscen Is 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 Mood-ves - pass over the tumour, the vas 
 deferens behind it, v -ice versa ; or they are attached to the 
 _ the tumour. The relativ : itions 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." * 
 
 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 form of Inguinal Hernia 
 than in the oblique. In its passage from the abdomen it 
 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 (bnbo). 1 
 
 Scrotal or Oscheocele and Pedendal. — When a complete 
 Inguinal Hernia passes through the external ring and escapes 
 into the scrotum it is called Scrotal, when into the labia majora, 
 Pedendal. 
 
 Ventral. — When it escapes through some part of the ab- 
 dominal walls usually strong and muscular it is called Ventral 
 (See note.) 
 
 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. 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 from 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 males than in females. 
 
 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 
 Enter o-E pipl oceh. Rarer forms of hernial tumours from the 
 abdomen are Gastrocele, Hepatocele, and Cystocele, protrusions 
 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 Hernias 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. 
 
 Incarcerated, when the Hernia has become temporarily irre- 
 ducible because of a constriction in the intestines which prevents 
 passage of faeces. 
 
 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. 
 
 FREQUENCY OF HERNIA. 
 
 The frequency of the occurrence of Hernia varies in different 
 kinds of hernise according to kind, sex, age, population, occupa- 
 tion, walls of the abdomen, social state of the nationality. 
 
 1. Relative frequency of the different Kinds. — The In- 
 guinal and Femoral are the most frequent, and after them 
 come Umbilical, while all the others can be considered as 
 very rare. Out of the 93,355 Hernias 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 624 Inguinal. Of 30,575 double Hernias 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, bein£ 
 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 Hernial 
 
 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 Hernia3 in the two sexes the 
 Truss Society in 1853 claim about 1 Femoral in the male to 
 75 Inguinal, but in the Report for 1SG3 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 
 1*04 Femoral in the female, figures which seem a priori much 
 more reasonable. 
 
 As regards Umbilical Hernias, they are more frequently 
 found in the female than in the male. 
 
 3. Frequency according to Age. — In 300 Hernise 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— 
 
HERNIA : KINDS AND FREQUENCY. 
 
 45 
 
 Befor 
 
 e 1 year 
 
 there is 1 
 
 From 
 
 1— 2 
 
 >> -*- 
 
 »> 
 
 2— 3 
 
 »> -*■ 
 
 t> 
 
 5—13 
 
 » -*■ 
 
 To 
 
 20 
 
 » -*- 
 
 » 
 
 28 
 
 j> -*■ 
 
 From 
 
 30—35 
 
 >} -*- 
 
 )> 
 
 35—40 
 
 » -*• 
 
 At 
 
 50 
 
 » ■*■ 
 
 V 
 
 60—70 
 70—75 
 
 
 Hernia in every 21 individuals. 
 
 » 
 
 29 
 
 >> 
 
 » 
 
 37 
 
 » 
 
 » 
 
 77 
 
 » 
 
 » 
 
 32 
 
 >» 
 
 >> 
 
 21 
 
 >> 
 
 » 
 
 17 
 
 99 
 
 J> 
 
 9 
 
 u 
 
 >> 
 
 6 
 
 99 
 
 
 4 
 3 
 
 as 
 
 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 Hernire. 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. 
 
48 
 
 HERNIA. 
 
 Report of Kingdon 
 
 (Truss Society). 
 
 
 According to Census of 1S51. 
 
 1869. 
 
 I860. 
 
 1SC1. 
 
 Farm labourers .... 
 
 
 171 
 
 173 
 
 Farmers .... 
 
 
 
 776 
 
 503 
 
 734 
 
 Boot and Shoemakers 
 
 
 
 38 
 
 53 
 
 12 
 
 Carpenters and Joiners . 
 
 
 
 173 
 
 178 
 
 99 
 
 Tailors .... 
 
 
 
 20 
 
 33 
 
 28 
 
 House servants (male) . 
 
 
 
 101 
 
 176 
 
 131 
 
 Workers in Silk 
 
 
 
 63 
 
 71 
 
 58 
 
 Blacksmiths . 
 
 
 
 48 
 
 51 
 
 63 
 
 Masons and Paviors . , 
 
 
 
 — 
 
 18 
 
 
 
 Porters and Gardeners . 
 
 
 
 478 
 
 410 
 
 351 
 
 Gardeners 
 
 
 
 65 
 
 119 
 
 114 
 
 Bookmakers . 
 
 
 
 — 
 
 
 
 49 
 
 Butchers 
 
 
 
 53 
 
 52 
 
 52 
 
 Painters and Plumbers . 
 
 
 
 33 
 
 45 
 
 50 
 
 Bread makers . 
 
 
 
 35 
 
 69 
 
 52 
 
 Carters .... 
 
 
 
 73 
 
 87 
 
 82 
 
 Commercial Brokers 
 
 
 
 29 
 
 30 
 
 C5 
 
 Clerks .... 
 
 
 
 — 
 
 . 
 
 41 
 
 Boatmen 
 
 
 
 — 
 
 44 
 
 35 
 
 Sawyers .... 
 
 
 
 35 
 
 34 
 
 29 
 
 Pedl irs . . . 
 
 
 
 33 
 
 57 
 
 37 
 
 Wheelwrights 
 
 
 
 10 
 
 — 
 
 18 
 
 Engineers 
 
 
 
 26 
 
 51 
 
 42 
 
 Coopers .... 
 
 
 
 20 
 
 32 
 
 23 
 
 We can, however, go further than this and investigate the 
 influence of position during work. This question has heen 
 especially discussed in regard to Inguinal Hernias, and the 
 question that has arisen is, " Are various attitudes capahle of 
 modifvincj 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 Hichet 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 not to modify the causation of Hernia but 
 only the development when the Hernia has once been formed. 
 
 6. Frequency according to the Side of the Body. — 
 Hernial 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. Schinkens 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. Malgaigue as usual doubts the state- 
 ment, and by figures seeks to show that Hernia? in right- 
 handed persons are more frequently on the left side than on 
 the right. Thus of 313 Inguinal Hernia? 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 
 regions. Then of course we can make the general statement 
 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 II 
 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, 
 denning 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, Bechilt and Ramsey, 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. — A Treatise on Ruptures. By 
 W. Lawrence. Philadelphia, 1843. — A System of Surgery. Edited by T. 
 Holmes. Vol. IV. — Surgical Diagnosis. By Ambrose L. Ramsey. New 
 York, 1879. — The Essentials of Anatomy. By William Darling and 
 Ambrose L. Ramsey. 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 Hernise 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. ISTo blood-vessels, unless it be superficial 
 vessels or abnormal veins, as seen by Mance, Maniere and 
 Velpeau, are situated near 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 
 1' are-lip or club foot. It has a covering formed by the union of 
 the peritoneum and the envelope of the umbilical cord. If the 
 
 B 
 
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 
 
 Fia 1.— Umbilical Hernia. 
 
 The three most common forms of Hernia, named in the order of their occurrence in the female, 
 nrft Umbi iea Femoral and Inguinal. Ob.ique Incuinal. or Pi-dcndal in the female, is very 
 fine y shown on the right side of the figure. Umbilical as well as Femoral on the left sido 
 speak for themse'ves. The fibres and fascia transversals in the Umbilical rc,ion are very 
 wel drawn, and shew the appearance of a Hernia in that stag- of its formation when the 
 intestine has already passed the internal ring and commenced to protrude from 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 clanger of strangulation and fatal results. 
 Such Hernise 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. OF THE ABDOMINAL REGION RELATING TO 
 INGUINAL HERNIA. 
 
 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-hypogastrie and ilio-inguinal 
 nerves and the upper group of the inguinal lymphatics. 
 
 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 puclic 
 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 fascia;. 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 dasc, 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 
 
ANATOMY : DESCRIPTIVE AND SUEGICAL. 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 ec\ge 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 its long 
 diameter from pubes to internal angle, and about one half inch 
 
64 
 
 HERNIA. 
 
 transversely between the columns. It is larger and stronger in 
 the male than in the female. 
 
 The fascia of the obliqtms internus muscle along the middle 
 line over the re< tus for the upper two-thirds- of its extent is 
 divided into two layer?, 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 
 
 Fig. 2. — Inguinal Hernia. 
 
 This figure shows the various coverings ; 1, skin, superficial fascia ; 3. intercolumnar ftiscia; 4, 
 crtmnster muscles, hifundibu liforin fascia, subserous cellular tissue; 2, sac, epigastric 
 artery with veins on either side of it. 
 
 fasciae passes in front of the rectus. The fibres of the internal 
 oblique from the upper half of Poupart's ligament arch down- 
 ward and inw T ard 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- 
 tenral abdominal ring, and strengthens the ring towards the 
 abdomen. Sometimes it is insufficient to resist the pressure 
 
ANATOMY: DESCRIPTIVE AND SUKGICAL. 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 become 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 Astle^r 
 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 formed 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 denned 
 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 parts 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 to 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 tbe 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 interims 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 brandies 
 of the artery ought to be known to the operating surgeon, the 
 cremasteric, which accompanies the spermatic cord, the iwbic, 
 which runs across Poupart's ligament and then descends to 
 the inner side of the femoral rin» and the muscular branches. 
 
58 
 
 HERNIA. 
 
 Fig. 3. 
 
 Superficial dissection of inguinal and crural regions. Below the groove upon 
 front of thigh is seen the triangular depression forming the lower part of 
 groin. This is described in connection with Femoral Hernia. Above tho 
 pubis may be felt the opening in the deep parts of the superficial abdominal 
 ring through which the spermatic cord escapes to testicle. Beneath tho 
 skin of groin and fascia superficialis are two layers, between which are 
 found the superficial vessels and lymphatics. The layer below this is 
 made up of clastic areolar tissue, and fat, closely attached to Poupart's liga- 
 ment c, anterior pubis and crest of iliac b. Crossing the groin are seen 
 three blood-vessels turned obliquely inwards and upwards from common 
 femoral artery. Outer one, superficial circumflex iliac, passes up to superior 
 iliac spine, d. The middle one, superficial epigastric, supplying glands and 
 integuments of groin to umbilicus, c, e. inner one. . superficial external 
 pubic, enters fascia lata near the pubis, crossing beneath spermatic cord to 
 scrotum and root of penis. Tbe external pubic is liable to be divided in 
 cure of Inguinal Hernia ; if a dull bistoury be used in making the division, 
 haemorrhage is less liable to occur, unless the vessel is very much enlarged, 
 which 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 strong, and the fibres 
 curve downwards and inwards towards median line and pubis, forming with 
 other tendons a vertical line and by union with opposite side linea alba. 
 
ANATOMY: DKSCPJPTIVE AND SURGICAL. 59 
 
 Externally towards thigh, fibres growing thicker and oblique, running in 
 with fascia lata, and uniting with deeper fascia forms crural arch or the 
 ligament of Poupart's, g. This band of fibres forms the arch between, 
 anterior superior iliac spine and spine of pubis. To the two bony pro- 
 tuberances is attached a convexity downwards, outwards, and backwards, 
 forming concavity of groin. Fibres of the aponeurosis bound together by 
 areolar tissue all form the intercolunmar, Ji, various sized openings through 
 which pass vessel and nerves in abdominal Avail. The larger opening forms 
 the external abdominal rin£>\ 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 S3'mphysis 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 cp : gastric artery . 
 
 to coinse of epigastric artery on 
 
 inner side of upper opening 
 to middle of the lunated edge of 
 
 fascia lata .... 2^ 3^ 
 
 From the anterior edge of the crural arch to the saphena 
 
 major vein .... 1 l-£ 
 
 From symphysis pubis to middle of crural ring . 2± 2^ 
 
 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. 
 
 ihclas. 
 
 5? 
 
 6 
 
 H 
 
 If 
 
 £ 
 
 1 
 
 o 
 
 s* 
 
 2^ 
 
 u 8 
 
 Sf 
 
 2 5 - 
 
 n 
 
 3 
 
 H 
 
 22 
 
 n 
 
60 
 
 HERNIA. 
 
 Fig. 4.— Rale. 
 
 This sliding aDrt revolving rule will be found very handy in talcing ihc?e nnatomical 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. 
 
 The spermatic vessels situated behind the peritoneum 
 descend over ihe psoas and iliacus interims muscles connected 
 to them by loose cellular tissue, and at the divisions of the 
 transversal is 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 transversaiis 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 interna,! 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 ancde of 
 the ring in front of the cord, ascend again immediately, to be 
 fixed to the pubes behind ihe 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 interims 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, 
 
 
 »fe^ 
 
 mi 
 
 k 
 
 Fig. 5. 
 
 Deep dissection of inguinal canal and abdominal wall. After external oblique 
 and the aponeurosis comes internal oblique, b and c, trans versalis muscle, 
 and thin conjoined tendon, taking origin from Pou part's ligament, a, in- 
 ternally conjoined tendon, d. rectus muscles, e, which bars hernial protrusion 
 at the point, /, trans vers; lis fascia, internal or deep ring. From its margins 
 arise fascia propria or infundibularis. Base of triangle above outer half of 
 pubic crest is seen, the sills slit in two bands, pillars of ring, the outer 
 forming inferiority, opening obliquely, intercolumnar fascia. 
 
 Fascia spermatica externa, i ; cremaster iiio-inguinal nerve-branch of first lumbar 
 plexus is seen ; Gimbernat's and Poupart's ; triangular aponeurosis ; muscle 
 oblique at b ; muscle transversalis, c ; see Fig. 3, page 53— umbilical branch 
 of iliac internal, external iliac artery ; lymphatic ducts crural-ring to arotic 
 chain, g ; genito canal nerve to internal abdominal ring. 
 
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 Ave 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 
 €ach other, and near them is that prolongation of the peritoneum 
 which const. ■ 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 sheath 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 crema>ter 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 
 
 IIICRNIA. 
 
 fascia transversalis and under the margin of theirternal 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 n fleeted hy an oblique rupture ; 
 peritoneum, fascia and fascia transversalis ; the epigastric artery is seen in 
 its relation below the neck, inner- side removed, showing deep aspect of 
 conjoined tendon, k. 
 
 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 rings is 
 rarely seen in Hernias of long standing ; in fact the normal 
 distance is rarely preserved in any convpletc inguinal Hernia. 
 The spermatic cord is placed behind the hernial sac. After the 
 
ANATOMY: DESCRIPTIVE AND SURGICAL. 
 
 65 
 
 Hernia has escaped beyond tlie 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. 
 
 Is a part of Inguinal and Crural Hernia, with internal surface of peritoneum and 
 its fascia removed, b, epigastric artery passing across and behind Poupart's 
 ligament between internal abdominal and crural rings to sheath of rectus at 
 the fold of Dough; s. c ; Poupart's and Gimbernat's ligament, Hcsselbach's 
 triangle, d; cord cf hypogastric artery,/; vas deferens duct spermatic, g ; 
 spermatic plexus of veins, artery, and nerves, h ; subperitoneal fascia, I. 
 
 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 
 
 Such a Hernia 
 P 
 
 and then through the external abdominal ring. 
 
CG HEUNIA. 
 
 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 m iv lie behind it as in the 
 external or oblique variety. The epigastric artery is pretty 
 constant in its relation to the Hernia, that is as 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 : — 
 
 T j. , ,_ , , N I Superficial fascia (2 layers'). 
 In front (5 structures)^ E £ em] ob , iquc ( \, nfi ,: c h]? „ th y 
 
 ^Internal oblique (outer third). 
 
 Con joined tendon of internal oblique 
 
 and transversalis. 
 
 , Transversals fascia. 
 Behind ^5 structures) <j Tl ^ ngu]aT ligament 
 
 Sul'-p nitoneal tissue and fat. 
 Peritoneum. 
 
 Above (2 structures) j -pV 1 , 
 
 Fibres of internal obliquo. 
 es of trans versalis. 
 
 Below (2 structures) (Poupart's ligament. 
 
 v ' \ Transversans fascia. 
 
 Femoral Hernia. — The superficial fascia of the femoral 
 region is of two layers just as in the abdominal region, between 
 which are the cutaneous vessel and nerves and the lymphatic 
 glands. These vessels are the internal saphenous vein and 
 the superficial epvjaHric, superficial circumflex iliac, and super- 
 ficial external pubic arteries from the femoral, while the 
 cutaneous nerves are from the ilio-in'/. /nal, gcnito-crural, and 
 anterior crural from the lumb.ir plexus. The ilio-inguinal 
 
ANATOMY: DESCRIPTIVE AND SURGICAL. 
 
 67 
 
 nerve lies upon the inner side of the internal saphenous vein, 
 the genito-crural on the outer side, and the middle and external 
 cutaneous nerves still more external. The superficial layer 
 of this superficial fascia is continuous above with the super- 
 ficial fascia of the abdomen, while the deeper layer is con- 
 tinuous below with the fascia lata a little below Poupart's 
 ligament. Where it adheres to the saphenous opening in 
 this fascia lata it is pierced by small blood-vessels and 
 lymphatics ; hence the name cribriform fascia has been applied 
 to it in this situation. 
 
 Fio. 8.— Femoral Hernia. 
 
 The deep fascia lying beneath the superficial fascia is called 
 from its great extent the fascia lata,. At the upper and inner 
 side of the thigh, a little below Poupart's ligament and on 
 the pubic side of its centre, is seen an oval opening directed 
 obliquely downward and outward about an inch and a half 
 in length and half an inch in width. This is the saphenous 
 opening. To understand it properly the fascia lata may be 
 described as consisting of two portions, iliac and pubic. The 
 former "is attached externally to the crest of the ilium and 
 its anterior superior spine, to the whole length of Poupart's 
 
 F 2 
 
08 HERNIA. 
 
 ligament as far internally as the spine of the pnbes, and to 
 the pectineal line in conjunction with Gimbernat's ligament, 
 where it becomes continuous with the pubic portion. From 
 the spine of the pubes it is reflected downwards and out- 
 wards, forming an arched margin, the outer boundary (superior 
 cornu) of the saphenous opening. This is sometimes called 
 the falciform process of the fascia lata or femoral ligament of 
 Hey; it overlaps and is adherent to the sheath of the femoral 
 vessels beneath ; to its edge is attached the cribriform fascia, 
 and it is continuous below with the pubic portion of the fascial 
 lata by a well-defined curved margin." 1 The pvMc portion 
 attached above to the pectineal line and internally to the 
 margin of the pubic arch is upon the inner side of the 
 saphenous opening, and at its lower margin is continuous 
 with the iliac portion. We see therefore that the iliac portion 
 "passes in front of the femoral vessels, the pubic portion 
 behind them, while an apparent aperture exists between the 
 two through which the internal saphenous joins the femoral 
 
 vem 
 
 "2 
 
 The outer margin of the saphenous opening forms a curved 
 process, the falciform process of Burns, Burns' or Hey's liga- 
 ment or femoral ligament. It curves inward upon its upper 
 border to join Poupart's ligament, the spine of the pubes and 
 pectineal line where it is continuous with the pubic portion. 
 The inner margin of the opening is on a lower plane, lying 
 behind the femoral vessels, and is less distinctly marked in its 
 contour. When the limb is extended or rotated outward, the 
 saphenous opening will be found tense and constricted; on 
 the other hand, when the limb is flexed, or rotated inward, the 
 opening is relaxed. So that this position of the limb is an 
 important point to be borne in mind during the operation 
 of taxis. 
 
 1 Gray. 3 Ibid. 
 
ANATOMY : DESCRIPTIVE AND SURGICAL. 69 
 
 The triangle at the upper and anterior surface of the thigh 
 where femoral Hernia makes its appearance is called Scarpa's. 
 It is bounded above by Poupart's ligament, which forms the 
 crural arch already described under inguinal Hernia, and which 
 has a reflection at the pectineal line called Girnbernat's ■ liga- 
 ment. Externally this triangle is bounded by the sartorius and 
 internally by the adductor longus, while its apex is formed 
 by the meeting of these muscles. 
 
 Covered by the iliac portion of the fascia lata, and resting 
 upon the pubic portion of the same fascia, is a continuation 
 downward of the abdominal fascia, called the femoral sheath, 
 the transversalis fascia passing in front of the femoral vessels 
 and the iliac behind them. About an inch below the saphenous 
 opening the femoral sheath intimately blends with the vessels, 
 but at Poupart's ligament it is much larger ; hence it presents 
 a funnel shape. 
 
 Besides the crural arch already described we have the deep 
 crural arch, which is a thickened band of fibres running across 
 and in front of the crural or femoral sheath. " It is apparently 
 a thickening of the fascia transversalis, joining externally to 
 the centre of Poupart's ligament and arching across the front 
 of the crural sheath, to be inserted by a broad attachment into 
 the pectineal line behind the conjoined tendon." It is often 
 altogether wanting. 
 
 By removing the anterior wall of the femoral sheath we 
 see the femoral artery and vein separated by a thin septum ; 
 the artery being upon the outer side and the vein upon the 
 inner. The interval between the vein and the inner wall of 
 the sheath is filled only by loose areolar tissue and a few 
 lymphatics ; it is the femoral or crural canal through which 
 femoral Hernia protrudes. It should be borne in mind by the 
 dissector that this canal only exists as a distinct canal when 
 distended by a Hernia or other tumour, or when artificially 
 
70 HERNIA. 
 
 separated in dissection. It varies in length from a quarter 
 to a half an inch, and extends from Gimbernat's ligament to the 
 saphenous opening. It is bounded in front by the transversalis 
 fascia, Poupart's ligament, and the falciform process of the 
 fascia lata, behind by the iliac fascia and the pubic portion 
 of the fascia, lata, on the outer side by the fibrous septum 
 between the artery and vein, and on the inner side by the 
 junction of the transversalis and iliac fascia, which cover the 
 outer edge of Gimbernat's ligament. The lower opening of 
 this femoral canal is the saphenous opening closed by the 
 cribriform fascia, already fully described, while the upper 
 opening is the ftmoral or crural ring, closed by the septum 
 crnrcde. This septum crurale is a layer of condensed areolar 
 tissue with its upper surface concave and separated from the 
 sub-areolar tissue and peritoneum by a lymphatic gland. When 
 this sub-areolar tissue has become infiltrated with a large 
 amount of adipose tissue it may frequently be mistaken for 
 the omentum, and lead one astray in his diagnosis. As the size 
 and degree of tension of the saphenous opening is modified 
 by the limb being flexed and rotated inward, so is the 
 size and tension of the femoral canal likewise favourably 
 influenced. 
 
 The femoral ring, like the canal, is an " artificial product " 
 made by the descent of a femoral Hernia. It leads into 
 the cavity of the abdomen, is of an oval form, measures 
 about half-an-inch in its long, or transverse diameter, and 
 is larger in the female than in the male; hence the more 
 frequent occurrence of femoral Hernia in the former sex than 
 in the latter. 
 
 In front it is bounded by Poupart's ligament and the deep 
 crural arch, behind by the pubes, internally by Gimbernat's 
 ligament, the conjoined tendon, the transversalis fascia, and 
 the deep crural arch, externally by the femoral vein. 
 
ANATOMY : DESCRIPTIVE AND SURGICAL. 71 
 
 It is important to bear in mind that the spermatic cord and 
 round ligament lie immediately above the anterior margin of 
 the femoral ring, that the femoral vein lies upon the outer 
 side of the ring, that the epigastric artery crosses the upper 
 and outer angle of the ring, and that the obturator artery, 
 instead of lying in its ordiriry position on the outer side of 
 the ring, occasionally " curves along the free margin of Gim- 
 bernat's ligament," and therefore runs along nearly the whole 
 circumference of the ring. 
 
 The viscera in a femoral Hernia descend from the abdomen 
 at first in nearly a perpendicular direction and lie in the 
 hollow of the pectineus muscle. Covering the peritoneal sac 
 is an investment named by Sir Astley Cooper the fascia 
 propria. It lies "immediately external to the peritoneal sac 
 but is frequently separated from it by more or less adipose 
 tissue," and anatomically it is identical with the sub-serous 
 cellular tissue already mentioned. 
 
 The protrusions of the hernial sac occur almost invariably on 
 the inner side of the femoral vein. Cloquet, however, says, 
 " The epigastric artery may be found on the inner side of the 
 sac of a crural Hernia, the parts having descended in front of the 
 femoral vessels;" and, together with Hesselbach, thinks this 
 sufficient to warrant the division of femoral Hernia into inter- 
 nal and external. Besides these varieties, Cloquet also mentions 
 a case where the Hernia '■ passed through an opening in the pos- 
 terior part of the sheath, so that it lay immediately upon the 
 peeiineus and IcJrind the femoral artery and vein." Such cases 
 are however very rare ; by far the greater number being of the 
 internal variety. 
 
 To recapitulate. The femoral ring is situated internal to the 
 femoral vessels, and is bounded as follows : — 
 
 .1 /0 t. \ f Ponpart's ligament. 
 
 Above (2 structures) •{ n l P , 
 
 v ' ^ Deep crural arch. 
 
72 HERNIA. 
 
 ( Pubic bone. 
 
 BeW (4 structures) ) ^ i[ ^\ muscle ' 
 v ; \ Iliac fascia. 
 
 f Pubic portion of fascia lata. 
 
 fGimbernat's ligament. 
 
 T . n /( , , x I Con joined tendon. 
 Internally (4 structures) -J ^ cnn . a] ^ 
 
 ^Transversalis fascia. 
 Externally (2 structures) Femoral vein and septum. 
 
 Going from the spine of the pubes outward, we meet the 
 following in their order : — 
 
 1. Gimbernat's ligament. 4. Femoral artery. 
 
 2. Femoral opening. 5. Anterior crural nerve. 
 
 3. Femoral vein. 
 
 The femoral canal, about half-an-inch long, extends from the 
 femoral ring, where it is closed by the septum crurale to the 
 upper part of the saphenous opening, closed by the cribriform 
 fascia, and is bounded as follows : — 
 
 igament. 
 In front (3 structures)^ Fascia transversalis. 
 
 •ocess of fascia lata. 
 
 {Poupart's ligamei 
 Fascia transversa 
 Falciform process 
 
 Behind (2 structures) | ^ ^^ of fagda ^ 
 
 Externally (2 structures) ( ? emora } vei ?' 
 
 J K J ^ femoral septum. 
 
 f Fascia transversalis. 
 
 Internally (4 structures) J I|i*c fascia. 
 
 J v J 1 bnnbernat's ligament. 
 
 V.Ueep crural arch. 
 
 Let us now look at the formations of a hernial sac. 
 
 The essential parts of a hernial tumour are three in number — 
 
 The sac. 
 
 The tissues enveloping the sac. 
 
 The contained viscus. 
 
ANATOMY : DESCRIPTIVE AND SURGICAL. 73 
 
 The sac is a prolongation of the peritoneum, and consists of 
 the mouth, which is continuous with the abdomen; the neck, 
 that portion of the parietes through which the sac protrudes; 
 the body, which makes up the main bulk of the tumour, and 
 the fundus, which is that portion of the body furthest from the 
 abdomen. The neck undergoes many abnormal changes. It 
 becomes thickened, discoloured, and opaque, from deposition of 
 plastic adhesions, from irritation by a truss, or from a puckering 
 of the sack consequent upon compression within the aperture 
 from which it protrudes. It may, instead of being single, con- 
 sist also of two constrictions representing the anatomical condi- 
 tion of the surrounding parts, wdiile Gant mentions a large 
 scrotal Hernia with three such necks. 1 
 
 The body varies greatly in different individuals, both in size 
 and shape, being usually pyriform, but often globular, ovoidal, 
 cylindrical, or constricted, like an hour-glass. It varies in size 
 from a cherry to a tumour as large as a man's head. At first it 
 is thin, but often, as in femoral, it becomes thickened and lami- 
 nated in structure, although in umbilical Hernias it is like to 
 be thinned and atrophied, while in some rare cases there may 
 be a fibrous or even calcareous degeneration of the component 
 tissues. 
 
 The formation of the sac varies in different Hernias. The 
 congenital hernial sac is found only in Inguinal Hernias, and is 
 a tubular prolongation of the peritoneum formed by the descent 
 of the testicle, the natural foetal opening of the tunica vaginalis 
 not having been closed because of some abnormal condition. 
 The formation of such a Hernia is rapid, occurs in infancy, and 
 has only a single layer of peritoneal covering. The artificial 
 
 1 The aperture may become a^ercd too in shape, losing its triangular 
 form, and becoming circular, and gradually with the lapse of time being 
 displaced toward the middle line by the elongation of the peritoneum and 
 the thickening of the transversalis fascia, so that the two rings become 
 merged into one. 
 
74 HERNIA. 
 
 sac formed by the protrusion of a viscus through the abdomen 
 by the stretching of the parietes, has been named by Birkett 
 the "acquired sac." The formation of such a Hernia is gradual, 
 and belongs only to middle and old age. 
 
 In some cases, as in internal and csecal Hernia?, in tystocele, 
 or in rupture of the sac, either from violence or ulceration, the 
 sac may be absent. On the other hand, just as there may be 
 two or more necks to a single sac, so there may be two sacs 
 protruding through the same aperture, and forming a double 
 Hernia. Indeed, Sir Astley Cooper mentions a case where six 
 sacs occurred together in the same person. 
 
 Proceeding from without inward, and observing the coverings 
 of a Hernia, we meet in Inguinal Hernias- the following tissues : — 
 
 Oblique. Direct 
 
 1. Integument. 1. Integument. 
 
 2. Superficial fascia., 2 layers. 2. Superficial fascia, 2 layers. 
 
 3. Irjterco'unmar fascia. 3. Intercolumnar fascia. 
 
 4. Cremaster. 4. Conjoined tendon (occasionally). 
 
 5. Fascia transversalis. 5. Fascia transversalis. 
 
 G. Sub-serous cellular tissue. G. Sub-serous cellular tissue. 
 
 7. Peritoneum. 7. Peritoneum. 
 
 In femoral hernia the following are the coverings :«— 
 
 1. Integument. 
 
 2. Superficial fascia. 
 
 3. Cribriform fascia. 
 
 4. Femoral sheath, or fascia profunda. 
 
 5. Septum crurale, or sub-serous cellular tissue. 
 
 6. Peritoneum. 
 
 Since the superficial fascia consists of two distinct layers, the 
 coverings of Inguinal Hernia are generally considered to. be eight, 
 and those of femoral seven, in number. 
 
 The coverings of the hernial sac may undergo pathological 
 modifications. The peritoneum is very tough and firm in 
 texture, being able, according to Scarpa, to uphold a weight of 
 fifteen pounds. It usually suffers little change, although it 
 
ANATOMY: DESCRIPTIVE AND SURGICAL. 75 
 
 may become thickened, opaque, and firmer near the abdominal 
 opening, and may have serous or lymph effusions upon it. The 
 sub-serous cellular tissue often becomes thickened, exceedingly 
 vascular, and fatty, so as greatly to resemble omentum, while 
 the fasciae and integument become stretched and, if a truss has 
 been long worn, very much thickened and condensed. The 
 fibrous and sub-cellular tissues covering old and long standing 
 hernise often become so blended together that it is impossible 
 not only for the young student, but also for the skilled and 
 practised dissector, to distinguish more than a single layer. 
 
 The muscular fibres are, however, usually more distinct in 
 their structure, and preserve their identity intact. 
 
 Fig. 9.— Coverings of Femoral Hernia. 1, skin; 2, superficial fascia, cribriform fascia; 
 3, crurale sheath ; 4, femoral sheath ; 5, septum crurale ; 6, peritoneum. 
 
 Adhesions are commonly within the sac, and in long-standing 
 cases, although often a hernia is rendered irreducible on account 
 of fibrous adhesions to the tissues surrounding the rings. When 
 the adhesions are within the sac, they may be between the 
 coils of viscera, between them and the omentum, or between 
 the contents and the walls of the sac. In recent cases these 
 adhesions are soft and easily broken down, but in old cases 
 they often become very firm anci fibrous, and especially strong 
 around the neck of the sac. 
 
 The symptoms of a reducible Hernia are as follows : — 
 There is a soft compressible swelling or tumour in the 
 
7fi HERNIA. 
 
 abdominal parietes, or on the thigh, commonly in the groin, either 
 above (inguinal) or below Poupart's ligament (femoral). This 
 tumour enlarges, and is well marked when the patient stands, 
 and still more so when he coughs or forces down. Coucfhimj 
 will moreover cause a distinct pulsation perceptible to the 
 touch. When the patient assumes the recumbent position the 
 tumour diminishes, and can be reduced by proper manipulation 
 in the direction of its protrusion. The tumour is like to be 
 larger after a meal, and the patient to suffer from flatulence, 
 grumblings in intestines, and other inconveniences resulting 
 from the difficulty of passage of matter through the protruded 
 intestines. There is usually no other pain or sign of inflamma- 
 tion. The hernial tumour, if it attains any considerable size, 
 becomes pendulous, hanging in scrotal and umbilical hernioe 
 even to the knees. Such hernias may at any time be made 
 irreducible by blows or pressure, by improper manipulation, by 
 the application of a truss when the hernia has not been fully 
 reduced, or by undue violence in taxis. Oftentimes, although 
 the intestine can be readily restored to its normal position, the 
 sac remains protruding because of adhesions which have formed. 
 Further manipulation is then of no avail, and may produce a 
 severe inflammation. Although it has been sometimes recom- 
 mended to confine these tissues in the aperture of the rings in 
 order to excite adhesive inflammation for the support of the 
 Hernia, such methods have usually been fruitless in results 
 except in young children. 
 
 The presence of fluid in the hernial sac will be almost certain 
 to obscure the visceral nature of the contents of an epiplocele 
 or of an entero-epiplocele so as to simulate an enterocele. 
 Hydrocele of the cord may also lead us far astray in our 
 diagnosis of a Hernia as the following case will show. 
 
 A little boy with a congenital oblique inguinal suffered at the 
 age of five a strangulation. Dr. J. Leonard, an old friend of 
 
ANATOMY : DESCRIPTIVE AND SURGICAL. 77 
 
 mine, succeeded in reducing the strangulation after long efforts, 
 although he told the parents that to his mortification he had 
 so enlarged the hernial rings, that the hernia could not be 
 retained in the abdomen although he knew he had reduced it. 
 The fact was, as I have since learned by personal examination, 
 the boy was suffering from hydrocele as well as strangulated 
 Hernia and the parts were dilated not so much by the doctor's 
 manipulation as by the pressure caused by the effusion in the 
 hydrocele. 
 
 Since the symptoms of many other varieties of tumours so 
 closely resemble hernial tumours it will be necessary to dis- 
 tinguish accurately between them in order, not to be misled in 
 our diagnosis. In surgical practice we have to distinguish be- 
 tween the two forms of Inguinal Hernias, direct and indirect; 
 between Inguinal Hernia and the following conditions : — 
 
 Femoral Hernia. Variocele. 
 
 Hydrocele of the cord. Hasraatocele. 
 
 Hydrocele of testicle. Bubo. 
 
 Sarcocele of testicle. Impacted fasces. 
 Undescended testicle. 
 
 We have also to distinguish between femoral Hernia and 
 enlarged glands. 
 
 j Psoas abscess. 
 
 Varix of saphenous vein. 
 Lipoma of femoral canal. 
 
 Ventral Hernia3 may be confused with Umbilical, Thyroid 
 with Perineal, Diaphragmatic Hernias with Mediastinal Tumours, 
 Congenital Hernias with Hydrocele, and with Infantile or 
 Encysted Hernias. 
 
 To make clear the different points of distinction between 
 these various conditions, I have thought it best to arrange in 
 tabular form the following differential diagnosis. 
 

 
 s . 
 
 "5 ^ 
 
 2-2. 
 
 § 
 
 1 
 
 a'ft 
 
 i^ 1 
 
 2 •— >-. 5 
 
 w s e 
 
 
 ft 
 
 >• y - "d 
 
 p 
 .2 
 
 2 3 . 
 
 
 a 
 < 
 
 fi 
 
 5 E 
 
 C CO 
 
 £ 5 
 g to 
 
 3 CD 
 
 — a 
 
 a * 
 
 .~ x 
 
 c S- 
 P.O 
 
 = 73 
 
 S 2 
 
 '8 
 
 tp 
 
 2 
 
 P 
 
 c 
 
 
 2 — - ° 
 
 si lli 
 
 5H.5 p, - 
 
 5 s Top? 1 
 
 V t. 
 
 
 
 n 'r 
 
 ft 
 
 _g-.-P 
 
 C/J 5G 
 
 1 
 
 <1 
 
 E l pi 
 
 ^ M y. -u 
 
 g 2 a ft 
 
 dc-" M 
 
 ^3 
 ft 
 
 
 c 
 .2 
 
 2 §*E 1 £ b*S 
 
 S"H % 53 > 
 
 co P £ , <r. zj ., 
 
 £ £ 3 ! £ •= 3 
 
 ■* 1 §s P • r 
 
 S o » S '- 
 
 S 
 
 p 
 
 >,2 
 
 2 3 
 
 CO 
 
 eg -3 
 
 2 2 ' 
 
 73 
 
 2= i? - - =' 
 
 >.5 
 
 p: ^5 
 
 3 
 
 3 
 
 p 
 
 
 •3 
 
 w pP> I M P> 
 c 
 3iqi:)npa.i 
 Aipnsn 
 
 ■5 <J8 * . •- 
 
 lllSI 
 
 13 
 eg 
 
 • CO 3 
 
 ^1 
 
 
 2 1 S = S 
 
 S| 
 
 i-i 
 
 
 
 
 i 
 
 
 rz . 
 
 
 -0 
 
 
 'S 
 
 
 
 £ . 
 
 ■q.uaursst?.i.tBqTU9 
 
 
 M 
 
 
 CU CU 
 
 ® 2 
 
 ei 
 
 cu -7i 
 
 a> cu 
 
 '^3 
 
 03 CO 
 CO 
 
 few 
 
 
 o 
 
 PQ 
 
 oiqissoj 
 
 ei 5 2 
 
 o § 
 
 
 M 
 
 P 
 
 "1 1 
 
 H 
 
 
 
 
 
 
 
 
 cu 
 
 
 
 
 
 o 
 
 coo 
 CO 
 
 c" 5 -J 
 o.~ 2 
 
 ft ^ ° 
 
 tog* <b 
 
 PSp 
 
 
 111 
 
 O 3c0 
 
 o^ p 
 
 en 
 3"2 
 
 O 3 
 
 CO"^ 
 
 5 - °" 
 
 8§| 
 
 S3^3 
 
 ■ssa 
 t5 
 
 r ~ 
 
 o> 2 a 
 
 
 cu c rt 
 
 2^ft 
 .« 
 
 -a 
 
 •d 
 
 S| 
 
 
 
 ! 
 
 
 
 fto 3 
 
 
 
 13 
 
 
 
 
 3 . 
 
 £"3 
 
 ■P 
 CO 
 
 ft 
 
 >> 
 
 1^ ' 
 
 >> 
 ft 
 
 
 ft 
 
 P3-P 
 
 rt cu 
 
 3 
 
 33 
 
 "ft 
 
 
 fcflrt 
 
 •3 
 
 s 
 
 
 
 "^ P "P P 
 
 p 
 
 — IP 
 
 £ 
 
 
 s 
 
 
 fit 1 
 
 ft 
 
 B 
 
 tj-«a 
 
 W 
 
 ^P O 01 
 
 H 
 
 £- 
 
 3 
 
 fi^ 
 
 H 
 
 
 "3 P 
 
 p S 
 
 
 .So 
 
 d 
 
 p 
 
 P 
 
 
 ill 
 
 J= * £ CO 
 
 £ ^3 ?D 
 
 p 
 
 " - • 
 
 
 o3-£ 
 
 •^uasajd 
 
 Ol JU CO 
 
 Pm s 
 
 ft 
 
 3 
 
 i 
 
 33' 
 
 p a> 
 
 p 05 
 
 1-1 
 
 3 ^ 8 
 
 CO S X 
 
 CU-«J 
 
 > p 
 
 eo 
 
 fe ft 
 
 rt P '^ co 
 
 fe |8 
 
 
 ft 
 
 3 
 ft 
 
 1^1 
 
 § ,2 
 
 "lag 
 
 W 5? 
 
 
 "§3" 
 
 -p"S 
 
 CO 'm 
 
 if 3 
 
 CQ-P 
 
 S.2 
 'E'P 
 
 - 
 
 S to 
 
 to 
 
 eo c« . 
 
 H O CO 
 
 "^ to 2 
 P3jj g 
 
 8 ^ 
 
 ft. 
 
 1 if a 
 
 CO* 
 
 1^ 1 . 
 
 +> -5pj p 
 
 K2 
 
 
 ^ri 
 
 4^ 
 
 
 >, . W) 
 
 1 U « 
 
 +i 
 
 ^ 
 
 
 
 >, . ei 
 
 ^ CO 
 
 > 
 
 p:+j3 
 
 P rf bO 
 
 
 o 3 
 to £ o 
 
 p 
 o 
 
 1| 
 
 
 Pli tD 
 
 ■: cs 
 
 j P 
 
 o 
 
 i 5^' 
 
 s S 
 
 3 
 fi 
 
 ft' 
 
 ill 
 
 
 g^l 
 
 « 
 
 Ph 
 
 h 3 3 
 ^ wo 
 
 ! w ^ 
 
 CD 
 
 PS 
 
 ! fi* 
 
 fi£ 
 
 &S5 
 
 . eu w 
 
 fi«R| 
 
 
 £g 
 
 Ph 
 
 
 Ph-^ 
 
 [^ <-• 
 
 ft 
 
 ft 
 
 a, ^ 
 
 
 ft-^ 
 
 PM ^ 
 
 
 p^ 
 
 •uappns ;uaApv 
 
 p 
 
 a) 
 
 ■a 
 
 -a 
 p 
 
 >> 
 
 53 
 I* 
 
 P CO 
 
 o 
 
 1 il 
 
 ! §£ 
 
 5 P 
 10 P 5 
 ft| I" 
 
 rP "" C> 
 
 g s 
 
 CU *« 
 
 Q -0 
 
 ^ 3 
 S3 
 
 Q M 
 
 ft^ 
 >3 
 
 cu rt 
 
 £3 
 
 «4- 2 e CO 
 
 ?••§- 2? 
 
 £|li s 
 
 
 
 ?« ; "3 
 
 . 
 
 >. 
 
 _^ 
 
 1 .2 
 
 . 
 
 ^> -d 
 
 • 
 
 .3 >, 
 
 
 J a 
 
 ^■^ P? i 4? >> 
 
 irs ?? : * £3 
 ^ S : S = 5 
 
 h-< co j» 13 ai 
 =0 i =° 
 
 IS 
 
 3 " 
 
 CO -w 
 
 E-i op 
 3 
 
 S'rp 
 *H rP 
 
 W =0 
 
 ce 
 
 .s • 
 
 3c .2 
 >t 
 
 3 
 H 
 
 °0 
 
 ; oi rt 
 
 l|lo 
 ^33 
 
 3 
 pS'P « 
 
 9* -0 3o 
 
 33-< 1 
 
 OB g 
 
 a ° & 
 
 ^ CO 
 
 j 3b 
 
 i C3d 
 co 3 
 
 i-i 
 
 3^ to 
 
 § | 
 
 
 © !- S 
 
 55 c3 P 
 
 ca 
 H 
 
 d 
 
 & 
 
 "to 
 
 3 
 
 ■Q 
 
 o 
 
 3 
 
 3J 
 
 pS-p 
 
 ST 
 3 S . 
 
 -p p 2 
 p|°S 
 
 5 ■- o 
 
 ■d 
 
 ft a3 
 JS a 1 
 
 Si a 
 
 CO O 
 
 ■ 
 
 ! & * 
 
 i EtJ 8 
 i >. p 
 
 p3 
 as g 
 
 IP 
 
 III 
 
 £0 
 
 1 3 .S 
 i ^3-° 
 
 ! ^ 5 | 
 
 ^ C _ee 2 
 
 it 1 ?" 
 l3«g 
 
 EP3| 
 
 CO 
 
 ^ 2 2 
 
 i ftll 
 1 S s 
 
 
 
 i 1 
 
 3 
 .S 
 
 S 
 
 S 
 
 "S 
 
 F-l 
 
 w 
 
 3 
 
 o 
 o 
 
 a 
 
 CO 
 
 .3 
 
 "p 
 
 W 
 
 
 
 ,2 cu 
 23 
 
 S 
 3 
 
 CD 
 
 3 
 
 CO 
 
 
 
 © . 
 3^ 
 3 
 
 
 rH 
 
 1 
 
 •33 
 
 PI P 
 
 P 
 
 S 
 
 o 
 
 CO 
 
 3 
 
 o 
 o 
 
 IV2 
 
 2^ 
 
 3 
 
 2 
 
 
 CO 
 
 ^O 
 
 l 
 
 3 
 § 
 
 CO 
 
 3« 
 

 
 
 
 
 
 
 
 
 
 
 e! 
 
 C 
 
 © 
 
 © 
 
 S 
 © 
 
 .s 
 
 o 
 Fj 
 
 03 
 
 fa 
 &* 
 
 .2 © 
 :3 a: 
 
 3 
 to 
 
 IB 
 
 "3 
 
 5 
 
 o 
 a 
 5 
 
 -(J 
 
 c 
 
 © 
 >> 
 I- 
 
 ft- © 
 
 ■- ~ 
 e= ~ 
 
 a o 
 
 03 S3 
 
 | 
 
 1 
 
 3 
 o 
 
 e 
 3 
 
 to 
 
 "3 
 3 . 
 
 2 « 
 .2 
 
 sa 
 
 3 ** 
 © 
 
 -h's 
 
 S3 a 
 
 II 
 
 >>3 
 3^ 
 
 © g 
 
 !•§ 
 
 £2 
 
 1 
 
 03 U 
 
 o a> 
 gtf 
 
 s« 
 
 P. g 
 
 *e 3 
 « 2 
 
 3 3 © 
 
 ce 3 o 
 
 -1? 
 
 3 © fij 
 
 8 fi om . 
 
 fifStfic 
 .. . fa-d c 
 
 - 3 > S- c 
 
 c ~r >- 3 
 = 35 0: 
 
 -.?"=£ = 
 
 * i & ^ ? 
 
 ^'3 s "3 tr 
 
 r p-3 — .e 
 If "si 
 
 3 C*h > Z. 
 gT3 C O 03 
 
 H 
 
 If" 5 
 ? 3 
 
 nil 
 
 s U O 5; 
 
 "to "2 fcn 
 
 S "g 3 c 
 
 3 C -t; "•; 
 "" 3 "_ 
 "3 c "3 ?5 
 
 § 2-S 2 
 ^3i p,J 
 
 CO 
 
 2 ® 3 ^ 
 c © S g* >? 
 
 "S iS-3-2 1 
 
 S 3 c 2 6 " 
 
 3 "|"1 i 
 
 2 J |l S 1 'B 
 
 F? 3.3.3 03^ g 
 
 « 3 H 
 
 
 g : : r 
 
 co 3 
 
 25 
 © p 
 
 © 
 
 £3 CO 
 
 <3a 
 
 33 
 O » 
 
 lg 
 
 >c © 
 
 li 
 
 Ml 
 
 3^ * 
 
 3 
 
 3 
 
 2 
 © 
 
 CD 
 
 3 
 V 
 
 
 
 OJ 
 
 •3 
 
 ct 
 
 to 
 
 3 
 O 
 
 *3 . 
 
 v-, a 
 — 
 
 -1 
 
 c 3 
 3.T2 
 3 co 
 
 EH 
 
 a* 
 
 o 
 33 
 o 
 
 3 
 
 © 
 
 „ to" 
 <g > 0J 
 
 111 
 © c 
 MS 
 
 .a 
 
 "o 
 
 3 
 -a 
 
 1 
 
 111* 
 
 eg 1 ;' 
 £ s S g be 
 
 a: c: .b P< 
 
 2 
 
 t 3 c 
 S- a. — 
 
 =o£3° 
 
 P,S 
 
 s 
 
 3 g § 
 
 3^ 
 ^ " cc 
 
 ss » 
 
 g ^ 83 
 
 B5^= ^ 
 
 Ip-lo' 
 
 3 a, 3 
 .2 ^"S to 
 
 ■SS 3 
 
 6 
 
 3 
 
 *3 
 
 3 
 
 CO 
 
 t3 
 
 d 
 
 3 
 
 1 
 
 'S'S 
 
 U 
 
 3 3< 
 © e! 
 
 N 
 
 2& 
 
 £^"2 . 
 
 °3 =: ^ S 
 £ C to 3 
 
 ^H2g 
 
 0-3 -^^ 
 £" {3 S © 
 
 © 
 
 is 
 
 o 
 
 ■d 
 
 © 
 
 g 
 
 a 
 © 
 
 O CD 
 
 £g 
 
 cj 
 g 
 
 © 
 
 — fi s 
 
 .S 3 O 
 
 CO tC P< 
 B p 4, 
 
 c gS 
 •o O 
 
 1* 
 
 "S 3 
 3 C 
 
 ■d 
 
 <u 
 _ 03 
 3 0: 
 
 • 5 s 
 
 s 
 
 CD 
 
 3 
 C to 
 
 a. 
 
 s 
 
 — 5 g 
 P S 3 
 
 CC CZ Sj 
 
 3 O 
 5 3 
 
 O . 
 3-3 
 0- ° 
 
 11 
 
 CD "© 
 
 © © 
 
 -3 C • 
 
 tn CO 
 ° C«« 
 
 © a 
 
 3 !-. 
 
 "o 
 © 
 
 a 
 
 «™ 
 
 Eel 
 
 "3 
 § . 
 
 © 3 
 eo C 
 
 faS 
 S-g 
 
 o 
 
 Iiji 
 
 Coo 
 
 111? 
 
 S — — - 
 
 sir 
 
 © 
 
 © © 
 
 3 i> 
 
 do 
 
 fa 
 
 § 
 
 fa 
 
 3 
 O 
 
 s 
 *-!§ 
 
 •r-l 'J 
 
 eocC 
 3 ^ 
 
 o S 
 
 3 to 
 
 o 
 
 fa 
 
 ',3'? 
 
 'S •- c 3 
 o3 S 
 
 °«3 
 
 sis 
 
 o § '1 
 
 3 
 OX 
 
 £| 
 
 IS, 
 
 O s 
 
 .3 "C 
 
 -^ — 
 
 ^o3 
 
 -_33 
 
 c = 3 
 fafc35 
 o^ 5 
 
 3 
 ® 
 to 
 
 fa 
 
 CD 
 
 © 
 
 . ^2! © 
 
 3 ©-3 
 
 O © •+■» 
 ^3 3 c 
 
 1 5* 
 
 fa =i = 
 
 _ S to <s 
 
 03 ©3 © 
 | -§ 
 
 fa ©-S 
 fa ^ 
 
 © O 
 
 a a 
 
 £-2*5 
 
 ?.2 
 
 £"? rt 
 
 "Si ft 
 
 © 3 
 
 to© 
 
 fa 
 
 .1? 
 
 =1 
 "id 
 
 23 
 
 "3 to 
 g s 
 
 © a 
 fa<! 
 
 eg 
 
 "§"3 
 fa W 
 
 fa* 
 
 es 
 3 
 o 
 to 
 o 
 
 fa 
 
 c3 
 
 u 
 o 
 
 3 
 
 Q 
 fa 
 
 II 
 
 3 
 
 fa'O 
 
 j3 
 
 fa 
 
 fa 
 
 3 o) 
 
 fa S 
 
 . 
 3 
 O 
 
 fa 
 
 >> 
 
 "3 
 
 2 
 
 sHi 
 
 fa 
 fa 
 
 1 
 
 a 
 
 
 CO 
 
 © 
 
 fa- 
 fa" 
 
 3| 
 
 © 
 
 o 3 
 ol 
 
 -3 = = 
 X' © 
 "i 5 
 
 Er re 
 
 eo 
 'to 
 
 - 
 ,3 
 
 to 
 
 3 
 O 
 
 "3 
 o 
 © 
 in 
 
 p 
 3 
 > jj 
 
 P 3 
 -«-> e> 
 
 gj 
 
 ■a "3 
 
 >>" 
 
 to "" 
 
 1® 
 
 ._ S. 
 
 S-3 
 
 
 
 3 3 
 
 J-, 
 JO 
 
 3 N O 
 ? " fe- • 
 
 C O — ' .3 
 
 a" 
 
 <u 
 •3 
 -3 
 
 3 
 
 CO 
 
 ■ "a 
 
 <a 
 •3 
 <1 
 
 >> 
 
 & 
 
 
 CO 
 
 en 
 
 fa 
 O 
 © 
 © 
 P 
 
 3 ° 
 
 i I! 
 
 c"© 
 
 s -^ © 
 eS ^ s 
 
 S s^ 
 f ? ° 
 
 -3 OT 
 SO 
 
 * 2 
 
 S 
 
 © 
 "3 - 
 
 — u 
 
 "5 !*• ,^ 
 
 S 3 *- 
 
 H 
 i o; a 
 
 < 
 
 05 
 
 « rt 3 
 
 ~ ^ ^ 
 
 ^3 £ 
 
 "3 . 
 
 ■ s 
 
 So 
 
 Z^ — 
 2 3 
 
 r c 73 
 .=! 0^ 
 
 Q=5 
 
 .3 
 
 3 "3 "3 
 3-^.2 
 
 2 
 
 -3 5 
 
 P .g 
 
 ■a 
 
 3 
 
 i • 
 
 3 - 1° 
 
 c 3 
 ■^ 3; © 
 
 ? £ = 
 * 
 5ei 
 
 fa= 3 
 z: a: Z 
 
 ^^3 
 
 "© " — . 
 gg*3 
 
 CO , 
 
 fell 
 
 ?-•<=_• 
 °- §• 
 S*» © a 
 
 •3 2 5 K 
 1=1? 
 
 d 
 
 1 
 
 2 
 
 o 
 
 s 
 
 © 
 
 fa 
 
 I 
 1 
 
 s 
 
 g 
 
 o 
 
 g 
 5 
 fa 
 
 GO 
 CO 
 
 <1) 
 o 
 
 CO 
 
 -i 
 
 m 
 e3 
 O 
 
 fa 
 
 1 
 
 w 
 
 3 
 
 
 3 
 1 
 
 1 
 
 II 
 
 & 
 
 SB 
 
 ed 
 
 3 
 
 O 
 
 3 
 
 
 fa 
 
 l! 
 
 c g 
 
 .S'S 
 
 faS 
 
 d 
 *B 
 © 
 
 US 
 
 1 
 
 s 
 
 © 
 
 fa 
 
 I 
 
 _a 
 
 3) 
 
 a 
 
2 
 
 .9 
 
 Sl-i 
 
 lg'§ 
 
 (5 
 
 Absent : 
 tumour sup- 
 plies its place. 
 
 s 
 
 o 
 
 .3 
 
 05 
 
 3 
 
 XI 
 
 Sudden advent. 
 Resonant percussion. 
 Reducibiiity. 
 Cough impulse as a rule. 
 Possible intestinal embar- 
 rassment. 
 
 1 
 
 13 
 ^3 
 
 2 
 
 ^05 -Q 
 
 '/.- 3 ~- 
 
 ft2 p 
 oi' 
 
 ■° s 
 
 Extreme i 
 
 thirst is i Never produced. 
 
 absent. 
 
 1 
 
 43 
 
 
 2 
 w 
 
 £3 
 To 
 
 Translucent at upper portion. 
 
 3 
 & 
 
 CS 
 
 O 
 
 1 
 
 cS 
 ft 
 
 2 
 
 Pi 
 
 CO 
 
 8.5*2 
 
 bo - ._ -a 
 
 13 a) i d 
 H ft2 2 
 o -o o 
 -a 
 
 ■— c 4) 
 2^ 
 
 GS 0_£ 
 
 Hi 
 
 o ©73 
 
 H 5 
 
 .1 
 
 ^ 3 
 
 a. 5 
 ^3 
 
 d 
 
 o 
 
 1 
 
 © 
 Pi 
 
 cS 
 
 IS 
 
 s 
 
 1 
 
 ■+3 
 
 i 
 
 73 
 © 
 
 a 
 
 1 
 
 to 
 
 5 
 
 © 
 
 to 
 
 .2 
 
 c3 
 
 O i-J-2 
 
 - £ s 
 
 1/0) k 
 .j " 05 
 
 03 
 
 Pi 
 & 
 o 
 
 j£2 03 
 .4) 4> 
 tt-l 05 
 
 Id o » 
 
 cu ° '43 
 
 7322 
 
 43 ■" P* 
 
 2 S3>> 
 
 ■ ^ 43 f-l 
 
 CS >->2 o) 
 
 CT3-PW 
 S O O u 
 
 © o CD O 
 
 ^ !-( 43 
 
 -3 ® n (=t 
 
 °^03° 
 <I> o ^ 
 5g cS 
 
 fig 
 
 45 Tl.i jj 
 03 'S ^ 
 
 03 S C 
 
 P P ~ 
 
 i2 43 rH 
 Q.g* 
 
 05 <- ' © 
 
 O r/l 2 
 
 ''Ol. 
 03 £ — 
 
 Ss c " 
 S K,c 
 
 05 O 
 
 O != ™ 
 
 ^^ o 
 
 "5 
 
 43 . 
 
 05 X 
 CI 4) 
 
 B 1? 
 
 "° 2 
 2 
 
 -d 
 
 o 
 
 &2 
 
 5 
 
 3 
 
 43 
 ft 
 
 2 . 
 
 &■ 2 J - 
 7i-2 ft 
 
 2 
 3 
 
 3 
 
 || 
 p 2 
 2| 
 
 Ift 
 
 O O 
 
 & ° 
 
 2 2 
 
 CO JH 
 
 S a 
 
 w 2 
 
 a 
 
 0) 
 OS 
 
 5 
 
 ci 
 
 "el 
 
 03 
 
 to 
 O 
 
 oS 
 43 4) JP, 
 
 43 f3 — 
 
 ?5 p 2 
 
 di 
 o 
 
 43 
 ft 
 
 73 
 
 03 
 
 3 
 
 D 
 
 o 
 
 4) 
 
 2 
 
 I 
 
 B 
 o 
 
 3 
 
 2 
 
 H 
 cS 
 
 ft 
 
 a 
 
 o 
 'vi 
 
 75 
 
 3 
 
 05 
 
 ^ i- 43 
 
 43 - 43 B 1 
 
 .3 g 05 
 
 C3^_V5 
 
 2 2 =3 
 _o j5 —• 
 
 III 
 
 a 
 
 n 
 2 
 
 13 
 
 'S 
 
 43 
 3, 
 
 ci 
 
 to 
 < 
 
 cs a 
 
 "3 !^ 
 
 rr. 73 
 o 43 
 
 2 05 
 
 ~v, 
 
 CO 4) 
 ^ OS . 
 
 a os >■. 
 
 = 2 2 
 n us 
 
 2 ci 
 
 2 * 
 
 p 2 
 
 43 43 
 
 -4J 
 
 a 
 
 o? ai 
 
 2«° 
 
 «a >, 
 
 c a 
 •~ cS 
 
 •-"S 
 
 c a 
 a 43 
 
 §§» 
 
 ■ss 
 
 © 
 
 >> 
 
 § 
 2 
 
 1 
 w 
 o 
 
 1 
 
 -3 
 
 1 
 
 a 
 
 -(J 
 
 1 
 
 -IJ 
 o 
 
 g 
 
 O 
 
 © 
 O 
 
 isl 
 
 O 4) 
 G 4) 
 
 T3 
 43 
 
 "S 
 O 
 
 -S 
 
 § 
 
 1 
 
 05 
 
 ci 
 to 
 
 c? 
 . C 
 
 "g "J CO 
 
 £732 
 
 .5-22 
 22 d 
 
 "" -*3 .2 
 
 >, c ^ 
 
 11? 
 
 X 3 M 
 
 c: .2 
 co > 
 CO S 
 
 43 S 
 ° ft 
 
 73 c3 
 . 4) W 
 
 43 +r 
 fcO.y 
 c: ^ 
 >»? 
 
 i 
 i 
 
 © 
 
 I 
 
 ©•£ 
 
 S 3 
 o © 
 
 O 
 
 © 
 2 
 rt cS 
 
 *\ 
 
 "3 03 
 
 O ft 
 ,© 
 
 &a 
 H 
 
 •oiqpnpaa 
 
 73 
 
 43 ^ 
 
 n 
 
 gg . 
 
 S ft'g 
 
 V| ft 
 
 4h 
 
 3 
 •3 
 
 45 
 Eh 
 
 -S2 r o 
 •2c=|£. D rt 
 2 « ^ §>•* 
 
 i 1 43 .2 '> 53 o; 
 ; a 2 +J ffl °* "3 
 
 |||a| 
 
 ^^|o?2 
 
 t> 75 3 
 
 2 
 '3 
 
 73 
 
 2S**| 
 « '43 5 r2 ft 
 
 a- c?43 =i 
 
 .2 - 33 ^ t0 
 
 c "^ 3 o- ^ 
 -g o £ 2 gp 
 
 43 "^ C3 tO jj 
 
 r;- =+j 'o; to 
 
 3 73 45-- ^J 
 
 o H 
 
 2-S 
 
 c2 t 
 c s 
 
 || 
 
 2 Or 
 
 43 33 
 
 2 03 
 O 4) 
 
 «5 
 
 4) 
 
 it 
 
 43 >-. 4J a " 
 
 a 1 ^ to a os 
 
 o •• ,o cd a 
 
 O >, 03 # "3 
 
 . ?h - 03 3 
 
 S o a © o 
 
 «253 £-* 
 
 02 
 
 'x&B © 
 
 43 =w 03 M 
 
 tD © t," £ 
 
 § t»o ft 
 
 •iwppng 
 
 2 C a 2 
 2.2 N 
 
 rj 43 oS 
 
 53 2 g 
 
 S^ 05 
 05 +J 43 
 
 S 3 ft 
 
 ^ 2 43 
 ||| 
 
 c ft 3 
 
 2 8 
 50 -*: 2 2 
 
 a> "* *S 3 1 
 o a ?h 
 R -* a, « 
 
 g >>03 > 
 
 3^ 3 
 o -2 
 
 73 
 
 ft__ 
 22 >> 
 
 O! ? ci 
 
 pTo -0 
 
 <5 
 
 •2 -^ 
 
 r-" 2 K S 
 
 3 *^2 §5 . 
 
 •22§«r 
 tf 2 5 § o 
 
 |2^J 
 
 ^ 43 
 
 03 • 
 £ CO 
 
 11 
 
 "'to 
 
 ii 
 
 2 2 
 
 o -H 
 
 O o 
 
 a 
 .2 
 
 o 
 
 1-3 
 
 a 1-1 05 4) 
 
 •"8 1-3 
 
 °2 s 
 
 cc!^ ci 
 
 a • 2 
 
 S3J 
 
 8 , o §" © 
 
 S .2 g 2 1 
 I°l 1 M a * 
 
 -= r- 05 -~ © 
 
 -^•"'3 -73 W 
 2 43 2 ?5 £ 
 
 a © £*-• 
 
 « c „; 
 
 03 fl J 
 
 .£ 3 
 
 43 O 
 
 ft g 
 
 2 3 
 
 .it 
 
 a. 
 
 a 
 
 22 
 
 4- 75 o> 
 
 111 
 
 2g§ 
 
 to.2 « 
 
 ►2'° 
 
 2 
 
 ci 
 
 45 >, 
 
 2 3 
 
 60 
 
 a 
 
 ^£3 
 
 2 2 ®2 
 
 ai|l# 
 
 C3 -° "S 05 '3 
 
 C 43 = a f 5 
 
 2 
 
 a 
 
 | 
 
 
 ci 
 
 1 
 
 <D 
 
 I 
 
 
 '2 
 
 S 
 
 w 
 I 
 
 '3 
 
 03 
 
 s 
 
 is 
 ii 
 
 2 . 
 
 Si rt 
 
 p"2 
 
 43 n 
 
 to 3 
 
 c3 
 
 43 
 43 
 
 o 
 u 
 
 13 
 
 2 
 
 •=.2 
 S3 a 
 
 © • 
 ~ .2 
 
1 
 
 
 
 |s 
 
 O 40 
 
 3 2 
 3 3< 
 
 3 to 
 
 13 
 
 "o bb 
 
 
 .a 
 
 
 • a 
 
 
 
 •o 
 3 
 o 
 
 3 
 
 S+3 ^ 
 
 :3 3 o 
 
 13 8-8 
 
 eg -3 
 
 O co gP^ 
 
 5: = » ca 
 ~ ce" y "* 
 
 co 
 
 Ii 
 fc.3 
 
 &»1 
 
 S So 
 
 ■3 S^to 
 
 O CU QJ 
 
 too S 
 
 CO ° > K 
 
 ii 3 '-H o 
 a ^'55 -3 
 s g go 
 
 *j 3 to 3 . 
 3 C0_, 3^ 
 
 s «■ J33; 
 
 ; o ."S3 
 
 - ^ "55 w '~ 
 
 ■*» 
 
 §| 
 
 F CO CO 
 
 3 . 3 
 
 co 3 O 
 
 p 2 
 
 to s 5 
 .2+2 > 
 
 ^ co cS 
 
 £ c^ 
 O g 
 
 <1 
 
 r; 3 cu "3 
 
 O J3 =" 
 
 o~ 3 a 
 
 2 - 3 ' rt 
 
 "^Ph^ p 
 O ' _3 co 
 
 42 "S^ 3 
 
 RA co O 
 
 a> 3 S 'co 
 
 .2oi2 
 "•3 °C 
 
 -S - C ° 
 
 ^ jS 
 O .3 -3 .i 
 
 ~ flK 
 g « 
 
 
 
 
 3 cS M 
 
 3 
 
 81 
 
 o 3 
 
 •3 O 
 
 9° 
 
 33.3 
 
 3 "3 
 
 3 3 
 
 ^ J 
 
 -.2 3 
 
 'II 1 
 
 S" s s » 
 1 * 
 
 3 m s to 
 O - 3-« 
 
 
 
 1 
 +3 
 o 
 
 3 
 
 •3 
 
 o 
 « 
 
 3 
 © 
 
 o 
 
 •3 . 
 a >> 
 
 I 
 
 3 
 
 ?d 
 
 g]J 
 
 33 3 
 
 O tO 
 3 
 -3 
 CO 
 
 Ph 
 
 3 
 
 CO . 
 
 B sb 
 
 1 
 
 -s 
 
 -1 
 
 3 O 
 
 £| 
 Lo ^ 
 
 CO 
 
 Ph 
 
 Si 
 
 CO '-^ 
 
 84s 
 
 -3-2 
 
 N "* 
 ~ CO 
 
 I! 
 
 3 
 
 w To 
 
 3 
 
 3 3) 
 
 -3 
 
 3 
 
 . 3 
 
 S if 
 2 to 
 
 £** 
 
 S> 
 
 ^P 
 
 53 
 
 'O 
 -3 
 
 •2o 
 ^ s . 
 
 3^- to 
 < p to 
 
 V, ft 3 
 
 g 3=0 
 3 3 
 O 
 Ph 
 
 
 
 
 
 CO 
 
 
 
 
 
 
 j 
 
 P-l 
 
 
 
 J5? • 
 
 s-s 
 
 io-sgi 
 
 i.£-S53§ 
 
 ^3 2 =i-3 
 
 £-• S 2 2 .2 
 !; » 3 3 M 
 
 >> CO 
 
 CO •§ 
 
 | 
 
 1? 
 
 It 
 
 CO •§ 
 
 C 3 
 3 u 
 3< to 
 
 3 
 
 "3 
 
 Pi 
 
 1 
 
 
 
 
 
 
 
 - 
 
 
 
 
 
 3 
 
 1 
 
 •3 
 gS 
 
 — to 
 
 |i 
 
 S 
 
 1 
 
 p 
 
 O 50 
 
 H 
 
 -6 
 
 & 
 a 
 
 3 
 
 P 
 
 8.3 © 3 
 
 £ 
 
 till 
 
 •*a '3 rO CO 
 N 5 <= 3 
 
 ■3 
 
 
 
 3 M 
 
 a> cj 
 
 §| 
 
 3 
 
 C3 
 CO 
 
 » - 
 3 
 
 >3 
 
 el 
 
 — c3 
 
 ^■2 
 
 2 ~ o"3 
 
 
 V 
 
 
 o 
 
 
 «i CJ 
 
 CO « 
 
 O 
 
 
 
 P3 
 
 fill 
 
 3 ;+»• 
 
 "3 3 
 
 -I 3 
 
 0~&H 
 
 *3 . "£ .2 
 
 co 3 $£ ~ 3 
 
 ■m 
 
 oqo; 
 
 H3.5 
 
 ,§ co 
 
 h2§ 
 
 3-3 
 CO S 
 CO 
 
 -5 8 
 
 ■+3 
 
 ■it 
 
 
 nouiu 
 
 ioo i -0 
 
 Ph^' 
 
 
 
 2^ 
 
 P 
 
 .2 
 0"3 
 
 g 
 
 1 
 
 ft 
 
 >> 
 
 3 3 
 
 CO CO 
 
 p 
 
 1- 
 
 M 3 
 
 >> 
 
 3 O 
 to co 
 P 
 
 " 3 
 
 S to 
 
 3 3 
 co co 
 P 
 
 C 3 
 
 ci-3 
 
 Kg 
 
 III 
 
 "3 
 
 © - O 
 
 !s *» 
 
 HO s 
 
 43 
 
 III 
 
 to to 
 
 ^J co ci 
 
 . -3 . 
 
 To h a 3; 
 
 P 3 «s 
 rfS'S — 
 
 
 >» 
 
 
 ^ 
 
 -IJ 
 
 
 
 to 
 
 
 
 
 11. 
 
 
 O 
 
 S to 
 
 3§ 
 SI 
 
 
 
 
 
 
 >> 
 
 
 
 "3 "3" 
 
 g-g-5 
 
 11 
 
 "§ 
 
 s -.2 
 S-2To 
 
 ^'1 
 
 
 | 
 
 PH=P 
 
 
 P g> 
 
 C 3 3 
 
 H ^ 
 
 co 3 
 
 "-^ CO 
 . 03 
 
 Ph * 
 
 fa 
 
 §S3 
 
 M 
 
 
 Ph 
 
 Ph 3 
 
 ft*« 
 
 Ph^ 
 
 £§0 
 
 P* 
 
 Ph 
 
 pT° 
 
 ft 525 
 
 ft' 
 
 3 
 
 «i 
 
 Ph <i 
 
 p4^ 
 
 
 
 ft ^ 
 
 < 
 
 
 
 a 3 
 
 u 
 1 = 
 
 3 
 o 
 
 o 
 
 3_j 
 
 
 
 
 -3 
 
 ■S c g a 
 
 3-3* 
 
 ■J! 
 
 ■3 =0 
 
 2 - 
 
 oO >"p 
 
 '? 
 
 3 
 if 3* 
 
 ^1 
 
 <3 -n 
 
 c -£ 
 
 a>3 
 
 c 3" 
 
 o 3 
 
 3 
 «9 
 
 •uappn 
 
 s aq £bji 
 
 S 
 ■3 3 
 
 H 
 " 
 
 > !h 
 
 O O 
 
 ^.2 |«g 
 
 Q.-S 
 
 11 
 
 ■8? 
 
 3 
 
 3h ^ 3 
 
 « »■ a z 
 
 a a H d 
 
 i; 3 3 > 
 
 3 2 ? 
 3 C--3 
 
 => '> 
 -S >, 
 
 U}J3 
 
 co "5 
 +> 3 
 a te 
 
 CD 
 
 ■3 
 
 < 
 
 te'3 
 
 I ft 
 
 
 
 "3 
 <1 
 
 
 ___; ^ 
 
 -3 ,§►» 
 
 
 
 
 3 3 
 
 
 "3 
 
 O 
 
 CO . 
 
 S 2 
 
 
 a' 
 
 o 
 
 ° °3_3 ■ 
 ■3 o go 2 
 
 = ^^3 l-d 
 
 
 
 3 
 
 .3 3 
 
 ^? 3 t>, 
 
 ~ to 
 
 cS 
 
 1 
 
 H 
 
 o 
 P 
 
 1 
 
 ri x: «j 
 
 S-S = 6o 3 
 
 't'CUTJO 
 
 \vum°m 
 
 3 " 
 
 +2 ■— ' ^ 
 
 
 CO 3 
 
 
 Q~ tC3-= 
 
 .— °" 5 to 3 "^ 
 
 piTB 
 
 ntsuig 
 
 -t 3 3 
 
 
 fa to ^ 
 
 0.2 
 5 
 
 r— *> 
 
 =2^ 
 
 .2 
 cs 
 
 Ph 
 
 
 
 
 
 
 3 
 
 
 ^ 
 
 
 
 
 d 
 ft 
 
 C 3 
 
 H'5 
 
 ^3° 1 
 
 
 "3 
 o 
 
 3 
 c 
 
 .3 
 
 -3 
 
 1.2 
 
 CD O 
 
 P 
 
 P 
 
 a 
 
 S 
 
 3 
 
 3 
 to 
 
 P 
 
 
 2 
 
 fa 
 
 I 
 
 3« 
 
 3 
 
 I i 
 
 •a i 
 1 
 1° | 
 
 C 
 CD 
 
 C O 
 -3° 
 
 
 
 
 
 CD 
 
 a 
 
 3 
 
 
 ^o 
 
 s 
 
 
 
 
 
 
 M 
 
 
 
 
 
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 
 testicle. 
 
 Fig. 10. 
 
 Pio. 11. 
 
 Fio. 12. 
 
 Fig. 10.— This diagram illustrates the tubular vaginal process of peritoneum cpen 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 lite the " congenital form," Birkett's "hernia 
 into the vaginal process of peritoneum." or Malgaigne's "hernia of infancy." 
 
 Fig. 11. — The same process of peritoneum open half-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." 
 
 Fig. 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. 
 
 Fig. 13. 
 
 A 
 
 Fig. 14. 
 
 Fig. 15. 
 
 Fig. 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. 
 
 Fig. 14. — Diagram illustrating the formation of the "acquired" hernial sac, distinct from the 
 testicle or vaginal process of peritoneum which has closed. 
 
 Fig. 15.— Illustrates the neck of the hernial sac pushed back beneath the abdominal parietes 
 with the strangulated boweL 
 
ANATOMY: DESCRIPTIVE AND SURGICAL 
 
 Fio. 16 
 
 Fig. 17. 
 
 Fio. 18. 
 
 Fig. 16.— Shows the space in the superitoneal connective tissue into which intestine may be 
 pushed through a rupture in ths neck of the hernial sac ; the intestine being still strangulated 
 by the neck. 
 
 Fig. 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 ths muscles and the internal abdominal 
 fascia— forming the intra-parietal, iuter-muscular, or interstitial sac; hernia en bissac of the 
 French ; "addiiional sac" of Birkett. 
 
 Fig. 18.— Diagram illustrating the reduction of the 8ac of a femoral hernia en masse with tho 
 Btrangulated intestine. 
 
 Fio. 19. Fio. 20. 
 
 Drawing illustrating the second varieties of displaced hernia. 
 
 Fig. 19. 
 
 A. A portion of abdominal muscles, with the peritoneal lining. 
 
 B. The strangulated fold of intestine. 
 E. The testicle. 
 
 The dark lines at the neck of the sac represent the dnplicature of the peritoneum, 
 which being unfolded formed a sac for containing the intestine when reduced. 
 
 Fig. 20. 
 
 A. Peritoneum lining the abdominal parietes. 
 
 B. The tumour formed when the strangulated intestine was pushed through the spermatic 
 
 canal into the sac formed by peritoneum in tho inside. 
 
 C. The superior portion of the intestine. 
 
 D. The interior. 
 
 E. The scrotal hernial sac. 
 
 F. The testicle, with the vaginal coat opened. 
 
 c, 2 
 
84 
 
 Testis 
 
 Fig. 21.— Third variety. 
 Interstitial hernia with ruptured neck of hernial 
 
 Fto. 22.— Drawing illustrating the fourth variety or intra-parietal form of displaced hernia. 
 
 A. Peritoneum lining the abdominal muscles (B). 
 
 C. Intra-parietal sac with strangulated bowel. 
 
 D. Scrotal hernial sac 'leading down to testicle (T). 
 
 E. Director passed f^om the congenital scrotal sac through the internal ring. 
 
 In the drawing the strangulated bowel has been introduced to make the description clearer. 
 
CHAPTER III. 
 
 Strangulated Hernia. 
 
 A Hernia is said to be strangulated when not only the passage 
 of fasces 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 Herniaa 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 setiology 
 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. 
 
 1. What is the condition of a Strangulated Hernia ? 
 
 2. What changes take place in it ? 
 
 3. 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?eal 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. 
 
 The coverings of the hernial sac undergo pathological 
 modifications due to ecchymoses, inflammations, 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. 
 
 M 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." 1 
 
 1 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 fluccidant, 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 faBces and" before burst- 
 ing though the walls of the intestine may infiltrate its tissues 
 of 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. As a 
 
STRANGULATED HERNIA 89 
 
 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 HEKNIA. 
 
 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 
 constriction lies. 
 
CHAPTER IV. 
 
 Operations foe 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." — Velpeau, 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 sumical science. I know that some of the most 
 honoured men that have brightened the pages of surgical litem- 
 
92 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. 
 
 il 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 in all the various operations 
 in Hernia it was a well-established fact and a true principle in 
 surgery that all of the operations for Hernia had sooner or later 
 with hardly an exception given way in a few clays 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. 93 
 
 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. 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 
 thuse 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 
 
94 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 disease of women, all their ideas of the suffering and illness 
 of the fair sex are centred in the uterus and its appendages ; if 
 the disease 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 perform. This is the reason we find Von Gaff, 
 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 Sequard of Paris, taking the 
 
OPERATIONS FOR HERNIA. 95 
 
 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 T not look 
 for its full approval and adoption ? 
 
 " What has been called a Radical Care ? 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 
 on inflammation of the parts as will provoke adhesions of the 
 enlarged opening, and hence a contraction. Some of these 
 
9G HEBNIA. 
 
 methods are plausible, others probable, while others may justly 
 lay the claim to fairly successful result-. 
 
 Amoug operations long ago obsolete, may be mentioned the 
 ' 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 tilings with 
 internal administration of diamond, Armand's decoction of dog- 
 grass and laurel, the application of ammonium carbonate, as 
 recommended by Belmas, fee, 
 
 "Compression. — Among the advocates of this well-known 
 palliative remedy are Celsus. Theodoras Aetius, de Saticet, 
 Xorsia, Blegny, Tre court, 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 Bavin, Riviere, de Hilden, Eeneaume, 
 Armani Fedran, Hey. anil Riech 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 laying bare the hernia, 
 
OPERATIONS FOR HERNIA. 97 
 
 raising up the internal envelope without opening it, and cau- 
 terizing the ring with a red-hot iron is spoken of by Avicenna. 
 Franco was in the habit of laying open the sac and touching the 
 neck with a button cautery. Anions 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. 
 
 " 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. 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 were fatal almost immediately ; and while Armand, 
 Lieutaud, and Le Blanc favoured the operation, Acrel, Eiehter, 
 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 cne cure by opening the sao 
 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, 
 Laufranc, Amand, Smucher, Lanaenbeck and others of more 
 
 H 
 
98 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 hemorrhage 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. — Oiosely 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 Desault and 
 Dupuytren. For an improved cure by ligating with carbolized catgut see 
 p. 101 for Lister's antiseptic method. 
 
OPERATIONS FOR HKKN1A. 
 
 n 
 
 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 1850 performed the operation in the following manner : — i'he 
 doable 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 rivg. The sac was now in- 
 vaginated and the needle passed through both superior and inferior tendons 
 
 ' io. 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 is 
 invaginated into the ring. The needles are then pushed* out through the 
 
 C '"* l&M ANN "itO." F 
 
 Fio. 24. 
 
 integument and a ligature tied over the two handles and knobs C and D t 
 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 pla.ee for some days. 
 
 H 2 
 
100 HERNIA. 
 
 " S. R. 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 lon^ a«o 
 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. 
 
 " Gilded Point. — To prevent the loss of the testicle, this 
 operation w r as invented. It was used by Buchwall, in Denmark, 
 and by Berrault and A. Pare, 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 Hernia3, 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 FOR HERNIA. * 101 
 
 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 Guerrin, 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 : 
 
 1. Plug of the Epiploon. 
 
 2. Plugging with the testicle or the sac. 
 
 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. H. 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 MoinicheD and Scultetus. Garengest 
 and Steffen 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 clown to the ring, cut from the neighbouring integuments 
 near th*» ilio-pubic ligament a strip two inches long and ten 
 
102 
 
 HERNIA. 
 
 lines wide, which he succeeded, he says, in engrafting into the 
 riii". 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 Redfern 
 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. 
 
 Fig. 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, held 
 there by two interrupted sutures introduced about 1 — 3 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. 
 
 103 
 
 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 results, 
 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, e.g., Wurtzer and others. 
 "D. Hayes Agnew, of Philadelphia, used an instrument (Fig. 26) 
 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.— Agncw's Instrument. 
 
 could be removed after 10 — 14 days. This operation is no 
 logger performed. 
 
 " Belmas' Method. 1829, — The original operation consisted 
 in the introduction and attachment of a small $oucli 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 
 
104 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. :i7. — Wurrzer'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. 
 
 In 1833, Wurtzcr, of Bonn, Germany, invented an instrument 
 (Fig. 27) which carries out Gerdy's method of invagination simply 
 
OPERATIONS FOR HERNIA. 105 
 
 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 about three inches long and from 3 — Sths to 3 — 4ths inch in 
 diameter, according to the size of the Hernia, of a flattened 
 shape, perfectly smooth and rounded 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 allowed to remain in 
 position 6 — 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 Eothemund, 
 in Munich, Sigmund in Vienna, and by Spencer Wells in 1854, 
 in the United States. 
 
 " Professor Armsby, of Albany, JSTew York, has modified the 
 operation by allowing a thread, which is occasionally moved to 
 
10G 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. Eiggs, of New York, in March, 1858, also 
 advocated the use of a seton, but on a larger scale, and reported 
 several successful cures. 
 
 " IS till 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 
 
 Fia. 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. 107 
 
 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 scro f al 
 aperture, one end projecting from the puncture above. Then, 
 with the finger placed behind the external pillar, this pillar and 
 Foupart'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 shin 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 — 15 days the wire may be withdrawn. 
 It is reported that Go — 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." 
 
 I would next to Wood's operation place my friend Dr. 
 Dowell's operation, which he has very kindly written out for me 
 to insert in this work in his own words. 
 
 Melrose, Mass, July 11th 1880. 
 "Dk. J. H. Wapjien: 
 
 "Dear Sir, 
 
 " Inclosed herewith I give you a synopsis of my 
 siibcutancoas ligature for the radical cure of Hernia?. I com- 
 menced the investigation of the cure more particularly in 1 858, 
 and continued these investigations until in 1859, 10th Sept. 
 in the night and in bed, thinking over an operation with 
 AVackye's instrument I was going to perform next morning, I 
 
108 HERNIA. 
 
 planned the entire operation as I now perform it with slight 
 modifications as to the needle and other details which I will 
 give yon 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 loiih 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 18C6 by Messrs. George Tiemann 
 and Co., New York, the needle shown in Fig. 23, p. 90, with 
 an eye in each end, which I have only changed since 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 : — 
 
 7a. 29; 
 
OPERATIONS FOR HERNIA. 109 
 
 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 have 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 ringer 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 bo. 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, but a bougie or piece of wood or cork will 
 answer, it simply being fastened as a quill-suture; but the' 
 adhesive plaster is soft and tits 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 sullicient 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 
 clays. The ligatures before tving 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 thej^ will cause suppuration, 
 and perhaps a failure, as all my failures suppurated and as I 
 
110 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 (1869), 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. 30.— 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 (see Fig. 30). The 
 whole is covered with soft leather, and adjusted over the 
 rupture only making very light pressure and 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 (a 
 my operation) and suh cutaneous 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. Ill 
 
 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. Wilkins and Trubest, of 
 Gobresfeon, Texas; Drs. Worthington and Bibb, of Austin, 
 Texas ; Dr. Powell, of Florence, Texas ; Dr. Ruskin, of Grose- 
 buck, Texas ; Drs. Allis and Hunter, of Philadelphia ; Dr. 
 Johnson, of Richmond, 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 
 
112 HERNIA. 
 
 ligatures by the invaginating finger. What about the arteries ? 
 I pay no attention to them, save but little if they are included 
 in the ligatures. It does no harm. Now as to the comparison 
 of the two operations. Subcutaneous ligature and subcutaneous 
 injection, both have their special advantages and mutually aid 
 each other. The subcutaneous injection is specially useful in 
 Hernias of small size and recent date, while the subcutaneous 
 ligature is suitable to large Hernia and of long standing and as 
 I believe contains the only principles of success in large Hernias 
 and of long standing. 
 
 " Yours most respectfully, 
 
 " Greensville Dowell, M.D." 
 
 dowell's stjbcutanaeotjs ligature for the cure of hernia. 
 
 " Patients prepared by moving the bowels a few hours before 
 the operation. Urinating before going on the table. Tarts 
 shaved over the rupture. Three lines are then made over the 
 rupture, one in centre, one on each side about one to two inches 
 from centre line. Patient is then etherised. I then take my 
 Hernia needle threaded with strong thread, twisted on the eye 
 and well waxed. I then pinch up the skin and cellular tissues 
 between the centre line and the one on the iliac side and then 
 put the threaded end in the centre line and bring the threaded 
 end out until the unthreaded end lies on the tendon outside 
 of the rupture. At this stage the index finger of the left hand 
 invaginates the sac and the threaded end is then pushed down 
 into the peritoneum through the sides of the tendon. The 
 end of the needle is then moved from side to side, to see if 
 its point is loose, when it is passed under the invaginated 
 sac to the opposite tendon, and then pushed forward to the 
 inside line and out. In this stage I usually stop to see and 
 
OPERATIONS FOP. HERNIA. 113 
 
 feel if the tendons on both sides are included in the body, 
 if the needle end show the invaginated sac is not caught. If 
 it is caught the needle must be pulled back and reinserted 
 without catching the sac. This seen and done, the needle is 
 pulled on until the threaded end comes above the inside tendons, 
 when it is reversed and pushed out where we started, thus 
 putting a ligature only around the tendons -over neck of the 
 sac. The first ligature is put up as high as possible and 
 others afterwards until enough are put in to close the opening 
 entirely. These ligatures are then replaced by silver wire as in 
 the operation for vesicovaginal fistula. These are all pulled up 
 smooth and secured over a quill suture made with a small roll 
 of adhesive plaster and the whole tied over the quill. I then 
 put on lint wool saturate with collodion and let patient out from 
 under the anaesthetic and put him to bed. If there should be pain 
 I give him full doses of morphia and continue it. If much swell- 
 ing occurs I apply cold cloths wet with sugar of lead and 
 morphia. The ligatures are left in from three to eight days and 
 then removed. Before removing, the patient's bowels are again 
 moved ; after this the ligatures are taken out and compress with 
 a figure-of-eight bandage is put on, and patient put to bed and 
 kept quiet for a week or more when he is allowed to get up. 
 I have invented, 1869, what I call my buggy-spring truss, to 
 be put on and worn for a while until the parts get solid and 
 firm. The buggy-spring truss is made by putting two additional 
 springs over the bend around the ilium and held together as 
 the springs of a buggy. The whole is covered with soft leather. 
 The pads may be made of any shape or size that has been used, 
 celluloid or hard rubber first made almost flat on its surface is 
 the best. The bend of the spring is made more open than usual 
 and should only press smoothly over the place when the patient 
 is at rest but becomes very strong when there is a tendency 
 to protrude. If it be desirable to wear it day and night the 
 
 I 
 
114 IIERNIA. 
 
 springs are made only to reach the spine and not cross it. It 
 
 is best to have a perineal strap, but in many cases this can be 
 
 done away with. 
 
 " Yours respectfully, 
 
 " Greensville Dowell, M.D." 
 
 Before we come to speak of the method by injection I wish, 
 to refer to an operation by the Antiseptic Use of the Carholiscd 
 Catgut Ligature. For the purpose of explaining it, I, with the 
 consent of the author, Dr. Henry 0. Marcy, of Cambridge, 
 Mass., reprint from the Transactions of tlie American Medical 
 Association, 1878, the following essay. 
 
 " October 11, 1871, I read a paper before the Middlesex 
 County Medical Society, which was afterward published in the 
 Boston Medical and Surgical Journal, November 1G, 1871, page 
 315, entitled 'A New Use of Carbolised Catgut Ligatures/ 
 I there reported the two following cases, operated on for 
 Strangulated 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 
 stercoraceous, and the patient seemed in extremis. The hernial 
 tumour was of 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 monorrhagia, 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. "VV. 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 
 
11G HEHNIA. 
 
 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 woim ] 
 by the patient, who felt a slight uneasiness, and I discovered , 
 small swelling in the cicatrix about the size of a bean; thi>, 
 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 clays 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 retaiu 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 w T as 
 ^adily returned unopenH, and sutures were used as upon the 
 other side, perhaps eight in number. I included in my stitches 
 
U8 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 eland 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. 
 
 a 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 repa:r 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 
 five 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, 18G9 : '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. 
 
 <c< 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. 
 
 " c The vessel containing the emulsion 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 rae 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 and 
 oblivion. In plastic operations, especially of mucous tissues, I 
 would never think of using catsmt ligatures. 
 
 o o o 
 
 "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 mv own observation I am inclined to believe 
 the ligature properly, that is antiseptically, 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 
 peiformance 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 a canula 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. Pan coast 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. 
 
 f< This method was practised for many years as a secret cure by 
 Dr. Heaton of Boston, with reported success. Eecently 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 the sac. — J. H. W. 
 
 2 Dr. D. informs me, July 3rd, 1880, that he succeeds in 80 per cent, of 
 his cases. — J. H. W. 
 
OPERATIONS FOR HERNIA. 127 
 
 of catgut antiseptically, and union followed by first intention. 
 Alter 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 care, 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 clanger of the patient." 
 
 The method by injection 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 Hernias 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. Pancoast 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. 
 
OPERATIONS FOR HERNIA. 129 
 
 But the honours of the true hypodermic injection without 
 any preliminary incision, I think, after much careful 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" 1 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. 
 
 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. 
 
 K 
 
130 HERNIA. 
 
 with me in the United States service know that a soldier must 
 he 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. Janney, 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 
 Heatonish 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. 
 
 " Beaton'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. Atiee 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 w r as 
 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. G-emrig, 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 Fitche'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 
 
132 HERNIA. 
 
 by a bayonet joint. The patient being placed on the table, his 
 hips slightly raised and the instrument properly armed with a 
 concentrated aqueous extract of quercus alba, and the cutting 
 sheath 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 niy finger into the external ring. 1 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 V. 
 
 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 
 Bupture : " Although allusion has been frequently m? 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 Hernias 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 treatment 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 
 I 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 tohacco. From this wound most of the 
 small intestines had escaped to the floor of a room covered with 
 coal dust and the debris 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 Cushing, 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 Surgical 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 1 have had, that if in any way, by accident, or in 
 iiij eting, 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 
 ivsult 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 
 pos-dbl) be avoided. 
 
 1 am a firm belie 1 - - o S you m.i) Infer from reading these 
 Crises, in the appl < . <>f 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 
 gastric 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 bng, because 
 the tissues of the body take more kindly to an animal tissue 
 than to a smooth, clammy, rubber surface. 
 
 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 serum 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. 
 
 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, lor 
 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 flrst patient was Mr. G , aged twenty-three, with double 
 
 direct Inguinal Hernia. I was assisted by Dr. Win. 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 evaoorated to the consistency of glycerine, and united 
 
142 HERNIA. 
 
 with an eighth of a grain of morphine; on the left side about 
 fifteen drops. 
 
 J n about six hours after the injection the patient began t.» 
 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 pl^ce 
 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 Ilcrnise, and on the twenty-third day of 
 
 Fio. 31. — Hciitoa's Instrument, with Davenport's Needle. 
 
 July the patient came to my office, when a temporary truss 
 was ordered. This he was to wear for several months until we 
 should conclude that the tissues had gained sufficient strength 
 fur him to dispense with it. 
 
 It will be seen from the nature of the case that I here felt 
 oblL^d 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. 
 Ihe needle was pierced for the exit of the fluid with two small 
 
AUTHOE'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 tlie 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 He 'ion on Hvpfwre, 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 ev<ui the merits of Dr. Heaton's old needle, 1 which was in 
 shape not unlike a bradawl at its point, and which,, b.canse 
 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 perforin 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 penetration. 
 
 1 See Fig. of Heaton's case, letter b in Appendix. 
 
144 HERN r A. 
 
 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 iluid 
 
 Fig. 32.— My First Instrument, witli Revolving Nccdlo. 
 
 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 tins 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 bradawl. 
 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, which 
 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 application 
 of the fluid to the peritoneum in 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 
 
 L 
 
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 Fitche'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. 
 
 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. 
 
 L 2 
 
148 HERNIA. 
 
 Heaton is not well held in solution, being liable to much sedi- 
 ment, 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 drachm 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, combining 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 favourable results in this operation of inject- 
 ing the hernial rings for the radical cure. 
 
 The use of an ordinary hypodermic syringe would be, I 
 consider, an operation attended with much danger, not onl}' 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 integu- 
 ments, 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 
 
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 clanger 
 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. 
 
 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 ail practical surgeons thoroughly 
 to understand this latter operation. 
 
 So long, however, as thousands upon thousands are ruptured 
 
150 HERNIA. 
 
 with reducible Hern ire, which have heretofore required nil the 
 ingenuity of mechanical art to support ami retain within t lie 
 
 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 rim 
 strangulated intestines becoming sphacellated and gnn;rrenniia, 
 before relief can be obtained by the surgeon's knife, or the mure 
 gentle operation of taxis ; so long as this is the case, the dis- 
 covery of a'peruianeut 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 manipu] i- 
 tion in all its details, or a steadier and firmer hand in 1 he 
 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, thai the 
 effusion of plasto-lymph around the parts is not sufficiently 
 
A UTIIOll'S OPERATION BY INJECTION. 151 
 
 organised in five or ton days after the operation into adherent 
 ami Hindus tissue, to bear any strain at all upon them. They 
 wuu I i lit once separate and give way. Dr. Heaton caused his 
 oases 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 
 cit-u in mine. 
 
 Fundi v, I wish to add a word of caution and advice to those 
 wlin 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 separate*!, ami of course let the lT#rnia 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 
 aj.-iin appeur in the track of the first swelling and inflammation 
 which usually all ends the primary operation. 
 
 This secondary swelling, more particularly if it follows after 
 we have made I wo 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, nut unlike uii 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. 
 
 Tl is is not. lmwever, the case ; it is only a slight effusion and 
 exudation of | lasmatie serum, together with some mingling with 
 the (li-colorarion 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, earning the appearance of the tannate of albumen. This 
 will show itself by the striated, shioudy, and granulated sub- 
 stance resembling dry blood when moistened again. If we 
 should now constantly apply compresses of cold water and 
 
152 HERNIA. 
 
 allow tho 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 rin^s 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 %f the rupture, and put the patient's life 
 in great and needless clanger. 
 
 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 walls of the 
 abscess. And if still in doubt, from our diagnosis, whether 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- 
 No w, 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 i s examining what previous to 
 the operation was so repulsive, he will try to lift a heavy weight, 
 pull a Ss md-cart : - r h*» 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 ring, 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 paits 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 
 
161 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 he repeated several times 
 before we get a full and strong occlusion of the rings, particularly 
 in hern ia3 of large and long standing. If, after we have once 
 operated and have succeeded in partly closing the opening, we 
 find we have not clone 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 necessan r , 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. AVhile 
 
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 opeiation as safer and freer from the follow- 
 ing complications than all operations 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 Medecine, 31st August, 1883. 
 
 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 mv 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 country 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 that in giving my 
 new instrument and method to the profession, that I do not 
 wish to detract any credit from the late Dr. George Heaton, of 
 Boston, nor underestimate his valuable work on rupture, or the 
 great labour 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 foT mv 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 hypo derm ically. 
 
 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 probably should be ? 
 
 The following is a short description of new syringe and 
 instrument for injecting the hernial rings in the cure of 
 Hernia. 
 
 Fiq. 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 flattish, 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 Hernias 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 hy 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. 
 
 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, and this 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 
 to 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. 
 
160 
 
 HERNIA. 
 
 ANATOMY OF FEMORAL AND INGUINAL HERNIA. 
 
 The real and essential anatomy of the parts where our seat of 
 operation lies, we find to be the following : 
 
 Fig. 34. 
 
 Shows the anatomical relation and coverings of Oblique Hernia, b, transversalis 
 fascia ; c, peritoneum ; a, muscles, internal oblique transversalis, and ex- 
 ternal oblique ; d, external integuments. These illustrations were drawn 
 under Mr. Cooper's directions from my friend Dr. John Wood's work on 
 Rupture, who very kindly permitted me to make use of them for this work. 
 
 The inguinal or spermatic canal begins at the internal ab- 
 dominal ring, its length being about one and a half inches. It 
 
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 Hernise 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 : 
 
 o 
 
 Oblique. Direct. 
 
 1- Skin. 1. Skin. 
 
 2. Superficial fascia. 2. Superficial fascia. 
 
 3. Intercolumnar fascia. 3. Intercohmmar fascia. 
 
 4. Cremaster muscles. 4. Conjoined tendon of internal 
 
 5. Fascia transversalis. oblique and transversalis muscles. 
 
 6. Sub-serous cellular tissue. 5. Fascia trnnsvers llis. 
 
 7. Peritoneum. 6. Subserous cellular tissue. 
 
 7. Peritoneum. 
 
 M 
 
162 
 
 IlEliNiA. 
 
 FEMOKA.L HERNIA. 
 
 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. 35. — Femoral Hernia. 
 
 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 
 
AUTHOR'S OPERATION BY INJECTION. 163 
 
 fascialata 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 — seftuni 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 usually perform 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 tw r o 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 welj 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 accuiately 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. Th« 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 Hernia? may 
 now be returned within the abdominal cavity, where they will 
 remain on account u: the position of the patient, and can be at 
 once operated upun. 
 
 This table can idso 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 T 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. 
 
 OPEEATION FOE INGUINAL HEENIA. 
 
 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, 
 and by slightly raising the end of the middle finger as above 
 mentioned, the same is felt by the forefinger, which also helps us 
 to indicate the exact point, and 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. 
 
1M 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. — Thethree most common forms ot Hernia, in the order of their occurrence in the male, 
 are (1) Oblique Inguinal ; (2) Direct Inguinal ; (3) Femoral. 1 
 
 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 left 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 OI'EHATIUN 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 pas- id 
 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. 
 
 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. 
 
 1 In most cases ten to twenty-rive drops will be sufficient. It will be 
 remembered by tho.se present at my operation, August 19th, 1880, at Guy's 
 Hospita', where the ring was very large, as demonstrated by Mr. Bryant 
 and Mr. Smitli of the Seamen's Hospital, that I was obliged to use thirty 
 drops in this case. 
 
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 Hernia? lying below this ligament and inguinal 
 Hernias above), and having selected the position of the saphenous 
 opening to which 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 
 
 Piq. 37.— Femoral Hernia as usually seen In femalei 
 
 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 which may be thickened and hypertrophied from 
 friction. This is formed by friction of the truss and the 
 Hernia, and forms our landmark, for its curve is peculiar 
 and not readily mistakable in making our definition. For 
 similar operation see Heat on en 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. 
 
 Fig. 38.— Spica 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 Hernise the sac 
 is often ramified by branches of largj 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. Where 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 Herniae 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 tumori- 
 fication 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 mi^ht think at »first 3 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 shoit duration, seldom larger 
 than a pea, and after ten to fifteen days may he 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 Herman From this it will be evident that 
 in all cases of umbilical Hernise 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 will 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 distuvbance 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 beginning to 
 end. Morphine or some other anodyne can be administered to 
 secure quiet. The bowels should not be moved, if possible, 
 until the sixth or seventh day, and then by some gentle cath- 
 
AUTHOR'S OPERATION BY INJECTION. 173 
 
 artic. Fluid as drink can be had ad libitum in the way of cold 
 water, but no stimulants of any kind except under the utmost 
 urgency, and on ,no account is tobacco to be used. 
 
 This treatment should be continued for at least a week 
 or ten days, the patient lying in bed and as much as possible 
 upon his back. The first four days he should remain constantly 
 upon the back, as any other position might injure the process of 
 adhesion of the rings caused by the irritant. 
 
 This is an operation which, if it should not be successful, has 
 put the patient to but little pain, inconvenience ; or danger ; and 
 should we not fully succeed, we have not left our patient worse 
 than we found him, as there is always a partial if not a full 
 occlusion of the rings, and so if we do not fully close them, we 
 have somewhat benefited the patient. This cannot be said of 
 many other operations performed for the relief of Hernia. 
 
 It now, perhaps, would not be out of place to consider the 
 various kinds of Hernia which would promise the most favour- 
 able results from this operation in our next chapter. See Sec. IT. 
 
 In performing this operation it is not desirable to use ether, 
 as it is apt to excite vomiting, and I only resort to it with the 
 very timid and sensitive. It will be found more necessary to 
 etherise in children and women than in men, to overcome their 
 fear rather than from any pain they would experience in the 
 operation. 
 
 Chloral hydrate may be given a few hours before the operation 
 with almost as good results as these obtained from ether, pro- 
 ducing sleep and freedom from pain and fear. 
 
 Great care also should be taken not to allow the patient to 
 stand upon his feet too soon, as from past experience I am 
 convinced that very few cases which have needed a second 
 operation after they have in the opinion of the physician and 
 the patient himself, completely healed, would have required a 
 repetition of the injection, had they been more prudent and 
 
174 HERNIA. 
 
 been content to remain quiet a little longer. Do not he too 
 anxious then to see the results of the operation, but let nature 
 take her time in occluding the rings. 
 
 Moreover, when we allow the patient to stand upon his 
 feet for the first time, we should support the injected parts 
 with the tips of the fingers and on no condition remove this 
 support while he is standing. He should not be allowed to 
 cough, bear down or make any undue exertions for two or three 
 months, at least. 
 
 A bandage or truss should now be worn for from three 
 months to a year or even longer if the patient follows any 
 occupation where great violence or powerful exertion is liable 
 to occur. After this if the rings remain occluded and firm 
 he may dispense with the truss or bandage. 
 
 ON OBSERVING CASES. 
 
 From a careful watch kept over the after history of cases 
 we have operated upon, we shall probably from every case learn 
 something new and valuable to us which will be of perhaps 
 incalculable benefit to us in some future operation. I have yet 
 to see two Herniae precisely alike in every particular. Although 
 the kinds of Herniae usually met are few the variations upon 
 these few kinds are indefinite in number and appearance. 
 
 Examine each case carefully, study it in its minutest detail, 
 mark well all the surrounding and attending circumstances, 
 whether the Herniae be large or small, painful or not, congenital 
 or accidental, age of patient at the time the Herniae first 
 appeared and at the time of operation, history of the Hernia, 
 habits and occupation of the patient and whether there is any 
 hereditary disposition to Hernia in the family. 
 
 Carefully noting all these points we are enabled to treat the 
 patient and the Hernia more intelligently and carefully than if 
 we knew nothing more than the mere fact that a Hernia exists 
 upon which we are requested to operate. 
 
CHAPTEE VI 
 
 General Remarks. — I. Selection of Patients. IT. Kinds of 
 Hernia best treated. III. Percentage of Cures. IV. 
 Causes of Failure. V. Record of Interesting Cases. 
 
 i. — selection of patients. 
 
 A careful discrimination between the diffe:ent conditions of 
 the Remise and of the patients to be operated upon should always 
 be most scrupulously made if we would have success attend our 
 efforts for relief and cure. The operation I present is no more 
 adapted indiscriminately to all suffering from Hernia than is 
 any other surgical operation for the relief of any other bodily 
 affliction. No surgeon in capital operations would think of 
 disregarding the physical condition and attendant circumstances 
 of a patient submitting himself for treatment. Why should 
 this disregard be so common in the treatment of 'Hernia ? I 
 am convinced that the vast majority of Hernia cases are treated 
 in just this careless way, and that in this method of treatment 
 lies the secret of the poor success of many of the operations. 
 
 This subject has never to my knowledge been stated, dis- 
 cussed or emphasised in any essay or work on Hernia, and I 
 am more and more surprised every day to think that such an 
 important and indispensable element of the operation should 
 be allowed to pass unnoticed by the many writers upon the 
 subject. 
 
176 HERNIA. 
 
 Although Dr. Heaton said nothing of this in his work I am 
 convinced from my personal friendship and intimacy with him 
 that he always made a careful selection of his cases and that 
 in this was one secret of his success. When speaking of his 
 invariable success he v/as in the habit of giving me a peculiar 
 wise and knowing look of the eye, and he would say that he 
 cured all, or about all, that he ivould operate on. At that time 
 I did not attach much importance to this expression, but now 
 that I have been operating myself I think I see the meaning. 
 The selection of his cases was the great and only secret that 
 he withheld from the profession. He often ridiculed the idea 
 of the indiscriminate application of the method of injection to 
 any and all cases of rupture, saying that the general health 
 of the patient had much to do with the success of the 
 operation. 
 
 I am sorry that in his work on rupture he still preferred to 
 keep this important portion of his secret to himself. From what I 
 have already said I think the reader can safely judge that I am 
 perfectly free and open in the whole operation, and that I am 
 desirous that the operation shall stand and be criticised only upon 
 its true and tried merits. I would under no consideration lead 
 a single operator astray in the operation whether by being too 
 self-confident or by unfairly and with prejudice and conceal- 
 ment stating my candid views upon the subject. What I seek 
 is that mystery may be removed from the operation. 
 
 When this operation is attempted upon persons in poor and 
 indifferent health or of great delicacy enfeebled by age or a 
 broken constitution, upon those who have lived lives of in- 
 temperance and debauchery or who are suffering from syphilis 
 or scrofulous affections, upon those living in crowded and 
 unhealthy places as in the filth and poverty of a great city, 
 upon those in hospitals, or public institutions as almshouses, 
 jails, places of detention, or prisons, or upon poorly nourished 
 
GENERAL REMAKES. 177 
 
 and anaemic persons and upon dispensary patients the prognosis 
 will be very unfavourable and the chances of success very small 
 and uncertain. 
 
 On the other hand we may expect to get the best and most 
 successful results with the least trouble and vexation from the 
 operation when it is performed upon persons in a high state of 
 health, muscular strength and vigour, upon those who live in the 
 country, or who are in the habit of being in the open air much 
 of their time. I find persons who are in the following out-of- 
 door occupations to be the most favourable to receive the 
 operation for Hernia, and I have endeavoured to arrange the 
 list in a careful order placing the occupations that promise the 
 greatest health in their successive order : Farmers, country 
 gentlemen and their domestics, teamsters, lumbermen, sportsmen, 
 soldiers, sailors and marines, masons, carpenters, civil engineers, 
 men employed on railways, and professional men. 
 
 II. — KINDS OF HERNIA BEST TREATED. 
 
 Having now spoken of those upon whom this operation is 
 likely to succeed, it now, perhaps, would not be out of place to 
 consider the various kinds of Hernia which would promise the 
 most favourable results from this operation. 
 
 In accidental or congenital Hernia in persons between the 
 ages of four and twenty years, the most favourable results may 
 be expected. Unless the Hernia be large and of long standing, 
 the injection need not be very stimulating. The youngest 
 child I have operated upon was four years of age. This was a 
 very delicate operation for a large umbilical Hernia, which was 
 not easily controlled by mechanical means, owing to its size and 
 extensive protrusion. The operation resulted in a cure. I 
 would not advise the operation for femoral or inguinal Hernia 
 unless the patient was at least five or six years of age, pre- 
 ferably ten or twelve. In the cases of these little patients a 
 
 N 
 
178 HERNIA. 
 
 properly fitting truss, which may itself effect cure, should 
 usually be tried first, unless the child be very nervous or the 
 parts so irritable as to render the truss or other support 
 intolerable. 
 
 After the age of twenty-one the cure is more difficult. 
 Satisfactory results are only to be obtained by the use of a 
 more stimulating injection. More than one injection is often 
 required. The older the patient and the larger the Hernia, 
 the greater the difficulties become, though enormously lar^e 
 Herniae, such as, to all appearance, would preclude reasonable 
 hope of cure in accordance with our previous ideas, may now 
 be relieved or cured. Almost certainly if -we do not succeed in 
 closing the hernial rings, we may cause a certain amount of 
 contraction and a corresponding degree of relief, if not of cure ; 
 at least the patient w 7 ill be benefited rather than injured by the 
 operation. Some patients even say that they would gladly 
 submit to the operation once in a few months rather than suffer 
 the hernial protrusion. The opinion of certain critics that the 
 operation, if unsuccessful, would do harm by leaving the edges 
 of the rings fringed and jagged, and sensitive, may be safely left 
 to the honest opinions of such gentlemen as may give the 
 matter their careful consideration. The absence of cutting and 
 irritation of the surrounding parts with the knife, or sharp 
 instrument, is opposed to this criticism. The parts, after the 
 operation, naturally become infiltrated, from the internal to the 
 external rings, with plastic lymph. Should this give way, which 
 may possibly occur, the previously agglutinated parts, we may 
 presume, would remain as smooth and free as before the 
 operation. 
 
 I have never seen a case once fully cured by this operation in 
 which the relief has not been permanent. Even partial con- 
 traction of the rings certainly favours more or less retention 
 of the Hernia within the abdominal cavity. I have never 
 
GENERAL REMARKS. 179 
 
 observed a case in which reabsorption of the effused lymph 
 had taken place, although subsequent rupture of the new 
 plastic formation may occur. But in my experience, at least, 
 it has not occurred to its former extent. I now refer to cases 
 operated upon by Dr. Heaton, in which his plan, his instrument, 
 and his mixture were employed. In these cases I believe 
 the cure would have been perfect had the treatment been 
 repeated once or twice. 
 
 In my personal experience I have yet to see a case of relapse, 
 after a cure has been perfected, nor do I believe such a case 
 will occur except in extreme old and congenital Hernia, or 
 as the result of undue straining due to convulsions, or to any 
 other cause. Inguinal Hernia, direct or oblique, is most 
 easily treated by this operation, and a favourable result is 
 most nearly certain. Umbilical Hernia, in respect of results, 
 stands next to the inguinal. The most uncertain variety, 
 and the most dangerous to treat, is the femoral, which will 
 be found to require much less fluid in proportion to its size 
 than any other variety. I have expressed the opinion that 
 ten drops injected into the femoral, are equal in irritative 
 power to twenty drops in inguinal or umbilical Hernia. Old 
 ruptures with thickened sac and adhesions are more difficult 
 to manage, owing to their attachments. In such cases, after 
 reducing as much as possible, do not inject the sac all around, 
 but throw the greater portion of the fluid upon the superior part 
 of the adhering sao so as to get abundant effusion to form 
 attachments on the upper u face of the protruding sac. By this 
 means we shall more probably secure both occlusion and con- 
 traction of the rings. This is because the superior parts of the 
 hernial rings generally give way first, on account of contraction 
 of the abdominal muscles. In such cases more or less bulging of 
 the parts after the operation will generally be present, an appear- 
 ance which may wrongly be considered by the inexperienced an 
 
 N 2 
 
180 HERNIA. 
 
 evidence of failure. Close examination, however, will show 
 that the protruding intestines are held securely in place. This 
 bulging may be expected in all cases of old or long-standing 
 ruptuie, because the muscles and integuments which have been 
 so long distended by the protruding Hernia, naturally remain 
 pendent. 
 
 I desire to lay additional stress upon the fact that this latter 
 class of Hernias should receive the most stimulating fluid to 
 produce an effusion that would be at all effective in forming 
 adequate adhesions. Eepeated injection will also be required 
 more frequently. The cases most difficult to effect a cure upon 
 are those of old congenital Hernias in patients over forty. In 
 these cases the pressure of the abdominal visceras has been so 
 strong at the superior portion of the internal and external rings 
 that the two rings have practically been fused, so to speak, into 
 one, and the surrounding muscular fibres have been changed into 
 an unyielding condensed tissue. Upon this structure no fluid 
 injection whatever is to be relied upon as capable of producing 
 much exudation of plasma. The adhesions, therefore, would be 
 very delicate, and it is questionable whether such adhesions and 
 contractions would form in these cases, even though the patient 
 were kept quiet for a considerable time. I am now engaged in 
 the study of these doubtful cases, and have devised a procedure 
 which seems to have promise of success. Should it succeed, I 
 shall present it to the profession at a future time. 
 
 When the Hernia is in a state of inflammation from whatever 
 cause, whether from the galling of a truss, or from an irritation 
 produced by the reduction of a strangulation, or by the more 
 or less forcible attempts to reduce an irreducible Hernia by 
 dilating the rings after the manner of M. Vidal, no operative 
 procedure by injection should be attempted. We should wait 
 until the inflammation has subsided. 
 
 If the rupture is of long standing, is very large, and 
 
GENERAL REMARKS. 181 
 
 accompanied with a greatly thickened sac of omentum, it would 
 not be advisable to return, the omentum with the intestines, 
 particularly if it has formed adhesions and attachments around 
 the rings and other parts. By attempting to return it we should 
 almost inevitably stretch and enlarge the hernial rings that are 
 about to endeavour to contract by our injection. Therefore it 
 would be far better to excise the protruded portion of it, and to 
 apply a carbolised ligature just above the point of excision. A dull 
 knife, or the herniotomy saw of my device (see Fig. 73 Appendix 
 for description and cut) will be found of very great advantage 
 in dividing this omentum. After it has been sufficiently reduced 
 in size to be returned into the abdominal cavity with the in- 
 testines, we may paint the parts with the fluid described under 
 the treatment of strangulated Hernia, and proceed to dress and 
 bandage as I have directed in reducible Hernia (see p. 169 and 
 Fig. 39). 
 
 In brief and to recapitulate : 
 
 Congenital Hernias of all kinds in children from five to twenty 
 years of age are very favourable, and almost effectually cured 
 by this operation. No child under four years of age should 
 undergo this operation except in extreme cases. 
 
 Hernias, caused by accidents, when of short duration, even 
 when quite large, are very effectually and generally cured by 
 this operation. 
 
 Hernias that have been caused by over-exertion such as 
 convulsions, child-bearing, and the like, and which have existed 
 over twenty years, can also be generally cured, requiring, how- 
 ever, more than one injection usually. The longer their duration 
 and extent the more liable are we to be obliged to perform 
 repeated injections in order to fully close the ring. 
 
 Congenital Hernias of large size and long standing are difficult 
 to successfully relieve and cure, unless we make several injec- 
 tions, although I operated this summer (1879) on a double 
 
182 HERNIA. 
 
 congenital Hernia (inguinal), one ring being two inches in 
 diameter and the other one and a half inches. The one was 
 fully closed with the primary operation, and the larger opening 
 was closed by two injections. At the time of operating, the 
 patient told me his Hernia had existed for eighteen years, but 
 after he was cured he informed me that his mother said that 
 he was born ruptured, he being at this time upwards of forty 
 years old. 
 
 I speak of this case here to show what this operation is 
 capable of doing. This patient was formerly not able to retain 
 the Hernia on one side, .it being so large, and the rings were 
 so thin and the integuments so dilated that it would bulgje out 
 over the support which he was obliged to wear constantly. Yet 
 the bowels of this patient are, to-day, retained within the 
 abdomen, and he is very comfortable, although as a precautionary 
 measure he is to wear for a year or more, as may be necessary, 
 a very delicate and soft French spring truss of Tiemann's 
 importation or manufacture. From such results as these I have 
 astonished myself, perhaps, more than anyone else, as previous 
 to my experiments and trials of the operation I could not believe 
 that it was possible to produce such favourable results. 
 
 III. — PERCENTAGE OF CURES. 
 
 It will be seen from what I have said that Dr. Heaton 
 professed hardly ever to have had a failure. Although he was re- 
 markably successful yet I know he did have failures, especially 
 in the last year of his life, because I have already met such 
 cases, have operated on some of them, and shall operate on 
 others in the near future. Dr. Janney, of Philadelphia, who 
 next to me has now operated on the greatest number of patients 
 by this subcutaneous method, thinks that he may fairly and 
 without exaggeration claim 75 per cent, of cures. How many 
 out of any given number of persons can receive a permanent 
 
GENERAL REMARKS. • 183 
 
 cure by the method of operation as I do it I am not at present 
 able to say with exactness. I can however make an estimate 
 based upon the cases I have thus far treated, and should judge 
 that fully 80 — 85 per cent, of all I have operated on have been 
 successfully cured. I base this high estimation upon the more 
 stimulating fluid that I use, and the method of using it, as well 
 as in the careful after-treatment. If such success shall continue 
 to attend my efforts, and the efforts of those who may take up 
 the operation, I shall certainly think that I have not in vain 
 called the attention of the profession to the value of the cure 
 by subcutaneous injection. Time and trial is the only means 
 of settling this matter satisfactorily and conclusively. In all 
 cases remember never to warrant a cure. Such confidence is 
 beyond the bounds of all professional propriety. 
 
 IV. — CAUSES OF FAILURE. 
 
 Many who undertake to perform this operation will perhaps 
 meet with failures upon their first attempts, and thus be ready 
 to condemn the operation as useless, and think it overrated by 
 the author and by those who may have been equally successful. 
 They will imagine that we are too sanguine in our expectations, 
 and referring to all the operations hitherto attempted from 
 Celsus to Wood will class them and this in the same category 
 as dangerous, seriously liable to failure, and outside the doors 
 of legitimate surgery. They will not stop to consider that their 
 ill success may be from fault of the operator, and not Gf the 
 operation, but will jump at once to their hasty conclusion. 
 
 I have already spoken of the cause of failure as a result of 
 performing the operation upon subjects not fitted to receive the 
 full benefits of the injection. To show how little the operators 
 upon Hernia have considered this matter I will mention the 
 following instance. 
 
184 HERNIA. 
 
 While I was recently present at St. Albans, Vermont, to read 
 a paper before the Vermont State Medical Society, a Professor 
 in the Vermont University of Medicine, and also in one "of the 
 New York Schools of Medicine, told me that he should operate 
 on every one that would let him. He said he had already 
 operated once on a child without good results, and wished to 
 know why I would not operate upon a child that was among 
 other patients there presented to me to illustrate my method 
 of cure. I told him the case was a very improper one. The 
 child was only about three years of age, and the Hernia 
 being an oblique inguinal, the spermatic and inguinal 
 canal was not large enough to admit the middle finger freely 
 into it. Besides all this, the child was nervous and uncon- 
 trollable, so that it would have been impossible to keep it still 
 without opiates long enough to effect a consolidation of the 
 lymph effused, even if we could have succeeded in producing 
 such an effusion, which in a majority of these young cases is 
 very doubtful. 
 
 Now this professor is one of the best surgeons in New York 
 city, very highly esteemed by me, and has performed many fine 
 and difficult surgical operations that are a credit to the pro- 
 fession he so ably adorns. This very fact that gentlemen of 
 such distinction do not comprehend this operation, leads me more 
 to the conclusion that the profession at large do not comprehend 
 it, to say the least, any more fully. 
 
 Another cause of failure is that we may not have used a 
 fluid, for the injection that was sufficiently stimulating to 
 agglutinise the parts around the rings, or if we use a proper 
 fluid we may use too little to produce the desired effect. If on 
 the contrary we use too much, we shall run into the clanger of 
 producing abscesses and suppuration, which is fatal to tissue 
 formation from lymph. Sufficient compress may not have been 
 made over the parts operated upon, the patient's bowels may 
 
GENERAL REMARKS. 185 
 
 have been moved too soon, absolute rest may not Lave been 
 enforced for the first four or five days succeeding the operation, 
 so that the primary stage of tissue formation shall not be in the 
 least disturbed, the patient may have been made to cough or 
 perform some muscular exertion too soon alter the operation, or, 
 as I have before insisted, an improper instrument may have 
 been employed. Prom all of these causes, it may happen that 
 the injection will not be followed by success. 
 
 To illustrate how inconsiderate some may be in the after 
 treatment, I mention the following incident selected from the 
 many that could be cited. The gentleman under whose pro- 
 fessional care I left the patient that I operated upon in St. 
 Albans, June loth, 1880, wrote me, July 3rd, as follows : — 
 
 "Dear Sir, — The man J. B. on whom you operated is 
 
 apparently well. T kept him on his back eight days ; then put 
 
 on the truss. There has been no appearance of the Hernia thus 
 
 far. I had him cough the other day with bearing down without 
 
 bringing down the gut. 
 
 "Yours truly, 
 
 "G. D." 
 
 Such heedlessness is provoking, and contrary to all my advice. 
 It is a wonder that such experimental coughing and bearing 
 down does not often bring down the Hernia again in spite of all 
 we have done for its retention. 
 
 One more cause of failure must be mentioned even at the risk 
 of seeming to speak of a point so simple as to be almost self- 
 evident. After all that has been said and written upon Hernia, 
 many do not select, or seem to know, the precise locality or the 
 proper part where to introduce the injection. Some have even 
 thought that we could cure a Femoral Hernia by injecting above 
 Poupart's ligament. The merest tyro knows better. Others 
 have asked whether the injection is to be thrown into the sac or 
 
186 HERNIA. 
 
 into the spermatic cord. I am sorry to say that both these 
 methods have been tried and success foolishly awaited. 
 
 V. — RECORD OF INTERESTING CASES. 
 
 In order to emphasise what can be done by this operation of 
 injection, and to present a record of some very interesting cases, 
 I insert, with a few changes to adapt it to book form, a paper 
 read by me before the Otsego County Medical Society of New 
 York, and before the Suffolk District Medical Society of Boston, 
 Mass : — 
 
 When we consider the terrible distress this complaint of 
 Hernia entails upon humanity, is it any wonder that a vast army 
 of our fellow beings, rather than submit to the knife and the 
 painful operations now performed for the cure of Hernia, seek 
 relief at the hands of irregular and often itinerant practitioners, 
 who by flaming advertisements and artful promises offer sure and 
 painless cures, only to entrap, and so to say, devour their innocent 
 victims, like the wolf in the fable ? In view of such impostors 
 and impositions, is it not high time that every son — I was about 
 to add every daughter — of Esculapius should heartily aid every 
 honest endeavour you or I or any member of the regular 
 profession may make to develop, in an open and legitimate 
 manner, an operation that has been many times performed with 
 success ? Nay, more, are we not in duty bound to the cause of 
 science to endorse and encourage all such efforts, at least so far 
 as they rest upon a tnie surgical principle and' possess the merit 
 of an honourable attempt to advance the medical and surgical 
 art ? 
 
 Many have been the attempts in the past to operate for the 
 cure of Hernia by injection, and among the operators we find 
 the noted names of Yelpeau, Pancoast, J. Mason Warren, and 
 others. "Wliile one discovered this important principle, and 
 another that, none except Heaton ventured to inject hypoder- 
 
GENERAL REMARKS. 187 
 
 mically without first cutting down upon the parts, and none 
 were so successful as to warrant us in saying that they had 
 really discovered a radical and lasting cure, except Dr. Heaton. 
 
 But because Dr. J. Mason Warren successfully injected 
 sulphuric ether in one case (see Observations on Surgery, page 
 1G6), I am not bound to use only sulphuric ether in my injec- 
 tions ; because Schwalbe, of Germany, injects alcohol, and 
 Heaton oak bark, I am not bound to use either alone, if I can 
 find a better formula. We all must reason for ourselves, and I 
 feel confident that by combining ether, alcohol, oak bark, and 
 morphia, in my injecting mixture, I occlude the rings with less 
 disturbance, of the constitution and of the heart's action, than 
 where a single fluid is used alone. I wish to say just here, that 
 'at the time when I made up my formula I knew nothing of the 
 use of sulphuric ether by Dr. Warren, or of alcohol by Dr. 
 Schwalbe, in the cure of Hernia. (Although it is a strange 
 coincidence, the idea was as truly original with me as it had 
 been with them.) I recall one of my cases where the pulsation, 
 which just before the time of operation was eighty per minute, 
 fell after the operation about ten beats, and continued to fall, 
 until in an hour it was sixty-five. While, then, this mixture 
 exerts a sedative influence on the arterial system, its stimulating 
 properties cause a rapid and localised effusion of lymph where 
 it is desired for the organisation of new tissue. 
 
 In developing the operation, as I have said, I have not been 
 necessarily the apostle or disciple of any one, nor have I felt 
 myself bound by the teachings or examples of any one, except 
 so far as I recognised that true principles and worthy precepts 
 had been given. I present it to you simply on its merits, and 
 ask only that you fairly investigate its principle and results 
 before passing judgment on it. 
 
 I think I know somewhat of the conservativeness of the better 
 part of our profession, and while I am, upon proper grounds, the 
 
188 HERNIA. 
 
 most conservative of conservatives, I do not believe it fair or just 
 to be unreasonably prejudiced. Judging from the history of 
 medicine and surgery, I feel very confident that when this opera- 
 tion is examined in its details and thoroughly understood, it will 
 be accepted as one of the most legitimate operations for cure of 
 Hernia. I do this operation as we perform all surgical operations, 
 as an experiment (for we should always remember that every 
 operation in surgery is on this principle). 
 
 I cannot with regard to truth and modesty, boldly assert such 
 favourable terminations in all of. my operations as we are led to 
 infer by Dr. Heaton, in his work upon Hernia and in his reply 
 to the committee sent him by the American Medical Association. 
 Although he boasted so freely, yet you and the medical gentlemen 
 in every city in the country know that he did not cure all upon 
 whom he operated. There are some half dozen whom he attempted 
 to cure, who are to present themselves to me for operation ; one 
 in particular, to whom Dr. Heaton said : " You see that sun 
 shine ? well, just as sure as that sun shines I can and will cure 
 
 you." 
 
 I also find much in his book that is vague and unreliable, and 
 might, if implicitly followed, lead one astray in the operation. I 
 have the best of reasons for saying that had he lived he would, 
 in a future edition, have corrected many statements, particularly 
 in regard to the inflammation set up. This I know from going 
 over the whole ground with him personally. Indeed, he greatly 
 regretted that he had ever given the operation to the profession, 
 from the fear that all would not fully comprehend his meaning, 
 and that some one would use a dangerous-pointed instrument 
 and bring discredit upon his pet operation, and, possibly, seriously 
 injure or even kill a patient. 
 
 He would again and again refer to these hypodermic needles, 
 spear- and lancet-shaped instruments, in terms far from com- 
 mendatory, saying, " They will yet cut some artery so minute 
 
GENERAL REMARKS. 189 
 
 that it will escape their notice at the time, the patient will bleed 
 to death, and then they will condemn me and my operation." 
 
 T have thought that perhaps the best way for me to show you 
 the merits of this operation for the cure of Hernia is to tell 
 you of its success in my experience. I will therefore detail 
 a few of my cases very carefully. 
 
 Operations Nos. 1, 2. — On July 10th, 1879, I operated upon 
 Mr. G., aged twenty- three, for double inguinal Hernia direct, on 
 both sides. The openings in the rings were one and a quarter 
 inches and one inch, respectively I injected about twenty 
 minims into the larger rupture, which was on the right side, and 
 fifteen minims into the smaller one, on the left side. After 
 .going through the ordinary course of a slight feverish condition, 
 with an incrense of temperature for three or four days, the case 
 made the usual recovery, by perfect occlusion of the hernial 
 rings and retention of the intestines w T ithin the abdominal 
 cavity. 
 
 Thy patient appeared at the expiration of ten or twelve days 
 as if he had never been ruptured, and no one would have known 
 that he had ever been, unless by previous knowledge of the fact. 
 The cure was simply perfect, without even the bulging of the in- 
 teguments that we often see when by this operation a cure has 
 been effected in large Hernise. 
 
 The patient being a labourer, dusting and washing cars, I 
 thought it best for him to remove the bandage which we had 
 applied while he was undergoing the treatment, and wear a truss. 
 I therefore ordered a double, hard rubber truss, thinking that this 
 would give him the best security and freedom from accidents. 
 
 For this truss I sent him to an old friend of mine, a regularly 
 educated and once practising physician, but now the head of one 
 of our largest surgical instrument establishments in this country. 
 "With this patient I sent a note telling the doctor that I had just 
 operated on the man for the cure of a double Hernia, and 
 
190 HERNIA. 
 
 requesting him to fit the case with a nice, suitable truss. After 
 the patient had the truss put on by my friend, the doctor, he 
 returned to me, and as it was not a suitable one I sent him back 
 to the same place for a better one. 
 
 As I saw no more of him I supposed, from my long experience 
 with the manufacturing establishment, that he had been properly 
 fitted the second time. On the contrary, to my mortification 
 and chagrin, I was soon told by the attending physician that this 
 second truss was no better than the first, but that when the man 
 sat down, it would strike against the back of the chair, and be 
 thrown forward off the seat of the rupture, and thus would not 
 support and sustain the weakened rings. Of course, our whole 
 design in ordering it was to sustain these rings, as the adhesions 
 had not yet become sufficiently strong fully to resist the pressure 
 of the intestines and other parts against them. 
 
 His physician stated, also, that the patient said that the 
 doctor, when he fitted him, made him strain, force down and 
 cough all he could. 1 By such treatment there was naturally 
 produced some protrusion of the parts, and I said that if he 
 had not by this means re-ruptured the man I should think it 
 almost a miracle. As, moreover, he assumed the liberty with 
 this patient to tell him he was not cured, I took it rather ill at 
 first. 
 
 Now I hear you say if this had been my patient I should have 
 been indignant at such proceedings on the part of my friend the 
 doctor, particularly after I had written to him that the operation 
 had just been performed, and after I had in the most friendly 
 manner possible requested him to fit the patient with great care. 
 Please defer, for one moment, your harsh criticism, for in the 
 first place the doctor did in this case just what most of us might 
 
 1 This story should be taken with a grain of allowance, as my friend, 
 who adjusted the truss, says he thinks the patient brought this condition 
 of his rupture on himself, and I certainly would credit the doctor sooner 
 than any patient. 
 
GENERAL REMARKS. 191 
 
 have done under similar circumstances. The patient is said to 
 "be cured, and to all appearance is cured (I may add that I truly 
 think that this man was cured, and that such was also the 
 opinion and belief of his attending physician) ; now I say, this 
 being the case, the doctor did not stop to consider, it may he, the 
 young and tender state of the united tissues, any more than many 
 others wouid. This is an operation all are not conversant with, 
 and just how strong the parts are and how far they will bear 
 straining, all are not supposed to know at present. 
 
 Suppose, too, on the other hand, we were a dealer, fitting, for 
 example, a wooden leg, and wishing to sell, would it not be 
 natural for us, regardless of the very recent cicatrice, to cause 
 the patient to force his amputated limb into the artificial one, 
 and to try and convince him that he could walk more miles 
 without fatigue with this leg than with the one lost in battle ? 
 
 No, gentlemen, I do not blame my friend for thus treating my 
 patient, and it is with no ill feeling that I refer to the matter at 
 this time, although it is true that this was my first operation for 
 the radical cure of Hernia, and naturally a pet one. I speak of 
 the case to show that it proves one thing certain, viz. : that a 
 great amount of violent treatment can sometimes be endured im- 
 mediately after the operation without a new rupture taking 
 place ; for with this man one side, strange to say, did not move 
 •or protrude in the least, while the other did. 
 
 Still, I would not advise much violence to be done to the 
 tissues while they are in a fresh state of adhesion, since their 
 -condition soon after, nay, for months after the operation, may 
 be compared to freshly-glued pieces of wood. Tt is true, there 
 will immediately be some adhesion, so as to hold them together, 
 but if any force, even of a very slight nature, be at once 
 applied, it will cause them to part. Should, however, a longer 
 time be allowed to elapse before force is applied, the pieces 
 will be found adhering so firmly that the fibres themselves will 
 
192 HERNIA. 
 
 separate sooner than allow the wood to part. Just so is it with 
 the tissues of the body after this operation. The tenor of 
 adhesiveness of the rings and surrounding parts is at first slight, 
 but after a period of time the new formation of adhesive fibres 
 will often be found stronger in cohesion, because of their con- 
 traction and consolidation, than any other part of the dependent 
 tissues composing the rings. 
 
 This case is instructive, then, in three ways : First, it shows 
 how a severe Hernia may be successfully cured : secondly, how 
 much ill treatment a Hernia thus cured may sometimes endure;- 
 thirdly, how easily this relief may be forfeited by interference 
 with the process of healing, whether in fitting a truss or by 
 making the patients cough, force down or strain in any way, to 
 gratify a mere idle curiosity. 
 
 Operations Nos, 3, 4, and 5. — This case is a unique one, and 
 in many respects more instructive than any we may ever meet 
 again. Mr. P., aged between forty-five and fifty, applied to the 
 late Dr. Heaton for an operation, but for some reason was 
 deferred. After Dr. Heaton* s demise the gentleman presented 
 himself to me for the operation, telling me that he had been 
 ruptured for eighteen years and that Dr. Heaton had promised 
 to operate on him. I examined him, and frankly told him that 
 I did not have much faith that he could be cured by the opera- 
 tion, but that if he wanted me to try to effect relief I would do 
 so, with the distinct understanding that I did not know what 
 the result would be, and that I would not, on any account 
 warrant the least relief or cure. 
 
 Accordingly, on the 25th of July, 1879, at 220 Harrison 
 Avenue, formerly occupied by Dr. Heaton as his hospital, I 
 operated on the man for tw r o of the largest Hernia? I have ever 
 seen. They were double inguinal, on the left side with a ring 
 two inches in diameter, on the right side with a ring one and a 
 half inches in diameter. He said it had been well nigh im» 
 
GENERAL REMARKS. 193 
 
 possible to retain the bowels in their proper cavity by any or all 
 artificial means, and so great had been his pain that he was 
 constantly longing for the time to come when he could lie down, 
 to ease his sufferings. At the time of operation he was wearing 
 a very large elastic abdominal supporter and truss combined, 
 although neither this nor the " hundred different trusses he had 
 at home" could retain the ruptures in their proper position, 
 because, as he expressed it, the Hernia? were so large, especially 
 on the left side, that they would " boil over " any truss that was 
 applied. It is needless to say that the patient was suffering not 
 only this physical anguish, but also mental depression. 
 
 In my operation I found it necessary, on account of the greatly 
 dilated rings, to inject a larger amount of quercus alba than 
 usual. About eight hours after the injection the pulse and 
 temperature began to rise, reaching their maximum on the 
 second and third day. On these days the temperature was 
 99*5° and the pulse about 90. They now began to diminish 
 until on the fifth day only a slight increase over the normal 
 condition was noticeable. On the same day he had a free 
 evacuation of the bowels, from a dose of seidlitz powder. 
 
 During all the time since the operation the urine was passed 
 normally, and he complained very little of pain, except in the 
 immediate vicinity of the rings, where the injection had been 
 made. 
 
 On the eighth day after the operation the swelling, which at its 
 maximum, had extended up as high as the crest of the ileum, 
 running along the oblique muscles on both sides, had wholly dis- 
 appeared. There was no tenderness around the umbilicus, nor 
 any indication of inflammation of the peritoneum, except in a 
 very limited spot around the rings. The hernial sac on both 
 sides was enormously enlarged and thickened, and on the left side 
 bound down by some adhesion. Upon examining the patient 
 in the erect position, I found the Hernias well retained in the 
 
 
 
194 HERNIA. 
 
 abdominal cavity and the rings firmly and well filled, except in 
 a small portion of the superior part on the left side. 
 
 Fearing this might dilate, and finally allow a hernial pro- 
 trusion, I operated again on August 2nd, on the left side, to 
 guard against such an accident. This second injection pro- 
 duced phases similar to those in the first operation, with a 
 little greater swelling, hut on Auqust 11th the swelling be^an to 
 pass away, and everything to assume a normal condition. Now, 
 standing my patient upon his feet, there was no protrusion on 
 either side, and I thought of discharging him in a few days, 
 cured of a most remarkable Hernia. I therefore allowed him 
 to sit up, for an hour or two daily, but on the 13th I found that 
 he had extended my hour of allowance to the liberty of sitting 
 up from morning till night. Secondary swelling immediately 
 began to appear, but from the applications of cold water and 
 enforced recumbent position, they had diminished on the next 
 day to about a normal state. 
 
 The man was continually anxious to return to his home, in 
 Lawrence, but both I and the matron urged upon him the 
 expediency of remaining at rest a few days longer. I told him 
 that there was danger that the effort of the journey might 
 produce an abscess, or even loss of life. In spite, however, of 
 all our arguments and persuasions, go he would, and go he did, 
 assuming to himself all responsibility and risk in such a reck- 
 less act. Accordingly, at noon on the fourteenth he left our 
 care for his home. In consequence of this exertion there was, 
 as we anticipated, a return of the swelling and the formation of 
 an abscess. He was treated very successfully in his trouble 
 by Dr. G-. W. Garland, as the following letter will show : — 
 
 Laweence, Sejjt. 15$, 1879. 
 "Dr. J. H. Warren— 
 
 "Dear Sir,— Mr. P. came to Lawrence Thursday, August 
 14th. I saw him the following Friday. It was perfectly 
 
GENERAL REMARKS. 195 
 
 apparent at that time that he was to have an abscess. It was 
 opened August 20th, under ether and a disinfectant spray. An 
 openiug was made large enough to explore the bottom with the 
 finger, which seemed firm. The abscess proper was quite as large 
 as a common saucer, and swelling, tenderness and pain extended 
 up the groin as far as the crest of the ilium ; another abscess 
 formed in the scrotum, just above the testicles and over the 
 cord, which was opened August the 30th; still another was 
 opened September 10th, just above the original one. The one 
 on the scrotum has healed, the others are doing finely. A large 
 portion of dead tissue came from the floor of the main abscess. 
 The surrounding induration has been treated with tincture of 
 iodine, and both hot and cold lotions, and is quite rapidly 
 subsiding. 
 
 " I have neglected to mention that after Sunday, the 17th, a 
 severe fever followed a chill for a day or two. There is no 
 protrusion of the Hernias, and the ease, for so bad a one, is doing 
 well. Mr. P. is to go to Andover next Wednesday, p.m., a mile 
 and a half from Lawrence. He is gaming strength fast. 
 
 " Very truly yours, 
 
 " G. W. Garland, M.D." 
 
 On September 26th, Mr. P. cailed at my office, and I found 
 that the principal abscess had been just above the seat of my 
 operation, and was still slightly discharging, as was also the one 
 in the upper part of the scrotum. There was considerable in- 
 duration and a large cicatricial indentation of the parts around 
 the lower portion of the ring, extending down to the spermatic 
 cord. There was a slight protrusion of the upper portion of the 
 omentum, but no sign that the intestines had descended through 
 the ring. I ordered cold compresses, with proper supporting 
 bandages, and enjoined absolute quiet, in bed. He now regrets 
 
 o 2 
 
196 HERNIA. 
 
 that he did not remain longer in Boston, instead of hurrying 
 home. 
 
 On October 8th I again examined him, and found the swelling 
 and congestion still existing, although greatly diminished. I 
 found that instead of a good supporting bandage he had applied 
 a very frail and wholly inadequate affair, and I now applied a 
 delicate, French double truss, and ordered frequent bathing of 
 the parts in cold water and carbolic acid. It will be remem- 
 bered that he told me at the time of my first operation on him 
 that he had been ruptured eighteen years. He now told me 
 that his mother had informed him that he had been born 
 ruptured, and that his father had taken him when a child to 
 have a truss adjusted. I told him that had I known this before 
 I operated I should on no account have taken the risk of 
 operating on such an enormous congenital Hernia. My opera- 
 tion in this case had been performed with the simple extract of 
 ouercus alba and morphine that Dr. Heaton recommended, but 
 with a needle of the Doctor's that I had improved by making 
 two more orifices near the point. 
 
 Although performed with so unsatisfactory a needle and 
 mixture, it establishes three very important points : first, it gives 
 us the pathology of such cases soon after the operation ; second, 
 it shows how very important it is, if we would escape dangerous 
 consequences, to insist upon and enforce rest in the recumbent 
 position, together with constant applications of cold water at 
 the least appearance of a secondary swelling and i n flam mat ory 
 process ; third, it shows what a wonderful result can be obtained 
 by the operation in cases hitherto deemed incurable, as e.g., 
 congenital and enormously large Hernire. 
 
 January 29th, 1880. I examined this patient, and find he 
 is perfectly cured on one side ; on the other side there is some 
 omentum, protruding, which will require another injection, and 
 with the mixture I am now using I hope to fully close up the 
 
GENERAL REMARKS. 1^7 
 
 rings, as it is more stimulating than the mixture of Heaton 
 that I used in my operation on him. He is very anxious 
 to have me try again, which I promised to do as soon as I 
 think proper. 
 
 Operations Nos. 6, 7. — Having found these cases so fruitful 
 in instruction and encouragement, I undertook my sixth operation 
 with increased confidence. Mr. M.", aged sixty- two, had been 
 ruptured when eleven years old. This rupture, oblique inguina 
 on the left side, continued to enlarge until he was twenty-one 
 or more. 
 
 For nine or ten years it gave so little trouble that he did not 
 think it necessary to wear a truss. Ever after that time, how- 
 ever, he wore one, until July 30th, 1879, the day I operated on 
 him. The hernia was an inch and a half in diameter, and 
 protruded about the size of a duck's egg. I injected twenty 
 minims of fluid extract of quercus alba with one tenth grain of 
 morphia. He went through the customary phases — slight rise 
 in temperature and pulse, then a gradual subsidence — until, 
 after eight or ten days, he returned to his normal condition. 
 On the 11th of August, only twelve days after the operation, he 
 rode out, free from his rupture, without even the slightest bulging 
 of the tissues so long dilated. 
 
 We have now come to the interesting and instructive part of 
 the case. I have said that so far as I could ascertain by careful 
 examination, in the erect and recumbent position, the ring was 
 entirely occluded with firm surrounding parts. 
 
 The confidence both of myself and of the patient in the 
 perfect results of the operation was so great that it is true we 
 applied only a supporting bandage, and the man returned to his 
 usual occupation. In this condition he remained for nearly two 
 months, when, relaxing in his attention to the proper support, 
 he suffered a slight protrusion of the ring and at the same time 
 a descending of the sac. 
 
198 HERNIA. 
 
 To remedy this protrusion I re-injected him on October Gth, 
 with my mixture of quercus alba, alcohol, morphia and sulphuric 
 ether. This injection created a slight local disturbance, but no 
 increase of pulse or temperature, and produced a further contrac- 
 tion of the ring. Although it was not so fully contracted as after 
 the first operation, still it was sufficiently contracted to retain 
 the hernia within the abdominal cavity. Unwilling longer to risk 
 a bandage, I ordered a light and soft French spring truss, to wear 
 six or eight months, which he continued to wear until December 
 9th, when he again presented himself to me, and this time with 
 a strangulated Hernia on the right side. It was a most curious 
 case. 
 
 I reduced this new rupture and fitted the man with a soft 
 double French truss. Having much soreness on this right side, 
 extending down to the spermatic cord, he was ordered to resume 
 the recumbent position in bed. 
 
 In spite of various soothing applications the pain continued 
 for several days, extending now to the testes and scrotum, pro- 
 ducing intense neuralgia in the former, with irritation and 
 swelling. This state of affairs lasted with more or less acuteness 
 until December 23rd, when I applied a bandage with compress, 
 and allowed him to go to his office. I applied the compress" 
 bandage instead of the truss, from fear that too severe a pressure 
 on the springs of the truss might produce violent irritation of 
 the still tender parts. During all this time since the operation 
 for Hernia I made frequent examinations, and found that since the 
 last injection the ring on the left side had continued constantly 
 to contract, so that the man may now consider himself healed 
 on that side, at least. 
 
 The lesson here to be learned is, first, that had he been more 
 careful, after once firmly closing the ring, to support it properly 
 for a little length of time, so that nature might complete the 
 consolidation, we should never have needed to make a second 
 
GENERAL REMARKS. 109 
 
 injection; secondly, that the patient must be made to be careful 
 of himself until nature has done her work, and that he must not 
 unwarrantably presume upon his perfect recovery until several 
 months have elapsed ; thirdly, that for a long period after the 
 injection the fibres of the surrounding parts continue to contract 
 and consolidate, so that cases where we at first may be inclined 
 to think we have not yet obtained a full occlusion may ultimately, 
 if properly attended and cared for, become perfectly healed. 
 Finallv, we can a^ain see that the lonc^ duration of Hernia is no 
 bar to a radical cure by injection. For this patient has been 
 ruptured forty-two years. 
 
 The first of these operations T performed witli the old original 
 needle of Dr. Heaton ; the two latter with his needle as I had 
 improved it by adding more orifices for the exit of the fluid. I 
 have detailed them minutely and fully, that you may see what 
 great obstacles lie in our path, and how the slightest inattention 
 or carelessness, either on the part of the operator or the patient, 
 may cause a deal of trouble, not to say danger. It cannot be 
 too solemnly impressed upon the patient that the success of the 
 after treatment, (and that means the success of the whole 
 operation) depends as much upon him as upon the operator. If, 
 then, we retain all the valuable instruction these unfavourable 
 symptoms inculcate, we may with a little cheerful perseverance 
 wonderfully triumph by our success. 
 
 I will now give a few of the cases that I have had since the 
 time that I reduced the operation to a more scientific basis, as 
 I believe, by perfecting both the instrument and the injecting 
 fluid (see New York Medical Record of October 18th, 1879). 
 It will be seen that with this new instrument and fluid I 
 encounter less danger, cause less constitutional disturbance, 
 less unnecessary irritation and more intense local action where 
 it is needed, and there alone, than could ever be possible by 
 the crude methods formerly used. 
 
200 • HERNIA. 
 
 Operation No. 8. — F. M., aged twenty-eight, had for two 
 or three years suffered intensely, and had consulted several 
 physicians, some treating him for disease of the liver, others 
 for disease of the kidneys and bladder. The true seat of dis- 
 tress was an inguinal Hernia upon the right side, which was 
 very annoying and painful, since the Hernia was exceedingly 
 sensitive and irritable. 
 
 I found the protrusion was slight, with a ring about one 
 inch by half an inch in dimension, and operated on it for 
 radical cure, on September 6th. The patient made a rapid 
 and full recovery, and sixteen days after the operation accom- 
 panied me- to New York. Among the physicians who there 
 examined him was Dr. E. F. Weir, who was fully convinced 
 that there was a complete occlusion of the hernial ring. The 
 man was ordered to wear a bandage, and was then discharged 
 from my care. I saw this patient on January 24th; he is 
 still free from his rupture. 
 
 Operation No. 9. — L. B., aged four years, was, after etheri- 
 sation, operated on, November 4th, for a congenital umbilical 
 Hernia, about three-quarters of an inch in diameter, and in 
 appearance and size not unlike a red acorn. I injected eight 
 to ten drops of the mixture. Passing through the usual slight 
 feverish excitation, she was discharged from my care after two 
 weeks' time, fully cured. 
 
 Operation No. 10. — On December 18th I operated upon 
 J. E., aged forty -one, for direct inguinal Hernia on the right 
 side. The opening was in size one inch by three-quarters of 
 an inch, and had existed for more than two years. I was 
 assisted by Dr. Joseph Eedfearn, Jun., of Ashland, whose patient 
 the gentleman was. I injected about fifteen minims of the 
 mixture. The only pain was a sharp smarting for about five 
 minutes after the operation, and on January 1st Dr. Eedfearn 
 and myself examined him, and were satisfied that the man had 
 
GENERAL REMARKS. 201 
 
 fully recovered, with a perfect occlusion of the ring, and was 
 ready to be discharged. I had a note from him on January 13th, 
 and he is well and free from all trouble from his Hernia. 
 
 Operation No. 11. — Mrs. M., aged fifty-six, had had 
 a femoral Hernia on the right side for more than thirty 
 years. The opening through the tissues was flat oval, about 
 one inch and a quarter by three-quarters of an inch, with a 
 protrusion the size of a large goose egg. On December 25th 
 I operated upon her, injecting about ten drops. She had just 
 recovered from typhoid pneumonia, and still had a slight cold, 
 so that it was only at her urgent request that I operated when 
 I did. The smarting pain from the injection was very severe 
 for five or ten minutes. On the second morning after the 
 operation her cold was much worse, attended with pleurisy 
 on the left side and a heavy cough, and her food had caused 
 her to vomit. For three or four days her temperature was 
 100 and her pulse about 95, but whether from the fever or 
 the injection could not be determined. On January 6th I 
 caused her to assume the erect position, and found the rings 
 occluded and the intestines completely retained in their cavity. 
 So firmly occluded are the rings that, as she is rather fleshy, 
 a little dimple is seen over the seat of the operation. 
 
 January 15th. She is cured of rupture. 
 
 Operation No. 12. — Mrs. L., aged forty-five, of delicate 
 constitution, had a very painful Hernia on the right side, which 
 had been strangulated three times, twice with ureat danger to 
 her life. The Hernia had existed for fifteen years, occurring 
 from a strain in child-bearing. It was very painful, and pro- 
 truded about the size of a common cowry. There were two 
 openings through the crural ring, the larger, from which the 
 protrusion took place, near the femoral vessels. This opening 
 was about three-quarters of an inch in length and measured 
 three- eighths of an inch in. width. 
 
202 HERNIA. 
 
 I operated by injecting about ten drops of my usual mixture. 
 She was in the evening but slightly feverish, with pulse about 
 normal, 78. The next day the parts about the ring were tender, 
 and covered with a profuse effusion of lymph. She suffered 
 great pain through the back, right hip and limb, owing much, 
 as she thought, to the constrained position of lying on her back, 
 as she had often suffered equally severely for months at a time. 
 A pill of extract of hyoscyamus, lettii and morphia was given 
 her, to secure rest and ease from the pain. Third day — Her 
 temperature and pulse are about the same as on yesterday. I 
 afterwards found that the cause of her pain was her periodical 
 turns appearing. Upon examination, January 12th, the rings 
 were found perfectly occluded and she cured of her hernia. 
 
 July 10th. She is free and cured from her painful Hernia, 
 and a happy woman. 
 
 In all these operations I find that in order to insure success I 
 must produce a certain, though limited, amount of inflammation 
 of the surrounding parts. You will see that I have aimed to 
 produce this. Dr. Heaton considered the inflammation very 
 dangerous, and said that in his operations it seldom occurred. He 
 meant peritoneal inflammation. Dr. Davenport, 1 editor of Dr. H.'s 
 work, as directed by Dr. H., worked up a sort of pathology, to 
 the effect that only, " tendinous irritation/' as they call it, was 
 caused, and no inflammation. I find that Dr. Heaton was 
 mistaken in his pathology, as it is impossible to contract and 
 occlude the rings without an inflammation, to cause an effusion 
 of plasto-lymph. I learned, too, from Dr. Heaton s old matron, 
 a very intelligent woman in such matters, that Dr. H. always 
 got more extensive inflammation, swelling, and often abscesses, 
 
 1 No disrespect is here intended to so good a man as Dr. Davenport, but 
 this is nevertheless a fact, as toM me by his cousin, Dr. D., of Boston, 
 who said he knew that Dr. Davenport had to work up a sort of pathology 
 to meet the statements of Dr. H. in his operations. 
 
GENERAL REMARKS. 203 
 
 when he was successful, than I ever get in my cases. This 
 excessive inflammation was probably due to the crude injecting 
 mixture arid instrument which he used. Indeed, I am often led 
 to wonder that he ever succeeded with his operations at all. 
 
 I have now gone over all the ground that Dr. Heaton passed 
 over, and have performed upon all the various kinds of Hernia 
 which he operated upon, and I feel confident that my results, to 
 say the least, have been as successful as his, in the same given 
 number of cases. 
 
 In fact, the question whether Dr. Heaton ever cured any one 
 of rupture, has been asked by those whose opinion is entitled to 
 much weight. I can answer in the affirmative, because I have 
 examined a large number of those upon whom he has operated 
 for Hernias of from one to twenty years' standing. 
 
 That he failed in many cases is also true. But in all his 
 failures we should find, if w T e traced the operation, that there 
 was only a slight infusion and only the most limited amount of 
 inflammation, or what in his work is styled tendinous irritation. 
 It is a well-known fact, that if we would produce a blister with 
 cantharides, for instance, we must, in order to get an effusion of 
 plasto-lymph, destroy the cuticle and create a given amount of 
 inflammation. The same holds good in this operation. The 
 parts must receive a certain amount of irritation from some stimu- 
 lating material, to excite the secretion of this lymph. The more 
 plentiful the effusion the more sure we are of strong adhesions 
 and attachments, which will organise into fibrous bands, not 
 unlike the cicatrice of a severe scald or burn. This draws and 
 binds together the hernial rings and surrounding parts, and 
 when properly performed retains the hernial protrusion in its 
 proper cavity, more firmly than ever before, in many cases. 
 
 You will see that I have given you the history of twelve 
 
 operations on genuine ruptures of various kinds. This does not 
 
 , include all that I have operated upon, but only a few interesting 
 
204 HERNIA. 
 
 cases. Of these twelve the first two were partial failures, and 
 one later on. Two of these are soon to be re-operated upon, and 
 I have no doubt that, with the mixture of such a stimulating 
 nature as I now use, they will be permanently cured by the 
 second injection. I have some doubts as to the possibility of 
 retaining the large congenital Hernia, but as the patient is very 
 anxious for another operation, I presume I shall try it. I have 
 freely expressed all my doubts to him, but unless I operate upon 
 him he will not be contented, nor shall we know whether such 
 cases can be successfully treated. This includes all the 
 unfavourable cases that I have had in my operations thus far- 
 I might cite many other successful cases, but I have presented 
 a sufficient number to give an idea of the results of the 
 operation. 
 
 You will see, gentlemen, that I have felt it my duty to 
 develop this operation with open hands, concealing nothing, 
 but recording careful observations on all my cases, keeping 
 nothing to myself in a selfish way, but offering everything in 
 my power to the profession, in order to establish a legitimate 
 operation. Others may have undertaken to relieve the ruptured 
 sufferers by methods known only to themselves ; I am determined 
 to do what I can to demonstrate to myself, and I trust to you, 
 that this operation, when properly performed, possesses many 
 advantages over every other now known for the cure of this dis- 
 tressing malady. Whatever discouragements, whatever obstacles, 
 whatever successes I have met, all have been freely given to the 
 scientific advancement of surgical knowledge. To say that this 
 operation for the radical cure is simple, and when carefully used 
 by skilful operators presents no greater danger and no more 
 unsuccessful results than other well-known surgical operations, 
 is only the barest justice to its past and present success. 
 
 I am, therefore, encouraged to hope that other members of 
 the profession will test it in the course of their practice, and ' 
 
GENERAL REMARRa 206 
 
 present us with reports upon the cases, that we may all, 
 
 dispassionately and without prejudice, judge of its true value. 
 
 In reply to the gentleman who has performed Wood's opera- 
 tion successfully with wire, catgut, or pins, while these ligatures 
 or the pressure of a truss may cause suppuration and an absorp- 
 tion or melting away, as he termed it, of the plasto-lymph 
 effused, still I must maintain that the condition of the parts and 
 the materials that I use produce very different effects, in the 
 quantity of lymph effused, as well as in the permanency of the 
 effusion. As this gentleman has never performed the operation 
 for the cure by injection of the hernial rings, I cannot take 
 his statements as of any authority in regard to the melting 
 away of the lymph after my operation, whatever may have been 
 the results, good or indifferent, after his operations by other 
 methods. 
 
 Another gentleman's experience of twelve operations, with 
 only one success, goes only to substantiate more fully what I 
 discovered after my second operation, that a more stimulating 
 mixture was required and a better instrument than the one 
 recommended by Dr. Heaton. Anotner disadvantage he might 
 have had is that his patients occurring in hospital practice were 
 anaemic, not properly nourished, and therefore not in so favour- 
 able a condition as regards their systems as those in private 
 practice. 
 
 Whenever Dr. Heaton's instrument and mixture are used 
 the results will be very uncertain and unsatisfactory; although 
 an abundant intiammation will be set up, the effusion of lymph 
 will be proportionally small. In fact, the great cause of failure 
 is not in all cases, as is commonly supposed, the lack of proper 
 after- support, but that the lymph attachment is severed by 
 muscular contractions, and the lymph readily absorbed. 
 
 I am not at all astonished at the questions asked as to my 
 operation, when I talk with gentlemen at our medical meetings 
 
20G HERNIA. 
 
 i 
 
 and read the numerous letters of inquiry which I receive. For 
 if one has not seen the operation and had it explained to him, 
 he can have only the faintest conception of it, be he ever so 
 good a surgeon or operator in general surgery. 
 
 Physicians and surgeons of no little renown have asked me 
 if I pass the needle through the scrotum and follow up on the 
 spermatic cord ? Another asks if 1 go through the columns, 
 and at precisely what point I cut through the rings ? Some 
 think there must be great danger in operating on Umbilical 
 Hernia, since, as they say, we penetrate the peritoneum. In 
 reality, the needle is not passed either into or on to the 
 peritoneum. 
 
 Others think the inguinal region must be dangerous, because 
 of the numerous vessels and nerves. The truth is that the 
 umbilical region is the safest region to operate upon, inguinal 
 less safe, and femoral the most dangerous. None should operate 
 upon the latter, unless they are experienced. 
 
 Upon infants, as I have before said, 1 have never operated. 
 .The youngest patient was four years old. Mechanical appliances, 
 such as a good truss or elastic bandage, J have found productive 
 of good results. 
 
 I prefer a bullet, partially flattened and fastened to a linen 
 bandage, because the compression of the abdominal muscles by 
 the elastic bandage prevents their development, and conse- 
 quently the closure of the rings, and also that these muscles 
 are liable to be thinned by the constant pressure and for ever 
 weakened. 
 
 In conclusion, I would say that above all the congratulations 
 from gentlemen of note in the profession, the resolutions and 
 the honorary membership of the Medical Society of Otsego 
 County, New York, I esteem the commendation of my friend, 
 Dr. B. Codman, who has, as is well known throughout this 
 country, for many years attended to the mechanical treatment 
 
GENERAL REMARKS. 207 
 
 of Hernia. He says, "I believe you have at last perfected 
 this operation, and I know that with your instrument and fluid 
 you will be successful in the treatment of Hernia by injection, 
 and will have greater success than has been hitherto met with 
 by any one ; with the adjustment of a proper temporary truss 
 after the operation, a permanent closure of the rings will 
 crown your efforts, and you will receive your reward from an 
 appreciative profession." 
 
CHAPTER VII. 
 Treatment of Strangulated Hernia. — Taxis. 
 
 The treatment of Strangulated Hernia is one of the most 
 important of surgical operations. We have not only to effect a 
 reduction of the strangulated intestine and to remove the con- 
 striction, but also to treat the peritonitis. We accomplish the 
 reduction by the operation of taxis, by which we mean all the 
 manual methods used for the purpose of returning the protrud- 
 ing intestine into the abdominal cavity. The peritonitis may be 
 excited either by the compression caused by the strangulation 
 or by the attempts and efforts at reduction. We may in some 
 cases have to deal with a, peritonitis, the result of strangulation, 
 increased by a peritonitis, the result of taxis. The taxis, how- 
 ever, when properly done, is rarely, if ever fatal, if a judicious 
 after treatment be adopted. 
 
 The following valuable hints from Birkitt, I trust I may be 
 pardoned for extracting verbatim. 
 
 "The principal circumstances to which attention should be 
 directed are as follows : 
 
 " 1. The kind of variety or the Hernia regarded in its 
 anatomical relations. 
 
 " 2. The duration of its existence ; whether it be of old 
 standing and slow formation, or of recent and sudden develop- 
 ment 
 
TREATMENT OF STRANGULATED HERNIA. 2C9 
 
 " 3. The constitutional condition of the patient at the im- 
 mediate mcment, as influenced by the present illness. The 
 hour at which vomiting commenced ; and the variations which 
 have taken place in the composition of the fluids vomited, 
 should he determined with exactitude. 
 
 "4. The state of the tumour. Its usual size when not causing 
 
 o 
 
 illness ; its hulk before vomiting commenced; the changes 
 which have taken place in it during this stage ; the pains to 
 which it gives rise, if merely local or extending into the 
 abdomen, with or without manipulation; the condition of its 
 coverings ; its probable contents, so far as may be conjectured 
 by the evidence, assisted by touch and sight. 
 
 " o. The treatment already adopted by the patient, the friends, 
 or other persons before the observation of the surgeon." 
 
 In employing the taxis it is necessary, firstly, to have the 
 bladder evacuated either naturally or by the catheter, and also 
 the rectum; secondly, to gain a relaxatiou of the abdominal 
 muscles, and thirdly, it is always advisable to administer an 
 anaesthetic and preferably sulphuric ether. 
 
 The position to gain the relaxation of the abdominal muscles 
 is important. After placing the patient upon his back with a 
 pillow under his buttocks to elevate the pelvis, and with his 
 head and shoulders raised, the thighs should be flexed by 
 bending them up at nearly right angles to the trunk, and 
 slightly rotating them inward. 
 
 The surgeon, getting into the position which gives him the 
 greatest control of the tumour and the freest action of his 
 hands, should make gentle manipulation upon the tumour for 
 from two to five minutes, when, if reduction be not effected, he 
 should try the application of cold to the parts. This application 
 can be made with powdered ice, and sometimes by pouring a 
 small stream of ice water from a considerable height upon the 
 tumour and surrounding parts. The tumour can now be gently 
 
 P 
 
210 HERNIA. 
 
 squeezed between the thumb and finger and drawn outward to 
 relieve the gut of its cramped position before renewing our 
 manipulations. Should this not succeed we may, after a few 
 minutes of rest, pour sulphuric ether upon the parts and fan it 
 to cause a rapid evaporation. This evaporation causing intense 
 cold contracts the superficial integuments, the sac and the 
 included intestines much more rapidly than it does the solid 
 fibrous Poupart's ligament ; hence if we immediately apply 
 gentle taxis we may often succeed in reducing cases hitherto 
 supposed to be irreducible without the use of the knife. 
 Changing the position of the patient from side to side will 
 often aid in reduction by the specific gravity of the parts 
 tending to suck the intestines into their proper cavity. If 
 this be not sufficient to accomplish our purpose, the injection of 
 large amounts of hot water per rectum is useful by distending 
 the intestines and dragging them into the abdomen. 1 
 
 To obtain a proper relaxation of muscles it has been recom- 
 mended to use blood-letting to the point of fainting, to inject an 
 infusion of tobacco or to administer tartarised antimony, opium, 
 cannabis indicus, hyacyamus, stramonium, or belladonna. But 
 although these have all been tried with more or less success, 
 
 1 Another method has been devised and successfully applied to irre- 
 ducible Hernise by my distinguished friend J. Collins Warren, editor of 
 the Boston Medical and Surgical Journal, and Professor of Surgery at the 
 Haward Medical School. His plan is to use a " rubber water bag exter- 
 nally inelastic, but containing an elastic lining inclosing a space t<> which 
 water or air could be admitted by a tube." To this a stout T bandage is 
 sewed to secure it in the scrotum, and when once buckled in place it 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 continued for 
 any length of time. It is indeed a great improvement over the simple 
 rubber bandage devised by Maissonneuve. If uniformly successful it 
 will give us a fair prospect of relieving many cases hitherto incurable 
 except by the more serious operations of herniotomy, because, manifestly, 
 if Hernise hitherto irreducible may be reduced they will then be subject 
 to the same conditions of treatment as the reducible. 
 
TREATMENT OF STRANGULATED HERNIA. 211 
 
 they are not measures which in these days of anaesthetic I 
 would recommend, since by anaesthetic we gain a greater relaxa- 
 tion of the muscular system than is otherwise possible, and 
 avoid the deteriorating and exhaustive influences of these drugs 
 I have mentioned. 
 
 The taxis should be continued at intervals of a few minutes 
 for from thirty minutes to three hours according to the alarming 
 symptoms, the condition and vitality of the patient, and the 
 length of time since the Hernia became strangulated. Of these 
 the surgeon can judge when called to the case. In general 
 we may say that we can treat old and large Hernise, accom- 
 panied by omentum and occurring in persons of advanced years, 
 with greater impunity by prolonged manipulation than small 
 Herniae with very acute symptoms. These symptoms will have 
 shown themselves by violent retching, pain in the parts, and 
 a feverish excitement of the system accompanied by giddiness 
 or delirium. Femoral Hernise are to be treated with the greatest 
 gentleness as with too violent pressure and manipulation there 
 is great danger of rupturing and fatally injuring the intestines. 
 Of all this let the younger men ot the profession take good 
 warning. In treating a strangulated Hernia let no undue 
 violence be used. It can do no good and may result in extreme 
 danger to the life of the patient from the forcible constriction 
 of the inflamed intestine against the constricting ring. If the 
 inflamed state has passed to gangrene we should never attempt 
 the taxis for fear of fatal peritonitis. From the observation of 
 many years I am convinced that the taxis is often too long con- 
 tinued before resorting to the operation of kelotomy, and I 
 feel as confident that thousands of lives that are lost might have 
 been saved by employing this operation in due season. The 
 following quotation from Surgical Anatomy, by William Ander- 
 son, will illustrate my point. " I know of no excuse that would 
 apologise for the delay which we generally witness before this 
 
 p 2 
 
212 HERNIA. 
 
 operation is resorted to, or which would authorise the surgeon 
 who is to be the operator in allowing half a dozen consultants 
 to take their turn in squeezing the tumour under the pretence 
 of giving full trial to the taxis." 
 
 To illustrate a position for the patient, which in my opinion 
 is very favourable for the operation of taxis, as well as to show 
 the permanency of the ordinary operation by injection, I give 
 the following rare form of femoral Hernia occurring in a patient 
 of mine previously operated upon for inguinal Hernia upon 
 the same side. 
 
 The history of this case is as follows : Mrs. M. L. L. of Athol, 
 Mass., aged forty-five, was ruptured, at the time or soon after the 
 birth of a child, some ten or twelve years ago. On right side the 
 Hernia was oblique inguinal with protrusion of the size of an 
 English walnut. It had been strangulated twice, both times 
 with near loss of her life. It was reduced once by H. A. Dean, 
 M.D., a cautious and skilful medical gentleman of fine scientific 
 attainments in the profession, and the second time by Dr. Lynde 
 in company with the above-named physician. 
 
 Dr. L. is also a physician and surgeon highly esteemed in the 
 profession as an expert diagnostician. These gentlemen saw 
 the patient soon after the Hernia became strangulated, and after 
 etherisation succeeded with some difficulty in reducing the 
 rupture by taxis. 
 
 This Hernia was very painful and difficult to retain with a 
 truss. At the suggestion of her physician she applied to me for 
 a cure by injection. Being on my vacation I did not see her 
 until my return in the fall of 1879. It still gave her great pain 
 and was very sore from the truss. I operated on her in the 
 first part of January, 1880, with success, by injecting fifteen 
 drops of fluid extract of queicus alba, alcohol, ether, and mor- 
 phia. This Hernia was well retained and the rings occluded. 
 In the early part of May, 1880, she had an attack of colic. 
 
TREATMENT OF STRANGULATED HERNIA. 213 
 
 She felt something give way, and soon after had pains and 
 symptoms of strangulated Hernia. Dr. Lynde being called 
 tried to reduce the Hernia by taxis. After continuing his 
 attempts for the greater part of a day, he thought that as I 
 had once operated on her she had better again come under my 
 care. As the seat of rupture and strangulation was not well 
 defined, he in his diagnosis leaned to the opinion that it was an 
 oblique inguinal, the same that had twice before been reduced 
 and on which I had operated; but was not certain since my 
 operation had left more or less cicatricial tissue, and had there- 
 fore a tendency to blind completely the seat of strangulation. 
 This with the peculiar form of rupture was sufficient to lead the 
 most experienced astray in his diagnosis. 
 
 The patient arrived in great pain in the night of April . 29 ; 
 with parts much inflamed and swollen. With the assistance of 
 Dr. Broughton, I placed her under the influence of ether, and 
 upon a most careful and thorough examination by both of us, 
 we found the rupture was femoral, and about 2\ inches from the 
 oblique inguinal that I had succeeded in curing. It had de- 
 scended on the outer side of the femoral vessels and beneath 
 the femoral artery, the pulsations of which could be distinctly 
 felt. The sac was preceded for a distance by the sheath of the 
 pectineus muscle. After it had passed down beneath the femoral 
 vessels it turned a short angle toward the left side, the largest 
 part of the swelling being immediately beneath the seat of her 
 former Hernia. 
 
 This diagnosis was qualified differentially by a most thorough 
 examination, with some efforts to reduce it through the inguinal 
 rings. Finding no opening, since the rings, as I have before 
 said, were firmly occluded, T began to investigate and examine 
 the crural ring, and soon discovered the seat of strangulation, 
 as I have above stated, firmly held. 
 
 It should be borne in mind that the diagnosis was much more 
 
214 HERNIA. 
 
 than usually obscured by the parts being so inflamed and swollen. 
 After placing the patient in every conceivable position, such as 
 elevation of hips, curvature of spine, limbs flexed on abdomen, 
 &c, and after working with great earnestness at reduction by 
 taxis without gaining in the least on the strangulation, I thought 
 of suspension. The patient being very slight, the limbs were 
 seized under the knees by Dr. B., who stood over her, and I 
 again worked with great ardour, but failed to gain any reduction 
 of the strangulation. I was about to perform kelotomy on her, 
 when, after farther consideration of the anatomy, it occurred to 
 me that if I forcibly flexed the thigh 1 toward the left shoulder it 
 would bring the obturator and other muscles, together with 
 Poupart's and Gimbernat's ligaments, into a greater state of 
 relaxation. On the first trial in this position of the parts, the 
 Hernia was returned into the abdominal cavity, to the delightful 
 sensation that rejoices the anxious heart of the operator. 
 
 On June 13, I was at Athol to operate upon this femoral 
 Hernia. As the patient was not properly situated in her house- 
 hold affairs, the operation was deferred until the coming autumn. 
 At that time I examined her in the presence of her attending 
 physician, Dr. Lynde, and before Drs. Oliver and Parsons, of 
 Athol, and Dr. Alcott, of an adjoining town, and demonstrated 
 to their perfect satisfaction the seat of the oblique inguinal 
 and of the late strangulated femoral Hernia. The latter was 
 still somewhat tender from the strangulations as well as from 
 our efforts at reduction several weeks before. This shows, also, 
 better than anything I have yet seen, the permanency of my 
 operation' on reducible Hernial by injection, for there must have 
 been considerable force upon all the parts before she became 
 ruptured in the femoral region. Still the injected rings of my 
 first operations remained firm and strong, and to-day retain 
 the rupture without any protrusion whatever. 
 
 This then is a very instructive case, first, in proving my 
 
TREATMENT OF STRANGULATED HERNIA. H15 
 
 operation to be permanent, and secondly, in being a form of 
 femoral Hernia seldom seen. Even the older writers have 
 diagnosed or mentioned this form of Hernia very rarely, Yelp e an 
 and Cooper giving only two or three instances of this peculiar 
 form. Thirdly, it will always serve as a guide to me in Hernia 
 of this form, by teaching me to throw the leg of the patient 
 toward the left shoulder, if the rupture be on the right side, and 
 vice versa if on the left side, and to flex the thigh forcibly on 
 the abdomen. Since this will give us the greatest possible 
 relaxation of the muscles and ligaments that hold the intestines 
 in strangulation, and allow by this relaxed state an easy 
 reduction. 
 
 If, for study, one will take the cadaver and experiment he will 
 find this position the very best for reduction. I would state that 
 this form of strangulated Hernia is rather difficult to handle by 
 injections, owing to the close proximity of the vessels supplying 
 these parts, sometimes further complicated by fine branches of 
 the obturator and epigastric arteries which are thrown im- 
 mediately over the point of rupture just beneath Poupart's 
 ligament and at the angle formed by this and Gimbernat's 
 ligament, at or near the junction of the pectineus and other 
 muscles in this triangle. Greater care must be used in the 
 operation for this form of Hernia than in any other, irom the 
 liability to penetrate these blood-vessels. Study well each 
 individual case before proceeding to operate, or you will cer- 
 tainly do more mischief and harm than good to the patient 
 submitted to the operation by injection for the cure of femoral 
 Hernia by closing the crural ring. 
 
 Finally, after we have exhausted every effort of taxis by the 
 various means above mentioned, before resorting to herniotomy 
 we must consider whether it is not best to apply the aspirating 
 needle (Fig. 40) to the distended sac and intestine, since by 
 relieving the tumefaction of gas or other matter we can often 
 
216 HERNIA. 
 
 quite readily reduce the strangulated parts. For this purpose I 
 use a needle of my own device, of a thin oval section, which 
 will be found very advantageous since coaptation of the wound 
 takes place much more readily than when the common needle, 
 round in section, is used. This is apparent to any one con- 
 versant with the wounds made by a round or flat oval instrument, 
 
 Pio. 89.— Aspirating Needla. 
 
 When we are obliged to cu^ down upon the parts, to return 
 strangulated Hernise, it will often be found the best way to 
 evacuate the gas and fluid which may be present in the sac 
 before we divide Poupart's ligament, as by so doing we may be 
 able to return the strangulated parts without carrying an in- 
 cision so far into the parts, owing to the diminished volume 
 of the tumefaction. 
 
 Fio. 40.— The first Aspirating Needle for topping hernlcal sac in cases of Strangulated Hernia. 
 
 This fig. represents a trocar, invented by a farmer in Athol, Mass., to relieve himself of 
 Strangulated Hernia while his physician was gone to get his instruments to perform herniotomy. 
 The patient Thought he would tap the tumefaction, and by so doing reduce the rupture, in 
 •which he fully succeeded. This is one of the earliest uses of the aspirating needle being applied 
 to restore Strangulated Hernia. It was given to me by Dr. James Oliver, of AthoL He said 
 the patient madeuse of it on himself twenty-eight years ago, as above described. 
 
CHAPTER VIII. 
 
 Kelotomy or Herniotomy. 
 
 If taxis does not succeed, and the more serious operations 
 of kelotomy or herniotomy be decided to be employed, it is 
 ordinarily performed in the following manner, although I have 
 some suggestions and improvements that very much simplify 
 the operation. Always supposing the patient to be under the 
 influence of an anaesthetic, the patient is placed upon his back 
 in much the same position as in taxis. 
 
 The bladder being evacuated, and the pubic parts shaved, the 
 first step is to make an incision through the skin and superficial 
 fascia over the prominence of the tumour, beginning at the 
 superior extremity, and terminating near the base, and varying 
 in length from an inch and a half to three inches, according 
 to the size of the Hernia. This incision may be linear, crucial, 
 Y-shaped, or of the shape of an inverted V, and is to be made 
 through layer upon layer of coverings until the hernial sac is 
 reached, the groove director bein^ used to bring to view the 
 deeper seated structures, and it being always a good rule to have 
 a large external wound, but as small an internal one as possible. 
 " In inguinal Herniae this incision should be made along the 
 line of the inguinal canal, from the internal to below the 
 external ring ; in femoral, over or on the inner side of the 
 crural ring, either in a vertical or oblique direction, in the course 
 
218 
 
 IIEHNIA. 
 
 of Poupart's ligament, the former being preferable." ! The sac 
 will appear to our view of a bluish and vascular appearance 
 in recent Herniae ; thick and opaque in older Herniye. It should 
 now be pinched between the thumb and finger, and the opposing 
 surfaces rubbed against one another which could not be done 
 were it anything beside the sac. The diagnosis can be confirmed 
 by pricking the sac with a small needle. If this puncture be 
 followed by a few drops of serous fluid our previous diagnosis 
 will be confirmed. An opening is now made into the sac just 
 
 Jiing 
 
 External n 
 
 Obturator 
 Ring 
 
 Fio. 41. 
 
 large enough to admit the point of the director, and the division 
 carried upward and then downward, allowing at the same time 
 the escape of the contents of the sac. In recent strangulations 
 t'lis ifciid is small and sometimes absent; so that we should be 
 ;;r:nnled not to carry our dissection to too great an extent. The 
 f ir finger is now introduced as far as possible to search for the 
 seat of obstruction at the superior part of the sac. The probe 
 poiured bistoury is carried flatwise along beneath the stricture 
 which is divided by bringing the edge of the knife against it. 
 
 1 Bryant. 
 
KELOTOMY OR HERNIOTOMY. 219 
 
 An absolute rule should be observed as to the direction in which 
 this incision is to be made. We wish to avoid the epigastric 
 artery. In an oblique inguinal, the artery is internal to the 
 neck of the sic; in direct, it is external to the sac, but since 
 old oblique Hernise so often simulate direct Hernias in appearance, 
 the safest rule for cutting is to cut neither outward nor inward 
 but directly upward. 
 
 Usually only a very slight incision will be necessary, perhaps 
 only a line and a half in length. 1 After removing the dislocated 
 viscera and sac from the seat of strangulation, we carefully re- 
 place all the abdominal parts that have escaped, that being 
 reduced first which protruded last, and of course the bowel 
 before the omentum. The wound is now drawn together by 
 sutures, and the dressing completed by adhesive plaster, com- 
 press and a spica bandage. 2 The patient should now be made 
 as comfortable as possible in bed, cold water slightly acidulated 
 with carbolic acid being applied under the compress, and re- 
 newed from time to time. Morphine or opium should be 
 administered, both to secure rest and also to secure the patient 
 agair.st that inflammation always to be dreaded — peritonitis. 
 The spica bandage and compress should be continued until the 
 patient can bear the pressure of a truss, when a properly 
 adjusted one should be applied and worn. 
 
 A few of the many modifications of directors and hernia- 
 tomes are here illustated. Some are very useful, while others 
 
 1 In our operation of Kelotomy ahvays remember that it only requires 
 the cutting or severing but a few fibres of Poupart's ligament, and it is as- 
 tonishing how very small an amount of this ligament, on becoming divided, 
 will release a strangulated sac or intestine, so as to be readily reduced into 
 the abdominal cavity. Bear in mind while dividing this ligament to cut as 
 little as possible, for too much cutting here leaves our patient in a much 
 worse condition for the descent of his rupture than before strangulation, and 
 more liable to become again strangulated by a too free division of these 
 ligaments. 
 
 2 See figure of spica bandage on page 169. 
 
220 
 
 HERNIA. 
 
 Fia. 42.— Cooper's Hernia Knife. 
 
 Fig. 43.— Peter's Hernia Director, 
 
 Fio. 44.— Hernia Director. 
 
 jfro. 46.— Levi's Director. 
 
 Fig. 47.— Stewart's Hern a Knife. 
 
 I ig. 43.— Kinge Hernia Director. 
 
KELOTOMY OR HERNIOTOMY. 221 
 
 Are seldom resorted to. The author's instrument (p. 239) will 
 take the place of all of them, as it simplifies the operation and 
 gives great security from dangerous consequences. All that 
 is absolutely necessary to use, I find, is a short bistoury, 
 Dr. Golding Bird's Percian forceps, needles armed with silver 
 wire or carbolized cat-gut, and my herniatome. No director is 
 needed as the herniatome combines director and knife. 
 
 OPERATION WITHOUT OPENING THE SAC. 
 
 The return of the hernial sac is not prevented merely by 
 the narrowness of the constriction ; it may also be due to adhe- 
 sions which have formed either between the intestines and sac, 
 or between the sac and the adjoining tissues. The existence of 
 these anatomical and pathological adhesions led early operators 
 to the belief that it was necessary, in these cases at least, to 
 open the sac. Later surgeons have for many years, however, 
 realised the dangers of such an operation, and have come to 
 believe that there is not so urgent a necessity as was formerly 
 supposed. They divide the stricture external to or without 
 opening the sac. By this means the peritoneal cavity is not 
 exposed, the danger from peritonitis is reduced, the inflamed 
 intestine is not exposed to the atmosphere or to the hands of 
 the operator, and the risk of haemorrhage into the peritoneal 
 cavity, from arteries that have been cut is entirely absent. To 
 say, however, that the sac is never to be opened, would be in 
 my opinion as erroneous a conclusion as to say that the sac is 
 always to be opened. Exceptional cases may occur in which 
 the adhesions may be so firmly knit together that they cannot 
 be broken unless the sac be opened. Here, as in every operation, 
 there is the greatest demand for exact anatomical knowledge, 
 for cook and deliberate judgment, for delicacy of manipulation, . 
 
222 
 
 HERNIA. 
 
 and for refraining as much as possible from interference with 
 the tissues surrounding our seat of operation. 
 
 The first to employ this operation of dividing the stricture 
 without opening the sac was Jean Louis Petit. In his TraitS 
 des Maladies Chirurgicales, published in 1774 as a posthumous 
 work, he says he operated in this way more than thirty years 
 before 1750, and goes oq to say, "Let us ask ourselves the ques- 
 tion, of what use is it to open the sac ? The only purposes that 
 I know of are to expose the intestine and omentum in order to 
 
 Flo. 49.— Key'g Director passed beneath the seat of stricture of a Strangulated Femoral Hernia, 
 
 outside of the sac beneath the fascia propria. 
 
 remedy morbid changes, if there should be any, to separate these 
 parts if they should have become adherent, and to be able to 
 handle the intestine, and push back hardened fseces or foreign 
 substances. Now I except these cases ; in all others, which are 
 far more numerous, why open the sac ? . There is no indication 
 for such a proceeding ; while, on the other hand, the obvious 
 advantages of omitting it are that we avoid exposing the pro- 
 truded parts to the air, and escape the risk of wounding them ; 
 moreover, I shall show that, in respect to the consequence of 
 the operation, it is desirable that the sac should not have been 
 
KELOTOMY OR HERNIOTOMY. 
 
 223 
 
 opened. From these several considerations I conclude that it 
 is better to enlarge the ring on the outside than from the inside 
 of the sac." In all these arguments he is sustained by Sir 
 Astley Cooper, who frequently in practice and in lecture advo- 
 cated the method. 
 
 Petit's operation was as follows. Dissecting down to the sac, 
 where it passes out from the ring, he insinuated between the 
 ring and the sac a flat grooved director curved toward its end. 
 A bistoury carried along the groove divided what was thus 
 raised. If this division be not sufficient, it may be repeated 
 until sufficient space has been made to allow redaction. 
 
 »'■■ 
 
 Fio. 50.— Direct Inguinal Hernia. 
 
 "Mr. Key recommends in inguinal hernia a mode, of proceed- 
 ing by which the surgeon may be enabled to divide the stricture 
 either at the internal or external ring. He makes an incision 
 of an inch and a half over the neck of the tumour, so as to lay 
 bare the lower portion of the external oblique tendon, where it 
 forms the ring. A small opening should then be made in the 
 tendon just above the ring : by introducing the director it will 
 be found whether the stricture is at the lower or upper opening. 
 In the former case the director is carried under the margin of 
 the tendon, which is then divided to a sufficient extent. If the 
 
224 
 
 HERNIA. 
 
 stricture should be at the upper opening, the incision in the 
 aponeurosis of the obliquus externus must be enlarged so as to 
 expose the lower margin of the two succeeding muscles with 
 some fibres of the cremaster. The latter may be separated by 
 the end of the director, which should be carried under the end 
 of the transversus, the instrument being depressed upon the 
 sac in order to carry its point under the border of the muscle, 
 which may be divided to the required extent." 
 
 As to the statement which Petit so wisely made in his day, 
 that the necessity of opening the sac because of adhesions, &c. r 
 
 Fig. 51.— Oblique Inguinal Hernia. 
 Bubonocals on right side, but passing through external ring on left. 
 
 was the decided exception to the general rule of cases, Duprey- 
 ten, in 1818, estimated that "six times out of nine strangulation 
 is caused by the neck of the sac. Not much later H. Berard 
 raised the proportion to eight out of nine, and ultimately Mal- 
 gaigne maintained, in 1840, that genuine strangulation was 
 always caused by the neck, and that the cases of supposed 
 strangulation by the rings were cases of inflammation of the 
 hernial sac." E. Coulson (Arch-Gen. 1863, L, 273 &c.) in re- 
 commending the operation without opening the sac, advises that 
 when the hernia is very large, and when the symptoms are more 
 those of inflammation or gangrene than strangulation, or when 
 
KELOTOMY OR HERNIOTOMY. £25 
 
 large adhesions have been formed, the intestine should not be 
 reduced, but watched so that the sac may, upon emergency, be 
 immediately opened. 
 
 TREATMENT AS GIVEN BY BERNARD AND HUETTE. 
 
 I have found the description of the operations upon strangu- 
 lated Hernia, both the taxis and kelotomy, so admirably and 
 clearly stated by Claude Bernard and Charles Huette (de 
 Montargis) in their Medicine Opiratoire that I have ventured to 
 translate it in full. I trust this description will be as interesting 
 and instructive to the reader as it has been to me. 
 
 "The operation for the reduction of strangulated Hernia was 
 proposed and described for the first time by Franco in 1561 
 Adopted and practised latter by Ambroise Pare, and perfected 
 and described as an operative method by Dionis. 
 
 " The instruments are as follows: — an ordinary straight bistoury, 
 a convex bistoury, a probe-pointed bistoury, or Pott's or Cooper's 
 herniotomy knife. These bistouries have been variously modi- 
 fied, a director, a pair of blunt scissors, and several dissecting 
 forceps. Several fine sponges are necessary to soak up the 
 blood during the operation ; finally various pieces of dressing, 
 lint, compresses, wax, &c. 
 
 " The operator places himself at the right of the patient having 
 assistants at his side, and at the left of the patient to hold the 
 instruments, to sop up the blood, and to take part in the operation 
 as there is need. 
 
 " Tins operation having for its end the removal of the strangu- 
 lation, by section of the opening which causes it, is composed of 
 several stages, in which successive incisions are made. First, 
 the skin. Second, the subcutaneous envelopes of the hernia. 
 Third, the hernial sac. Fourth, the constricting ring. Fifth, 
 the reduction of the bowels. 
 
 Q 
 
226 HERNIA. 
 
 " First. — Incision 'of the Skin. The incision should be made 
 following the great diameter of the tumour, and proportional in 
 extent to the volume of the Hernia. It can be made front within 
 outwards ; or from without inwards ; when the skin is intimately 
 united to the envelopes of the Hernia and cannot be detached by- 
 wrinkling. In this case it is necessary to make the incision 
 with great precaution, and slowly to deepen it little by little. 
 The essential point is not to cut the intestine. When the skin 
 is soft, adhering but slightly to the deep parts, it is preferable to 
 raise a fold of skin from the upper part of the tumour. The 
 operator seizes one extremity of this fold, an assistant holding 
 the other, and makes an incision from without inwards, or 
 better from within outwards by entering the bistoury to its base, 
 the edge upwards. 
 
 "This first incision has to do with the skin only, and should 
 exceed the tumour in height and depth by a centimetre. It 
 is sometimes necessary to make a crucial or T-shaped incision. 
 
 " After the incision of the skin, several small superficial 
 arteries give off blood. Before continuing the operation, it is 
 well to arrest this slight haemorrhage by torsion and cold lotions. 
 
 " Second. — Incision of the Subcutaneous Envelopes of the 
 Sac. — Much precaution and great delicacy of hand is required 
 at this step. Some operators cut directly from without inwards, 
 holding the bistoury like a fiddle-bow, the edge upon the tumour. 
 The surer method is to raise the thin folds which envelope the 
 Hernia, with a pair of pincers, and to make a horizontal incision, 
 withdrawing each fold by the pincers. Then a director is intro- 
 . duced at the small opening thus made and pushed under the 
 folds to the extremity of the tumour, and the bistoury, with 
 its edge upwards, directed by the groove in the director, divides 
 the envelopes of the Hernia clown to the sac safely and without 
 peril. Blunt scissors may also be employed. 
 
 *' The number of these envelopes are variable. We have enume- 
 
KELOTOMY OR HERNIOTOMY. 227 
 
 rated and described these in treating of the surgical anatomy of 
 the inguinal and crural region. But the age of the Hernia, the 
 duration of the Hernia, &c, so modify the relations and nature 
 of these envelopes that the normal anatomy cannot serve as a 
 guide in investigations, and it is often extremely difficult to find 
 the sac in the midst of the abnormal layers produced by the 
 hernia. 
 
 " Serous cysts, deposits of fat, gangliotic abscesses, old sacs, &c. 
 &c, may obscure the operation, and cause perilous uncertainty 
 to the most experienced hand. Several signs are characteristic 
 of the sac, viz., a smooth and polished surface, a spherical form, 
 a fluctuation caused by an accumulation of lymph, the omentum 
 or the intestine seen by transparency, &c. 
 
 " Third. — Incision of Sac. — The sac being found beyond a 
 doubt, must be incised with care, in order not to wound the 
 intestine. For this a fold of the sac between the circumvolu- 
 tions of the intestine, or rather at the level of a portion of the 
 omentum, is raised by pincers. This stage of the operation is 
 rendered easy in the majority of cases by the lymph which 
 bathes and distends the interior of the sac. An incision is 
 made close to the pincers so as to make an opening through 
 which to introduce the director, guided by which the sac is 
 opened through its whole visible length, first above, then below. 
 This opening ought to be made as much as possible forward and 
 a little outward. It is of importance then to prove that the sac 
 is opened. A certain quantity of lymph which escapes after 
 the incision, the easiness of exploring the interior of the sac, 
 with the director or. the finger, when no actherence with the 
 intestine exists ; the intestine or the omentum floating freely 
 and not adherent except at a point corresponding to the 
 abdominal ring • all these si<ms together leave no doubt as 
 to the nature of the sac which has been opened. Some Hernia), 
 Hernia of the cgecum, for example, have no sac at all. When 
 
 Q 2 
 
228 HERNIA. 
 
 this particular embarrassment occurs, which is extremely rare, 
 it is always easy to recognise the intestines from the structure of 
 its investments. In the more ordinary cases the intestine 
 appears of a variable colour, according to the duration of the 
 strangulation. Its surface is vascular, its colour is a reddish- 
 brown more or less deepened, and marked in several places by a 
 layer of plastic lymph. The omentum can be easily unfolded 
 when it has contracted no adherence. 
 
 "Fourth. — Kelotomy. — Before proceeding to the division of 
 the constricting ring, exploration of the neck of the sac should 
 be made with the finger, and traction should be carefully made 
 upon the intestinal protrusion, in order to effect reduction without 
 kelotomy if possible. 
 
 "The situation of the strangulation being well known, and 
 kelotomy judged indispensable, the operation can be performed in 
 two ways. 
 
 " 1. By cutting the constricting ring at the side where one does 
 not expect the presence of vessels. 
 
 " 2. By making several incisions at different points over the 
 seat of the strangulation ; these multiple incisions extending 
 but a short distance, were adopted as a method by M. Vidal 
 (de Cassis). 
 
 " Kelotomy is practised with a probe-pointed, straight, convex 
 or concave bistoury. The straight probe-pointed bistoury is 
 generally preferred, with the blade surrounded by a piece of 
 tape, leaving bare only one or two centimetres of the extreme 
 edge of the instrument which ought to be entered under the 
 constricting ring. The bistoury may be guided by the index 
 finger, or by a director. When the extremity of the finger 
 cannot be pushed as far as the obstruction, the director must be 
 used; but if the nail can be introduced under the frenum, the 
 bistoury can be guided along upon the finger, at first flat then 
 raised on edge, and the back of the instrument pushed by the 
 
KELOTOMY OR HERNIOTOMY. 229 
 
 finger on which it rests, divides the constricting ring. The 
 index finger can then be entered still more deeply, and the 
 division carried still farther. 
 
 "Dining the operation, the assistants keep apart the lips of 
 the wound and hold back the intestines, which surrounding the 
 blade of the instrument, might be wounded and hinder the 
 operation. 
 
 " M. Vidal has prepared a grooved spatula to guide the bistouiy. 
 This director is extremely useful when it is impossible to follow 
 the course of the bistoury with the eye. The end of the director 
 is first passed between the hernial protrusion, and the part causing 
 strangulation. The grooved face is turned upward towards the 
 part which is to be divided, and on this face the bistoury is 
 pushed forward, with the blade lying flat so that the edge 
 cannot act in any way. In division the bistoury is turned upou 
 its axis in such a manner as to raise the bistoury on edge, 
 scraping as well as cutting the ring. This director protects the 
 intestines from the edge of the blade, and keeps them at a 
 distance. 
 
 " We have said before that reduction should be tried before 
 division is performed, but we must not forget that the location 
 of the strangulation is more often at the neck of the sac than at 
 the aponeurotic ring. On this account the Hernia may be re- 
 duced with the sac, and yet the strangulation may exist at the 
 neck after the reduction into the abdomen. It is of importance 
 therefore to be well assured of the precise location of the strangu- 
 lation, and not to forget that some hernial sacs have multiple 
 necks, and that the location of the strangulation may be very 
 extended, and reach as far as the superior ring of the inguinal 
 canal. Only by feeling and successive divisions can the 
 operator discover the difficulties which may complicate the 
 operation. 
 
 "There is much difference among authors, concerning the 
 
230 HERNIA. 
 
 direction and the extent of the division. When the strangu- 
 lation is located at the exterior ring, and the neck of the sac can 
 be drawn out of the canal, the division is always easy and 
 without danger to the epigastric artery. But when the strangu- 
 lation is deeper, the impossibility of knowing whether the 
 hernia is internal or external, ought to render the operator 
 prudent. The division above is less dangerous to the organs 
 which must to be respected. At no part should the incision be 
 more than four millimetres, in order to avoid puncturing the 
 artery. In the case of external Hernia, the division being from 
 without safely admits of a larger incision, which should always 
 be proportional to the organs to be reduced. To obtain these 
 results it is often preferable to resort to the multiple method 
 adapted by M. Vidal. 
 
 " Multiple Division. — When it is necessary to greatly dilate 
 the abnormal opening, in order to avoid a too extensive incision, 
 causing danger of haemorrhage. M. Vidal proposes to make 
 three, four, or a greater number of incisions of two to three 
 millimetres. 
 
 " Method of M. Malgaigne. — M. Malgaigne makes the incision 
 not in ,the sac and scrotum, but at the place where the strangu- 
 lation appears to be located, prolonging the incision above and 
 below to an extent which the obesity of the subject and the 
 volume of the Hernia demands. All the tissues are then divided 
 as far as the peritoneum, and on this account there is nothing to 
 be feared from the vessels which one has under his eyes or puts 
 aside at will. If it is discovered that the strangulation is caused 
 by a fibrous opening the Hernia is reduced without touching the 
 sac. If not, the neck of the sac is divided by short cuts from 
 without inwards ; or better if the stricture is very firm, a small 
 incision is made either above or below the neck of the sac, 
 which is raised by the director which guides the incision. 
 
 " M. Malgaigne found by this proceeding, before all things, the 
 
KELOTOMY OR HERNIOTOMY. 231 
 
 advantage of allowing the surgeon to see what he had done ; in 
 the second place, of reaching the strangulation by the shortest road 
 and the least possible incision ; thirdly, respecting the scrotum 
 and sac, and avoiding suppuration and cicatrisation of a wound 
 entirely useless. 
 
 " In support of his method, M. Malgaigne cites a case of very 
 volumiuous scrotal Hernia. The neck of the sac was located at 
 the level of the abdominal ring ; the neck of the sac was opened 
 and the sac refilled, the first day with a certain quantity of 
 liquid, which was re-absorbed in a measure, when the inflamma- 
 tion of the upper wound was allayed, and the wound healed 
 without accident. 
 
 " Fifth. — Reduction. — In the case of intestinal Hernia, 
 when the intestine is healthy, it is necessary to draw it a 
 little forward to break up any adherences which may exist, 
 when they are weak ; to cause by gentle pressure, the gas which 
 fills the intestine, to pass into the abdomen, and to return the 
 portion of the intestine near the ring portion by portion. If the 
 intestines are accompanied by a portion of the omentum, this 
 is reduced last. 
 
 " When gangrene has begun in a portion of the intestine, the 
 indications to be followed are various, according to the extent of 
 the disease. If any doubt exists as to the existence of gangrene, 
 M. Vidal advises that an incision be made with the bistoury, 
 upon the diseased intestine, of small extent and very superficial. 
 If circulation is active, a large drop of blood immediately forms 
 at the small wound ; if on the contrary the intestine is gan- 
 grened, the surface of the wound remains dry. In the first case 
 the intestine is reduced, in the second not. In case of doubt 
 the gangrened portions should be retained at the level cf the 
 ring. If there is gangrene, the faecal matter can escape at the 
 abdominal opening. 
 
 " When the intestine is gangrened to a large extent, we must 
 
232 HERNIA. 
 
 retain the two healthy ends at the ring to facilitate the passage 
 of faecal matter at the superior end from the abdominal opening, 
 so as to establish an artificial anus which will hsal later. It may 
 be possible to excise the gangrened parts, and after reuniting the 
 healthy parts, to reduce the intestine as a whole. 
 
 " When it is necessary to establish an artificial anus, the 
 adherences which unite the end of the intestine to the neck of 
 the sac must be gently broken up. The destruction of these 
 adherences will allow the intestine to enter the abdomen. If 
 the strangulation prevents the faecal matter from escaping 
 freely, a speculum may be introduced at the superior end of the 
 intestine, and if this introduction is impossible on account of 
 the adherences which must be regarded, division should be made, 
 with precaution, in front of the sac. 
 
 " Gangrene of the omentum, according to the extent and 
 volume of the omentum involved, requires various methods of 
 operation. When the gangrened portion is sufficiently extensive 
 the omentum is unplaited, divided at the level of the healthy 
 parts, and after the ligature of the vessels, secured at the 
 opening of the ring. 
 
 " Crural Hernia. — WTien the caecum and the superior iliac 
 region of the colon are involved by their extra peritoneal part, 
 they form a Hernia without a sac. Beyond this exceptional case, 
 Crural Hernia is composed almost of the same elements as 
 Inguinal Hernia. They are first directed downward in the 
 sheath of the femoral vessels, then across the lamina of the 
 fascial crebriformis ; then its direction changes, and it remounts 
 toward the abdomen under the skin and the layers of the 
 subcutaneous tissue. 
 
 " In the majority of cases the neck of the sac is formed at the 
 level of the opening of the fascia crebriformis, and here also the 
 strangulation takes place caused by the aponeurotic ring of the 
 iascia erehtiformis. Bnt when the strangulation takes place at> 
 
KELOTOMY OR HERNIOTOMY. 233 
 
 the superior orifice of the canal, or in the canal, it is alwa} T s 
 the neck which is strangulated. (Malgaigne.) 
 
 " That which we have said of taxis in the case of Inguinal 
 Hernia being applicable to Crural Hernia, we will not review it. 
 We will only observe that it is necessary for the Hernise to follow 
 in a reversed way the sinuosities which they have traversed. 
 
 " Kelotomy. — A simple or reversed T-shaped incision is made 
 according to the needs, parallel to the great diameter of the 
 tumour. The different tissues which cover the Hernia having 
 but little thickness, we must proceed with great precaution, and 
 it is often impossible to raise a fold of skin from the surface of 
 the tumour. The ' fascia propria ' which covers the sac is very 
 slight, and may be taken for the sac itself; and some fatty 
 collections lining the sac, and seen by transparency under the 
 fascia propria, may be mistaken for the omentum, and render 
 this error easy. It is of importance, then, that the incision 
 of the layers which cover the Hernia should be made with 
 caution, and division should never be performed frpni the 
 exterior of the sac when the neck of the sac is the cause of 
 strangulation. Eecent researches of modern surgery have 
 caused the older methods of kelotomy to be given up. The 
 works of M. Derneaux have shown that the location of the 
 strangulation was at the aponeurotic ring of the fascia crebri- 
 formis, and that the neck of the sac never caused strangulation 
 of the Hernia. We can therefore with safety make an incision 
 from without at the upper part, but below we might meet the 
 saphenous vein. If after the division of the aponeurotic ring it 
 is proved that the neck of the sac causes the strangulation, we 
 can easily draw it forward and divide it. 
 
 " Umbilical Hernia — Kelotomy. — Umbilical Hernia may 
 become obstructed or strangulated, and call for the operation 
 of kelotomy. 
 
 " We must remember that the envelopes are very fine, and 
 
234 HERNIA. 
 
 that the sac contains but little lymph. These particulars 
 render the operation difficult. 
 
 " The operator very carefully makes an incision of a + or 
 or T shape. Umbilical Hernia being seldom strangulated at 
 the neck of the sac, some authors recommend only a division of 
 the fibrous ring without touching the sac, in order not to 
 expose the peritoneum to inflammation. This should be fol- 
 lowed in the case of large Hernise when it is not necessary to 
 lay bare the intestine. 
 
 " A multiple division is preferable to single division, and if 
 only a single incision is necessary, it should be directed upwards 
 and to the left, in order to avoid the course of the urachus and 
 the umbilical vessels." 
 
 John Gays, 31 D. Operation for Femoral Rupture. — 
 Published London, 1848. — To more fully illustrate the operation 
 of Herniotomy in femoral Hernia I would here introduce his 
 operation from his work on femoral rupture, by giving the 
 following description and illustrations reproduced by Mr. Cooper. 
 The operation of Dr. J. Gay has certainly no little merit, and 
 some slight drawbacks when reduced to actual practice which 
 I will not stop to discuss at present. 
 
 These drawings are made by Mr. Oxenham, and are greatly 
 to be admired for their great beauty and finish. Mr. Oxenham 
 was a student of Mr. J. D. Cooper, 18S, Strand, and I think 
 he does him great credit 
 
KELOTOMY OR HERNIOTOMY 
 
 235 
 
 ScH 
 
 Fia. 52. 
 
 The hpmi.il sac and parts, the subject of this drawing, were discovered in the course of a 
 dissection. The tumour did not pr> sent those external indications that led ton suspicion of 
 its < xistonce. rnti' 1he snp'erfieia 1 and raibrifi rm fascisehad been cutlhrouvli. The en: roving 
 was made from a cast and drawing if the parts taken by Sir E. Wi son, and is well 
 adapted to show the parts 7 rior to their nit* rations by the proeess< s < f disease. The. sac 
 is denuded of its fascia pr< pria. Any further description, but fur the sake of iunior 
 students, would be superfluous. 
 
 a a. — Upper layer of the iliac p< rti< n of fascia 'ata. 
 
 b 6.— Pubic portion of the same fascia. • r pectineal fascia, forming ih^ floor of the femoral fossa. 
 
 c. — Fa'cif rm process, and portion of the bnrd< r cf the saphenous < pen in g. 
 
 d. — External or semilunar portion of the s'me b rd r 
 
 e.— Burn's ligament, cr pubic portion of the arch formed by the lower border of the samo 
 opening. 
 
 f.— Inn rior pillar of the external abdominal ring ; or that portion of the crural arch which 
 terminates upon the tuberosity cf the pubis and adjoining portion of the iko-p^ctiueal 
 ridge 
 
 g. — Spermatic cord. 
 
 7t. — R.!]->1 enous v^in. 
 
 f.— Hernia 1 tumour. 
 
 A black line shows the situation and direction of the incision which i3 made through the 
 integuments into the femoral fossa, for the new operation. 
 
236 
 
 HEliMA. 
 
 
 Fio. 53. 
 
 Represents a hernial tumour and the adjacent parts of the thigh, as th°y are displayed by the 
 removal of the superficial fascia and the contents of the femoral fossa. The crural aicn 
 and upper layer of the iliac portion of the fascia lata have been divided and turned back, 
 to show the "deep layer of that fiscia. and its relations to lley's ligament The knife is 
 passed fiom the femoral foss'a behind those scats of stricture, which are here seen. 
 
 O. — The hernia tumour with its cribriform covering. 
 
 bb.— The crural arch divided and turned back. 
 
 c. — Pubic insertion of the tendon of the external oblique muscle. 
 
 d.— Tendon of rectus. 
 
 e. — Pubic attachment of the conjoined tendons of the internal oblique and transversal is muscles. 
 
 /. — Portion of Giiubcrnat's ligament, formed by the outer pillar of the external abdominal ring. 
 
 g. — Portion of Gimhernat's ligament, formed by the falciform process of the fascia lata. 
 
 h. — Situation of the band of fibres belonging to the internal inguinal ligament of Htsselbach. 
 below the under Inner of the iliac fascia lata. 
 
 {. — The femoral, or Key's ligament; or the deep crural arch. 
 
 k. — Upper lamina of the iliac portion of the fascia lata, divided vertically and thrown back, in 
 order to display the deep lamina, with Hoy's ligament, and its continuity to the arched 
 margin of the internal oblique muscle. 
 
 I. — The femoral fossa. 
 
 TO.— Process from ihe deep abdominal fascia which completes tho upper arched border of the 
 saphenous opening on the pubic side. 
 
Fig. 54. 
 a. — The front wall of the femoral sheath, as displayed on the careful removal of the iliae fascia 
 
 lata. 
 b, c. — Its iliac and pubic, walls. 
 
 d, e,f. — The angles formed by tbp union of these wal?s. 
 g, h. — The sepia by which the sheath is divided. 
 t — The upper orifice of the crura cana 1 .. orrrnralring. 
 k. — The venous obinpart.nmt of th- she: h 
 2 1. — Lines showing Lite direction of the septa of the sh ath. — the. outer one being between the 
 
 art' ry and v in. 
 m. — The front margin of the lower orifice of the sheath. 
 «. — The crural canal 
 ©.—Dotted line, showing the re.ative position of Hey's ligament to the front wall of the 
 
 sheath. 
 p. — The bind of fibres appertaining t" th ■ front wad of the sheath, described as the "fibne 
 
 crassiores" of the internal inguinal ligament of Hesse'.bach. 
 q. — Tendon-of the rectus 
 r.— The pubic margin of the crural ring : the septum crural has been pushed before a hernial 
 
 y-xG, by which ihe canal has b -en occupied. 
 «.— The terminal portion of the saphenous vein 
 
 Fig. 55. 
 The front of the thigh, with a h rnial tumour, with dotted lines showing the situation Of the 
 
 cuural arch, and the margins of the saphenous ring. 
 a. — Edge of process o 1 fcw'n atn 
 b. — Situation of the sp-rmatic cord. 
 <?.— A line representing the sent and direction of the external wound for the ne.v method of 
 
 operating 
 The iine of incision represented in fc'ig. 5J is, in some instances, white; in others, black. 
 
238 HERNIA. 
 
 AUTHOIt*S MODIFICATION OF THE OPERATION OF KELOTOMY. 
 
 Before closing the abdominal walls that we have divided in 
 
 our operation with the knife, I would recommend that we apply 
 
 to the edges of the rings Lugol's solution of iodine, the fluid 
 
 extract of white oak bark, or the following, which I think far 
 
 superior : — 
 
 B Ext. Quercus Albse, grs. xil 
 
 Proof Spirit, §j. 
 
 Morp. Sulph. grs. iv. 
 
 Sulph. Ether, 3iv. 
 M. 
 
 This mixture is to be applied with a long soft earners hair 
 brush, or by means of a bit of absorbent cotton, and will causo 
 an effusion of lymph over the wounded parts, which effusion 
 will consolidate the rings with new tissue not unlike the results 
 of our operation on reducible Hernia by subcutaneous injection. 
 Whether by this means we obtain a cure or not, we shall at 
 least do no harm from our simple application, and may dispense 
 with the succeeding subcutaneous injection. 
 
 Dr. Derby, of Vermont, has succeeded in effecting a cure in a 
 strangulated Hernia by means of the application of iodine, 
 which I have mentioned. 
 
 In case we use iodine, or the preparation of oak bark I have 
 given, I would advise that we apply no moisture on our com- 
 press for the first twenty- four hours. Powdered ice in a bladder, 
 or rubber bag, would be preferable as an application if inflam- 
 mation sets in or is feared ; in fact I think very highly of such 
 an application as a constant dressing in all cases of inflam- 
 mation after any surgical operation of any importance over the 
 abdominal region. 
 
KELOTOMY 0?, HERNIOTOMY. 239 
 
 NEW HERNIOTOMY KNIFE. 
 
 In place of the ordinary Herniotomy knife I have adopted an 
 instrument devised by myself, and here figured. 
 
 In shape it is like a bistoury of the ordinary form, as made 
 by Milliken of London. Instead of a cutting blade, I have 
 adapted to it the narrow saw used by Dr. George F. Shrady, 
 surgeon to the Presbyterian Hospital of New York. This saw 
 can be withdrawn into the hollow shaft of the instrument, 
 which can then be used as an ordinary groove director. When 
 it has been introduced beneath the ligament to be cut, this 
 saw can be pushed forward and used to make our necessary 
 incision. 
 
 Fig. 56.— Tli's is a probe-pointed bistoury, having the ocfjro a b serrated and prowled bv a 
 sliding rod c which keeps it from cutting during its introduction, but is withdr^vu when 
 the desired region is reached. 
 
 We shall, by this means, serrate the ligament instead of 
 cutting it smoothly, and shall avoid, or at least lessen, the 
 danger of severing the epigastric, or obturator arteries, or 
 branches from them. 
 
 The ligaments being roughened will consolidate under the 
 effusions of lymph much more readily than they would if the 
 cut had been smooth and the arteries, should they happen to be 
 injured or severed will from their lacerated edges contract like 
 the edges of a lacerated wound with very little haemorrhage and 
 danger to the patient. Such minute details if we would meet 
 success should always be as faithfully attended to as the major 
 and seemingly more important steps in the operation. To illus- 
 trate the safety of these operations where the ligature of 
 arteries is not so indispensable as once was thought, I insert the 
 
240 HERNIA. 
 
 following quotations, upon surgical operations without ligatures 
 from one of my communications to the Boston. Medical and 
 Surgical Journal. This only brings to our notice the old and 
 well known fact of the contractility of lacerated vessels when 
 severed by sawing or tearing them asunder. 
 
 In 1872, Mrs. , of Kittery, Maine, aged about thirty- 
 eight, of light, sanguine complexion, mother of two children, 
 had a tumour of the left breast about the size of a duck's ecj" 
 which began soon after the cessation of lactation with her last 
 child. This tumour made its appearance on the inner side of the 
 left breast just below the nipple, which felt hard and doughy to 
 the touch. The nipple was retracted, and there was a deep,, 
 dark areola around it. Her suffering was so great that she was 
 unable to sleep, and it had occasioned a general loss of appetite 
 and strength. 
 
 She was placed under the influence of ether, and the usual 
 elliptical incisions were made. In so doing branches of the in- 
 ferior mammary artery were laid bare, and traction was made 
 upon them previous to their general division with a saw-like 
 movement of the bistoury. Retraction of these arteries took 
 place, completely closing them against any haemorrhage. Some 
 slight haemorrhage from smaller vessels was controlled by 
 torsion. The parts were now brought together without the use 
 of any ligatures. The wound was closed with five silver 
 sutures and adhesive plaster, and healed almost entirely by first 
 intention. 
 
 In the fall of 1878 a young girl from Attleboro', aged fifteen 
 or sixteen, received an injury by a stone thrown against her 
 breast, where a hard swelling arose and developed into a cystic 
 adenocele. The whole breast became much enlarged, swollen, 
 and painful just above the nipple. The tumour and the hard 
 swelling continuing to grow in spite of treatment, it w 7 as de- 
 cided to amputate the breast. Being called to perform the 
 
KELOTOMY OR HERNIOTOMY. 241 
 
 operation, I proceeded after etherisation to remove the greater 
 portion of the breast "by making semi-elliptical incisions, keeping 
 the vessels well on the stretch. Her attending physician wrote 
 me that the entire wound healed by the first intention, or at the 
 primary dressing without any suppuration. This patient being- 
 young and in vigorous health, well nourished, and with breasts 
 enormously large, the circulation was very free, and the tendency 
 to haemorrhage much greater than in the first case, where con- 
 tinued suffering had caused a reduction in the vital forces, and 
 at the same time enfeebled the circulation. 
 
 This operation shows the contractile power of the muscular 
 coats of the arteries when traction is made on them before 
 their division. To illustrate still further how much can be done 
 in many operations without the use of ligatures by taking 
 advantage of this contractile power of the arteries I will relate 
 the following case: — 
 
 Mrs. H., of Concord, Mass., aged sixty-eight, on November 7, 
 1878, consulted me for a large fatty, bell-shaped, fibroid tumour 
 which grew from the gluteus maximus, was suspended by a 
 pedicle of about two and a half inches in diameter, and extended 
 nearly to her knee on the left side. It had existed over 
 twenty-five years, and a portion of the inferior part had sloughed 
 obliquely off, leaving a largo ulcerated surface which was dis- 
 charging a very offensive fluid. The constant weight — about 
 three pounds — had caused a prolapsus uteri, together with a 
 partial prolapsus of the anus and bladder. This tumour, from 
 its discharge and the burden of carrying it, as the patient was 
 very slight in stature, — was very weakening and enfeebling. 
 
 On the 12th of November, after etherisation, I operated on 
 the tumour, with the assistance of Dr. E. B. Webb, of Boston, 
 by making two longitudinal elliptical incisions as close as con- 
 venient to the pedicle, and removing all the attachments except 
 where the arteries ramified into the substance of the tumour. 
 
 R 
 
242 HERNIA. 
 
 These arteries were very large, and accompanied by a vein fully 
 equal in size. Before the final division of the vessels I made 
 retraction, placing them greatly on the stretch, and then pro- 
 ceeded slowly to divide them with a saw-like motion, as related 
 above. Full contraction and closure of the arteries took place. 
 The wound was now brought together, and coaptation effected 
 by silver sutures and Dr. Martin's Unite! States army adhesive 
 plaster. It healed almost entirely from the first dressing, ex- 
 cepting a small portion, about three quarters of an inch of the 
 lower part of the incision, which was designedly left open for 
 drainage, and so kept by a few threads of coarse saddler's silk. 
 The patient in two weeks was able to return home perfectly 
 healed, with her prolapsed organs restored to their natural con- 
 ditions, the uterus being supported with a Hodge's hard rubber 
 pessary. She was ordered to take quinine and iron, and when 
 she visited me in the winter she had gained so much flesh and 
 strength that she considered herself comparatively young again. 
 Neither in major nor minor operations have I had secondary 
 haemorrhage by this method so frequently as when T have been 
 obliged to resort to ligatures, and I have had better success in 
 the healing, since the parts so brought together have generally 
 united by first intention. My attention was called to this con- 
 tractility of the arteries from the fact that in early life I noticed 
 that in many lacerated wounds we have but little haemor- 
 rhage where we should have supposed from the size of the 
 arteries that there would be much, and that such wounds, when 
 proper coaptation could be had, — when freed from dust and oil, 
 — would generally heal by first intention ; but where ligatures, 
 even though small, were used in fresh wounds, suppuration took 
 place almost invariably. 
 
CHAPTER IX. 
 Trusses. 
 
 I AM more and more convinced that so important a matter 
 as the proper fitting of a truss has been most terribly over- 
 looked by the medical and surgical profession, and that it should 
 receive more careful and personal attention at their hands. 
 Who in our profession if called to adjust a fractured limb would 
 think of referring his patient to the care of the mere mechanic 
 who may make splints or to the dealer who may vend them, and 
 feel that he had done all that was necessary and right, or that 
 could be expected of him ? If no surgeon would think of 
 excusing such criminal conduct in the case of a fracture, which 
 will heal with the most limited amount of surgical supervision, 
 why should it be considered unprofessional to adjust the truss 
 which may have to be worn for years or even for a lifetime, and 
 which if improperly fitted may endanger life far more than pro- 
 tect it ? Has not this very important matter been left altogether 
 too long — to our shame be it said— -in the control of the 
 manufacturer and the vendor ? 
 
 I feel confident that I do not draw an exaggerated picture 
 when I say that many a patient when he has asked where or 
 how to get a truss has been told by his medical adviser to "go 
 
 to Mr. , driur^ist, who has them for sale, for as I was com- 
 
 ing by his store this morning I saw some fine ones there made 
 by a celebrated maker, I at this moment forget who, but you 
 
 it 2 
 
244 HERNIA. 
 
 can easily find them, for the leather covering is stamped all over 
 with bright gilt letters. I know you will get a good fit there, for 
 
 Mr. used to be a coope^, and of course he is used to fitting 
 
 any body or thing that needs hooping." 
 
 Many are the patients that call upon me wearing barbarous 
 appliances, that I certainly would not think of putting upon a 
 brute animal. Let me give one instance. Last winter a poor 
 deluded man came to me wearing a contrivance with four rollers 
 similar to those used on parlour skates. These were applied as 
 a pad to a spring, as stiff and hard as the hoop upon an oaken 
 cask, and the whole was adjusted by heavy straps of stout 
 leather around the body, and having the usual perineal attach- 
 ment. It pressed so hard that I have often wondered how it 
 was possible that the circulation could act in the large blood- 
 vessels of the lower limb. More than all, it was a very imper- 
 fect fit. The swollen and excoriated skin that these implements 
 of torture produce in order, as the dealers say, to produce a 
 radical cure will, I think, if my previous arguments have not 
 been sufficient, show why I object to the term as applied 
 to an exact and scientific surgical operation. The agony 
 these poor sufferers endure is only helped along by the ex- 
 treme delicacy which many of them feel to confess that they 
 are afflicted with a disease, which for purposes of selfish and 
 sordid gain the dealers in trusses often call an immoral disease. 
 Immoral indeed ! Would that half the ills of mortals were as 
 free from taint and immorality ! 
 
 It will readily be understood that in this general condemna- 
 tion I do not condemn those dealers in these articles who are 
 known to be proper men with honest principles, and who endea- 
 vour to fit a truss as the physician may direct. To such men, 
 generally to be found, I should have no hesitation in recom- 
 mending patients for a proper instrument (Fig. 57). 
 
 A properly fitting truss should combine lightness, strength, 
 
TRUSSES. 
 
 245 
 
 and elasticity, so that it can be worn with grace and ease by the 
 patient, and retain bis hernia always within the proper place. 
 The steel should be the finest, and as elastic as the mainspring of 
 a watch (Fig. 58). Such a spring can be worn with ease, and is 
 at the same time capable of exerting sufficient force to retain the 
 hernia. A truss like this is now easily obtained from any of 
 our first-class instrument makers, and no others should ever bo 
 recommended to be used. Sucb makers' firms are Codman and 
 
 Fio. 57. — Proper position for Umbilical 
 Truss. 
 
 Fio. 58.— Proper position for Truss in 
 Inguinal Hernia. 
 
 Shurtleff, of Boston ; Tiemann and Co., of New York ; Milli- 
 ken, of London ; and Charviere, of Paris. Their styles are 
 numerous, but for effective service the truss should be as 
 plain and as little ornamented as possible. Instruments like 
 these will usually not disappoint us in performing all that is 
 recommended for them, and of course the patient is not endan- 
 gered by the truss slipping or giving way should he jump or 
 make any sudden movement of the body. It would be well if 
 the patient could always have an 'extra one at hand, especially in 
 
24G HERNIA. 
 
 travelling, so that lie may be forearmed in case of any possible 
 emergency. 
 
 For a few practical hints upon trusses, their various patterns, 
 and their application, I refer to a paper written for this work by 
 my friend Dr. Benj. S. Codnian, of the firm of Cod man and 
 Shurtleff, and a gentleman whose experience in this matter we 
 all highly value, from the fact that he has received a regular 
 medical and surgical education, and has spent nearly a lifetime 
 in the proper adjustment of trusses. 
 
 " Human ingenuity has ever been taxed to its uttermost to 
 invent a truss, supporter, or appliance, comfortably to restrain 
 and hold this uncomfortable protruberance of the abdominal 
 viscera. 
 
 "In the great world's Exposition in Paris in 1SG7, in the 
 ' Surgical Department/ was to be seen a collection, both 
 ' ancient and modern/ of these appliances, winch served well 
 to mark the improvement that has been made in their manu- 
 facture. Yet we must still look forward, as perfection has not 
 yet been attained, and until it has, we must continue to use 
 the best attainable substitute. 
 
 " Which is the best truss ? Year after year the cry has been 
 raised, ' T have found it ; ' and a new patent truss has been 
 launched forth, with the promise of meeting every want, and 
 being capable of curing the most obstinate cases of Hernia; 
 only too soon, alas, to disappoint this large class of suffering 
 humanity with its utter failure, and only to see their fond 
 hopes dashed to the ground. 
 
 " Trusses are a necessity, and the surgeon should study to meet 
 the want, and thoroughly to understand the anatomy of Hernia, 
 so that he can recommend the most suitable instrument, and 
 the proper person to make the application if he is unable to 
 attend to it personally. 
 
 " The best truss is the one best adapted to the case ; and when 
 
TRUSSES. 247 
 
 we say that, we mean that age, sex, and condition are to be 
 considered. 
 
 u Is it proper to apply a truss to a very young infant with 
 congenital Hernia ? Yes ; and the sooner the better, provided 
 it is skilfully doue, as the rings contract if properly supported, 
 and the bowels enlarge, so as not to easily force through the 
 inguinal or femoral openings (Fig. 59). 
 
 "Trusses for infancy and childhood should be light, springy, 
 and delicate. Children wearing napkins should have the pad 
 constructed of black ebony or ivory, for the following reasons . 
 such pads never change their form ; they are more durable, as 
 a soft chamois-covered pad becomes wet with urine, and foetid, 
 
 Ft,-. SP. 
 
 ~^ '^| 
 
 Spiral Sjmug Tad. 
 
 and falls to pieces in a few weeks ; and, better than all, the 
 hard pad holds better, is smooth and less irritable, and in 
 many cases will permanently close the rings, and obviate the 
 necessity of a second truss. But to do this the case will re- 
 quire careful watching on the part of both doctor and parents. 
 If parents think a hand-pad is too hard, it may be safe to allow 
 them to place beneath the pad a few layers of an old soft linen 
 handkerchief, which can be changed as circumstances require. 
 
 " The surgeon may direct to whom to go and the kind of truss 
 best adapted to the case; but after all, so much depends on the 
 right application and nice adaptation that no one should be 
 patronised or allowed to apply trusses but the most experienced ; 
 and if lie has made this affliction a life study, and has had 
 
248 
 
 HERNIA. 
 
 the advantage of a medical and surgical education, so much tho 
 better for the patient. 
 
 " The cuts in this work illustrate only a few of the many kinds 
 of trasses, all of which have had their clay as ' patent trusses/ 
 but are now common property and subserve a general good 
 purpose. (Fig. 60.) 
 
 Fio. 60. 
 
 Single Trench Style or Long Pad. 
 
 " The French style of truss is a popular truss. It has a light 
 elastic spring and a soft stuffed pad. . It affords gentle but firm 
 support to the hernial rings and the lateral muscles, and for 
 persons of either sex advanced in life, or of delicate health, it 
 serves an admirable purpose. It is strongly recommended for 
 
 Fro. 61. 
 
 Double French Style. 
 
 wear after the operation by injection until the parts become 
 firmly united. (Fig. 61.) 
 
 " The Eatchet truss is emphatically the working man's truss, 
 for its construction, strength of spring, and its adaptability. It 
 is the truss generally sold to the country druggist, because it 
 
TRUSSES. 249 
 
 meets more wants than any other, and because of its easy 
 applicability. Discretion ought always to be used. 
 
 "Take the case of a porter with a bad Scrotal Hernia, who has 
 to shoulder a Saratoga trunk and carry it to the fourth story of 
 a mammoth hotel. He must have a truss that will meet every 
 demand of His case. The same is true of an express-man, ever 
 handling heavy boxes and goods. (Fig. 62.) 
 
 "The Ball and Socket truss. has been for many years a popular 
 truss, and will always take its place among the good appliances. 
 It seems to be the happy medium between the French style and 
 the Hatchet truss. The ball and socket movement to the pad 
 allows the truss to become self-adapting to any position of 
 
 Doublo Spiral Spiing Pack 
 
 the body, such as stooping, mounting a ladder, &c. It has a 
 light flexible spring, is capable of good work, and gives great 
 satisfaction to those who use it. 
 
 " Umbilical trusses may be mentioned. We will begin with 
 the treatment of infants. If our nurses were thoroughly edu- 
 cated, and applied a suitable bandage at the first dressing, the 
 truss-maker's services would rarelv ever be needed. Lidit steel 
 
 V O 
 
 springs covered with soft leather, with a small convex pad, may 
 serve a good purpose; but we find a better substitute in a small 
 flat pad (Fig. 63) a little larger than a silver dollar, with a 
 small convexity in the centre. It should not be too convex or 
 pointed, as that would tend to open rather than contract the 
 orifice. It will give a gentle pressure like the human thumb, 
 
250 
 
 HEKNIA. 
 
 hold the Hernia, allow the ring to contract and entirely cure 
 the difficulty. This pad may have an elastic band passing 
 round the body, with leather ends, to be secured to two sm,l! 
 nobs on the front pad. Great care should I e exercised in no'. 
 
 Child's Umbilical Celt, elastic. 
 
 stretching the elastic more than just enough to keep the appli- 
 ance in its place (Fig. 64). In the adult we find the most dis- 
 tressing cases of Umbilical Hernia in obese women, many of 
 them the size of an infant's head. Steel spring trusses as a 
 general thing do not meet these cases. The best thing for such 
 cases is a wide French twilled drilling abdominal supporter, say 
 eight or ten inches wide in front, to fit and support the entire 
 
 Fig. C4 
 
 Adult Umbilical Truss. 
 
 abdomen, passing around the body, and fastened on the sides 
 with four elastic straps and buckles. The next step is to have 
 a large centre pad, to suit the case, stretched to the inner side, of 
 the supporter. The pressure is controlled by the elastic side 
 straps. 
 
TRUSSES. 251 
 
 " There are, of course, many good and useful kinds of trusses 
 not mentioned. My object has been to point out a few only 
 that can safely be relied upon. In cases of inguinal and 
 femoral rupture there is one principle necessary for a good truss, 
 viz. — the inward and upward, or in other words the lifting 
 power of the pad. As the inguinal and femoral rings are 
 always above the pubic bone the pads should be so adapted as 
 to cover the rings securely, always above the bone. Although 
 there may be some exceptions to this general rule, they are so 
 rare that at this time we will not stop to mention them, as my 
 sole object is to give a few practical hints how to meet a want 
 or an emergency until the time shall come when all shall be 
 convinced that surgery Juts provided in the cure by injecting 
 the hernial rings a substitute for tncsses and cqjpttances, and until 
 those who are afflicted shall come and be thus healed of their 
 distressing malady. " 
 
BIBLIOGRAPHY. 
 
BIBLIOGRAPHY. 
 
 Agnew, D. Hayes, Surgery. Last Edition. 
 Arnaud, On Hernias, 1748. - 
 
 Mem. de Chir. 
 
 Mem. de Chir. Paris, 1743. 
 
 Observations sur plusieurs hernies 
 
 B. 
 
 Bell, C. Surgical Observations. Part II. London, 1816. 
 Birkett, John, in Holmes' Surgery. 2nd Ed. Vol. IV. 
 Boinet, De la Cure radicale des Hernies. Paris, 1839. 
 Brendel, De Herniarum Natalibus. 
 Breschet, G. Considerations sur la Hernie Femorale. 
 
 Bryant, Thomas, Analysis of 126 cases of Hernia followed by death* 
 Guy's Reports, 1856. Vol. II. 
 Clinical Surgery. Part III. 
 
 0. 
 
 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, &c. Phil. 1837. 
 Chopart et Desault. Parisian Surg. Journal. 
 Cloquet, J. Recherches Anatomiques sur les Hernies. 1817* 
 Colles, A. Treatise on Surgical Anatomy. Part I. 
 Cooper, Sam. Surgical Dictionary. 8th Ed. 
 Cooper, Astley, Anatomical and Surgical Treatment of Inguinal and 
 
 Congenital Hernia. Folio. London, 1804. 
 The Anatomical and Surgical Treatment of Crural and Umbilical 
 
 Hernia. 1807. 
 
256 HERNIA. 
 
 D. 
 
 Darrah, William E. Drawings of the Anatomy of the Groin. Folio* 
 
 Phil. 1830. 
 Demaux, De, L' Evolution du Sac Hernaire. 
 
 Ann. de la Chir. Francaise ^trangere. 1842. Tome V. 
 Dowell, G. on Hernia. 
 
 E. 
 
 Erichsen's Surgery. Edited by Brinton. 
 
 F. 
 
 Franco, P. Traite* de3 Hernies, &c. Lyons, 1561. 
 
 G. 
 
 Garengeot, Sur Plusieurs Hernies Singulieres. Me*m. de l'Acad. de Chir* 
 
 1743. Tome II. 
 Gant, Science and Practice of Surgery. 
 Gay, On Hernia. 1848. 
 
 Gerdy, Cure Radicale de la Hernie par Invagination. 
 Gerdy, P. N. Remarques et Observations sur les Hernies. Arch. gen. do 
 
 Med. 1836. 2 Serie. Tome X. 
 Gibson's Surgery. 
 Goldschmidt, Practische Erfahrungen iiber die Behandlung und Heilung 
 
 der Unterleibs-Briiche. 
 Goursand, Sur la Difference des Causes de l'Etranglement des Hernies. 
 
 Mem. de l'Acad, de Chir. Tome IV. 
 Goyrand, Sur les Hernies des Enfants. Presse med. 1837. 
 
 Clinique Chir. Paris, 1871. 
 Gross, Surgery. Vol. II. 
 Gu&in, J. Cure Radicale des Hernies par la M&hode sous-cutanee. Aim. 
 
 de Chir. Franchise et Etrangere. Paris, 1842. Tome V. 
 Guntz, J. G. Observations Anatomico-Chirurgicarum de Herniis. Libellus, 
 
 Leipsic, 1744. 
 Prolusio Invitatoria in qua de Entero-Epiplocele agebat. Leipsic. 
 
 1746. 
 Guy's Reports. 1842. 
 
 H. 
 
 Haller, Opera Minora. 
 
 Hammen, De Herniis. Lugd. 1581. 
 
 Heaton, George, The Cure of Rupture, Edited by J. Henry Davenport. 
 
 Boston, 1877. 
 Heister, Instit. Chirurg. et de Hernia' Incarcerata Suppurata non semper 
 
 lethali. 
 
BIBLIOGRAPHY. 257 
 
 Hesselbach, F. 0. Disquisitiones Anatomico-pathologicaa de Ortu et Pro- 
 gressu Herniarum Inguinalium et Cruralium. Wiirzburg, 1816. 
 The original edition was published in 1806. 
 Besclireibung und Abbildung eines neuen Instrumentes sur Sichern 
 Endeckung und Stillung einer beidem Bruchschnitte entstandenen 
 gefahrlichen Blutung, 1815. 
 Die Sicherste Art der Bnichschnittes in der Leiste, 1819. 
 Hewett, P. Med. Chir. Trans. 1844. 
 Hey and Leeds, Infantile Hernia. 
 Hey's Practical Observations. 3rd Edition. 
 Hildanus, F. Cent. 5, Obs. 54. 
 Disputationes Chir. 
 De Herniis Congenitis, 1749. 
 Herniarum Adnotationes, 1755. 
 History of Rebellion, U. S. of America. Surgical Vol. Part IL 
 Hoin, Essai sur les Hernies rares et peu Connues, 1767. 
 Hutchinson, London Hospital Report, 1865. 
 
 J. 
 
 Jalade-Lafond, Considerations sur les Hernies Abdominales, sur les 
 
 Bandages. Paris, 1832. 
 Memoire sur une nouvelle espece de bandage a pelote medicamenteuse 
 
 pour la cure radical e des Hernies. Paris, 1836. 
 James, On Hernia, .1859. 
 
 K. 
 
 Key, Aston, On Hernia, 1833. 
 
 Kingdon, Mechanism and Causes of Hernia. 
 
 Med. Chir. Trans. 1864. Vol. XL VII. 
 Kok, P. S. De Herniis, 1782. 
 
 L. 
 
 Labrey, D. J. Observations sur les Hernies accompagnees d'autres maladies 
 graves. Journ. Compl. der Diet, des Sci. Med. Paris, 1819. Tome V. 
 Langier, Diet, de Med. En 30 Vols. Paris, 1837. Tome XV. 
 Lassus, Pathologie Chir. Tome I. 1809. 
 
 Langenbeck, C. J. M. Commentarius de Structura Peritonei, Testiculorum 
 Tunicis, eorumque ex Abdomine in Scrotum Descensu ad illus- 
 trandam Herniarum indolem, 1817. 
 Bibl. Eur die Chir. Band IV. 
 Neue Bibl. Band II. 1819. 
 Lawrence on Ruptures. 3rd Edition. 
 Le Blanc, Nouvelle Methode d'operer les Hernies ; avec un Essai sur les 
 
 Hernies par M. Hoin, 1767. 
 
 Le Drau, Traite des Operations de Chir. 
 
 Observations de Chir. Obs. 57. 
 
258 HERNIA. 
 
 Le Quin, Le Chirurgien Herniaire. Paris, 1697. 
 
 Lionet, De l'Origine des Hernies. 
 
 Littre, Observation sur une Nouvelle Espece de Hemie. M6m. de l'Acad. 
 
 des Sciences, 1700. 
 Sur une Hernie Rare. Same Work, 1714. 
 Louis, Reflexions sur l'Operation de la Hernie. Mem de l'Acad. de Cliir. 
 
 Tome IV. 
 Luke, Med. Chir. Trans. Vols. XXVI and XXXI. 
 
 M. 
 
 Malachgeiger, Kelegraphia sive Descriptio Herniarum cum earundem 
 
 Curationibus, tarn Medicis quam Chirurgicis, 1631. 
 Malgaigne, Lecons de Clinique sur les Hernies, 1841. 
 Marshall, Henry, Contribution to Statistics of Hernia among Recruits for 
 
 the British and Conscripts for the French army. Edin. Med. and 
 
 Surg. Journal, 1838. 
 Medical-Chirurgical Trans. 1859. 
 Medical Observations and Inquiries. 
 Moreau, Sur les Suites d'une Hernie Oper^e. Mem. de l'Acad. de Chir. 
 
 Tome III. 
 Mery, Mem. de l'Acad. des Sciences. Paris, 1701. 
 Monro, A. Crural Hernia, 1803. 
 
 Morbid Anat. of Human Gullet, Stomach, and Intestines. Edin. 
 
 1811. 
 
 N. 
 
 Naphey's Surgical Therapeutics. 
 
 P. 
 
 Pelletau, Clinique Chir. Tome III. 
 
 Petit, J. L. Traite des Mai. Chir. Tome II. 
 
 Peyronie, Observations, &c, sur la Cure des Hernies avec Gangrene. 
 
 Mem. de l'Acad. de Chirurg. Tome I. 
 Pott's Works, by Earle. Vol. II. and III. 
 
 R. 
 Ravin, F. P. Memoire sur la Theorie et la Cure Radicale des Hernies. 
 
 Arch. Gen. de Med. 1831. Tome XXVII. 
 Riege, C. Ueber die Aetiologie der Treisten und Schenkelbriiche. Berlin, 
 
 1878. 
 Richerand, Diet, des Sci. Med. En 60 Vols. 1827. Tome XXI. 
 Richter, A. G. Traite des Hernies, trad, de l'Allem. Par J. C. Rougement. 
 
 Bonn, 1784. 
 Richter, E. Zur Lehre von der Unterleibsbriichen, 
 Ronstan, De quelques modes de guerisons naturelles, etc. Journal de 
 
 Chir. de Malgaigne. Paris, 1843. Tome I. 
 
BIBLIOGRAPHY. 259 
 
 Radtorfler, F. X. Abhandlung iiber die einfachste und Sicherste Opera- 
 
 tions-methode EmgesperrterLeisten-und-Schenkelbniche. 2 Band e. 
 
 WkD, 1808. 
 
 S. 
 Sabatier. Medecine Operatoire. Tome I. 
 Sanson, L. J. Diet, de Med. et de Chir. Pratiques. Paris, 1833. Tome 
 
 IX. 
 Scarpa, Antonio, sull 'ernie Memoire Anatomico-Chirurgiche, 1819. 
 Trans, into French by Cayol, 1812. 
 
 „ „ English by Wishart Edin. 1814. 
 Schmucker, Yermischte Chir. Schriften. 
 Schreger. B. G. Versiiche Chir. Tome 1. 
 
 Yersiiche zur Yervollkomming der Herniotomie. Niirnberg, 1818. 
 Seiler, B. G. Observationes nonnullse Testiculorum ex Abdomine in Scrotum 
 
 descensu et Partium Genitalium Anomalis, 1817. 
 Sharp, S. Operations and Critical Inquiry. 
 Simon F Guerison Radicale des Hernies, 1841. 
 Smith, Henry H. Surgery. Vol. II. 
 Smith, Stephen, Operative Surgery. 
 Soemmering, Uber die Ursache der Bruche am Banchen und Becken, 
 
 ausser der Xabel und Leistengegend, 1811. 
 Stephens, On Obstructed Hernia, 1829. 
 Sully, Surgical Operations. 
 Symes, J. Fascia of Groin in Edin. Med. Jour. No. 81. 
 
 T. 
 Thieert, Des Diverses Methodes Operatoires pour la Cure Radicale de 
 
 Hernies, 1841. 
 Travers, B. Injuries of Intestines, 1812. 
 Trustedt, F. L. De Extensionis in Solvendis Herniis Cruralibus Incarceratia 
 
 prae Incisione Praestantia, 1816. 
 
 V. 
 
 Velpeau. Edited by Mott. Vol. III. 
 
 Verdier, P. L. Traite Pratique des Hernies. Paris, 1840. 
 
 W. 
 
 \Taed, On Strangulated Hernia, 1854. 
 
 Walther, De Hernia Cmrau, 1820. 
 
 Wheelwright, J. Hernia through a laceration of Diaphragm in Med. Chir. 
 
 Trans. Vol. VI. 
 Wishart, Treatise on Hernia. 
 Wood, John, On Rupture, 1863. 
 
 Application of Trusses to Hernia. London, 1878. 
 Wrisberg, Comment. Reg. Societ. Gotting, 1778. 
 
 s 2 
 
t26G 
 
 IIERXIA. 
 
 PERIODICAL LITERATURE. 
 
 G. Elder. Notes on three Successful Cases of Herniotomy. London 
 Lancet, 1878, 11, 657. 
 
 H. Hancock. Remarks on Hernia and Diseases Simulating it. Londoa 
 Med. Times, 1878, 11, 514 : 543: 597 
 
 M. Kempf. Operation for Radical Cure of Right Reduc. Inguin. Hernia 
 Louisville Med. New-, 1878, VI. 215, 217. 
 
 Mabbox. (Strangulated Hernia.) Rev. de Mim. De Med. mil. Par. 
 1878, XXXIV. 461-467. 
 
 Radical Operation elner Kindshopfgrossen Freien Rechtsseitigen Leisten- 
 Heraie. Prager Med. Wochenschrift, 1878, 111, 434. 
 
 S. Stevenson. Three Cases of Hernia Reduced by Unusual Methods. 
 Med. & Surg. Reporter, 1878, XXXIX. 373. 
 
 W. J. Tivy. Successful Case of Wood's Operation. Brit. M. J. 1878, 
 11, 559. 
 
 Braithwaite's Retrospect, Jan. 1879, p. 137. 
 
 (Officinal Alcohol as a Stimulant. Med. & Surgical Reporter, Aug. 9, 
 1879.) 
 
 Strangulated Hernia relieved by stretching the Abdominal Rings. Ibid, 
 Oct. 18, 1879. 
 
 Strangulated Hernia treated by New Method. Ibid, Oct. 25, 1879. 
 
 Schwalbe of Germany used Ethyiic Alcohol. See No. 61, 1879, of the 
 Algm. Med. Central Zeitung, Berlin. 
 
 A FEW OF THE OPERATORS ON HERNIA. 
 
 OLD METHODS. 
 
 Schmuker. 
 L an gen beck. 
 Richter. 
 L'Estrange. 
 
 Petit in 1718. 
 
 Rareton in 1750 revived Petite 
 
 method. 
 Franco, 1561. 
 
 MODERN METHODS. 
 
 Schuh. 
 
 Bel mas. 
 
 Signoroni. 
 
 Gerard 
 
 Baron Linten of Brussels. 
 
 J. Birkett. 
 
 T. Bryant, 
 
 F. H. Hamilton. 
 
 Sir A. Cooper. 
 
 Sir W. W. Fergusson. 
 
 G. Pollock. 
 
 T. Holmes. 
 
 C. Heath. 
 
 A. Scarpa. 
 
 Frorieps. 
 
 C. Dowell. 
 
BIBLIOGRAPHY. 261 
 
 PLUGGING AND INVAGINATION. 
 
 Gerdy, Wurtzer, 1838, followed by Rothmund in Munich and Sigmnnd 
 in Vienna, brought to this country by Spencer Wells in 1854, and 
 advocated by Redfern Davies and others. 
 
 D. Hayes Agnew. Armsby. 
 
 Mosmer. Riggs. 
 
 LIGATURE. 
 
 John Wood of London (King's College Hospital.) 
 
 SCARIFYING THE NECK AND COMPRESSION. 
 
 Alphonse Gue*rin. 
 
 ACUPUNCTURE. 
 
 Bonnet of Lyons. 
 
 HARE-LIP SUTURE. 
 
 Proi 8. B. Beckwith (Homeopath.) of Cleveland 0. 
 
 SUBCUTANEOUS SUTURE WITH SILK BRAID, 
 
 Thomas Wood of Cincinnati, 0. 
 
 INJECTION. 
 
 VeTpeatu Woogencraft. 
 
 Joseph Pancoast Bowman of Kentucky, 
 
 Geo. Heaton. Schwalbe. 
 
 W. H. Roberta. Wm. Janney 
 
 And many others. 
 
APPENDIX. 
 
APPENDIX. 
 
 After I had devised my instrument for Hernia and applied it in 
 practice, I soon ascertained that this spiral-shaped needle passed 
 with such ease through the tissues, that it could be applied to a 
 number of surgical instruments with marked advantage. I began 
 to experiment upon a needle for aspirators ; being of the same 
 
 Fig. 66.— Aspirating Needle. 
 
 Bpiral form they easily penetrate every kind of tissue, muscle, 
 ligament, tendon, &o, and remain at any depth and position where 
 we place them. As I have said in my work on Hernia, they are 
 very useful in tapping all deep-seated abscesses, effusions about the 
 pericardium, knee-joint, &c. They are made from the smallest size 
 of the aspirator in general use, revolving once in one half an inch 
 to those of No. 10 revolving once in two inches, and can be used as 
 a trocar for hydrocele, if desired. They can be adjusted upon an 
 ordinary Davidson's syringe, or upon the common aspirating 
 syringe. 
 
 Fio. 67.— Trocar. 
 
 Trocars, made of the ordinary sizes with flat oval and spirally- 
 twisted point, revolving upon a staff, which may be withdrawn 
 
266 
 
 HERNIA. 
 
 after the introduction or the point to open as on the tubes for stone 
 in bladder, below described, will be found very useful in paracen- 
 tesis thoracis, because, the point being flat, they pass through the 
 intercostal spaces very easily and resist expulsion by any muscular 
 contraction. They will also be found useful in ascites, and in 
 
 Fio. 68.— Uterine Sound. 
 
 tapping ovarian dropsical cysts, since they run less danger of tear- 
 ing the membrane of the cyst than do ordinary trocars or of the 
 overflow of the cystic fluid into the abdominal cavity. 
 
 The same kind of a point applied to an ordinary uterine sound 
 will be found very useful in treating uterine diseases ; applied to a 
 malleable shaft it will be also useful in probing fistula in ano ; 
 attached to an ordinary probe, and tipped with a drop of unglazed 
 
 Fio. 69. — Catheters with vermicular point. — Sound for urethra. 
 
 porcelain, will readily detect the presence of lead in probing gun- 
 shot wounds, being scratched and blackened by the foreign body ; 
 or for a probe in general use for the field or pocket case. 
 
 The same combination of the screw and wedge has been applied 
 to sounds and catheters, and by its peculiar spiral motion it avoids 
 to a very great extent the friction met with in using the ordinary 
 sound and dilator of Otis and others in common use, since but a 
 
APPENDIX. 267 
 
 small portion of the urethral canal is in contact with the instru- 
 ment at any one time. It will be seen that it partakes of the 
 spiral twist in common with my new aspirator and syringe for 
 injecting hernia. This new idea in surgical instruments was 
 suggested to me while treating an old and difficult stricture 
 last spring. I found that I could introduce the ordinary dilator 
 with much greater ease and with far less pain by giving it a twist- 
 ing motion. I think you will find, if any of you have under 
 treatment long and tortuous strictures, that this dilator will glide 
 through with great ease, and will fully accomplish its»purpose with 
 much less pain than the sounds in general use. 
 
 These instruments can be obtained of the varied sizes which are 
 in general use, American or French scale. 
 
 Case I. On January 12th Mr. applied to me with a very 
 
 severe stricture of several years' standing. He was unable to pass 
 a stream of water larger than a small knitting-needle. It was im- 
 possible to introduce the smallest sound through the stricture with- 
 out the greatest pain, and it had been said by several physicians 
 who had attempted it that, owing to the extent of the contracted 
 and strictured canal, it would be impossible to pass again a catheter 
 or sound. I passed this instrument which I now show you with 
 such little pain to the patient that he asked if I had really pene- 
 trated through the stricture. Upon learning that I had, he said he 
 never had one introduced so easily and successfully before.^ 
 
 The vermicular catheter is in shape like the catheter in common 
 use except at its point. This point is about one and three-tenths 
 centimetres long, of the same peculiar wedge shape, and revolves in 
 precisely the same manner as the vermicular sound and dilator. 
 On account of its shape and power of revolving it is passed through 
 and made to dilate the urethra with very little friction, and of 
 course with far less difficulty, and with little or no pain when com- 
 pared with the usual catheters. 
 
 Case II. Mr. B , aged sixty-six, has had an enlarged pros- 
 tate, and for many years has passed his water with great difficulty, 
 and in a very small and irregular stream. The parts were so com- 
 pressed by this enlarged gland that it was impossible to introduce 
 a common catheter or a soft rubber bougie, No. 9 French or No. 6 
 
208 
 
 HEKNIA. 
 
 -American scale, yet this vermicular catheter passed with perfect 
 ease and without pain into the bladder. It has to be used only 
 once to show its superiority over every other catheter in the ease 
 and freedom from pain with which it penetrates the strictured parts 
 during catheterisation. 1 These catheters are made for both male 
 and female. 
 
 They are introduced in the ordinary way, the staff being held 
 firmly in the hand ; but the withdrawal should be gradual, little 
 force being used in order that the mucous membrane may not close 
 around the vermicular point by any possible means. 
 
 In the many diseases of the uterus requiring dilation of the 
 cervix and uterine canal, a dilator made to revolve like the sounds 
 above described, but larger and somewhat thicker through its 
 centre, and fastened to an adjustible handle, will be found equally 
 
 Fio. 70.— Bigelow's. 
 
 Fia. 71. — Thompson's curve. 
 
 advantageous. These dilators should vary in size from 10 to 30, 
 and can be made of white metal or hard rubber. 
 
 The same shaped dilators, but of larger size, varying from 20 to 
 60, can be used for dilation of the stricture of the oesophagus and 
 anus. The handles should be about sixteen inches long and two 
 in number, one straight, the other of the proper curvature, for 
 insertion into the oesophagus. 
 
 A cap made in this spiral form and adjusted over and upon the 
 end of Sir Henry Thompson's, or the Bigelow tube, used for the 
 removal of debris after the operation of lithophaxy will be found 
 to allow a much larger tube to be passed through the neck of the 
 bladder and urethra, and with far greater ease than would be 
 
 1 Mr. Bryant demonstrated this at Guy's Hospital, where he used these 
 instruments in two cases of stricture, in the presence of a number of 
 gentlemen, using the few instruments which I happened to have with me. 
 
APPENDIX. 
 
 269 
 
 possible with tlie ordinary instrument, even of a smaller size. 
 After the tube has entered the bladder the cap is opened off from 
 the end by a concealed spring in the hinge, and then from its 
 peculiar shape can be used as a ladle to gather up the debris which 
 is to be drawn through the tube by the aspirator. If this instru- 
 ment is successful in performing all I expect it will I shall call this 
 the Thompson American Tube, in honour to Sir Henry. This is 
 made by Messrs. Weiss and Son, London. 
 
 Thus far the shape of the instruments has gone much beyond 
 my expectations in its effectual results. It allows the instru- 
 ments to be applied with great ease, very little pain to the patient, 
 and very little injury to the parts. They are manufactured, and 
 for sale by Tiemann and Co., of New York. 
 
 After devising the tube, figured below, for the removal of a 
 crushed stone from the bladder, I planned another tube differing 
 
 Fio. 72. 
 
 in its details. It will be remembered by those members of the 
 British Medical Association who saw my various instruments, that 
 this particular tube had a tip, one half of which was thrown back, 
 by a spring in the hinge, after it had entered the bladder, so as to 
 allow the crushed stone to pass freely through the tube ; the other 
 half being unjpinted, and serving as a scoop to take up any 
 particles remaining in the bladder. The improved tube has the 
 same tip, and there is a flat steel wire attached to the jointGt* por- 
 tion, passing through the tube and having a screw cut upon its 
 free end so that the end may be opened or closed at will by means 
 of a thumb-screw. By this means pieces of stone may be caught 
 and removed, and the same principle may be used for the removal 
 of polypi ; or for the removal of shot or bullets from the wounds 
 of the chest or abdomen, having the advantage over the common 
 
270 HEKNIA. 
 
 forceps that the bullet will readily fall into the spoon-like jaws 
 and be withdrawn with great ease. By varying the size it can be 
 used for the nasal cavities or the ear, and by passing a piece of 
 cotton or sponge through the canula any medication desired may 
 be applied to the internal parts. The instrument will be particularly 
 useful in uterine cases and ulcerations of the rectum, as being closed 
 it enters very smoothly and easily, and allows the medication to be 
 thoroughly applied to the interior of this organ, the mother of so 
 many painful ills, many of them indeed real, but many imaginary 
 either to physician or patient. 
 
 The same principle may be used for extracting foreign bodies 
 from the oesophagus and bladder ; and by placing mirrors in tho 
 tube it will serve as a laryngoscope, the un jointed half of the tip 
 carrying the first mirror. 
 
 In calling attention to these instruments with either revolving 
 or fixed vermicular points I would lay claim to them all as being 
 entirely original with me, and as such I give them freely to tho 
 profession, for proper use, wherever they can be applied to alleviate 
 human suffering, and all I ask of those who may use them as 
 already made or as modified, is that they may retain my name as 
 the first designer. I am led to make these remarks and suggestions 
 on account of the advice of some in the profession to patent these 
 instruments, which is very far from being my intention ; as to my 
 ideas, the profession is the last place to look for self -aggrandise- 
 ment, and I would advise any one intending to enter the profession 
 for any such personal motive to consider well before he takes any 
 steps, and choose some occupation where his motives will be more 
 highly esteemed. 
 
 I took the idea of the herniotomy knife, which I here illustrate. 
 
 Fio. 73. — Weiss's Hernia Bistoury. 
 
 from my friend Mr. Bryant's work. It is a sheathed knife, tho 
 blade of which has been serrated and slightly modified in other 
 respects by Messrs. Weiss and Son, so as to adapt it to divide 
 
APPENDIX. 271 
 
 Poupart's ligament by sawing instead of cutting, and by this means 
 avoiding haemorrhage to a very great extent. 
 
 The following formulae I find to be the best injection : — 
 
 For infants and children to the age of five, for accidental or con- 
 genital Hernia?, use the aqueous extract of oak bark of Dr. 
 Heaton's formula. 
 
 For children of five to fifteen years of age, extract of oak bark 
 distilled to the consistency of glycerine, with ten drops to the 
 drachm of sulphuric ether. 
 
 For old and long standing Hernia?, congenital or otherwise, I 
 find the latter extract of oak bark, with one drachm of absolute 
 alcohol to four of the extract, and one drachm of sulphuric ether, 
 with one or two grains of sulphate of morphia, gives me the best 
 results in my operation. 
 
 Or if we wish to vary the above, the following is a good formula 
 suitable to the large majority of cases presented for operation :— 
 
 R Fluid Ext. White Oak Bark (Quercus alba), Jiv. 
 
 Reduced by distillation to 5i. 
 
 Alcohol 90°, oiii. 
 
 Ether Sulph. 5ii. 
 
 Morphia Sulph. gr. ii. 
 Sig. injecto 10 to 25 drops. 
 
 heaton's formula. 
 
 R Fluid Ext. White Oak Bark, |i. 
 
 Solid Ext. White Oak Bark, gr. xiv. 
 
 Morphia Sulph. gr. ii. 
 Sig. injecto 8 to 10 drops 
 
 The inclosed case of instruments belong to the late Geo. Heat on, 
 M.T)., of Boston, Mass., U.S.A., and contain all the instruments 
 used by him in his treatment cf Hernia. At his decease they were 
 given to me by his wife and daughter, and at my suggestion are 
 placed in the Museum of the Royal Chirurgical Society, to per- 
 petuate his memory by ever remaining there, amongst the many 
 other instruments devised for the relief of human suffering by those 
 whose names are inscribed upon the roll of honour of this highly 
 
272 
 
 HERNIA, 
 
 respected and venerable society. In behalf of the above-mentioned 
 wife and daughter, I present this little case of instruments to the 
 society, to be for ever kept and exposed to view with similar 
 objects ; and in accordance with the wishes of his heirs, give the 
 
 ; 
 
 Fig. 74. 
 
 (a)— Instrument for injecting the solid extract of Oak Bnrk. which he seldom used. 
 
 (fe)— Syringe for injecting the fluid extract of White Oak Bark, with which he- ejected -the 
 
 most of his cures 
 (c. d. e)— Instruments used in the operation of variocele 
 (/)— An instrument which acted as a scarificator, and at the same time was rseii to introduce 
 
 the solid extract. 
 
 following short notice of the instruments and operation used and 
 devised by Dr. Heaton for the cure of Hernia by subcutaneous 
 injection of the fluid extract of White Oak Bark (Que revs alba), 
 strengthened by the addition of fourteen (14) grains of the solid 
 
APPENDIX. 273 
 
 extract of Quercus alba to the ounce of fluid. His method was to 
 inject eight (8) or ten (10) drops of this mixture into the hernial 
 rings, and by this means, for -more than forty (40) years, he was 
 successful in curing a vast number of all kinds of Hernia? affecting 
 persons of all nationalities, classes, and ages. 
 
 Dr. Heaton was born in Thetford, Vermont, U.S.A., in 1809. 
 His parents were natives of that state, and were of pure English 
 descent. George went to the common Town School, and by dint of 
 hard work in teaching and study fitted for college. He graduated 
 as M.D. from Dartmouth Medical College in 1831, but I find by the 
 records that he passed his examinations satisfactorily in 1830. He 
 first practised his profession in Alton, Illinois, but soon went to St. 
 Louis, Missouri, where he resumed his operation for Hernia, which 
 he had first taken lip in Alton. We next find him in Boston, in 
 1842, struggling to develop his operation, and to interest the 
 profession in it. Being coldly treated by the profession there, he 
 went to London, where he met with a cordial reception, and gained 
 the attention of the profession. Sir William Fergusson, and others, 
 took him kindly by the hand, and introduced him to the profession 
 of London, and he was induced by them to operate, successfully, in 
 the various hospitals. He was highly honoured by them, and made 
 a member of the Royal Chirurgical Society, and of the Westminster 
 and London Society. Crossing over to Paris, he was well received 
 by the faculty there, and made a member of the Parisian Medical 
 Society, and after a short stay here he returned to Boston. He 
 again began to operate, with his courage and strength renewed by 
 his success in Europe, and he continued his work till near the time 
 of his death, in July 1879. His success was very great, as he 
 effected cures in hundreds of cases, as many now living can testify. 
 
 He married, quite early in life, Miss M. Emerson, the daughter 
 of Dr. Emerson, the honoured president of the Massachusetts 
 Medical Society. This marriage was blessed by the birth of 
 children. Charles, his son, took his degree of A.B. at Harvard 
 University, and the degree of M.D. at Harvard Medical School. 
 He served with honour as Surgeon in the U.S. Army, but during 
 this service he contracted Bright's disease, which caused his death 
 some eight (8) or ten (10) years before his father. His second 
 
 T 
 
274 HERNIA 
 
 child, Laura E., a lady of culture and refinement, married an 
 educated and wealthy gentleman, by the name of Sturtevant, of 
 Boston. 
 
 Dr. Heaton, after the loss of his darling and promising son, 
 whom he had fondly hoped would be his staff in his old age, was 
 afflicted with heart disease, caused by grief; and at the age of 
 seventy died of cystitis in July 1879, leaving a widow and one 
 daughter, and many patients and friends, to mourn his loss. He 
 died respected and honoured, leaving no little wealth, mostly 
 accumulated by successful operations in various branches of 
 surgery. 
 
APPENDIX TO AMERICAN EDITION. 
 
 After devoting much thought and study to the subject of Hernia, 
 the author would take this opportunity to state the following con- 
 clusions : In small herniae 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 I have given are carefully followed out in every 
 particular. In very large herniae, or those of long standing, the 
 cure will be more difficult of accomplishment, and we cannot 
 expect a permanent cure so confidently as in the simpler cases of 
 small and recent herniae. The cure can be accomplished only by 
 impressing 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 truss. I would add that my experience 
 with various instruments and injecting fluids leads me to believe 
 that the use of the instrument and mixture devised and recom- 
 mended by the author, together with the various improvements and 
 modifications^ suggested in this work, will, in all cases, give the 
 greatest freedom from danger and assurance of success in the 
 treatment of Hernia by the subcutaneous method of Dr. Joseph 
 Pancoast, as practised for many years by the late Dr. George 
 Heaton. 
 
 These large and old herniae 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 examined from time to time, so 
 that successive irritation and inflammation 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 
 
ii APPENDIX TO AMERICAN EDITION. 
 
 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 author, we inject only a little fluid, use only a cloth 
 bandage and discharge the patient after a few days have elapsed 
 as cured, we shall be most certainly disappointed. 
 
 To facilitate the operation still more I would present to your 
 attention the following remarks upon bandages : — 
 
 BANDAGES. 
 
 As the bandages and compressing pads are a very important 
 factor in obtaining satisfactory results in this operation, a few 
 words upon this point seem to be necessary. 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 during 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 long, 
 and 3 or 3 1-2 inches wide, and of the thickness usually in use. 
 
 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 maintained, as we 
 pass the bandage around the body twice or more. 
 
 The elastic webbing is too thick and bungling to be adjusted 
 well, so that I have abandoned its use in these operations. The 
 perineal bandage, I prefer, should be made of cotton flannel, as 
 it is much softer. Those who prefer linen will find that a little 
 cotton rolled within it will make it far easier to the patient. 
 
APPENDIX TO AMERICAN EDITION. 
 
 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 satisfactory 
 compress. 
 
 A NEW INSTRUMENT. 
 
 Being desirous of having a lighter and less com- 
 plicated instrument for performing the operation 
 of subcutaneous injections, I have devised the in- 
 strument here figured. This was made for me by 
 Messrs. Codman and ShurtlefF of Boston, and 
 Milliken and Down of London. It is equally as 
 effective as the one figured and described on page 
 157, and is not a quarter part 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 hypodermic syringe, regulaets, 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 previoi s instruments. 
 
APPENDIX TO AMERICAN EDITION. 
 
 From information which I have obtained from records and 
 documents, and other sources, I am convinced that the honor of 
 the discovery of the subcutaneous operation and method of curing 
 Hernia, by injection, belongs rightly to my esteemed and dis- 
 tinguished fellow-countryman, Professor Joseph Pancoast, 
 M.D., at that time Surgeon in the Philadelphia Hospital, who 
 operated on thirteen cases of Hernia, in 1836, using Lugol's 
 solution of iodine, or tincture of cantharides, drams ss. Vide 
 page 283 of the " Treatise upon Operative Surgery," by Joseph 
 Pancoast, M.D., 1844. The instrument there figured and described 
 is similar to the one used by Dr. Heaton in his first operation, in 
 1840-41. Vide present work, page 272, fig. 74a. Dr. Heaton 
 experimented with Lugol's solution of iodine, tincture of can- 
 tharides, essential oils, and various other liquids; but soon 
 abandoned these for the extract of Quercus alba, which he 
 injected with a syringe of his own invention. Vide page 272, 
 fig. 74 b). 
 
 In the present work I have given to Dr. Heaton the honor and 
 credit of being the originator of the method of injection for the 
 cure of Hernia ; but I am convinced that the first operator who 
 used this method was Professor Joseph Pancoast, and to him 
 belongs the honor of originating it. Dr. Heaton, by experimen- 
 tation, found a fluid more suitable for the purpose than that used 
 by Professor Pancoast. 
 
 In honor of Professor Pancoast, who originated the method of 
 injection, I would most respectfully suggest the propriety of calling 
 the operation the " Pancoast Operation for the Cure of Hernia by 
 the Subcutaneous Method." 
 
ERRATA. 
 
 Page 271, 4th line from bottom, read Museum of Royal College 
 of Surgeons. 
 
 Page 273, 16th line from bottom, read Royal Medical and 
 Chiruro-ical Society. 
 
INDEX. 
 
 Aetiomen, remarkable cure of wounded, 
 
 137 
 Accidental Hernial, 37 
 Acupuncture as a cure, 105 
 Adhesions, 75 
 After treatment, 172 
 Agt; as affecting Hernia, 44 
 
 ,, most suitable for injection, 177, 181 
 Agnew's instrument, 103 
 
 ,, method of cure, 103 
 Ellis' hcrniotonic, 220 
 American Medi.al Association, review 
 of the report of the Committee of 
 the, 5 
 Anatomical measurements, sliding and 
 
 revolving rule for taking, 60 
 Anatomy of Hernia, 48 
 
 „ Femoral, 66, 160 
 
 „ Inguinal, 51, 160 
 
 „ Strangulated, 48 ct seq. 9 
 
 86 
 ,, Umbilical, 43 
 
 Animal ligatures in surgery, 119 
 Antiseptic carbolised cargnt ligature, 
 
 operation by the use of, 114 
 Appendix, 265 
 Arteries — 
 Deep Epigastric, 57 
 Femoral, 69 
 Superficial Epigastric, C6 
 
 ,, Circumflex Iliac, 60 
 
 ,, External Pudir, 66 
 
 Artificial Anus, 232 
 Aspirating needle, 216; do. for tapping 
 hernical sac in Strangulated Hernia, 
 216 
 Author's — 
 
 Instruments for Hernia, 142, 144, 
 157 
 
 Author's — 
 
 Modification of Injection, 141, 154 
 ,, Kelotomy, 238 
 
 Operation, 134, 154, 165, 168, 170 
 „ for Femoral, 168 
 
 „ Inguinal, 165 
 
 „ Umbilical, 170 
 
 ,, Position in, 163 
 
 Treatment after operations, 172 
 
 New Herniotomy Knife, 239 
 
 B. 
 
 Bandage, the Spica, 169 
 
 Belmas' method of cure, 103 
 
 Bernard on operations for Strangulated 
 
 Hernia, 225 
 Bibliography, 255 
 Bigelow's dilator, 268 
 Birkett on Strangulated Hernia, 208 
 Bistoury, Weiss's hernia, 270 
 Bonnet's method of cure, 104 
 Bryant's Surgery, diagrams from, 82, 
 
 84 
 Bubo, 42 
 Bubonocele, 41 
 Burn's ligament, 68 
 
 C. 
 Canals — 
 
 Crural or Femoral, 69, 72 
 
 Inguinal, 56, 66 
 Carbolised catgut, on the use of, as a 
 
 ligature in Strangulated Hernia, 
 
 114 et scq. 
 Cases, reports of a few of Dr. Heaton's, 
 
 27 ; of irreducible hernia, 32 ; on 
 
 observing, 172 
 
 186 
 
276 
 
 INDEX. 
 
 Castration, 100 
 
 Catgut as a ligature in surgery, 114 ; 
 
 use of catgut amongst the ancients, 
 
 119 
 Catheters with vermicular point, 266 ; 
 
 cases illustrative of the value of the, 
 
 267 
 Causes of failure by injection, 183 
 Causes of success by ,, 134 c^ scq., 
 
 141 etseq., 163, 177, 202 
 Cauterisation as a cure, 96 
 Cerebral Hernia, 37 
 Cloquet on hernia, 71 
 Colon, hernia of the transverse, 38 note 
 Compression as a cure, 06 
 Congenital Hernia, 37, 181 
 Conjoined tendon, 54 
 Cooper, Sir Astley, his opinions on 
 
 various points connected with Hernia, 
 
 55, 59, 71, 74, 85 
 Cooper's Hernia knife, 220 
 Coverings — 
 
 Femoral Hernia, 74 
 
 Inguinal, 74 
 Cremaster muscle, 61 
 Cribriform Fascia, 67 
 Crural. See Femoral. 
 Cures — 
 
 Acupuncture, 105 
 
 Author's, 134, 141, 154 
 
 Castration, 100 
 
 Cauterisation, 96 
 
 Compression, 96 
 
 Dilation by organic plugs, 101 
 
 Dowell's, 1(7 
 
 Excision, 97 
 
 Gilded point, 101 ' 
 
 Incision, 97 
 
 Injection, 128 
 
 Ligature, 98, 114 et seq. 
 
 Position, 96 
 
 Eoyal suture, 100 
 
 Scarification, 100 
 
 Suture, 98 
 
 Wood's, John, 106 
 „ Thomas, 98 
 Cures, percentage of, 182 
 Cystocele, 42 
 
 D. 
 
 Davenport's instrument, 143 
 Davies' Kedfern ,, 102 
 
 Deep crural arch, 69 
 
 ,, Epigastric Artery, 66 
 
 ,, Fascia, 67 
 Diagnosis, 78, 79, 80, 81 
 Diagrams illustrating the different 
 
 kinds of Hernia, 82, 83, 84 
 
 Dilators, 268, 269 
 
 Diaphragmatic or Phrenic Hernia, 37 
 
 Direct Inguinal Hernia, 41 
 
 Directors, Levi's, 220 ; Kinge, do. ib. ; 
 
 Peter's, do. ib. ; Hernia, do. ib. 
 Dowell's needles, 99 ; method of cure, 
 
 9y, 107 et aeq. 
 
 E. 
 
 Encysted or Infantile Hernia, 
 Enterocele, 42 
 Entero-Epiploeele, 42 
 Epigastric Artery— 
 
 | Deep, 57 
 
 ( Superficial, 66 
 Epiplocele, 42 
 Excision as a cure, 97 
 Exoniphalos, 38 
 External abdominal ring, 56 
 External Inguinal Hernia, 40 
 „ Oblique muscle, 52 
 „ Spermatic fascia, 53 
 
 F. 
 
 Fatltre, causes of, 183 
 Falciform process, 68 
 Fallopius ligament, 52 
 Fasciae— 
 
 Cribriform, 67 
 
 Deep or Fascia Lata, 67 
 
 Intercolumnar or External Spermatic^ 
 53 
 
 Internal Oblique, 54 
 
 Propria, 71 
 
 Superficial, 66 
 
 Tran sversalis, 55 
 Femoral Arch, 69 
 
 Hernia, 42, 168, 212 
 ,, ,, Anatomy of, 48, 66 
 
 „ ,, Kelotomy in, 233 
 
 Pare form of, 212 
 ,, ,, Symptoms of, 51, 75 
 
 Femoral rupture, Gav's operation for, 
 
 234 
 Foetus, the, 49 
 
 Formation of hernial sac, 72, 73 
 French truss (double and single), 248 
 Frequency of Hernia according to 
 
 Age. 44 
 
 Kind. 43 
 
 Nationality, 47 
 
 Occupation, 45 
 
 Population, 44 
 
 Sex, 44 
 
 Side of body, 47 
 
INDEX. 
 
 277 
 
 G. 
 
 Gangkene in Strangulated Hernia, 86 
 
 Gnstrocele, 42 
 
 Guv's operation for femoral rupture, 
 
 234 
 General remarks, 175 et seq. 
 Gevdy's method of cure, 102 
 Gilded print as a cure, 101 
 Gimbernat s ligament, 52 
 
 H. 
 
 Heaton, Dp. Geo. 2, 5 et seq., 273 
 Heaton's instruments, 142, 272 
 Hepatccele, 42 
 Hernia director, 220 
 Hernia knife— 
 Cooper's 220 
 Stewart's, 220 
 Hernia, operations for, 91 
 
 ,, kinds of, best treated, 177 
 „ relative frequency of the dif- 
 ferent kinds, 43 ; according 
 to sex, 44 ; age, ib. ; popula- 
 tion, ib. : occupation, -45 ; 
 side of the body, 47 ; race 
 of men, ib. 
 ,, of Transverse colon, 38 vote 
 Hernia, history of Dr. Heaton's opera- 
 tion for the cure of, by subcutaneous 
 injection, 5 et seq. 
 Hernia, various kinds of — 
 Accidental, 37 
 Bubonocele, 41 
 Cerebral, 37 
 Congenital, 37, 181 
 Crural, 42, 232 
 Diaphragmatic, 38 
 Encvsted or Infantile, 37 
 Enterocele, 42 
 Entero-Epiplocele, 42 
 Epiplocele, 42 
 Exoniphalos, 38 
 Femoral, 42, 66, 168 
 Incarcerated. 43 
 Infantile or Encysted, 37 
 Inguinal- 
 External, 40, 77, 165 
 Internal, 41. 165 
 Irreducible, 32, 34 
 Ischiatic, 40 
 Lumbar, 40 
 Merocele, 42 
 Oblique, 40 
 Omphalocele, 38 
 Oscheocele, 42 
 Pe lineal, 40 
 Pudendal, 42 
 
 Hernia, various kinds of — 
 
 Eeducible, 43, 75 
 
 Scrotal, 42 
 
 Strangulated, 43, 8'5 et seq,, 208 
 
 Transverse colon, 38 note 
 
 Thyroid, 40 
 
 Umbilical, 38, 48, 170, 233 
 
 "Vaginal, 40 
 
 Ventral, 42 
 
 Ventro- inguinal, 42 
 Hernial sac, 40, 41, 72, 73 
 Herniotome, various kinds of, 220 
 Herniotomy. See Kelotomy. 
 Hesselbach's Triangle, 57 
 Hey's ligament, 68 
 History of operations, 186 
 Huette on Strangulated Hernia, 225 
 Hypodermic syringes, 145 
 
 I. 
 
 Ilio-ingi t ixal nerve, 52 
 Incarcerated Hernia, 43 
 Incision as a cure, 97 
 Infantile or Encysted Hernia, 37 
 Inguinal canal, 56 ; boundaries of, 66 
 ,, Hernia, 40 
 ,, ,, anatomy of, 51 
 
 ,, ,, internal, 41 
 
 ,, „ symptoms of, 51 
 
 Injection as a cure, 134 
 
 ,, as modified by author, 141, 
 
 163 
 ,, causes of failure, 183 
 ,, ,, ,, success, 134 et seq., 
 
 141 etseq., 163, 177, 202 
 Instruments — 
 Agnew's, 103 
 Allis' herniotome, 220 
 Author's, 144, 157, 239. See also 
 
 Appendix 
 Cooper's Hernia knife, 220 
 Davenport's, 143 
 Davies' Eedfern, 102 
 Dowell's, 99 
 Heaton's, 142, 271 
 Hernia director, 220 
 Janney's instrument, 132 
 Kinge hernia director, 220 
 Levi's director, 220 
 Peter's ., 220 
 " Stewart's Hernia knife. 220 
 "Wurtzer's instrument, 104 
 Intercolumnar Fascia. 53 
 Internal abdominal ring, 55 
 ,, Oblique Eascia, 54 
 Introduction, 1 
 Irreducible Hernia, 33, 43 
 Ischiatic Hernia, 40 
 
278 
 
 INDEX. 
 
 J. 
 
 Jameson's cure, 101 
 Janney on Injection, 130 
 ,, Instrument, 132 
 
 K. 
 
 Kelotomy, 217-242 
 
 Author's modification of, 238 
 „ new knife for, 239 
 
 in Crural, 232 
 
 Gay's method of, 234 
 
 Bernard and lluette's method of, 
 225 et seq. 
 
 in 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 
 
 Petit's method of, 222 
 
 Reduction in, 231 
 
 "Without opening sac, 221 
 :Kinds of Hernia, 37, 43 
 
 „ as affecting occurrence, 43 
 
 „ best treated, 177 
 Kingdon's Tables of Hernia, 46 
 Kinge hernia director, 2:0 
 Knife, new herniotomy, 239 
 
 Merocelo, 42 
 Muscles — 
 
 Cremaster, 61 
 
 External oblique, 53 
 
 N. 
 
 Navel, ruptured, 38 
 
 Nationality as affecting Hernia, 47 
 
 Needle, aspirating, 216 ; do. for tnp- 
 
 ping hernical sac in Strangulated 
 
 Hernia, 216 
 Needle, Dowell's, 99 note 
 Nerves — 
 
 Anterior Crural, 56 
 
 Geuito „ 52. 56 
 
 Ilio- Inguinal, 52, 67 
 
 Oblique Inguinal Hernia, 40 
 
 Observing cases. 174 
 
 Occupation as affecting Hernia, 45 
 
 Occupations most favourable for opera- 
 tions in Hernia, 177 
 
 Omentum, treatment of the, 165, 
 232 
 
 Omphalocele, 38 
 
 Operation for Hernia, 91, 165, 168, 
 170, 189. See also " Cures." 
 
 Organic plugs as a cure, 101 
 
 Oscheocele, 42 
 
 L. 
 
 Life, time of, at which Hernia occurs, 
 
 37 
 Ligaments — 
 
 Burn's, Hay's or Femoral, 68 
 
 Gimbernat's, 52 
 
 Poupart's, 52 • 
 
 Triangular, 53 
 Ligature as a cure, 98, 119, 120; 
 
 Dowell's subcutaneous do., 112 ; 
 
 animal, in surgery, 119 
 Ligatures, surgical operations without, 
 
 240 
 Lister's ligature (carbolised catgut) as 
 
 a cure, 120 et seq. 
 Lumbar Hernia, 40 
 
 M. 
 
 Measurements of the region of the 
 abdomen by Sir Astley Cooper, 59 
 
 Medical Association, Committee of the 
 American, and Dr. Heaton, 5 et seq. 
 
 Paget, Sra James, on Strangulated 
 Hernia, 87, 127 
 
 Pathology — 
 After injection, 1.10 
 Gangrene in Strangulated Hernia, 
 
 86 
 in sac coverings, 87 
 in Str uigulated Hernia, 86 
 
 Patients, on the selection of, for treat- 
 ment, 175 
 
 Percentage of cures, 183 
 
 Perineal Hernia, 40 
 
 Peritoneum — 
 
 Davenport on, 134 
 John Wood on, 135 
 Nature of the, described, 74 
 Toleration of, illustrated by cases, 
 136 
 
 Peritonitis, efficacy of cold water or ice 
 in cases of, 139 
 
 Persons in whom injections best suc- 
 ceed, 176, 177, lSi 
 
INDEX 
 
 279 
 
 Peter's hernia director 220 
 
 Petit's operation of Kelotomy, 222 
 
 Phrenic or Diaphragmatic Hernia, 38 
 
 Pillars of external ring, 53 
 
 Plugs, organic, as a method of cure, 
 101 
 
 Population as affecting Hernia, 44 
 
 Position — 
 as a cure, 96 
 
 in Author's operation, 163 
 in Taxis, 209 
 
 Poultices injurious in abdominal in- 
 flammations, 139 
 
 Poupart's ligament, 52 el seq. 
 
 Piocrss of Burn's, ti8 • 
 „ Falciform, 68 
 
 Pudendal Hernia, 42 
 
 R. 
 
 Pace of men, frequency of Hernia ac- 
 cording to, 47 
 
 Radical cure, 7, 91, 95, 127 
 
 Piatchet truss, the, emphatically the 
 working man's, 248 
 
 Kecord of interesting cases, 186 
 
 Reducible Hernia, 43 
 
 ,, symptoms of, 75 
 
 Pings- 
 External inguinal, 56 
 Femoral or crural, 70 
 Internal inguinal, 55 
 
 Rupture, Gay's operation for femoral, 
 244 
 
 Royal suture as a cure, 100 
 
 Ruptured navel, 38 
 
 Sac— 
 
 ,, consequence of the presence of fluid 
 
 in the, 76 
 ,, formation and nature of, 72 
 „ in Strangulated Hernia, 86, 226, 
 227 
 Saphenous opening, 67 
 Scariri cation as a cure, 100 
 Scarpa's triangle, 61 ; cellular structure 
 described by, ib. ; on the texture of 
 the peritoneum, 74 
 Scrotal Hernia, 42 
 Sex as affecting Hernia, 44 
 Side cf body as affecting Hernia, 47 
 Specialists, 94 
 Spermatic cord, 61 
 
 ,, ,, relation to sac, 61 et 
 
 seq., 66 
 Spica bandage, the, 169 
 Stewart's Hernia knife, 220 
 
 Strangulated Hernia, 43, 85 et seq., 
 208 
 „ Birkett on. 208 
 
 „ Operations for, 91 el seq. 
 
 „ Reduction of, 209 
 
 by J. C. War- 
 den, 210 note 
 „ Taxis in, 209 
 
 ,, Treatment cf, 225 
 
 Subcutaneous ligature for cure oi 
 
 Hernia, 112 
 Success of injections depending upon 
 ,, age of patient, 178 
 ,, kind of Hernia. 177 
 ,, selection of patients, 175 
 Superficial Circumflex Iliac, 66 
 ,, Epigastric. 66 
 
 ,, External pudic, 66 
 
 Surgery, animal ligatures in. 119 
 Surgical operations without ligatures 
 
 illustrated by cases, 240 
 Suture as a cure, 98 
 Symptoms — 
 
 Reducible Hernia, 75 
 Strangulated ,, So 
 Umbilical ,, 48 
 Syringe, new. description of, fop in* 
 jecting the hernial lings, 157 
 
 Tables of Diagnosis. 78-81 
 
 Taxis and position for, 209 
 
 Tendon, the c mjoined, 54 
 
 Thompson's dilator, 268 
 
 Thyroid Hernia, 40 
 
 Toleration of peritoneum, illustrated 
 
 by cases, 136 
 Trades in which Hernia is most fre- 
 quently found, 46 
 Transversalis fascia, 55 
 Transverse colon, Hernia of the, 38 
 
 note 
 Treatment of omentum, 165, 232 
 Treatment of Strangulated Hernia as 
 
 given by Bernard and Huette, 225 
 
 et seq. 
 Triangles — 
 
 Hesselbach's, 57 
 
 Scarpa's, 61 
 Triangular ligament. 53 
 Trocar, 265 
 Truss, proper position for, in Umbilical 
 
 Hernia, 245 ; in Inguinal do. 245 ; 
 
 the working man's truss, 248 
 Trusses, 243-251 
 
 Dowell's bupgy spring. 110 
 
 French, double and single, 248 
 
280 
 
 INDEX. 
 
 Spiral spring pad, double and single, 
 
 247 
 Umbilical belt, adult's and child's, 
 
 250 
 
 U. 
 
 Umbilical belt, adult's and child's, 
 
 250 
 Umbilical trusses, 249, 250 
 
 Hernia, 38, 48, 170 
 ,, Anatomy of, 48 
 „ in adult, 50 
 ,, ,, child, 50 
 
 ,, ,, foetus, 49 
 
 „ Symptoms of, 51 
 Urethra, sound for, 266 
 Uterine sound, 266 
 
 Uterus, remarkable case of rupture oi 
 the, 138 
 
 Vaginal Hernia, 40 
 Ventral ,, 42, 80 
 Ventro-inguinal Hernia, 42 
 
 w. 
 
 "Weiss's Hernia bistoury, 270 
 
 White's met hod by ligature, 99 
 
 Wood, John — 
 
 method of cure, 106 
 on the peritoneum, 135 
 
 Wood, Thomas — 
 method of cure, 98 
 
 Wurtzer's method of cure, 104 
 
 THE my. 
 
Surgical 
 
 AND 
 
 MECHANICAL/ 
 
 Appliances 
 
 OF 
 
 Every Description 
 
 FOR 
 
 Physical 
 
 Deformities, 
 
 Deficiencies 
 
 Debility, Etc, 
 
 ON HAND, OR MADE TO ORDER. 
 
 The various instruments of Dr. J. II. War- 
 ren, described in this book, may be obtained 
 of us. 
 
 CODMAN & SHURTLEFF, 
 
 MAKERS AXD IMPORTERS OF 
 
 SURGICAL & DENTAL INSTRUMENTS, 
 13 and 15 Tremont Street. 
 
 BOSTON, MASS. 
 
ESTABLISHED 1826. 
 
 Geo.Tiemann&Co. 
 
 Surgeons' Instruments. 
 
 67 Chatham Street, - New York City. 
 
 REGINALD HARRISONS SYRINGE and TIE- 
 MANN'S CATHETER, for Treatment of Gleet and pre- 
 vention of Stricture. (London Lancet, May 15, 1880.) 
 
 Patented June 
 12, 1S77. 
 
 N^\.\*.\ V<S-. 
 
 G. TIEMANN & CO.'S "Velvet Eye" CATHETER. 
 
 N. B. — A card Scale with American and French Catheter and Bougie 
 Gauge and Measure, metrical and in inches, will be mailed on application. 
 
 SKENE'S NEEDLE FORCEPS. 
 
 GARRIGUES' SERRE-FINES, 
 for Treatment of Ruptured Peri- 
 neum. 
 
 Parties wishing our instruments, and finding it more convenient to ob- 
 tain them through dealers, are requested to order "Tiemanx's Manu- 
 facture," as otherwise inferior goods are frequently substituted.