ARTES
SCIENTIA
LIBRARY VERITAS OF THE
UNIVERSITY OF MICHIGAN
SALUTE
WITH
TCEBOR
CIRCUMSPICE
The
George E. Wantz
(UM Medicine 1946)
Collection


₤18

ON RUPTURE,
INGUINAL, CRURAL, AND UMBILICAL.

PREPARING FOR PUBLICATION, BY THE SAME AUTHOR.
THE
SURGICAL ANATOMY OF THE PELVIS AND PERINEUM,
In the Infant, Young, and Adult Male and Female;
CONSTITUTING
A GUIDE TO OPERATIONS UPON THE URETHRA, BLADDER, RECTUM,
AND OTHER PELVIC VISCERA,
And to Diagnosis in some of their Diseases.

ON RUPTURE,
INGUINAL, CRURAL, AND UMBILICAL;
THE ANATOMY, PATHOLOGY, DIAGNOSIS,
CAUSE AND PREVENTION;
WITH
New Methods of effecting a Radical and Permanent Cure;
EMBODYING
THE JACKSONIAN PRIZE ESSAY OF THE ROYAL COLLEGE OF SURGEONS,
LONDON, FOR 1861.
With Numerous Illustrations.
BY
JOHN WOOD, F.R.C.S., ENG. (EXAM.)
DEMONSTRATOR OF ANATOMY AT KING'S COLLEGE, LONDON;
ASSISTANT-SURGEON TO KING'S COLLEGE HOSPITAL;
SURGEON TO THE LINCOLN'S INN DISPENSARY.
LONDON:
JOHN W. DAVIES, 54, PRINCES STREET,
LEICESTER SQUARE.
EDINBURGH: MACLACHLAN AND CO.
MDCCC LXIII.
DUBLIN FANNIN AND CO.
The right of Translation is reserved.
IA1

Taubman / Rare
Book Room
RD
621
ما ماليا .

PREFACE.
BEFORE giving to the profession the results of some years'
careful study and experience of the various forms of rupture,
and of the possibility of curing permanently a deformity so
common and so disabling, I have fully felt the importance of
a sufficient lapse of time, or duration, as a test of the reality
of the cure.
Chiefly for this reason, and partly to enable me to make
such modifications of my original method as might simplify
and render more effective the steps of the operation, I have
hitherto deferred this publication, preferring rather to answer
privately, as far as I could possibly do so, the numerous appli-
cations I have had, both from the provinces and from abroad,
for descriptions of my latest plans.
Having been honoured by the award of the Jacksonian
prize for 1861, of the Royal College of Surgeons, London, for
my Essay on "The best Method of effecting a Radical Cure of
Inguinal Hernia," I feel it now incumbent upon me to embody
the contents of that essay in the present publication. Much
of the following pages has been added to the original essay.
The anatomical descriptions have been extended, with a view
to the better comprehension of the parts concerned in an
operation difficult to be understood by those who have not an
every-day familiarity with the structures involved.
The section on the use of Trusses has been also amplified;
the description of a new truss, without actual inspection of the

vi
PREFACE.
specimens which accompanied the essay, requiring more minute-
ness, and involving a consideration of the action of trusses
generally, in preventing or promoting a radical cure, both with
and without an operation.
That part of the work which treats of Femoral and Umbi-
lical Rupture has been added entire to the original essay. The
former subject enables me to make public an operation which
I have been in the habit for some years of showing on the
dead subject to the pupils of King's College, but which, for
reasons given in the text, I have not yet performed upon the
living body; and also a description of a truss which I have
employed with a view of promoting, in small cases, a radical
cure by pressure at the most effective point. Under the head
of Umbilical Rupture I have given for the first time to the
public, an operation which I have performed with very good
results, both as regards the absence of serious symptoms in
the after progress of the cases, and their ultimate result.
Upon the principles laid down in the text, I have devised a
truss, or compress, for umbilical protrusion, which is herein
figured and published for the first time. It is probably right
to state here, that the drawings from which the illustra-
tions are taken are all original, and made by the author from
actual dissections, operations, and instruments.
It is not, in the present treatise, contemplated to include
the whole of the points connected with the diagnosis and treat-
ment of the various kinds of hernia, nor to attempt a substitute
for the valuable and compendious works of Sir A. Cooper and
Mr. Lawrence upon this subject, but simply to take such
points as it is important to consider in effecting a radical cure.
Centuries of experience of the futility of proposed plans for
curing rupture have had the effect of producing an excusable
hesitation and doubt in the profession as to the reality and
permanence of the cures produced.

PREFACE.
vii
The liberality of my colleagues, the senior surgeons of
King's College Hospital, has enabled me publicly to test my
various methods in most of the cases given in the Appendix;
and from time to time to exhibit in the theatre of that institu-
tion the condition of many of the patients, at periods of time
after the operation varying from six months to five years.
In many cases, the additional test of heavy labour has been
applied for more than a year, without truss or any support what-
ever. Six of the cases given in the Appendix to this volume
were publicly exhibited at the meeting of the Medico-Chirur-
gical Society, in February, 1860. In all the cases I have been
at much pains to ascertain, as far as circumstances would
allow, the condition of the patients up to the present time.
To numerous friends, whose generous sympathy for the
advancement of surgical science has led them to second my
efforts in a direction considered by many as hopeless, and in
which, but for such support, I should have found it impossible
to proceed, my best thanks are here sincerely tendered.
4, MONTAGUE STREET, RUSSELL SQUARE, W.C.
April, 1863.


ANALYTICAL TABLE OF CONTENTS.
INTRODUCTION.
Demand for a radical cure of hernia
Supposed dangers from peritonitis.
.
Inconvenience and risks from strangulation and from an operation
compared
•
Risk compared with that of similar operations
Degree of safety and probabilities of success
Success of other modern efforts for a radical cure
Proper choice of cases
Superior eligibility of inguinal hernia
PART I.
ON INGUINAL HERNIA.
SECTION I.-ANATOMY OF THE PARTS.
Superficial dissection-fasciæ, &c.
22
29
vessels
·
.
General arrangement of the lower abdominal wall and groins
Internal abdominal ring and fascia
Position and length of inguinal canal
•
.
External abdominal rings, its pillars and fasciæ.
Anterior wall-cremaster muscle and fascia.
Posterior wall-transversalis fascia
99
22
.
conjoined tendon.
triangular aponeurosis
Superior boundary of the canal.
Inferior boundary, rectus muscle
.
.
PAGE
2
3
4
5
6
7
69
8
. 10
12
•
13
15
15
.
16
.
17
19
20
21
21
22

X
CONTENTS.
Peritoneum-superior false ligament of bladder
Subperitoneal fascia, external iliac artery
·
PAGE
23
24
Deep circumflex iliac.
•
epigastric and branches
.
25
26
Triangle of Hesselbach, vas deferens, spermatic cord and vessels
Composition, course, and coverings of cord
27
28
SECTION II.-CAUSES AND PATHOLOGY OF INGUINAL HERNIA.
Theory of elongated mesentery-objections.
Formation of sac
.
Failure of the tendinous walls and openings.
Varieties of inguinal hernia.
Oblique hernia and coverings
Direct hernia and coverings.
30
33
35
36
37
39
40
41
42
44
46
47
.
•
48
.
51
58
59
60
61
Influence of the rectus muscle
•
•
Bubonocele-relations to spermatic cord
.
Neck of the sac-influence on the abdominal rings
Varieties in the sac coverings
.
Different points of contraction in the canal
Differences between recent and old formations
Varieties in shape and outline of the sac.
General characteristics of hernial subjects
Congenital hernia and its formation
Causes-canal of Nuck
•
Infantile hernia-mode of formation
•
Direct hernia in the child
SECTION III.-DIAGNOSIS OF INGUINAL HERNIA.
Physical signs-cough impulse.
Modifications of impulse.
Mode of formation and progress
3539
62
64
65
Effect of manipulation or taxis.
66
Position of testis, imperfect descent of testis
67
Fatty tumours, cysts
68
•
Hydrocele of the cord
69
Glandular tumours
Abscesses, hydrocele of tunica vaginalis
Enlarged testis, varicocele
70
71
73

CONTENTS.
xi
SECTION IV.-HISTORY OF THE RADICAL CURE OF INGUINAL HERNIA.
Ancient methods-ointments, plasters, actual cautery, caustics.
Excision of sac, ligature, royal stitch, punctum aureum.
Older methods-operations of Schmucker and Langenbeck.
Richter and L'Estrange's methods by pressure
.
Modern operations. 1st class-Schuh's, Riggs', Belmas', Vel-
peau's, and Pancoast's
Bonnet's method. 2nd class-Gerdy's and Signoroni's methods
Wurtzer's method-its advantages
Objections causes of failure.
•
SECTION V.-PRINCIPLES OF THE AUTHOR'S OPERATIONS.
PAGE
སྩ བྱ་བབ
Adaptations of anatomical peculiarities.
Differences from former operations
•
Variations in the means employed, viz.-thread, wire, and pins
Use of external compress, advantages of metallic sutures
Main principles of the operations
•
SECTION VI.-OPERATION BY THREAD AND COMPRESS.
88
90
92
93
94
Description of the instruments employed
Description of the steps of the operation
Arrangement of the apparatus in reference to the anatomy of the
•
•
95
98
parts
•
Dressings, after-course, and treatment
SECTION VII.-OPERATION BY WIRE AS USUALLY PRACTISED BY THE
.
104
.
106
AUTHOR.
Instruments used, choice of wire, &c.
Description of the steps of the operation
Dressings, after-course, and treatment
SECTION VIII.-VARIATIONS OF THE WIRE OPERATION.
Variations with single suture.
99
27
.
double cross suture
Another variation with double suture
Variation with transverse sutures
•
. 107
. 109
114
. 119
. 122
.
124
127

xii
CONTENTS.
SECTION IX.-OPERATION BY RECTANGULAR PINS.
Description of rectangular pins
Longitudinal application of pins
Method of dressing
Transverse application of pins
After-treatment and progress of cases
SECTION X.-MODUS OPERANDI OF OPERATIONS.
PAGE
130
132
134
136
137
Effect upon the tendinous hernial canal
the sac
·
Illustrative cases-effect upon
Effect upon the invaginated scrotal fascia
Effect
upon
the external ring
Direct action upon the tissues
SECTION XI.-CAUSES OF FAILURE AND DANGER.
Shape and application of instruments
Protection to the large vessels and bowel
Failure in securing the conjoined tendon and remedy
Malposition of the sutures.
Relation of the sutures to the spermatic cord
Difficulties of direct cases .
•
•
•
140
142
144
.
145
.
146
147
149
.
151
•
152
153
. 154
155
156
157
Choice of operation for youths and children-small cases
Best operation for adults and large cases
158
159
Importance of sufficient separation of scrotal fascia
Importance of good health in the patient
Degree of compression to be employed.
.
SECTION XII.-SUMMARY OF THE CASES.
Cause of death in the single fatal case, average duration of the cases 160
Number and methods of operating in the 60 cases given in the
Appendix
•
•
Number and causes of the failures in the operation by thread and
compress
Number and causes of the failures in the operation by wire
Number and causes of the failures in the operation by pins
After-condition of the ruptures in unsuccessful cases
. 161
162
162
163
164

CONTENTS.
xiii
Numbers and condition of the doubtful cases, cases of repetition
of the operation
Consequences to the testis in three cases
Total result and percentage
PAGE
165
. 166
167
SECTION XIII.-USE OF TRUSSES IN INGUINAL HERNIA.
Injurious effects of convex truss-pads
•
.
Effect of efficient truss pressure
Description of horse-shoe boxwood truss-pad for oblique hernia.
29
29
99
lever-spring pad
H-spring pad
.
Method of application and mechanical effects of the foregoing.
Description of the ovoid ring pad for direct hernia
99
22
27
27
lever-spring ring pad
•
double pad and spring truss for large cases
PART II.
FEMORAL OR CRURAL HERNIA.
SECTION XIV.-ANATOMY OF THE PARTS.
.
168
.
169
170
173
174
175
.
176
177
178
Scarpa's triangle, superficial fascia
183
Superficial vessels and nerves, &c.
184
Arrangement of deep fascia
186
Description of the saphenous opening and cribriform fascia
187
Falciform border-Heys' ligament
188
•
•
Infundibular crural sheath-deep arch.
189
•
Lymphatic compartment-crural ring
Septum crurale-crural canal
190
•
191
Relations to important vessels
192
.
Important and dangerous irregularities
194
Abdominal relations of crural ring
196
Irregularities of obturator artery
197
SECTION XV.-CAUSES AND PATHOLOGY OF CRURAL HERNIA.
Causes of its prevalence in the female
Abdominal aspect and axis of crural ring
. 200
201

xiv
CONTENTS.
First direction of the rupture-relation to the femoral vein
Final direction of the rupture and its causes
Alteration of the axis and its consequences
Coverings of crural hernia.
Alterations of structure in old cases.
Varieties and their causes
Conditions favourable for a radical cure
PAGE
202
203
204
205
.
206
.
207
208
SECTION XVI.-DIAGNOSIS OF CRURAL HERNIA.
Position, shape, and other signs distinguishing from the inguinal
variety
Effect of obesity, direction of cough impulse
Enlarged glands
•
Fatty tumours
Cysts
·
Chronic abscess, &c.
SECTION XVII.-OPERATION FOR THE RADICAL CURE.
Operations by Dr. Jameson and Mr. Davies
The author's operation by wire
.
Effect of the operation-necessary precautions
Risks of, and proper subjects for operation
Radical cure after the operation for strangulation
SECTION XVIII.-RADICAL CURE BY TRUSS PRESSURE.
Importance of a proper application of the pressure
Description of the elliptical truss pad
دو
99
.
•
lever-spring pad
210
. 212
213
214
215
216
.
217
. 218
221
222
•
223
224
226
227
SECTION XIX.-PREVENTION OF INGUINAL AND CRURAL HERNIA.
Classes most affected, predisposing habits
229
Signs of a tendency to rupture
230
.
•
Description of a preventive bandage for weak groins
231
SECTION XX.-TREATMENT OF IRREDUCIBLE HERNIA.
Truss pressure in omental hernia
234
Operation for radical cure in ditto
236

CONTENTS.
XV
PART III.
UMBILICAL HERNIA.
SECTION XXI.-CAUSES AND PATHOLOGY.
Infantile cases-closure of the navel in development
Circumstances interfering with closure
.
PAGE
238
240
Causes of the adult variety
241
Differences between the adult and infantile forms
242
Position of recti muscles, shape of hernial openings
243
SECTION XXII.-DIAGNOSIS OF UMBILICAL HERNIA.
Symptoms and appearance in the child
244
in the adult
246
27
27
SECTION XXIII.-TREATMENT.
Operation for radical cure by Dessault.
Objections made by Scarpa
Advantages of a subcutaneous wire method
247
249
250
SECTION XXIV.-THE AUTHOR'S OPERATION FOR THE RADICAL CURE
OF UMBILICAL HERNIA.
Instruments used, choice of wire, &c.
Description of the steps of the operation
Dressing and after-treatment.
Conditions favourable for operation
.
.
251
253
256
257
SECTION XXV.-TREATMENT OF UMBILICAL HERNIA BY PRESSURE.
Objections to the ordinary apparatus
Description of the author's ring compress
Its action upon the hernial opening
Its use in irreducible cases
·
APPENDIX OF SIXTY CASES OF OPERATION FOR THE RADICAL CURE
OF INGUINAL HERNIA
.
258
259
260
262
. 263


ON RUPTURE.
INTRODUCTION.
remedy what was
powers of Nature
LONG before the present time, the radical cure of hernial pro-
trusions has occupied the attention of surgical minds of the
highest order. Both in ancient and medieval times, operations
were done in great variety with a view to
then, as now, a very common failing of the
in fulfilling the destiny of man to labour. The fatality attend-
ing some, and the inutility and inconvenient results of more of
these operations, together with the improvement and extensive
employment of a most useful palliative-the truss-have
brought about a very general conviction, shared in by the most
trustworthy authorities, of the folly and uselessness, and, by
some, of the recklessness even, of any attempt to cure a disease
which had been attempted so often in vain.
Rupture is not a disease directly or necessarily fatal, and, by
care and the use of a truss, may be reduced to the category of
a simple inconvenience. It is not, therefore, justifiable to
induce a patient to undergo an operation which may cause
pain, and even endanger life, in the uncertain hope of a per-
manent cure.
Such is the position held by some eminent in the profession
B
102

ON RUPTURE.
to be the judgment of medical ethics.
opera-
Some would not even
allow of such an operation being classed among the "
tions de complaisance," upon which the surgeon may permit
his patient, after having the case fairly stated, to judge for
himself, but would heartily dissuade his patient from the step.
Like many other diseases which the profession has pronounced
incurable, it has been the fate of ruptures to fall into the hands
of unscrupulous men, who in every age have obtained a spurious
reputation for curing a disease which is not to be distinguished
except by experienced surgeons from many others easily curable,
and concerning which it is not in some cases easy to decide
whether it be cured or no. Both one way and the other the
public have been repeatedly deceived, and professional men are
naturally placed in an attitude of suspicion towards all such
attempts to remove the stigma of impotence which in too many
instances is fixed upon their art.
In these latter days of attention to the social sciences, the
physical qualities of races and their deterioration are justly
considered to be of paramount importance. Habits of active
exertion and muscular training are encouraged with a view to
military, scientific, mercantile, and colonizing capabilities.
Doubtless, the frequency of ruptures, frequent as they already
are, will be thereby increased until the habit has invigorated
more than one generation, and impressed its influence upon
their descendants. Thus has arisen an increasing demand for
something to be done for ruptures leading to the revival of
attempts, most of them futile, to cure this prevailing deformity.
In America especially, where the frequency of rupture among
the slave labourers has given a considerable money value to its
cure, resuscitations of old operations, and a multiplicity of new
methods have been practised, with, as far as I can learn, a want
of success almost invariable. Many of them having a pretty
well marked stamp of recklessness, have added to the distaste

INTRODUCTION.
3
with which thinking men in this country view the revival
of attempts towards the radical cure of rupture by operation.
On reading over the opinions of modern writers on this
subject, one cannot but be struck by 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 made to operative interference. The theory alluded
to seems to have been deduced from experience of operations
performed upon this membrane in a state of disease or inflam-
mation, as in strangulated hernia, or of operations exposing it
extensively to external influences. Hundreds of operations im-
plicating the healthy peritoneum, both upon herniæ and under
other circumstances, without bad results, have been overlooked
or ignored. This prejudice is, I believe, at the bottom of most
of the objections; as it prevailed formerly against early opera-
tion 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.
A
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.
closer examination of the fatal cases of attempted radical cure
will show that they have mostly succumbed, not to primary
peritonitis, but to the results of burrowing of matter, pyæmia,
or wounded bowel. The danger of peritonitis cannot, there-
fore, be considered sufficient to deter the surgeon from endea-
vouring to perfect our means of curing rupture.
Having thus briefly alluded to the screens which obscure the
view and cloud the judgment of the claims of hernia to a
radical cure, we may endeavour to ascertain by the experience
already obtained in what class of cases rupture should be placed
B 2

4
ON RUPTURE.
by the surgeon, considering what is best to be done for his
patient, and for our common humanity.
Rupture, especially inguinal, is a very common disease, more
particularly in those classes of men who are the backbone and
support of nations-viz., the labouring, military, and naval
classes, the sons of adventure, exertion, and toil. The disease
renders them incapable, for the most part totally, of the effec-
tive performance of their duties, and may place their lives in
jeopardy under circumstances in which their greatest efforts are
required, and surgical help, generally, not available.
result has been found by experience not to be effectually
guarded against by the use of trusses, which often fail just
when most needed, or cause so much trouble and expense that
they are discontinued as unprofitable. Military and poor-law
records show how frequently this is the case.
This
Before we can obtain a proper light from statistics upon this
subject, we must compare the total number of deaths from at-
tempted radical cure with that from strangulation and other
fatal consequences of rupture, and the proportions of each to
the total number of hernia cases. This alone will show
whether society at large is a gainer by the radical cure of
rupture.
In an individual case, upon the merits of which alone must
the conscientious surgeon decide, it is futile to say-but this
patient may never have his hernia strangulated; since it is
easily answered-but also, he may have it strangulated. His
habits, occupation, and position in life only exert their influence.
in rendering its occurrence more or less probable, not im-
possible. In a moment of extraordinary exertion, this result
may occur to any hernia patient, and he may die from it.
Again, rupture is a very troublesome and incapacitating
disease, rendering the patient's life uncomfortable, compara-
tively useless for bodily exertion, and not unfrequently mise-

INTRODUCTION.
5
rable, exposing himself, and often a family, if in the lower
ranks of life, to the perils of destitution. It is from this
point of view that we may most justly consider the value
of an operation for a radical cure to the patient himself,
as regards its chances of success or failure in effecting its
object. It is readily conceded that it is most difficult to
obtain reliable statements of the ultimate results of these
operations. Some which have been ushered into notice with
most favourable accounts of success have been found to be
attended with almost universal failure in other hands. Upon
this point, therefore, it is incumbent upon the surgeon to speak
from personal experience only, founded, as far as may be, upon
cases openly treated in a public institution.
In the Appendix to the present work are inserted such cases
only as have been operated on by the author himself, nearly
all having had the guarantee of public observation. The total
result is, that out of the sixty cases there given, treated by
various modifications of the same principle, there have been
eleven failures, two doubtful, four partially successful, and one
death from pyæmia.
If these results are compared with the statistics of operations
which are now considered by most surgeons as good and safe
operations, they will not be found to contrast unfavourably.
Let us take varicose veins, hæmorrhoids, stricture, prolapse
of the uterus and rectum, as affording a class of diseases ad-
mitting, like hernia, of both a palliative and radical system of
treatment. Though but few of these are so severe a disability
as a rupture, or so often dangerous to the life of the patient,
yet they are now almost universally considered as fit sub-
jects for operation with a view to a radical cure. Yet fatal
casualties are not uncommon, while failures are certainly as
frequent.
It is a question generally asked of the surgeon by his

6
ON RUPTURE.
patient, "Is the operation a safe and certain one?" The
answer will vary somewhat with the experience, and more, pro-
bably, with the individual character of the
surgeon.
The most reasonable definition of a safe operation seems to
the author to be "an operation which has no peculiar dangers
arising from the situation of the part, or the method of pro-
cedure, and which is not subject more than others to those
accidental diseases which may occasionally follow any inter-
ference whatever with the surface of the body, such as erysi-
pelas, tetanus, and pyæmia. The results above given will
entitle the operations practised by the author to admission into
this category.
Next,-is the proportion of success to failure such as to offer
to the patient chances of cure which will overbalance the
dangers and inconveniences of a rupture treated by a truss
more or less efficient?
In estimating this, it must be borne in mind that in almost
all of the cases called unsuccessful the patient is in a better
condition than before the operation, inasmuch as a truss was
rendered effective which had previously failed in keeping up the
rupture. In none of the cases has the condition of the patient
been rendered worse.
Many of the failures have resulted from causes which have
led to various modifications of the proceeding. Some of these
are better adapted for peculiar forms of the disease, others for
the more simple varieties. That which I have found most
generally applicable is the wire operation without compress, as
given in the text. The great majority of the cases have been
followed by such results as to afford great relief and satisfaction
to the patient, and to raise the admiration of many experienced
surgeons who have examined the patients from time to time.
By the methods followed by the author, and described in
the following pages, we have the large percentage of forty-two

INTRODUCTION.
7
out of sixty successful cases, i.e., cases in which the use of a
truss may usually, after a time, be dispensed with.
Of other methods which have latterly been practised, both
in this country and abroad, the author has had experience only
of the difficulty of obtaining accurate information as to their
ultimate results.
In the hands of all surgeons from whom he could obtain
such information, the general results have been very discou-
raging; and he has himself not been able to meet with a single
case in which the patient has been able to go without truss
with absence of protrusion one year after the operation, while
he has had occasion several times to operate after other methods
have failed.
It may
be said that in an operation of this kind a certain
tangible percentage of successful cases is absolutely necessary to
induce patients to submit to the necessary inconvenience. The
occasional occurrence of a fatal case, though somewhat dis-
couraging, will, if the cause of death be not inherent in the
nature of the operation, hardly constitute so formidable an
objection as the chances of success being but slender. The
numerous deaths from the use of chloroform but little affects
its extensive employment, although its perils are well known to
the public. The objection of a general want of success weighs
very heavily against nearly all these modern operations.
The results of the cases appended to the following pages give
both patients and surgeons ample encouragement to an extended
trial of these methods of operating, and appear to the author to
justify the inference that his operation for inguinal hernia is at
the least as successful and as safe as any operation for the cure
of prolapsed viscera, or that for varicose veins. Applied as it
is to a deformity, more common, more dangerous to life, and
more disabling, and affecting a class of persons to whom bodily
strength and activity is of more vital importance to themselves

8
ON RUPTURE.
and the country at large, it must be acknowledged that with
an equal risk we have in this operation a greater power for
good.
Again, the question arises :-In what kind of hernia, and in
what class of persons, is an operation most desirable?
In old people, whose declining vital powers render them less
capable of heavy labour or active exertion, and whose pursuits
are generally of a light kind, and in whom any operation be-
comes proportionably hazardous, a radical cure of hernia is less
imperative. Such protection as a good truss can afford is,
except under peculiar circumstances, amply sufficient. After
sixty we may consider such an operation generally unadvisable.
Females have, with some exceptions, lighter occupations than
men, and may be sufficiently guarded against strangulation by
a proper truss. They are, moreover, subject to the crural
variety; which though happily less common, I consider, for
reasons hereinafter given, less fitted for operative interference
than inguinal. Except in market-women, milk-women, and
others carrying loads habitually, and of a proper age, or in
cases of inguinal hernia affecting the female sex, an operation
is unadvisable. Inguinal hernia in females, however, may be
more easily dealt with even than in males, on account of the
absence of the spermatic cord and the complications which it
involves.
In inguinal hernia affecting the young and able-bodied, who
may at any time be called upon for such exertion as may en-
danger strangulation, a means of radical cure is a boon not
lightly to be discarded; and as this is far more frequent than
any other variety, indeed than all others put together, this
desideratum is proportionately valuable.
Congenital hernia and the hernia of children are by many
considered as perfectly curable by the pressure of a truss; but
how common is it to find, even in these days of perfected trusses,

INTRODUCTION.
9
a congenital hernia in an adult. The difficulties of adjustment,
of constant and effective application, from the frequency of ex-
coriation and abscesses, and of the supply of worn-out trusses
among the poor, are almost insuperable, and in most cases prevent
a cure. A simple, easy, and almost painless method of closing
the inguinal canal in a child, totally free from danger, has
surely as great a recommendation to the surgeon as the opera-
tions for hare-lip and club-foot, and is much more frequently
required. Such an operation will be found described in the
following pages, with cases in the Appendix. The results are so
encouraging as to give a certainty and celerity to the process
of cure, with which the tedious process by the pressure of a
truss alone can by no means be compared.
To inguinal hernia and its varieties, then, is due the chief
consideration with a view to a radical cure.
The presence of the spermatic cord, and the propriety of
preserving intact the functions of the testicle, present the chief
difficulties which beset the surgeon in effecting this end satis-
factorily. The dangers will be easily avoided by surgical tact
and anatomical skill.
The less frequency of crural and umbilical hernia renders
them of less importance in a social point of view.
To the former, therefore, the chief part of the following
treatise is devoted. Of the rarer forms of rupture, the experi-
ence of the author has not justified any especial mention.

10
ON INGUINAL HERNIA.
PART I.
INGUINAL HERNIA.
I.
THE ANATOMY OF THE PARTS CONCERNED IN INGUINAL
HERNIA.
Ir will be useful in this place to call attention to such par-
ticulars in the anatomy of inguinal hernia as are concerned in
the operations about to be described, and necessary to be kept in
view in considering the causes and treatment of the displacement.
An inspection of the surface of the groin before the removal
of the skin will bring to notice externally a hard, bony pro-
jection. This is the anterior termination of the upper border
or crest of the ilium or haunch-bone, and is called the anterior
superior iliac spine. From this point downwards and inwards
is a hollow groove curving gently with the convexity downwards,
indicating the union between the trunk and leg at Poupart's liga-
ment, and terminating internally near the genital organs at a
slight eminence, composed chiefly of fat and covered with hair in
the adult, the mons veneris. To the lower side of this may be
felt another hard bony ridge, formed by the upper margin or crest
of the pubis or share-bone. This presents, to a careful touch, a
slight bony tubercle externally, projecting forwards, and called
the spine of the pubis. Below the groove, upon the front of the
thigh, is a triangular hollow forming the lower region of the
groin, and hereafter to be described in connexion with crural

ANATOMY.
11
rupture.
Above is the rise or swell of the abdominal wall, pro-
Close above the pubis, and
jecting forward in a gentle curve.
a little external to the mons veneris, may be felt an opening in
the deep structures. This is the superficial or external abdo-
minal ring, through which, in the male, emerges a soft cylin-
drical cord-like mass, passing downward into the purse or
scrotum to the testicle. This is the spermatic cord, containing
the duct, vessels, and nerves of the testicle, which pass this way
into the interior of the belly.
Under the skin of the groin the superficial fascia is arranged
more distinctly than usual in two layers, between which are
placed the cutaneous vessels and lymphatics. The superficial
layer contains a loosely connected fat, and is continuous with
the corresponding fascia on the abdomen and thighs. Towards
the median line it is more plentiful and firm, and is composed
of a greater proportion of fibrous tissue, contributing to make
up the cushion of the mons veneris (Figs. 1 and 6, a).
The deep layer contains little or no fat, and consists of a
very tough and elastic areolar tissue, with large and moveable
spaces of a shiny bursal or synovial appearance. It is closely
attached to Poupart's ligament to the front of the pubis, and to
the iliac crest. Upon its elastic extensibility chiefly depends
the facile gliding motion of the skin over the subjacent aponeu-
rosis. In a normal condition of the parts a puncture or spot
in the skin can be moved more than an inch in every direction
(Figs. 1 and 6, b).
Both layers of fascia may be observed to pass down into the
scrotum, surrounding the spermatic cord with a distinct tubular
investment, within which it can be felt to move freely. This fascial
tube is connected on the one hand with the mons veneris and
investments of the penis, and on the other with the pubic spine
and descending ramus. These connexions contribute to pre-
vent any invagination of the posterior portion of the fascial tube
MiU

12
ON INGUINAL HERNIA.
into the inguinal canal beyond a certain extent; their recogni-
tion is consequently of some importance to the present subject.
Between the layers of fascia are placed the upper chain of
lymphatic glands, which transmit the ducts from the penis and
scrotum. These are arranged parallel with, and usually directly
superficial to Poupart's ligament. (Fig. 1, c). Supplying them
with blood, and crossing the groin obliquely upwards and
inwards over Poupart's ligament, are three small branches of
the common femoral artery.
The outer of these, the superficial circumflex iliac, is directed
towards the superior iliac spine, about which it is distributed
to the integuments (d). The central one-the superficial epi-
gastric, crosses the inguinal canal a little external to its middle,
supplying chiefly the glands, and is distributed to the integu.
ments below the umbilicus (e). The inner one, the superficial
external pudic, passes inwards and a little upwards to supply
the mons veneris, and crosses the spermatic cord superficially
as it emerges from the external abdominal ring (f). A fourth
branch of the common femoral, the deep external pudic, per-
forates the fascia lata near the pubis, and crosses behind the
spermatic cord, a little below the pubic spine, to reach the back
of the scrotum and root of the penis, where it is distributed.
In the operations for the cure of inguinal hernia, the only
branches likely to be involved are the external pudic. They
are usually so small as to require no ligature if divided, and
give no trouble. Occasionally, however, one or other may be
so enlarged as to give a considerable supply to the skin on the
dorsum of the penis. It may then be felt pulsating over the
hernial tumour, and require a ligature if divided.
At the root of the scrotum the subcutaneous fat suddenly
ceases, and about an inch below the pubic spine is replaced by
the unstriped muscular fibres composing the dartos, which
completely lines the scrotal bag, mingled with a very tough,

ANATOMY.
13
elastic, and vascular areolar tissue. A vertical septum of the
same tissue forms a partition in the median line separating the
testes. In the scrotum the layers of fascia are readily sepa-
rated from the skin, the thin handle of a small scalpel being
sufficient to detach almost any extent of fascia.
FIG. 1.
Superficial dissection of the inguinal and crural regions.
Below the level of the iliac crests the abdominal wall is
made up of layers of muscular and aponeurotic structures.
Most superficial is the strong tendon of the external oblique,
the fibres of which curve downwards and inwards towards the
pubis and median line, where they contribute with the other
tendons to form a vertical line of union with those of the op-

14
ON INGUINAL HERNIA.
posite side-the linea alba. Externally, towards the thigh, the
fibres become thicker and more oblique, blending with the
fascia lata, and with the deeper fascia to form the crural arch
or Poupart's ligament (g). This strong band of fibres is ar-
ranged archwise between the anterior superior iliac spine and
spine of the pubis, to which two bony projections it is firmly
attached. It has a slight convexity tending downwards,
outwards, and backwards, so as to form the hollow of the
groin. Extension and abduction of the leg renders it tense
by traction on the fascia lata, and through it compression is made
upon the inguinal and crural rings by this position of the leg.
The fibres of the aponeurosis are bound firmly together by a
thin, closely adhering layer of tough areolar tissue, which may
be traced upwards to the fascia immediately investing the mus-
cular fibres, and downwards into a fascia presently to be de-
scribed as the intercolumnar (h). Openings of various sizes give
passage to vessels and nerves lying in the abdominal wall. A
larger and more important opening of a similar kind forms the
external abdominal ring (i).
Immediately behind the aponeurosis of the external oblique
are placed the internal oblique (Fig. 2, 6) and transversalis (c)
muscles with their conjoined tendon. Their muscular fibres lie
externally, both taking origin from Poupart's ligament (a), the
former extending down further and covering the latter, one
occupying the outer two-thirds, and the other the outer third of
the whole extent of the crural arch. Internally is placed their
united or conjoined tendon (d), passing in front of the rectus
and pyramidalis muscles to the linea alba and pubis. The
rectus muscle (e) spreads out over the hypogastric region, and
offers an effectual bar to hernial protrusion at this place. To-
wards the median line it closes up with its fellow muscle,
separated only by the linea alba. Close to the pubis, the small
pyramidalis muscle arising from the crest of that bone, and in-

ANATOMY.
15
serted into the linea alba for about two-and-a-half inches,
renders tense the latter structure, and assists in closing the ab-
dominal wall in front of the rectus tendon.
Posterior to all these, and lining the transversalis muscle and
conjoined tendon, to which it is very closely adherent, is the
transversalis fascia (Figs. 2 and 3 f). Internally, this fascia
passes behind the rectus to the linea alba, forming with the
subperitoneal tissue the only posterior covering of the muscle at
its lower fourth, and continuous above with the posterior layer
of the split tendon of the internal oblique which completes the
sheath at the middle and upper parts of the abdomen. Exter-
nally, the fascia is continued downward below the edge of its
muscle to be firmly attached to the deep surface of Poupart's
ligament and to the fascia iliaca, and to form the internal ab-
dominal ring and the anterior part of the crural sheath.
this part it is much thicker than above, and is further
strengthened by scattered fibres derived from the tendon of the
transversalis, forming an important barrier against direct hernial
protrusion, and protecting the epigastric vessels which lie be-
hind it, with the peritoneum and obliterated hypogastric cord.
At
The inguinal canal is an oblique passage through the layers
of the abdominal muscles and fascia, varying from an inch and
a half in the male, to two inches or more in the female. It is
placed immediately above the inner half of Poupart's ligament.
The superior or deep opening is situated about half or three-
quarters of an inch above the centre of Poupart's ligament; and
the inferior or superficial opening, immediately above the pubic
spine into which that ligament is attached internally. These
openings are called respectively the internal and external abdo-
minal rings.
The internal or deep ring is an oval opening in the fascia
transversalis, with its long diameter directed upwards and a
little inwards (Fig. 3, a). Its inner and lower margins are

16
ON INGUINAL HERNIA.
tolerably sharply defined when viewed from the inner aspect.
The outer and upper borders are less prominent, from the
obliquity of the surface. From its margins is derived a thin
funnel-shaped tube of areolar membrane, the fascia propria vel
infundibularis, the deepest covering of the spermatic cord.
The external or superficial ring is an oblique triangular slit
or opening between the fibres of the external oblique aponeu-
rosis. The base of the triangle is placed above the outer half
of the pubic crest, the superior angle is directed upwards and
outwards (Fig. 1, i). A line bisecting the triangle would be
placed rather more vertical than Poupart's ligament. The sides
of the slit are arranged in two bands called pillars of the ring,
the inner of which is also superior, and the outer, inferior, from
the obliquity of the opening. Crossing from one to the other
pillar in front of the ring, and continuous with the fascia
before mentioned as closely investing the aponeurosis, is a tole-
rably strong layer of closely woven tissue called the inter-
columnar fascia (h). At the upper part of the ring are deve-
loped in it strong bands of fibres, which, connected externally
with the outer half of Poupart's ligament, arch transversely
over the opening in curves having the convexity downwards and
outwards, and which, separating from each other as they pass
inwards, become finally directed upwards, and are lost in the
aponeurosis near the linea alba (k). These bands have received
the name of the arciform fibres. At the lower part of the
ring the intercolumnar fascia is prolonged downwards over the
cord into a tubular investment which has been named the
fascia spermatica externa (seen at i). To the yielding of the
intercolumnar fibres it is that dilatation of the external ring by
a hernial protrusion is chiefly owing. When deprived by close
dissecting of this investment, the pillars of the ring are fairly
exposed. The internal pillar is flat and riband-shaped, and
composed of parallel fibres. A little way from the border of

ANATOMY.
17
the ring, at an oblique line passing downward and inward to
the pubis, it becomes blended with the subjacent conjoined
tendon of the internal oblique and transversalis muscles. It
gives off many fibres into the tissue forming the mons veneris
(some of which join the suspensory ligament of the penis), and
is implanted below upon the front of the angle of the pubis
and anterior ligament of the symphysis, at a little distance
below the crest of that bone.
The
The external pillar, triangular in shape, with the apex
downward and implanted upon the pubic spine, is connected
externally with Poupart's ligament, with the insertion of which
it is so blended as to be identical, forming a rounded tendon
very evident to the touch. To form this tendon the fibres
of the pillar converge to those of Poupart's ligament.
strength and width of this pillar vary much in different sub-
jects. In some it is thin and weak, and lost in Poupart's liga-
ment at some distance from its attachment. Near its lower
end, it is grooved above by the passage of the spermatic cord,
which crosses it obliquely just above and external to the pubic
spine. The presence of a hernia tends to evert the border of
the pillar, and to diminish its width.
Placed immediately behind the aponeurosis forming the
outer pillar at the upper third of the inguinal canal, are the
lower muscular fibres of the internal oblique, arching over the
cord obliquely and covering the internal abdominal ring
(Fig. 2, 6). In well-developed subjects, the lower part of this
muscle is thicker and more bulky than the upper, and often
separated from the rest by a distinct cellular interval, below
which it is strengthened to resist protrusion through the in-
ternal ring.
Passing downwards from behind it, and blended more or
less both with it and the transversalis muscles, are the muscular
fibres of the cremaster (Fig. 2, h). These are attached ex-
C

18
ON INGUINAL HERNIA.
ternally to the lower third or more of Poupart's ligament, pass
downward through the external ring, and form distinct bundles
or loops over the cord in the scrotum. The bulk of the mus-
cular fibres lie on the outside of the cord upon Poupart's
ligament; the lower become lost on the tunica vaginalis; the
FIG. 2.
Deep dissection of the inguinal canal and abdominal wall.
upper re-enter the external ring, and become implanted upon
the conjoined tendon; while the middle set of loops become lost
in the fascial tube which connects the different bundles to-
gether into a continuous layer called the cremasteric fascia.
This investment of the spermatic cord lies between the inter-

ANATOMY.
19
columnar fascia and fascia propria, and forms the chief thick-
ness of the deeper coverings of the cord.
Lying upon the fibres of the internal oblique and cremaster
muscles is seen the termination of a small nerve, the ilio-in-
guinal, a branch of the first nerve of the lumbar plexus. This
nerve, after perforating the deeper muscular fibres near the
iliac spine, pierces the intercolumnar fascia at the lower part of
the external ring (at i, Fig. 1), and is distributed upon the
upper and inner part of the thigh and adjacent scrotum. The
accidental inclosure of this nerve in the ligature for the cure of
hernia occasionally causes pain along the iliac crest, which
may give rise to unfounded apprehensions of mischief.
The structures just described make up the anterior wall or
boundary of the inguinal canal,-intervening between it and the
integuments.
The posterior wall or boundary is formed by three layers of
fibrous and areolar tissue intervening between the spermatic
cord and the peritoneal structures.
The deepest and most extensive of these is the before-
mentioned fascia transversalis (Figs. 2 and 3 f). Thin and
unimportant at the upper part of the abdominal wall, where it
lines the transversalis muscle, towards the groin it becomes
much thicker and denser by the addition of fibres from the
tendon of the transversalis, and is connected closely with the
deep surface of Poupart's ligament, with the iliac fascia, and
with the outer border and deep surface of the conjoined tendon.
Here it forms the oval opening of the internal abdominal ring,
and gives off over the cord, the funnel-shaped investment called
the fascia propria or infundibular fascia (Fig. 2, i). This
fascia covers and obscures in front the edges of the ring from
which it springs, and the spermatic cord, which it invests as it
passes through the ring. The best view of the ring and the
derivation of the fascia is consequently to be obtained from
c 2

20
ON INGUINAL HERNIA.
within, where the fascia will be seen to present a prolongation
similar to that of the finger of a glove from the hand cavity
(See Fig 3, 7).
The connexion of the fascia transversalis with Poupart's
ligament forms a groove for the lodgment of the spermatic
cord. This groove is deepest above, opposite to the internal ring,
at which point the finger of the operator, invaginating the scrotal
fascia, can be placed easily between the cord above, at the in-
ternal ring, and Poupart's ligament below. The groove be-
comes shallower downward, and terminates upon the external
pillar itself near the pubic spine.
The union of this fascia transversalis with the iliac fascia
around the iliac vessels, forms the crural sheath to be hereafter
described in relation to crural hernia. It covers and protects
the external iliac vessels and their epigastric and circumflex
iliac branches, all of which lie behind it.
In the operations for inguinal hernia hereafter described, it
is of great consequence to recognise the fascia transversalis in
the above important relations and functions, as affording a
guide to the finger and a protection to the vessels and peri-
toneum.
Placed in front of, and blended with, the last fascia at the
inner two-thirds of the posterior wall, is the conjoined tendon
of the internal oblique and transversalis muscles (Fig. 2, d).
At its upper border the tendon is connected with the muscular
fibres of the transversalis, which terminate in it about three
inches above the pubis. Upon its anterior surface are im-
planted the fibres of the internal oblique, which, continued lower
down than those of the former muscle, are attached in bundles, at
varying distances from the linea alba, forming an oblique line of
attachment downwards and inwards. Below these are inserted,
fibres of the cremaster
by a cellular attachment, a few of the
muscle at their inner extremities, after passing in loops over

ANATOMY.
21
the cord and through the superficial ring (h). From the line
of attachment of the internal oblique muscular fibres inwards,
the tendon is much thicker and stronger. Externally, the
tendon is thin and its fibres are scattered, becoming appa-
rently lost in the fascia transversalis. Internally, it passes
in front of the rectus and pyramidalis to the linea alba, blend-
ing with the aponeurosis of the internal pillar of the outer
ring, and with the triangular tendon. Below, it is connected
firmly with Gimbernat's and Poupart's ligaments, with which it
is implanted into the pectineal line and spine of the pubis.
Directly opposite to the external abdominal ring, this tendon
is strengthened and much thickened by the superposition of a
triangular layer of fibrous tissue passing across the linea alba
from the external oblique aponeurosis of the opposite side.
These fibres, after decussating with those of the internal
pillar, pass outwards and downwards to the pubic symphysis,
crest and spine, and sometimes as far as the pectineal line, where
they are implanted with those of the conjoined tendon. This
structure is best named the triangular aponeurosis (Fig. 2, g). It
is more conspicuous in some subjects than in others, and usually
more in females than in males, especially those who have borne
children. In some it is so much blended with the conjoined
tendon as to be almost indistinguishable, except by a percep-
tible thickening. It contributes an important aid in resisting
a direct protrusion through the external abdominal ring at the
outer edge of the rectus.
The conjoined tendon and its associated structures may be
raised from the deeper tissues, and its obscured external border
rendered salient and perceptible to the touch, by passing the
finger along the inguinal canal, and raising forwards the lower
fibres of the internal oblique muscle upon it. The edge of the
tendon will then be felt on the inner side of the finger.
The superior boundary of the canal is formed by the appo-

22
ON INGUINAL HERNIA.
sition of the several layers of muscles and fasciæ, between
which the canal is placed. Crossing obliquely from its attach-
ment to Poupart's ligament in front of the canal to its inser-
tion upon the conjoined tendon, and arching over the middle
of the canal in the manner of a skew-bridge, is the lower
border of the internal oblique muscle (b). This peculiar
obliquity is such, that the finger of the surgeon inserted along
the inguinal canal when dilated by a hernia, passes behind the
muscle at the upper part, but in front of its tendon at the
lower part of the inguinal tract. Its position would thus limit
the upward dilatation or rise of a hernial tumour, which it would
at the same time closely embrace on the upper and anterior
aspects.
The inferior boundary of the canal is formed chiefly by
Poupart's ligament, along its inner half, and partly by the
attachment of the fascia transversalis, conjoined tendon, and
triangular aponeurosis to its deep surface, forming together a
deep groove which lodges the spermatic cord, and which ter-
minates below upon the external pillar of the superficial ring.
Bounding the inguinal canal at its upper and outer ex-
tremity, and indicating the position of the internal ring, not
otherwise readily distinguished from without, is the lower
border of the transversalis muscle (c), passing horizontally to
be connected with the conjoined tendon. In some cases this
muscle does not descend so low as the ring, a condition usually
accompanied by a similar want of development of the internal
oblique, and indicating a hernial predisposition.
The inferior termination of the canal is indicated on its
deeper aspect by the edge of the tendon of the rectus abdominis
muscle, lying behind the conjoined tendon and internal pillar
of the outer ring. A close inspection of this muscle will show
that its origin from the pubis is arranged into two tendinous
portions connected by areolar tissue. The inner one is more

ANATOMY.
23
bulky, and more or less intermixed with muscular fibres, and
arises from the superior ligament and fibro-cartilage of the
pubic symphysis; the outer one is thin, entirely tendinous,
connected by its thin outer border with the fascia transversalis,
and implanted below into the pubic crest (see Figs. 2 and 3 e).
Above the tendon, the belly of the rectus muscle in well formed
subjects curves boldly outwards and upwards towards the
false ribs. In hernial subjects it may be distinctly felt from
the inguinal canal, and in many, the finger may be pushed
completely behind it, while contracting, without rupture of
tissue.
If the peritoneal cavity be opened by a transverse incision
from one iliac spine to the other, joined by a vertical one down
to the pubis symphysis, on the bowels being drawn aside, the
serous pouch in the groin will be seen to present a dimple op-
posite to the internal ring, where, upon close inspection, faint
traces of a cicatrix may be observed, indicating the closure of
the canal of Nuck or vaginal prolongation of the peritoneum,
after the descent of the testis. Below it is a smooth line, in-
dicating the position of Poupart's ligament and separating it from
the depression over the crural ring still further down. To the
inner side, the serous membrane is slightly raised in a line di-
rected upwards and inwards, by the epigastric vessels. On the
other side of this line another slight depression is seen, which
is bounded internally by a still more prominent ridge, also
directed upwards, inwards, and forwards. This latter ridge is
caused by the obliterated cord of the hypogastric artery, the um-
bilical branch of the internal iliac in the foetus (Fig. 3 i). This,
after curving forward along the side of the bladder, ascends above
the fundus of that viscus, and contributes to form the border
of its superior false ligament. The chief portion of this latter
compound structure is made up of a very loose fold of peri-
toneum of a triangular shape, having its base at the bladder

24
ON INGUINAL HERNIA.
and its apex at the umbilicus, and containing in the median
line the remains of the obliterated urachus, and a quantity of
very loose areolar tissue and fat. Its office is to form an in-
vestment to the fundus of the bladder, when so much distended
as to rise out of the pelvis.
On raising the peritoneum, its superficial surface is seen to
be connected to the fascia transversalis in the groin by a very
lax and plentiful areolar tissue containing much yellowish fat,
which, on being seen against the greyish blue of the serous
membrane and viscera, obtains usually a tinge of greenish
grey. This has received the name of the subperitoneal fascia.
It is especially plentiful in the superior ligament of the bladder
and behind the conjoined tendon, less so on the outer parts of
the groin. In the former situation it permits the finger to be
passed easily between the conjoined tendon and the peritoneum.
It is here joined by a deep layer from the fascia transversalis,
with which it forms the posterior part of the sheath of the
rectus at this point.
Lying in this fascia, behind the fascia transversalis, and in-
ternal to the internal ring, passes the epigastric artery on its
way upwards and inwards to the sheath of the rectus.
The external iliac artery (a), of which it is a branch, is
placed a little external to and about an inch below the internal
abdominal ring, upon the border of the psoas muscle, along the
side of the pelvic brim. The vein is to the inner side and a
little below its level. They are covered by a sheath, divided by
a septum, and derived from the subperitoneal fascia which binds
them down to the fascia iliaca. Internal to them, and consi-
derably below their level, are placed the glands which transmit
the lymphatic ducts from the crural ring to the aortic chain
(Fig. 3, k). Lying upon the artery is the genital branch of
the genito-crural nerve on its way to join the spermatic cord
at the internal abdominal ring; and crossing superficial to it, is

ANATOMY.
25
the vein of the circumflex iliac branch passing inwards, and the
vas deferens directed upwards and outwards, on its way from
the pelvis to the internal abdominal ring (g).
Close above Poupart's ligament the artery gives off two
considerable branches, the deep circumflex iliac outwards and
upwards, and the deep epigastric upwards and inwards.
FIG. 3.
Dissection of the parts of inguinal and crural hernia from the deep or
internal surface, the peritoneum and its fascia removed.
The former, rather the larger of the two, lies behind the
iliac fascia along the deep surface of Poupart's ligament, passing
towards the iliac crest, above which it anastomoses with the
lumbar and gluteal arteries (Fig. 4, d). A considerable branch
often passes upwards and inwards close to the outer side of the

26
ON INGUINAL HERNIA.
internal ring between the internal oblique and transversalis
muscles, to anastomose freely with the epigastric and inter-
costals.
The epigastric artery, of the size of a small quill (Fig. 3, b),
passes across, behind Poupart's ligament, between the internal
abdominal and crural rings, to the lower and inner side of the
former, whence it ascends obliquely upwards and inwards to-
wards the sheath of the rectus, which it enters at the fold of
Douglas (c), to be distributed to the muscle and to anastomose
freely with the terminal branch of the internal mammary.
Like the circumflex iliac, it is accompanied by one and some-
times two veins; one is usually found to its inner side. The
branches of the epigastric, when abnormally enlarged, may be-
come very important in relation to hernia of both kinds.
1st. The pubic.-This is a branch to supply the symphysis
pubis, and to anastomose with the obturator as it passes under
the subpubic notch. This branch is very often enlarged so as
to substitute the typical obturator from the internal iliac. It
then constitutes a very important and dangerous relation to
crural hernia. 2nd. The cremasteric,-given off at the internal
ring, perforates the fascia transversalis, and supplies the cre-
master muscle, anastomosing freely
freely with the spermatic.
Occasionally I have found it enlarged, and supplying the place
of the latter. Lastly, there are superficial, perforating the
aponeurosis with the cutaneous branches of the intercostal
nerves, and-internal and external branches of anastomosis with
the intercostals, the circumflex iliac, and the opposite and
superficial arteries of the same name.
The course of the epigastric artery, upwards and inwards
towards the border of the rectus muscle, will be seen to form
the external boundary of a triangular space formed between it
and the border of the rectus tendon, which has for its base
below, the spine and pectineal line of the pubis and the attach-

ANATOMY.
27
ments of Poupart's and Gimbernat's ligaments to these points of
bone. This triangle (Fig. 3, d), which being particularly described
by Hesselbach, has been called by his name, is filled up or
closed in by the deeper wall of the inguinal canal, which is
made up for a short space near the artery, externally, by the
transversalis fascia only, at the inner two-thirds, by the addi-
tion of the conjoined tendon,-and at the inner third, by the
additional superposition of the fibres of the triangular aponeu-
rosis, which strengthen it superficially opposite to the external
abdominal ring. Passing upwards and inwards, across the
deeper surface of this space, is seen the obliterated cord of the
hypogastric artery (i). This, enveloped in the outer border of
the superior false ligament of the bladder, is placed a little
outside the vertical centre of the conjoined tendon. About the
inner half of this tendon, then, is in apposition behind to the
superior false ligament of the bladder, when that viscus is
moderately distended.
The vas deferens, or spermatic duct (g), after crossing the
external iliac vessels on their inner side, makes a sharp curve
round the epigastric vessels to enter, through the internal ring,
the inguinal canal, where it lies to the inner and back part of
the cord.
On its outer side are the spermatic plexus of veins with the
artery and nerves (h) which, after crossing the psoas and iliacus
muscles, enter the canal, lying external and superficial to the
vas deferens. At the inner aspect of the internal ring itself
may be seen a portion of the subperitoneal fascia (1), holding
together the constituents of the cord, uniting them slenderly to
the depressed cicatrix of the peritoneum, and connected with the
margins of the internal ring. These margins will be seen to
be more prominent internally and below, near the epigastric
vessels and vas deferens, and to give off anteriorly the thin
areolar infundibuliform prolongation over the cord.

28
ON INGUINAL HERNIA.
The spermatic cord effects its passage through the abdominal
walls in an oblique direction from above downwards, and from
without inwards. The inguinal canal thus formed is an
oblique valvular passage, with its upper end placed deeply and
externally at the internal ring, and its lower superficially and
internally at the external ring. Consequent upon this oblique
course its anterior wall is thicker above than below, and its
posterior wall thicker below than above. Thus is formed a
true valve which, in its normal condition, resists powerfully any
irregular protrusion of the abdominal contents.
At the upper
part of the canal the cord is placed at the distance of half or
three-quarters of an inch above Poupart's ligament; but at the
lower end it lies directly upon that structure. Thus the
course of the cord through the canal is oblique in a double
sense, viz., it is oblique from above downward and inwards, as
well as from the deeper to the more superficial parts. It is
doubly oblique, also, in reference to the axis of the canal itself,
as the canal is to the abdominal wall in which it lies.
During its passage, it has obtained, at short intervals, a thin
covering from each of the layers of fascia and muscle which it
has traversed, viz., 1st,-from the fascia transversalis at the
borders of the internal ring; 2nd,-a thicker layer, containing
the muscular loops of the cremaster, from the lower border of
the internal oblique and transversalis muscles; 3rd,-from the
intercolumnar fascia at the borders of the external abdominal
ring; and lastly, a thick investment from the superficial
fascia.
Inclosed in these coverings, the constituents of the cord
itself, composed of the spermatic duct, vessels, and nerves, are
connected loosely together by cellular tissue formed of the
remains of the canal of Nuck, which, in foetal life, connects the
peritoneum with the cavity of the tunica vaginalis, and in
adult age can be distinguished in the areolar connexion of the

ANATOMY.
29
cord with the digital impression and cicatrix on the peritoneum
at the internal ring.
The spermatic cord is freely moveable in the canal, and its
constituents may generally be distinguished, and sometimes
considerably separated, by the finger, when pushed through
the external ring. The vas deferens is known by its whipcord-
like feel, lying internal and posterior to the vessels. In old
hernia cases, the connexions of these different parts of the cord
to the walls of the canal are usually looser, giving a greater
mobility to the structure, and enabling the surgeon easily to
turn them aside with the finger. When the spermatic veins
are varicose they are still more easily distinguished. This con-
dition, also, often is present in old ruptures. The anatomy of
the parts concerned in inguinal rupture is more free from
irregularities than in most other regions. The arrangement
of the epigastric vessels is not commonly found subject to
variation, and they may always be calculated upon in their rela-
tion to the deep inguinal ring, whatever be their origin from
the parent trunk. The irregular origin of the obturator, de-
scribed more particularly in the parts of crural hernia, does not
affect the relations of the inguinal canal. A want of de-
velopment of the lower part of the internal oblique and its
conjoined tendon, sometimes present, has been before re-
ferred to.

30
ON INGUINAL HERNIA.
II.
CAUSES AND PATHOLOGY OF INGUINAL HERNIA.
Two theories have been broached as to the cause of this com-
plaint; and as the adoption of one or other may influence the
judgment as to the curability of the disease, it is necessary
briefly to notice them in this place. One, which has received
the support of Warton, Morgagni, Brendel, Richter, and
others, and which is now held by some surgeons, is, that the
immediate cause, of inguinal hernia especially, is an abnormal
elongation of the mesentery, permitting such an extent of play
to the bowels as to allow of protrusion through the openings of
the groin, under the pressure of the abdominal muscles. The
assumption is, that a mesentery of proper length would not
allow any protrusion of the intestines through an opening in
the abdominal wall at this point.
Without recapitulating the able arguments in refutation of
this opinion, from the eminent pens of Scarpa (Traité pratique
des Hernies), and of Samuel Cooper (Surgical Dict.), and
others, some facts may be mentioned which any anatomist may
observe, and which tend to support the conclusion of the first-
named surgeon:
"that the necessary elongation of the
mesentery does not precede the displacement of the intestine,
but is more probably simultaneous with it, and caused by the
dragging of the already displaced bowel."
When the bowels are distended with food or air, the whole
front wall of the abdomen is projected forward. There being
no vacuum, and action and reaction being equal, the pressure

CAUSES AND PATHOLOGY.
31
is equally distributed over the whole of the containing parietes.
The distension of the bowel must stretch the mesentery to its
utmost, one fold pushing another before it. If the sides be
sound, and equally resisting, the whole of the flexible part of
the abdominal walls yields equally to the pressure, and no
hernia occurs; but if one part be weak while another is re-
sisting, it yields to the pressure at the time of its greatest
force. This culminating point is produced by the action of
the recti, and other abdominal muscles, antagonizing the down..
ward force of the diaphragm and the inspiratory action of the
lungs. The effect of this combination in producing protrusion
is seen in cases of wound of the abdominal wall passing into
the peritoneum. Wherever may be the site of such a wound,
protrusion of bowel invariably occurs, if the latter be in a state
of distension.
The most likely, as well as the most frequent, place for the
abdominal walls to yield before such pressure is at the sides of
the recti muscles in the aponeurotic structures of the groin,
especially when Nature has not sufficiently fortified the in-
ternal abdominal ring. But often the umbilical opening yields,
especially in children, being at that time less firmly closed.
This opening is placed nearer to the point of attachment of
the mesentery than those of the groin. In some cases the
obturator opening, the vagina or the sciatic notch, are found to
be the weak part, although these are placed much further from
the root of the mesentery than the groins.
The comparison of these facts leads to the induction that
the vice is essentially in the containing walls, rather than in an
elongated mesentery.
We find in the dissecting-room that there is a great variety
in the position of the attachment of the mesentery to the spine.
It is often attached to the posterior part of the abdominal wall
one or two vertebræ lower than usual.

32
ON INGUINAL HERNIA.
It is thus very common to find a great part of the small
intestines lying in the cavity of the true pelvis, between the
bladder and rectum. This result may also be brought about
by a hypertrophy of the liver, stomach, or spleen. And yet
hernia is by no means more frequently associated with these
conditions, because the abdominal walls may be efficiently re-
sisting at every point, and yield equably before the pressure.
If the mesentery, then, be long enough to allow the small
intestines to lie in the true pelvis, a fortiori, it is long enough
to permit of protrusion at the groin, in ordinary cases.
Again, the direction of the mesentery is towards the left
side of the abdominal cavity, and the small intestines lie chiefly
in the left lumbar and iliac and hypogastric regions. On the
left side, also, the mesentery is considerably longer than on the
right, though its point of attachment is higher. If the suppo-
sition in question were true, hernia should be more common on
the left than on the right side, whereas the precisely opposite
is the fact.
In cases of hernia irreducible from strangulation or
adhesion to the sac, post-mortem examination usually shows
that the mesentery or omentum are dragged down with the
bowel and pulled upon, by that adherent or strangulated part
only, the rest of these membranes remaining of their normal
length, and considerably shorter than the retained portion.
But perhaps the most conclusive argument of all is to be
drawn from the fact that we find hernia to be most common,
not in subjects with elongation of the mesentery, but in those
with deficient or peculiar formation in those parts of the
abdominal parietes in which the hernia most commonly
occurs.
It will be at once seen by the reader, that if hernia be pri-
marily and principally owing to abnormal elongation of the
mesentery, any attempt to cure it by closing up the opening,

CAUSES AND PATHOLOGY.
33
and strengthening the abdominal wall, must be futile, or result
in a protrusion elsewhere. It is such a notion which has led
to the popular opinion that the cure of a hernia on one side
will lead to its production on the other. This argument has
been sometimes urged against the use of a truss even on one
side only. The real fact, however-as those who have seen
the most hernia subjects will the most readily allow-is, that
double rupture is as commonly found where no truss at all has
been used-such as congenital cases; or where, on the side first
affected, the rupture has become irreducible, rendering the
retaining power of the truss ineffective.
This much, however, may be granted to the theory under
consideration, that a general laxity of the intestinal attachments
to the posterior wall of the abdomen, coinciding with a similar
condition of the abdominal walls themselves, will predispose in
some measure to the production of a rupture.
But, fortunately for the patient and the reputation of
surgery, the main cause of the evil lies more within the reach
of remedy.
The most eminent authorities on this subject are unani-
mous in support of the second theory alluded to,-that the chief
cause of hernial protrusion lies in a deficiency in some part of
the walls containing the intestines. As to the precise struc-
ture in which the retaining power resides, there is again some
difference of opinion.
Some suppose that the parietal peritoneal layer, spread
over the inner surface of the groin, is the most powerful agent
for retaining the viscera opposite the tendinous openings.
In a perfectly healthy subject, the peritoneum, as well as
the other serous membranes, is more tough, elastic, and re-
sisting than its thin, transparent appearance would at first sight
indicate. At the internal abdominal ring there are evident
traces of a cicatrix closing up the canal of Nuck. This, as
D

34
ON INGUINAL HERNIA.
before seen, is closely attached to the margins of the opening in
the fascia transversalis, and continuous with the tissue which
binds together the elements of the cord. It must evidently afford
considerable resistance to a protrusion, aided as it is by the
slippery smoothness of the serous surface upon which the in-
testinal pressure slides. A sense of something giving way,
which is experienced on the first occurrence of many ruptures,
is probably due to yielding of this resistance coinciding with a
forcible dilatation of the internal ring. Sometimes such yield-
ing may be due to a degeneration of the cicatrix: such com-
paratively adventitious tissues are usually the first to de-
generate. When a pouch is once fairly formed, the process of
dilatation begins; such a pouch, however, cannot be formed until
the internal ring is more or less dilated. Until a rim be
formed round the sac, the intestine cannot fix itself for dilata-
tion, but slips off, and expends its force equally upon the
surrounding parts. Digital impressions without distinct margin
are common enough in the parietal peritoneum, unattended by
hernial protrusion.
In the immediate neighbourhood of the internal ring, the
serous membrane forms a loose fold, the superior false ligament
of the bladder. This is attached to the muscular wall by
tissue so loose and yielding as to afford space and play to the
bladder for its varying volume. When the connexion of the
peritoneum to the margins of the ring is detached, here is
ample supply of serous membrane to form one sac or more of
any ordinary dimensions.
For cases of direct hernia the supply of sac is still more
ready, many of such cases being formed entirely within the
limits of the bladder-fold of peritoneum.
Though weakness and general laxity of the peritoneal invest-
ment may, then, predispose to the formation of hernia, and, in
common with a general laxity in the connexions of the abdo-

CAUSES AND PATHOLOGY.
35
minal layers, facilitate a rapid production and growth of hernial
tumours, yet that this is the chief cause of hernia, as some
suppose, can scarcely be maintained, seeing that hernia frequently
occurs in situations where no such laxity is present. The
lining membrane of the arterial system does not form the chief
resistance against aneurismal protrusion, nor is the synovial
membrane of the joints their principal bond of union.
That the sac of a hernia, however, when thickened by fric-
tion, pressure, and inflammatory deposit, may form a barrier to
further distension, is shown by the dense ring which is formed
at its neck in many old cases. In some it has been found to
have resisted further dilatation so much that a fresh sac
has been formed above it, and the unyielding ring displaced
downwards bodily, so as to form an hour-glass constriction
internally.
In a few cases this separation of the sac into distinct compart-
ments has been found to be complete, affording a valuable hint,
not only as to the inefficiency of a mere adhesion of the sides of
the sac alone in preventing a further escape of sac and intestine,
but also on the possibility of inducing, by external means, such
action in the sac cavity. Sir Astley Cooper, in his valuable
work on Hernia, figures two cases of this kind, in which the
division of the sac was placed at the external abdominal
ring, converting a scrotal hernia into a bubonocele (Plate V.)
In one case serous effusion had occurred in the lower or
closed sac. In Fig. 3 of the same Plate is given a repre-
sentation of a hernial sac interrupted in its formation by many
incomplete septa, each of which had evidently at one time
formed the internal opening of the neck of the sac into the
peritoneal cavity, and become in its turn displaced downwards
by a fresh protrusion of sac above under increased pressure.
Here, as often, Nature points out a means to help us in the
more perfect construction of a barrier, which has failed only
D 2

36
ON INGUINAL HERNIA.
for want of further combination with the tendinous sides of the
hernia track high up the canal.
The chief cause of rupture, then, consists in the inefficiency
of the tendinous or muscular containing walls of the abdominal
cavity in resisting the pressure from within.
The cause of inguinal hernia lies in the failure of the valvular
action of the walls of the canal. According to the way in
which this is effected, the hernia is called oblique or direct
FIG. 4.
inguinal hernia-the one following throughout the oblique
course of the inguinal canal, and the other passing more directly
through the external abdominal ring. Both of these, in ex-
treme cases, descend into the scrotum.
In the adjoining figure (Fig. 4) is represented, on the right
side, the external appearance of an oblique inguinal rupture,
while yet in the limits of the canal, in the condition called
bubonocele; and on the left side, that of a direct hernia

CAUSES AND PATHOLOGY.
37
which has passed into the scrotum.
In oblique hernia it results
primarily from a simple dilatation of the deep ring, followed by
that of the walls of the canal, the pillars of the superficial ring,
and, in the male, of all the coverings of the spermatic cord
which invest it, in regular succession.
In direct hernia it is formed by the giving or splitting of the
fibres of the conjoined tendon and fascia transversalis, internal
to the epigastric artery. The inguinal canal is entered from
the side by a deficiency in the deeper of its valvular walls. In
both, the dilatation of the canal and outer ring is a secondary,
and often a protracted process. The weakness and tenacity of
the layers, the laxity of their connexions, the degree of mus-
cular power residing in the abdominal walls, the prevalence
of a distended condition of the intestines from digestive causes,
and the extent of deposit of adipose tissue in the peritoneal ap-
pendages, all contribute-by the varying amount of disturbance
of the balance between the protruding and resisting forces-to
facilitate or retard the formation of the sac.
The form assumed by the internal opening is always more
or less circular, from the equable nature of the fluid pressure of
the intestinal contents, or of the soft, loose fat of the omentum.
In oblique hernia, the deep epigastric vessels, even in an
early degree of distension, are in close relation, internally and
inferiorly, with the neck of the sac, which is, in fact, half sur-
rounded by them. The larger the internal opening becomes,
the more closely is the neck of the sac embraced by these
important vessels, and the more near is the centre of the
opening brought to the edge of the rectus muscle. The
dilatation is accomplished chiefly at the expense of the
inner and lower borders of the ring, until in large cases of
scrotal hernia, the inner and outer openings are brought fairly
opposite to each other, and the case assumes the appearance of
a direct hernia. It has, however, this important difference-

38
ON INGUINAL HERNIA.
that the neck of the sac is three parts surrounded by the epi-
gastric vessels which are found below, internal to, and sometimes
even partly enveloping, the upper margin of the opening. In
the early stage, the protrusion through the internal ring is re-
sisted by such of the lower fibres of the internal oblique as may
be placed in front of the ring, and by the strong aponeurosis of
FIG. 5.
Dissection from the peritoneal surface of the parts affected by an oblique
rupture. The peritoneum, its fascia, and the fascia transversalis, except a
small portion around the neck of the sac, are removed; the sac is cut off at
its neck in the deep ring; the epigastric artery is seen in its relation below
the neck, at the inner side it is removed to show the deep aspect of the
conjoined tendon (h).
the external oblique forming the upper part of the outer pillar of
the superficial ring. The resistance of these structures turns
the direction of the rupture downwards and inwards towards the
outer ring; while the interval between the cord and Poupart's
ligament at this point is dilated into a cavity lodging the sac,
by the protrusion of the superficial wall forwards, and the

CAUSES AND PATHOLOGY.
39
deeper wall backwards. If the more superficial structures be
very resisting, little tumefaction is produced at the surface, the
yielding of the deeper wall forming the greater part of the space
for the sac.
In direct hernia the protrusion occurs in the triangle of
Hesselbach (see d, Fig. 3, page 25); the epigastric artery is
consequently placed to the outer side and above the neck of the
sac.
Not unfrequently, the protrusion occurs on the inner side
also of the obliterated hypogastric cord which bisects this
triangle, as before described; the serous membrane forming the
sac being derived entirely from the superior false ligament of
the bladder. In such cases, the hernia is rapidly formed, and
increases to a very large size, partly from the abundance of the
supply and the laxity of the serous membrane in this place, and
partly from the directly opposite position in which the internal
opening is placed with regard to the superficial ring. In these
ruptures the finger, passed into the neck of the sac, can feel
the edge of the rectus muscle bounding directly the neck of the
sac internally, while the conjoined tendon is not distinctly per-
ceptible. The functions of the bladder are more interfered
with, and in large cases the fundus of this viscus has been
found involved in the hernia. More frequently, however, the
protrusion of the rupture takes place between the epigastric
artery and the hypogastric cord, in the depression which there
normally exists on the surface of the peritoneum. In all cases,
however, of direct hernia, the protrusion is somewhere within
the limits of the triangle of Hesselbach, and placed inferior and
internal to the internal abdominal ring,-entering the inguinal
canal near the middle of its posterior wall. To accomplish
this, it must either dilate a portion of the conjoined tendon into
a sac covering, or split and separate its fibres from each other;
or, in some cases, it may escape outside the conjoined tendon
altogether, between it and the epigastric artery, pushing before

40
ON INGUINAL HERNIA.
it only the fascia transversalis. In the first case, which is most
common, the sac is covered by an attenuated dilatation of the
outer part of the conjoined tendon, rendering the complete in-
vestments of the hernia rather thicker and more resisting than
in the latter. In the second case, the coverings are thin, but
the edges of the internal opening more acute, and more apt to
form a dangerous strangulation. In the last case, there may be
a close resemblance in appearance to an oblique hernia, even
extending to a covering of a few of the fibres of the cremaster
muscle spread over the sac, while the conjoined tendon remains
untouched, forming the chief part of the deeper wall of the
hernial canal.
When a hernial protrusion is once fairly established in the
inguinal canal, the action of the rectus abdominis muscle upon
its posterior wall tends powerfully to aid in its dilatation.
Enclosed in a sheath derived from the upper part of the con-
joined tendons of the internal oblique and transversalis
muscles, and more or less attached to the fascia transversalis at
the thin border of its outer tendinous origin,-the backward
and upward traction of this muscle upon the posterior and
superior boundaries of the canal tends to open up the passage
and to admit of the further progress of the hernia. At the
same time, its backward pressure upon the intestines forces them
outward upon the yielding aponeurotic structures in the groin.
On a close inspection of the hernial passage, it will often be found
that the chief yielding takes place at the superior and posterior
parts of its walls, and that the cavity within the abdominal
walls is much larger than the degree of bulging of the anterior
wall indicates. If the aponeurosis of the external oblique be
"strong, the arciform and intercolumnar fibres resisting, the ex-
ternal ring small, and its pillars well bound together, a consider-
able dilatation, at the expense of the superior and posterior walls,
take place with but little external evidence of its presence.
may

CAUSES AND PATHOLOGY.
41
This condition of an inguinal hernia, confined within the
thickness of the abdominal walls, with a bulging of anterior
wall or of the fascia covering the superficial ring, is termed
bubonocele. (See Fig. 4.) In such a state the rupture may con-
tinue for a greater or less period without making any apparent
advance in size, and may be retained by the pressure of a truss
without entire reduction of its contents; which, consequently,
are still subject to the danger of strangulation at the internal
opening. In bubonoceles of long standing I have often found
a large internal cavity, with a superficial ring but little dilated,
and a very slight external tumour. When, in such
When, in such cases, the
superficial ring is at length dilated, and the tumour escapes
into the scrotum, it assumes the appearance of a direct hernia,
though it may traverse the entire inguinal canal. The influ-
ence of the rectus muscle upon the hernial passage and back-
ward protrusion of the posterior wall, has an important bearing
upon the radical cure of hernia, as showing the necessity of
including this part in the action of the ligature, and thus pro-
curing its adhesion to the anterior wall.
The sac of an oblique hernia is placed in front of, and to
the outer side of the spermatic cord, and exerts its dilating in-
fluence primarily and chiefly upon the outer pillar of the outer
ring. Invested with all the coverings of the cord, the deepest
or infundibular fascia keeps it in close relation with the elements
of this important structure.
The sac of a direct hernia is placed to the inner side of
the cord and its infundibular and cremasteric coverings;
and, while in the canal, is more distinct and distant from
it than an oblique hernia. It exercises its dilating action
chiefly upon the inner pillar and intercolumnar fascia. When
emerging into the canal outside the conjoined tendon, it
is apt to get quite behind the cord, as seen by Le Dran,
Schmucker, and Blizard. An instance is given by Sir Astley

42
ON INGUINAL HERNIA.
Cooper, of the elements of the cord, as well as the cre-
master muscle, being spread over the surface of the sac; the
vas deferens being separated, by the lateral distention, from the
spermatic vessels. (Op. cit. Plate V., Fig. 5.) A somewhat
similar case is recorded by Camper. The possibility of such a
condition must be carefully borne in
treating hernia.
mind by the surgeon, in
The
That part of the sac of a hernia which is involved in the
abdominal wall becomes the neck of the sac when the tumour
has passed the superficial ring, and entered the scrotum.
distention in the latter place is then termed the fundus of the
tumour. In the direct variety the neck of the sac is short,
and the opposing influence of the valve action of the canal
is more or less completely destroyed. This renders it more
difficult to produce an extensive union of its sides by the
radical cure.
It is, therefore, more liable to a return after
operation than in the oblique variety, in which the neck of the
sac is more extensively embraced by the canal, and in which
the valve action of the latter may be completely restored, and
a broader surface of adhesion secured. At the same time, the
greater separation from the spermatic cord in direct hernia
gives a greater facility for the application of ligatures to unite its
borders to each other and to the coverings of the superficial ring.
The form assumed by the external ring under the distend-
ing force of a hernia of either kind is usually an obliquely
ovate. The sides are formed by the pillars of the ring, the
upper end by the intercolumnar and arciform fibres, and the
lower by the crest and spine of the pubis. Upon the number,
extent, and strength of the intercolumnar fibres depends the
degree of resistance afforded by the superficial ring to dilatation,
which is effected by a separation of the sides of the opening
in the tendinous fibres of the external oblique. In open con-
ditions of the superficial ring, the intercolumnar fibres are often

CAUSES AND PATHOLOGY.
43
arrayed in one mass or bundle placed above the middle of the
opening.
Occasionally, in oblique hernia, the long diameter is so
great that the opening feels somewhat like a slit. These con-
stitute generally more favourable cases for operation. Some-
times the orifice is so widened that the long diameter is ren-
dered almost transverse. In direct hernia the shape of both
the deeper and more superficial opening has a tendency to be
nearly or quite circular. This difference is accounted for by
the more direct pressure from within, in the latter variety.
The pillars form a much more resisting and compact tissue
than the intercolumnar fascia, and are simply pushed aside and
everted by the pressure of the tumour, while the latter is dis-
tended and dilated into a covering for it as it passes into
the scrotum. In the oblique variety the outer pillar is usually
the more everted, and placed at its insertion more completely
behind the sac than in direct. Between it and the sac lies
the spermatic cord, usually plainly distinguishable just outside
the pubic spine. The intercolumnar arciform fibres, in large
cases, are stretched and frayed out to the utmost above the
neck of the sac. In a direct hernia the protrusion affects more
and earlier the internal pillar of the ring, but, when large, the
outer pillar also is compressed and everted; the spermatic cord
is also pushed outwards so as to lie further from the pubic
spine than its normal position.
It is of the greatest importance to recognise the eversion of
the pillars of the outer ring just alluded to, in performing the
operations for the radical cure hereinafter described; and to
place the ligatures or pins so as to include the everted portions,
and to bring them fairly in apposition by the pressure of these
instruments.
Both the varieties of inguinal hernia receive an additional
covering of the intercolumnar or external spermatic fascia, as

44
ON INGUINAL HERNIA.
they traverse the external ring. This fascia is often very strong
in old herniæ, and, when folded, compressed and consolidated
by the action of the ligature after an operation, forms an addi-
tion to the barrier against a fresh protrusion. In an oblique
hernia, covered by the cremasteric fascia, that structure forms
the thickest of the deeper coverings, and constitutes the greater
bulk of the invaginated tissue after operation. As a rule, the
coverings of a direct hernia are thinner and less bulky;
many exceptions, are, however, found in old cases.
In some cases of scrotal hernia I have met with, the
external ring has been so small, and its pillars so resisting, as
to admit with difficulty the fore finger. The tumour in the
scrotum, in these cases, was considerable, and the cavity within
the abdominal layers so large, as to give a distinct hour-glass
shape to the sac of the hernia (see Fig. 6). In the adjoined
figure, taken from a dissection of an oblique rupture, the upper
dilatation is so large as to distend and fray the thinner inter-
columnar fascia above a centrally placed bundle of arciform
fibres, and give a distinct double-bellied appearance to the
protrusion externally. The firm resistance of the outer ring to
distension, in such cases, seems to depend mainly upon the bulk
and strength of this bundle of arciform fibres. The hernia
had probably existed for a long time as a bubonocele before it
finally burst through the ring into the scrotum.
In some eases recorded by Cooper, and in one or two met
with by myself, a rupture has escaped from the inguinal
canal, not through the superficial ring, but by splitting the
fibres of the external pillar itself. In these instances, ap-
parently, the strength and resistance of the arciform fibres has
been concentrated in one spot lower down than usual, and the
rupture has burst through or distended the thinner fascia bind-
ing the fibres of the pillar together above. In such a case the
sac of the hernia, covered only by the infundibular and cremas-

CAUSES AND PATHOLOGY.
45
teric investments, would lie close to Poupart's ligament, and
immediately under the superficial layers of fascia. Thus it may
simulate a crural hernia by resting more or less upon the
adductor muscles of the thigh. In one of my cases, as
seen in the Appendix (Case 22), this occurred after operation
FIG. 6.
for the radical cure, through the internal pillar; probably
through one of the needle punctures.
The principal thickness of the covering of a hernial sac is
the superficial fascia, especially if the patient has a tendency to
obesity. Its loose connexions, yielding nature, and the varying
amount and want of permanence of the fat, which is its chief
constituent in bulk, render it little to be depended upon as a

46
ON INGUINAL HERNIA.
barrier against the descent of a hernia; and in the operations
about to be described, it is little used as an effective agent of
security. Its looseness is so great in some patients that an
inexperienced hand may invaginate the scrotum under the
skin of the groin, so as to produce the appearance of having
entered the superficial ring, without getting into the inguinal
canal at all. Operations have even been done under these
circumstances with a result that will easily be imagined.
As a general rule, the structures described in treating of
the anatomy of inguinal hernia are demonstrated more decidedly,
and are more evident to the touch, when a hernia has been
present in the canal for any length of time; and the looseness
of their connexion to each other in such cases permits of a
more distinct discrimination. This is the case to a remarkable
extent in old scrotal herniæ.
The different points at which the layers of the abdominal
walls react upon a distended hernial canal and produce strangu-
lation, gives us some hints as to the assistance which Nature
is disposed to render in effecting a closure of the canal.
The most frequent situation is at the internal opening of
the sac into the peritoneal cavity.. Except in a certain
class of cases, the increase of danger consequent upon enter-
ing with instruments the abdominal cavity itself, will deter
the surgeon from including freely this part of the rupture
in his manipulations. He can, however, so operate as to
cause adhesion of the parts which lie superficial to and
around it, so as to cause them to become bound together,
and prevent protrusion through the opening. The next
point in the order of frequency is the lower border of the
internal oblique and edge of the conjoined tendon. These
structures, by the methods given in the succeeding pages,
may be fairly and easily included in the ligatures. Oc-
casionally, but least commonly, and generally in large rup-

CAUSES AND PATHOLOGY.
47
tures, strangulation occurs at the external ring.
This
part of the canal is necessarily included in reaching the parts
above it, and may be reached and operated on with great ease,
and effectively closed by adhesive action. But if no more be
effected, its closure does not prevent the formation of a bubono-
cele in the unclosed canal above, which remains sufficiently
long to admit of a considerable knuckle of bowel, and to permit
of strangulation at the inner opening. At the same time, the
narrow line of adhesion accomplished by the operation will in
time yield before the persevering efforts of the protruded bowel
to escape into the scrotum.
In a recently formed hernia of either kind, in which the sac
has not had time to form strong adhesions to the spermatic cord
or canal, it may be detached by the finger, and pushed up into
the abdominal cavity. The sides of the canal may then be
drawn together and made adherent, without implicating the
serous membrane at all. The elastic resiliency of the tissue
composing the sac, when not diminished by too much or too
long a state of distension, will speedily obliterate the "cul de
sac" when the distending force is withdrawn. In such cases, the
sac partaking more entirely of the character of peritoneum, and
deriving its vascular supply altogether from its parent source, is,
perhaps, less tolerant of operative interference than a sac of
greater age. It may therefore be more satisfactory to some
surgeons to avoid implicating it in the operation, if possible.
In ruptures of long standing, especially if scrotal, the sac
contracts intimate vascular connexions with the cord and
scrotal coverings. These vessels are supplied almost entirely
from external and parietal sources, and the sac itself has thus
become a structure almost independent of its source, the peri-
toneum. This is the case to a still greater extent, if a gristly
ring of consolidated effusion be formed around the mouth of
the sac at its junction with the peritoneum, as frequently

48
ON INGUINAL HERNIA.
happens, cutting off its vascular and nervous continuations, and
rendering it a structure more or less distinct. That under such
circumstances it may be cut off, or subject to inflammation,
suppuration, or even mortification, without giving rise to any
symptoms of peritonitis, is an observation made long ago by
surgeons of experience.
In the scrotum, the adhesions of the sac are much more
close and extensive behind, and about the spermatic cord, than
to the more anterior structures, especially in oblique hernia.
When invaginated into the hernial canal above under these
circumstances, it usually drags up the cord with it and elevates
the testicle. The circular fold or "cul de sac," formed by
invagination, is thus rendered necessarily deeper behind than in
front of the invaginated part. (See Fig. 20.) This fact has an
important bearing in estimating the causes of a return of the
protrusion after any operation by invagination of the sac.
The shape and outline of the hernial sac and canal present
many varieties, the recognition of which is of considerable im-
portance, since the surgeon may often take advantage of their
aid in effecting a radical cure.
In the dead subject, the shape of the sac may be obtained
very readily by injecting plaster of Paris, and thus forming a
cast of the interior. The outlines of the chief varieties I have
met with are given in the margin.
FIG. 7.
As a rule, it will be found that the
irregularities are in the inguinal canal,
affecting the sac near its neck, precisely in
that part most important to the operator.
In most cases of oblique hernia, the
narrowest part of the sac is at the internal
opening, and the sac is more or less pyriform (Fig. 7). In
some cases of congenital hernia, and frequently in bubono-
celes, the sac may continue of the same diameter through-

CAUSES AND PATHOLOGY.
49
out (Fig. 8). In many cases the sac is
compressed or flattened antero-posteriorly
between the layers of the abdominal wall.
In some old bubonoceles, the widest part
of the sac is found at the internal ring, a
large cavity existing in the dilated inguinal
canal (Fig. 9).
In some, there is a well marked con-
striction at the lower border of the internal
oblique muscle, extending more or less to
the inner and posterior part by tension
of the conjoined tendon (Fig. 10).
In many of the scrotal variety, as before
alluded to, the superficial ring is more
resisting than usual, and indents the sac
all round (Fig. 11). The impression caused
by unusually strong and compact arciform
fibres in front of and above the neck of
the sac has also been before mentioned
(Fig. 12). So also has the occurrence of
a double or many times repeated sac, one
above the other, and separated by a per-
forated diaphragm of thickened and callous
serous membrane
membrane (Fig. 13). In some
cases this partition is more imperfect, a
ridge or ledge being present on one side
only. This is usually found at the inner
and posterior side of the sac, being origi-
nally formed at the more acute part of the
margin of the deep ring (Fig. 14).
In direct hernia, the shape of the sac
is usually more simple, the constricted
portion being at the opening in the con-
E
FIG. 8.
FIG. 9.
FIG. 10.
FIG. 11.
FIG. 12.
FIG. 13.
FIG. 14.

50
ON INGUINAL HERNIA.
FIG. 15.
FIG. 16.
FIG. 17.
FIG. 18.
joined tendon; and the fundus, globular or
flask-shaped under distension (Fig. 15).
When the hernia is fairly in the scrotum,
the uniform yielding of its coverings
usually gives a more or less globular shape
to the fundus. To this there is an occa-
sional exception in the presence of a slight
hour-glass constriction in front, impressed
by a more compact line of fascia about the
middle of the scrotum (Fig. 16). This
appearance is not uncommonly seen in
hydrocele of the tunica vaginalis. In some
cases, the scrotal tumour approaches closely
in form to the pyriform shape of a hydro-
cele, with a small inguinal passage, espe-
cially in muscular subjects who have not
worn a truss (Fig. 17).
I have myself met with a few. cases in which there was a
formation, more or less complete, of a double sac within the
inguinal canal; one protruding at the internal ring, and another
through the conjoined tendon in the
usual site of a direct hernia (Fig. 18).
A case of such a kind will be found in the
Appendix, cured by operation by ligature
(Case 21).
FIG. 19.
Other cases are recorded, in which a
double sac has been found protruding at
one internal opening in the abdominal
wall (Fig. 19). The explanation of such
cases seems to be, that the neck of a small
primary sac has become thickened and
closely adherent to the fascia transversalis or conjoined tendon,
so as to be immovable downward under the pressure of the
intestines, while the loose serous membrane on one side of its

CAUSES AND PATHOLOGY.
51
neck has protruded under the pressure into another sac. A
remarkable instance of direct hernia, where this occurred on
both sides in the same patient, between the epigastric and
obliterated hypogastric arteries, with the addition of a third
protrusion on each side between the latter and rectus muscle,
is illustrated by Sir A. Cooper, (Op. cit., Plate VIII.) In
this case the sacs passed through separate openings in the
conjoined tendon, the interval between them being in both
cases very small. Another more simple case is also figured by
this author in the same work.
The presence of a tumour upon some part of the cord may
modify considerably the shape of a hernial sac; as may also the
co-existence of a hydrocele of the tunica vaginalis.
In children, its investments may be modified by the invagi-
nation downwards before the pressure of the fundus of a large
tunica vaginalis; constituting the variety called infantile hernia.
This variety, however, does not appear to call for any particular
modification in the attempt to produce a cure.
In operating for the radical cure of hernia, a ready surgeon,
following the principles recommended in the following pages,
will take advantage of and employ most of the irregularities
just described, in applying his instruments.
The same pecu-
liarities, however, will be found to present difficulties almost
insuperable, in the treatment by invagination with a plug.
So much has this been experienced, that various contrivances
for increasing the internal dilating power of the instrument
have been had recourse to, with the usual result of failure;
being based upon the false principle of dilatation of the openings
in order to effect their closure.
General Characteristics of the Subjects of Inguinal Hernia.-
An extended observation of cases of inguinal hernia will not
fail to recognise at least three different conditions of individual
development co-existent therewith,
E 2

52
ON INGUINAL HERNIA.
The
In one class of cases, the muscular system is well developed.
The recti are distinctly defined, curving boldly at the outer
border, and between the linea tranverse; and so broad as to
reach nearly half-way over Poupart's ligament. The external
oblique is massy, and its muscular outline well defined.
internal oblique and transversalis hug closely the spermatic
cord; the former muscle passing well down at its origin from
Poupart's ligament, so as to cover the internal ring. The cre-
master is powerful, affording a thick covering to the finger
when passed into the hernial canal. The hips are narrow; the
anterior iliac spines well closed in; the inguinal canal and
Poupart's ligament short; the genital organs small and well
braced up.
The pillars of the superficial rings are usually
tense, and easily recognised by the finger. The outer pillar is
sometimes narrow and cordlike, and for some distance from the
pubic spine is completely identified with Poupart's ligament.
The distinction between the margins of the ring and the
coverings of the hernial sac is very evident to the touch; the
tenuity of the intercolumnar fascia contrasting with the firm
and tense pillars of the ring. The arciform fibres often form a
sharp impression across the neck of the sac. The hernia is
frequently direct, sometimes separating the fibres of the outer
pillar. The sac is small in diameter; but, when scrotal, much
elongated, with a narrow and flask-shaped neck; the fundus apt
to become pyriform, and, if irreducible, to simulate a hydrocele,
or other affection of the cord and testicle.
Under the dissector's knife, the tendinous structures are
found to be firm and strong, but thin and disposed to sepa-
rate in fissures, from the delicacy of the connecting tissue. The
fasciæ are fine, but tough, elastic, and resisting, containing but
little fat in the meshes. The peritoneum is pliable, elastic, and
translucent; and the whole of the abdominal layers are flexible,
but glide upon each other to a limited extent only. The tissue

CAUSES AND PATHOLOGY.
53
of the sac itself is thin; the areolar network of its fibres spread
out and frayed, still, however, retaining a considerable portion
of elasticity.
The subjects of the rupture are able-bodied men, soldiers,
sailors, or labourers. The rupture occurs suddenly, with a sense
of something giving way, often with pain and sickness; in con-
sequence of violent simultaneous action of the powerful abdo-
minal muscles, compressing the viscera upon the comparatively
thin tendinous and fascial structures. There is a want of
proportionate development between the muscular compressing
forces and the fibrous resisting tissues; resulting in a splitting
of the latter, or a dilatation of the more yielding portions.
These cases are prone to that violent form of strangulation
mostly dependent upon spasmodic contraction of the internal
oblique across the neck of the sac.
A second class of cases is marked by a greater development
of the fibrous and fascial structures, with less extent and power
of muscle. The subjects are wiry and sinewy men, often of
a loose and shambling gait. The pelvis is large, with wide-
spreading wings; the inguinal canal and Poupart's ligament
consequently long, giving a broad appearance to the flanks.
The tendon of the rectus is long, and the belly of the muscle
begins to spread out at a higher point than in the first class of
cases, leaving a greater space in the groin to be closed in by
aponeurotic structure. The muscular part of the external
oblique is small in proportion to the extent and thickness of its
aponeurotic expansion. The internal oblique and transversalis
arise from a small part only of Poupart's ligament. Their
lower fibres, though tolerably thick, do not close up to, nor
cover perfectly the internal ring. The cremaster is often large,
and arises high up from Poupart's ligament, often so as to cover
the internal ring, and thus to supplement, though less effec-
tively, the imperfect downward development of the internal

54
ON INGUINAL HERNIA.
oblique. The total effect of this arrangement of the muscles
and aponeurotic layers is to depress the belly towards the
median groove, and to produce extensive bulgy projections
towards the iliac wings and Poupart's ligament; an appearance
which is so remarkable as to be recognised at a single glance,
and indicates a hernial predisposition when no hernia is actually
present. The genitals are usually large and loose, with a
pendulous scrotum; indicating an abundance of fascial formation
and a feeble development of the muscular fibres of the dartos.
The tendons and fascia are thick, close, and bulky; but in-
elastic, and apt to be weakened by rheumatic changes or fatty
degeneration, especially after middle age, rendering them less
able to resist pressure. The abdominal rings are long and
open, and the canal loosely built. The pillars of the superficial
ring are stout and thick; but lose themselves more imper-
ceptibly in the thick coverings of the hernia sac, so that their
edges are less evident to the touch. The outer pillar is often
loose, baggy, and much everted, giving great play to the rup-
ture, or to the surgeon's finger placed in the inguinal canal.
The hernia is usually of the oblique variety, and of slow formation,
increasing by starts after greater exertion than usual. It is
often large, with a wide and infundibular neck, and a large in-
ternal opening. Its investments are generally thick, firm, and
resisting, especially where the arciform bands pass across the
neck. When these are unusually developed, which is often
found in these cases, rendering the superficial ring small, the
rupture is apt to remain for a long time as a bubonocele ;
dilating into a large cavity the internal ring and inguinal canal,
and producing a bulge between the aponeurotic fibres above
the arciform bands. When in the scrotum, the tumour is often
rendered more or less hour-glass shaped, by an obliquely trans-
verse band of strong fibres developed in its superficial invest-
ments halfway down the cord.

CAUSES AND PATHOLOGY.
55
In these cases, a thick gristly ring is apt to form in the
substance of the sac at its neck, or strangulation may be caused
by thickened bands of the deeper fascia. The serous membrane
of the peritoneum and sac is found to be thick, and not unfre-
quently opaque; and, probably, in old cases undergoes fatty
degeneration, rendering it yielding and inelastic. Under the
microscope, its yellow fibrous element is found to be more
scanty, and to curl less vigorously than normal, while the
areolar meshes are loose and large.
cure.
This kind of rupture is a favourable one for effecting a radical
The fibrous structures being thick and resisting, hold
well under a ligature; and a large amount of consolidation and
adhesion is usually the result. Barriers are often partially set
up by Nature in the progress of the case; and these, though
imperfect, may often be taken advantage of and fortified by
the surgeon.
In a third class of cases, the groins and spermatic apparatus,
and, in a less degree, the whole system, retain many of the
foetal peculiarities. The individual is usually plump, fat, and
round. The pelvis may be ill-formed through rickets; having
a tendency to the ovate deformity, with an unsymmetrical
widening of the ventral notch, and spreading of the iliac wings.
The abdomen is protuberant from imperfect abdominal mus-
cular development. Towards the pubis the integuments are
often wrinkled transversely; the mons veneris being large, loose,
arranged in transverse masses of fat, and scantily clothed with
hair. The penis is small, usually with a redundant prepuce;
and the scrotum is shallow, broad above, and tapering inferiorly
into the rounded infantile form. The spermatic cord is short
and thick, and often encumbered with fat. The inguinal rings
are very patulous, lax, loose, and capable of easy dilatation.
The pillars of the superficial ring are small, thin, and not so
easily made out as in the former cases, being gradually and

56
ON INGUINAL HERNIA.
insensibly lost in the coverings of the sac. They are weak,
easily torn and cut, and do not hold a ligature well. No im-
pression is made on the sac by the arciform fibres. The finger
placed behind the outer pillar recognises Poupart's ligament
as the only decided salient structure, and thin, narrow, and
sharp. The inguinal canal is short and wide; the internal
opening large, and its edges not easily distinguished. The
lower border of the internal oblique is feeble and indistinct; and
the conjoined tendon can only be felt by making strong traction
forward, so as to raise considerably the lower edge of the
muscle. The cremaster is feebly developed, and its fascia par-
takes of the general character of tenuity.
The muscular tissues are found, on examination, to be ill-
developed; the fibres with a tendency to spread out, and separated
by large areolar intervals. The fascia and coverings of the
hernia are thin, the bulk of these tissues being made up of
fat. The interposition of masses of adipose tissue permits the
different layers to slide over each other more readily and ex-
tensively.
The peritoneum is lax and loose, and plentifully bestowed
upon the superior false ligament of the bladder, which rises more
than usual out of the pelvis when distended, and is broader in
proportion to its depth. The serous membrane of the sac is
more apt to be the subject of complications and adhesions than
in other cases; and more frequently contains omentum, in which
fat is apt to be plentifully developed.
These cases are commonly congenital or infantile in origin.
Retarded development has probably led to a late descent of the
testis, and to an imperfect closure of the inguinal openings,
followed closely by a protrusion of bowel or omentum. It may
attain to a very large size almost imperceptibly, and with little
or no pain. Some of the largest ruptures I have met with
were of this kind. In one which has lately come under

CAUSES AND PATHOLOGY.
57
my observation the testicle had almost entirely wasted
away from the pressure of the tumour. This kind of rupture
is perhaps less subject to strangulation than the others,
because of the laxity of the circumjacent parts and the size
of the internal opening. The same looseness of tissue, however,
favours the occurrence of burrowing of matter after operation
for strangulation or the radical cure. A certain want of vigour
in the constitution also renders ultimate success in the latter
operation less certain than in other cases.
Coexistent with this condition of the soft parts, the
pelvis in such subjects often presents an increased degree of
obliquity upon the line of the spinal column, attended with an
increase of the forward projection of the lumbar curve and
sacral promontory.
The effect of this arrangement is to
diminish the containing capacity of the cavity for the viscera ;
and to cause the abdomen to be unusually projecting, and to
slope rapidly and deeply into the hollow of the groin. The
weight and bearing of the intestines are thus, in the erect
and sitting postures, thrown mainly upon the lower part of the
anterior abdominal walls; and the pressure of the abdominal
muscles is exerted more directly upon the inguinal openings.
When such a condition is accompanied by a tolerable size of
the deep hernial aperture, there is great difficulty in fixing pro-
perly the bearings of a truss, so as to be effective in keeping up
the rupture. In extreme cases, indeed, I have experienced the
difficulty of retaining the rupture, during muscular exertion,
by any kind of truss or support whatever. The increased
obliquity of the pelvis normal to young children, frequently
baffles the truss-maker in the retention of congenital cases of
rupture. Its persistence in the adult period, in the class of
cases under consideration, may be taken as a further instance of
the prevalence of the foetal type. I have, however, met with
it, though less commonly, in cases which I should place in one

58
ON INGUINAL HERNIA.
of the two former classes of cases, giving rise to much difficulty
in the efficient adjustment of trusses.
It is commonly in the last class that those cases may be
placed, in which the development of masses of fat in the sub-
serous tissues, and within the coverings of the cord, by their
presence and pressure increase the tenuity of the areolar and
fibrous tissues, and open the lax spermatic passages.
In dissecting these cases, the peritoneum is usually found
thinned to the utmost extent by the gradually filling up and
dilatation of its areolar meshes by fatty deposit. In the omentum,
particularly, it may be entirely perforated in many places, so as
to assume a cribriform appearance; while vast masses of fat
fill up the folds. This takes place also, to a great extent, in
the parietal portion of peritoneum, especially about the kidneys
and inguinal region. The serous membrane is of great
tenuity, but at the same time retains much of its elasticity.
If in such a state of things the fat be quickly absorbed by
illness or starvation of the patient, the more temporary tissue,
-the fat, becomes used up more quickly than the containing
tissues are able to contract and follow it. The inguinal, and
other hernial openings are left patulous, and the weakened and
yielding peritoneum quickly contributes a thin sac. A rapidly
forming hernia is the result; the looseness of the layers, and
their easily-sliding connexions, quickly accommodating them to
the change.
Congenital Hernia. (See Fig. 68.)-In this form of rup-
ture the sac is formed of that process of the peritoneum
which, being drawn down along with the testis by the
gubernaculum, forms, under conditions of uninterrupted de-
velopment, the separate shut sac of the tunica vaginalis.
The passage of the testis through the inguinal canal usually
takes place about the eighth month of intra-uterine life. Under
conditions retarding the processes of development, however,

CAUSES AND PATHOLOGY.
59
few years.
this transit may be delayed until after birth; and may be ob-
served to occur in some children at any period during the first
Cases are not uncommon in which this process is
retarded until the period of puberty has passed. In such
instances, the gland is almost always retained permanently
within the abdomen by adhesions to the colon or parietes; and
is usually more or less atrophied. Sometimes it is arrested in
the inguinal canal itself, and is not unfrequently mistaken for
a hernia. The impulse given to the gland on coughing, under
these circumstances, results from the presence of a portion of
intestine or omentum in a "cul de sac" of the peritoneum
above the gland, arrested in its development into the tunica
vaginalis and canal of Nuck.
There can be little doubt but that the main cause of the
formation of congenital hernia resides in the retardation and
want of vigour of the developmental changes which seal up the
inguinal rings and canal, after the testis has accomplished its
transit. If the gland at the period of birth has but just
escaped from the canal, or still lies lodged above the super-
ficial ring, the cries and struggles of the infant during its first
powerful inspiratory efforts, will force down a portion of bowel
through the deep opening into the canal. The habitual re-
currence of this protrusion will afterwards prevent the due
closure of the openings. The cure or permanence of the
rupture will then depend upon the issue of the struggle between
the power of developmental change and the habitude of dis-
placement of the bowel. As a rule, the later the descent of
the testis through the rings is accomplished, the larger and
the less disposed to close is the rupture opening which
succeeds.
In many individuals not ruptured in childhood, a late descent
of the gland leaves a patulous condition of the superficial ring,
which predisposes greatly to the subsequent formation of a

60
ON INGUINAL HERNIA.
hernia; the only resistance in such cases being a limited extent
of adhesion at the upper part of the canal and deep opening.
It is generally associated with the feebleness and deficiency of
the lower fibres of the internal oblique muscle before alluded
to. A similar formative deficiency in some of these cases, ex-
tending to the gubernacular contractile apparatus, may account
also for the non-descent of the testis.
In the early period of life, while development is proceeding
with more or less vigour, the tendency of an inguinal rupture,
as in the case of an umbilical protrusion, is always to close up
and become obliterated. To aid the process, and in most cases
to render it at all effective, it is necessary to exclude the bowel
completely from the sac for a sufficient length of time. This
is not frequently accomplished by the ordinary way of applying
truss pressure; and, in most cases, demands a more effective
method. From the time that the sac was last dilated by the
intestine, we must continue to date the commencement of the
curative process.
The first part of the canal of Nuck to close, after the
passage
of the testis, is its communication with the peritoneum at the
deep ring, leaving the cicatrix, before described, at that place.
Occasionally, at this stage of the process, an extraordinary
degree of pressure of the viscera above, will protrude a distinct
sac of peritoneum through the still patulous opening in the
fascia transversalis; and by involuting the upper part of the
elongated tunica vaginalis in the manner of a double nightcap,
will produce that form of rupture called "Infantile Hernia."
This is characterized by the intervention of three distinct
layers of serous membrane, between the skin and that which
covers the intestine. Of these, the two outer belong to the
invaginated tunica vaginalis, and the inner constitutes the true
sac of peritoneum. It will be evident that this kind differs in
an important degree from the usual form of congenital hernia,

CAUSES AND PATHOLOGY.
61
in which, the sac being formed by the cavity of the tunica
vaginalis itself, the bowel lies immediately in contact with the
testis and its appendages.
It follows from the above description, that congenital rupture
must necessarily be of the oblique variety in its relation to
the deep ring and epigastric artery. In long-continued and
neglected cases, the deep and superficial openings are often
closely applied to each other, and the rupture becomes, in its
treatment and the difficulty of its management, like a direct
hernia. A true direct hernia is, in my experience, rarely seen
in the child. One specimen, however, I have recently met
with, and operated on successfully for the radical cure.
58, Appendix.)
(Case

62
ON INGUINAL HERNIA.
III.
DIAGNOSIS OF INGUINAL HERNIA.
IN no other disease is a correct diagnosis more necessary, or
a mistake more glaring, and in certain cases more dangerous,
than in the treatment of this complaint; whether urgent, or
palliative, or with the view of effecting a radical cure.
It is in the latter relation, especially, that it is proposed to
consider its diagnosis in the present volume.
The complications resulting from its association with the
spermatic cord and testicle, with their coverings, render it very
liable to difficulty in diagnosis. It may be said that the side
to which a mistake generally tends is, to that of treating a
doubtful tumour as a rupture.
A hernial tumour, when small, is more or less globular, the
most part of its surface being, in a greater or less degree, ob-
scured and engaged in the abdominal wall. When large, it
has a tendency to be flask-shaped; a distinct neck of uniform
thickness fairly disappearing into and distending the abdominal
opening, while the dilated globular fundus is lodged under the
skin of the groin or scrotum. (See Fig. 4.)
The great characteristic of hernial protrusions of the abdomen,
when not strangulated, is the peculiar distending impulse im-
pressed upon them by coughing, sneezing, or other sudden
effort of the respiratory muscles; giving rise to a quick com-
pression of the abdominal viscera against the sides of the con-
taining cavity. It is important carefully to distinguish the
true hernial impulse from the general impulsion of the abdo-
minal walls which takes place in the above actions.

DIAGNOSIS.
63
If a hand be placed upon each groin in a healthy subject,
when a cough is given-it will be found that a forward impulse
is communicated to the inguinal structures by the jerk of the
viscera against them from behind. Now, if the finger be placed
upon or within the superficial ring, a similar impulse will be
felt, and in the same direction-viz., forwards, outwards, and a
little downwards. This impulse is communicated by the pos-
terior wall of the inguinal canal.
Again, if a tumour exist on the surface of the groin, or is
connected with its aponeurotic structures, the impulse will be
communicated to it in the same direction. Nothing is more
common than to mistake this for a hernial impulse.
If an oblique inguinal rupture be felt under the same
circumstances, the impulse will be felt to be directed forwards,
and more or less inwards; and it will be a dilating impulse,
similar in character to the dilating pulse of an aneurism, as
distinguished from the pulsation impressed upon a tumour
placed in mere contact with the artery. This dilatation, at
the moment of succussion, may be rendered more evident
by holding lightly upon the tumour the ends of a couple of
pencils or quills, placed at a little distance from each other.
They will be seen to diverge from each other at the projecting
extremities; showing a distending influence in the basis on
which they rest.
The value of the evidence derived from this symptom depends
entirely upon a proper appreciation by the hand of the surgeon,
of this dilating impulse. If the rupture be large, and have a
narrow neck, the ballottement will be to an appreciable extent
consecutive to the general abdominal cough impulse, from a
retardation in the wave of impulsion. This retardation, how-
is absent in hernial sacs with wide necks.
ever,
At an early stage of the protrusion, or even before a true
hernial sac has formed, a yielding or bulge is observable at the

64
ON INGUINAL HERNIA.
moment of coughing, above the middle of Poupart's ligament;
indicating a yielding condition of the internal ring, and a
weakening of the deeper structures. I have found this con-
dition present in a great many patients to whom no suspicion
of rupture had occurred. It indicates a strong predisposition
to hernia.
The degree of dilating impulse in a hernia depends much
upon the nature of its contents. If it contain bowel (enterocele)
it is more evident than if it contain omentum only (epiplocele).
The fluid or gaseous contents of the bowel more readily transmit
the pressure.
If the omentum be thickened by inflammatory
Adhesions of
or other deposit, the impulse is still less marked.
the contents of the sac to each other, or to the sac itself,
especially near the neck, also diminish the impulse.
In a
In certain cases, on the other hand, the dilating charac-
teristic of the impulse is increased. This is remarkably the
case when effusion has taken place into the sac itself.
remarkable case of irreducible hernia, shown in the theatre of
King's College Hospital two years ago, in a child sent to me
by Mr. Colgate of Eastbourne, the presence of two hard bodies
connected with the omentum, and which I considered to be
peritoneal concretions of the ordinary albuminous nature and
cartilaginous consistence, gave rise to a peculiar and distinct
ballottement, by their contact with the hernial walls, while
floating in effusion set up by their presence in the sac.
In large ruptures, the presence of scybalous or other hard
substances, floating in the liquid contents of the bowel, will also
increase the impulse communicated to the fingers.
It is usually greater when small intestine is contained in the
sac than where the large bowel is present, on account of the
greater liberty of movement allowed to the former within the
peritoneal cavity, and its smaller calibre.
Another characteristic of hernial protrusions is recognised in

DIAGNOSIS.
65
the mode of their formation. They make their first appearance
in the deeper parts, and grow from within and above, down-
wards and forwards, towards the most depending part of the
superficial investments; and generally in the direction of the
fascial or other structures constituting a natural outlet.
The patient is usually made conscious of the formation of
the rupture by a sense of something giving way, or of a greater
weakness on the affected side when under muscular exertion.
In a certain proportion of cases, the sudden sensation of a rup-
ture having just occurred is absent. When the increase of the
tumour is rapid it is always attended by a certain degree of
pain. This, as well as the size of the swelling, is increased by
any disturbance of the functions of the intestinal canal. Flatulent
distensions and dyspepsia, with constipation and occasional ob-
structions occur. In ruptures containing omentum only these
signs are, however, absent or faint. In congenital hernia they
are also less marked. If the patient becomes corpulent about
middle age, from an accumulation of abdominal fat, omental
hernia increases more rapidly in size.
The course of the tumour in inguinal hernia is wholly, or in
part, through the spermatic canal; and its tendency is to in-
crease towards the scrotum or labia majora.
Its growth is neither uninterruptedly gradual nor uniform.
In its earlier stages, the tumour appears only when the patient
is in the erect posture. It becomes larger on his making any
extraordinary muscular exertion, and disappears altogether when
he lies down.
Frequently it remains absent for a longer or shorter period,
even when the patient is standing and moving about. This
peculiarity seems to depend upon the state of distension or
flaccidity, which the bowel immediately opposite to the opening
of the sac happens to be in at the time. An empty convolution
will pass into an opening which will not admit of one more
F

66
ON INGUINAL HERNIA.
distended. This total disappearance of the hernial tumour,
continued for some time, even during moderate bodily exercise,
has a favourable bearing upon the probability of a radical cure
being effected, inasmuch as it indicates a small internal opening,
or a narrow and elongated neck, with considerable efficiency
still remaining in the valve-like action of the walls of the canal.
A hernial tumour gradually disappears under pressure pro-
perly applied by the taxis. The best way of applying this
manual force in a hernia of tolerable size, is by firmly grasping
the fundus of the tumour in one hand, and making steady com-
pression; while the other kneads gently the neck or deeper
part of the tumour between the finger and thumb, with a view
to returning first that part of the contents which emerged the
latest.
The subsidence of the tumour under the taxis is sometimes
rapid, and is attended by a gurgling noise, if intestine be pre-
sent. If omentum only be contained, the reduction is effected
more slowly, gradually, and silently. In enterocele, the tumour
is more round and elastic; in epiplocele, it is more irregular in
outline, doughy, and heavier to the touch.
The greatest amount of difficulty likely to be experienced, is
in the diagnosis of a rupture while it yet remains in the inguinal
canal as a bubonocele. In such cases, the superficial ring will
generally be found large enough to admit the point of the
finger; and a certain downward and inward impulse on cough-
ing will be felt by the finger in that situation. If the thumb
of the same hand, or the fingers of the other, be now placed
upon the anterior wall of the canal opposite to the internal
opening, the effect of the cough impulse in dilating the tumour
will be rendered evident.
When an inguinal hernia has become scrotal, it forms a
rounded tumour in front of the cord, resting below on the tes-
ticle, and can be traced by the touch to enter and become lost

DIAGNOSIS.
67
in the inguinal canal.
The spermatic cord can usually be dis-
tinctly felt behind the tumour, and the testicle forms a distinct
and evident mass below it, a little towards the posterior part.
The cases in which the elements of the cord are separated,
and the whole obscured by the hernia, are exceptional. Their
nature may be recognised by the hernial impulse and other
signs.
When of long standing, a scrotal hernia is often associated
with a testicle more or less atrophied. So often has this con-
dition come under my observation, that I am inclined to regard
it as a common result of rupture, especially when the pressure
of a powerful convex truss has been necessary to retain the
rupture.
Some degree of varicocele is also often found in old cases of
hernia, the result of the same conditions of pressure from a
truss, or from the hernia itself.
The morbid conditions of the spermatic apparatus which are
likely to be mistaken for inguinal hernia are various. One of
the most common is an undescended testicle lying in the in-
guinal canal, and held there by a band of adhesion to the colon
or parietes. These cases mostly come under the surgeon's notice
in young lads. A considerable impulse on coughing, an increase
of protrusion on making a muscular effort, and a considerable
subsidence of the tumour on lying down, would lead to much
doubt if there were not also the valuable indication of the ab-
sence of the testicle from the same side of the scrotum.
want of development of the scrotum on the same side, giving a
striking and characteristic want of symmetry in the part, is
usually found when the gland has not yet reached its destina-
tion. Pressure upon the tumour in the groin gives to the
patient the peculiar sickening sense of pressure on this gland.
and is usually accompanied by a degree of tenderness resulting
from its abnormal position; thus giving a ready token of the
A
F 2

68
ON INGUINAL HERNIA.
character of the swelling. It is, of course, of great importance
that its true nature should be recognised, since the
a truss in these cases is most injurious.
pressure of
Fatty tumours in the inguinal canal are sometimes met with,
and closely resemble an omental hernia. The origin of these
growths is often found to be in the subserous fat of the peri-
toneum. In this case they are much impressed by the cough
impulse, and are likely by their enlargement to produce dilata-
tion of the upper part of the canal, so as to be followed by a
true hernial protrusion. For this reason it cannot be wrong to
treat these formations by a proper truss, with the double in-
tention of producing absorption of the tumour by pressure, and
of preventing the formation of a rupture.
Development of an adipose mass in the substance of the cord
itself, I have met with several times in dissecting-room sub-
jects. This is the more likely to be taken for an oblique
hernia, as it lies commonly in front of the elements of the cord
itself, and is invested by most of its more superficial coverings.
It is less liable to be impressed with a cough impulse than the
foregoing; and may be distinguished by a careful exploration
over the internal ring, at which point no cough impulse will be
observed. The superficial ring may be dilated by such a
growth sufficiently to admit the point of the finger. With one
finger placed here, and another over the internal ring, while
the patient coughs, a proper conclusion may generally be ar-
rived at. The pressure of a truss would always be beneficial
in such a case, for the same reasons as in the condition last
mentioned.
Cysts may be developed in connexion with the spermatic
cord in the inguinal passage. Though less common in this
situation than in the scrotum, they give rise to more doubt in
the diagnosis. They are usually formed in connexion with the
vas deferens, either by the occlusion and dilatation of a diverti-

DIAGNOSIS.
69
culum so commonly found upon the duct, or by the growth of
an independent acephalocyst. The contents of a cyst of the
former origin will sometimes be found to contain spermatozoa.
In the latter case they contain a clear liquid, holding in solu-
tion some of the salts commonly found in the blood, but with
little or no albumen. A case is recorded by Sir A. Cooper of
a steatomatous cyst, placed upon the cord about the external
abdominal ring, which was treated by a truss in mistake for
hernia. In making a diagnosis it must not be forgotten, that a
true hernial sac may be cut off by adhesion from its continuity
with the peritoneum, and converted into a cyst presenting many
of the characters of those just described. It usually contains a
serous fluid more albuminous in its composition than the fore-
going. Cysts are usually distinctly defined in their outline,
shifting readily and eluding pressure; they feel very hard and
plastic from tension of their contents, and are more or less
globular. They are to some extent affected by the cough im-
pulse, according to their position in the canal, but they may
not implicate the deep ring, and have not the dilating character
of a true hernial protrusion.
From the hardness and mobility of most of these cysts, the
pressure of a truss, instead of producing absorption, will prove
injurious by pressing the cyst into the superficial or deep ring,
and dilating them so much as to predispose to a true rupture.
In doubtful persistent tumours placed deep in the canal,
therefore, it is better to suspend treatment and to watch the
case. If the growth of the tumour be gradual and uninter-
rupted, and no sign of rupture follows, a puncture with a
grooved needle will render the case clear which may at first
be doubtful. Cysts superficial to the canal may be decided
upon at an earlier period, and more easily, and treated by the
ordinary methods.
Diffused hydrocele of the spermatic cord is often more diffi-

70
ON INGUINAL HERNIA.
cult to distinguish, inasmuch as it possesses one of the most
important characters of a rupture in disappearing altogether on
the patient lying down, by the fluid passing through the dis-
tended areolar meshes at the internal ring into the subperi-
toneal tissues. In the erect posture it quickly returns, but
without the hesitation frequently shown by a true rupture, and
gives a certain impulse on coughing.
If the swelling, however, as is generally the case, extends
down the course of the cord into the scrotum; its narrow and
elongated form; its close contact with and obscuration of the
cord, its fluctuation; and the marks of pitting left on it by
pressure with the tops of the fingers, will lead to its recogni-
tion. A case of this kind which came under my observation
presented this difference from a hernia, much greater pressure
over the deep ring and canal was necessary to prevent the
swelling from reappearing on the assumption of a standing
posture after lying down.
Glandular tumours are less common in the inguinal than in
the crural canal and rings, but are sometimes found in the
former situation, closely resembling a bubonocele. Like cysts,
they are more moveable, more defined at the upper and outer
part, and harder than a hernia, and may have no connexion
with the internal ring. The presence of some condition of the
testis or cord accounting for them, of a scrofulous diathesis or
syphilitic taint, especially when accompanied by glandular
swellings elsewhere, will lead up to a correct diagnosis.
It may be remarked in this place, that disease affecting the
more superficial parts of the penis and scrotum induces irrita-
tion and swelling of those inguinal glands which are placed
superficial to Poupart's ligament, and may finally lead to the
enlargement of the glands which lie in the crural canal,
through which their ducts pass into the abdomen. Disease of
the testis and cord, on the other hand, affects primarily the

DIAGNOSIS.
71
lymphatics in the inguinal canal, and not the superficial glands.
Such disease is usually evident enough to show the nature of a
tumour of this kind simulating a hernia.
Abscesses may form in the inguinal canal. These may be of
glandular origin and confined to that region; or may pass
into it in the progress of a suppuration in the course of the
vas deferens or round ligament. In the former case, they may
be sufficiently removed from the internal ring to be unaffected
by a cough impulse; and, in the latter, there will usually be
present distinct evidences of coexistent disease affecting the
prostate, bladder, uterus, or ovaries. In the ultimate progress
of such cases, some degree of fluctuation, cedema, or tenderness
will be apparent in the canal, which will explain the condition
of the parts.
The rules ordinarily laid down in the text-books on Sur-
gery, founded mainly upon the observations of Cooper, Law-
rence, and others, will be found sufficient to distinguish the
ordinary diseases of the testicle and cord, and their coverings in
the scrotum, which are apt to simulate a scrotal hernia. In
this place only a very brief allusion is required.
Hydrocele of the tunica vaginalis, encysted or otherwise, can
give rise to doubt only when sufficiently large to enter into and
dilate the superficial ring. Their growth from below; the
greater obscuration of the testis and cord; their translucency on
the application of a candle flame; their greater weight and
evident fluctuation; and the absence of pain and cough impulse,
are the distinctive marks. The shape of a hydrocele of the
tunica vaginalis is mentioned by some as being distinctively pyri-
form; this, however, is subject to so many modifications, both
on one side and the other, as to be untrustworthy, except in
combination with other signs. Many cases of encysted
hydrocele present themselves to the surgeon, in which the testis
has all the appearance given to it by a hernia. The cord,

72
ON INGUINAL HERNIA.
however, is usually lost in the tumour; the inguinal canal is
normal; and the superficial ring closed, unless in very large
cases. The cord in these cases can be felt to be implicated in
the tumour; by moving the testicle from side to side in the
scrotum, its movements will be found to be followed closely by
the tumour.
In the following pages will be found the details of a case of
effusion into a closed hernial sac, closely resembling a hydrocele
in its fluctuation, translucency, and shape. To render the re-
semblance more complete, the testicle was also enlarged, as is
often the case in hydrocele.
Young children are occasionally affected by an effusion into
the scrotal offset of the peritoneum, which may closely simulate
a congenital hernia. In such cases, however, the diameter
and obliquity of the upper part of the tumour which is so
characteristic of congenital hernia is not so marked, the dila-
tation of the inguinal canal not being, in the earlier stage,
so decided. (See Fig. 68.) Sometimes, the connecting canal
being patulous throughout, the fluid can be pressed up into the
peritoneal cavity, and the tumour made to disappear entirely.
A cough and cry impulse, dilating the tumour, is often plainly
evident, completing an exact resemblance to rupture in these
respects.
The deep ring is frequently, in these cases, so small as not
to admit of bowel passing into the scrotum, and the case will
get well on the application of pressure and evaporating lotions.
If the effusion be so abundant as to dilate the internal opening,
or if this be large from the first, a portion of bowel will
pass into the cavity, and a congenital hernia will be the
result.
Not unfrequently, the internal aperture is completely closed
at the ring, and the tumour cannot be dispersed by pressure;
though still retaining a considerable amount of cry impulse,

DIAGNOSIS.
73
from its close contiguity to the peritoneal cavity in the inguinal
canal.
On account of the thinness and delicacy of the coverings, in
an infant these tumours may readily be distinguished by their
weight, translucency, and fluctuation, as well as by the absence
of rumbling or gurgling noises and intestinal motions under
pressure with the fingers.
Doubts suggested by the shape and appearance of a hema-
tocele will usually be dispelled by attention to the history of
the case.
In certain cases of chronic enlargement of the testicle,
attended with a thickened condition of the spermatic cord, sus-
picion of a hernia may arise. The deposit in such cases is
usually of a tuberculous or carcinomatous nature.
I have lately had the opportunity of examining this condi-
tion of the testicle and cord after death. The patient was a
young man who died suddenly while under treatment for the
enlargement. The deposit in the gland was of the usual tuber-
cular kind, the thickening of the cord was tolerably uniform,
and extended along the whole length of the inguinal canal, but
presented at points a kind of knotty enlargement caused by an
accumulation of the same nature as that in the gland itself.
The glands in the neighbourhood of the external iliac vessels
were also enlarged and suppurating, involving the coats of the
vein in the inflammatory changes; which had connected a
softened clot, adherent to its interior surface, with the suppu-
rating mass outside. The case had a clear history; and more-
over, the hard unyielding nature of the swelling on the cord
and the absence of hernial impulse, distinctly marked its nature
and dissipated all doubts as to its true character.
Varicocele is a condition almost always popularly mistaken
for a rupture. To the surgeon the characteristic signs are
usually familiar. Its feel compared to that of a bunch of

74
ON INGUINAL HERNIA.
worms enclosed in a bag, eluding the pressure of the fingers.
Its usually affecting first the lower part of the cord; its speedy
subsidence when the patient lies down; and its gradual return
on rising to the erect posture, while the finger is firmly pressed
upon the superficial ring, which is usually of the normal
size; are signs, in ordinary cases, sufficient to distinguish this
condition.
In a certain proportion of the more severe cases, however,
the varicose condition may extend to the spermatic veins lying
in the canal; which may not only dilate the inguinal passage,
but may give a decided cough impulse to the whole swelling.
This varicocele cough impulse also closely resembles the true
hernial impulse, in having a distinctly dilating character, from
the fluid nature and internal communications of its contents.
In some such cases considerable doubts may arise, more
especially as this condition is often associated with a hernia;
and the feel of a piece of omentum has some of the characters
common to varicose veins. By close attention, however, the
tortuous course, tubular character, and elastic reaction of the
dilating venous channels can be satisfactorily made out; and,
taken with the characteristics of a varicocele just enumerated,
will render the case clear.
When a rupture containing omentum only is in the canal,
coexistent with the varix, the case may assume a very doubtful
character. In such a case the omentum does not recede so
quickly, as the distended veins become emptied on assuming
the recumbent position; and it may be recognised as a distinct
structure by the point of the finger in the canal remaining
still affected by the cough impulse. It will be found not to be
variable in its volume, and not to afford the elastic reaction
against pressure that varicose veins do. An inflammatory
thickening in the canal, such as is common to varicose veins
when injured, will be distinguished by the accompanying ten-

DIAGNOSIS.
75
derness on pressure, pain, and oedema; affecting, to a greater or
less degree, the testicle itself. By careful observation at dif-
ferent intervals, the presence of a portion of bowel, now and
then, in addition to the omentum, will enlighten the surgeon
upon the case. In the Appendix will be found the details of a
very large oblique hernia, associated with a large varicocele,
both cured by the same operation. (Case 8.)

76
ON INGUINAL HERNIA.
IV.
HISTORY OF THE TREATMENT OF INGUINAL RUPTURE WITH
THE INTENTION OF PRODUCING A RADICAL CURE.
A BRIEF review of the different methods which have been tried
for the cure of rupture, may throw some light upon the causes
of the want of success, which has been almost universal; of the
danger to life, which has been too often demonstrated; and
upon the essential requisites for effecting the desired end with
safety.
The older methods comprise many plans, the palpable
inadequacy of which render, to our eyes, their extension, adop-
tion, and recognition only to be accounted for by extreme
ignorance on the one hand, and impudent charlatanry on the
other. Some of these pretended remedies, by plasters and
ointments (most frequently containing elecampane in some
form), serve occasionally, even in the present day, the deft
hand of roguery in drawing contributions from the pocket of
gullibility. Other and more severe plans of cure, by caustics
or the actual cautery, possessed some more plausible claims on
the imperfectly educated medical men of two centuries ago;
and though less acceptable to the poor pain-dreading patients,
were yet more readily submitted to than any process which
would bear upon its back the formidable label of an operation.
One plan,-of causing ulceration of the coverings of the
rupture by the use of oil of vitriol, obtained so famous a repute
in this country at the early part of last century, as to lead
the government of the day to bestow knighthood upon an

HISTORY OF THE RADICAL CURE.
77
impudent quack; and to give him, in addition, the more sub-
stantial reward of 500l. a year, and 5000l. paid down for his
secret nostrum.
These severer plans were speedily found to be followed by
such serious consequences, and such imperfect or futile results,
as to be entirely abandoned.
Excision of the sac and its coverings, and in young boys, of
the testicle also, as practised by Celsus, must have led to many
fatal results, by exposing the abdominal cavity and its contents
to much rough manipulation and deleterious external influences;
as well as the general system to a severe shock.
Another plan, described by Galen and Paulus Egineta, con-
sisted in ligature of the sac at and below the superficial ring;
the ligature embracing also the spermatic cord and skin, the
testicle being at the same time removed or left to slough out.
For centuries after the time of the last-named medical lumi-
naries, the practice of some modification of this plan is stated
by Dionis and Scultetus to be extensively in vogue by unqua-
lified charlatans perambulating among
the poor and ignorant
populations of Italy, France, and Germany; achieving serious
and extensive public injury, and bringing into discredit all
more rational plans for the cure of rupture. Such are the
marked examples of the value placed upon a radical cure of
this common complaint in all ages and countries.
As a competitor for public approbation and patronage against
this wholesale mutilation of the king's lieges and military
recruits, another, a more mild and scientific proceeding, was
introduced under the prepossessing name of the royal stitch.
This consisted merely in opening the sac freely and stitching
the edges close by a continued suture, with a view to obliterate
the cavity.
About the same date a plan, called the punctum aureum,
was also practised by the more scientific and regularly educated

78
ON INGUINAL HERNIA.
medical men. As described by the celebrated Ambrose Paré, it
consisted in passing a golden wire, or sometimes a leaden one was
preferred, behind both the sac and spermatic cord at the super-
ficial ring, and including both these and an intervening por-
tion of skin in a loop; which was then twisted down tight
enough to close the hernial opening, without totally interrupting
the passage of blood to and from the testicle.
Of both these plans it may be said that, even if effectual in
closing the sac at the point operated on, the result was simply
the temporary conversion of a scrotal hernia into a bubonocele ;
with the certainty of a further protrusion at some future period,
sooner or later. The closure of the inguinal canal itself was
not attempted, and yet the exposure of the sac, and through it
the peritoneum, to the air, would render them liable to the
bad consequences which have at times ensued from this cause.
Of the last-mentioned plan it may be said further, that there
was every likelihood of troublesome complications arising in the
testicle, if the ligatures were twisted a little too tight to allow
for the succeeding tumefaction; and of direct failure if not
twisted tight enough to close the hernial channel.
The operations practised at a later date by Schmucker and
Langenbeck of Berlin, consisted in exposing the sac by a free
incision at the superficial ring, separating it from the cord, and
passing a ligature round the sac alone. The former surgeon
then proceeded to remove the whole of the fundus of the sac
below; while the latter was contented with suffering it to re-
main in the scrotum, either to slough or to become obliterated
by inflammatory adhesion.
The large proportion of fatal cases (two or three in ten), and
the great severity of the symptoms in all cases resulting from
these methods, together with the want of a successful result in
many; as shown by the experience and testimony of these
surgeons themselves, as well as of Acrel, Arnaud, and Petit, in

HISTORY OF THE RADICAL CURE.
79
France, and of Abernethy and Sharp in this country; were such
as to deter these celebrated surgeons from prosecuting their
attempts, and the methods above described fell into disuse.
It is evidently the extensive exposure of the serous membrane;
the rough handling of the cord; and complete strangulation of
the sac in these operations, which exposed the patients afterwards
to the very severe symptoms and great risk of life recorded by
the several operators; from primary peritonitis, burrowing of
matter, and other mischievous consequences to the testis and
cord. The theory assumed by Langenbeck,-that the neck of
the sac from the point ligatured along the canal to the internal
opening became degenerated and obliterated, like a tied
artery, up to the nearest branch, was totally unsupported by
observation; and from what experience has since taught us,
will not, at this day, be received as even probable. Moreover,
the tendinous openings being altogether untouched and un-
compressed, a free course was permitted for matter to burrow
upwards in the abdominal walls to the peritoneum; or if the
patient escaped these consequences, a free exit was afterwards
allowed for the return of the hernial protrusion.
The plan of producing a radical cure of rupture by the use
of a strong tight truss with a hard pad of wood, was originally
recommended by Richter. It has, of late years, been much
practised by American surgeons, and by some in Ireland, upon
the plan of Mr. L'Estrange. The results which have been
thereby obtained have not been hitherto publicly presented in
a satisfactory manner. The injurious effect upon the testicle
and cord in some cases I have heard of, and the want of
success in many others, have appeared to me to depend in a
considerable measure upon a deficiency in the shape of the
compressing pad, as will be described more completely in a
proper section of the present volume.
It is in small and incipient cases only, that hope is to be

80
ON INGUINAL HERNIA.
entertained of a radical cure from the pressure of a truss,
however skilfully made and applied, so far as present ex-
perience seems to indicate.
The more modern operations that have been devised for the
cure of hernia are so various, that some difficulty is experienced
in classifying them so as to estimate fairly their different capa-
bilities. Such a fertility of invention is an additional evidence
of the activity of research and scientific ability which has been
brought to bear, through so many centuries, and under such
different conditions of anatomical and surgical knowledge, upon
this important subject.
The methods most worthy of notice may be classed under
two heads. First,-those which deal with the interior of the
sac only, with a view of causing adhesion of its opposed surfaces
to each other. This has been attempted in various ways-viz.,
by a simple seton of threads, candle-wick, or sponge, passed
through the sac by a needle, or other instrument.
Such are,
briefly, the methods practised by Schuh of Vienna, and Riggs
of New York. Belmas of Paris, passed into the interior of
the sac a bag of goldbeater's skin, which was then distended
by jelly, with the same object; proceeding upon the principle of
the radical cure of hydrocele. M. Velpeau in Paris, and
Professor Pancoast in New York, injected into the sac a solu-
tion of tincture of iodine or cantharides.
Of all these plans it may be said that, even if effectual in
accomplishing their object without danger to the patient (which,
for many of them, is a very liberal concession indeed), a simple
adhesion of the surfaces of the sac itself, will not prevent the
formation of another sac from the abundant and loose peri-
toneum at the internal opening; since the real, effective boun-
daries of the inguinal canal and rings are left as patulous as
before. This was long ago pointed out by Mr. Lawrence in his
able treatise On Ruptures.

HISTORY OF THE RADICAL CURE.
81
In the treatment by seton, the profuse and continued suppu-
ration which is induced exposes the patient to an increased
risk of the occurrence of burrowing of the matter between the
abdominal layers, or of pyæmia.
In the same class as the foregoing, may be placed the opera-
tion proposed by M. Bonnet of Lyons, which consisted in
passing needles across the sac and coverings, and thus pinching
them up, as they emerge from the superficial ring. This pro-
ceeding evidently deals only with the anterior part of the sac
below the inguinal canal; leaving the upper and posterior por-
tions, and the tendinous boundaries unaffected.
The result was
the temporary retention of the hernia in the canal, and an
ultimate return to its former condition; with the inconvenient
alteration of a constriction, or incomplete adhesion, opposite the
point operated on, increasing the liability to strangulation.
The ultimate condition of the cases operated on in this
manner, as I have been informed by an eminent fellow-citizen
of M. Bonnet, was invariably unsatisfactory.
The second class of operations,-are those which follow the
method of invagination of the skin and fascia of the scrotum, to
plug up the hernial canal. Upon this principle are founded
two operations-one, practised by Signoroni and Gerdy, and
followed considerably of late years by different surgeons in this
country, with various unimportant modifications; and another,
originated by Wurtzer of Bonn, and followed by Rothemund in
Munich, Sigmund in Vienna, and by Spencer Wells, Redfern
Davies, and others in this country.
In Gerdy's method,-the skin of the scrotum, containing some
portion of the fundus of the hernial sac, is pushed up into the
superficial ring by invagination upon the finger of the ope-
rator.
A curved needle, armed with strong ligature thread, is
then carried along the finger, and thrust through to the surface
of the groin on each side of the point of the finger. The
G

82
ON INGUINAL HERNIA.
ligature is then tied up, so as to hold the invaginated sac and
skin in their new position, till adhesion has taken place in the
interior of the canal. Signoroni used a piece of catheter for
invaginating; while Gerdy attempted further, to cause adhesion
of the opposed surfaces of the hollow cone of skin by the re-
moval of the cuticle by caustic ammonia, and by placing
sutures at the mouth of the invagination,-a proceeding which
was usually futile.
In Wurtzer's method,-there is substituted for the finger of
the operator, a stout wooden plug (variously modified by his
followers), which is intended to fill up the hernial canal and
openings, and to stretch them so much as to set up adhesive
inflammation on the serous surface, all round the invaginated
sac. The plug is held in position by one or two needles, pass-
ing out at its extremity, through the anterior wall of the canal
in the groin, and fixed externally to a grooved compress of
wood. Between the plug and compress, the folds of the skin,
fascia, and sac are then forcibly compressed by a screw; with
the object of producing their adhesion to each other.
The essential difference between this plan and Gerdy's, con-
sists in the retention of the plug, (usually about seven days,)
until it is supposed to have set up adhesive action to a sufficient
extent, by its dilating pressure upon the opposed serous surfaces
and boundaries of the canal. The theory is, that this will
take place to such an extent as to obliterate the neck of the
sac, to prevent the unfolding of the invaginated skin, and so to
plug up the hernial opening by a permanently inverted cone of
skin and fascia.
In all the foregoing methods of producing a radical cure of
hernia, it is intended to puncture the sac, or otherwise to cause
it to become obliterated by inflammatory effusion. It may be
assumed, therefore, that the danger of an extension of the in-
flammation to the peritoneum itself is nearly equal in all. In

HISTORY OF THE RADICAL CURE.
83
this respect, however, we must except the objectionable practice
of injecting the sac with irritant fluids, where the unusual
danger of an escape of some portion into the peritoneal cavity
is obvious, and has in many cases proved fatal.
With this exception, the records of the numerous cases
which have been operated on up to the present time, both
in this country and abroad, clearly prove-that the danger
of serious peritonitis is by no means great, nor such as to
cause any apprehensions on the part of the surgeon or his
patient.
Such fatality as has been placed on record, following all the
operations just reviewed, has been, in most instances, owing to
the burrowing of matter between the layers of peritoneum and
deep-seated fascia.
When small punctures only are made in the integuments,
and a seton or ligature traverses through them the deep-seated
tissues; and more especially, when distending force is at the
same time used; free suppurative action is set up in the deeper
structures; and the pus, not being able freely to escape through
the obstructed punctures, makes its way along the areolar in-
tervals between the abdominal layers; or along the spermatic
cord into the pelvis; or through the inner opening of the
hernial sac into the peritoneum. In this way, and as a
secondary effect, peritonitis ensues; or the patient may succumb
to exhaustion induced by profuse discharges from an extensive
suppurating surface. Such dangers are, of course, more im-
minent if the pressure of the invaginating instrument produces
a deep-seated slough, which has sometimes followed the use of
dilating plugs.
Unlike the older and more severe operations previously
mentioned, the failings of these more gentle proceedings do not
seem to lie in their danger or fatality, but in their inefficiency
to accomplish a good and permanent cure in a sufficient pro-
G 2

84
ON INGUINAL HERNIA.
portion of the cases operated on, as to give to the patient good
grounds for expecting a successful issue.
Most, if not all, of Gerdy's thirty-six cases of operation had
a relapse of the hernia; and the operation subsided from public
observation until resuscitated recently in various forms and dis-
guises. Of the ultimate condition of cases operated on by
Wurtzer's method, it is very difficult to arrive at sufficient
satisfactory information. In all the cases seen by the author,
or occurring in the practice of nearly all the surgeons known
to him, these results have been entirely unsatisfactory. With
very few exceptions, the rupture re-descended soon after the
plug was withdrawn; or as soon as the constant use of a truss
was discontinued.
A very general impression prevails among surgeons, both in
this country, in France, Germany, and the United States, that
none of the foregoing operations have given such a promise of
satisfactory results as to bring them into general use.
A few successful cases among a great majority of failures
will not counterbalance occasional fatal terminations. Still
more objectionable, are operations which render the use of a
truss afterwards painful or impossible, as sometimes occurs.
FIG. 20.
An endeavour to point out the causes of failure
in these operations will put us in a better position
to judge of means adopted to overcome them.
In Fig. 20 it will be seen that invagination
of the hernial sac from the scrotum into the
inguinal canal leaves, by its reduplication, a cir-
cular fold or "cul de sac;" which, from its closer
attachment to the spermatic cord and posterior
structures, extends much lower down behind
than in front. In Gerdy's operation, and in
those following the principle of his plan, no
attempt whatever is made to close this posterior fold. Adhe-

HISTORY OF THE RADICAL CURE.
85
sion is simply sought and obtained at the anterior part of the
inguinal canal, at the apex of the invagination at (a); or is
futilely attempted on the inner surface of the invaginated cone.
In Wurtzer's method, the theory is,-that the circular dilating
pressure of the plug suffices to cause adhesion of the serous
surfaces round the entire circumference of the neck of the sac,
as well as consolidation of the hernial canal. This I believe to
be an entirely mistaken assumption, and one not founded upon
accurate observation. Except under an amount of pressure
quite unbearable to the patient, and sufficient to give rise to
sloughing of the compressed structures, such a result does not
occur,-and for the following reason.
Between the two hard compressing surfaces and the serous
surfaces intended to be affected, are many mobile layers of
tissue, doubly folded by the invagination, and expressly arranged
by Nature to escape injury, and ward off pressure from the sper-
matic cord; viz., skin, fat, fascia, subserous tissue, and tendinous
aponeurosis. Effectively to overcome their conserving power by
pressure alone, nothing less than very severe inflammation and
sloughing is necessary. Such a result, produced by the wooden
plug, gives the operation a character at once clumsy and severe.
Into the posterior fold of the reduplication of the sac, then,
in the generality of cases where these operations have been
performed, a portion of bowel or omentum in due time makes
its way, along the posterior wall, and behind the adhesions in-
tended to restrain it. Gradually and not less surely, the com-
plete dilatation of the canal, temporarily diminished in dia-
meter by the invagination, is fully re-established. The hollow
cone of skin is the first to become obliterated by its elasticity
of reaction; the slender adhesions become elongated by its
downward traction; the hernial protrusion follows close, and
completes the dilatation of the hernial passage and the disten-
sion of the sac to its former dimensions.

86
ON INGUINAL HERNIA.
In the cases which I have examined after failure of
Wurtzer's operation, the superficial ring and canal have been
more than usually patulous. The effect of the plug is to dilate
the superficial ring and inguinal passage as far as it extends,
and to prevent any adhesion of the sides together. Conse-
quently, when the hernia returns, a larger protrusion than
before is permitted. It is here that the inherent vice of the
principle upon which that operation is founded becomes more
apparent. To plug up and distend a dilatable opening with the
view of closing it, is evidently a mistaken proceeding.
The patulous condition of the superficial ring permits the
weight of the testis and its coverings, and the elastic reaction
of the stretched skin and resilient dartos of the scrotum, to
exert their full effect in dragging down and stretching the
slender adhesions to the anterior wall of the inguinal canal.
The hollow cone of skin becomes thus quickly obliterated; and
the dilatation of the posterior fold of the invaginated sac is
accelerated by the backward traction of the rectus muscle upon
the posterior wall of the canal. In front of the lower part of
the returned rupture, are borne the cicatrices of the ruptured
or elongated adhesions.
It will be seen, in the progress of such cases, that the mass
of inflammatory exudation apparent in the earlier stages is only
temporary in character, sufficing for a short time only to block
up the passage and keep up the rupture. The parts sooner or
later resume their normal flexibility from absorption of the
mass of consolidation. Nothing less than a close and extended
adhesion of the permanent structures forming the walls of the
canal, will suffice to keep up its permanent closure. Such a
result, it is evident, cannot be obtained by dilatation.
In ruptures having a narrow inguinal passage, the skin can
be invaginated only a very short distance into the superficial
ring; the plug effecting a mere indentation into it, with a

HISTORY OF THE RADICAL CURE.
87
limited area of adhesion around the needles. A bubonocele
thus remains in the chief part of the canal, the dilating pres-
sure of which from above soon suffices to overcome such slight
resistance.
In the numerous cases in which a considerable constriction
of the sac takes place at the superficial ring, with a much di-
lated canal forming a large cavity within the abdominal walls
(as described in the former pages of the present volume), the
plug cannot be made to act by filling up the interior; unless
either forcible dilatation of the superficial ring be previously
made to admit a larger plug, or the plug itself is made to ex-
pand after its passage through the ring is effected. To effect
either of these processes is difficult to the operator, and very
painful to the patient; and may give rise to such severe in-
flammation as to add much to the objectionable character of the
whole proceeding.

88
ON INGUINAL HERNIA.
V.
THE PRINCIPLES OF THE OPERATIONS PRACTISED
BY THE AUTHOR.
To effect a radical cure of inguinal hernia in a satisfactory
manner, it is necessary to adopt a plan to shut up permanently
the inguinal openings and canal, by drawing together and pro-
ducing adhesion of its tendinous walls as far up as the internal
opening. If we succeed in doing so much as to restore the
valve-like action of its oblique sides, we shall restore the part
to its normal power of resistance to dilatation and hernial pro-
trusion.
The most obvious way of doing this is by the application of
sutures through the sides of the canal, in such a manner as to
ensure its complete closure, both behind and in front of the
spermatic cord, sufficiently close to the latter to procure its
adhesion without interrupting its functions.
To accomplish this, it is necessary to obtain a hold upon the
posterior and superior boundaries of the canal, so as to cause
their firm and close adhesion to the anterior and inferior wall;
or, in other words, to unite the conjoined tendon firmly to
Poupart's ligament in front of and above the spermatic cord;
so that these structures shall be made to hug the cord as closely
as in their normal condition. This union tends directly to
counteract the dilating influence of the rectus muscle upon the
posterior wall of the canal. To ensure success, complete union
must be established along the whole length of the inguinal
canal, which will afford a broad extent of adhesion, able to

PRINCIPLES OF THE OPERATIONS.
89
resist the future efforts of the bowel to open up the passage.
Slender points of adhesion, or simple closure of the pillars of
the superficial ring, will not afford this requisite amount of
resistance.
A careful study of the anatomical description in the preceding
pages, especially if aided by an inspection of the inguinal canal
in a dissected subject, will show that the conjoined tendon may
be taken up by a needle without difficulty, if the forefinger be
first passed along the canal and placed fairly behind the lower
border of the internal oblique muscle, and then made to hook
it forward towards the surface, so as to raise the tendon to
which it is attached into salient relief.
It will be seen that the border of this tendon is placed but a
short distance from the margin of the deep ring on the posterior
wall; and that the epigastric vessels are at this point screened
from injury by the fascia transversalis, as well as by the finger
of the operator placed in front of them. If a subject affected
with oblique inguinal hernia be selected for the demonstration,
it will be seen, as before remarked, that these tendinous struc-
tures are more distinct than in a subject not so affected,
especially if the rupture be large and of old standing. The
laxity of the tissues in most hernial cases also enables the
operator to pass the finger behind the edge of the conjoined
tendon itself; and, in some cases, even to push it between the
peritoneum and the back of that tendon, so as to feel the edge
of the rectus muscle. The looseness of the subperitoneal fascia
at that part, enables this to be done without any tearing of
the tissues. A ligature properly placed through the conjoined
tendon, and then drawn outwards and forwards, encroaches
on the inner side of the deep opening of an oblique hernia, so
as to diminish the size of this opening itself. In this manner
is obtained as near an approach to the deep opening on this
side, as can safely be procured without danger of wounding the

90
ON INGUINAL HERNIA.
epigastric vessels, and interfering with the peritoneal membrane
itself.
On the outer side of the sac, towards Poupart's ligament, a
much higher point can be safely reached with the needle; which
may be made to puncture the aponeurosis of the external pillar
directly opposite to the internal opening. When these two
points are drawn together by tightening the ligature, the deep
hernial opening is compressed both above and at the sides. The
induration which follows the retention of the ligature suffices
to close, more or less completely, this part of the neck of the sac.
The ligatures, placed as above described, will be found neces-
sarily to include also the pillars of the superficial ring, and to
lie for some distance along the sides of the inguinal canal,
crossing from one side to the other, so as to close them up to
each other.
It will be seen, that in the various methods originated and
practised by the author for the cure of hernia, this novel prin-
ciple of compression and closure of the tendinous sides of the
hernial canal in its entire length, prevails throughout.
In this important particular, they differ entirely both from
the older and more modern operations; all of which either deal
with the sac almost solely, or rely upon the principle of dila-
tation or plugging of the canal.
They differ also from the more effective, but more severe
and fatal ones of Schmucker, Langenbeck, and others, in being
of an entirely subcutaneous character. The sac, if punctured
at all, is pierced by a small and valvular opening only; and
remains deep-seated and removed from atmospheric influences.
The connexions between the sac itself and the layers of deep-
seated tissues, are not broken down or interfered with, being
traversed only by the needle and ligature. In many of the
cases given in the Appendix, the sac has probably not even been
punctured; but, being recent and mobile, has been pushed up

PRINCIPLES OF THE OPERATIONS.
91
before the invaginated fascia beyond the ligatured points, which
have thus closed the canal external to the sac altogether. In
young, small, and congenital cases, this has been effected with-
out any transplantation of the scrotal structures; but by simple
closure of the hernial canal by the use of pins. In larger and
wider cases of longer standing, however, the distance separating
the sides of the hernial channel, and the advisability of retain-
ing as much as possible of the sac coverings within it, have in-
duced the author to invaginate permanently the front and outer
parts of these coverings; and to fix them in the canal as a basis
to tie down the ligatures upon. Thus is produced, by the suc-
ceeding inflammatory and adhesive actions, a solid agglomeration
of adherent and resisting tissues.
In direct hernia, the circumference of the short canal at the
neck of the sac is closely embraced by the ligature nearly all
round, so as entirely to shut it off from the peritoneal cavity.
The pillars of the superficial ring are by the same process
closed round the invaginated fundus, so as to compress and
enclose it in a folded mass, and so to fortify the deeper adhe-
sions against the protrusion of the bowel.
When invagination is practised, a small opening in the skin
of the scrotum, sufficient to admit the forefinger, permits of the
easy separation of a sufficient extent of the deeper sac coverings,
to enable the invaginating finger to discriminate more closely
and distinctly between the structures in the canal; to reach a
higher point of invagination than can be effected with the skin;
and to guard from injury the peritoneum, viscera, and deep
vessels, during the passage of the needle. A direct and free
escape is thus provided, also, for any discharge which may form
in the progress of the case, at the most depending point of the
ligature track; in addition to a puncture at the opposite end in
the skin of the groin. In this manner, the possibility of the
burrowing or pocketing of matter is rendered as small as may

92
ON INGUINAL HERNIA.
be. This incision in the scrotum gives, also, a much greater
firmness, steadiness, and security of hold to the invaginating
finger; and counteracts the tendency of the scrotal layers to
slide off the tendinous structures during the passage of the in-
strument through them.
The means employed to hold the structures together in their
new position until adhesion takes place have, for reasons to be
hereafter given, been changed from ordinary ligature thread to
stout wire or pins.
The method of procedure in fixing them has necessarily been
varied, according to the requirements of the material used, and
the peculiar exigencies of the case operated on.
In the first twenty cases given in the Appendix, stout hempen
ligature thread was used to draw together the structures. This
was chosen with the idea that its greater flexibility rendered it
more fitting than wire to follow the needle in the somewhat
delicate manoeuvres required. As an additional precaution in
large cases, the ligature was passed also across the canal low
down, close to the external ring. The irritation set up by a
ligature thread was, at first, thought to be favourable to the
formation of solid effusion in the deep parts. In some of the
cases operated on considerable suppuration was the result, and
it was observed that the amount of solid matter effused, and of
permanent adhesion, was by no means in proportion to the
suppurative action; but that, on the contrary, in some cases in
which but little pus was formed, a greater degree of consoli-
dating action and contraction than usual ensued.
In some
measure this was due, no doubt, to the state of health and condi-
tion of the constitution of the patient at the time of the operation.
Hearing much of the non-irritating properties of wire sutures,
about that time reintroduced to public notice by Dr. Simpson
of Edinburgh; and having had, unfortunately, a case which ter-
minated fatally from pyæmia three weeks after the operation

PRINCIPLES OF THE OPERATIONS.
93
for the radical cure (Case 20), the author was led to try liga-
tures made of metal.
The diminution of the amount of suppuration which there-
upon followed was so marked, that, with some modifications in
the manipulation of the wire which were found necessary after a
few trials, the plan now practised in most cases by the author
was adopted with great advantage and success.
Although it will be seen, in the remarks upon Case 20, that
the amount of suppuration was not so great even in that patient
as in some others, and that the patient was nearly convalescent
when attacked by the symptoms; yet it was indisputable, that
to lessen the suppurative action would be an important step
gained, especially as the desired consolidating and adhesive
action was not in proportionate ratio.
The operation by pins was suggested by the effects produced
in the treatment of varicocele and varicose veins, by the use of
the rectangular pins originated by the author. It was thought
that in children with congenital herniæ having narrow elon-
gated necks, it would be possible to close up the yielding and
rapidly developing tissues by means simple and free from danger;
so as to present great advantages over the slow and uncertain
process of pressure by a truss.
The results obtained in thirteen cases have been, so far, so
satisfactory in these respects, as well as in the permanency
of the cure, that this plan may fairly claim a good place among
the radical cures of rupture.
In the operation by ligature thread it will be seen, that an
external compress is necessary, to tie down the threads upon
and to compress the more superficial parts between the ligature
and the surface. In that by wire, as latterly practised, this
proceeding, from which most of the pain suffered by the
patient arises, has been abolished; or only had recourse to in
large and exceptional cases.

94
ON INGUINAL HERNIA.
In most cases, the scrotal fascia and sac fundus are inva-
ginated, and retained in the canal by the adhesions set up by
the ligature. In the operation by pins, the sides of the canal
are simply skewered, as it were, together; and no permanent
invagination is effected.
In all, the main principle of securing the conjoined tendon
with the posterior and superior boundaries of the canal, on the
one hand; and the anterior and inferior walls up to Poupart's
ligament, on the other; is adhered to.
In some cases which I have seen, inattention to the former
important and more difficult part of the proceeding has re-
sulted in a return of the rupture. In some of the failures
which have occurred in the early part of my own experience,
I have considered the unsatisfactory result to be owing to a
want of success in securing a good hold of the conjoined tendon,
and thus leaving too much room in the back part of the canal
close to the cord. This has led to the practice of applying
backward pressure by a bandage upon the wire loop, as recom-
mended in the description of the operation.

OPERATION BY THREAD AND COMPRESS.
95
VI.
THE OPERATION BY LIGATURE THREAD AND COMPRESS.
THIS operation was described by the author in the Transactions
of the Medico-Chirurgical Society for 1860, vol. xliii.
The instruments used in performing it are, First,-a stout,
unyielding needle, mounted in a strong handle, with a blade
much curved near the shaft, and less so near the point; so as
to lie conveniently in the curve of the forefinger. The point
is blunt, with tapering, wedge-shaped shoulders; formed, not
to cut, but to split its way through the tendons. Near the
point, the concave surface is flat horizontally, so as to take up
readily a layer of tissue; while the convex part is rounded off
laterally, so as to slide easily along without danger of puncturing
the finger of the operator. Towards the handle, the blade is
thicker in the opposite diameter, and more sharply curved than
near the point; giving it more resisting power, and a tendency
to come short up to the surface when pushed far into the
tissues. The handle is long and stout; giving a good leverage
to the operator, and enabling him to control the point with
greater facility. (See Fig. 21, b.)
For those who have not acquired facility in performing the
last-mentioned manipulation, I have devised a needle of the
same form, but provided with a sliding guard; which, projecting
from the back surface of the point slightly beyond it, covers it
until it is fairly planted in a satisfactory position for puncturing.
By drawing with the forefinger a trigger placed under the
handle, the guard is withdrawn and the point exposed to

96
ON INGUINAL HERNIA.
a sufficient extent to make the puncture with ease and
safety. (c.) The eye of the needle should be well drilled and
smoothly countersunk; and when used in the wire operation,
should be slightly grooved towards the point, to lodge the
hook of wire which holds it to the instrument.
FIG. 21.
b
C
d
a
Second.-A small knife, with a blade resembling a tenotomy
knife; the points harp and lancet-shaped; the edge cutting only
for an inch near the point; and a stout back. The handle
should be thinned off at the end, so as to make a rounded edge
like that of a paper-knife. This instrument is used for the purpose
of making the preliminary scrotal incision, and separating the
fascia from the skin. (a.)
Third.-A compress or pad, made of boxwood, glass, or
porcelain, long and broad enough to cover the hernial canal.

OPERATION BY THREAD AND COMPRESS.
97
It may be cylindrical, flat, or boat-shaped, with a hole or groove
about the middle to fasten the threads upon. (d.)
Fourth.-A stout hempen thread of sufficient length, free
from irregularities, well waxed, and then soaped.
This operation is one in which much advantage is obtained
by the operator from the administration of chloroform, which
should be carried so far as to remove that spasmodic con-
traction of the abdominal muscles which involuntarily takes
place under a painful manipulation of the deeper parts of the
hernia, even when made for purposes of diagnosis only. In
some patients this is difficult to effect with the usual expen-
diture of the agent. The stage of struggling should be com-
pletely passed before the needle is introduced. Violent con-
traction of the internal oblique muscle renders it difficult to
obtain a satisfactory position for the finger and needle; while
that of the recti and other muscles forces the rupture into the
canal, and embarrasses the point of the invaginating finger at
the critical time of passing the needle through the deeper
structures. Accidents have occurred to the protruding bowel
under the circumstances, which have mainly arisen, in my
opinion, from a want of attention to the importance of passing
the needle at the time of the most complete relaxation of the
muscles of the patient under the anaesthetic agent. Great in-
convenience also arises from cough, which may be set up by
the use of an impure chloroform, containing irritating com-
pounds.
The pubis and scrotum of the affected side being cleanly
shaved, the patient is laid upon his back with the shoulders
well raised. The surgeon will find it most convenient to stand
on the side to be operated on, and to use for the purpose of
invagination the forefinger of the right hand for the right side
of the patient, and vice versa.
The rupture being carefully and completely reduced, the
H

98
ON INGUINAL HERNIA.
finger is first passed into the canal by invaginating the scrotum
pretty low down, to ensure a complete absence of the viscera
from the sac, and to investigate the boundaries and pecu-
liarities of the hernial passage. If the patient have a tendency
to cough or struggle, or the hernia is easily protruded, an
assistant must carefully command, by pressure, the internal
opening during the preliminary incisions.
FIG. 22.
The Operation.-An incision is first made in the skin of the
scrotum, over the fundus of the sac if the rupture be large, and
a little below it if small. The most convenient direction of
the incision for the future steps of the operation is obliquely
downwards and outwards, terminating a little on the outer side
of the scrotum. It should be long enough to admit easily the
point of the finger with the needle in addition. (Fig. 22.) If
the rupture operated on be a bubonocele, the point chosen for
the scrotal incision should be 14 inches below the spine of the

OPERATION BY THREAD AND COMPRESS.
99
pubis.
Then the knife, being insinuated flatwise between the
skin and fascia for about an inch, is to be carried round the
edges of the incision, so as to separate the former from
the latter over an area of at least two inches in diameter.
More than this will be required if the rupture be a very large
one. The thin end of the handle of the knife will suffice to
separate the loose connexions of the scrotal fascia to any extent
that may be required, in ordinary cases.
Next, the knees of the patient should be brought together
and bent up so as to relax the structures in the groin.
FIG. 23.
The operator's forefinger is then passed, with the nail
directed backwards, into the scrotal aperture, and made to
invaginate the detached fascia into the inguinal canal. This
invagination should be commenced at as low a point as pos-
sible, so as to force the finger as much as may be behind the
hernial sac, between its fundus and the spermatic cord. The
latter may, at this time, be steadied by an assistant making
gentle traction upon the testis. (Fig. 23.) The invagi-
nating finger should be made to reach as high as possible in
the canal, towards its superior opening. The position of the
cord and of Poupart's ligament should then be distinctly made
H 2

100
ON INGUINAL HERNIA.
out. Then, by hooking forward the finger well towards the
surface, the lower border of the internal oblique muscle will be
felt raised upon it. This may be more distinctly recognised
by placing the other hand upon the surface of the groin, when
the thicker portion of the deep-seated structures in front of the
rupture will be felt between the fingers. By directing the
FIG. 24.
In this and many of the succeeding figures the skin and fasciæ are repre-
sented turned aside, to show the disposition of the invaginating finger and
instruments, in the various steps of the operation. This takes place in the
operation under these tissues, by the guidance of the sense of touch and out
of sight of the operator, as seen in Fig. 25.
finger inwards, the operator will now feel at its thumb side
the edge of the conjoined tendon raised with the muscle, and
placed in relief on the posterior wall of the canal.
The needle, unarmed and well oiled, is then passed along
the same side of the finger, and pushed through the tendon at
its most salient part, so as to take up a considerable portion

OPERATION BY THREAD AND COMPRESS.
101
of it. (Fig. 24.) It is then turned towards the surface,
traversing the internal pillar of the superficial ring obliquely
upwards and inwards, till the point is seen to raise the skin of
the groin. In these manoeuvres the point of the needle
should be carefully preceded and covered by that of the
finger. The skin is then drawn inwards and a little upwards,
as much as its deep attachments will allow, and the needle
pushed through it. (Fig. 25.)
FIG. 25.
One end of the thread is then connected with the needle,
and the latter withdrawn with a quick motion, leaving the
other end in the puncture.
The invaginating finger is then placed behind the external
pillar of the superficial ring, as close as possible to Poupart's
ligament, opposite the internal hernial opening, in the groove
which is there found between the spermatic cord and the
ligament. The finger being again raised towards the surface,

102
ON INGUINAL HERNIA.
the aponeurosis is stretched well upon it. (Fig. 26.) The needle
carrying the ligature is then passed along the finger between
it and Poupart's ligament, and pushed through the latter oppo-
site to the point of the former. When its point is seen to
raise the skin, the latter is drawn outwards, until the needle
can be pushed a second time through the puncture before
made. A loop of the thread is then left in the puncture, and
the needle withdrawn, carrying the free end.
FIG. 26.
The finger is next placed on the inner side of the spermatic
cord, just above the pubic spine, and pressed firmly upon the
conjoined tendon, pushing it backwards and the cord outwards,
so as to feel prominently the border of the rectus tendon. Into
the tendinous layer of the triangular aponeurosis covering this
part of the rectus, the needle is then thrust, so as to take up
obliquely a considerable portion of that structure as near as
possible to the pubic spine, which affords a good guide to the

OPERATION BY THREAD AND COMPRESS.
103
proper place for the puncture. (Fig. 27.) The point of the
needle is then turned obliquely upwards towards the surface, and
the skin drawn downwards and inwards over it, until it can be
passed through the puncture for the third time. The needle is
then freed altogether from the thread, and withdrawn. The whole
of the ligature thread is now found in the upper puncture, pre-
senting two ends and an intermediate loop. The upper end
FIG. 27.
encloses the conjoined tendon and the internal pillar of the
super-
ficial ring; the loop passes through the outer pillar, close to the
centre of Poupart's ligament; and the lower end through the
triangular aponeurosis and the insertion of the internal pillar
low down. Two portions of thread are thus placed across the
hernial canal, invaginated fascia, and sac, closely embracing,
but not including, the spermatic cord, and connecting the pos-
terior or deep wall with the anterior or superficial (Fig. 28),

104
ON INGUINAL HERNIA.
perforating the aponeurosis in three places, as seen in A; but
escaping by the same aperture in the skin, as seen in transverse
section in B.
The compress, or pad, is then applied over the canal in an
oblique direction, with its centre opposite to the threads as
they emerge from the groin puncture. The two ends of the
thread are drawn over to the outer side, and the loop to the
inner, the latter crossing between the former. (Fig. 29, B.)
One end of the thread is then passed over the compress and
through the loop, and tied back to the other end in a loop knot
or bunch (A). This method of fastening the thread in one
instead of two portions gives an equable adjustment to the
pressure.
A
FIG. 28.
When the thread is tightened up, direct evidence of its
action upon the canal and rings can be obtained by the finger.
The posterior wall of the canal should be ascertained to be
drawn forward by the ligature, and the pillars of the superficial
ring closed in. If this effect on the posterior wall is not
recognised, it may be apprehended that the conjoined tendon
is not properly secured in the grasp of the ligature.
The lower end of the compress should reach as far down as
the scrotal incision, which is usually tucked up close to the
superficial ring by the traction of the ligature invaginating the
fascia and sac. (Fig. 29, A.)
Pledgets of dry lint are then placed at the sides of the

OPERATION BY THREAD AND COMPRESS.
105
compress, and a fold of linen retained by a spica bandage over
all.
The patient should be placed in bed with his shoulders well
raised, and a bolster under his knees to keep the groin struc-
tures relaxed. If much pain be experienced, a full dose of
opium in some form should be given to allay it, and repeated as
often as this symptom may require it.
After the foregoing method were operated on the patients
whose cases in the Appendix are numbered from 2 to 20.
A
FIG. 29.
B
In the first case, the same principles of operating were also
strictly followed, but two separate ligatures were used, and the
instruments employed were of a more complicated character,
which subsequent reflection and experience modified into the
simplicity of form and number just described.
If the pressure were much complained of, the spica bandage
was removed the next day. In small cases, or when much
thickening and consolidation were quickly apparent about the

106
ON INGUINAL HERNIA.
canal, the ligature thread was untied, and the compress re-
moved on the third or fourth day. In other cases it was kept
on till the sixth or seventh day.
In some cases the discharge was small in quantity, appearing
as a serous exudation on the second or third day. If the sac
were freely punctured, the discharge was usually more abun-
dant, in the form of a reddish serum, becoming purulent about
the fourth or fifth day. Sometimes the lower opening in the
scrotum healed entirely by the adhesive process. When the
strain on the ligatures was great, and a large sac was included,
the discharge escaped freely at both the openings. The threads
were usually left in the wound to act as conductors of the dis-
charge, and to keep up a seton-like action in the canal for as
long a time as was deemed necessary, judging by the amount
of solid effusion.
In one case (No. 8) in which a large rupture was com-
plicated with an extensive varicocele, profuse suppuration in
the interior of the sac ensued, and sloughs escaped freely by
the lower aperture. The upper one discharged little; the liga-
ture appeared to have cut off the sac entirely from the peri-
toneal cavity. No untoward complications whatever ensued,
the patient made a most excellent cure, and was completely
freed both from the rupture and the varicocele, while the tes-
ticle remained entirely uninjured.

OPERATION BY WIRE.
107
VII.
OPERATION BY WIRE, AS AT PRESENT USUALLY
PRACTISED BY THE AUTHOR.
A thick
THE instruments used in this operation are the knife and needle
before described, and a piece of stout copper wire silvered, about
two feet long. The wire should be as thick as may be consis-
tent with tolerable flexibility. The advantages of having the
wire thick are that a fine wire cuts the tendinous structures
when drawn tight, acting like a tenotomy knife upon their tense
fibres, so that these important tissues become set free from its
grasp, instead of being held firm in their new position until
made adherent by the slower process of ulceration.
wire also, when twisted, carries round with it, not only the in-
cluded parts, but also the deeper structures attached to them; so
that all the structures near the parts immediately traversed
by the wire are dragged and twisted up more or less, so as to
complete the entire closure of that part of the hernial passage
which is not included in the grasp of the ligature. A thick
wire also retains its form with more tenacity, and holds the
openings which it traverses more in a line with each other; so
that any discharge which may form escapes from the wire track
with more facility, its passage being more direct and less ob-
structed. Copper wire is better than silver, because it is
stronger, more tenacious, and not so liable to form kinks and
break off;-it is better than iron, because at the proper thick-
ness it is more flexible. Any disadvantages possessed by a
thick wire are experienced at its bend in the eye of the needle.

108
ON INGUINAL HERNIA.
If the doubled wire be as thick as the needle itself, the bend
will not pass through the needle track with the point. The
needle used in this operation, however, should be so thick as to
be perfectly unyielding. Its broad blade will open a track suffi-
ciently large to receive back with ease the point with the wire
attached. Any little hitch will be readily overcome by with-
drawing the needle with a rapid motion, accompanied by a
slight jerk. In many instances, I have had the wire thinned down
at the ends by gradations, made by passing them through the
diminishing holes of the draw-plate for about six inches at each
end. In some of the trials, however, the shoulders thus left on
the wire were arrested in some part of the track, and the wire
broke off-an awkward accident, necessitating a fresh appli-
cation of the needle. Upon the whole, it is better to trust to
a thick, stout needle with the eye grooved, and a wire of a
degree of thickness limited only by convenient flexibility, and
undiminished at the extremities. No. 20 is the degree of
thickness I have generally used.
In preparing the wire for this operation, it should be drawn
rapidly several times through a woollen cloth, so as to clean it
perfectly, straighten it out, and by the heat of the friction to
render it a little more flexible. About half an inch at each
end of the wire should be carefully bent into a hook, suffi-
ciently round to render its passage through the eye of the
needle easy, and quite free from side twists. The wire should
be then well oiled, folded in the middle, and given in charge of
an assistant to keep it unaltered in form.
It has been remarked that the needle should be strong and
unyielding. This is especially the case when wire is to be
used, partly for the reasons above given, and partly because in
performing the various passes of the needle considerable resis-
tance by the muscles is sometimes experienced in drawing the
tendon transfixed by the needle towards the proper place for

OPERATION BY WIRE.
109
This was
puncturing the skin. In the figure given of the needle used by
myself (Fig. 21, a), it will be seen that near the point it is
flattened from side to side, but as it gets nearer the handle the
diameter in the cross direction becomes the larger.
found to be requisite to prevent the tendency of the
open out under pressure, and so allowing the point to slide be-
tween the abdominal layers, instead of coming short to the
surface when intended to do so. Such an accident on the
living subject might give rise to serious complications.
curve to
It will be noticed in the succeeding description, that in the
operation by wire each pass of the needle is made with the in-
strument unarmed. With a wire of the necessary thickness,
or with any kind of wire, or even thread, passed through the
eye of the instrument, it is difficult, if not impossible, to
transfix the tissues with the exactitude which is desirable.
With the needle perfectly free, on the other hand, great preci-
sion is attainable by a moderate amount of practice.
The Operation. The patient and surgeon being placed in the
position described in the first operation, the same preliminaries
being gone through, and the scrotal incision, the separation of
the fascia and its invagination with the sac, being accomplished
as before detailed, the border of the internal oblique is felt for
and raised; the conjoined tendon recognised and carefully taken
up on the needle, which is then made to traverse the more
superficial parts obliquely upwards and inwards. The skin is
then drawn in the same direction, and the needle pushed
through it. So far the steps of the operation are precisely
similar to that first described. (See Figs. 22, 24, and 25.) One
end of the prepared wire is then hooked on to the eye of the
needle, care being taken that it fits fairly into the groove, and
the instrument is then withdrawn rapidly and with a slight
jerk through the tissues, drawing the wire after it.
The needle is then disengaged, and passed upon the finger to

110
ON INGUINAL HERNIA.
its outer side as high up as the internal opening of the hernia,
opposite which it is pushed through the anterior aponeurosis
close to Poupart's ligament. It is then turned so as to traverse
the same cutaneous aperture through which the wire has
already passed, which is to be drawn upwards and outwards to
meet it. The opposite end of the wire is then hooked on,
drawn through the puncture after the needle into the scrotal
aperture, and then disengaged as before. (See Fig. 26.)
Thus far the steps of the operation differ only in the one
small particular of hooking on and off the ends of the wire,
from the operation with threads.
At this stage of the operation the two ends of the wire
emerge together at the lower or scrotal aperture, after traversing
the conjoined tendon and internal pillar on the inner side and
Poupart's ligament at the outer side respectively; while the loop
which connects them emerges at the upper or groin puncture.
The sac of the hernia and the fascia covering it opposite the
scrotal aperture is then pinched up between the finger and
thumb, and the spermatic cord is slipped back from their grasp,
in the same way as in the operation for tying the veins in
varicocele. The needle is then passed from without inwards
and a little upwards, in the direction of the incision across the
scrotum, close to and in front of the spermatic cord. A slight
twist given to the point of the needle will enable it to take up
all the structures which lie in front of the spermatic cord, and
at the same time to enter and emerge entirely within the limits
of the scrotal incision. The curve of the blade and the ex-
tensibility of the scrotal tissues will permit this to be done
easily, without making a fresh cutaneous puncture. If this be
accidentally done, however, the incision may be extended so
far as to meet the new puncture. One of the ends of the wire
is then again hooked on to the needle (see Fig. 30), and drawn
with it across the cord through or behind the sac, traversing the

OPERATION BY WIRE.
111
scrotal fascia. I have usually been in the habit of drawing
that end of the wire which has already traversed the con-
joined tendon through the scrotal portion of the sac, as being
better placed, when drawn up, for making pressure upon the
deeper parts of the canal, and more easily withdrawn after-
wards. Either end, however, may be taken, the outer end
having another recommendation of giving an extra twist to the
sac when drawn up and tightened.
FIG. 30.
If the sac is small and recent, reaching only as far as the
scrotal aperture, the wire may be thus placed entirely behind
it, and between it and the cord. But if the sac be larger, and
of long standing, its close adhesion to the cord will hardly
permit this to be done, and it is unavoidably punctured
posteriorly.
In still smaller cases, wherein the sac does not descend

112
ON INGUINAL HERNIA.
much beyond the external ring, the last step of transfixing the
fascia must be performed nearer to the insertion of the pillars
of the ring.
In accomplishing this manoeuvre, the needle may also be
made to take up a portion of the pillars themselves close to
their respective insertions on the inside of the spermatic cord.
The crest of the pubis will afford a good guide and protection
to the deeper parts, the point of the needle being made to slide
close to the bone. This additional precaution is very desirable
in large cases of inguinal hernia occurring in females, in whom
there is not much fascia capable of being invaginated at this
point.
In some very small cases, both in male and female subjects,
this last transfixion of the fascia or pillars by the needle may
be altogether dispensed with; as any great amount of per-
manent invagination of the sac or fascia is not necessary to fill
up a narrow hernial canal when drawn together by the suture.
In some small female cases, a simple incision over the super-
ficial ring, without any separation of fascia, will suffice to apply
the necessary sutures with accuracy, and to afford a free escape
for the discharges.
The next step in the operation is to straighten, stretch, and
draw down both ends of the wire, until the loop above is close
to the skin. Here it is held by the finger of an assistant
while the surgeon twists the ends round each other, giving them
three or four turns. This manoeuvre twists also the enclosed
sac and fascia which are held between the ends of the wire.
Next, the loop is drawn steadily upwards so as to invaginate
the twisted sac and scrotal fascia firmly into the hernial canal,
stretching them as far up as possible towards its deep opening.
The loop is then, in its turn, twisted well down into the upper
or groin puncture, giving it the same number of turns.
The forefinger of the operator should now be placed in the

OPERATION BY WIRE.
113
scrotal puncture to ascertain whether a satisfactory closure of
the superficial ring has followed the tightening of the wire.
The effect of traction on the wire upon the posterior wall can
also be distinguished. Great care should also be taken that
the skin of the scrotum is not drawn upwards between the
pillars of the ring, so as to prevent their direct union.
FIG. 31.
B
A
C
The projecting ends of the wire are then cut off by pliers
about three inches from the surface; and both together bent
into a hook, which is carried upwards to meet the loop curved
down to receive it, till the two are locked together, and form
an arch over the intervening skin. (Fig. 31, A, B.)
A pad of lint, rolled tightly up to a size sufficient to fill up
the interval between the arch of wire and the skin, is then
placed under it between the punctures. (Fig. 31, c.) A
broad spica bandage is then placed over all, so as to make
firm compression upon the wire steadied by the pad of lint.
I

114
ON INGUINAL HERNIA.
In male cases, it is advisable to ascertain that the cord is
moveable behind the lower twist of wire, and not included in
its grasp.
It should also be ascertained that the superficial
ring is entirely closed up by the tightening of the wires.
In large scrotal herniæ, the testis on the side operated on
will be more or less drawn up towards the ring.
When the patient is removed to bed, care should be taken
to keep the abdominal structures relaxed, by raising the
shoulders and placing the knees bent over a bolster. The
scrotum may be supported by a small cushion covered with gutta
percha skin. As a support to the testes, I have been in the
habit of employing a long and broad strip of common adhesive
plaster, carried across the upper parts of both thighs, and pass-
ing behind the scrotum. This is not so likely to permit the
scrotum to slip down as the piece of wood used by Ricord as a
support. Attention to this point will obviate any bad con-
sequences in the way of swelling and pocketing of matter, which
might follow a dragging and dependent condition of the testes.
A slight enlargement of the testis on the affected side,
coming on in twenty-four or forty-eight hours after the opera-
tion, is a satisfactory indication, showing a sufficiently close
embrace of the substance of the cord, and a sufficient pressure
upon that part of the sac which immediately invests it, as well
as upon the posterior wall of the canal. If this swelling be
great, or there is much pain in the gland, the spica bandage may
be removed after twenty-four hours' application. Generally,
however, it will not be found necessary to remove it till the
third day. General abdominal uneasiness may also necessitate
its removal. To this, the application of a hot fomentation
flannel will usually give immediate relief.
The after-treatment consists simply in giving opium in some
form, as often as pain or restlessness renders it advisable.
Patients differ much in this respect. For the most part, they

OPERATION BY WIRE.
115
suffer hardly any pain after the first twelve hours. In some
cases they are restless, and complain of the tightness of the
bandage, of flying pains in the abdomen, and of a flatulent
condition of the bowels. No tenderness on pressure upon the
abdomen is, however, experienced, pressure rather giving relief.
Sometimes pain is complained of along the iliac crest, which I
attribute to the pressure upon the small ilio-inguinal nerve, by
the ligature enclosing it. Five grains of pil. sapon. co. given
soon after the operation, and repeated every night at bedtime,
or as often as rendered advisable by the pain, is the usual
treatment I have pursued, with hot fomentations in some of
the cases.
It is important in the after treatment of these cases not to
keep the patient too low, as we thereby diminish the power of
reparation on which so much of the permanency of the cure
depends. The diet should be mild and unstimulating, and
taken more freely when the patient feels inclined to eat it. To
begin with a milk diet is best, with strong beef-tea ad libitum,
and two eggs daily.
If the bowels have been properly cleared before the operation
by a mild dose of castor oil, and the diet thus carefully regu-
lated, it is better to leave them to their normal action after..
wards than to irritate them by purgatives. If moved within
the first three or four days it will be sufficient.
the patient complains of distension, a tablespoonful of castor
oil will be found to make him more comfortable.
If not, and
After the bowels have been opened, the patient is generally
allowed to have a slice of meat or a chop, if he can eat it; but
no vegetables, until a longer time has elapsed, and the wound
is fairly healing. If the latter process be somewhat sluggish,
six ounces of wine daily will be beneficial. If the patient have
been previously accustomed to stimuli, this may be increased to
eight or ten ounces.
1 2

116
ON INGUINAL HERNIA.
The wire usually gives rise to very little irritation or suppu-
ration, and may be kept "in situ" much longer than threads,
which seem by their retention of putrid or decomposing matter
to cause more suppuration in the wound.
In the course of the first week, when the tumefaction of the
more superficial parts has subsided, and the discharge, after
being serous, has become purulent, evidences of thickening
and consolidation of the transplanted tissues within the canal
become distinct.
The effective effusion in the canal may be distinguished from
an exudation into the superficial tissues, by the skin being
moveable over it as freely as over the surrounding parts. In a
short time, the effusion becomes so large and hard, that it may
be held between the finger and thumb, and felt to be deep-seated
behind the aponeurosis of the external oblique.
I have generally untwisted the wire about the eighth or tenth
day, and removed it altogether about the fourteenth. In cases
where the amount of solid effusion seemed to be less than usual
and slow to form, I have kept it in as long as twenty-one days
with benefit. Its withdrawal has rarely given much trouble,
and but a small amount of pain. By acquiring the habit of
giving the twist to the wire always in one direction, and count-
ing the turns, it becomes easy to untwist in the opposite direc-
tion, and with the same number of turns reversed. The track
in which it lies in the tissues is usually so much enlarged by
ulceration as to permit of the wire to pass with slight traction,
although one or two of the irregularities caused by the twisting
may remain on it. The two wire tracks are usually, at this
time, blended into one by ulceration of the intervening parts,
and the wires may be felt rubbing against each other in their
whole length. In large cases, where they are widely separated,
this may not be the case. The movements of the two ends on
each other will indicate their freedom from each other's em-

OPERATION BY WIRE.
117
brace. It has usually been necessary to untwist only the lower
ends of the wire; the loop and the upper twist generally coming
away unaltered by upward traction. It is better always to
draw the wires out upwards, if possible, to avoid the chance of
tearing downwards the new adhesions of the invaginated fascia.
In one or two cases only, it has been necessary to divide the
wire at the loop, and to draw out the two portions separately;
or to stretch the wire straighter by forcible traction at both
ends previous to withdrawing it.
In
After the wire is withdrawn, the groin in the neighbourhood
of the puncture must be compressed gently every day, to free
the deeper parts of the wire track from pus. This must be
done carefully, by pressing the groin deeply in a direction
towards the puncture on each side, so as to get the pressure
behind the wound as much as possible. The fistulous track
may be afterwards washed out every day with zinc lotion.
some cases, where the granulations appeared weak and relaxed,
I have used a solution of tannin, and also a lotion of the
muriated tincture of iron, with great benefit. The tissues were
rendered firmer and harder, and the tendency to their suppura-
tion checked. I have thought that, in these cases, the succeed-
ing induration was harder and more enduring. The upper
puncture is usually the first to close, the lower acting for
some time longer as a drain to carry off the discharges. This
usually takes place in the third week, when a spica bandage
and a pad of good size may be applied firmly, and the patient
allowed to get up and walk about his room. As soon as the
parts will bear it, a light truss of the proper shape may be
worn without waiting for the complete healing of the lower
wound.
The kind of truss I recommend, and have been lately in the
habit of treating patients with after operation, is the horseshoe
pad truss, of which a description will be found in the following

118
ON INGUINAL HERNIA.
pages.
The spring of the truss must not be too strong; it
should be strong enough to support but not to compress; and
the pressure should be quite flat, and be spread over the neigh-
bouring parts as well as the obliterated canal, so that the pad
of the truss should not be too small. (See the section on
Trusses.)

VARIATIONS OF THE WIRE OPERATION.
119
VIII.
VARIATIONS OF THE WIRE OPERATION.
IN some of the earlier wire cases, various modifications in the
application of the wire were tried.
One was adopted in con-
sequence of the length and pendulousness of the hernial sac.
FIG. 32.
A great redundancy of the skin of the scrotum led me to
remove altogether an elliptical portion with the knife, after
pinching it up between the finger and thumb, in the manner
shown in Fig. 32. Then, after separating the skin around the

120
ON INGUINAL HERNIA.
margins a little, the fascia was invaginated, and the needle first
passed through the conjoined tendon as before described-the
wire, with one end thinned off, hooked on above and drawn
through into the scrotum. The needle, disengaged from the
wire, was then passed across the sac in front of the cord at the
scrotal incision, the lower end of the wire hooked on and drawn
back with it across the back part of the sac. (Fig. 33.) The
FIG. 33.
needle, carrying the thin end of the wire, was then passed in
the usual place through the middle of Poupart's ligament, as
seen in Fig. 34. The wire was then freed, and the needle
withdrawn, leaving the two ends of the wire in the upper
puncture; these were then crossed over each other and twisted
round a wooden compress, as seen in Fig. 35, A, B.
Thus the loop of wire was sunk in the hernial canal, en-
closing the conjoined tendon, the sac, and the two pillars of

VARIATIONS OF THE WIRE OPERATION.
121
the superficial ring, invaginating the sac and scrotal fascia, and
retaining them powerfully upwards against the internal open-
ing of the hernia.
The above proceeding differs somewhat from the one before
described. Carrying the needle fastened to the wire through
Poupart's ligament is, perhaps, a little more difficult to ac-
complish. The use of the external compress is also retained.
FIG. 34.
It is an operation to be preferred, perhaps, where it is desir-
able, from the length of the sac and of the hernial canal, to
obtain greater upward traction of the former into the latter.
Another modification is represented in Fig. 36. It was ren-
dered necessary by the great width and lax condition of the
inguinal canal and external ring, amounting to a direct open-
ing into the belly, and requiring an additional precaution for
the closure of the superficial opening. After invagination of

122
ON INGUINAL HERNIA.
the scrotal fascia, the needle was passed, and the wire placed
in the usual way through the two sides of the canal, as high
up as possible, and the two ends of the wire drawn into the
scrotal incision in the manner before described. The ends
were then made to cross each other in the interior of the sac.
This was accomplished by hooking the inner end of the wire
(both ends of which must be drawn thin in this operation) on
to the needle, pushing it across the sac from without inwards
A
FIG. 35.
B
in the manner before described; and then, by freeing that end
from the instrument and hooking on the outer end, which was
then drawn through the sac in its turn by withdrawing the
needle. The sac was then invaginated as much as possible by
traction on the loop, the wires being made to hold by bending
their ends forwards. The needle was then passed through
the insertion of the internal pillar into the front of the
pubis, and the nearest end of the wire is drawn back with

VARIATIONS OF THE WIRE OPERATION.
123
the instrument. The same process was repeated at the inser-
tion of Poupart's ligament, taking through it the remaining
end of the wire on the inner side of the spermatic cord, which
was pushed outwards during the manœuvre. The additional
hold thus given to the wires upon the pillars of the superficial
ring lessens the strain upon the punctures during the action of
the recti, which, in large cases, has a tendency to split or fray
the parallel fibres forming these structures.
At the same
FIG. 36.
time, the hernial opening is closed at the lower part, close
above the pubis, where I have found the greatest tendency for
the rupture to escape after an operation, in large cases. In
large and difficult cases, these advantages more than compen-
sate for the additional time and trouble in operating. The
pubic crest and spine are prominent guides to the operator in
the latter part of the operation, and prevent any danger to
the deep-seated parts from the point of the instrument. An

124
ON INGUINAL HERNIA.
elongated, cylindrical boxwood pad was then applied to the
surface; the upper end was inserted into the loop of wire
emerging from the upper puncture, and round the lower end
were twisted the two free ends of the wire at the scrotal in-
cision, as seen in Fig. 36, on the right groin. This method
was employed in Cases 23, 37, and 59 (Appendix).
In Fig. 37 is seen a representation of the wires "in situ,"
applied in a large case of direct hernia. (Case 22.) It differs
from the operation just described only in the two lower
ends being applied to their respective pillars, on the oppo-
site side, instead of the same side, of the spermatic cord.
This is easily accomplished by pushing the cord outwards
before applying the last end of the wire. By this means, the
inner wire is made to traverse the hernial canal and sac twice,
opposite to and below the deep opening, and in front of the
spermatic cord, which is also crossed twice by the wire.
By these two operations, intended for very large cases, we
obtain additional holds upon Poupart's ligament, at its insertion
into the pubic spine, and upon the internal pillar of the super-
ficial ring, and tendinous origin of the rectus muscle. The
tendency of these hernia to escape close above the pubic crest
is thus provided against. In very large and lax cases, the addi-
tional employment of the compress is desirable; though, if pre-
ferred, the loop and ends of the wire may be twisted down
into their respective apertures of egress, and then united over
a rolled pad of lint, as usually employed.
Mature observation of the effects of the external compress
has led me, in ordinary cases, to prefer the method of twisting
the wire into the punctures.
up
The effect of the compress is chiefly exerted upon the super-
ficial parts, consolidation or effusion in which has no beneficial
effect in imparting a resisting power to the inguinal canal. At
the same time, the pain and uneasiness to the patient are con-

VARIATIONS OF THE WIRE OPERATION.
125
siderably increased by it. In most cases, it has a tendency
also to prevent the free escape of the discharges, and usually
requires an early removal for this reason.
In other cases, it
becomes speedily so loose by the ulceration of the wire track
as to be of no use after the first week. Its effects will be seen
to be chiefly felt by the tissues which are superficial to the wire
or ligature, and are included between them and the compress;
FIG. 37.
while it tends to prevent an effective pressure by the wire
upon the deeper parts of the canal, in which adhesion is the
most essential to success.
The twisted wires, on the other hand, favour the escape of
the discharge along them, and serve to transmit the pressure of
the bandage to the posterior or deep wall of the hernial canal,
along which the rupture is apt to make its way and recur.
The facility with which the wires are usually untwisted and

126
ON INGUINAL HERNIA.
removed, on account of the enlargement of the track along
which they lie by ulceration, removes a theoretical objection
which I at first felt against this mode of fixing them, on the
score of the difficulty of getting them out of the wound after
the parts had become consolidated.
At the same time it must be said, that the action of the
compress is beneficial where there is great laxity about the
superficial ring, upon which part its effects may be considered
as more direct and certain than upon the deeper structures.
Before the acquisition of experience had proved the feasibility
and advantages of twisting up the wire, one case was operated
on by the following method.
The usual preliminary scrotal incision and invagination of
the fascia being effected, and the wire applied to the conjoined
tendon and Poupart's ligament in the manner described, the
upper loop was drawn entirely into the groin puncture, so as to
lie under the integuments close upon the aponeurosis. The
ends of the wire in the scrotal incision were then held together
by a sort of clamp, made of a thin elongated piece of steel,
with a loop or ring at the upper end and a cross piece at the
lower to fasten the wire upon. In fixing it, the ends of the
wire were passed through the ring of the clamp, which was
then slid over them up into the wound, and made to invaginate
the fascia as high up into the canal as possible; the ends of the
wire being finally bent round the cross piece at the bottom, and
so fastened.
In the case on which this plan was tried (Case 25), the
upper puncture healed completely over the wire by the ad-
hesive process.
The discharge which resulted, not being able
to escape freely enough by the lower incision, accumulated in a
small abscess in the groin over the loop end of the wire, and
required an incision for its escape. The pressure of the steel
clamp in the canal resulted in the sloughing of the sac in the

VARIATIONS OF THE WIRE OPERATION.
127
scrotum. The ultimate result of the action thus set up around
the cord was considerable atrophy of the testicle.
These serious drawbacks led me to discard the use of the
clamp in succeeding cases, and to resort to twisting of the wire
above and below, and to the maintenance of the upper as well
as the lower opening by the twisted ends of the wire. This
provision for the free escape of the discharge has been so effec-
tive, that I have had, since the time I adopted it, no instance
of retention of matter or the formation of an abscess in the
groin or deeper parts, and in the scrotum but rarely; nor of any
atrophy of the testicle, except in one instance from other causes.
Lastly, in a very large case of congenital rupture (Case 48),
in which the hernial apertures were directly opposed to
each other, and the previous use of the rectangular pins had
obliterated the scrotal portion of the sac, and reduced the
opening to a chink at the edge of the rectus muscle, an opera-
tion was performed, the arrangement of the wire in which
is given in Fig. 38. In this case, no incision was made in
the scrotum, the coverings of which were so thin as to
permit distinct tactile perception by simple invagination of
the skin.
A common stout suture needle, large enough to carry a wire
somewhat thinner than that ordinarily used, was employed.
The little finger of the operator being firmly invaginated as
high up as the aperture would allow, the skin of the groin was
drawn well upwards by an assistant. The needle was then
passed from the surface of the groin through the skin and outer
pillar, on a level with the upper part of the hernial aperture.
The point of the needle, being felt to impinge upon the apex of
the invaginating finger, was then carried across the canal, and
made to transfix the internal pillar, and the covering of the
rectus muscle placed behind it. It was then pushed through the
skin over the internal pillar. A short length of the wire being

128
ON INGUINAL HERNIA.
thus drawn through, was cut off and left in the puncture.
The skin of the groin was then drawn downward, the inva-
ginating finger receding a little at the same time, and placed
firmly upon the spermatic cord behind the extremity of Pou-
part's ligament. The needle being passed through the same
external aperture as before, was again made to transfix Pou-
part's ligament upon the end of the finger, and carried across
FIG. 38.
A
B
In this figure an opening is represented in the skin and aponeurosis of the
groin, in order to show the arrangement of the wires in the canal.
the cord to the edge of the rectus at its attachment into the
pubis. Through this and the overlying internal pillar its point
was next thrust, and carried through the skin-aperture before
made in this situation. Another length of the wire was then
cut off, and the skin of the scrotum suffered to drop out as
much as it would. The extremities of the two wires at each
puncture were then twisted firmly up, with the effect of com-

VARIATIONS OF THE WIRE OPERATION.
129
pletely closing the aperture in its whole length. At one end a
loop was made by twisting, as seen in figure (A), and at the
other end of the wires two hooks were bent. The hooks were
then fastened to the loop over a pad of lint (B). Instead of
the pad of lint, a cylindrical boxwood or glass pad may be
used in preference, in large cases, as in Fig. 36.
K

130
ON INGUINAL HERNIA.
IX.
OPERATION FOR CONGENITAL HERNIA IN CHILDREN BY
THE USE OF RECTANGULAR PINS.
IN congenital hernia, and the smaller kinds of rupture in chil-
dren and young boys, the hernial canal is usually narrow; the
internal opening often contracted; and the sides elongated so as
to retain much of their valve-like action, and so flexible and
yielding as to admit of easy approximation in their entire length.
Coupled to these advantages, the scrotal fascia and coverings
are thin, and the fundus of the sac often small, so that the tissues
between the skin and the sac do not constitute any great bulk,
and are consequently of little use as a connecting medium,
when transplanted into the hernial canal. The flexibility of
the canal itself, also, is such as to need no interposed tissue to
fill
up the hernial openings; while the thinness and delicacy of
the scrotal tissues permit of a distinct perception of the ana-
tomical relations of the deeper inguinal structures by simple
invagination of the skin, and without a preliminary incision.
To draw together and cause to unite the sides of the canal
under such circumstances, I have used, in thirteen of the cases
given in the Appendix, the rectangular pins which I had been
for some time in the habit of using for the cure of varicose
veins and varicocele, by double subcutaneous acupressure. For
the cure of rupture, however, these pins are made a little larger
and stronger than for the purpose just named, and both are
curved considerably more near the point.
The pins are represented in action in Fig. 39. They are of

OPERATION BY PINS.
131
various sizes, from three to five inches long, and of propor-
tionate strength; hardened at the point, but made in the shaft
soft, so as to bend rather than break off short under ten-
sion.
They are spear-pointed, flattened on the
concavity, with slightly cutting edges, and
curved boldly, like the ordinary suture needle,
near the point. The shaft is rounded, and
at about three or four inches from the point
it is bent at right angles, the angle being
twisted into a loop large enough to receive
the point of the fellow needle. The pro-
jecting end is about an inch long, and
terminates in another loop, for the purpose
of securing it in position by the dressings.
When about to be applied, the pins are
held by the middle of the shaft between
the thumb and middle finger, the last
phalanx of the forefinger being placed upon
the bent extremity, with the terminal loop
towards its point. (See Fig. 40.)
FIG. 39.
They are applied separately, and in oppo-
site directions, through the structures intended to become
adherent, on each side of those intended for obliteration; and
are pinned through and through as in fixing an ordinary toilet
pin. Each point is then passed through the loop at the angle
of the fellow pin; and the bent ends afterwards rotated in
opposite directions upon the axis of each other's shafts, so as
to twist up and compress the included structures, somewhat
like the twist given to the neck of a mail-bag.
The Operation.-The method of applying them to a case of
rupture, as I have most frequently practised it, is as follows:-
the hernia being reduced completely and carefully, and the
K 2

132
ON INGUINAL HERNIA.
child laid on its back, with the knees bent up; the scrotum is
invaginated into the canal, and the position of the cord, the
conjoined tendon, and Poupart's ligament, carefully recog-
nised and noted. In small cases, this can be most con-
veniently done by using the little finger. This is carried
up into the canal as far as possible, until the border of the
internal oblique muscle can be felt as a thick covering in
FIG. 40.
front of the point of the finger. The conjoined tendon may
then be made, by traction, more salient and evident at its
inner border.
The skin of the groin being drawn directly inwards by an
assistant, a pin, with its concavity directed downwards, is
passed through it, and all the intervening tissues, straight
upon the inner side of the nail of the invaginating finger, till it
can be felt to touch it. (Fig. 40.) It is then slid downwards

OPERATION BY PINS.
133
along the side of the finger, which is at the same time
withdrawn along with it, protecting it on the outer side until
the point of the pin can be felt to touch the upper border of
the pubis. Skirting this bone, it is then carried down into
the scrotum, and brought out through the skin over the
fundus of the hernial sac, upon which the invaginating finger
has been pressed. In this manoeuvre the points of the finger
and pin must be kept fairly "pari passu;" and the rupture kept
FIG. 41.
out of the sac, by the pressure of the little finger of the hand
carrying the pin, over the internal ring. This position will, at
the same time, give steadiness to the hand.
The second pin is then taken, and its point, with the con-
cavity forwards, passed through the skin into the same
scrotal puncture at which the former emerged. The inva-
ginating finger is then placed below it, and the scrotum again
pushed up before it into the canal, carrying the point of the

134
ON INGUINAL HERNIA.
pin upon it till it touches the posterior surface of the outer
pillar of the superficial ring. Through this it is then passed
obliquely upwards and outwards, so as to raise the skin of the
groin directly below the situation of the deep ring. The skin
is then drawn outwards by an assistant as much as possible,
when it will be found that, by turning the concavity of the
pin inwards, its point can be brought out through, or suffi-
ciently close to, the puncture made by entering the first pin.
(See Fig. 41.)
FIG. 42.
The pins are then to be locked into each other's loops, a
proceeding which will be much facilitated by first cutting off the
sharp end of one of them with pliers, so as to make it shorter
than the other. The point of the other pin is then to be re-
moved by the pliers, and the bent ends twisted round once.
This may be accomplished best by simply turning over the end
of the upper pin towards the thigh. The punctures and skin

OPERATION BY PINS.
135
are then carefully protected, by lint or wash-leather and
adhesive plaster, from the effect of pressure by the loops and
ends of the pins, and the extreme loops of the pins are tied
together by string, or a strip of lint or sticking-plaster, so as
to prevent slipping. (See Fig. 42.) The whole is then re-
tained by a pledget of lint and spica bandage.
FIG. 43.
In this operation the conjoined tendon and the internal
pillar are transfixed by the pin first applied, and the outer
pillar is transfixed and included by the second. The sac is
transfixed by both the pins, which lie for some distance in its
interior. The whole of these parts are twisted together by the
revolution of the one pin on the axis of the other, so that the
posterior wall being drawn forward, and the anterior drawn
backward, the hernial canal is firmly closed; tightly embracing
the cord, which lies behind and between the pins, but without
being included by them.

136
ON INGUINAL HERNIA.
In one case operated on (Case 31), the pins were placed
transversely across the canal,-one deep, so as to lie close upon
and across the cord (as shown in Fig. 43); and its fellow,-
superficial to the external oblique aponeurosis, and under the
integuments only. (Fig. 44.) When only a couple of pins
are applied in this way, however, the power of twisting together
the sides of the canal in its whole length is not obtained, and
it is closed only at one point, constituting a less resistant
barrier against future protrusion. A want of complete success,
FIG. 44.
which followed this plan in the case referred to, led me to
follow it only as an additional precaution to the operation first
described, in instances of large herniæ requiring it.
In the instances last mentioned (Cases 47 and 48) the
ruptures were congenital, of great size, and the openings so
large as to admit easily of three fingers directly into the
abdominal cavity, close above the pubis. No truss had been
obtained which could keep up the bowel at all, and the little
patients (brothers, of the ages of four and a half, and seven

OPERATION BY PINS.
137
years respectively) were in a deplorable condition in regard
to their future prospects of maintaining themselves by labour.
Under these circumstances, I combined the two operations
by fixing a couple of pins of the larger size, in the manner first
described; and afterwards passing another couple of the smaller
pins transversely across the sac and pillars, close above the pubis.
The deeper of these two was passed close to the bone, trans-
fixing both pillars of the ring at their insertion upon it; the
more superficial one passing under the integuments only,
through the same skin punctures. Enclosed between them
were the larger pins first applied along the sides of the canal.
The result of these two cases has been, so far, very satisfactory,
requiring only a little additional interference afterwards to close
up (in one case completely) a hernial aperture so large as to
permit the finger to traverse almost the whole of the lower part
of the peritoneal cavity. Not a single unpleasant symptom
occurred in either of the cases afterwards.
The pain experienced by the little patients after the opera-
tion by pins was uniformly so slight that no sedatives were
employed. The tongue was barely, or not at all, whitened;
the appetite undiminished, except for one day or so after the
operation (and this might be properly attributed to the chloro-
form); and the action of the bowels unaffected. In no case
was there any suppuration worthy of note; in the smaller cases,
none at all. A drop or two of serum oozing from the punc-
tures and crusting the dressings, was usually the only discharge.
The dressings were changed only once or twice in the course
of the treatment, and then more to ascertain the progress of
the consolidating action and the state of the punctures than
from any real necessity. The little patients suffered so little
that they were with difficulty kept still enough, or in the re-
cumbent posture. The pins were usually withdrawn, without
difficulty and with little pain, on the tenth day. In one or two

138
ON INGUINAL HERNIA.
cases they were withdrawn about the fourth or fifth; and, in
another, on the second day, in consequence of the amount of
consolidation and thickening set up in that short time. In one
instance they were withdrawn early, because of the occurrence
of some symptoms which were thought to betoken the access
of scarlatina. (Case 39.) All these cases were perfectly
successful. The case first referred to (Case 31) was not
successful, chiefly, I believe, in consequence of a bad state
of health from bronchitis, teething, and general tubercular
diathesis. A violent cough which supervened gave rise to a
partial return of protrusion; but this, by the pressure of a
proper truss, was much more under control than before the
operation. The same child was operated on on the opposite
side (the rupture being a double one) with uninterrupted suc-
cess. In another case (Case 34) I thought there had occurred
an increase in the impulse at the site of the operation the last
time I saw it, but this was easily controlled by the truss.
A hard cord, and sometimes a great amount of thickening,
could be felt in the canal after the withdrawal of the pins. The
fundus of the sac could be felt obliterated and hardened into a
solid mass of effusion within the scrotum, while the superficial
ring could scarcely be distinguished. In some of these cases
the testicle was somewhat enlarged for a while, but gradually
recovered its normal condition.
The foregoing operation must be viewed rather as an adjunct
to exclude the bowel, and so to accelerate and render certain
the treatment by the pressure of a truss, with a pad constructed
on the proper principle for closing up the sides of the canal.
Besides obliterating the interior of the original sac, the action
of the pins on the canal gives an additional tendency to that
closure around the cord which should normally succeed the
descent of the testicle. The pressure of a truss-pad, of the
proper shape, will doubtless often accomplish the same result,

OPERATION BY PINS.
139
but by a much longer, more tedious, and more uncertain pro-
cess; while the use of an improper truss-pad, instead of accele-
rating a cure, will increase the size of the hernial openings
and make the state of things worse, as is commonly met with
in practice.
An operation so little painful, so simple, and so totally free
from danger when skilfully conducted, does not seem to be
open to any of the objections commonly urged against operative
interference in cases of congenital hernia in children; while it
renders the certainty of a cure so much greater, and its accom-
plishment withal so speedy, as to constitute strong recommenda-
tions to its adoption; especially in cases where the prolonged
friction of a truss strong enough to retain the rupture, is
followed by frequent sores, gallings, and abscesses in the delicate
groins of infants.

140
ON INGUINAL HERNIA.
X.
THE MODUS OPERANDI OF THE FOREGOING OPERATIONS.
THE results aimed at in these operations may be briefly re-
capitulated in the order of the importance attached to them
respectively.
l
FIG. 45.
First.-The posterior and superior boundaries of the dilated
tendinous canal are drawn forwards, downwards, and outwards,
and become permanently united by adhesion to the anterior
and inferior walls; or, in other words, the conjoined tendon,
the internal pillar of the superficial ring, and, in
some cases, the edge of the rectus tendon, are
firmly united to Poupart's ligament and the ex-
ternal pillar of the ring. This adhesion follows
upon the close compression and slow ulceration
induced by the action of the wire, thread, or pins.
In Fig. 45 it will seen, that the effect of this
adhesion is to restore the retaining power of the
valve of the posterior wall (v), by approximating
it to the anterior (a), in cases of oblique hernia.
The contraction of the cicatrix, subsequent to the
operation, promotes the closeness of the appo-
sition and increases the future security against protrusion.
The spermatic cord is closely embraced by the contracting
tissues as it lies in the groove above Poupart's ligament, the
latter protecting it from undue pressure.
In cases of direct hernia, this restoration of the overlapping
valve is necessarily imperfect, since there is a deficiency here in

MODUS OPERANDI OF THE OPERATIONS.
141
the limb of the valve itself. Here the ligature acts mainly as
a circular compressing force upon the opening, uniting Poupart's
ligament and the outer pillar, to the edge of the rectus tendon,
the inner portion of the conjoined tendon, and the internal
pillar. For greater security in ruptures of this kind, an addi-
tional point of union of the pillars of the ring close to the pubis
becomes necessary, especially where the opening is large; and
the employment of some of the modifications of the wire
operation given in the preceding pages will give rise to a greater
extent of adhesion and consolidating action.
b
FIG. 46.
a
Secondly. The consolidation and con-
traction of the tendinous structures traversed
by the ligature or pins under the healing
process which succeeds the withdrawal of
the latter, render them more adherent to
each other, and more resistant to pressure
from within. This effect will be better
understood by reference to the adjoining
figures, showing, one (Fig. 46) a vertical, and
the other (Fig. 47), a horizontal section of
the parts opposite the cicatrices.
The con-
traction of the circular cord of effused fibrin
will draw the skin at a, towards the deeper
parts and peritoneum at v; enclosing and
compressing the canal,-thus supplementing
the retaining power of the "arciform" and
"intercolumnar" fibres. Thus Poupart's
ligament becomes a "point d'appui" for the compressing forces,
and a direct opposition is afforded to the yielding of the superior
and posterior walls. The effect is also to resist that dilatation
of the canal, before pointed out as produced in hernial cases
by the action of the recti muscles, by transmitting their traction
force along the cicatrix to Poupart's ligament, and aponeurosis
FIG. 47.
V

142
ON INGUINAL HERNIA.
of the external oblique. The mobility of the different abdo-
minal layers upon each other, which has been before adduced
as a cause of the more easy formation of a rupture, is also
limited and restrained by these adhesions.
Thirdly.-The transit of the ligature or pin across the sac,
and along its interior surfaces, sets up adhesive action there,
which results in its entire obliteration and adhesion to the
spermatic cord, as in the treatment of hydrocele by seton.
Combined with the compression exercised upon the neck of the
sac, which throws the serous membrane there into a multitude
of folds, and with the action set up in the surrounding tendinous
structures, the result is the formation of one mass of adhesion,
which totally precludes the formation of another rupture in the
same sac.
In the small cases before referred to, in which the sac is not
implicated at all, but pushed up into the deep ring, this oblite-
ration of the sac is not at once effected by the operation, but
is accomplished by the slower process of contraction through
the elasticity of its serous membrane and the absence of dis-
tending force from its interior.
In older and larger cases, where the sac has formed adhe-
sions in the scrotum, the obliteration of its cavity becomes a
matter of more importance, as it then forms a support to the
adhesions at its neck in resisting a return of the rupture.
In one or two of the cases given at the end of the volume,
it will be seen that a liquid effusion into the posterior fold of
the fundus of the sac followed the obliteration of its neck by
the suture. That part of the sac which became the seat of
this effusion was thus in a condition similar to a hydrocele.
The most evident course was to treat it on the same principle.
In one, the liquid serum was drawn off by puncture with
a grooved needle, with the best results. (Case 30.) In
another, the effusion spontaneously disappeared, the case making

MODUS OPERANDI OF THE OPERATIONS.
143
a good cure. (Case 1.) In a third, the effusion continued,
combined with some varicocele, up to the time I lost sight of
the case. (Case 5.) At that time a communication evidently
still existed between the sac and the peritoneum, since the fluid
could be pressed very slowly upwards, and the greater part of
the tumour could be made to disappear. The opening, how-
ever, must have been small, the sensation given to the com-
pressing fingers being exactly like that communicated by an
india-rubber bottle from which the contents are escaping by a
small opening. Much induration was present about the neck
of the sac and inguinal canal.
Since such a condition might result in a re-dilatation of the
hernial passage,
passage, I should not hesitate, at the present, as I did
at that time, to puncture the sac and let out the fluid.
A
A short time ago I had sent to me a most interesting case of
rupture, the condition of which had an important bearing upon
the present subject. The rupture was large and scrotal.
hard mass, evidently omentum, could be felt in the inguinal
canal, immovable and adherent to the neck of the sac. The
fundus was distended by a translucent serous effusion, which
had all the characters of a hydrocele, except that the testicle
was entirely distinct, though considerably enlarged. It could
be freely moved without dragging the swelling along with it.
The history stated that the rupture was of one year's stand-
ing, and had been scrotal for some time, but was easily and
completely reducible until a week previous to his application.
At this time, in consequence of wearing a powerful but ill-fitting
truss, much pain and great increase of swelling occurred in the
scrotum, and it was found impossible to return the rupture as
before. The bowels, however, continued regularly to act. A
puncture was made in the swelling, and about three ounces of
serous fluid, highly albuminous, escaped. The omentum block-
ing up the neck of the sac could then be distinctly felt just

144
ON INGUINAL HERNIA.
above the superficial ring. The patient was much relieved by
the operation, and I advised him to have nothing further done
to it at present, since there was a strong probability that a cure
would be the result by adhesion of the omentum to the sac.
In three cases (Nos. 8, 25, and 52) the sac suppurated and
sloughed below the neck, the ultimate result being in one
case highly satisfactory, and in the other some atrophy of the
testis. This result, however, has been quite exceptional; and
only in the last case has it followed the many operations by
the most approved methods of using wire or pins. In the case
alluded to, sloughing was endemic in the hospital at the time.
Fourthly.-When the scrotal fascia is invaginated into the
hernial canal, the adhesion of its opposing raw surfaces to each
other, uniting with the general mass of consolidation in the
track of the ligature, and to the surface of the spermatic cord,
forms an additional provision against a return of the rupture.
(See Fig. 46.) In very large ruptures this fascia, being com-
monly very strong and hypertrophied, contributes beneficially
to fill up the large internal opening at the neck of the sac, and
serves for a connecting bond of union to the widely separated
boundaries of the opening; affording, at the same time, a con-
venient bed or point of resistance to tighten the ligatures upon.
The fascia of the scrotum is extremely vascular, and apt to
take on a consolidating action, in the fibrin which is abundantly
effused in the presence of a foreign body. It is at the same
time very tough and resisting when condensed by inflammatory
changes. Thus, in large ruptures, it assists in maintaining the
closure of the canal.
The new adhesions which are formed by the edges of the
scrotal incision to the margins of the superficial ring, also con-
tribute powerfully to support in its new position the invaginated
scrotal fascia against pressure from above.
Fifthly. The union of the pillars of the superficial ring to

MODUS OPERANDI OF THE OPERATIONS.
145
each other, either directly, as after the use of the pins, or
through the medium of the invaginated fascia, as in the other
operations, has also a powerful influence in supporting the ad-
hesions formed higher in the canal. In direct hernia this
result becomes especially valuable, increasing the limited area
of adhesion around the neck of the sac. It will be remarked
that this union, although one of the most original of the features
of the operations devised by the author, cannot be effective in
itself and alone, in permanently closing the hernial canal, since
it would be simply the conversion of the hernia into a bubono-
cele, while the limited area of adhesion would give way anew
upon any great force acting from within.*
The closure of the superficial ring can be distinguished in
most of the cases after operation. A firm fibrous band passing
from one to the other, and adherent firmly to the cord as it
emerges, resists the passage of the surgeon's finger into the
canal. Passing down from it to the cicatrix in the scrotum
can usually be felt also a firm cylindrical fibrous mass, the re-
sults of the invagination of the scrotal fascia and its firm union
to the sides of the ring. Such a fibrous band can be discerned
also in the cases treated by the pins. In some cases it is formed
by the remains of the fundus of the sac remaining in the scro-
tum, shrivelled, and contracted into a hard, firm cord.
These
*The operation proposed by Professor Chisholm, of Charleston, America,
of applying subcutaneously small wire sutures to the pillars of the superficial
ring, and leaving them permanently under the skin, is not likely to result in
permanent benefit, for the reason given in the text. Under the pressure
of the bubonocele which is left in the canal, the small wire thread will cut
like a knife the tense fibres of the pillars, and the rupture will again
protrude, carrying the sutures on its anterior wall. It should, in justice,
be here mentioned that the above-named gentleman, when in this country
some years ago, and before his cases were operated on, was present at a
demonstration by the author of his operation on the dead body, at King's
College; when the possibility of such an application of the sutures was dis-
cussed, and the reasons against its adoption given in the text were stated.
L

146
ON INGUINAL HERNIA.
conditions have been detected in many cases years after the
operation. Any invagination of the skin itself between the
pillars of the external ring in the operation will, of course,
prevent this union of the sides of the opening, and must be
carefully guarded against.
It may be found, by some, difficult to understand how such
union can be produced, without denudation by the knife of the
surfaces of the tendinous and other structures. The action of
the suture and pins upon the tissues which they traverse, and
which lie in their grasp, is that of slow division by ulceration
and absorption. The effect of this is to produce a denuded
surface in a subcutaneous position, and with but little, if any,
exposure to the atmosphere. The adhesive process, or that of gra-
nulation, consequently follows directly and closely upon the track
of division of the tissues, and is uninterrupted by the accidental
complications which commonly follow an exposed wound. An
additional advantage is derived from the fact that the parts are
held and retained in the position which it is desired they should
maintain, by the suture or pins, until adhesion and granulation
have accomplished a more permanent retention and occlusion
of the abnormal openings.

CAUSES OF FAILURE AND DANGER.
147
XI.
CAUSES OF FAILURE AND DANGER IN THE OPERATION.
THE main cause of the repeated failures in the ancient and
modern operations to close up the hernial passages, lay in the
want of recognition of the necessity of including the posterior
wall of the canal in the parts operated on. The anterior parts
of the hernial coverings only being influenced, the rupture
generally descended behind the site of the operation.
This difficulty may be also experienced by a surgeon, unac-
customed to manipulate the parts, in the performance of the
foregoing operations, hesitating at the dangers of wounding the
epigastric artery, the peritoneum, the spermatic cord, or the
bowel, when fixing the sutures.
In some cases, the conjoined tendon is not well marked, the
attachment of the fascia transversalis obscuring its outer border.
If, in these cases, however, the finger be well pushed up behind
the lower border of the internal oblique, and then flexed forcibly
towards the surface, the tendon sought after may generally be
distinguished as a ridge or border placed on the stretch. The
point of the needle should then be passed inwards, so as fairly
to take it up. It may be thought that the epigastric vessels
are endangered at this part of the proceeding. An inspection
of the parts in a hernial subject will show, however, that the
finger pushed upward between the internal oblique muscle and
fascia transversalis, opposite the deep ring, will press back the
fascia covering these vessels and the peritoneum, forming for
them a safe protection; so that they will be out of the reach
L 2

148
ON INGUINAL HERNIA.
of the needle placed properly on the inner side of the invagi-
nating finger. The exercise of a little delicacy and experienced
tact is certainly required in taking up the requisite amount of
the tendon and no more. The edge of the rectus tendon, which
may be distinctly recognised, will indicate the depth as well as
the distance inwards, to which the needle may with safety be
passed. In direct cases, this portion of the rectus may be
partially included in the ligature.
The shape of the point of the needle, as before described, is
such as to split rather than cut across the tissues, which may
result if there be any cutting edge on the shoulders. A neglect
of this precaution in one operation I witnessed, led to a com-
plete division of Poupart's ligament, as if with a tenotomy
knife. The same result may follow the use of thread or wire
too thin; or a too great tightening of the sutures. In one of
my own cases, such a cause led to the enlargement of the needle
puncture so great, as to permit of a small protrusion after the
operation. This, however, was diminished by the pressure of
a flattened truss pad. The blade of the instrument should
be well and sharply curved towards the handle, so that when
deeply inserted into the parts, the point has a tendency to come
short to the surface. When the point is fairly implanted be-
hind the tissues intended to be included, the curve of the blade
should be placed across the invaginating finger, which may then
be used as a fulcrum upon which to turn forward the point,
by depressing the handle. At this time the invaginating finger
may be itself brought forwards, carrying the needle upon it.
The concavity of the latter should be kept carefully and firmly
turned forwards and a little upwards during the performance
of these manœuvres.
A similar manoeuvre performed behind Poupart's ligament
will guard the iliac vessels and cord, by lifting up the aponeu-
rosis forming the external pillar away from them, during the

CAUSES OF FAILURE AND DANGER.
149
passage of the needle. A firm pressure by the thumb of the
invaginating hand upon the femoral vessels at the same moment
of time (as seen in Fig. 26), will render the precautions certain.
It may be pointed out here, in reference to the danger
menacing the vessels and peritoneum, that in none of the cases
given in the Appendix has there been any hæmorrhage. In
one case there was a slight venous oozing, evidently proceeding
from one of the spermatic veins, which were varicose. In the
two cases in which alone some degree of peritonitis was
suspected, the symptoms did not appear until the lapse of a
week, and were caused, as I believe, by the burrowing of matter
towards the peritoneum.
In some operations for the radical cure of rupture, I have
heard of the bowel having been pierced, and even tied up in
the suture; the result being, as may be anticipated, death in a
very short time after the operation. Unless the operator be
rash and over-confident, or the patient struggles so much as to
bring the bowel forcibly down at a critical moment unprepared
for by the operator, such a disastrous result ought not to occur.
The complete return of the rupture, and the recumbent position
of the patient, with the pelvis raised, generally suffice to prevent
trouble from the presence of the bowel in the sac. I place the
most reliance, however, upon the firm pressure of the invagi-
nating finger in the neck of the sac blocking out the bowel,
and giving a clear perception of the tissues about to be per-
forated. If due care be taken to hook the point of the finger
firmly forward and a little towards the side of the canal about
to be punctured, so as to feel the parts fairly stretched over it;
and, at the same time, to be sure that the point of the instru-
ment is not permitted to pass beyond that of the finger towards
the inner opening of the sac, the greatest confidence may be
felt that no bowel can be included.
When the patient struggles much under the chloroform, it

150
ON INGUINAL HERNIA.
is better to wait until its full effect is produced, if it can safely
be done. If not, an assistant should command attentively the
internal ring by pressure with his fingers, whenever the steps
of the operation will permit him to do so. If coughing occur,
the needle should be kept out of the canal, or quickly but
carefully withdrawn if already placed there, especially if there
be a tendency of the bowel to pass down beside the finger in a
wide canal. If the point of the needle, however, be at the
time fairly engaged in the walls of the canal, the occurrence of
the cough can do no damage, and the operation may be calmly
proceeded with. In some very obstreperous cases in children,
I have had recourse to inversion of the patient, by placing the
pelvis higher than the head, as a precautionary measure, which
had all the effect intended. I found this plan of placing the
patient topsy-turvy very effective also in the succeeding dress-
ings, when it was necessary, during the change of the com-
pressing agents, to prevent a forcible disruption of the newly-
formed adhesions, by a violent pressure of the intestines from
within during the struggles of the patient. (Cases 46 and 47,
Appendix.)
If the surgeon has sufficient tactile perception of the struc-
tures in the canal, a proper amount of caution and discretion,
a steady hand, and that precision and confidence in the use of
the instruments, which can only be obtained by experience,
there is, I conceive, but little danger of mischief being done.
I say this after performing the operation sixty-six times on the
living, and a great many more on the dead subject.
At the same time, the possibility of passing the needle into
the peritoneal cavity, of including the epigastric or wounding
the iliac vessels, of transfixing the body of the rectus muscle,
and even of transfixing and including the bowel, must not be
forgotten by the operator.
The fear of passing the needle too deeply may cause the

CAUSES OF FAILURE AND DANGER.
151
conjoined tendon to be imperfectly secured. Many failures
have resulted from this cause. With a view to lessen the
chances of such failure, I have employed and recommended in
the wire operation as well as in that by pins, the application of
external pressure by a pad and spica bandage upon the wire
loop or pins. When such pressure is made upon the stiff and
unyielding loop formed by the twisted wire, bent over a pad of
lint, it is communicated to and mainly exerted upon the deeper
parts behind and in contact with the wire. Adhesive action is
thus set up in that part of the hernial sac and canal which
may have escaped the grasp of the wire, but which still remains
in contact with, and is crossed by, its deepest part. By this
direct pressure is secured adhesion to the spermatic cord, and
complete obliteration across the hernial tube at the deepest and
highest part traversed by the wire. (See Fig. 31, B and C.)
This direct pressure is obtained also, in a great degree, after
the application of the pins. It is much more effective on that
part of the canal which it is so important to secure, than any
pressure which can be applied by a hard compress on the surface
of the groin, the effect of which is experienced by the more super-
ficial structures which intervene between the ligature and the
compress, while scarcely any pressure is exerted upon the deeper
parts. In some cases, however, in which much laxity is present
about the superficial ring, a compress may be used with advantage
as an addition to the wire. The advantages of both may be
thus combined.
In some cases of oblique hernia which have returned after
operation, I have observed that the first reappearance of the
protrusion took place close to Poupart's ligament. The rup-
ture afterwards crept along the course of the spermatic cord to
the superficial ring, which became thenceforth slowly dilated.
This result I attributed, in some cases, to a mal-position of the
outer end of the suture, i.e., its not being placed sufficiently far

152
ON INGUINAL HERNIA.
from the border of the outer pillar, or sufficiently close to
Poupart's ligament. The width of the external pillar varies
much in hernial subjects. In the smaller cases, the pillar is
usually felt broad and distinctly triangular in form, preserving
more or less its normal shape. In such cases the needle must
be carried far outward behind the tendon. In other cases, the
outer pillar is very thin and narrow, and can scarcely be dis-
tinguished from Poupart's ligament. In these the needle must
be made to split the fibres of the latter structure itself, and the
precautions before detailed to avoid wounding the femoral
vessels must be carefully practised. In large cases, the outer
pillars may be so lax and loose as to be distinguished with
difficulty from the proper hernial coverings, and care must be
taken to include the whole of the relaxed fibres in the suture.
Another source of failure consists in not placing the sutures
opposite the exact centre of the openings which are sought to
be closed. If too low, the hernial opening may be imperfectly
closed above, or the contrary fault may permit the rupture to
escape below. The latter is, perhaps, the more common result.
The size of the opening will indicate to the surgeon the pro-
priety of applying one or more points of suture on each side.
In the operations by wire, a more extensive approximation of
the sides and openings of the canal is attempted by placing the
wires obliquely in reference to the axis of the canal. (See Fig. 31,
B.) If the wire be placed too low, a good deal of the effect of
this obliquity is lost, and a bulging condition of the groin at
the site of the internal ring remains after the cure has been
effected. In these cases an insufficient action has ensued
opposite to the internal ring, and its sides have not become
adherent to the surface of the aponeurosis which covers it in
front. If, on the other hand, the wire be placed too high,
when twisted up tight it leaves the lower part of the canal
comparatively unclosed, and the rupture may make its
way
be-

CAUSES OF FAILURE AND DANGER.
153
hind the adhesions set up by the operation. This may be con-
siderably, if not altogether, remedied in the latter stage of the
operation on passing the wire across the hernial sac at the
scrotal puncture, when a portion of the outer or inner pillar, at
their insertion, may be included with the sac and its coverings.
It will be seen that in effecting this part of the operation,
the canal being already closed more or less completely by the
wire already placed on each side, the intestines are effectually
prevented from passing into the sac, and getting into the way
of the needle. This may be still further secured by holding
the ends and loop of wire firmly together during the passage of
the needle across the sac.
The most likely mischance to occur here, is the puncture or
enclosure of the whole or some part of the spermatic cord in
the grip of the suture. To a surgeon accustomed to operate
for varicocele, this danger will seem but small, the sac of a
hernia not being so close to the cord as the veins are to the
spermatic duct. The cord can always be readily felt, and
slipped back between the finger and thumb; and before the wire
is tightened the cord can be distinguished as moveable freely
behind it, and thus the operator is satisfied as to its safe con-
dition.
In large cases, where it is necessary to pass the wire a second
time through the pillars of the ring, the cord must be carefully
distinguished, and pushed away from the side about to be punc-
tured, before each application of the needle. The wire may be
thus made closely to surround the cord without enclosing it.
(See Fig. 28, B.)
If ligature thread is used, the success of the operation almost
entirely depends upon the precision with which it is made to
hug the spermatic cord, since the effect of the external com-
press is to make traction towards the surface of the groin, and
away from the cord and posterior wall.

154
ON INGUINAL HERNIA.
Failure may result in large and long-standing cases, from
neglect in passing the wire fairly across the interior of the sac,
the result being that the cavity of the sac in the scrotum is not
obliterated, although the internal communication with the
abdomen may be more or less completely closed. There is
thus a want of support from below to the adhesions which have
formed at the neck of the sac; or the fundus, as before men-
tioned, may become the seat of liquid effusion, which may in-
crease so much as to redilate the canal from below.
Ruptures of the direct kind are more difficult to cure, and
more apt to return after operation than the oblique variety,
especially if the internal opening be large. In these difficult
cases, the additional strain upon the adhesions binding the
conjoined tendon to Poupart's ligament during the action of
the recti muscles, after the operation, should be met by an
additional hold by the wires upon the lower part of the pillars
of the superficial ring; so as to ensure a more extensive perma-
nent adhesion, as well as to lessen the immediate strain upon
the upper point of suture, which might result in a fraying or
splitting of the edges of the opening. (Figs. 36 and 37.)
Such herniæ usually present short necks and wide lax open-
ings, and are generally found intractable to treatment by trusses.
Cases 2, 10, 21, 28, 37, 38, 40, 52, and 53 in the Appendix
are specimens of this variety, fortunately not the most common.
In three, I failed in accomplishing, ultimately, a satisfactory
cure, though the size of the hernia was much reduced, and the
patient rendered more comfortable by the truss being made
available.
In one of the cases (Case 21) the splitting or fraying of the
aponeurosis above alluded to, as a consequence of over-tension,
resulted in a slight protrusion at the side of the puncture in
the outer pillar. This, however, became smaller under the
pressure of a truss with a broad pad. Its occurrence has led

CAUSES OF FAILURE AND DANGER.
155
me to modify the degree of tightening in the twist of the upper
wire loop at the time of the operation.
The necessity of separating the fascia of the scrotum to such
an extent as to allow of perfect invagination without dragging
up the skin between the pillars of the superficial ring, has been
before alluded to. A neglect of this precaution may cause
imperfection in the adhesion and closure of this part of the
canal. In some cases, the toughness of the fascia, or the
presence of cicatrices from former operations, may necessitate
a more careful and extensive employment of the knife than is
usually required.
It is well to bear in mind, that as little rough handling and
disturbance of the tissues as may be, is desirable in the mani-
pulation necessary for placing the sutures.
In one
or two cases, where thread was used for the
ligature, the facility with which it is drawn too tight led to the
production of small sloughs in the enclosed structures. These
cases appeared afterwards to present a greater degree of
bulging at the groin opposite the internal ring, in consequence
of the diminished bulk and strength of the cicatrization.
Latterly, I have been careful to twist the wire ligature to such
a degree of tightness only as was necessary to hold firmly
together the enclosed parts.
The bulging above alluded to occasionally remains after the
operation, for the same reason that it exists in many cases of
predisposition to rupture where no rupture has actually taken
place - viz., from a deficiency in the development of the
lower part of the internal oblique.
-
In some,
I have succeeded in correcting it by placing the
outer wire very high, so as to cover the deep ring, and cause
adhesion between it and the superjacent aponeurosis. In the
cases in which invagination of the fascia was done, the hard
cord of adhesion resulting from the union of its raw surfaces

156
ON INGUINAL HERNIA.
can usually be felt plainly in front of the cord, and blocking
up the superficial ring long after the operation. In a few
instances it has been observed, after some time, to shift slowly
downwards under the weight of the testis and scrotum, which
had been previously tucked up by it. This occurrence ap-
peared to indicate a less perfect closure of the superficial ring
than might be desirable, and a tendency in the tissues to
slide over each other. It is not to be taken, however, as an
indication of the return of the rupture, since its connexion
with the cicatrices in the inguinal canal causes it, as it descends,
to draw the walls of the passage closer to each other, as shown
by its effect upon the upper cicatrix. By the patient, or an
inexperienced observer, it is apt to be mistaken for a return of
the rupture. (See Case 43, Appendix.)
The condition of the patient's viscera and general health
previous to the operation must be carefully examined and
considered.
It is of essential importance that his powers of reparation
should be vigorous and well sustained. Upon this depends
much of the permanent nature and resisting power of the
newly formed adhesions. The urine should be examined for
albumen and phosphates, and the action of the liver upon the
fæces carefully noted. An examination by the stethoscope of
the heart and lungs should also be instituted.
With a view of sustaining the vigour of reparative action, I
have recommended a generous diet as soon as the patient feels
inclined to take it after the operation, care being taken pre-
viously to have the bowels fairly opened. If there be more
suppuration than usual, bark, the mineral acids, and chloric
ether may be advantageously prescribed; and stout, wine, and
brandy given. The testis should be carefully supported, and,
if inflamed or painful, evaporating lotions, or a leech or two,
may be applied. I have, by attention to these matters,

CAUSES OF FAILURE AND DANGER.
157
avoided, in all the cases except two or three, any disagreeable
complications in the testis, cord, or scrotum during the after
treatment.
In stating the reasons for the change from the use of
threads to that of wire, it was mentioned that the proportion
of adhesive and consolidating action is not at all measured by
the degree of suppuration induced. Still less are the per-
manent adhesions dependent upon the violence of the local
action following the operation. In the earlier cases, I was
inclined to hasten matters by a tight compression and an early
removal of the sutures. Although succeeding in many cases
in obtaining an earlier escape from the recumbent position,
one or two failures from this cause have induced me to leave
the sutures." in situ" for a much longer period; which the non-
irritating properties of the wire latterly employed enable me
to do without inconvenience.
An attentive observation of the daily progress and results
of the cases so treated has led me to believe that a slow con-
tinued action, carefully regulated by the occasional pressure
of a bandage upon the wire loop, gives rise to a more solid and
permanent change in the canal and sac without the occurrence
of the more disagreeable symptoms, which interfere with the
favourable progress of the adhesive action. The effect of this
pressure upon the testis should be carefully noted.
A slight
enlargement is a favourable sign, as indicating a sufficiently
close influence upon the cord in the hernial canal. So
slightly is the testis affected in most cases, that a gonorrhoea,
which happened in two cases to have been contracted just
before the patient's admission, did not give rise to any great
increase of irritation in the gland, and urethral injections were
continued during the whole course of the treatment. (Cases
12 and 38.)
In three cases, the testicle was permanently affected after

158
ON INGUINAL HERNIA.
the operation by a degree of atrophy. In these it was
evidently originated by sloughing, from endemic causes, or from
peculiarities in the apparatus employed, which the result of
these cases led me to discontinue. (Cases 17, 25, and 52.)
The activity of the developing and reproductive powers
during early life gives a much greater chance of success in the
cure of rupture when the patient is young. In a child, a
closure of the hernial canal, even if so slight as to serve only
to keep out the bowel for some months, gives a stimulus to
the development of the parts which will lead to a complete
and permanent cure. In congenital cases, the operation by
pins may be performed at a very tender age without any fear
of bad results. I am in the habit of operating as soon as the
point of the little finger can be passed into the hernial canal.
The use of a small pair of pins will then close up the canal, so
as to keep out the bowel effectually, the closure being maintained
by the subsequent use of a proper truss. In the smaller kinds
of rupture in young boys, the same operation may be done
without any symptoms whatever resulting from the operation.
In some cases under my care, the tongue has not even been
whitened in the whole progress of the treatment, and no pain
has been experienced except during the one or two dressings
which were necessary for cleanliness.
In these cases, also, a careful examination of the abdomen
is a necessary preliminary. Any tubercular disease, especially
of the mesenteric form, strongly contra-indicates interference.
In healthy children, on the other hand, a great deal of
operative manipulation will be borne by the hernial offset of the
peritoneum with perfect impunity, and much can be done with
the testicle and cord which cannot, without more serious
symptoms, be practised when the generative organs are fully
developed and active.
The radical cure of rupture is, therefore, an operation

CAUSES OF FAILURE AND DANGER.
159
especially suited for children and young lads, in whom the
probabilities of a cure by the pressure of a truss may be slight,
while the great restorative and plastic power of the tissues,
especially about the procreative organs, seconds vigorously the
efforts of the surgeon.
For ruptures occurring in adult life, the operation by wire
is more suited. Except under specially favourable conditions
of health, or peculiar exigency of circumstances, I do not re-
commend the operation at a late period in life.
A proper
truss may then effect all the relief that may be required.
Where trusses fail altogether, however, an operation may be
safely done, and so far successfully as to render a truss after-
wards available and effective for support.

160
ON INGUINAL HERNIA.
XII.
SUMMARY OF THE CASES.
A FAIR objection may be entertained against any operation
for the cure of rupture, if many fatal cases result after its fair
employment and skilful performance, or if such serious
symptoms commonly arise as call for active and debilitating
measures for their suppression.
That such an objection cannot be urged against the opera-
tions practised by the author, a study of the cases appended
to the volume will prove. Of the cases there given, there is
but one fatal. (Case 20.) In this, the sad result was clearly
due to a disease which, though certainly following the opera-
tion three weeks afterwards, cannot be said to be otherwise
than an accidental occurrence, inasmuch as it occasionally, and
at certain seasons, frequently, follows the most trivial in-
terference with the integrity of the tissues. The uncon-
trollable course and fatal results, by which pycemia, the disease
alluded to, is usually characterised, render it one of the most
portentous enemies of the surgeon in his endeavours to
remedy the deformities of the human frame. Objections,
therefore, founded upon such a case, would apply equally to
any surgical proceeding opening the skin, even to venesection,
which has frequently been followed by this disease, and so
proved fatal.
Of the fatal cases I have heard of in the practice of
other surgeons, one was owing to erysipelas, which was present
in the wards of the hospital, and another to the violence and

SUMMARY OF THE CASES.
161
struggles of the patient at the time of passing the needle,
rendering it probable that the bowel had been included or
punctured.
The severity of the symptoms following the operation will be
best judged of by an inspection of the Appendix.
The average duration of the cases, though hardly a fair
test of an operation which requires the slow action of ulcera-
tion and adhesion, under acupressure, to produce a safe and
permanent result, still presents these operations in a favourable
light in this respect. It must be borne in mind, however,
that in many the recumbent position was rendered advisable,
to avoid testing too much, at an early period, the newly-formed
adhesions. In children, this can only be effected by keeping
them safely in bed. With but few exceptions, the general
symptoms were so slight as to call for little attention.
Of the cases in which the duration of treatment was over
thirty-one days, one was kept in bed two months from
burrowing of matter and profuse suppuration; one from
sloughing of the hernial sac; another from sluggish action in
the parts retarding consolidation. Two children were kept in
the hospital by small additional operations, rendered necessary
by the enormous size of the ruptures, and the large abdominal
openings. The symptoms in these latter cases were through-
out so slight that the tongue was scarcely whitened, the
appetite being almost wholly unimpaired.
Some of the cases were kept in bed until the proper trusses
could be supplied; or for reasons totally unconnected with the
severity of the operation.
The average duration of the cases in bed has been about
twenty-one days. Of the 60 cases given in the Appendix (one
case being operated on on both sides), 21 were operated on by
thread and compress, 27 by various modifications of the wire
operation, 10 by the use of a pair of pins, and 2 by a combi-
M

162
ON INGUINAL HERNIA.
nation of pins and wire.
cases operated on is 11.
tion by ligature-thread and compress (one being a female).
(Cases 2, 6, 14, 15, and 18.) One of these failures is ac-
counted for by the indiscretion of the patient in returning to
very heavy work, as a sailor, three months after the operation,
without truss. (Case 18.) Another also was owing to the
neglect of the patient to continue his truss when doing very
laborious harvest work, such as forking hay, &c., a few months
after the operation. (Case 6.) Under such trying circum-
stances as these, the adhesions resisted a fresh protrusion for a
twelvemonth after the truss had been discontinued. Even at
the present time (three years after) it is smaller than when
operated on. Another was owing to the age of the patient at
the time of the operation, and the laborious nature of his sub-
sequent occupation, as a seaman in a collier ship. (Case 2.)
In this case there was also some sloughing at the time of the
operation. Case 14 is accounted for by considerable altera-
tion having resulted in the anatomy of the parts from a
previous severe operation, rendering a repetition of the opera-
tion by threads and compress also unsuccessful. In the female
(Case 15), I found it difficult to obtain such invagination of
the fascia as to enable me to reach the higher part of the
inguinal canal, and to plant the sutures fairly.
The number of failures in the 60
Five of these followed the opera-
Four of the 26 cases operated on by wire failed to effect a cure.
In Case 23, this was clearly owing to the nature of the man's
occupation-viz., pushing heavy trucks along with the belly, at
the same time wearing no truss. In this case, the tenacity
of the adhesions was demonstrated by the rupture not re-
appearing until four months after the truss was discarded,
under the idea that the rupture was permanently cured, after
wearing it four months only. In Case 40, the rupture was
immensely large, and passed directly out of the abdominal

SUMMARY OF THE CASES.
163
cavity by a very large opening. The protrusion which
happened after the operation, occurred after a hard day's
work as a Covent-garden porter, and was only a tithe of its
original size. The opening into the abdomen is at the
present time much diminished, and barely admitted the point
of the finger when I last saw the case. I have no doubt that
a repetition of the operation, if the man will submit to it, will
achieve a complete success. It will be observed that in this
case, although large and direct, I performed the simpler of the
operations by wire, with a view of testing its capabilities. The
result, indeed, can scarcely be called a failure; although the
success was not perfect, the man's condition was very much
improved. Case 29 was a rupture attended with a very loose
condition of the hernial walls, and a conformation of the
groins and genitals which I have before described as partaking
of a foetal character. Such cases may be considered as difficult
to cure, on account of the general laxity of the tissues, and the
yielding nature of the new adhesions. In this case, I had
some doubt as to having secured properly the conjoined tendon.
In Case 36, there was unfortunately some sloughing of the
tissues in the track of the ligature, which had the effect
of weakening the parts after recovery. The age of the
patient (fifty-seven) militated against a satisfactory result; and
he wore no truss after the operation, until the hernia reappeared.
In two only of the ten cases in which the rectangular pins
were used, has a failure been the result. The second case
operated on (Case 31) was one of double congenital rupture,
on both of which the operation was performed. The operation
first performed was completely successful. After the other
side was done, the patient, from an attack of teething,
diarrhoea, and cough, became much emaciated and reduced; a
tumid belly and hardened mesenteric glands revealing the
existence of tubercular disease. According to the mother's
M 2

164
ON INGUINAL HERNIA.
account, the rupture on this side returned as a small tumour
several times after a smart attack of coughing. In many exa-
minations without truss, and under coughing and crying, I was
myself not able to detect any protrusion. When last seen, how-
ever, the mother said that some months ago the tumour had
reappeared to some extent several times, (after an attack of
bronchitis and diarrhoea, which produced much emaciation,)
but had not lately been observed. In another case (Case 33),
the subsequent occurrence of avaricocele and an obscure swelling,
to some extent rendered the case a doubtful one. When last
seen, the signs of a return of the rupture were more decided.
The two cases in which pins were first applied, and after-
wards a wire suture, were cases so exceptional in their
enormous size, the thinness of the sac coverings, and the
deficiency of the abdominal walls, that I had but small hope
of a complete success, and operated at the mother's earnest
request, in order, if possible, to reduce the rupture in size, so
as to render a truss available. Though time is not yet,
perhaps, sufficiently elapsed to enable me to pronounce with
certainty upon the ultimate result under such formidable cir-
cumstances; yet in one case the result is at present so satis-
factory as to render a complete cure all but certain; and in
the other, a satisfactory termination is very probable.
It is important to mention, that in none of the cases operated
on unsuccessfully, as regards a complete cure, has the rupture
returned to the full size which they had attained before
the operation. In none has the rupture been rendered irre-
ducible, or become strangulated, and all can wear a truss with
more comfort than before the operation. The facts just men-
tioned remove entirely one of the most important of the
objections sometimes made to an operation for the radical cure
of rupture.
In six more of the cases the result may be considered at

SUMMARY OF THE CASES.
165
the present time as either doubtful, or the success only par-
tial. In three of these, however, the ruptures were SO
enormous that the operation was only attempted on the un-
derstanding and with the view of rendering the use of a truss
available.
One of the cases operated on by ligature-threads and com-
press resulted in a varicose condition of the spermatic veins,
and an effusion into the fundus of the sac, which rendered the
condition of the patient, when last seen, doubtful as to the
ultimate result. (Case 5.) Having, however, met with an exactly
similar state in another case which subsequently resulted in a
satisfactory cure, I have hesitated in recording it as a confirmed
result, either successful or unsuccessful.
In another case, after an operation by wire of an expe-
rimentary character (Case 22), a small protrusion afterwards
took place, apparently through one of the punctures in the
aponeurosis. This, however, was perfectly commanded by the
pressure of a truss, which was not the case with the original
rupture; and it will probably be completely closed up in time,
by carefully persevering in the proper truss-pressure.
One patient (Case 14) was twice operated on by the
ligature-thread and compress unsuccessfully, for reasons before
given. Two other patients were also twice operated on for the
same rupture. One was done first with the thread and com-
press, and afterwards with wire in the ordinary manner
(Case 12.) The return of the rupture after the first operation
was due entirely to the patient's recklessness in lifting a heavy
weight three weeks after the operation, without the support of
a truss. The second operation was done more than a year
ago, and has been perfectly successful up to the present time.
The other case (Case 37) was one of direct hernia, scrotal, and
with a large internal opening, in a muscular man. Both
operations were by wire-the first, the ordinary operation; and

166
ON INGUINAL HERNIA.
the last, the operation illustrated in Figure 36. After the
first operation the rupture returned on making efforts to
evacuate the bowels without truss. After the second ope-
ration, the case remained in a satisfactory condition up to
the period of his discharge from confinement.
Two of the cases have been followed by some degree of
atrophy of the testis from causes removed by a modification
in the operation, and one from sloughing in the scrotum,
originating from impure air. In two cases, a coexistent
varicocele was completely cured by the operation, as well as
the rupture. One of these varicoceles was enormously large.
In two others, some atrophy of the testicle which previously
existed, seemed to improve, and the gland to increase in size,
after the operation.
Of the 42 cases put down as successful, 10 have not been
heard of since they left the hospital cured. The rest have either
been seen (and many exhibited in public from time to time), or
have been heard of by the author. All the patients were
earnestly enjoined, and promised to communicate directly with
the author in case of any change in the condition of the parts
operated on. Some of the cases present a slight degree of
bulging opposite the internal ring, which results from the
tenuity of the abdominal wall at that part. These might pos-
sibly have been improved by a higher position given to the
outer point of suture. Such a weakness of the groin is, how-
ever, commonly met with in persons not actually affected by
rupture, as we have before seen.
Since the sixty cases given, three or four more have been
operated on, but so recently that no deductions can safely be
drawn from them, though they have been fairly tested by
coughing and walking without truss, and are in a very satisfac-
tory condition.
Eight of the cases operated on by thread and compress were

SUMMARY OF THE CASES.
167
Of
treated entirely without truss throughout, as an experiment to
test the reality of the cure, and the proportionate share to be
fairly attributed to the support given by artificial means.
the six cases shown at the Medico-Chirurgical Society in the
month of February, 1860, one has since had a decided return
of the malady. (Case 6, before alluded to.) This and three
others of these cases were among those treated entirely without
truss. The patient first operated on, one year and eleven
months before the above date, has been doing very heavy lifting
work without truss up to a recent period, nearly five years
after the operation.
The total result, then, of the cases given in the Appendix
yields, without reckoning the doubtful and imperfect cases, and
with a fair allowance for future casualties and imperfect
records, the encouraging proportion of 65 to 70 per cent. of suc-
cessful cases. And this, it must be borne in mind, is drawn
from cases that have been taken entirely without selection, and
as presented, good and bad, direct and oblique, many of them
of a very aggravated kind, some of enormous size, and treated
by operative measures some of which were more or less
tentative.

168
ON INGUINAL HERNIA.
XIII.
THE USE OF TRUSSES IN INGUINAL HERNIA.
Ir has been a matter of common observation, both to myself
and other surgeons, that by the continued wearing of the
trusses in ordinary use, although the rupture may be entirely
retained, yet the aperture becomes gradually larger, and the
protrusion, when suffered to appear, is also constantly increasing
in size.
This is caused in the following manner :-The truss-pad is
usually made more or less convex or conical on the surface
applied to the skin, in order that, by biting into the soft parts,
and making for itself a cup or depression, it may hold its place
firmly over the rupture with less retaining apparatus, and give
less trouble in fitting and retaining. The effect is, that the
soft parts are pressed like a wedge into the already dilated
inguinal openings, opening and stretching the intercolumnar
fascia and bands, and operating upon them from without
exactly in the same manner as the bowel itself does from
within. The chief force of the side spring is exerted in the
axis of the dilated canal and hernial openings, and its upward
and downward movement upon the haunch during exercise
acting upon the conical pad as the centre of motion, works it
continually deeper into the superficial ring and hernial canal,
and gradually dilates them by a sort of invagination.
It has been seen, in treating of the pathology of inguinal
hernia, that the borders of the superficial ring are everted and
protruded by the rupture so as to be divergent from each

TRUSSES.
169
other, at the same time that their fibres are opened out and
thinned by distension, and eventually, in large herniæ, are lost
upon the coverings of the sac. The intercolumnar fibres
around, and their connecting fascia, are thus stretched out and
weakened, permitting a greater separation of the parallel fibres
of the aponeurosis, giving a more open texture to this structure,
and diminishing its resisting powers.
If
pressure by a rounded convex surface be made upon the
centre of this thinned and bulging wall, its concavity is simply
inverted, and the dilatation upon the sides of opening continued
to the same extent as before. In many of the trusses in
common use, the lower extremity of the pad is made the most
convex and projecting part, and is the part most prominently
forced into the external ring by the action of the side spring.
Such truss-pads, especially if small, are very objectionable,
a constant state of invagination of the soft parts being
maintained.
After a rupture is returned by the taxis, the fingers of the
operator retain it in the abdomen, not so much by pressure in
the centre of the protrusion, as by grasping the sides and com-
pressing them together by pressure upon the pillars of the
superficial ring. Such a compression of the sides of the
hernial canal and openings, if continued long enough, would
promote the contraction of the calibre of the canal, and give a
much greater chance of an ultimate closure. In small and
incipient cases, such an application of the pressure may be
fairly expected to produce a cure without further interference.
Undoubted cases are on record in which the pressure of truss
brought to bear, perhaps accidentally, upon the proper place,
has been followed by this satisfactory termination. The chief
reason why such good results do not more commonly ensue,
lies in the faulty construction of the truss-pads ordinarily worn.
Much more objectionable are these trusses after the opera-

170
ON INGUINAL HERNIA.
tion for a radical cure has been performed. The pressure of
the highly convex surface falls exactly upon the adhesions which
have been obtained in the ring and canal, binding together
their sides. When the resistance of the pillars of the super-
ficial ring is thus weakened and overcome, the conical pressure
falls upon the conjoined tendon and posterior wall, forcing
them backwards in the direction in which the contractions
of the rectus muscle tend to draw them, and producing by
continued pressure absorption of the adhesions within the
canal. Continued observation of the effect of such trusses
upon the cases in which the rupture has returned after opera-
tion, has convinced the author that, in many of them, it has
been the main cause of the reappearance of the hernia. These
effects are much accelerated by the movements of the side
spring working over the hip during exercise, and boring the
pad into the rings, especially if the spring be strong enough to
compress instead of merely supporting. The adhesions are
thereby gradually loosened, and the sliding of the transplanted
structures over each other promoted.
The above considerations have led me to the construction of
truss-pads for the different forms of rupture, both before and
after operation, more in accordance with the necessities of the
hernial condition and the mechanical relations of the weakened
structures. These will, I think, be found to obviate the faults
just pointed out.
Truss for Oblique Inguinal Hernia.-The essential pecu-
liarities of this truss-pad are, that it is an elongated ovoid with
a flat surface, wider above than below, and with a chink cut
clean out at the lower half of its long axis, making it resemble
altogether a horse-shoe made oblique, with the extremities well
rounded off, and one a little shorter than the other. (See
Fig. 48.)
For ordinary cases and hospital purposes generally, no better

TRUSSES.
171
material can be got than boxwood of which to construct the
pad. It should be about five-eighths of an inch thick, and have
the ends and corners well rounded off, and may be left quite
uncovered. It is attached by a screw to the end of an ordi-
nary side-spring at about its geometric centre, with a couple of
studs at the ends to fix an under strap to. The top of the
screw being provided with a brass stud grooved across, serves
both to fix the body strap and to adjust the angle of connexion
with the spring. The size must be regulated by that of the
rupture; the larger it is the better, consistently with comfort
to the wearer.
It should cover all the weak parts in the
A
FIG. 48.
B
The Horse-shoe Pad.-A. Superior view. B. Section.
groin, and fit easily into the curve of the groove between the
thigh and abdomen. The size most generally useful is from
2 to 24 inches long by 14 to 12 inch broad. The upper end
of the oval is broader than the lower, so as to cover and
support the deep ring. The fissure is to be placed over the
opening of the superficial ring, or over the adhesions which
block it up after operation. At the lower part of the chink
the spermatic cord emerges, and thus escapes the hard pressure
of the pad. The spine of the pubis should also be felt between
the ends of the horse-shoe. The inner horn of the horse-shoe
is larger and longer, and is intended to be placed upon and
compress the inner pillar of the superficial ring. The outer

172
ON INGUINAL HERNIA.
end, about half an inch shorter, tapers gradually to the rounded
point, corresponding in shape to the triangular outer pillar of
the ring upon which it fits, its lower border lying upon, and
shaped to, the groove of the groin. The proportionate size of
the horns and intervening slit may be increased or diminished
according to the width of the pillars of the ring in each in-
dividual case. If an extraordinary projection of the pubic crest
and spine require it, the lower ends may be well sloped off in
the downward and inward direction, care being taken to pre-
serve the general flatness of the surfaces when taken laterally
or transversely. The screw which fixes the side spring should
be placed close to the upper end of the chink, as near as pos-
sible to the geometric centre of the pad, so as to bring its
pressure to bear fairly at the middle of the inguinal passage.
The double bearing of the horse-shoe ends of the pad, and its
accurate adaptation to the fold in the groin, give a great steadi-
ness to its hold upon the surface. A slight projection of a
fold of skin into the fissure tends still further to secure it
against shifting. The limited diameter of the chink, and the
tension of the skin upon which it rests, prevent any protrusion
of the hernia, or any strain upon the adhesions at the super-
ficial ring; while the spermatic cord and pubic spine escape
pressure between the rounded extremities. The studs placed
at the ends of the horns enable increased pressure to be made
upon them, when desirable, by the tightening of the under
strap.
For cases more difficult to control, either from the size of
the superficial or deep hernial openings, or from the pro-
tuberant abdomen and deep groin resulting from a great
obliquity of the pelvis, and an increase of the lumbar curve, de-
scribed in the section upon the pathology of rupture, I have con-
trived a simple combination of pad springs and lever, which will
transmit the pressure of the hip spring, or body strap, to any

TRUSSES.
173
part of the compressing surface where the rupture may have
a tendency especially to escape. In some cases, this occurs
towards the internal pillar; in others, behind the external
pillar.
As the basis of this form of truss pad is employed a thin
plate of steel or German silver, curved up round the edges into
a sort of dish-shape, with a border half an inch deep.
Placed in the hollow of the plate, and working in each of
the horns of the pad, is a double C-spring, the limbs of which
are connected at the upper end by a broader part, so as some-
what to resemble in shape the letter Y. (See Fig. 49, A and B, a.)
A
FIG. 49.
α
B
The Horse-shoe Lever Spring Pad.-A. Superior view. B. Section.
The upper end of the united springs is held to the border of the
plate by a common hinge (6), upon which the spring can be
turned back to adjust the attachment of the side spring, or
strap. The curve and strength of the springs may be increased
or diminished according to the degree of retaining force re-
quired. It is necessary, however, to proportion them care-
fully to that of the hip spring, when this is used. The elastic
reaction of the pad springs, taken together, should exactly
equal that of the body spring or belt, when either of these is
employed.
The shank-piece connecting the springs is prolonged between
them so as to overlap the centre of the pad, forming a lever

174
ON INGUINAL HERNIA.
upon which the side spring or strap may be fixed by a simple
screw and nut, which should be screwed tightly down. To give
a power of adjusting the point of pressure of the side spring,
six holes, made in the lever-plate in the shape of a square,
for the reception of the screw and nut, will enable the maker
to shift the pressure higher, or more laterally, as the case may
require. This method of fixing is seen at c, in Fig. 51.
A more nice and ready adjustment may, however, be obtained,
(as given in Fig. 49,) by having an additional plate carrying
the side spring, moveable upon the lower end of the lever,
round a pin near the centre (c), and fixed in the required
position by a hand-screw above (d), fastening into holes
in the spring plate. By this means the pressure can be in-
creased or diminished upon one limb or other of the horse-
shoe pad. When fitted, the end of the body strap buttons
upon the screw-head of the side spring. If an under strap is
necessary, it may also be fastened upon the same point, or
studs fixed at the ends of the horse-shoe may be used for that
purpose, if the case seems to require it. One or other of these,
or both, may be fastened to the under strap. The compressing
surface of the metal pad may be covered by a thin layer of
vulcanized india-rubber, which passes across the fissure between
the ends, so as to restrain by its elasticity the projection of the
skin between them. The whole is covered by wash-leather,
or other soft substance, made into a sort of case or bag.
In a few cases I have employed a double spring of the
shape of the letter H, working under braces at the upper and
lower ends of the pad plate. The attachment of the hip
spring is effected by a screw sliding along a slit in the central
transverse bar. This arrangement acts very well, but does not
present the regulating capabilities of that last described, which
possesses also the additional advantage of a lever pressure upon
the lower part of the pad.

TRUSSES.
175
The pad may be fitted to a spring over the hip on the same
side as the rupture, as in the ordinary manner; or, what in
some cases is better, to a spring over the opposite hip, as in
Salmon and Ody's plan ;-in this way no under strap is usually
required.
The spring pad just described will in many cases be equally
effective under a simple circular body belt without side spring,
combined with an under strap, in the manner of the mocmain
truss. The hollow curve of the groin may be filled up by an
increased central elevation given to the springs, so as to render
effective the circular pressure of the body strap, at the same
time accommodating the pressure to the movements of the
abdomen, and bringing an equable and steady bearing, which
will not yield readily to a tilting lift of the hernial pro-
trusion, upon the circumference and extremities of the com-
pressing surface of the pad.
When applied, the finger should be placed upon the project-
ing spine of the pubis, the cleft between the forked ends of the
pad should be then placed directly above the finger, and placed
nearly parallel to the groove of the groin. The adjusting screw
should then be fixed immovably tight, giving the pad the proper
degree of obliquity. In corpulent persons, a considerable inward
twist should be given to the hip spring near its extremity, so as
to permit the pad to lie flat upon the surface. An under strap,
properly fixed, will then keep up the proper angle, and so
produce a flat pressure upon the hernial surface.
By the use of this pad we have the boundaries of the
hernial canal and openings supported and compressed by a flat
surface, tending to resist outward and lateral dilatation in
exactly the same manner as the fingers of the surgeon. There
is no dilating pressure in the axis of the canal whatever, and
no invagination of the soft parts, as in the use of the convex
truss-pads. The whole of the canal is equably compressed, and

176
ON INGUINAL HERNIA.
In
the deep ring supported by the upper part of the truss. The
difficulties of maintaining the position upon the proper site
which are usually experienced in the use of a perfectly flat pad,
are met by the double bearing of the horse-shoe forks, and the
anatomical outline given to the borders. An extended ex-
perience acquired with this pad since its adoption has convinced
me that it retains its position as well as any pad before in-
vented, and has not, as nearly all have, the injurious property
of increasing the size of the hernial openings by invaginating
the hernial coverings into the rings by convex pressure.
small and incipient cases, the patient may expect from its use
the utmost benefit that pressure can effect towards producing a
radical cure without operation. Adapted to the anatomical
peculiarities of the weakened part, its mechanical arrangement
tends, under all positions of the body, to exclude the bowel
from the sac, and to close up the sides of the hernial canal.
In two cases of oblique hernia associated with a thickened and
varicose condition of the spermatic cord, now under my care,
the horse-shoe pad has answered admirably in easing off the
pressure from the cord, by allowing it to lie opposite to the
chink (made wider than usual for that purpose). At the same
time the rupture is perfectly retained. In one case, the in-
flamed and tender condition of the cord had been entirely pro-
duced by wearing an ill-fitting convex truss.
Truss for Direct Inguinal Hernia.-In this form of rupture,
the neck of the sac and sides of the opening, being short and
limited, a somewhat different shape and adjustment of the pad
is required.
The shape of the pad best adapted here for making a closing
pressure upon the hernial ring is an ovate, with flattened sur-
faces; with a somewhat larger curve at the lower border, and
a more contracted one at the upper. (Fig. 50.) The size
most generally required will be about 2 inches to 24 inches in

TRUSSES.
177
its widest diameter. It is perforated in the middle by an
opening which occupies the middle third of its diameter.
For ordinary and hospital uses it may be made of boxwood,
like the last, and secured to a side-spring by a screw fastening
on to the centre of a transverse piece of metal bridging over
the central opening, as seen in the figure. To a couple of
studs placed near the middle of the lower part of the ring, the
under strap is buttoned in the ordinary way.
For particular and difficult cases it may be desirable to have
the power of adjusting the pressure over the borders, so as to
increase it at any part where the rupture shows a tendency to
emerge.
FIG. 50.
B
The Ovoid Ring Pad.-A. Superior view. B. Section.
For this purpose the basis of the pad should be, as before
described, a thin plate of steel, or German silver, beat up at
the edges into a dish-shape, and covered on the bearing surface
with a layer of vulcanized india-rubber stretching over the
central opening. The pad-springs for distributing the pressure
in this case are arranged in the same manner as those described
with the horse-shoe pad. The springs have, however, a vertical
instead of an oblique direction, their extremities bearing upon
the lower part of the ring. In Fig. 51, the adjustment of the
attachment of the side-spring, or body-belt, to the lever-plate,
is drawn after a model of the more simple arrangement, before
described. This method of fixing is equally applicable
N

178
ON INGUINAL HERNIA.
to all the forms
of spring pads herein described. The
elevation of the springs at the highest point of the
curve will be rather above the level of the curved sides of the
disc. (Fig. 51, B.) By the adjustment of the screw (e) in the
openings of the lever-plate (c), the force of the side-spring
may be increased upon either side of the lower circumference of
the ring. The strength of the springs must be regulated by
that of the side-spring, which may be worn over either hip.
The whole is covered and secured from the effects of damp and
dirt by an investment of wash-leather.
The circular flat bearing of this pad renders it less liable to
A
h
FIG. 51.
a
B
The Ovoid Lever-spring Ring Pad.-A. Superior view. B. Section.
be displaced than the convex or conical pad. The conforma-
tion of its margin to the shape of the groove in the groin con-
tributes also to sustain it in the proper position; while the
spermatic cord escapes its pressure at the outer side of its
bearing on the upper border of the pubis. Firm pressure is
thus made upon the margins of the hernial opening; no in-
vagination of the integuments is possible, and a closing instead
of a dilating action upon the hernial passage is effected. After
the operation for a radical cure the adhesions lying towards the
centre of the region thus escape that injurious pressure which
tends to stretch them, and induce their absorption.
The Double Pad and Spring Truss.--In cases of inguinal

TRUSSES.
179
rupture of either kind where, from the laxity of the pillars of
the superficial ring and of the tendinous structures in the
groin generally, it is difficult to keep the sides of the canal in
close apposition, success may be better attained by the use
of the double spring and pad truss, of which an engraving is
here subjoined. (Fig. 52.) This, as well as the other kinds of
truss, is made by Mr. Matthews, of Portugal-street, from the
author's designs. In this truss the pad is made in two separate
portions, which, when applied to each other, make a compound
pad with an oval outline. The inner portion (a) is rather
FIG. 52.
A
d
e
A. Anterior view of Truss. B. Section of Pad.
longer, and fits upon the internal pillar of the ring: the outer
one (b) rests in the groove of the groin, exerting its pressure
upon Poupart's ligament and the outer pillar of the ring. A
single spring (c) passes round the hips and back. Its longer end
is fixed by a revolving joint upon the inner segment of the pad,
and the opposite or shorter end upon the outer. This spring
may be made to adjust at the central or back part, like that of
a truss for double rupture. A strong elastic band (d) fixes the
two segments of the pad firmly together, when applied, by but-
toning upon the two studs which fix the ends of the body-
N 2

180
ON INGUINAL HERNIA.
spring. An under strap (e), fastened by two divisions upon
the pair of studs before mentioned, or, if the case requires
more pressure at the lower part, upon two other studs fixed
into the lower ends of the twin half-pads. The half-pads may
be made of box-wood, or of some softer material, such as vul-
canized india-rubber, fixed upon a basis of metal. The surfaces
applied to the skin are convex in transverse section (as seen in
Fig. B), but nearly straight in the longitudinal direction.
In this truss we have a separate pressure applied upon
each of the moveable halves of the pad, and directed upon
each of the pillars of the ring independently, in such a manner
as to press them towards each other, and to close up the
hernial canal towards its axial line. No invaginating effect
can be produced, the double bearing of the halves leaving a
chink in the middle line. The pressure can be increased upon
either of the pillars independently, by increasing the power of
the corresponding extremity of the body-spring.

FEMORAL OR CRURAL HERNIA.
181
PART II.
FEMORAL OR CRURAL HERNIA.
THE much less frequency of the occurrence of this form of
rupture, and the habits of the persons usually affected by it
(females), render operative interference for its radical cure less
frequently demanded than in the case of the inguinal variety.
It may also be said that the proximity of the great vessels of
the leg and their accompanying lymphatics to the site of the
rupture render necessary a great amount of anatomical skill and
manipulative steadiness in the operator, and expose the patient
to a somewhat greater amount of risk from the effects of
ulceration or purulent absorption in the after-progress of the
case. At the same time, it must be admitted that it is more
difficult to obtain for this kind of rupture an efficient and pro-
perly fitting truss, that patients in consequence often suffer
much for want of support, are more subjected to the dangers
of strangulation, while a cure by pressure is rarely obtained.
The light nature of the occupations of females generally renders
the pressure of a properly fitting truss sufficiently effective to
retain the rupture, but cases are not uncommon in which a
laborious occupation under these circumstances hourly en-
dangers the life of the individual, as in basket-women, milk-
women, and others. These employments involve a great
amount of strain upon the parts, often rendering trusses useless

182
ON CRURAL HERNIA.
in keeping up the rupture, and supplying our hospitals with the
chief part of the cases of strangulated hernia.
Under these circumstances so dangerously affecting persons
of otherwise robust health, I conceive it to be entirely justi-
fiable to attempt to cure or diminish the size of a large femoral
rupture by operation. Although I have not hitherto had oc-
casion to perform such an operation on the living subject, I
have been in the habit for some years of exhibiting to the stu-
dents at King's College the way in which it may be best
effected, and with the greatest amount of safety to the patient.
To understand properly the principles upon which the appli-
cation of operative methods for the radical cure, or of truss-
pressure as a palliative or radical remedy, should be based; as
well as those of a proper application of the taxis or operative
interference under conditions of strangulation;-it is of the
greatest importance to obtain an accurate knowledge of the
anatomy and pathology, and of the means of recognising this
dangerous form of rupture.
A brief description of the parts, succeeded by a review of
their modifications under hernial conditions, and from other
pathological changes which simulate rupture, will facilitate a
clear conception of the steps of the operation above alluded to;
and also of the action of the truss upon the hernial openings,
of the probabilities of a radical cure by either of these methods,
and of the proper direction to be given to efforts towards re-
duction by the hand.

ANATOMY.
183
XIV.
ANATOMY OF THE PARTS CONCERNED IN CRURAL HERNIA.
BELOW the inverted curve of Poupart's ligament, the front sur-
face of the thigh presents a slight hollow or groove towards the
inner side, having an obscure triangular form with the base
upwards. The outer side is bounded by the mass of extensor
muscles, and more particularly by the sartorius; the inner, by
the sloping surface and raised border of the long adductor and
edge of the gracilis; the apex below is produced by the ap-
proximation of these muscles to each other at the junction of
the middle and upper thirds of the thigh; and the base above,
by the structures of the abdominal wall. The floor of the
space slopes from each side towards the centre, which is placed
just below, and in front of the hip joint, and it lodges, at its
deepest part, the femoral vessels and their branches. The outer
part of the floor is formed by the insertion of the psoas and
iliacus muscles, between which is placed each of the branches
of the anterior crural nerve. The inner part is formed above
by the pectineus muscle, with a small portion of the adductor
brevis ; and is continued downwards and inwards by the sloping
surface of the adductor longus to the raised inner border. The
space is called, after the great Italian surgeon and anatomist,
Scarpa's triangle. To the inner side of this triangular space,
near the base or upper part, lies the region through which a
femoral rupture makes its way to the surface.
The superficial fascia in the crural portion of the groin, like
that before described in the upper or inguinal region, is suscep-

184
ON CRURAL HERNIA.
(See Fig. 1, a, page 14.) The
tible of division by the scalpel into two layers, within and be-
tween which lie the superficial vessels, nerves, and lymphatics.
The superficial layer usually contains much fat;-it is con-
tinuous with that covering the abdomen, and is but loosely at-
tached to Poupart's ligament.
deeper layer contains less fat, is thin, loose, and easily torn. By
its deep surface it is loosely connected with the subjacent struc-
tures, except at Poupart's ligament, and at the margins of the
saphenous opening in the deep aponeurotic fascia, where it is
more closely adherent to the underlying parts. It invests the
superficial glands, vessels, and nerves with an areolar envelope;
and is perforated by many oblique openings for the passage of
these structures through it. (Fig. 1, b.)
The superficial vessels of the part are those described in the
upper inguinal region,-viz., the superficial circumflex iliac; the
superficial epigastric; and the superficial external pudic; all
branches of the common femoral artery at this place. They
perforate, at different places, the deep fascia, or pass through
the opening above mentioned, and diverge to their respective
destinations. The circumflex iliac (d) is directed towards the
anterior superior iliac spine, near which it crosses Poupart's
ligament. The superficial epigastric (e) ascends slightly in-
wards towards the navel, crossing the same ligament about its
centre a little internal to the position of the deep abdominal
ring. It supplies the most of the superficial lymphatic glands.
The superficial external pudic (f), passes across the inner end of
the ligament, crossing the spermatic cord as it emerges from
the superficial ring, to be distributed to the mons veneris.
Besides these, there is a small branch, the inferior external
pudic, lying under the deep fascia internally, perforating it
close up to its attachment to the pubis, and crossing behind or
in front of the cord to reach the pudendum. These branches
are subject to many irregularities. Either of the two last may

ANATOMY.
185
be so enlarged as to give off the artery to the dorsum of the
penis. Any of them may be so small as to be scarcely observable.
The veins corresponding to them all open downwards into the
large trunk next described, just before it pierces the deep fascia.
The internal great, or long saphena vein (1), after reaching
the knee, lies along the posterior border of the sartorius
muscle, and in the upper part of the thigh is placed upon the
deep fascia in the groove between the adductor and extensor
muscles. When within one-and-a-half to two inches from
Poupart's ligament, it passes through the lower part of a con-
siderable opening in the deep fascia to join the femoral vein.
Besides the small veins before mentioned, it receives a conside-
rable tributary from the inner and back part of the thigh. In
some subjects the saphena vein has a more posterior position,
and its largest tributary comes from the front of the thigh.
others, these two trunks are connected just above the knee
joint, and appear as a double saphena.
In
The lymphatics of this region are very numerous. The
ducts lie chiefly along the inner side of the saphena vein, but
many also on the other side (m). They are provided with
numerous glands of an oval shape, arranged with their long
described, as lying upon and
The ducts of all these super-
same opening in the fascia lata
diameters in the vertical direction. These are connected above
with the set of glands before
parallel to Poupart's ligament.
ficial glands pass through the
which transmits the saphena vein.
The nerves of this region are as follow:-The internal and
middle cutaneous branches of the anterior crural; the ilio-in-
guinal; crural branch of genito-crural, and external cutaneous;
-all from the lumbar plexus. The ilio-inguinal (m) escapes
through the fascia covering the superficial abdominal ring, gives
off small twigs to the scrotum and mons veneris; then turning
outward and downward over Poupart's ligament, it is finally

186
ON CRURAL HERNIA.
distributed to the integuments about the saphenous opening.
The internal cutaneous passes downwards and inwards across
the front of the femoral vessels, under the deep fascia, giving
off many twigs to the integuments and sheath of the vessels,
and finally perforates the deep fascia below the middle of the
thigh to supply the skin on the inner side about the knee.
The middle and external cutaneous nerves, with the branch of
the genito-crural, are distributed to the integuments on the
front and outer surfaces, and do not bear any noteworthy re-
lation to the parts of crural hernia. (See Fig. 53, page 188, a.)
The deep fascia of the thigh, or fascia lata, is a strong and
aponeurotic-looking layer of white fibrous tissue, of which the
fibres are interwoven almost like a piece of cloth, the strongest
passing downwards and inwards. In the groin it is arranged
in two portions, named from their respective attachments.
The outer or iliac portion is connected with the crest and
superior spine of the ilium, and is closely attached to and
blended with the lower part of the tendinous aponeurosis of
the external oblique forming the crural arch or Poupart's liga-
ment (d). With the insertion of this ligament, it is attached
also to the spine and pectineal line of the pubis, upon which it
is blended in a common insertion with a triangular, deflected
portion of the same ligament, called Gimbernat's (c). This
part of the fascia lata is placed in front of the femoral vessels,
to the sheath of which it is pretty closely adherent. A falci-
form portion of it also crosses, immediately below Poupart's
ligament, the channel by which crural rupture passes down on
to the inner side of these vessels, assuming thus a very impor-
tant relation to it. This part (f) forms, by a curved edge, the
upper and outer borders of the opening which transmits the
saphena vein and lymphatics to the deeper vessels.
The inner or pubic portion of the fascia lata (e) is attached to
the united branches of the pubis and ischium which form part

ANATOMY.
187
of the inferior outlet of the pelvis, where it is connected
with the perineal fascia and crus penis. Above this point
it is attached to the front of the symphysis and angle of the
pubis, and stretching upwards, outwards, and backwards, fol-
lowing the border of the superior pubic ramus, it passes behind
the femoral vessels to become attached to the pectineal line
of the pubis, joining at that place with Gimbernat's ligament
and the falciform process of the iliac portion, and becoming
connected externally with the fascia iliaca, which has been
described as forming the posterior part of the sheath of the
femoral vessels, and with the capsule of the hip joint. In this
manner the femoral vessels are placed between the two por-
tions of fascia lata which are separated at this part by the
passage of the saphena vein and lymphatic ducts.
The opening thus formed is called the saphenous opening.
(See Fig. 1, page 14,0.) It is oval in shape, with its long diameter
in the direction of the thigh, and the axis of its plane directed
obliquely forwards, downwards, and inwards; lying over the
crural canal, the femoral vein, and termination of the saphena.
It is covered in by a tolerably firm network of fibrous tissue,
which, when freed from the pellets of fat which are involved
in it, presents the peculiar appearance of a large number of
oval openings for the transmission of the numerous lymphatic
ducts. Hence it is called the cribriform fascia. This is con-
nected externally with the falciform margin of the iliac portion
of the fascia lata, and internally with the sloping surface of the
pubic portion. Below, it affords a funnel-shaped investment to
the saphena vein. Superficially, it is closely connected with the
deep layer of the superficial fascia investing the lymphatics;
and by its deep surface with the sheath covering the femoral
vessels derived from the fascia transversalis. When divested
of the cribriform fascia, the saphenous opening is seen to present,
externally and above, the crescentic margin of the iliac portion

188
ON CRURAL HERNIA.
of fascia lata. This is called the falciform process of Burns.
The upper part forms a horn-shaped process-superior cornu,
which, from its important anterior relation to the femoral
vessels and crural canal, was especially noticed by Hey, and has
been called the femoral or Hey's ligament. This is attached
internally to the spine of the pubis, and blends with
Gimbernat's ligament above, and with the pubic portion
FIG. 53.
Deep dissection of the parts of crural rupture. The upper corner of the
saphenous opening is separated from Gimbernat's and Poupart's ligaments
and turned back, showing the three compartments of the crural sheath opened
by vertical slits.
of fascia lata below its point of insertion. In Figure 53, this
ligament (f) is seen turned back, along with the falciform mar-
gin of the saphenous opening, to show the femoral sheath placed
behind it. The lower part of the falciform process-inferior
cornu, passes under the termination of the saphena vein, and

ANATOMY.
189
becomes lost on the surface of the pubic portion of the fascia
lata at the deepest part of the adductor groove.
On removing the iliac portion of fascia lata, the sheath of
the femoral vessels can be observed to emerge from behind the
centre of Poupart's ligament, as a funnel-shaped investment of
dense fascia. Above, it is continuous with the fascia trans-
versalis anteriorly, and with the fascia iliaca posteriorly; the
two uniting round the vessels to form a loose sheath, which
encloses also, to the inner side of the vessels, the channel through
which the lymphatics pass upwards into the abdomen. The
sheath is intimately connected anteriorly with the deeper portion
of Poupart's ligament, at which point a strong band of fibres,
placed between and connecting them, forms an arch over the
vessels and crural passage, which reaches from the psoas
muscle externally, to Gimbernat's ligament and the pubic in-
sertion of the conjoined tendon internally. This band of fibres
is more marked in some subjects than in others, and is impor-
tant as being usually the seat of strangulation in femoral rupture.
It has been called by Cooper the deep crural arch. The sheath
will be seen to occupy the interval between the psoas muscle
externally and the edge of Gimbernat's ligament internally,
reaching to within an inch of the spine of the pubis. The
latter bony tubercle, usually evident enough to a careful touch
in the living subject, becomes, from its position between the
superficial abdominal and the crural rings, an useful guide to
the distinction between the two varieties of rupture. The
centre of the superficial abdominal ring is directly above the
spine, and that of the crural ring from an inch to an inch and
a-half external to it. The distance between the centre of the
crural ring and that of each of the abdominal rings is about
equal, and usually measures rather more than an inch, when in
a normal condition, in the male. In the female, this distance is
usually nearly half an inch greater. Externally, the femoral

190
ON CRURAL HERNIA.
sheath seems to be prolonged over the psoas muscle, to form
a covering for the anterior crural nerve as it emerges behind
Poupart's ligament, and is finally lost in the fascia which
invests the iliacus muscle to its insertion. If the latter fascia
be lifted up from the surface of the muscle, it will be ascer-
tained to be an offset from the united fascia iliaca and trans-
versalis; which, after lining the posterior and anterior walls of
the iliac region, form internally the sheath of the vessels, and
pass down externally to become attached to the capsular
ligament of the hip-joint and pubic portion of fascia lata,
after uniting together at Poupart's ligament to form a "cul de
sac," which closes up the fissure between that ligament and
the psoas and iliacus muscles, and prevents the escape of hernia
at this part. The crural branch of the genito-crural and the
middle cutaneous of the anterior crural may be seen to per-
forate just outside the vessels.
If three parallel longitudinal cuts be now made at equal
distances into the sheath of the vessels, the outer one will
expose the artery; the middle one, the vein; and the inner
one reveals a tubular compartment or canal, which transmits
the bundle of lymphatic vessels passing into the abdomen
behind Poupart's ligament (Fig. 53, k). A firm longitudinal
septum on each side of the vein divides its compartment
from those lodging the artery and the lymphatics. These
septa, on further careful dissection, will be found to be derived
from the proper sheath of the external iliac vessels, as they lie
under the peritoneum; and they become blended with the
additional funnel-shaped sheath from the fasciæ transversalis
and iliaca at Poupart's ligament.
The interval between the femoral vein externally and the
edge of Gimbernat's ligament internally is called the crural
ring. In front of it is the deep crural arch, forming in
appearance the deeper fibres of Poupart's ligament. Behind it

ANATOMY.
191
is felt the pectineal line of the pubis, with the origin of the
pectineus muscle, and the attachment of the pubic. portion of
fascia lata upon it.
The fibres of Gimbernat's ligament may
then be seen, as well as felt, to pass backwards from Poupart's
ligament in an acute curve, or free border, which is prolonged
outwards at its insertion into the bone so as to reach conside-
rably along the pectineal line behind the crural ring. Here,
by its union with the pubic portion of fascia lata, it sometimes
forms a prominent ridge, which it has been proposed to divide
by cutting upon the bone in cases of strangulated crural hernia.
(See Fig. 60, a, page 203.)
A clear recognition of these relations of the crural ring is
of great importance in the treatment of crural rupture. The
ring is lined by the inner division of the funnel-shaped sheath;
and through it pass the superficial inguinal and crural
lymphatics. Stretching transversely across the ring, inside
the sheath, is a thin layer of fascia containing fat, and investing
a lymphatic gland, which transmits through its substance some
of the ducts. (See Fig. 3, k, page 25.) This fascia was described
by Cloquet under the name of the septum crurale.
It is really
derived from the subperitoneal fascia, being connected with the
upper opening of the funnel-shaped sheath and with the longi-
tudinal septum. It is rarely of sufficient thickness to form a
distinct covering for crural hernia, and can have but little effect
in preventing a protrusion. The aspect or axis of the crural
ring in the erect posture is downwards, with but a slight in-
clination forwards and outwards. The principal direction is
given by the great obliquity of the pelvis, jointly with the advanced
position of Poupart's ligament in reference to the superior branch
of the pubis. In the treatment of this rupture by the taxis,
by operation, or by the application of trusses, it is very essential
to recognise the true direction of the crural opening.
The term crural canal is given to the short tubular passage

192
ON CRURAL HERNIA.
from the crural ring to the saphenous opening, which consti-
tutes respectively its upper and lower terminations. It is
bounded on the outer side by the femoral vein, covered by its
inner longitudinal septum; on the inner, by the insertion of
Hey's or the femoral ligament into the pubic portion of fascia
lata, and by the inner part of the funnel-shaped sheath;
in front is placed the same ligament and the front of the
sheath; and behind is the superior branch of the pubis, covered
by the origin of the pectineus muscle, upon which lie the pubic
portion of fascia lata and the back part of the crural sheath.
A
α
FIG. 54.
B
The entire shape of the crural canal may be compared to an
oblique slice of a cylinder (Fig 54, A) with the short side in
front (c), the long side behind (dd), the crural ring forming the
top section (a), and the saphenous opening the more oblique lower
section (6). The anterior wall (c) is
represented by Hey's or the femoral
ligament, which varies in width in
different subjects from half to three-
quarters of an inch, and constitutes
with Poupart's ligament the only sur-
face upon which pressure can be effectively made to keep a
hernia within the crural ring. The posterior wall (d) is sup-
ported by the outer part of the pectineus muscle arising from,
and resting upon, the superior branch of the pubis at the inner
side of the hip-joint.
Normally, the crural canal contains only the lymphatic
ducts and one or two small glands, with some fat. In crural
hernia, it invests and moulds the form, and determines the
direction of the neck of the sac. (Fig. B, a to b.)
The vessels of a size important to the operator, which are
usually placed in the neighbourhood of the saphenous opening
and crural canal, and comparatively superficial, are the femoral
vein externally, and the saphena inferiorly. The position of

ANATOMY.
193
these can usually be recognised and avoided.
Close behind the
femoral vein, on its way inwards, backwards, and downwards to
the inside of the hip joint, and passing close to the outer border
of the pectineus muscle, is placed the internal circumflex branch
of the profunda. In several instances I have found this artery
giving off the inferior external pudic branch, which then passes
across between the pectineus muscle and the fascia covering it.
The precautions necessary for avoiding injury to the femoral
FIG. 55.
vein will usually protect this artery even in its more common
irregularities.
The anterior boundary of the crural ring has, in the male,
an important relation to the spermatic cord, which lies in the
inguinal canal just above Poupart's ligament, crossing that
structure just outside the pubic spine. In operating upon a
crural rupture this must carefully be allowed for.
The irregularities of the arteries in this important region,
0

194
ON CRURAL HERNIA.
which might be a source of inconvenience in operating, are not
very common. One of the most so is the origin of the deep
epigastric artery from the common or deep femoral. A drawing
of the former irregularity, taken from a dissected female subject,
is copied in Fig. 55. It is the more interesting in being co-
existent with a crural rupture, across the front of which the
irregular artery lies. The obturator artery also arises from
the abnormal epigastric after it has passed across the femoral
FIG. 56.
vein, and reached the middle of the hernial sac at its lower
side. The sac will be seen to have pushed down before it
the abnormal vessels, so as to place them in a position very
embarrassing in any operation upon the rupture. The vessels
would, however, be rendered tolerably apparent in such a con-
dition by their pulsation, especially when the integuments
were divided.
This irregularity was present on both sides of
the subject. As seen on the ruptured side in the figure, it

ANATOMY.
195
illustrates very well the tendency of this abnormal position of
the artery to resist the formation of a crural hernia, as sup-
posed by Sir Astley Cooper. (Op. cit. page 253.)
In a male subject, from which Fig. 56 was taken, the in-
ternal circumflex branch arises high from the common femoral,
and crosses superficial to the femoral vein, lying within the
sheath, and to the outer side of and below the inner or lymphatic
compartment. It gives off in its course the inferior external
pudic.
FIG. 57.
In a third subject, a female, the internal circumflex, epigastric,
(Fig. 57.) This
below Poupart's
and obturator branches arise by a common trunk from the
commencement of the common femoral artery.
crosses in front of the femoral vein just
ligament. The abnormal circumflex and obturator will be
seen both to hug closely the femoral vein on its inner side, and
would necessarily be placed to the outer side of a crural rupture,
0 2

196
ON CRURAL HERNIA.
which might have been formed in the canal. They would thus
be rendered safe by the precautions taken to avoid the vein.
The same may be said of the abnormal circumflex in the pre-
ceding figure.
By examining the crural canal from its upper or peritoneal
aspect, a relative view of the position of the inguinal and crural
openings will enable us better to estimate the arrangements
which predispose to one or other of these forms of hernia, the
operation of the means of cure, and the deeper dangers which
waylay the operator in this region.
On opening into the peritoneal cavity, and drawing the
viscera to the opposite side, the serous membrane lining the
inner surface of the groin will be seen to present three slight
hollows or depressions, placed with reference to each other as
the angles of an inverted isosceles triangle. Two of them are
above and one below, a smooth oblique elevation or broad line
indicating the position of Poupart's ligament. The more ex-
ternal one is also indicated by an indistinct cicatrix, showing
the position of the internal abdominal ring. The inner one is
shallower and less distinct, and occupies the interval between
the epigastric and obliterated hypogastric vessels in the position
of the triangle of Hesselbach. The one below Poupart's liga-
ment is placed over the crural ring, at the distance of about an
inch from each of the upper ones.
Its presence reveals the
first tendency to the protrusion of a crural rupture.
On removing the peritoneum, the two upper will be seen to
be closed in by the fascia transversalis, and the lower by the
septum crurale. This septum is seen to be closely connected
with the sheath of the femoral vessels externally; and less
intimately with the margins of Poupart's and Gimbernat's
ligaments in front and internally, and with the pubic ramus
behind. (See k, Fig. 3, page 25.)
The epigastric artery (b) on its way from the external iliac

ANATOMY.
197
lies in the sub-serous tissue, at first behind Poupart's ligament,
and placed obliquely across it between the crural and internal
abdominal rings. It then ascends, rather more vertically,
between the latter and the triangle of Hesselbach (d). The
obliterated hypogastric cord (i) passes obliquely forward and
upward across the area of the last-named space, from the side
of the bladder to the umbilical cicatrix. It is placed, ordi-
narily, to the inner side of the crural opening.
According to the calculations of Cloquet and Sir A. Cooper,
in one out of every three instances, both in male and female
subjects, there arises irregularly from the epigastric or from the
FIG. 58.
parent trunk near it, the obturator artery, which then descends
behind and across the superior ramus of the pubis, to occupy
its usual position in the sub-pubic notch. This irregular course
is usually taken on the outer side of the crural ring, close upon
the external iliac vein. (Fig. 58.) The precautions which are
taken to avoid injury to the latter in operating will, under
these circumstances, place the artery out of danger.
But sometimes its origin from the epigastric is placed at
some distance from the parent trunk of the external iliac. The
abnormal obturator then occupies a position to the inner side
of the crural ring, lying in the sub-serous fascia behind the con-
joined tendon and Poupart's ligament. When so placed in

198
ON CRURAL HERNIA.
reference to a strangulated femoral rupture, it is exposed to
great danger of being divided, if a free cut be made to the
inner or anterior side of the seat of strangulation. In these
cases, the irregular artery is placed usually at a greater
distance from Poupart's ligament, in front of and above the
hernial sac, than it is from Gimbernat's ligament to the inner
side of the sac. This is owing to the length and upward direc-
tion of the epigastric artery before it gives off the irregular
obturator, as seen in Figure 59. In this way, as pointed out
by Sir Astley Cooper, more room is given for an incision in
operating upon Poupart's ligament than upon Gimbernat's, and,
FIG. 59.
in cases of strangulation, with less danger to the artery. I have
found by many experiments upon the dead subject uninjected,
that on account of the very lax and moveable nature of the
connexions of the vessel in the loose areolar tissue in which it
lies, it yields easily to the pressure of the end of a blunt-pointed
hernia knife introduced from below, and so avoids injury; un-
less the instrument be passed more than half an inch beyond
the crural ring, and a fair cut be administered upon the tissues
rendered tense by distension.
It will be seen that the epigastric artery itself is not free
from danger, if Poupart's ligament be freely divided; but that

ANATOMY.
199
it may be easily avoided by attending to the precautions just
mentioned.
The circumflex iliac artery, by its external position and the
secure protection afforded to it by Poupart's ligament and the
iliac fascia, is remote from danger.
In a case of crural hernia figured by Sir Astley Cooper in
his valuable work before cited (Plate XIX.), the obliterated
hypogastric artery passes upwards to the outer side of the neck
of the sac; instead of being placed in its usual position to the
inner side. In such a case the sac is derived entirely from the
false ligament of the bladder, and this viscus is not unlikely to
be found partly within the hernial sac, if a large one.

200
ON CRURAL HERNIA.
XV.
CAUSES AND PATHOLOGY OF CRURAL HERNIA.
Ir a female subject be examined and compared with the male, it
will be found that a considerably greater distance intervenes
between Poupart's ligament and the margin of the bony pelvis
opposed to it. In the male, this interval is usually completely
occupied and securely packed up by the iliac and psoas muscles,
and the vessels and nerves which pass with them into the thigh.
It is, moreover, well protected by the junction of the strong
iliac and transversalis fasciæ. In a subject advanced in age,
the shrinking of these muscles, and the weakening of the crural
arch and fascia which takes place, predispose more to the for-
mation of crural rupture. Hence the greater frequency of this
kind of hernia in old persons of both sexes. The greater
space in the female results from the greater stretch and
expansion of the iliac wings, increasing the distance between
the iliac and pubic spines which afford attachment to Pou-
part's ligament. By this means, not only is the depth
from the ligament to the pelvic brim increased, but to a still
greater extent is the width of the opening amplified, to be filled
up by soft parts. Since these do not usually present so much
bulk as in the male, they are less effective as a stoppage in the
larger opening.
It may also be seen that when the thighs are extended and
abducted, the effect of the traction thus made by the fascia
lata upon Poupart's ligament, is to increase its inverted curve,
and to approximate it to the pelvic brim; thereby deepening

CAUSES AND PATHOLOGY.
201
the hollow of the groin and diminishing the diameter of the
crural passage.
The aspect of the crural ring being almost directly upwards
and downwards, the weight of the abdominal viscera and the
pressure of the muscles upon them, have a simultaneous effect
upon the peritoneum and the septum crurale covering the ring
above. When, therefore, the ring and canal are wide, as in the
female, and the bulk of the psoas and iliacus when contracting
less effective in diminishing this width, a rupture of the crural
kind is more apt to form. In males affected by crural rupture,
it will usually be found that the pelvic wings have much of
the wide, outstretched appearance of the female, and that the
muscular system is less developed than usual. The tendency
to crural rupture is increased after great distension of the abdo-
men by pregnancy, dropsy, tumours, or accumulation of peri-
toneal fat. This attenuates the structures which bind together
the fibres of the tendinous openings, and enlarges all the exist-
ing apertures. In males, such distension acts chiefly upon the
abdominal rings, because of their greater patulousness from the
presence of the spermatic cord; and it diminishes the tendency
to crural protrusion by pressure upon Poupart's ligament from
above. Cases are, however, on record, and I have myself met
with a specimen, in which both an inguinal and a crural pro-
trusion had occurred on the same side.
crural canal results, in the
in the septum crurale and
In the dissecting rooms it
subjects, an atrophied con-
In many cases, dilatation of the
first place, from the growth of fat
among the lymphatics in the canal.
is common to remark, in fat female
dition of the fibrous and areolar structures in this region, dis-
integrated by the deposit of adipose masses, which are found
projecting into and dilating the crural canal. These may even
be mistaken for an omental hernia, from a certain impulse
communicated to them by their passage from within the abdo-

202
ON CRURAL HERNIA.
minal walls. A certain degree of fulness is communicated to
the hollow of the groin by the presence of this fat in the canal,
raising to a certain extent the enfeebled crural arch. This
condition is usually accompanied by a facility or looseness of
sliding of the layers of fascia over each other, which has been
previously pointed out as favourable to the production of herniæ.
The first occurrence of the rupture is due to the yielding of
the peritoneum, and to the loosening of its connexions through
the sub-serous tissue with the upper margin of the crural sheath.
It then becomes readily formed into a pouch, at the expense of
the neighbouring folds or false ligaments of the bladder. The
force of the abdominal muscles is then brought to bear upon
the thin septum crurale. Having, in the female, a larger space
to cover than in the male, and weakened perhaps by the inter-
stitial deposit of fat in its meshes, it speedily gives way before
the protrusion. The combined resistance of the structures
being thus overcome, and the crural canal fairly encroached
upon, its sides formed by the funnel-shaped sheath then give
way more or less readily, and finally the cribriform fascia also
yields, both affording a covering spread over the sac. The
saphenous opening is then dilated, permitting the fundus of the
tumour to emerge under the integuments of the thigh.
If the last-named tissues be more resistant, the rupture may
remain for some time like a bubonocele in the canal, forming
an obscure tumour behind the crural arch, in the hollow be-
tween the pubic spine and the femoral vessels.
In this position
it may dilate considerably the crural ring, and encroach upon
the front of the femoral vein externally, by dilating the longi-
tudinal septum. (See Fig. 60, b.) The direction taken by
the rupture is first downwards, with a slight inclination forwards.
Sometimes it passes downward to the full extent of the funnel-
shaped sheath, as far as the lower border of the saphenous
opening, to the union of the saphena with the femoral vein,

CAUSES AND PATHOLOGY.
203
without passing the cribriform fascia.
In such cases, the
latter structure is unusually tough and resisting.
Instances are recorded by Cooper and Hesselbach of a portion
of the sac protruding through the dilated lymphatic apertures
of this fascia, forming one or more offsets from the front of
the sac-cavity, over which the coverings were thinner than in
other parts, sometimes producing the effect of an hour-glass
constriction.
On emerging through the saphenous opening,
the rupture alters its direction, and passes upwards and out-
wards towards the iliac spine, bending over the falciform
margin of the opening, so as to lie over the femoral vessels
upon the iliac portion of the fascia lata.
FIG. 60.
Occasionally, it may reach as high a position as Poupart's
ligament, or even, by bulging before it the deeper layers of
superficial fascia, expanding these structures over its distended
fundus, it may reach beyond that line.
The cause of this change in direction is to be found in the
very firm connexion which exists between the crural sheath
and cribriform fascia, and the coats investing the great saphena
vein and the chain of lymphatics at the lower part of the
saphenous opening, which the first-mentioned structures fur-
nish with a distinct sheath. It is partly also, doubtless, owing
to the direction of the vessels and lymphatics which pass be-
tween the abdominal wall and the inner part of the saphenous

204
ON CRURAL HERNIA.
opening, and which are bound together by a strong investment
from the cribriform and deep layer of superficial fasciæ. In order
to make its way down the thigh along the course of the saphena
vein, the rupture must split the coats of this vessel, which are
usually too closely combined to allow of this. In one in-
stance, however, I have seen this condition reach to a consi-
derable extent down the thigh. On the outer side of the
saphenous opening, the laxity of the attachment of the different
layers of fascia offers the least resistance to the protrusion,
which, consequently, usually makes its way in this direction.
While the rupture remains moderate in size, the cylindrical
outline and relations of the crural canal are in some measure
preserved and impressed upon the neck of the tumour; while
the fundus, after emerging through the saphenous opening,
dilates into a globular tumour lying external to it, the whole
presenting a bent or curved appearance (as seen in Fig. 54, B,
page 192, in which the upper dotted line (a) represents the posi-
tion of the crural ring, and the lower (b) that of the saphenous
opening).
The pathological and surgical consequences of this arrange-
ment are very important, and arise from the linear pressure made
at the upper and outer parts of the bend of the sac upon the
protruded bowel, by the edge of the falciform process of Burns'
and Hey's ligament. This pressure sometimes forms an evi-
dent contraction of the sac of an old crural rupture at this
part, exactly analogous to that before described as occurring in
inguinal rupture by an undilatable and narrow superficial ab-
dominal ring. By a misdirected pressure of the taxis igno-
rantly applied, or by extending and abducting forcibly the thigh
of the patient when the hernia is strangulated, this pressure
may be increased to a dangerous extent. If, by a misappre-
hension of the course taken by the tumour, a large crural
rupture be pushed forcibly upwards towards the abdomen, the

CAUSES AND PATHOLOGY.
205
bowel may be injured by the pressure against the tense falci-
form margin. A similar effect may be produced by stretching
the fascia lata in extension and abduction of the limb. By
such means the femoral ligament, already stretched tensely
across the sac, is made to indent the surface of its neck with
such force as to risk the bursting of the included bowel. During
a proper application of the taxis in a rupture of this kind, the
fundus is first brought inwards, and a little downwards. It
should then be compressed firmly, and pushed backwards
through the saphenous opening. When it begins to give way,
it will pass almost directly upwards through the crural ring.
The principal force required in these movements will generally
be the backward pressure, to cause the fundus of the tumour
to pass
the saphenous opening. At the same time, the fingers
of the other hand are made to knead gently the neck of the
sac at the crural opening, through which that part of the
bowel which descended last will return first into the abdomen.
The ordinary coverings of a crural hernia, commencing at
the skin, and taken in the order met with in operating, are as
follows-viz., 1st. The superficial fascia, arranged at this part
indistinctly in two layers, which together form generally the
chief thickness of the hernial investments, and contain and
support many small vessels, lymphatics, and nerves. 2nd. The
cribriform fascia, known by its fibrous network, oval perfora-
tions, open texture, and its attachments to the margins of the
saphenous opening. 3rd. The fascia propria, formed by the
internal or lymphatic compartment of the infundibular sheath
of the femoral vessels. This structure is the most dense and
of the closest texture of any of the rupture coverings. 4th.
The septum crurale, which is so thinned in hernia that it may
practically be taken as a portion of the sub-serous areolar
tissue; indicating, by the usual presence of a gland, and by the
yellow colour and loose pellety texture of its fat, its close

206
ON CRURAL HERNIA.
proximity to the surface of the serous sac of peritoneum im..
mediately investing the viscera.
In a large rupture the deeper coverings may be more or less
blended together, the superficial fascia being usually the most
distinct. After great and long-continued truss-pressure, how-
ever, this also may be found blended with the deeper struc-
tures. When crural rupture affects the male subject, the
course of the spermatic cord is obliquely across the front part
of the neck of the sac, lying above Poupart's ligament, and
crossing it just outside the pubic spine, and immediately over
the inner part of the crural opening. On the skilful appli-
cation of a proper truss, the cord escapes pressure by sliding to
the inner side of the compressing pad. In operating upon a
crural rupture in the male, this position of the cord must be
borne in mind.
In an old standing crural rupture of considerable size, Pou-
part's ligament and the deep crural arch are usually found in a
lax and enfeebled condition. The inverted convexity of the
former is more or less obliterated, and the hollow of the groin is
bulgy internally. The fascia lata is feeble and loose, permitting a
freer and more unbalanced play to the muscles of the thigh.
The upward and forward traction of the abdominal muscles,
acting against the weakened fascia lata, tends still more to di-
minish the hollow curve of the groin, to enlarge the crural
opening, and to alter the direction of its aspect by throwing
its axis more forwards than normal. Thus the rupture is
turned more directly to the surface, and the length of the
crural passage anteriorly diminished. In extreme cases, oc-
curring in fat subjects, this is so much the case that it becomes
often very difficult to determine whether a rupture, when
strangulated, be of the crural or inguinal variety, the tenuity
and laxity of Poupart's ligament rendering it difficult to deter-
mine its position with reference to the neck of the sac.

CAUSES AND PATHOLOGY.
207
Another important change of relations occurs under these
circumstances. The vein, instead of occupying its usual posi-
tion on the outer side of the sac, becomes placed, by the en-
croachment of the latter outwards between it and the crural
arch, almost entirely posterior to the sac, as seen in Fig. 60 (c),
(page 203). It is very essential to bear this in mind in treating
large ruptures by operation.
In a female subject met with in the dissecting-room of
FIG. 61.
King's College, I found an irreducible femoral rupture con-
stricted vertically across the middle, in such a manner as to
render the long diameter of the sac oblique, strikingly resem-
bling an oblique inguinal rupture. (Fig. 61.) The inner end of
the tumour was placed close to the labium, encroaching to some
extent upon the pudendum, and obscured by its fat. Upon
dissection, the constriction was found to be owing to an in-
dentation made by the ilio-inguinal nerve and superficial epi-

208
ON CRURAL HERNIA.
gastric vessels, enclosed and supported by a tough band of
fascia crossing the sac. The cavity of the sac was shut off
from the peritoneum by adhesions at the site of the crural
ring, and formed a distinct cyst. A case of complete sepa-
ration of the sac from the peritoneal cavity, and its conver-
sion into a cyst, is also recorded by Mr. Heath in the Patho-
logical Transactions for 1861.
The occasional occurrence of such a termination to crural
rupture, though less common than in the inguinal variety,
gives a reasonable ground for believing in the possibility of
producing such a result by proper pressure or by operation.
Such an event is evidently more likely to occur in those cases
in which the tubular shape and relations of the neck of the sac
before described have not been entirely obliterated. As in
oblique inguinal hernia, we have in these circumstances the
advantage of a valve action of the anterior upon the posterior
wall, and a more extensive approximation of the surfaces of the
sac, upon which the effect of pressure or ligature is more likely
to obtain a permanent resistance to redilatation. The retention
of this tubular form seems to depend entirely upon the depth,
strength, and resistance of that process of the fascia lata
described under the name of the femoral or Hey's ligament.
When this obtains a broad attachment to Gimbernat's liga-
ment, and, as is sometimes the case, to a considerable extent
of the surface of the pubic fascia lata below it, it may resist
powerfully any extensive dilatation of the saphenous opening
upwards, and may thus obscure the neck and throw the fundus
of the hernial tumour more outwards. Occasionally it thus be-
comes the seat of a dangerous strangulation. This arrange-
ment is usually associated with a low division of the common
femoral vessels, and a low junction of the saphena with the
femoral vein.
It is in such cases, more frequently found in the male

CAUSES AND PATHOLOGY.
209
subject, that the hopes of the patient for a radical cure by the
use of a proper truss may be rightly encouraged. On the
other hand, the wider and shorter is the neck of the sac, and
the more feeble and lax the structures about it, the more
forwards is directed the axis of the crural opening, and the less
is the chance of a radical cure being by this means effected.
These conditions are, according to my experience, more com-
monly present in female patients affected with the complaint,
in whom the hernial tumour is more evident, more moveable,
and more distinctly isolated from the surrounding structures.
Again, in the smaller and more recent cases, the sac of this
variety of hernia is usually but loosely attached to the sides of
the canal, and may be readily returned into the abdominal
cavity after its contents are pressed up. A more complete
adhesion of the opposing walls of the fascial crural sheath may
then be obtained, either by pressure only, or, in more intractable
cases, by the skilful application of a ligature in the manner
presently to be described.
P

210
ON CRURAL HERNIA.
XVI.
DIAGNOSIS OF CRURAL HERNIA.
ONE of the most necessary distinctions to be recognised by the
surgeon, either in operating for the radical cure, or for strangu-
lation, or following a palliative treatment, is that between
crural and inguinal hernia.
The sex of the patient may give a general idea, though many
cases of inguinal hernia occur in the female, while crural
rupture is not uncommonly seen in the male. It is more
frequent in women who have borne children, and in advanced
age, than in the young and barren. An unusual spread of
the iliac wings in a male patient would indicate a greater
probability of the crural form.
In thin persons a diagnosis is readily made from the low posi-
tion of the rupture. In such cases Poupart's ligament is readily
distinguished, and generally the principal fold or groove of the
groin is plainly placed above the tumour. The crural canal
and saphenous opening are felt distended and occupied by the
sac; and, when large, its fundus or more bulky portion lies
external to, and sometimes even above the neck; the very
reverse being the case in inguinal hernia.
The shape of a crural rupture, as presented to the fingers of
the surgeon, is usually more or less globular; that being the
outline of the fundus, the rounded extremity of which is fairly
presented, and most evidently perceived at the surface.
(Fig. 62.) The shape of an inguinal hernia is generally oblong,
the profile of the fundus and neck being both apparent at the

DIAGNOSIS.
211
surface. (See Fig. 4, page 36.) If large, the crural hernia
assumes an oval shape, the long diameter of which is more or
less transverse, while that of the pyriform inguinal is oblique,
or more vertical than horizontal. This distinction is less appa-
rent between a crural and a small inguinal hernia of the direct
variety; but it is rendered the less necessary by the greater
means of distinction, arising from the more internal and supe-
FIG 62.
rior position of the latter in reference to the pubic spine.
In Figure 62, the crural rupture on the right side is small,
and is just protruding the cribriform fascia; while, on the left,
it is represented after having turned upwards and outwards.
In fat persons, these points are not so easily rendered
certain; and it has doubtless happened in the experience of
most surgeons that in cases of strangulation requiring an
operation, the distinction has not been made clear until
P 2

212
ON CRURAL HERNIA.
Poupart's ligament has been exposed by incision. The posi
tion of the fold in the groin in such subjects is so uncertain
in its relation to crural rupture as to be of no value in
diagnosing doubtful cases. It may be depressed in position by
the weight and volume of the overhanging abdominal fat, causing
the attachment of the fascia to Poupart's ligament to sway, or
belly downwards. The same displacement may be caused by a
chronic enlargement of the upper chain of inguinal glands.
The spine of the pubis affords the most valuable guide to the
discernment of this point. This projection can usually be felt
sufficiently plainly even in fat subjects. It lies to the inner
side, and often a little above a crural rupture; and to the outer,
lower, and back part of an inguinal. The anterior superior
iliac spine can also, in all cases, be distinguished, being indi-
cated in the fattest subject by a dimple or depression. If a
line be drawn between these two points, and the bulk of the
tumour lies below it, the case is, probably, one of crural rupture;
if above, of inguinal.
The direction of the cough impulse, when present, affords
some guide. In an inguinal hernia it is invariably greatest in
a direction downwards, forwards, and inwards. In a crural
hernia it is greatest directly downwards and forwards in the
smaller cases; in larger, distinctly outwards; and in some it is
even directed slightly upwards at the fundus.
In the male, the spermatic cord lies on the inner side, and
rather superficial or anterior to a crural rupture; its position
in the inguinal variety being precisely opposite.
A crural hernia, although lying upon or partly, in some
large cases, even above Poupart's ligament, may be depressed
at the fundus so as to leave a chink or fissure, admitting the
fingers more or less, so as to distinguish this ligament above the
In inguinal hernia this movement cannot be accom-
plished more on one side of the tumour than on the other.
tumour.

DIAGNOSIS.
213
In a crural rupture which is not readily reducible, much
difficulty and pain is usually experienced in stretching, and
abducting at the same time, the limb. This is sometimes
experienced also in the inguinal variety when strangulated, but
to a less degree. The pressure made by a crural rupture
upon the femoral vein will, in many cases, produce an evident
distension of the saphena during the abovementioned posture
of the thigh; and when large and omental, a sense of numb-
ness, or even oedema of the limb, may be to some extent
present.
If the superficial abdominal ring can be felt by the finger
above the pubic spine unoccupied by the tumour, while the
saphenous opening is obscured by it, all doubt as to its crural
nature will be at once removed.
The general signs of a hernial tumour, described in the
section devoted to the inguinal variety as a means of diagnosis
from tumours of a different nature, may be referred to in dis-
tinguishing the present variety.
A common source of doubt arises from the presence of
enlarged glands in the crural ring and canal. If an enlarge-
ment affects the gland which lies in the septum crurale,
especially if associated with enlargement of those placed above
that structure, a certain degree of cough impulse may be ex-
perienced. If a similar condition is present in those glands
placed within or below the saphenous opening, the double or
multiple outline of the swelling is an evident means of distinc-
tion. The mobility of a chronic glandular tumour over the
subjacent parts has been adduced as a means of detecting its
nature. But if, as is often the case, the lymphatic ducts have
themselves acquired, from long continued irritation, a certain
degree of unyielding hardness and hypertrophy, and some of
the glands within the cribriform fascia participate in the change,
the mobility of the more superficial parts of the mass is

214
ON CRURAL HERNIA.
diminished, or altogether prevented, and a sensation is given to
the fingers like the neck of a sac containing hardened omentum
emerging from the saphenous opening. The absence of the general
signs of hernia; the history of the case; the state of the patient's
health; or may be the presence of some source of irritation in the
limb below, or in the penis and scrotum; or a similar glandular
enlargement in some other part of the body, will lead usually
to a proper diagnosis in such cases.
may
But it must not be forgotten that a small crural rupture
be co-existent with such a condition of the more super-
ficial glands, and, when associated with symptoms of obstruc-
tion or strangulation, may require an exploratory incision to
render a diagnosis certain, upon which the patient's life may
depend.
Cases of acute inflammation of these glands in the first
stage of gonorrhoea may occasionally give rise to symptoms
somewhat resembling those of strangulation, such as constipa-
tion, nausea, and even vomiting. In doubtful cases, therefore,
it is necessary to make a careful inspection of the genital
organs, as well as of the whole leg of the side affected, to clear
up the case, or narrow the area of diagnosis.
The elastic resilience and hollow percussion-sound afforded
by a small sac containing bowel, is readily distinguished from
the hard inelastic feel and dull sound of an enlarged gland.
The sac is usually more globular, and the gland more elongated.
But in an omental hernia, the contents of which are hardened
by inflammatory deposit, there are more sources of doubt.
The occasional presence of peritoneal concretions in a hernial
sac has been before alluded to.
A lobule or tumour of fat, situated in the crural canal, and
dilating by its growth the saphenous opening, is a condition
occasionally found, and may closely resemble an omental hernia.
The principal connexions of such a tumour are sometimes with

DIAGNOSIS.
215
the sub-serous fat of the peritoneum. As in the inguinal, so
in the crural canal, such cases may be to a certain degree
impressed with a cough impulse. Though not constituting or
requiring the treatment of a rupture, such a condition may be
followed by a hernial protrusion through the passages so dilated.
I have been in the habit of recommending the application of a
truss in such cases, not only as a preventive of hernia, but as a
means of causing the absorption of the fat, by pressure con-
stantly applied and securely fixed.
Most anatomists will recognise the occasional formation of
hypertrophied lobules of fat in the meshes of the cribriform
fascia. Unless such growths are large, so as to encroach
upwards upon the crural ring, their diagnosis from hernia is
not difficult. There is no cough impulse, and no fulness at
Poupart's ligament affecting the outline of the fold of the
groin. If large, a strict attention to the mode and history of
their formation, and a careful examination of the crural arch,
are necessary. Like other fatty tumours, they are much more
moveable upon the imbedding tissues than a hernial tumour.
If small, the pressure of a truss-pad as a precautionary
measure can do no harm, and may result in the absorption of
the mass.
Cysts occasionally form in connexion with the lymphatics of
the crural canal. Occasionally, as before mentioned, these re-
sult from the occlusion of the neck of a small hernial sac.
Their unvarying growth, rotundity, tenseness, mobility, and
elasticity, and the fluctuation which may occasionally be felt,
will usually suffice, with the absence of any implication of the
crural ring, and of other signs of hernia, for a clear distinc-
tion. Such a distinction is, however, rendered the more ne-
cessary, that the application of a truss to this kind of tumour
may do positive harm in opening up, by an effective application
of fluid pressure, the crural canal and ring.

216
ON CRURAL HERNIA.
Chronic abscesses, glandular in origin or connected with
disease in the lumbar region, pelvis, or hip-joint, may give rise,
in certain cases, to some hesitation, by occupying the saphe-
nous opening or crural ring. In ordinary cases of psoas ab-
scess, the distinction of a more external position, often clearly
on the outer side of the femoral vessels, is evident enough. In
some cases, however, the matter finds its way on the inside of
the muscle, behind the vessels, to the position of the lymphatic
compartment of the crural sheath; or, by giving rise to sup-
puration in the lymphatics, may occupy the crural and saphe-
nous openings, and result in a tumour having more or less
moveable coverings, a distinct cough impulse, and some in-
creased distension when the patient is in the erect posture.
Pelvic abscess has also been known to point in this situation.
In such cases the previous history, the effect on the patient's
general health, the accompanying pains in the back, loins, or
pelvis, the hectic and other symptoms, are usually marked
enough to rouse the most unready suspicion. The subsidence
of the tumour in the recumbent position, however long con-
tinued, is never considerable, the fluctuation is usually sooner
or later made evident; while the enlargement is gradual, in-
variable, and, in the latter stages, more rapid than in hernia;
of which also the other signs are absent. The concomitant
association of hip-joint disease is usually sufficiently apparent,
where that is the cause of the swelling.

OPERATION.
217
XVII.
OPERATION FOR THE RADICAL CURE OF CRURAL HERNIA.
IN the Lancet for May 2nd, 1828, a case of operation for the
radical cure of a crural hernia is recorded as performed by Dr.
G. Jameson, of Baltimore, North America; in which, after an
operation performed upon a lady for strangulation, leaving the
rupture still liable to protrude, this surgeon, following appa-
rently the operation proposed by Dzondi, dissected from the
skin of the groin a lancet-shaped flap, which he then forced
into the hernial aperture exposed by the incision, finally
stitching over it the edges of the wound. From the conclud-
ing remarks on the case, its termination does not seem to have
been so satisfactory to the patient as to the operator; whence
one is led to infer that it supports the conclusions previously
expressed, as to the inutility of dealing only or chiefly with the
integuments covering a rupture.
This case is the only one I can find recorded of an opera-
tion undertaken for the radical cure of this kind of hernia,
with the exception of one performed by Mr. Redfern Davies, of
Birmingham, a modification of Wurtzer's operation, upon the
principle of invagination of the skin into the crural opening, by
a hard plug retained by sutures. The death of the patient,
which followed some time after the operation, appears, from the
account given of the case by this enterprising surgeon, not to
have been directly connected with the proceeding.
An operation which I have been accustomed to show on the
dead subject for the cure of this form of rupture, is performed

218
ON CRURAL HERNIA.
as follows, the instruments used being the same as for in-
guinal hernia by the wire operation.
The patient being placed in the same position as for the
preceding operations, and the rupture completely reduced, a
vertical incision, about an inch long, is made through the skin
over the site of the tumour. (See Fig. 65.) In Figures 63
and 64, the integument is represented turned down by a
FIG. 63.
dissection, to show the exact position of the finger and instru-
ments beneath it. The fascia around the margin of the wound
is then detached in the usual way, to a sufficient extent to
allow it to be invaginated, free from the skin, fairly into the
crural opening.
The forefinger used for invaginating is then placed upon the
inner side of the femoral vein, pressing it carefully outwards
out of danger from the needle. This instrument is then passed

OPERATION.
219
backwards through the sac, sufficiently deeply to take up the
pubic portion of the fascia lata covering the pectineus muscle;
the point of the needle being afterwards made to appear in the
wound. (Fig. 63.) It is then carried forwards and upwards, and
made to transfix Poupart's ligament close to the nail of the
invaginating finger. The skin of the groin is then drawn out-
wards by an assistant, and the point of the instrument pushed
FIG. 64.
through it. The wire, prepared in the same manner as in the
operation before described, with a hook at each end, is then
hooked on to the eye of the needle, and drawn back with it
into the wound. Then the needle, being disengaged from it,
and leaving it protruding through the incision, is passed again
through the pubic portion of fascia lata, about an inch or three-
quarters of an inch (according to the size of the hernial opening)
to the inner side of the first perforation (Fig. 64); and its point

220
ON CRURAL HERNIA.
made in the same manner to pass through Poupart's ligament
directly above, and close to the curved border of Gimbernat's
ligament, of which a portion of the fibres may be included.
The skin is then drawn inwards, until the needle can be pushed
through the same puncture before made, which is already occu-
pied at this stage of the proceeding by one end of the wire.
The opposite end of the wire is then hooked on, and drawn
back with the needle, which is then finally disengaged. The
two ends of the wire are now twisted down into the incision,
and cut off about six inches from the twist. The loop which
emerges at the upper puncture is then twisted firmly down into
it, pressing down before it the portion of Poupart's ligament
opposite the crural opening, which is included in its grasp.
(Fig. 65.)
In a small hernia the ends of the wire may be bent up-
wards over a pad of lint rolled tightly, and hooked into the
loop above (B.) In a rupture of larger size, where the
ligamentous structures are much relaxed, a more steady com-
pression will be achieved by the use of a boxwood or glass com-
press of the cylindrical form, (depicted in the figure at A,) and
described in the operations for inguinal hernia. The upper
end of the pad is to be placed in the embrace of the upper
loop; and over the lower end the extremities of the wire are
fastened by a turn or two. In cases very large, two wires may
be employed in the same way, and twisted over a double pad,
or two pads, laid side by side, so as more effectually to occlude
the nec of the sac.
Pledgets of lint placed on each side, and a spica bandage
over all, complete the dressing.
By this operation, that part of the tendinous crural arch
which overrides the neck of the sac, is drawn backwards and
downwards, and becomes adherent to the pubic portion of
fascia lata included in the suture. If the rupture be large, the

OPERATION.
221
sac and its coverings are transfixed, and embraced in the
suture; if small and recent, the serous sac may be returned
easily within the abdominal parietes, and its tendinous invest-
ments united altogether external to it. The invaginated fascia
and sac coverings become adherent on all sides under the com-
bined influence of ulceration, traction, and pressure; and thus
form a consolidated mass, filling up the area of the crural ring.
The precautions which are chiefly necessary are-first, to
FIG. 65.
A
B
keep the finger carefully pressed upon the site of the femoral
vein, so as to interpose between it and the needle during its
passage; and secondly, to avoid pushing the instrument too
far into the abdominal cavity, by which the bowel, the
epigastric artery, and in the male, the spermatic cord, might
be endangered.
The wire may be kept in for the same time, and removed in
the same manner as before described for inguinal hernia.

222
ON CRURAL HERNIA.
In severe cases of crural rupture affecting the male, or in
healthy females whose laborious occupations may necessitate
great muscular exertion, I believe the foregoing operation to
be the most likely to accomplish a cure, or at least a diminu-
tion of the rupture, so as to render a truss available, with the
smallest amount of risk and inconvenience to the patient of
any that have hitherto been proposed.
The close proximity of the large femoral vein to the site of
the operation, and the implication of the numerous lymphatics of
the part, seem to afford a greater chance of bad results from the
subsequent suppurative action, than is the case in inguinal
hernia. The same risks, however, are frequently encountered
without bad results, in operating for strangulation.
The operation seems to be more likely to succeed in effecting
a complete cure, in the cases previously described as charac-
terized by a considerable extent of the hernial canal, between
the crural ring and the falciform margin of the saphenous
opening. In such cases, the depth of the upper horn of the
opening before described under the name of the femoral or
Hey's ligament, affords a broader surface of apposition for
adhesive action, and consequently a greater resistance to future
protrusion. Speaking without experience upon this point, it may
be said that, in the majority of cases of crural rupture, the short-
ness of the crural canal investing the neck of the sac, and the
more direct downward pressure of the intestines brought to
bear upon the area of the adhesions which may be obtained by
operation, will render a cure more difficult to accomplish than
in the inguinal variety. A diminution of the opening may,
however, be thus obtained, if not a complete cure; and thus a
more effective support be thenceforwards obtained by means of
a proper truss.
It is, I think, a question which may be fairly entertained,
whether, after an early operation for strangulated hernia of

OPERATION.
223
both the inguinal and crural varieties, where there is little
expectation of inflammatory action in the bowel released, wire
sutures may not be advantageously employed in drawing
together the edges of the tendinous opening, denuded and
severed by the incisions, and so accomplishing a radical cure
by the same operation. This might be done with still less
risk in cases where the operation is accomplished without
opening the sac; since in these instances the small chance of
mischief which may be expected to result from an implication of
this offset of the peritoneum may be taken away by returning
the sac within the abdominal parietes. This may usually
be done with great ease in cases of crural rupture of
moderate size and duration. It needs hardly be said that the
advantage of obtaining a radical cure, which so rarely, if ever,
follows from the operation for strangulated hernia as usually
completed, is, in favourable conditions of the patient, amply
worth so small an increase of risk as might ensue from
symptoms so slight as those produced by the application of
wire sutures in this way, in the great majority of the cases.

224
ON CRURAL HERNIA.
XVIII.
PROSPECTS OF A RADICAL CURE BY TRUSS PRESSURE
IN CRURAL HERNIA.
Ir the occurrence of a complete cure by external pressure only
is rare in inguinal hernia, such a result is still less frequent in
the crural variety, for reasons which will be readily appre-
ciated by a perusal of the foregoing pages.
That it does occasionally occur, however, is unquestionable.
I have myself examined the bodies of two persons at least, in
which the sac of a crural rupture had been cut off by adhesion
from the cavity of the peritoneum, as before mentioned.
It seems to me that the way in which such pressure is
applied by the ordinary form of truss pad is little likely to
accomplish the desired result. In the truss as usually em-
ployed, the pad is applied obliquely from above downwards and
inwards. A reference to the anatomy of the crural canal will
show this not to be in accordance with the direction of the
axis of the neck of the hernial sac, which is almost directly
downwards, with a slight inclination outwards. The widest
part of the pad is usually at its lower extremity, which presses
into the saphenous opening; while the narrow part is but
imperfectly applied to the upper part of the canal and crural
ring, and, from the manner of its connexion with the side
spring, has a constant tendency to slip away outwards from it.
It is essential to the production of a radical cure that the
bowel should be entirely shut out of the sac cavity for a sufficient
length of time to permit the sides of the latter to become

EFFECT OF TRUSS-PRESSURE.
225
adherent, or so contracted as not again to admit of protrusion.
For the permanent duration of the cure, it is necessary, further,
that the surrounding tendinous structures should also contract
upon and close up the neck of the sac.
To accomplish this in a case of crural hernia it is essential
to make the chief pressure upon Poupart's ligament, so as to
close the crural ring by approximating the crural arch to the
ramus of the pubis. The most prominent and widest part of the
pad should be placed then in the groove of the groin, in order
to shut out the bowel completely from the sac. To guard the
saphenous opening is a secondary consideration, and one which
will be necessarily carried out by the above means.
The objections to a convex truss pad, which were shown to
be serious in the case of inguinal rupture, do not, in the
present case, so strongly apply to such a pad when properly
placed. The axis of the crural ring and canal coincide, and
are directed upwards and downwards, and for practical pur-
poses may be considered as vertical. (See Fig. 54, A, a.) That
of the saphenous opening is directed forwards and slightly
downwards and inwards (b). The pressure of a truss pad
should fall chiefly exactly between the crural ring above and
the saphenous opening below, and at right angles to the axis
of the canal (c). Its effect would, in such a place, be to close
the sides of the canal, and not to dilate it by working into it in
the direction of its axis. If the pad, however, be improperly
directed and placed too low, and exerts its chief and most
convex pressure upon the saphenous opening, it will invert the
soft parts into the opening, and tend to dilate it and work its
way into the axis of the canal.
The truss pad I have had made for femoral hernia is com-
posed of the segments of two ellipses (Fig. 66, A), joining a
little above the centre of the pad at its broadest part (a). The
segment of the upper ellipse is wider from side to side, and that
Q

226
ON CRURAL HERNIA.
of the lower longer from above downwards, tapering off below,
so as to accommodate itself to the shape of the hollow between
the muscles of the part (b). In section (Fig. B) the pad is seen
to be thicker towards the upper border at a, thinning off in a
curve like the prow of a boat at b, while the central bearing
point at the middle third (c), opposite to the insertion of the
side spring, is flattened. The upper segment and the most
convex and widest portion are placed over and upon Pou-
part's ligament in the groove of the groin, exerting pressure
upon that structure. The lower part of the inferior segment
FIG. 66.
b
A & B. The Elliptical Pad and Section.
covers and protects the saphenous opening; while the flat cen-
tral third rests on and compresses the femoral or Hey's liga-
ment, which forms the anterior boundary of the crural canal.
For hospital purposes, and in ordinary cases, the pad thus
shaped may be made of boxwood, and held in place by a spring
passing round the hip of the same side.
In order to be able to regulate the pressure on any side of
the pad especially, at which the rupture may tend to escape, or
to increase its effect upon Poupart's ligament, the same
arrangement as before described in the section on inguinal
hernia may be employed. The basis of the pad is a thin plate

EFFECT OF TRUSS-PRESSURE.
227
of metal, shaped to the elliptical form, and raised at the borders
into a cup-shape. A Y-shaped spring, like those previously
described in the trusses for inguinal rupture, supports by its
central lever the extremity of the side spring or belt, and is
fixed to it by an adjusting screw. (Fig. 67, A and B.)
The upper limb of the spring is connected by the hinge close
to the margin of the upper ellipse (at b in the figure and section),
pressing it firmly against the crural arch. The two lower
press upon the longer ellipse covering the saphenous opening,
and bearing evenly upon the sides, preserve a steady lateral
FIG. 67.
A
b
B
a
A & B. The Elliptical Lever-spring Pad and Section.
balance. The force of the hip spring can be directed more
upon one or other side either by means of holes in the lever
plate simply, or by a revolving slide and hand-screw, as repre-
sented in the figure. By this simple means we have a more
steady and perfect control over the lateral motions of the pad
than can be obtained by the ordinary ball-and-socket joint or
spiral spring. The action of the pad spring, as seen in the
section at B, has a constant tendency to adjust the pressure of
the side or hip spring under the changing conditions of flexure
of the body upon the thigh in sitting or standing, and to keep
the pad always in the groove of the groin or deepest part of the
Q 2

228
ON CRURAL HERNIA.
surface to which it is applied. With a view to this effect, the
hinge fixing the upper part of the Y-shaped spring is placed
higher upon the margin than in the trusses for inguinal hernia.
By reference to the figure (B) it will also be seen that the sides
of the cup at the junction of the two ellipses are cut away, so
as to allow of a slight adjusting motion, by bending the thin
metal connecting the two together at the groove of the groin.
This enables the maker to accommodate the bearing of the
upper portion to the degree of protuberance of the abdomen of
the patient; and to obtain, if necessary, a greater proportionate
amount of pressure upon Poupart's ligament and the crural ring.
A very steady bearing of the pad may thus be obtained, and
any tendency to displacement upwards by the traction of the
side spring be also, in great measure, counteracted.
In this form of rupture the action of a hip spring is generally
even more required than in the inguinal variety, in order to
keep the pad secure in all positions of the limb. When a
simple body belt is used, it is necessary to combine with it a
strap round the top of the thigh. This is most effectually
accomplished by making the two cross the pad in a figure-of-8
way, with one upper and one lower end to fasten upon it.
But in most cases this is irksome in the erect posture, and
becomes relaxed in bent positions of the thigh.

PREDISPOSITION AND PREVENTION.
229
XIX.
PREVENTION OF INGUINAL AND CRURAL HERNIA.
IT has been found that inguinal ruptures are nearly three times
more common than femoral, and six times more frequent in
males than in females. It is especially important, therefore,
for persons of the former sex, who are liable to be called on by
the nature of their pursuits for sudden exertions and violent
muscular efforts, to use such precautions as may diminish the
tendency to the formation of rupture, and particularly to guard
against inguinal protrusions.
Soldiers, sailors, mechanics, colliers, and labourers, and the
numerous class of younger men who cultivate active and
athletic sports, such as cricketing and boating, are peculiarly
subject to this disagreeable consequence. This is especially the
case if such sports be violently indulged in without a proba-
tionary and gradual exercise of the muscles, accustoming them
and their associated tendons gradually to the demands of ex-
traordinary exertion and pressure. Among our soldiers, the
practice of riding with a military seat is justly considered to
produce many cases of rupture. Hard riding of any kind,
especially on heavy trotting horses, is to be avoided by those
who have a predisposition to the disease. The hot, close
atmosphere in which most of our mechanics and forgemen
pursue their avocations, producing violent and continued
perspirations, has a very relaxing effect upon the tissues, which
makes itself evident in the pale and sallow countenance, and
predisposes to hernial protrusion; while the violent muscular

230
ON INGUINAL AND CRURAL HERNIA.
efforts usually required in their work supply the exciting
cause.
The practice of training for boat races in the young men of
our universities will sometimes produce, in individuals pre-
viously fat, an open condition of the abdominal rings by the
sudden absorption of the fat which lodged therein, which is
very likely to give egress to a rupture during the violent tension
of the exciting contest. More than one instance of the kind
has come under my own observation.
Hereditary predisposition to rupture ought always to be a
significant warning. A certain conformation of the muscles
and tendons and bones about and in the groin, descending
to father and son, gives, as before pointed out in this volume, a
strong predisposition to rupture.
One of the most important of the appearances which indicates
a tendency to inguinal hernia is the fulness of the groin over
the internal or deep ring, increased by coughing or holding the
breath, and caused by deficiency in the development of the
internal oblique muscle. Another, not less important, is a
patulous condition of the superficial ring, which is often suffi-
ciently open to admit the point of the finger previously to the
appearance of a decided rupture. A lax condition of the
scrotum and coverings of the testicle is often co-existent with
such indications of predisposition. Varicocele and hydrocele,
if neglected and suffered to grow very large, may prepare
the way for a rupture by opening up the inguinal passage.
Crural hernia is to be apprehended in bodily conformations
where the iliac wings are wide apart, increasing the length of
Poupart's ligament; the hollow of the groin not well marked
by a concave curvature, indicating a loose condition of the
crural arch; and when the muscles of the thigh are loosely
held together, indicating feebleness of the fascia lata.
An open
condition of the saphenous aperture, and a pulsation of the

PREDISPOSITION AND PREVENTION.
231
common femoral artery, characterized by a certain degree of
mobility and distinctness, may be taken to show a patulous
condition of the crural ring and passages. This may be in-
creased also by a chronically enlarged condition of the femoral
glands, which, on their subsidence, may leave space for the
formation of a rupture.
A general increase of obesity, especially if affecting mainly
the omentum and other contents of the abdomen, associated as
this condition often is with a laxity of the fibrous structures,
produces a degree of tension upon the abdominal walls which
often terminates in this condition. The interstitial deposit of
fat disintegrates more than anything the close texture of the
fibrous aponeuroses of the body. At that period of life which
is often characterized by corpulency, I have met with cases
in which there has been a reappearance of a congenital hernia
which had been considered as cured, and absent for a long
period.
In the above cases the use of a light preventive apparatus
over the groins during exercise of any kind is much to be
recommended. An appropriate apparatus of this kind is made
by Mr. Matthews, of Portugal-street, Lincoln's-inn-fields, after
my own design.
It consists of an ordinary elastic suspensory bandage for the
scrotum, which is buttoned on each side to a belt passing over
the groins, and encircling the hips from one side to the other.
Embodied in, or connected with the belt upon each groin is an
elastic hollow pad, made of vulcanized india-rubber upon a
metallic basis, shaped and adjusted so as to cover both the
inguinal and crural rings. These may be inflated with air, or
filled with water, so as to exercise a greater or less area of
pressure, as the case may require. The pads are connected
together and braced up by a strap and buckle passing from one
to the other across the lower part of the abdomen above

232
ON INGUINAL AND CRURAL HERNIA.
the pubis. (See Fig. 69.) A double perineal or under strap
fastens on to the lower part of the pads on each side, and is
secured to the back part of the body strap above each hip. In
some cases it will be sufficient for these to fasten to the back
part of the suspensory bandage. In all cases it will be better for
the two straps to be connected to each other behind the scrotum
before reaching the body belt. This apparatus may be worn
without making any external show, and acts as a support to
the parts liable to rupture, without weakening them by undue
pressure, while its elasticity readily accommodates it to the
different movements of the body and limbs.
FIG. 69.
Patients with a predisposition to, or actually affected by,
rupture should avoid a flatulent diet, and the habit of drinking
large quantities of fluid of any kind. They should carefully
look after the condition of the bowels, and avoid constipation
by a due use of aperients or regulation of the diet. A ten-
dency to the accumulation of fat should be checked by the use
of a spare, dry diet, and walking exercise daily. The habitual
use of hot or Turkish baths, and excessive smoking, should be

PREDISPOSITION AND PREVENTION.
233
avoided, as tending to a relaxation of the tissues.
Cold plunge
or douche baths, on the contrary, are very beneficial, having
an especial effect upon the genital organs and the structures in
their neighbourhood, as may be seen by their effect in bracing
up the testes and scrotum by inducing vigorous contractions of
the cremaster muscles and dartos. In lax conditions of the
genitals and groin, with more or less varicocele, the adminis-
tration of muriated tincture of iron will be found of great
use, aided by the cold douche applied daily.
For young boys having a tendency to rupture, a moderate
use of gymnastics of a kind to employ chiefly the arms and legs,
is decidedly advantageous, as tending to strengthen by tension
the muscular and ligamentous structures. All feats of strength,
however, should be carefully eschewed, together with such
tricks as balancing on the abdomen over a pole, or sustaining
weights upon it, and all inordinate action of the abdominal
muscles. Open air bathing and swimming are also excellent,
but should be taken in moderation, and never to great
fatigue.
For working men who have a tendency to rupture nothing
can be better than a liberal use of the cold water douche daily
all the year round, over the groins and genital organs. The
tonic action of such cold affusion is speedy, palpable, and en-
during, and conduces to health and strength, both local and
general. The bowels should be carefully regulated, and all
things tending to flatulent distensions avoided.

234
ON INGUINAL AND CRURAL HERNIA.
XX.
TREATMENT OF IRREDUCIBLE HERNIA.
In
As a rule, when a hernia is irreducible from adhesion or incar-
ceration, no attempts should be made to effect a radical cure by
pressure or operation; but if the tumour be of small size, and
it be clear that the contained and adherent mass consists of
omentum only, much good result may be expected from wear-
ing a proper truss. In such a case the spring of the truss
should not be too strong, and the pad should be flat on the
compressing surface, so as to exercise little pressure upon the
adherent omentum lying in the axis of the hernial canal.
addition to blocking out the bowel, such pressure may produce
ultimately an extension of adhesive action all round the neck of
the sac, so as completely to obliterate its communication with
the cavity of the peritoneum. In these cases, decided invagi-
nation of the anterior coverings of the hernia under truss
pressure is not so apt to take place, on account of the presence
of the omentum filling the sac. If the contained mass be
hardened already near the neck by consolidated effusion, hope
may reasonably be entertained of an ultimate cure by this
means. Great care must, however, be taken lest a portion of
the bowel also slip into the sac, behind and obscured by the
omentum, and thus become exposed to, and injured by the
pressure of the truss. The occurrence of such an addition to the
protrusion will generally be indicated by the accompaniment
of abdominal disturbance, constipation, unusual pain, and
sudden increase of size in the tumour, and inability to wear

TREATMENT WHEN IRREDUCIBLE.
235
the truss comfortably. It has been thought that the pressure
of a truss upon adherent omentum would be likely to give rise
to unpleasant symptoms. I have, however, frequently ob-
served patients having a portion of omentum within the sac
able to bear the pressure of a truss upon the mass. The
pressure must not be too strong, but must be regulated by the
feelings of the patient. If too powerful a pressure be applied,
a congestion of the omentum may be induced, which may give
rise to symptoms. Generally speaking, the feelings of the
patient are the best guide in this matter, and will effectually
prevent so much or so long a pressure as will interrupt the cir-
culation through the incarcerated portion of omentum. A
moderate degree of pressure, on the other hand, will not only
prevent the further accession of omentum or of bowel into the
sac, but will tend to promote absorption of that already
adherent, or to cause a more complete blocking up of the
hernial canal.
The cases placed on record by Pott, Cooper, and others, in
which interference with the omentum has given rise to
symptoms of abdominal disturbance, have apparently been owing
to a degree of traction exercised upon this structure sufficient
to interfere with the free movements and functions of the
stomach and colon, to which it is connected above. Such
symptoms, however, can scarcely arise from a moderate degree
of
pressure upon an omentum long adherent to, or contained
in, a hernial sac, without having previously exhibited these
effects. If such symptoms have been occasionally induced by
the irreducible rupture, the case must not be considered as one
favourable for treatment by this means. There seems to be
nothing in the structure and formation of the omentum itself
which should prohibit some degree of pressure upon it, since
its nervous supply is not plentiful. Numerous cases are
recorded, and occur in the practice of most surgeons, in which

236
ON INGUINAL AND CRURAL HERNIA.
a portion of the omentum has been strangulated by liga-
ture, or in a state of mortification, or removed altogether,
without producing symptoms. Opinion at the present day
appears to be recurring to that entertained in the times prior to
the greater authorities on this subject-viz., that the omentum,
if properly dealt with, is much more amenable to interference
than was inferred by them on the authority of some peculiar
On the other hand, the number and arrangement of its
vessels, and the nature of its usual chief constituent, fat, would
indicate its capability of bearing considerable pressure, pro-
vided it does not strangulate, and also its facilities for becoming
adherent to the opposing surfaces of the sac without interruption
to its vascular supply.
cases.
In certain favourable instances in which the adherent
omentum, together with the sac itself, can be pushed up into
the internal ring, the judicious application of a wire ligature
below and outside the sac, embracing and closing up the
tendinous walls of the canal, may produce a closure of the
passage, which will prevent the descent of a further protrusion
of the abdominal contents. The adherent omentum and sac
will then block up the internal hernial opening and canal.
Such a case will be found in Case 60 (Appendix). Several
cases have come under my observation, both in the living and
dead subjects, in whom an adhesion of omentum at the deep
ring has effected a complete occlusion, and produced a radical
cure. (See page 143.)
When, however, a portion of bowel is permanently retained
in the hernial sac, or the retention of such omentum as
habitually resides there gives rise, under certain distended con-
ditions of the stomach and colon, to unpleasant symptoms, it is
evident that nothing should be attempted beyond the support
of the rupture by a bag, or properly fitting hollow truss-pad.
These are best made of some elastic material, such as

TREATMENT WHEN IRREDUCIBLE.
237
vulcanized india-rubber, of such a strength as to resist the
action of the abdominal muscles without causing distress to
the patient. This should be held on by straps round the hips,
upon the general plan of the arrangement before described in
connexion with the preventive belt and pads, with such addi-
tional perineal and thigh straps as the nature of the case may
require.
The precautions of diet and constitutional treatment, before
sketched out as necessary to be observed in hernial conditions,
are especially to be regarded under the circumstances of irre-
ducible rupture.

238
ON UMBILICAL HERNIA.
PART III.
UMBILICAL HERNIA.
XXI.
CAUSES AND PATHOLOGY.
So common is this form of protrusion, that Sir Astley Cooper
considered, that in point of frequency it comes after the
inguinal variety. It is certain, that including the infantile
form, it is more commonly seen by the surgeon than crural
rupture.
In the adult it is not so common, and usually occurs as a
consequence of pregnancy, ascites, or a large accumulation of
fat in the different processes of the peritoneum, especially the
omentum, which is placed directly behind the navel. The
distension resulting from the corpulency thus produced is more
evident in the central than in the lower parts of the abdomen,
and distends laterally the transverse abdominal section in
which the navel is placed to such an extent as to stretch the
fibrous structures, and to open up the normally small apertures
which there exist. The weaker parts naturally give way the
soonest, and admit of the protrusion of the abdominal contents.
In most cases, probably a somewhat imperfect closure of the
umbilical aperture in early infancy has preceded, leaving a
weakness of resistance at this part. This is perhaps, in the
adult class of cases, increased by the interstitial deposit of fat

CAUSES AND PATHOLOGY.
239
in the fibrous parts around the cicatrix of the navel itself,
which contributes to diminish its resisting power.
In the infant it is very frequent, and usually occurs from
the second to the fourth month after birth, while the aperture
for the umbilical cord is still open. It is often in consequence
of ill health retarding the tendency of the aperture to close up
in regular progress of development, and at the same time giving
rise to such suffering as to keep up frequent and violent fits of
crying, during which the abdominal muscles exercise spasmodic
pressure upon their contents, and force them continually
into the aperture, thus keeping up a constantly recurring dila-
tation.
In the development of the foetus the last portion of the
peritoneum to close into a shut sac around the abdominal
viscera is the central part, at the navel. At an early period in
the development of the ovum an opening in this part of
the abdominal walls transmits the omphalo-enteric duct, or
pedicle connecting the umbilical vesicle or yolk sac with the
intestinal tube; the omphalo-mesenteric vessels, which spread
over it; together with the urachus, or tube of communication
between the bladder and allantois sac; and the accompanying
placental vessels. Of these structures the two first mentioned
pass through the cavity of the peritoneum, to be connected
with the intestines and their mesenteric vessels respectively;
and the two latter pass outside and in front of the peritoneal
serous membrane, the umbilical or placental vein upwards to
enter the fold of the falciform ligament of the liver, finally to
join the portal and inferior caval veins; and the placental
arteries accompanying the urachus downwards to the bladder,
on the sides of which they are continuous with the hypogastric
branches of the internal iliac arteries.
After the third month of intra-uterine life, at periods varying
somewhat with the vigour of the development, the duct of the

240
ON UMBILICAL HERNIA.
umbilical vesicle and its associated vessels become atrophic, and
disappear. The peritoneal sac is then entirely closed up at
the navel, where a fine cicatrix may, at an early stage, be after-
wards observed. The aponeurotic tendons which invest this
part do not thereupon also entirely close, but leave a con-
siderable aperture up to the time of birth for the trans-
mission of the umbilical arteries and veins to and from the
cord.
After the latter is tied and cut at birth, the remaining stump
usually dries up completely to its root of attachment to the
abdominal parietes, and its vessels are obliterated; the fibro-
areolar remains of these structures completing the closure of
the opening by forming a very tough and resisting connexion
closely adherent to the peritoneum, the margins of the ten-
dinous opening, and the neighbouring skin. The opening in
the tendon at the linea alba is then normally reduced to the
size of a small quill; and the tissue covering and surrounding
it is very tough and difficult to be cut or pierced by a needle,
even in very young children; affording a hold to a suture very
valuable in any endeavour to close, by this means, an abnormal
dilatation of the aperture. The close attachment of the skin
to the tendon around the margins of the opening, together with
the absence of subcutaneous fat at the part, give rise to the
peculiar indentation of the umbilical cicatrix.
When the umbilical cord is large and tumid, its vein larger
than common, and a slowness of development usually asso-
ciated with this condition is coexistent, the opening in the
tendon is larger than normal, the skin is loosely adherent,
the child generally imperfectly developed, and a protrusion may
take place even during the first struggles of the infant, and the
bowel thus may be endangered by the ligature placed upon
the umbilical cord. In these cases of early formation, the
external structure of cord itself is distended near its junction

CAUSES AND PATHOLOGY.
241
with the skin of the abdomen, and forms part of the in-
vestment of the tumour before it has had time to shrivel and
dry up.
Generally, however, the protrusion takes place at a later
period, and the cicatrix formed by the dropping of the navel-
string is found upon or near the centre of the hernial cover-
ings. As the tumour grows larger it is increased at the
expense of the surrounding integuments, by the yielding of
their attachments to the margins of the tendinous opening.
This sac,
When formed at an early period, the peritoneal investment
or sac of the rupture is necessarily very thin and attenuated,
produced as it is by the dilatation of the most recently formed
portion of the serous membrane. Still it may usually be
distinctly demonstrated and separated from the superjacent
layers, upon which it is in some degree moveable.
in almost all cases, contains omentum, which completely
covers the bowel in this situation. In young children, this
structure is very thin, and contains but little fat, and the
contents of the hernial sac are chiefly made up of a portion of
the transverse colon or small intestine. The usual presence
of the former is due to its position exactly across this part of
the abdominal cavity.
When formed at an adult period of life, umbilical rupture is
most frequent in elderly women who have borne children.
In females of a conformation producing a great anterior pro-
jection of the abdomen during pregnancy, such as a limited
expansion of the iliac wings of the pelvis, or a great anterior
curvature of the lumbar spine, often seen in women of small
stature, an umbilical rupture is more apt to occur. The
carrying of twins, or multiples, or of large children, or dropsy
of the amnion, may also produce it, especially if negligence in
bandaging be displayed. Generally it is due to a combi-
nation of the distension of pregnancy with that of an
R

242
ON UMBILICAL HERNIA.
inordinate accumulation of peritoneal fat. Occasionally it is
present from the latter cause associated with a hypertrophied
condition of some of the viscera, or an habitually distended
condition of the stomach in corpulent men, who are fond of the
pleasures of the table. Sometimes it is due to dropsy of the
peritoneal cavity.
By such an extreme distension of the abdominal walls the
cicatrix closing up the umbilical opening is gradually thinned
and weakened, until it yields before the pressure of the bowels.
More frequently, according to Scarpa, the opening in adults
occurs not exactly in the site of the umbilical cicatrix, but a
little to one side of it, through an aperture in the tendinous
septum of the sheaths of the recti, by a combination, doubtless,
of distension from within and a deposit of fat between the
fibres, in the course of the small vessels and nerves which
traverse the part. At first, and in the smaller cases, a sac
of serous membrane is distinct, and easily demonstrated.
In some very large cases, however, it has been said by
Cooper, Lawrence, and others, to be incapable of demonstra-
tion over the whole inner surface of the tumour, having become
attenuated to a degree, and absorbed or burst through by the
pressure. This result, occurring so much more commonly
than in the other forms of rupture, appears to be due to
the more extensive and intimate adhesion of the peritoneal
membrane, and the greater thinness of its investment on the
inner surface of the abdominal wall at this part than in the
groins. At this part the subserous areolar tissue and fat is
usually entirely wanting, and the membrane has but little
scope of motion over the surface of the parietes; consequently,
the peritoneum available for a sac is scanty, and becomes much
attenuated by stretching, until it finally disappears by a process
somewhat similar to that which ensues to the inner and middle
coats of an artery subject to aneurism. A case is recorded and
NO

CAUSES AND PATHOLOGY.
243
figured by Sir A. Cooper, in which the omentum passed in two
separate places, through openings produced in the sac by
attenuation or rupture. (Op. cit.)
At this period of life the contents of the sac are often a mass
of fatty omentum. In large cases, however, it usually contains
in addition a portion of colon or small intestine. The omentum
is very apt to become adherent from inflammation set up by
the pressure and friction of the clothing, or occasional violence,
to which the position of the rupture renders it
very liable.
When the rupture is large, the recti muscles become
separated from each other at the linea alba to a considerable
extent. In the normal condition, the borders of these muscles
at the umbilicus are somewhat separated by the interposition of
the umbilical cicatrix, the separation being continued up-
wards to the ensiform cartilage by a broader development of
the fibrous band constituting the linea alba. This separation
is always more marked at the intersection of the fibrous lineæ
transversa. In a hernial condition, the muscles are usually so
far separated as to allow a suture to be placed at the borders
of the aperture, without including the muscular tissue or
opening their sheaths. In this kind of rupture, the size of the
tumour bears even less proportion to that of its internal
opening than is the case with the other varieties. I have
frequently found, in very large hernia, the internal aperture of
no considerable size. This has more usually been the case
where the sac contained omentum only. When bowel is
present, the opening is usually larger. When the protrusion
occurs through the true umbilical aperture, as in infants, the
form of the opening is almost always circular. When it occurs
in the linea alba, though close by the side of the umbilicus, as
is generally the case in the adult, the opening may be oval or
slit-like. This distinction becomes important both in the
diagnosis and treatment of the disease in adults.
R 2

244
ON UMBILICAL HERNIA.
XXII.
DIAGNOSIS.
IN the infant, umbilical rupture usually presents itself as
a soft, rounded tumour at the site of the umbilicus, bearing
on or near its centre the mark of the umbilical cicatrix. (Fig.
68.) It rarely exceeds in size that of a large chestnut. On
pressure, it readily returns into the abdominal cavity, with
a slight gurgling sound and flatulent feel, indicating presence
of a portion of bowel. When its contents are returned, the
smooth, circular edge of the tendinous aperture can usually be
readily felt, and the skin and sac of the tumour inverted into
the opening by the point of the finger, which can also, in cases
of some size, be passed under the edge to some distance all
round.
At this time of life there are very few or no conditions with
which this rupture can be confounded. Fatty and other
benign tumours are very uncommon in this situation, while
malignant growths, springing from the root of the cord, are
distinguished by well-known characters. The fungoid growth
which occasionally arises from an unhealthy ulceration of the
umbilical cicatrix, is usually easy to distinguish from hernia,
because of the absence of its usual characteristics.
In some rare cases, shortly after birth, a distended or
varicose condition of the umbilical vein remaining unobliterated
up to the point of ligature of the cord, may in some degree
simulate this hernia, and may predispose to it by keeping open
the umbilical aperture. Nævoid tumours of this part are rare,

DIAGNOSIS.
245
and easily recognisable by their irreducibility, vascular, elastic
dilating properties, and the absence of an opening in the tendon
beneath them. When implicating the surface of the skin, the
colour will distinguish them sufficiently. When subcutaneous
and venous in character, a dusky or bluish colour given by the
contained blood is usually seen through the translucent skin of
the infant. In some cases I have observed such an appearance
in a hernia also, caused apparently by the dark colour of the
intestinal contents.
FIG. 68.
So rarely do other tumours which might simulate this
disease occur in this part, and so easy is its detection and
recognition when present, that no further remarks are neces-
sary in this place in addition to the general signs of rupture
detailed in the preceding pages.
In the child it seems to give
rise to but few symptoms. In an infant at present under my
care, it is coexistent with a congenital inguinal rupture, neither
of which seems of itself to distress the little patient, though

246
ON UMBILICAL HERNIA.
they add considerably to its sufferings when labouring under
intestinal irritation from other causes common to its age. In
the adult, however, the symptoms are often very distressing,
interfering much with the functions of the stomach and colon,
with which its contents are closely connected, thus inducing
an early accession of nausea, vomiting, and constipation, when
distension or obstruction occurs in the tumour.
any
At this time of life a fatty, fungoid, or recurrent fibrous
tumour connected with the umbilical cicatrix, are the only
diseases which may be confounded with this form of hernia.
The manner of growth, steadily progressive, instead of alter-
nating in size with the degree of general abdominal distension
or disturbance, as is usually the case in hernial tumours; the
absence of the usual effects of pressure in diminishing the size
of the tumour to an appreciable extent, as we find in all cases
of rupture not very extensively retained by adhesions; the
evidence obtained from percussion and manipulation, which
give a more or less resonant sound in all cases of enterocele,
and a certain mobility, sliding, or yielding to the fingers,
characterizing the contents of a hernial sac, whether omental
or otherwise, all which are incompatible with the firm and fixed
nature of the constituents of the above solid growths, especially
in this part of the body; and the general appearance of the
tumour itself, as well as that of the patient, together with the
abdominal symptoms referable to the stomach, such as sickness,
&c., or to the large intestines, such as constipation or other
irregular action, will usually suffice for a clear diagnosis.

TREATMENT.
247
XXIII.
TREATMENT.
AN umbilical protrusion in the infant can usually be cured by
the application of a proper compress for two or three months.
The strong tendency of the aperture to close by development,
needs only that the viscera should be kept out of the sac to
secure the gradual closing in of the edges of the opening. In
many cases, however, this desirable result does not ensue, either
from the application of a pad so convex or conical as to dilate
the opening, into which it invaginates the integuments to as
great an extent as the rupture itself; or from the great size of
the aperture; or from a feeble power of development; or disease,
sickness, and constant violent crying in the sufferer. If the
hernia be left alone, or the means adopted fail to produce its
cure, the longer its continuance, and the older the patient,
the less likelihood is there of such a desirable result occurring
by means of pressure only; since the propensity of the
aperture to close grows weaker as the subject grows older.
The incessant care and length of time required in the treatment
by bandaging, and the difficulties of cleanliness under the cir-
cumstances, render these means more apt to fail in the children
of the poor.
It is said by Bichat that, after four years of age,
the cure, either by pressure or operation, becomes difficult, and
after nine years, impossible.
The operation referred to by this eminent surgeon is one
performed by Dessault, as well as by himself, in numerous cases

248
ON UMBILICAL HERNIA.
of umbilical hernia in children, and was simply a revival of the
ancient practice described by Celsus. It consisted in pinching
up the integuments and sac, and carefully squeezing out
between the finger and thumb the contents of the latter; and
then tying round the base of the tumour upon the surface
many folds of ligature thread, tightening them from time to
time until the included parts dropped off, leaving an open sore,
which was afterwards treated by the application of lunar caustic
and dry charpie.
The primary and most important objection occurring to this
operation is based upon its insufficiency in securing the edges
of the tendinous aperture, which were left untouched below the
surface of the parts secured by the ligature. This embraced
only the sac and integuments, as in all the earlier operations
for the radical cure of inguinal rupture, described in the former
part of this work. Most of the cases, consequently, demanded
afterwards the application of a bandage for as long a period as
is usually necessary for the cure by compression only; and one
of the most important of the reasons for preference of the
operation urged by Dessault, was thus rendered abortive.
Such as were left without such treatment had, usually, a return
of the protrusion afterwards. Another objection, urged by
Cooper and other English and foreign writers, is based upon
the supposed dangers of peritonitis; either primary, as the
immediate result of the proceeding, or secondary, from an opening
remaining after the slough dropped off, and communicating
with the peritoneal cavity. This objection seems to have been
founded rather upon the theoretically probable contingencies
prevalent at that time upon the subject of operations upon the
peritoneum, than upon the result of cases; but it may, at the
present day, be held equally valid in the event of a prolonged
opening into the cavity after the operation. A third objection,

TREATMENT.
249
made on the score of the danger of including the bowel in the
ligature, could only be referred, like others of the same kind,
to the skill of the operator. A fourth, based on the con-
sequences likely to result to the liver from its contiguity and
continuity of surface through the umbilical vein and broad
ligament, might with equal propriety be urged against the
umbilical ligature applied at birth.
The testimony of the eminent Italian surgeon Scarpa is,
however, strongly against the efficiency of Dessault's operation,
as never producing a truly radical cure, as often producing
dangerous symptoms, and as leaving an ulcer difficult to heal.
The want of efficiency is the most fatal of these objections,
and evidently proceeds from a failure in reaching the real seat
of the disease-viz., the tendinous aperture. The dangers of
the proceeding evidently accrue from the liability of the pro-
cesses of sloughing and ulceration to precede, instead of
following, that of adhesion of the apposed serous surfaces.
Of a still more severe and dangerous character seems to be
the practice recently followed by some, of opening directly by
incision into the sac cavity, paring the edges of the tendinous
aperture, and then bringing them together by wire sutures.
Such an operation has a character of severity, and involves
apprehensions of danger from a direct exposure of the peritoneal
cavity so near the more vital sympathetic nervous centres and
abdominal organs, which the necessities of the case in adults,
and still less in children, do not seem to require.
In infantile cases proving intractable to the treatment by
pressure, fairly applied, which are few, but do occur; and in
favourable cases in the adult, all of which have been hitherto
pronounced altogether incurable, the adoption of the sub-
cutaneous method of applying a wire ligature upon the prin-
ciple laid down in these pages is likely to produce all the

250
ON UMBILICAL HERNIA.
beneficial results obtainable by any operative procedure, without
being exposed to the more real and reasonable objections fatal
to the operations just mentioned. By this means the ten-
dinous aperture can be reached without exposure of, and with
very little interference with, the peritoneum; and its margins
denuded and rendered adherent by the slow action of the wire
ligature. The small size, great obliquity, and valvular nature
of the punctures transmitting the wire, combined with the
traction and compression of the loop formed by it under the
skin, effectually prevent the admission of any injurious external
influences to the cavity of the peritoneum, as will be seen on a
perusal of the next section. The parts are thus placed, during
the progress of the succeeding changes of ulceration and ad-
hesion, under those favourable conditions which render subcu-
taneous operations generally much less liable to the risks which
follow upon open wounds into important cavities or structures.

OPERATION FOR RADICAL CURE.
251
XXIV.
OPERATION FOR THE RADICAL CURE OF UMBILICAL
HERNIA.
IN three obstinate cases of umbilical rupture in children I have
operated for a radical cure.
In the first case, I applied a small pair of rectangular pins
vertically, and in opposite directions, one on each side of the
opening, transfixing the edge of the tendinous aperture, and
causing them to emerge close to each other through the
integuments above and below the opening. When locked into
each other, and twisted, the edges of the aperture were drawn
close together in a line with the linea alba, protruding the
integuments and sac of the rupture in a vertical fold above
them. The pins were surrounded, and the skin protected, by
strips of lint and plaster in the usual way, and were retained
four days, producing no unpleasant symptoms by their presence.
At the end of that time they were withdrawn, and the edges
of the aperture were found firmly adherent. The child was
afterwards dressed for a short time with a circular bandage
and pad, and then discharged. While under observation, no
return of the rupture had occurred.
Considerable difficulty having been experienced during this
operation, in forcing the point of the pins through the very
tough structures surrounding the hernial opening, I was led
subsequently to substitute for them a tolerably long suture
needle of the kind commonly used in operations, but stout,
curved well near the point, and flat and broad at the eye;
carrying a wire of the smaller calibre, but still stout enough

252
ON UMBILICAL HERNIA.
not to cut through the tissues too rapidly. (Fig. 70, d.) To
invaginate the coverings of the hernial sac, and to protect the
bowel during the passage of the needle, a small spoon-shaped
director (a), with a flat curved handle (figured edgewise in the
woodcut), and a bowl-shaped scoop (b), large enough to fill up
the hernial opening, is used. In small cases, an ordinary
pocket-case scoop is sufficient for the purpose; or the smaller
end of the director (c) may be used. The wire should be
prepared in two pieces, eight inches long, bent into a small
even hook at each end. It should be of copper wire, silvered,
thick enough to hold without cutting its way, and flexible
enough to follow the needle easily.
FIG. 70.
a
d
The patient being laid on the back, with the knees drawn
up and the shoulders raised, the protrusion is carefully and
completely returned. The convex surface of the bowl of the
director is then pressed into the hernial opening, so as to carry
the skin over the sac quite behind the edge of the tendinous
aperture, on one side of the median line. The rounded end of
the bowl must be pressed steadily and firmly against the deep
surface of the tendon, pushing the skin as far as possible
behind it. The needle, carrying one of the wires, is then
placed in the hollow of the director, and its point pushed
through the tendon from its deep surface, considerably above
the centre of the opening. When the point is seen to raise

OPERATION FOR RADICAL CURE.
253
the skin, the latter is drawn well upwards by the finger of an
assistant, so that the skin may be pierced as far as possible
below the aperture in the tendon. (Fig. 71.)
(Fig. 71.) The wire being
drawn through and disengaged from the needle, the second
FIG. 71.
wire is hooked on, and passed in the same way through the
lower part of the tendinous border on the same side; the skin
being this time drawn downwards by the assistant, so as to
enable the operator to pass the point of the needle through the
same aperture as before made, or as close to it as possible.
FIG. 72.
(Fig. 72.) The second wire is then drawn through, and the
needle again disengaged.
The operator next directs his attention to the edge of the
tendinous aperture on the opposite side of the median line; and,
by repeating the same processes, he draws the opposite ends of

254
ON UMBILICAL HERNIA.
the two wires consecutively through this border, at equal
distances from each other, and through the same aperture in
the skin.
In performing this manoeuvre the director must be planted
firmly within the hernial opening, between and behind the two
wires which emerge at the centre of the sac coverings, (in the
manner shown in Fig. 73,) so as to push the skin well over to
the other side of the median line behind the edge of the
tendon. The needle is then to be passed into the same
apertures in the middle of the sac coverings at which the wires
respectively emerge. (See also Fig. 74.) This can be more
FIG. 73.
conveniently done before the bent ends of the wires are hooked
on to the eye of the needle at each passage of the instrument.
It is easy to accomplish it in this way unless the opening be
very large, in which case it will be necessary to slide the
point of the needle a little way close under the skin before
piercing the tendinous structures, following the instrument
closely behind by steady pressure of the end of the director.
The two wires are thus drawn across the hernial opening and
through its tendinous borders, at equal distances apart, passing
out at each side through the same puncture in the skin, and
depressing under their pressure the sac coverings which lie in
the area of the opening, at which point the wires, when drawn

OPERATION FOR RADICAL CURE.
255
tight, disappear into the median punctures made for the tem-
porary purpose of their application. (See Fig. 75.) If difficulty
be experienced in bringing the needle through the same aper-
ture in the skin at the sides each time, it may be overcome
by making another temporary opening, drawing the wire
through it, and then carrying it under the skin by passing
the needle from one aperture to the other. If the hernial
opening be very large, a third wire may be applied in the same
manner across the centre of the opening between the other two.
FIG. 74.
The ends of the wire on each side are then to be twisted up
together into the puncture, until the hernial opening is felt to
be closely shut up, care being taken at this stage that no
protrusion of viscera occurs. This accident is, however,
effectually guarded against, first by the pressure of the director
in the area of the hernial ring, and then by the two wires
passing transversely across the aperture under the skin. When
the wires are firmly twisted up, the skin covering the sac is
raised in a puckered fold in the centre, which is placed
over the line formed by the approximated edges of the ten-

256
ON UMBILICAL HERNIA.
dinous aperture hereafter to become united by adhesion under
the pressure of the wire. (Fig. 75.) It will be seen, by re-
ferring to the figure of the parts in section (Fig. 76, a) that a
portion of the tendon itself, close to the edge, is raised or
everted under the pressure of the wire loop, so as to present a
FIG. 75.
a
b
broader surface of adhesion than the mere border would afford.
A very small portion only of the circumference of the tendinous
aperture is left above and below the wires, if properly placed,
as seen in Figure 75 at a and b.
The twisted ends of the wire being then cut off at a suitable
distance, are hooked together over a roll of lint (Fig. 76, b)
FIG. 76.
placed between them, so as to make pressure upon the puckered
fold of skin and sac; the whole being retained by a strap or
two of adhesive plaster and a circular bandage.
The patient should be laid on the back with the knees
drawn up and the shoulders raised, and kept as free from
crying and other exertion as possible.

OPERATION FOR RADICAL CURE.
257
In favourable cases of umbilical hernia in the adult this
operation may be tried with but little danger, considerable pro-
bability of success, and the certainty of not rendering the state
of things worse by interference. In many of these cases the
danger of symptoms occurring is lessened by the possibility of
performing the operation with very little interference with the
peritoneal membrane, as by a dexterous application of the
needle the edge of the tendon may be secured obliquely, without
puncturing the peritoneum which covers it behind, because of
the thickness of the former at this time of life.
The presence of much permanent distension of the abdominal
cavity, by fat or other causes, I should consider altogether to
preclude any attempt at a radical cure by operation, since a
continuation or increase of the distension would probably bring
about a return of the protrusion.
In a lax condition of the abdominal wall, and other favour-
able conditions, as of health, &c., being present, the adhesion
of a portion of omentum to the parietes of the sac might not
constitute a serious objection to the operation, since the
presence of an omental plug would contribute to the closure of
the aperture, and strangulation of this structure by the ligature
might be avoided in its application. In the disposition of the
sutures across the area of the hernial opening it will be ob-
served that no implication of the omentum will be necessary
under such circumstances, and no important strangulation of
the protruded part will be possible, since the tension of the
wires across it under the skin tends to force and keep back
any protrusion, and the closer and more numerous the sutures,
the less is the chance of such strangulation occurring.
this means, the opening in the tendon may be diminished very
considerably, if not altogether closed, and a truss may thus be
rendered much more effective.
By
S

258
ON UMBILICAL HERNIA.
XXV.
TREATMENT OF UMBILICAL HERNIA BY PRESSURE.
In the treatment of this variety of rupture by the pressure of
a truss, the objections to a convex or conical truss pad exist to
a still greater degree, especially in infants, where the opening
has a normal tendency to close up under development.
The method commonly followed in the latter class of cases
is to take a segment of a globe, or a graduated compress, com-
posed of a substance more or less resisting, to press it into the
aperture, and to retain it by plaster or a bandage round the
body pretty tightly applied.
Such an apparatus must necessarily invaginate the skin and
hernial coverings through the abnormal opening; and if it
retain its position at all, dilate the aperture. If not very pro-
minent, the convexity is rarely applied and kept upon
the opening
sufficiently accurately to accomplish its intention, and it thus
becomes simply superfluous, if not obstructive. That a closure
of the aperture often follows such an application only proves
that a circular support and a certain degree of pressure only
is necessary, in most cases, to prevent protrusion until the
progress of development has accomplished a complete occlusion.
The application of the principles laid down in the foregoing
pages to this subject has led me to employ an umbilical
compress, in which the pressure is brought to bear upon the
tendinous margins of the hernial opening in such a way as will
tend to close them towards the centre or median line; thus
aiding, instead of obstructing, the efforts of nature to contract
the opening.

TREATMENT BY PRESSURE.
259
The best material for the compress is vulcanized india-
rubber. A solid cylinder of this substance, about half an inch
in diameter, is formed into an oval ring by the junction of its
ends cut off square, leaving an aperture corresponding in size
to the diameter of the hernial opening, and of a shape tending
to an oval. Across one surface of the opening is then
stretched a thin piece of the same substance, which is secured
to the outer edges of the ring by an adhesive solution of the
same material in chloroform.
Thus is formed an oval cup-shaped pad (a), with a valvular
bottom fitting over the margins of the hernial opening.
FIG. 77.
a
b
(Fig. 77.) A circular strap of the same material (b), large
enough to enclose the body of the patient on a level with the
navel, and strong enough to apply sufficient elastic pressure to
retain the pad, is then fixed to the valvular bottom of the
cup, on the hollow side, by attaching it to the surface of the
valve by the adhesive solution, leaving the strap free and un-
attached as it passes over the rounded edges of the cup.
Around the outer margin of the pad may be fixed a cushion of
some soft material (c), with bevelled or sloping surfaces, to keep
the pad more steady on the surface of the abdomen under the
pressure of the strap.
When applied, the tip of the finger is passed into the cup-
s 2

260
ON UMBILICAL HERNIA.
shaped depression of the pad sufficiently far to cause the valve
to project at the surface. This projection is then fixed by the
pressure of the finger into the hernial aperture after the
pro-
trusion is returned, and the elastic belt strap passed over the
legs round the body of the patient. The surface of the skin
over and around the navel should be first brushed lightly over
with collodion, mixed with a little castor-oil, to protect it from
chafing, and to make the surfaces of the valve and ring
adhere more closely. When the pad is fixed with the long
diameter of the oval placed vertically along the median line,
the point of the finger is withdrawn, and the elasticity of the
belt strap coming into play, the valve is retracted into the
hollow cavity of the pad, drawing with it the skin covering the
hernial sac which adheres to it through the collodion medium,
and is thus drawn out of the tendinous opening through which
the rupture protrudes.
The pressure of the elastic belt is thus brought to bear
chiefly upon the thick margins of the cup, pressing them
laterally upon the borders of the hernial aperture, and tending
to close them towards the median line by pressure backwards
and towards the centre of the opening. This lateral pressure
brings the edges of the opening together from the side, pro-
ducing an oval form corresponding to the shape of the opening
in the pad, and excluding the bowel and viscera from the sac
cavity, while the skin and hernial sac coverings are drawn out
of the area of the aperture by the suction of the valve.
In
Fig. 78, (representing the apparatus and the parietes of the
abdomen in horizontal section,) the dotted lines, a c, bc, repre-
sent the direction of the pressure traversing the edges of the
tendinous opening (0). By this means all invagination of the
skin into the umbilical aperture is avoided, and the pressure
made entirely in the most effective manner-viz., upon the
tendinous margins of the ring towards the median line. Pro-

TREATMENT BY PRESSURE.
261
trusion of the viscera is effectually prevented by the closing in
of the sides of the oval ring acting through the attachments
of the skin on the margins of the tendinous opening. The
slight concavity which is produced by the suction action of the
valve is entirely filled by the skin and sac covering, and does
not admit of the protrusion of bowel.
For hospital purposes, a good substitute for the india-rubber
ring is gutta percha. The valve may, under these circum-
stances, be made of a broad strap of common adhesive plaster
placed across the skin surface, and bent over the edges of the
ring into the bottom of the cup surface thus formed, to which
it may be made to adhere, and afterwards be carried by the
FIG. 78.
long ends to encircle the body, so as to fulfil the part of the
circular belt, the whole being secured by a bandage. A little
collodion brushed on the surface of the skin, and the reverse
of the adhesive plaster which is applied to it, will preserve the
former from friction, and cause the latter to adhere. Pieces
of wash-leather, of diminishing sizes, laid over each other, with
a hole cut in the centre to receive the gutta percha ring, will
serve the purpose of a cushion around the pad, and keep it
steadier under the motions of the body. If considered ad-
visable, a piece of tape or ribbon may be used instead of the

262
ON UMBILICAL HERNIA.
adhesive plaster, which, in children with a delicate skin, is apt
to irritate, and always causes the adhesion of dirt, though
it possesses the advantage of more close adaptation to the
surface.
In the cases upon which these apparatus have been tried the
results have been very satisfactory, producing a more rapid
closure of the umbilical aperture than I have ever obtained by
the old method recommended by Sir Astley Cooper and others;
in which the compress is both difficult to retain "in situ," and
when fairly held in position, resists instead of promoting the
remedial processes of nature.
The same apparatus may be used with advantage in the
hernia of adults. If a portion of omentum be irreducible, the
opening of the pad may be made of sufficient size to include it.
The pressure is thus brought to bear upon the margins of the
opening around the protruded and irreducible portion; and
may, by being persevered with, set up adhesive action around
it, so as to prevent further increase of the tumour.

263
APPENDIX OF CASES.
RADICAL CURE OF INGUINAL HERNIA.
Case 1.-John Craig, æt. 25, a printer, applied at the Lincoln's Inn
Dispensary with a right, direct, inguinal hernia, of eighteen months'
duration. Has had during that period frequent obstructions of the
bowels, and was once on the point of being operated on for strangula-
tion, but the rupture was finally reduced by the taxis. Has had
seven trusses, none of which retained the rupture for any length of
time; the last giving rise to abscesses in the groin. The hernia filled
the scrotum, sometimes attaining the size of two fists. On reduction,
the deep opening was found large enough to admit the tips of three
fingers, with lax, loose margins. On the slightest cough or exertion,
the bowel dropped into the scrotum. The patient being willing to
submit to an operation, it was performed in April, 1858. The method
in which the operation was done was that first described, by ligature
thread and compress. The instruments used were, however, somewhat
different. Instead of the finger, a curved tube mounted on a handle
was used to invaginate the fascia, a needle of like curve being passed
through it carrying the thread. The use of this tube was afterwards
discarded, greater confidence being felt in the tactile perception of the
finger. The compress used consisted of a quadrangular piece of box-
wood, with a hole in the centre to transmit the ligature to the cross
piece of wire on which it was fastened. On the third day after the
operation, the incision in the scrotum was healed. On the 5th, the
compress and ligatures were removed; the upper puncture suppurating
freely. In a fortnight this also was completely healed. No pain in the
belly or testis was complained of, and the patient was out of bed in
rather less than three weeks; when he was exhibited in the theatre of
King's College Hospital. The inguinal canal was then felt to be oblite-
rated by a band of adhesion uniting the pillars of the superficial ring,

264
APPENDIX OF CASES.
with much consolidation along the canal and at the deep opening. No
impulse whatever was felt on coughing; the groin being more firm and
resisting than that on the opposite side. This patient wore a truss for
some months after the operation, and as the newly-formed tissues con-
tracted, a swelling appeared in the scrotum which had all the appearance
of a varicocele, with some effusion in the fundus of the sac. The truss
was thereupon discontinued for a while, and the enlargement then
slowly disappeared. During the first few months after the operation,
the patient underwent a severe test of the cure in the shape of a severe
bronchitis, which has occasionally affected him ever since. After seven
months the use of the truss, which had been resumed, was entirely dis-
carded. His occupation has necessitated the frequent lifting and
removal of heavy "forms" of type, which often weigh as much as a
hundredweight. This patient was among those exhibited to the Fellows
of the Medico-Chirurgical Society, on the occasion referred to in the
text, and since that time he has been frequently exhibited in the theatre
of King's College Hospital. On the last occasion (a few months ago),
the groin operated on could not have been distinguished from the other,
except by the presence of the small scars. No impulse whatever, or
any bulging was observable.
Case 2.-William Mayhew, æt. 54, a sailor, was on board the Dread-
nought hospital ship, under my friend Mr. Tudor. He had a direct
scrotal hernia on the left side, of six years' standing. It had been
strangulated three or four times, and narrowly escaped operation. He
has worn out as many as thirty-three trusses, which have, latterly,
failed in retaining the bowel. Wurtzer's operation for the radical cure
had been, a few weeks before, performed on the rupture, but on his
again assuming the erect posture, the bowel has redescended to as great
an extent as before. With the kind permission of Messrs. Busk and
Tudor, I operated on this patient (though from its size and character
it was far from being a hopeful case) April 6th, 1859. The forefinger
only was used to invaginate the fascia and protect the needle. Two
ligature threads were employed, passing through separate openings in
the skin. The deep opening and superficial ring being very large and
lax; the canal very short; and Wurtzer's operation having previously
interfered with the parts entirely unsuccessfully, I was not very san-
guine as to the result of the case. On the 9th, pus having begun to
show at the openings, and appearing to be retained somewhat by the
lower ligature, this was withdrawn. There was no sickness or tym-
panitis, the pain and tenderness being confined to the groin. On the
11th, the remaining ligature and compress were withdrawn; discharge

CASES III. AND IV.
265
free; bowels open naturally. On the 15th, he was not so well, having
caught cold during the severe weather which then prevailed; tongue
white; appetite bad; feels low; wounds looking well, and discharging
freely good pus. Had been ordered brandy. On the 20th, much
better; feels all right again; much less discharge; wounds closing up.
On the 13th of May, the patient showed himself at my house, with the
groin entirely healed, and much hard consolidation apparent in the
canal. A hard, cord-like mass of transplanted fascia passed into and
obscured the superficial ring, and was lost in the general consolidation
of the passages. When the patient coughs, there is less impulse than
on the opposite side, which is rather weak and bulgy. This patient has
shown himself at various times at King's College Hospital. When I
saw him, four months after the operation, the groin was still hard and
firm, and no impulse was apparent. He was still wearing a light truss.
He then went to sea, and I heard several times from his son (also a
hernial patient of mine) that he continued well, and able to do duty.
Last summer, however, he called upon me with the rupture returned to
some extent, though not so large as before the operation. He states
that it reappeared gradually some months before, after performing very
heavy labour in whipping coals with an inefficient truss, on board the
collier ship on which he was doing able seaman's duty.
The next two cases were operated on by me at Fort Pitt, Chatham,
May 11th, 1859:-
Case 3.-A sergeant of foot, æt. 45, tall, and very muscular, with a
right oblique and scrotal rupture, of, seventeen years' standing, with a
long and narrow inguinal passage. During the operation, notwith-
standing a fair amount of chloroform administered, the recti muscles
acted so powerfully, that some difficulty was experienced in passing
satisfactorily the needle through the conjoined tendon. Two ligatures
were applied, one close up to the internal ring, and the other close above
the pubic crest; all the ends being brought through the same cutaneous
aperture, in the skin of the groin. The large, square, boxwood pad was
employed. On the sixth day, the ligatures and compress were removed,
sufficient action being then set up, with very little constitutional dis-
turbance. The wounds healed satisfactorily. When last seen, a slight
fulness in the groin was the only evidence of the previous rupture.
Case 4.-The son of a sergeant, æt. 8 years, with a left, oblique, in-
guinal rupture, probably congenital, but only first observed when the
child began to walk. One thread suture only was applied, the sides of
the canal coming together very readily. Ligature and compress re-
moved on the sixth day. Two days afterwards, a nettle-rash appeared

266
APPENDIX OF CASES.
on the skin, succeeded by a smart diarrhoea, which continued two or
three days. On the twentieth day after the operation, the punctures
were completely healed, a complete cure of the rupture being effected,
with no impulse or fulness in the groin. This condition continued un-
impaired to the end of June, when the lad embarked with his parents
for India.
The particulars of the two last cases were afforded me by Surgeon-
major Matthew, under whose care the patients were placed. This gentle-
man has himself operated many times, after my method, with success.
In one case, however, he was unfortunate enough to have erysipelas in the
ward at the time the case was there, and the patient died from inflamma-
tion spreading along the sheath of the rectus muscle, which seems to have
been more interfered with in the operation than I have been in the habit
of doing.
Case 5.-Ignatz Gutler, æt. 31, a compositor, was operated on in the
theatre of King's College Hospital, May 14th, 1859, for a large oblique,
scrotal hernia, on the left side, of two years' standing. States that, of
late, it has been unusually painful. The operation was done in the
way described in the text, with thread and compress. The day after,
he complained of much pain in the testis, along the cord, and in the
groin, which was relieved by opium. There was no sickness, tympa-
nitis, nor abdominal disturbance or tenderness. On the 17th, a swelling
was apparent in the epididymis and cord, which was evidently mainly
owing to enlargement of the spermatic veins, with some oedema. There
was thirst, irritative fever, white tongue, and increased pain. Under
these circumstances, I thought it judicious to remove the pressure,
though earlier than usual. The lower or scrotal incision had then
nearly healed, but still discharged a little; the discharge of pus from
the upper puncture being copious. Next day, the patient was much
relieved, and consolidation to a considerable extent was apparent in
the canal. 19th.-Bowels opened by castor-oil; less swelling; no im-
pulse on coughing. From this time he daily improved, the swelling
gradually diminishing. On the 28th, he was exhibited in the theatre
of the hospital, with the lower wound entirely, and the upper nearly
closed; the varicocele having nearly disappeared. The superficial ring
could not be felt by the finger, and there was no cough impulse what-
ever. On the 8th of June, he left the hospital, wearing a light truss.
About a month after this, he sent for me, and I found that the swollen
condition about the cord and sac had returned, larger than before.
stated that the swelling had come on without pain or exertion, and
while still wearing the truss; the bowels were confined. A brisk
He

CASE VI.
267
aperient was prescribed, and he was directed to discontinue the truss, as
tending to increase the swelling. A week after this, the patient was
again exhibited at King's College Hospital. Though made to cough
freely, no impulse or impression could be distinguished at the superficial
ring, by careful examination with the finger. A hard, round, elastic
tumour could be felt amid the enlarged veins, which, from its weight and
obscure fluctuation, seemed to be an effusion of serum into the fundus
of the sac, cut off from the peritoneum by adhesions in the canal. The
difference between the feel of the tumour and that of a rupture was
evident. After that, I saw the patient twice, and on repeated examina-
tion fancied that there was possibly a small channel of communication
with the peritoneum still existing, as the fluid could be squeezed slowly
out of the distended sac fundus, with a sensation exactly similar to that.
given by an india-rubber bottle. At that time, there was clearly no
return of the rupture, though not having lately seen the patient, I am
disposed to set it down as a doubtful case, in which the distension of
the effused fluid might open up the canal afresh, so as to admit of a pro-
trusion of the viscera.
Case 6.-Thomas Dyer, æt. 58, a labourer, operated on in King's
College Hospital, June 11th, 1859, for a right, oblique, scrotal rupture,
about the size of an egg. Has had the rupture five years; it has latterly
been getting larger, and more difficult to retain. It has been twice
strangulated, the last time a month before, at which time the bowels
were not relieved for the space of a week, notwithstanding large doses
of purgatives. In operating on this case, I remarked that, though the
superficial ring was barely large enough to admit the finger, the canal
itself and the deep ring were much larger than the external appearance
indicated, so that it would have been impossible to distend the interior of
the canal by the use of Wurtzer's plug. The day after the operation, a
severe and troublesome bronchitis, to which he had been subject, came
on, the cough being so violent that I had fears of the ligatures giving
way under it; this, however, did not happen. The compress and
threads were removed three days after the operation. Much hard
swelling was observable in the canal; the discharge from the upper
puncture free; bowels opened by castor-oil six days after. In this
case I removed the ligatures so soon, rather experimentally, to ascertain
the amount of action absolutely required to produce the desired results.
Notwithstanding the bronchitis, the patient was out of bed on the
twelfth day after the operation; and on the seventeenth the wounds
were healed. He wore a weak truss for a short time, and then growing
impatient, he discontinued it, and went to harvesting, doing a great

268
APPENDIX OF CASES.
deal of heavy lifting entirely without truss support. On showing him-
self to me in January, 1860, I was gratified to find that the adhesions
were still resistant. The patient expressed himself very confident of a
cure after so severe and long-continued a test without any return. In
February of the same year, he was shown at the meeting of the Medico-
Chirurgical Society. There was then a slightly suspicious impulse
when the patient coughed hard. This impulse became more marked
each time I saw him, at different intervals, not being able to persuade
him to resume his truss. The last time I saw him, in the summer of
1862, there were decided evidences of the rupture having returned to
some extent, though it was much smaller than when operated on. The
case may, therefore, be looked upon as a failure, owing to three causes,
viz., the short time during which the ligatures were kept in, the
occurrence of the bronchitis, and the want of subsequent truss protec-
tion during heavy labour so short a time after operation.
Case 7.-William Mayhew, æt. 20 (the son of Mayhew, of Case 2),
operated on in King's College Hospital, June 17th, 1859, for a
left oblique, scrotal rupture, congenital, and for which no truss had
ever been worn. The tumour attains sometimes the size of a large
hen's egg, drops easily into the scrotum, and is reduced without diffi-
culty. On the night after the operation, had a morphia draught, but
did not sleep. Next morning had some sickness, which was relieved by
an effervescing draught. On the 20th, complained of much pain in
the groin; no tympanitis, or tenderness, on pressure over the belly;
sickness better. To have pil. saponis co., gr. v. every three hours, if
the pain continues. 21st.-Pain much less; sutures and compress re-
moved, sufficient consolidation being apparent in the canal. Free
suppuration in the track of the ligatures; abdomen quite soft and com-
pressible; tenderness limited to the groin. A small slough has
appeared at the upper margin of the scrotal puncture, apparently pro-
duced by the pressure of the end of the compress. Ordered wine ziv.
daily. 24th.-Free suppuration from both openings, slough separating.
30th. Both wounds fast closing in; slough gone; scrotum well tucked
up to the superficial ring; consolidation very apparent in the upper
part of the canal; no impulse felt on coughing. July 13th.-Patient
discharged cured; the upper puncture being entirely healed, the lower
nearly so. Has been kept longer in the hospital on account of a
diarrhoea, with which he was attacked, and which also affected, to a
greater extent, two other cases operated on about this time, being pre-
valent in the hospital in the autumn of that year. (Cases 10 and 11.) This
patient has never worn a truss, either before or since the operation.

CASE VIII.
269
He was exhibited at the Medico-Chirurgical Society, Feb. 28th, 1860;
having been employed since the operation in the laborious work of
piling shells in Woolwich Dockyard. At that time the groin was re-
markably firm and resisting, no impulse whatever being felt in the
canal. A slight bulging over the deep ring was the only evidence re-
maining of the original deficiency in the groin. I have since repeatedly
seen, and have heard of this case up to a recent period, through his
father and other hernia patients, whom he has sent for a radical cure.
He still continued sound and without a return of the tumour. I look
upon
it as a fair test of what can be done without the assistance of
truss support, after a radical cure has been attempted by operation.
Case 8.-Jacob Lorge, æt. 27, a German baker, operated on in
King's College Hospital for a right, oblique, scrotal hernia, of fifteen
years' duration. In this case, the scrotum was remarkably pendulous,
reaching eight inches down the thigh, from the combined effects of
hernia and varicocele. The sac was remarkably elongated, and rested
on the testis, which hung much lower down on the side affected than
on the left side. The veins of the cord were very large and tortuous,
and there was much loose tissue and fascia about the scrotum. Opera-
tion performed June 29th, 1859. The scrotal opening was made lower
down than usual, to get the finger well behind the sac, carrying it well
up into the deep ring. The patient was rather more restless and
feverish than usual, for the first few days after the operation. On the
evening of July 2nd, the scrotum had become so much swollen, tense,
red, and painful, that the compress and ligatures were removed. From
both punctures a reddish serum oozed copiously. Along the canal, and
at the superficial ring, a large hard mass could be felt, which appeared
at first like a return of the protrusion, a supposition rendered more pro-
bable from the patient having caught a smart cold, and coughed very
vigorously for the last two days. There was, however, no distress,
sickness, or vomiting, and the tenderness on pressure was confined to
the groin. There was no tympanitis whatever in the belly. The mass
felt solid, and could not be compressed or returned into the canal.
Fomentations, poultices, and pil. saponis co., gr. v. every night. On
the 4th, the bowels were well opened by castor-oil, and suppuration
freely established in the punctures. The hard swelling was more ap-
parent and pronounced, and was evidently solid effusion. On the 8th, the
scrotal enlargement was much diminished; a very free suppuration,
mixed with numerous white sloughs, issued from both punctures,
especially the lower, proceeding evidently from the interior of the sac,
by the walls of which they were apparently formed. On the 12th,

270
APPENDIX OF CASES.
sloughs in considerable quantity continued to escape, and the scrotum
was reduced to one-fourth of its former size; a hard mass blocked up
the inguinal canal entirely. On the 16th, the scrotum was reduced to
less than its size before the operation. Numerous healthy granulations
were apparent at both wounds. On the 17th, the patient got out of
bed; and on the 23rd, he was discharged, with the wounds reduced to
a very small size.
small size. He was afterwards exhibited in the theatre of the
hospital, and the extraordinary effect of the operation upon the length
of the scrotum and the varicocele excited universal remark. The
scrotum on the side operated on was reduced in length one half, the
right testicle being drawn up much higher than the left. The vari-
cocele had entirely disappeared. A hard, solid mass blocked up the
entire inguinal canal, and no impulse whatever was felt on coughing.
When I last saw this patient, he had worn no truss whatever since the
operation, and expressed his intention of visiting his native country,
and showing himself to several eminent German surgeons, who had
pronounced him incurable. He promised to let me know faithfully if
the rupture returned; and as he has not done so, I conclude that the
case remains still, as it bid very fair to be, an excellent cure.
Case 9.-John Batson, æt. 17, operated on, June 29th, 1859, for a
left oblique rupture of three months' duration, descending into the
upper part of the scrotum to the size of a small egg. This case went
on with remarkably little distress, the patient hardly losing one night's
sleep, with no opiate after the first night. The compress was removed
on the fifth, and the ligatures on the ninth day after the operation. On
the eighteenth day, the discharge (which had been pretty copious) had
nearly ceased. The scrotum being well tucked up, and adherent to the
superficial ring, the patient was allowed to move about the ward. His
general health had been excellent, his appetite good, and his bowels
regular throughout. After the sixth day, he had meat diet and wine.
On the 19th of July he was ready to be discharged, but was kept to
the 23rd, to be shown in the theatre of the hospital. The wounds were
then almost healed, the groin hard, firm, and resistant, and no impulse
was felt at the superficial ring, which was so blocked up by adhesions
as scarcely to be distinguished. He wore no truss after the operation.
On the 15th Oct., 1859, he was exhibited at the hospital, having gone
through his work, as an engineer in Woolwich Dockyard, without truss.
He was among the patients shown at the Medico-Chirurgical Society,
in Feb., 1860, having worn no truss whatever since the operation. The
groin was then very firm, the superficial ring closed up by adhesions,
and no hernial impulse could be felt to distinguish one side from the

CASE X.
271
other. A few months ago I again saw this patient. After some very
heavy work with the hammer, and lifting hard, he felt a slight pain in
the part, and applied to me for examination, having worn no truss up
to that time. No appearance of rupture was present, but, on coughing
hard, a weakness was very evident over the deep ring, and a looseness
of motion in the parts, which led me to recommend the adoption of a
truss during the hours of labour. The patient himself felt no incon-
venience beyond that above mentioned.
Case 10.-John Laramy, æt. 17, a pale, sickly-looking lad, was
operated on in King's College Hospital for an oblique scrotal rupture
on the right side, of sixteen months' duration. The case was remark-
able as presenting the largest internal opening of any I had operated on,
admitting with ease the tips of four fingers, with a very lax condition of
the surrounding tissues. Had never worn a truss. Operation done
July 13th, 1859. From the width of the openings, the case was like
one of direct rupture, and the strain upon the ligatures was great.
Being apprehensive of their retaining power, I kept on the spica
bandage and linen compress longer than usual. This, I believe, had an
injurious effect in retaining the discharges. On the 16th, the compress
was removed, the threads being left in two days longer, to lead off the
discharges, which had begun to appear copiously at both punctures.
He then complained of colicky pains in the belly, for which pil. sapon.
co., gr. v. was ordered thrice a day, with hot fomentations and a
poultice to the wound. 17th.-Complains still of pain, flatulence, and
distension of the abdomen, for which he was ordered a draught of
tinct. opii, tinct. rhei. co., sp. æth. chloric. and aq. menthæ, thrice
daily. 18th.-A copious discharge of thin, gruelly pus, chiefly from
the upper puncture; pain and flatulence easier, but still present;
tongue white and furred. Strong beef tea ad lib.; milk diet.
19th.-Discharge more copious; abdomen more distended, and harder;
tympanitic, but not tender on pressure, except over the groin; no
sickness; pulse 120. To have two drachms of castor-oil, and a large
poultice over the groins and stomach. 20th.-Bowels opened four times
with the oil; belly very tympanitic; no sickness, nausea, or vomiting;
tongue covered with thick white fur; pulse 120; discharge still very
copious, thin, and gruelly. To omit the mixture; to take pil. sapon.
co., gr. v. every four hours, and to have 4 oz. of wine daily. Tur-
pentine stupes to upper part of belly; continue poultice to the groins.
21st.-Bowels open four times in the night; symptoms continue un-
changed. 22nd. The distension of the belly continues, but no
vomiting or sickness is present, nor is the tenderness on pressure

272
APPENDIX OF CASES.
marked; a little is felt along the iliac and lumbar regions of the side
operated on; tongue very foul; pulse 100. A large enema of the
confection of rue, with gruel, was now administered by means of a
long rectum tube, with the effect of bringing away a large quantity of
flatus. Repeated the next two days with the same effects, giving much
relief to the patient, and diminishing the distension to a remarkable
degree. Pulse 98; discharge thicker and more creamy, still very
copious, but less in quantity; the punctures remain widely open.
During the four following days the bowels were much relaxed, but his
appetite recovered, and his looks were more cheerful. Sleeps well
without the pills, which are now discontinued. 29th. The diarrhoea
continuing, he was ordered decoct. hæmatoxyli 3j, tinct. krameriæ 3ss,
after each loose evacuation. 30th.-Diarrhoea checked; tongue cleaner;
pulse 98, soft and compressible; discharge again more copious. Pressure
forwards along the iliac crest induces a free evacuation of matter from
both the upper and lower punctures. The pus seems to have burrowed
between the muscles in this direction. Aug. 1st.-A drainage tube
introduced into each opening, and passed upwards towards the iliac
crest. This giving rise to pain and uneasiness, was next day removed;
the escape of matter is favoured by turning the patient on to his left
side. A large sponge kept to the wound to absorb the discharge.
His appetite is now very good: to have a slice of meat, potatoes, and
half a pint of stout. Nitric acid, chloric ether, and cinchona mixture,
thrice daily. From this time the discharge gradually lessened, and the
patient slowly gained strength. Much consolidation was apparent in
the canal. On Sept. 14th, he was able to walk about, the lower opening
being entirely healed, the upper one still discharging a little healthy
pus. No impulse whatever was felt on coughing; the groin was hard,
firm, and resistant, the hardness reaching upwards and backwards along
the iliac crest and lumbar region; wears no truss. Sent to Margate
for a change of air, after having been in hospital just two months.
Nov. 26th.-The patient was shown in the theatre of the hospital, having
worn no truss since the operation, four months ago. Has quite re-
gained his health and strength; rupture quite cured; no impulse
whatever. The superficial ring cannot be distinguished. Feb. 28th,
1860. Shown to the Fellows of the Medico-Chirurgical Society, having
worn no truss until within a day or two of this date, when he was
recommended to apply one on account of a slight fulness which had
become apparent in the groin. There was no impulse whatever on
coughing; the bulging limited to the centre of Poupart's ligament,
where also the abdominal cough impulse was limited at the upper

CASE XI.
273
cicatrix. Feels the groin strong and firm. When last seen, the patient
continued in the same satisfactory state, and was about to tramp for
work as a shoemaker.
Case 11.-John Albert, æt. 42, a healthy, muscular man, operated on
in King's College Hospital, July 23rd, 1859, for an oblique, scrotal
rupture, on the left side, brought on by lifting nine months before.
Had worn a truss, which did not prevent the bowel from slipping into
the scrotum, which it distended to the size of an egg. The compress
and ligatures were removed three days after the operation, when the
lower opening was found nearly healed, the upper one discharging
moderately. The same night he had sickness and diarrhoea, then
prevalent in the hospital. Next day the abdomen was flatulent and
distended, but not painful on pressure; respiration abdominal; tongue
white and foul; pulse 100. Had been sick, and vomited, and had the
bowels purged three times in the night. Discharge free and thin. Two
days after, the flatulence still continuing, but without further purging,
an enema of rue and gruel was administered, giving great relief, and
causing much discharge of flatus. The diarrhoea afterwards returned,
and continued for three or four days, notwithstanding the administra-
tion of logwood decoction and tinct. krameriæ; these medicines, how-
ever, had at length the effect of checking the diarrhoea, when the
tympanitic distension gradually disappeared. During this time the
skin and subcutaneous structures around the groin puncture had
assumed a brawny hardness and a dull reddish hue, with a thin,
purulent discharge. As he recovered from the diarrhoea this gradually
disappeared under the use of poultices, leaving a small, collection of
matter above the scrotal puncture, which was evacuated by opening
the latter up with a probe. On Aug. 10, he was discharged, cured,
having been about the ward some days with the punctures almost
healed; there was no impulse whatever. The patient left the hospital
wearing no truss. He was enjoined, and promised, to apply again, or
write, if the rupture returned. Not having done so, it may be con-
cluded that he has no trouble with it.
Three of the cases just given were in the hospital at one time during
an autumnal season, which was very sickly. They were affected with
very similar symptoms of flatulent distension and diarrhoea, which was
prevalent in the house, and so may fairly be attributed to this accidental
cause. Partly, if not chiefly, to the lowering effect of this epidemic
diarrhoea, may
be attributed the copious suppuration and retarded re-
covery of Case 10. In this case a burrowing of matter gave rise to
peritonitis, affecting chiefly the parietal layer, and secondarily, perhaps,
T

274
APPENDIX OF CASES.
the lower part of the small intestines; and therefore not giving rise to
the stomachic distress usually observed in this disease. The unhealthy
constitution of the patient, and the great strains upon the ligatures, from
the large size of the hernial openings, seemed to contribute to this
untoward result, leading to a prolongation of the period of recovery
nearly three times the usual extent.
Case 12.-George Jolly, æt. 15, a sailor boy from the Marine
Society's ship, operated on at King's College Hospital, Oct. 15th, 1859,
for a right, oblique rupture, distending the scrotum to the size of a
small egg, of four weeks' duration, and leading to his discharge from
the ship. One suture of ligature thread only was applied, and fastened
over a wooden compress. On the third day the thread was tightened
up by twisting round the pad. On the fifth day they were both re-
moved. The pain was confined entirely to the groin; belly quite
natural; discharge trifling in amount. On the 27th, the upper punc-
ture entirely healed; and on the 29th, the lower also, at which date he
was discharged, wearing no truss. A fortnight after he was exhibited
in King's College Hospital, the groin being then in a satisfactory state,
and no cough impulse being felt. A week after this, he was foolish
enough to lift a hundredweight without the support of a truss, and
thereupon felt a sudden pain and a sense of giving in the groin, attended
by a return of the rupture. Not being then able, as he wished, to
have the operation repeated at once, it was postponed from time to time
until the rupture, in spite of the truss he had resumed, got larger than
before, and more difficult to be retained. At length, after two years'
time, he was again admitted for operation, which was done on the im-
proved method by the twisted wire suture, Oct. 5th, 1861. On the
6th, it was found that he had contracted a gonorrhoea; for this he
was ordered frequent syringing of the urethra with warm water, an
effervescing draught every four hours, and pil. sapon. co., gr. v. at
bedtime every night. 8th.-Complains of occasional pains in the belly,
and scalding of the urine. No tenderness on pressure, sickness, or
tympanitis; pulse 80; tongue white; bowels not open. Castor-oil
ordered. 9th.-Bandage removed. No pain or swelling in testis or
scrotum, wound looking very well; little discharge from puncture;
free discharge from urethra. 10th.-Bowels opened with considerable
griping; complains of the scalding and increase of gonorrhoeal dis-
charge; no tenderness on pressure except around punctures; belly
quite soft and yielding; punctures rather red and obstructed by in-
spissated discharge; some healthy pus escaped on moving the wires; a
round mass of induration at lower puncture; no swelling or tender-

CASE XIII.
275
ness of the testis on either side. To have a draught of liq. potassæ,
tinct. camph. co. and sp. æth. nitric., with camphor mixture, thrice
daily. 12th.-Feels much better; less scalding; redness at punctures
disappeared; discharge lessened. 15th.-Doing exceedingly well;
tongue clean; appetite good; bowels open. Induration in canal
very evident. Gonorrhoea better. 19th.-Going on very well;
wires withdrawn, easily and with little pain (fourteen days after
the operation); no bleeding followed. 22nd.-Lower wound entirely
healed; upper shows healthy granulations with serous discharge;
gonorrhoea nearly well; dress with compress and spica bandage; to
get up to-morrow. From this time to Nov. 2nd he was about the
ward, with a small opening only present in the groin. He was at this
date shown in the theatre. No hernial impulse whatever was present.
Superficial ring obstructed by adhesion, and a hard mass felt in the
upper part of the canal. He was discharged from the hospital without
truss, and walked about without one until Nov. 18th, when he came to
me with one on. The groin was then all that could be desired, firm,
hard, and resistant, with the ring scarcely to be distinguished by the
finger. In the autumn of 1862, he was shown in King's College
Hospital, having remained well, and the groin giving no trouble. The
external ring could now be felt more distinctly, but would not admit
the tip of the finger; no hernial impulse whatever was to be felt; still
wears the truss when at work; promises to come directly any change
is evident to him.
Case 13.-J. F., æt. 35, operated on July 23rd, 1859, for a small
inguinal hernia on the left side, which had previously been twice
operated on, once by Wurtzer's method, and once by Gerdy's; the result
was, a very patulous condition of the superficial ring and canal, ad-
mitting the forefinger with ease. A tumour with a cough impulse filled
the canal, appearing at the ring; a thin, lax condition of the abdominal
wall, and a sense of great weakness and pain in the groin on making
any muscular exertion. The patient stated that his condition was quite
as bad as before the above operations were done. In this case I
operated with the threads and compress. They were removed on the
third day, and the patient was out of bed on the ninth day; the con-
solidation in the canal along the track of the ligature being very satis-
factory, and the closure of the superficial ring entire. A month after-
wards, a little bulging only was apparent in the groin opposite the deep
ring. To give this support a light truss was recommended. In the
September of 1861, I was accosted by this patient to thank me for the
excellent cure which had resulted. He had thrown off his truss en-
T 2

276
APPENDIX OF CASES.
tirely, and the groin was everything he could desire. This was more
than two years after the operation. Some months ago, I again saw this
case, at which time there existed a decided tendency to a return of the
rupture, as shown by the impression produced by the cough upon the
superficial ring. I therefore recommended the resumption of a proper
truss. He stated that the alteration appeared after making unusual
muscular efforts without truss.
Case 14.-J. S., æt. 38, a healthy, fine-looking man, who had come
from California to be operated on for the cure of a very troublesome
and painful rupture of the right side, of twelve months' duration.
Stated that he was operated on in America soon after the tumour
appeared, by a seton drawn through the sac. Describes the operation
as very severe and painful, keeping him in bed a long time, and pro-
ducing much suppuration. As soon as he began to move about, the
rupture reappeared, although a truss was constantly worn after the
operation. The cicatrices in the groin and scrotum were very ex-
tensive, and the external ring very patulous. The neck of the sac is
wide, its direction being more vertical than usual.
The rupture
descends directly into the scrotum, attains the size of an orange, and
has not been kept up by any truss that he has tried. As the anatomy
of the canal has been much interfered with, I was not very sanguine as
to the result of the operation, but, at the patient's earnest request, I
operated on the 17th Nov., 1859, with ligature thread and compress.
Some difficulty was experienced from the cicatrices, in invaginating the
fascia to the requisite extent, and in detecting the conjoined tendon.
The sac was funnel-shaped, with a large internal opening, the finger
moving freely within the dilated canal. To avoid the old cicatrices,
the scrotal puncture was made lower down than usual, and the puncture
in the groin close to Poupart's ligament. This I afterwards found to
have the effect of bringing the pressure of the compress too low,
so that it did not bear satisfactorily over the axis of the hernial canal.
The compress was removed on the 5th, and the thread on the 6th day,
not a disagreeable symptom having supervened. On the 28th he
walked about the room without truss. In a day or two, after the
wounds were completely healed, and on the 6th Dec., he walked out of
doors without truss. Soon, a certain mobility was apparent about the
fascia attached to the superficial ring, which, on pressure being made at
the upper cicatrix, was drawn a little upwards into the canal. Ten
days afterwards, he went to Geneva, whence he wrote, a month after
the operation, to say that the hernia had returned, expressing at the
same time a great desire for another operation. Accordingly, he re-
turned to London, and was again operated on January 21st. This

CASE XV.
277
time the punctures were made directly through the old cicatrices; the
thread and compress were again used. On passing the finger into the
canal, I could distinctly feel the fascia which had been transplanted in
the first operation, adherent to the cord and anterior wall. The hernia
had descended to its inner side, where the mobility of the fascia had
first appeared after the first operation The position of the con-
joined tendon was not at all evident, the width of the internal opening
having apparently almost obliterated it. The compress was re-
moved on the fifth day, the lower ligature kept in until the thirteenth,
and the upper till the eighteenth. In the meantime, he had got up and
walked about the room. Very little pain, and not an unpleasant
symptom had occurred. Not much action was set up in the canal, and
the discharge was very trifling. The speed with which reparation and
absorption proceeded in this case was remarkable, as well as the
little effect induced by the presence of the threads. On the 13th of
Feb., 1860, both wounds were closed, a hard, firm mass of consolidation
apparently filling up the canal. The scrotum was shortened, but the
testis was moveable, and free from enlargement. He went again on the
Continent, wearing a light truss. On returning, after a few weeks'
absence, he called upon me previous to sailing for California. There had
been great absorption in the canal, and the induration was nearly all
gone. The superficial ring was much narrowed, and the point of the
finger could not be inserted; there was, however, some impulse on
coughing, an impression upon the walls of the canal rendering the case
not entirely satisfactory. The truss, however, was rendered perfectly
available for supporting the weak groin, which had not been the case
before the first operation. I recommended him to wear the truss con
stantly for a year. Having then some intention of again visiting this
country, he promised to call again on me and report progress, but has
not yet done so.
Case 15.-Ann Martin, æt. 29, a healthy, unmarried woman, in
service, applied with an oblique inguinal rupture on the right side, of
four years' standing, which no truss that she had procured was effectual
in retaining. The rupture was of the size of a fist, and seriously in-
terfered with her means of livelihood. Operated on at her own home
Feb. 17th, 1860, by ligature, thread, and compress. In this case the
stitches were placed external to the sac, which was pushed up by the
invaginating finger. From the absence of scrotal fascia much difficulty
was experienced in getting far enough within the canal; the labial fascia
not being divided resisted the invagination, and the hold of the threads
upon the conjoined tendon was consequently doubtful. For the first
few days she complained of much pain in the wound, and was hysterical.

278
APPENDIX OF CASES.
The belly was soft and compressible, and no tenderness except in the
groin. Compound soap pill, gr. v., every night. On the 23rd, the
compress was removed, and a poultice applied; suppuration moderate;
consolidation slow in forming. March 8.-Ligature threads removed.
On the 12th, she walked to my house with the wounds entirely healed.
There was then no impulse on coughing, and she felt much stronger in
the groin than before the operation. She wore no truss. In about a
month she came again to me, and I found that the rupture had re-
appeared to some extent, but not so large as before the operation.
Recommended to wear a truss constantly, in the hope that continued
pressure might still produce contraction of the canal, after the action
that had already been set up. Since then I have not seen her.
Case 16.-Stephen Larkins, æt. 43, of Plumstead, a tall, stout,
healthy looking excavator, with a double scrotal rupture, produced by
a fall of earth, almost burying him alive, four years ago. Both are of
the oblique variety, the left one much the larger, attaining an enormous
size, equal to two fists, and admitting easily the tips of three fingers
through the deep opening. The right side gives him less trouble, the
truss being effective in keeping up the rupture, which is not the case
with the left side. Wished the left side to be operated on, as he could
manage the other with a truss. Operated on at King's College Hos-
pital, May 16th, 1860, by threads and compress. Two ligatures were
applied, one close to the deep opening, and the other near the pubis.
Much strain was apparent when the threads were drawn close. On the
17th, he had a slight retching, and was very restless, complaining of
much pain in the groin, which was allayed by repeated doses of
sol. of morphiæ hydrochlor., mxx. every three hours. His face was
flushed, and he perspired freely from the effects of the morphia and
pain. Respiration abdominal throughout; no tympanitis or tenderness
on pressure over the belly, except in the groin operated on; pulse 60;
bandage removed. 18th.-Did not rest much last night as the pain
returned towards evening, after having entirely abated. Had a little
nausea; slept pretty well all the morning; no tympanitis; tongue
white; pulse 60. Pil. sapon. co., gr. v. every four hours; fomenta-
tions. 19th.-Much better; slept during the night; no nausea or
vomiting; much less pain in the groin; tongue a little furred, but
moist; pulse 64. To leave off the pills. 23rd.-Compress removed to-
day; suppuration free; bowels open for the first time since the opera-
tion; pulse 60. 28th.-Discharge diminishing; much induration
evident in the canal and ligature tracks. On June 2nd, the wounds
being much contracted, he got up and walked about the ward. The
scrotal puncture healed entirely next day. The threads were kept in

CASES XVII., XVIII.
279
the upper wound until June 8th, and on the 11th the puncture closed.
On the 16th, the patient was exhibited in the theatre of the hospital;
a great deal of induration was evident in the canal; the scrotum was
well tucked up, and firmly adherent by its cicatrix to the pillars of the
superficial ring, which were firmly closed. No impulse whatever was
perceptible, and the contrast with the opposite side was very remarkable.
I have since had a note from the wife of this patient, in answer to my
inquiry, stating that he continued to be in a satisfactory condition, and
intended coming some day to see me.
Case 17.-George Vernan, æt. 21, of Chatham, operated on at King's
College Hospital, June 2nd, 1860, for a right, oblique, scrotal rupture,
of two and a half years' duration. When lifting, the rupture slips
behind his truss into the scrotum, and gives him much pain. The
operation was done with thread and compress. Next day complained
of much pain in the groin; had not slept since the operation, in spite of
the usual dose of opium; tongue furred; mouth parched; feels feverish;
no tenderness on pressure except in groin; pulse 88. 4th.-Pain de-
creased very much; felt comfortable; slept well; pulse 95; tongue
furred; skin rather hot. 5th.-Fever gone; very little 'pain; begins
to eat; pulse 72. 6th.-Compress removed; free suppuration.
8th.-Bowels moved; pulse 68; sleeps without pills. 12th.-Could
eat more; looks thin, pale, and anxious; pulse 76, not resisting;
ordered full diet; nitric acid and bark mixture. 13th.-Free suppu-
ration; testicle swollen, and a little tender on the side operated on; to be
supported and fomented. 14th.-The pain in the testis prevented rest
last night; pulse 72. This pain in the gland was easier the next day,
was attended by very little enlargement, and did not excite further
notice during his stay in the hospital. June 21st.-Threads withdrawn;
much induration. 23rd.-Walked about the ward. 26th.-Dis-
charged; external ring firmly closed; no impulse whatever; testicle
still a little tender when pressed. July 3rd.-Exhibited in the theatre of
the hospital; scrotum on the side operated on much contracted; testis
drawn up towards the ring, and about one half the size of its fellow;
canal and ring firmly closed by cicatrices; no impulse whatever on
coughing. Since that time I have once seen this patient many months
after the operation. The cough impulse was equal on both sides; the
wasting of the testis not greater than before. I have since heard of
him; he continued quite free from the rupture.
Case 18.-Bartholomew Connor, æt. 23, a sailor, operated on at
King's College Hospital, June 16th, 1860, for an oblique, scrotal
rupture in the right groin, brought about by an accident on board ship
a year and a half before. Operation by thread and compress. On the

280
APPENDIX OF CASES.
;
18th, had not had much pain since the operation; slightly feverish
pulse 80. 21st.-Bowels open naturally; slight tenderness. 22nd.-Sup-
puration established; did not sleep well last night; compress removed;
lower opening healed; thick pus squeezed out of the upper puncture.
23rd.-Pain and feverishness gone; begins to have an appetite; a good
deal of thick matter squeezed out of the upper puncture; poultice.
26th.-Less discharge. 28th.-Much induration apparent. 30th.-Liga-
tures removed; to get up and move about the ward. July 7th.-Dis-
charged; canal and rings firm and contracted; went out without truss.
Three months afterwards this patient, having been at work as a common
sailor, without truss, since his discharge, returned to the hospital with a
small tumour, which proved to be a return of the rupture, to about half
the size it was before. The superficial ring admitted the point of the
finger. Not having at the time a bed vacant in the hospital, the
patient's wish for an immediate repetition of the operation could not be
acceded to, and he was told to apply in a week's time or so. He did
not do so; and I heard afterwards that he had been operated on again
on board the Dreadnought by Mr. Tudor, after my method, suc-
cessfully.
Case 19.-James Mead, æt. 25, a grocer, sent to me for operation
by Mr. Coulson, for a right, oblique, scrotal rupture of a year and
a half's standing, upon which Wurtzer's method had been unsuccess-
fully tried. The rupture had returned as large as ever one month after
this operation, and had since then become more painful, the truss failing
to retain it. Operated on at his own home, June 25th, 1860, by thread
and compress. The anatomy of the canal was rather obscured by the
previous operation. 26th.-Has had a good deal of pain; bandage
removed; no tenderness anywhere but in the site of the operation;
pulse 84. 27th.-Slept better; compress removed; suppuration com-
mencing. 29th.-Much less pain; more discharge; belly quite soft
and natural. July 3rd.-Bowels opened by castor-oil. 9th.-Doing
very well; ligatures removed; suppuration moderate. 11th.-Got up
to-day. 13th.-Came down stairs. 15th.-Resumes his occupation
in the shop. 17th.-Upper wound quite healed; lower nearly so.
21st. Shown to-day in the theatre of King's College Hospital, not
having worn a truss since the operation. Superficial ring quite closed;
canal firm and resisting; impulse the same on both sides. To wear a
light truss when at his employment. May 30th, 1861.-Came to-day to
the Lincoln's Inn Dispensary; after wearing the truss four months has
left it off entirely; the impulse, on coughing, equal on both sides, each
presenting a slight bulge over the centre of Poupart's ligament; super-

CASE XX.
281
ficial ring does not admit the top of the finger. This patient has, since
this time, been many times exhibited in the theatre of King's College
Hospital, and the parts have remained without alteration. The last
time he was seen was on Aug. 29th, 1861, when he continued in a
most satisfactory condition, doing occasionally much lifting, and wearing
no truss.
Case 20.-Richard Cook, æt. 39, of Woolwich, married; operated
on in King's College Hospital, July 31st, 1860, for a left, oblique,
scrotal rupture, of six months' duration, by the thread and compress
operation. He had afterwards the usual amount of pain in the groin;
belly quite free from tenderness and tympanitis; no sickness; going on
quite in the usual way; no swelling of the testis. 24th.-Compress
removed; wounds look healthy; discharge healthy and moderate;
bowels not yet open; complains of cough, thirst, and pain in the chest;
pulse 90, full. To have a draught of liq. ammon. acet., chlorodyne, and
sp. æther. chloric., with aq. camph., every four hours, and sinapisms to
chest. 26th.-Much better; cough relieved; appetite pretty good;
pulse 80, compressible. 28th.-Cough nearly gone; tongue slightly
furred; punctures looking well; suppuration pretty free; consolidation
can be distinguished. 29th.-Bowels acted freely. 31st.-Ligatures
removed; discharge healthy; pulse 70. Aug. 1st.-Expresses himself
as feeling extremely well; appetite and pulse good. 4th.-Bowels
acted freely from a dose of castor-oil. 9th.-Has gone on very well
since last report; wounds gradually closing, and discharge decreasing
in quantity; lower puncture entirely healed, upper diminished to a
sinus, discharging healthy matter; much consolidation in the canal,
and less impulse than in the opposite groin; stood up to-day at the
bedside without pain or inconvenience, except from weakness. Up
to this time there had not been, in this case, the occurrence of a single
bad symptom; and at this date I left town for a short time, with
directions for his discharge as soon as the sinus was healed. For two
days after this he was up and about the ward. He was then seized
suddenly with a smart rigor, succeeded by feverish symptoms, foul
tongue, and quick pulse. Dr. Johnson and Dr. Evans saw the patient,
and he was put on ammonia, brandy, quinine, and strong beef tea. In
a day or two, the symptoms became those which characterize blood-
poisoning-viz., very quick pulse, recurring rigors, profuse perspira-
tions, dusky countenance, and diarrhea; the small sinus still remaining
ceased to discharge, and assumed a dark livid hue. Further notes of
the case were unfortunately not kept, it being the vacation. After a
week's absence I returned to town, saw the patient, and carefully

282
APPENDIX OF CASES.
examined the groin, perineum, and abdomen. Aug. 18th.-There was
no tympanitis; the belly was soft; no swelling, redness, nor tenderness
whatever on pressure about the wound; the canal was hard, firm, and
resisting; the groin puncture was reduced to a small fistulous track,
admitting a probe to the depth of three-quarters of an inch downwards
and inwards; it was dry and glistening. There was felt a slight, dull
pain, on pressure above the pubis into the pelvis. No pain or diffi-
culty was felt in passing the urine, which was rather high-
coloured, but in proper quantity; slight pain felt, on pressure in the
perineum, by the side of the urethral bulb. On seeing him next day,
I found the symptoms decidedly aggravated; the rigors were more
frequent and severe; the perspirations profuse, with a sweetish faint
smell. He had low muttering delirium, and a dusky, sunken face;
tongue covered with a dry brown fur; pulse 130, and very compres-
sible. There was now some tympanitis, and rather more tenderness on
pressure. He had taken 16 oz. of brandy during the twenty-four
hours. He sank and died, Aug. 21st, 1861.
Necropsis.-On opening the abdomen, there was found no effusion
of fluid into the peritoneal cavity, nor was the smooth glistening
surface of the intestines altered, but the ilium was more vascular than
normal, indicating commencing peritonitis. There was no effusion of
fluid or pus in the sheath of the rectus, or in the course of the sper-
matic vessels, or vas deferens of the side operated on.
All these parts
were perfectly normal. A small fistulous track led from the puncture
into the inguinal canal, and was arrested by the posterior wall. The
parts about the conjoined tendon were much thickened, and conso-
lidated into a hard, fibrous mass, adherent to the border of the rectus
muscle. On section of this indurated tissue, there exuded from small
points on the cut surface (apparently sections of veins) a small
quantity of purulent fluid. The peritoneum covering the bladder on
the opposite side of the body was dark and congested, but still smooth
on the surface. On raising this, and dissecting into the vesical fascia,
the tissues were found hard, and resistant to the knife, and an ounce or
so of thick pus flowed from the section. On closer examination of the
cut tissues, the pus seemed to have been contained, not in a single
cavity, but in canals of tortuous course, which were evidently the
dilated and hypertrophied veins of the vesical plexus between the
bladder and pubis, extending down towards the triangular ligament
and perineum. This deposit evidently accounted for the deep-seated
pain, on pressure in the perineum, observed two days before death.
It was remarkable as extending more on the opposite side of the pelvis

CASE XXI.
283
than towards the side operated on.
Behind the external pillar of the
ring operated on, a small channel still remained unclosed by the
ligature, in the neck of the hernial sac, extending along in front and to
the outer side of the spermatic cord. Its upper and inner boundaries
were composed of the thickened and puckered sac, thrown into longi-
tudinal folds, and matted together by adhesive inflammation. The
diameter of the remaining canal would admit only of a goosequill. Its
upper, posterior, and anterior boundaries were hard and unyielding.
Its lower side was the spermatic cord, and its serous covering of sac
little altered. At the deep opening of the hernial canal the omentum
was found adherent to its upper boundary for about one-half its extent,
and covering the greater part of the puckered opening. The gut in
immediate proximity was not more vascular than that which lay in the
pelvis, indeed, hardly so much so. The liver was large and light-
coloured, probably fatty; and the kidneys were large and flabby. The
mucous surfaces of the bladder and ureter were normal.
examination was prevented by the wishes of the friends.
Further
This unfortunate case bid fair both in its progress up to the occur-
rence of the pyæmic symptoms, and from the condition of the parts
operated on, as found after death, to have been a very satisfactory cure.
The symptoms and post-mortem appearances clearly indicate that the
fatal result was owing to those, as yet inscrutable causes, which are
quite independent of the position, nature, or severity of an operation,
and result in a purulent infection of the blood. Although, in the
present case, the quantity of suppurative action was by no means so
great as in many which preceded and did perfectly well, yet the
occurrence of a fatal case led me to turn my attention to some method
of diminishing, if possible, the amount of suppuration in the progress of
the case, and to the adoption of wire as the agent for drawing together
the sides of the canal. I had before remarked that the amount of
adhesive action was not generally proportionate to that of the discharge;
that the former appeared to depend more upon the vigorous condition
of the patient's health at the time of operating, and the length of time
during which the ligatures were kept in; and the latter, upon the
violence of the action set up and the degree of tension exercised upon
the sutures in bringing the sides of the canal together.
Case 21.-William Freeman, æt. 21, operated on in King's College
Hospital, Sept. 29th, 1860, for a left, oblique rupture of twelve months'
duration, brought on by lifting, in the course of his duty as a sailor.
This case was remarkable for the presence of two internal openings into
the inguinal canal-one superficial and external, in the site of the deep

284
APPENDIX OF CASES.
ring; and the other smaller, through the conjoined tendon, in the
triangle of Hesselbach. The hernial tumour protruded through the
former opening, and a cough impulse could be detected in the latter
also. The operation was done with threads and compress; the lower
end of the ligature was carried across the face of the lower deep
opening, so as to include its borders in the grasp of the ligature; the
upper end of the ligature crossed the front of the upper opening or
internal ring. A broad compress was used. During the two following
days he had pain in the groin and scrotum of the side operated on, but
no other unpleasant symptom, and, on the whole, expressed himself com-
fortable. Oct. 2nd.-The compress was removed (three days after the
operation). The swelling and tenderness in the groin was very slight;
no abdominal symptoms whatever; a small quantity of healthy pus
flowing from the upper puncture; lower nearly closed. Compress re-
applied, and ligatures tightened over it to produce more action.
4th.-Had a restless night; more tenderness and swelling in the groin;
discharge scanty; bowels acted freely; not much pain; enjoys his
food; compress removed altogether. 6th.-Comfortable; bowels open;
discharge natural. 10th.-Doing well. 16th.-Discharge much di-
minished; consolidation very evident in the canal; has been walking
about the ward. 18th. Ligatures removed; wounds closing up rapidly.
20th.-Wounds quite healed; much induration in the canal; super-
ficial ring quite closed; less cough impulse than on the opposite side.
This patient was discharged, wearing no truss, but was recommended
to get one on returning to his employment, and to let me know if
return of the rupture occurred. He has not hitherto done so.
any
Case 22.-Henry Holland, æt. 22, an engineer, operated on in King's
College Hospital, Oct. 6th, 1860, for a left, direct, scrotal rupture, with
a very patulous and lax canal and rings, of two years' standing. The
operation performed in this case was the first in which wire was used,
still retaining the use of the compress. On account of the great size of
the hernial openings, the two ends of the wire, after being passed
through the conjoined tendon and Poupart's ligament close to the deep
opening, were crossed over each other in front of the orifice, and again
passed through the pillars of the ring, as described at page 125, and
shown in Fig. 37. By this means the patulous superficial opening was
closed effectually, close above the pubic crest. Next day he had passed
a good night; pulse 82; tongue a little white. 11th.-Some oedema
of scrotum apparent; a little pain on pressure of the testis; no suppu-
ration; compress removed. Has had a troublesome cough, for which
a mixture was ordered; poultice to the groin and scrotum.

CASE XXIII.
285
13th.-Bowels open by castor-oil; punctures discharging a little; no
abdominal swelling or tenderness; tongue white; pulse 90; cough still
continues. 16th.-Edema of scrotum still continues; no pain in the
testis; cough and feverishness better; wires removed without difficulty;
poultice to the groin. To the 2nd Nov. he went on rather slowly but
gradually progressing; there was but little discharge; the lower wound
was then nearly healed, but a thickening of the scrotum in front of the
cord still remained. He then complained of pain in the scrotum, which
became more swollen and tender at the part where the fundus of the
sac lay. Suppuration in the sac being anticipated, fomentations,
poultices, and a dose of castor-oil were ordered. Next day the lower
wound began to discharge more freely, and during the next three days
the swelling and tenderness abated; and the testis could be felt a
little enlarged, but not tender. On the 6th he was all right again.
10th.-Wounds nearly healed; up and about the ward. 15th.-Dis-
charged; groin firm, hard, and resisting; no impulse on coughing
below the upper cicatrix; testis and cord a little enlarged, but not
painful or tender; to wear his truss when walking or at work, but not
at other times. Feb. 12th, 1861.-The patient came to me with the
parts but little altered; there was, perhaps, a little more bulging above
the upper cicatrix, but the testis and cord were diminished in size to
nearly their normal dimensions; still wears a truss when at work.
April 30th.-Again saw this patient; a slight protrusion can be felt
high above the pubis, to the inner side of the upper puncture, which
has a slight impulse on coughing; the superficial ring below this point can
be felt quite closed, and not admitting the point of the finger; no impulse
on coughing can be felt in this position; testis and cord of their normal
size. The small protrusion seems to be either through the puncture
made by the needle in the tendon, or through the upper part of the
hernial opening. The truss was adjusted upon the weak part, and he
was recommended to wear it constantly, and to apply again if the
tumour gets larger, and does not disappear. I have not since seen the
patient.
Case 23.-David Mumford, æt. 21, pale and sallow, a sawyer in
Woolwich Dockyard; operated on in King's College Hospital, Oct. 13th,
1860, for an oblique, scrotal rupture, which had been previously
operated on for the radical cure by another surgeon, without success, the
rupture returning when the patient began to move about. The failure
was apparently owing to the conjoined tendon not having been properly
secured. In this case I operated with wire in the manner described at
page 123, and shown in Fig. 36, being anxious, as the rupture was of

286
APPENDIX OF CASES.
considerable size, and had returned after one operation, to secure fully the
lower as well as the upper part of the canal. The opposite groin was weak
and bulgy; the hernial openings opposite to each other; and the whole
make of the individual such as described in the text under the second class
of hernia cases. The boxwood compress was used also in this case.
Next day, had slept well after the usual pill; no abdominal symptoms;
no pain except from the pressure of the compress; pulse 80.
15th. Very little pain; a little suppuration apparent. 16th.-A
slight swelling of the scrotum; doing very well. 18th.-Complains of
cough; a little feverish; no pain in belly or groin; bowels open by
castor-oil. 19th.-Cough more troublesome, giving pain in the groin;
to have a cough mixture. 20th.-Cough better; suppuration increased;
compress removed. From this time he went on very well, having but
little suppuration from the punctures, and much induration in the
canal and track of the ligatures. On the 30th, the wires were removed
without difficulty by dividing the upper loop, and untwisting and
cutting off the lower ends close to the wound, and then drawing the
two portions upwards separately. On Nov. 2nd, he was up and about
the ward; the punctures closing up with remarkably little suppuration;
testis and cord normal. On the 9th, he was discharged, with the
punctures healed; the superficial ring and canal quite closed and firm,
and no cough impulse below the upper cicatrix. He went out without
truss, but was recommended to wear one when at work. On Jan. 20th,
1862, this patient again applied at the hospital with the hernia re-
turned, but not to its former size. States that, after wearing the truss
three or four months, he discarded its use altogether, as it was in the
way of his work, which consisted in pushing heavy trucks along with
his belly, causing the truss to hurt him. After going on with this
work without truss for four months longer, the rupture began to re-
appear, and speedily obtained its present size, he having worn no truss
since. To resume his truss. Stated his resolution to have the operation
repeated at some future time, but has not since applied.
Case 24.-Captain B, æt. 26, a military man, operated on for a
right, oblique, scrotal hernia, of six years' standing, which gave him
great trouble from its constantly slipping down under the truss. Being
about to go out to India, he was anxious to have it permanently cured.
Operated on March 30th, 1861, in the manner shown in Figs. 33, 34,
and 35, at pages 120 to 122. At night the pulse was 80; no fever;
had a sedative draught, and slept very well. Next day expressed
himself as very comfortable; pulse 80; tongue clean; little or no
pain. April 2nd.-Suffers very little; sleeps well; bandage 'removed.

CASE XXV.
287
pus; more
5th.-Bowels open
An extra twist given to the wire over the compress to set up
more action; lower puncture nearly healed; very little action; no
tenderness anywhere. Bandage replaced firmly, so as to make com-
pression. 3rd.-Feels very little inconvenience; tongue clean; wishes
for more food; glass of sherry daily. 4th.-Restless night, but no
pain; a little matter oozing from the puncture; some incrustation over
the lower one; opened it with the probe, letting out a little
action in the canal; slight oedema of the scrotum.
by castor-oil. 6th.-More pain and discharge in the punctures;
thickening more evident, with slight cutaneous redness; compress
removed; poultice. 9th.-Discharge now tolerably free. 12th.-Dis-
charge lessening; lower opening a mere fistulous track; water dressing
and pressure upon the wires "in situ" by compress and bandage.
15th.-One half the wire removed, the other left to keep up a slow
indurative action. 17th.-Got up to-day; stood erect without pain;
lower puncture closed; discharge small, entirely serous; no impulse
felt on coughing below the wire; cord and testis quite free from
swelling or tenderness; the hernial sac seems to have been entirely
drawn up into the canal. On the 20th, thinking that not quite enough
action had been induced, I reapplied the boxwood compress over the
single wire which remained, and applied firm pressure by a spica
bandage. 24th.-The increased pressure having set up a considerable
amount of hard thickening, the remaining wire was removed, after some
difficulty, from a kink which had formed upon it, being retained by the
granulations. Serum only has been discharged from the punctures, no
pus having appeared during the last week, although moving about
with the bandage on. Compress and bandage lightly reapplied.
30th.-Wounds almost entirely healed; no cough impulse felt along
the canal; superficial ring completely blocked; can bear the pressure
of a light truss; to go out of doors. Aug. 27th.-Called to-day to
take leave previously to his departure for India; continues in a most
satisfactory condition, wearing the truss only when walking or riding;
the external ring can be a little more plainly felt; no cough impulse
whatever; a hard cord can be felt in the canal, which he states to become
a little more prominent when he sneezes or coughs sometimes. This I
could not detect. Is in capital health, and feels much stronger than
before the operation. Promises to write if he has any reappearance of
the rupture.
Case 25.-Thos. Rogers, æt. 23, a healthy, fresh-looking young man,
with a double inguinal rupture. That on the left side is large and
scrotal, and gives him much inconvenience; that on the right side is a

288
APPENDIX OF CASES.
small bubonocele, projecting halfway down the canal. The groin and
genitals have a general foetal outline, as described in the third class of
cases in the text; the lower part of the internal oblique is deficient in
development. Operated in King's College Hospital on the larger
rupture, March 16th, 1861. The operation done in this case was that
described at page 126, by means of wire held fast by a steel clamp.
17th.-Had a good night; very little pain; tongue clean; pulse normal.
18th.-Doing very well; bandage removed; upper puncture closed by
adhesion; very little discharge from the lower; testis a little swollen
and tender; some effusion into the fundus of the sac in the scrotum;
no abdominal pain or tenderness; tongue a little furred; pulse 80.
19th.-Doing well; sleeps without sedative; little discharge; wires
tightened one turn; water dressing. 23rd.-To-day the steel clamp
was removed, the wire being left in; more discharge; a good deal of
consolidation, which extends more than usual into the scrotum; the
fundus of the sac is hard and swollen. 24th.-Bowels freely opened by
aperient pills; no pain in belly or testicle. 26th.-Complained of pain
in the groin, at the site of the upper cicatrix, where a little induration
and some oedema can be felt. Fomentation and poultice to the groin.
27th.-Pain and swelling of groin increased; indistinct fluctuation; the
swelling in the scrotum is larger, and is evidently due to effusion into
the sac fundus, being distinct from, and to a certain extent moveable
upon, the testicle. Tongue furred; feverish; pulse 108. An incision
made over the cicatrix in the groin, and some thick pus evacuated.
Wire withdrawn from the lower puncture by traction on one end, some
force being necessary to accomplish its removal. 28th.-Much better
in every respect; swelling in groin nearly subsided; no tenderness or
tympanitis over the belly; tongue white; pulse 100; more free dis-
charge from the punctures. 29th.-Swelling in the groin disappeared;
free discharge of thick pus; pulse 90. 30th.-A small black slough
apparent within the scrotal opening, lying upon the cord, and formed
evidently by the fundus of the hernial sac; discharge free; tongue
clean; pulse 80. April 1st.-Much improved in every respect; in-
guinal canal much indurated; dark-coloured, thin discharge from
scrotal opening. 12th. The slough from the scrotal opening removed,
being about the size of half the little finger; upper wound nearly closed.
18th.-Rather more swelling and discharge from the upper part of the
scrotum, proceeding from the presence of more sloughing of the sac;
the testicle is painful when pressed, not otherwise, and gives its peculiar
sensation to the patient; groin hard and firm, and the neck of the sac
evidently completely obliterated. 24th.-Had more pain in the

CASE XXVI.
289
scrotum, at the lower part of which is a soft, red, fluctuating swelling
in front of the testis. This was opened, and a quantity of grumous pus
and shreds of slough were squeezed out; the testis could afterwards be
distinctly felt, rather diminished in size, but of normal shape and feel;
could eat more; to have two eggs daily; has been taking strong beef
tea; milk diet; and brandy, ziv. daily. 27th.-To-day, a slough two
inches in length, and of the diameter of the little finger, was drawn
through the scrotal opening, formed evidently by the remainder of the
sac. 30th. The swelling in the scrotum has entirely subsided; dis-
charge thick and yellow, from the fresh opening in the scrotum. Both
punctures granulating well; testicle can be distinctly felt, a little
wasted, but giving its normal sensation to the patient. Injection of
zinci sulph. Feels quite well; middle diet and half-a-pint of porter.
May 7th.-Testis can now be more clearly felt; is smaller than the
other, but still tolerably plump; to get up and walk about the
ward. From this time the punctures gradually closed up, and the
patient was discharged on the 22nd July, wearing a light double truss.
The superficial ring on the side operated on perfectly closed and firm;
no cough impulse whatever; a slight bulging apparent at the site of
the deep ring; the testis is about half the size of its fellow. The
patient expressed himself entirely satisfied with the result of the opera-
tion. I have seen him again a short time since, and find the groin
quite resisting; no return of the hernial protrusion, but with the slight
bulging before alluded to; the testis is shrunken to a fourth of its
natural size; still wears the double truss. I attribute the trouble in
the scrotum in this case, and the wasting of the testis, chiefly to the
pressure of the steel clamp, and partly to the healing of the counter
opening in the groin. The abscess in the groin was clearly due to the
closure of this aperture; the fever and excitement set up by it in the
parts, and the increased pressure upon the cord, aggravated the action in
the sac already set up by the presence of the clamp. The result was
sloughing of the sac, and so much interference with the supply of blood
to the testis, as to result in atrophy. Since this case, I have always
taken care to keep the groin puncture open, and have substituted
twisting of the ends of the wire for the use of a clamp.
Case 26.-Thos. Taylor, æt. 24, a seaman, H.M.S., operated on in
King's College Hospital, April 6th, 1861, for a left, oblique, scrotal
hernia. This patient had been twice before operated on by another
surgeon, by simply invaginating the skin of the scrotum into the
canal, and holding it there by sutures passed through the pillars of
the ring, by a method closely resembling Gerdy's. The second opera-
U

290
APPENDIX OF CASES.
tion, however, had been modified by making a scrotal puncture and
tucking up the fascia only, an attempt having been made to include the
conjoined tendon also. Directly after the first, and six weeks after the
last operation, the rupture returned into the scrotum, where it now
formed a tumour as large as the testicle. He had been much troubled
by a severe bronchitis, and when he first applied to me for a third
operation, was expectorating freely, and had much pain in the chest.
Consequently I strongly recommended him to wait until his cough had
been cured. Being very anxious to get back to his ship, he, a short time
after this, represented himself as free from cough, and ready to undergo
the operation. This was afterwards found not to have been the case, as
in the early part of the treatment he suffered much from the effects of
the cough upon the groin. The operation done in this case was the
wire operation without compress, described in the text (page 109). A
good deal of hard, thickened cicatrix was felt on the posterior surface
of the outer pillar of the ring, evidently the result of the former opera-
tions. The rupture had returned behind these adhesions. The wire
in the operation was placed above and beyond these, and passed fairly
through the conjoined tendon, upon which a distinct pull could be felt
when the wire was twisted up. The sac in the scrotum was very thick,
tough, and resisting to the needle, when passed across it in front of the
cord. On the night of the operation, the cough began to be trouble-
some, which he explained by saying that he had got a fresh cold. Next
day, the expectoration was copious and bronchitic. He complains
much of pain in the groin when he coughs, but not at other times;
tongue covered with thick, white fur; pulse 100. Bandage and dress-
ing left undisturbed, and a draught of liq. ammon. acet., sp. æther.
chloric., with aq. camph., ordered every four hours, with pil. sapon.
co., gr. v. every night. 8th.-Cough very violent; expectoration very
copious; complains of much pain in the testicle; scrotum red, and the
gland exquisitely tender and rather enlarged; pulse 110; tongue much
furred; face hot and flushed; dressings removed, upper puncture not
at all inflamed; no swelling in the canal; no pain, tenderness, or tym-
panitis in the belly; respiration abdominal, both flanks rising and
falling equally. Scrotum to be well supported and fomented; poultice
to the groin; turpentine stupes to the chest, and the pills three times
daily. At ten P.M. much easier; no pain in the testicle; sleeps much;
pulse 108. 9th.-Very much better in every respect; swelling, red-
ness, and tenderness of scrotum and testis much diminished; cough
and expectoration less; no abdominal pain or tenderness; pulse 100.
10th.-Continuing to improve; moderate thick discharge from the

CASE XXVII.
291
punctures; tongue cleaner. 11th.-Continues better; bowels not open
since the operation; pulse 96; to have an ounce dose of castor-oil. 13th.
-The oil not having operated, a common enema was given, producing
two copious stools; cough better; tongue slightly furred; pulse 94;
wounds look very well; discharge thick and moderate; testis less tender.
Light pressure over the wire loop was made by straps of adhesive
plaster, so as to make pressure against the posterior wall of the canal.
15th.-Doing well; cough still troublesome; testis slightly enlarged
and still a little tender. Water dressing and spica bandage over
wire loop. 24th.-Cough quite gone; bowels confined; eats well;
wishes for ale. To have a pint daily; wire untwisted but not with-
drawn; wounds granulating; discharge thick and moderate; testicle
and scrotum have resumed their normal appearance and size. 30th.-
Wires withdrawn (under chloroform, at the patient's request); no diffi-
culty experienced; the ends were moved freely in the wound, and cut off
close to the skin; the loop above was next drawn upwards and extracted
entire. May 1st.-Punctures closing in; much consolidation in the
canal and upper part of scrotum. To get up and move about the ward
with a spica bandage and lint compress firmly applied. 4th.-To-day
the patient was shown in the theatre of the hospital. Punctures en-
tirely healed; groin firm, hard, and resisting; superficial ring perfectly
closed; no cough impulse whatever; condition most satisfactory. Dis-
charged; recommended to have a light truss when at work; promised
to let me know if there be the least change or return of the rupture; I
have not heard from him to the present time.
Case 27.-Alfred Spencely, æt. 8 years, operated on at King's College
Hospital, Feb. 22nd, 1861, for a left, oblique, scrotal rupture, which
had been observed one month; the superficial ring was large, and cough
impulse extended. In this operation, the rectangular pins were used for
the first time, as described in the text, and given in Figs. 40 and 41.
Next day, the little fellow had some difficulty in passing his water, as
it seemed, from fear of hurting his groin. Complained of no pain any-
where; belly soft and pliant; pressure does not cause him to shrink,
except over the needles. He is intractable, and cries to go home;
tongue clean; eats well. 24th.-After being fomented he passed his
water freely and voluntarily, and finding it did not hurt him, has done
so ever since. Appetite good; tongue clean. March 2nd.-No pain
or irritation from the pins; dressings changed, dry lint only being em-
ployed; a drop or two of serum oozed from the punctures; no swelling
whatever; eats and sleeps well; bowels opened by an enema. 8th.-
A thick line of consolidation now felt in the track of the pins along the
U 2

292
APPENDIX OF CASES.
canal. Pins withdrawn with great ease; dress with dry lint. 15th.—
Punctures quite healed; the canal between them blocked up by a line of
induration, completely obscuring the superficial ring. On coughing, a
little more bulging is apparent on the side operated on than on the
other, above the site of the upper cicatrix. Discharged; to have a
light truss, worn only during the day. The mother promised to let me
know if there was any return in this case. I have not heard from her to
that effect.
Case 28.-Samuel East, æt. 15, operated on in King's College
Hospital, April 20th, 1861, for a right, direct, scrotal rupture, of six
years' standing. The neck of the sac very wide and lax, admitting the
fingers freely into the abdominal cavity; the usual operation by wire
(page 109) was performed, both ends of the wire being passed across
the sac.
21st. Had considerable pain last night; allayed by pil.
sapon. co., gr. v. at bedtime; no pain to-day; tongue a little white;
pulse 100; no sickness; no tenderness over the abdomen; no tympa-
nitis; respiration abdominal and equal in both groins. In a day or
two, the pulse returned to its normal standard; the tongue lost its
white fur, and no abdominal symptoms whatever appeared. Bowels
open by castor-oil. On the 29th, sleeps without sedative; wishes for
meat and porter; discharge moderate, from lower opening chiefly; in-
duration apparent in the canal; no tenderness above. Middle diet;
half pint of porter. May 2nd.-Continues well; pressure applied to
the wire loop by spica bandage; consolidation more evident. 3rd.-
Had a little more pain last night from the pressure; none this morning;
no increase of discharge; a little swelling evident in the testis, but it is
not tender. 9th.-Swelling of testis entirely gone. 13th.-Wire re-
moved without difficulty, from the lower opening; very little dis-
charge. 20th.-Wounds entirely closed; much consolidation; no
cough impulse whatever; superficial ring quite obliterated. Discharged.
To have a light truss fitted. June 12th.-Seen by me to-day; indura-
tion almost entirely disappeared; no cough impulse whatever; testis a
little enlarged, but otherwise quite normal. On August 24th he was
shown in the theatre of the hospital. The groin was in a most satis-
factory condition, a slight bulge above the upper cicatrix being the only
evidence of the hernia which had existed; the superficial ring was
completely blocked by adhesions; the testis had resumed its normal
size, and gave no trouble nor pain. Promised to apply in case of a
return.
Case 29.-John Belman, æt. 22, a sailor, discharged from H.M.S.
on account of a rupture, which had existed ten months. It was direct,

CASE XXX.
293
scrotal, large, and on the right side. Operated on in King's College
Hospital, May 4th, 1861, by the ordinary wire operation (page 107),
one end of the wire only being passed across the sac. The rupture was
easily reducible; the groins and genital had the imperfect foetal outline
strongly marked. 5th.-Did not sleep much on account of the pain;
tongue white; pulse 80; belly soft, not tender on pressure; no swelling
of the testis or scrotum. 6th.-Slept better; testis and scrotum a little
swelled; tongue white; pulse 80. 7th.-Complains of a slight griping
pain in the belly; no tenderness on pressure, no tympanitis, nausea, or
sickness; tongue white; pulse 80. Bandage removed; water dressing;
fomentations; pil. sapon. co., gr. v. every four hours. 8th.-Pain
entirely gone; feels much easier; testis more enlarged; effusion can be
distinguished in the fundus of the sac; little discharge of thick pus.
9th.-Bowels freely opened by castor-oil; belly soft and pliant; scrotum
œdematous, testis enlarged, but of normal feel. 10th.-Has again a
little pain occasionally in the bowels, but the tongue is cleaner, and he
wishes for a mutton chop. 11th.-Pain entirely gone; swelling of
testis and scrotum much diminished; testis not tender; scarcely any
discharge from the wounds. 13th.-Apply pressure by spica bandage;
middle diet, and half pint of porter. 18th.-Doing very well; sac can
be felt in the scrotum above the testis, hard and contracted. 20th.-
Wires untwisted, and one withdrawn without trouble and very little
pain, the other removed next day; slight serous discharge. 22nd.-
Patient about the ward; mass of consolidation evident in the canal.
30th.-Wounds closed; discharged. This patient was seen by me on
June 7th, July 18th, and August 10th. The indurated mass gradually
diminished, and at length disappeared; some varicose thickening upon
the cord was then apparent, a little enlargement of the testis remaining.
Thinking this might result from the pressure of the truss he was
wearing, which was not a very good one, and which chafed the skin,
I directed him to leave it off altogether. On October 26th, I again saw
him. He stated that three weeks after he left off the truss, he having
worked in the interval as a foundry man, while at work, he felt the
rupture give way. On examination, I found that it had returned to
about half its former size into the upper part of the scrotum, with a
decided cough impulse. The adhesions had not been able to resist the
test of lifting the foundry hammer without truss. Stated that he in-
tended to have the operation repeated when he has a little holiday.
Case 30.-John Carter, æt. 18, operated on June 8th, 1861, at
King's College Hospital, for a right, oblique, scrotal rupture of seven
months' duration. The operation was the usual one by wire.

294
APPENDIX OF CASES.
9th.-Passed a comfortable night by the aid of the pill, but had pain in
the groin for an hour or two; tongue slightly furred; pulse 86.
10th.-Had a good night, but has more pain this morning; no sickness,
tympanitis, or tenderness anywhere in the belly except near the groin
operated on; tongue and pulse as in last report; fomentations.
11th.-Pain almost entirely gone; testis rather swollen; some oedema
of the scrotum; bandage removed for the first time; very little serous
discharge, which passes freely through the puncture. 13th.-No pain
since last report; a small quantity of pus at the upper aperture; tongue
clean; pulse 76; bowels not yet open; swelling of the scrotum more
defined, and the testis can be distinguished from an elastic tumour placed
above it, which evidently arises from an effusion into that part of the
infolded sac which remains in the upper part of the scrotum. 15th.-No
pain whatever; bowels not moved, although two doses of castor-oil
have been given; hardly any discharge; the upper loop of the wire
twisted more closely down into the puncture; to have a full dose of
house medicine, and an enema. 16th.-Bowels moved freely by the
medicine; feels relieved. 18th.-Is quite well in health; the swelling
in the upper part of the scrotum is very tense, and moves freely
above the testis. To-day I made a puncture with a grooved needle
into its centre, and evacuated an ounce and a half of a deepish yellow
clear fluid, which was found, by the addition of nitric acid, to be highly
albuminous; the cord could then be clearly distinguished behind the
folded sac;
the testicle has nearly recovered its normal size.
20th.-Doing very well indeed; no pain; very little discharge, hardly
half a drachm daily; good appetite; bowels regular. 24th.-Wires
removed to-day without difficulty by untwisting the lower ends, and
drawing on the upper loop, without dividing it into two portions, as in
former cases. A hard mass was felt along the course of the canal from
the scrotal to the groin puncture. 26th.-A little more discharge since
the withdrawal of the wire, and a slight return of the effusion into the
fundus of the sac. 27th. On examining the parts closely to-day, a
hard mass is found blocking up the external ring, a fluctuating tumour
below it, and then, in the bottom of the scrotum, the testicle tolerably
distinct, and hardly at all enlarged or tender; the scrotal puncture
nearly healed; discharge very scanty; to have an evaporating lotion
applied constantly to the scrotum, and a dose of house medicine.
29th.-Up to-day, and about the ward, with a spica bandage and
compress on the groin; swelling above the testis much diminished; no
pain on pressure; wounds filled with granulations, and hardly any
discharge; much thickening about the inguinal canal; scrotum well

CASE XXXI.
295
braced up to the external ring. July 3rd.-To-day the patient left
the hospital with the wounds quite healed, and wearing a light truss.
Aug. 24th.-To-day the patient was exhibited in the theatre of the
hospital; has worn the truss in the daytime only when at work; the
external ring on the side operated can barely be distinguished by the
finger; cough impulse arrested at the internal ring above the upper
cicatrix. A slight bulging at the point is observable on both sides
equally; feels the side operated on stronger than the other; will apply
immediately he observes any change; has to wear a light double truss
for a few months. On Jan. 20th, 1862, this patient was again seen;
no change had occurred; superficial ring quite blocked up by adhesions;
a slight bulging apparent at the site of the deep ring; scrotum well
tucked up on that side. June 21st.-Shown to-day in the theatre of
the hospital; no change; the superficial ring quite impervious; the
bulging at the side of the deep ring still present, and evident to some
extent on both sides.
Case 31.-Joseph Andrews, æt. 3, a pale, unhealthy-looking child,
with a congenital hernia affecting both sides, that on the right side
descending into the scrotum. Two trusses have been tried, but failed
in keeping up the right side; the last caused so much swelling of the
testis that it was necessary to discontinue it. Operated on at King's
College Hospital, June 8th, 1861, on the left side first with a view of
closing the patulous canal. The rectangular pins were employed, and
applied in the manner given at page 131, and in Figs. 40 and 41. The
case was a favourable one for testing the effect of the pins upon
the canal,
as applied on each side in the two different ways described in the text.
After four days the pins were withdrawn, and a compress and spica
bandage applied. The child suffered very little from the operation,
although in a sickly state of health, and with occasional cough; the
right testicle was also at this time enlarged. Cod-liver oil and the syr.
ferri iod. were at the same time administered. After a short time,
however, diarrhoea, from teething, came on, and the oil was discontinued,
as it appeared to sicken the child and to act on the bowels. Notwith-
standing these unfavourable circumstances the pin punctures speedily
healed, only a little serous discharge having been induced, and the
closure of the ring and canal was very complete and satisfactory on
this side. On the 11th July, 1861, the right side was operated on; the
testicle had, by this time, somewhat diminished in size, and the right
hernia had increased rapidly under the effects of the cough. In the
second operation a more horizontal direction was given to the pins, as
described at page 135 (Figs. 43 and 44). The child was taken home

296
APPENDIX OF CASES.
by the mother. On visiting him in the evening, he was found in a
quiet sleep (without sedative), having been apparently as well as usual
since the operation. 12th.-Has not cried much, nor appeared to suffer.
from the presence of the pins; bowels open, and urine free; was again
asleep at the time of the visit; is taking no medicine whatever.
13th.-To-day the bandage and lint were removed; no redness nor
discharge about the punctures; testis not more enlarged; no swelling in
the groin; bowels open every day once; bandage and lint replaced.
July 16th.-Pins removed to-day, as a considerable amount of indura-
tion was apparent in the canal, and slight oedema of the scrotum, and
oozing of serum from the inner puncture. Has not cried more than
usual since the last report, and appears to suffer very little; pad and
spica bandage. 17th.-A good deal of consolidation apparent in the
canal and scrotum; a slight serous discharge from the upper puncture,
and a more purulent one from the lower; oedema disappeared; a light
truss applied to the interval between the punctures. 20th.-Punctures
entirely healed; no impulse felt on crying, nor increase of swelling in
the groin; child thin and pale. The room in which it lives is close
and confined, and the odour unpleasant; is in very unfavourable con-
ditions for health; continue constant wearing of truss. 27th. Child
suffering much from diarrhoea and teething; belly tumid and enlarged,
with the appearance and hard feel of mesenteric disease; an enlarged
gland under the left ear, which is tender on pressure, and red. Ordered
decoction of logwood mixture after each evacuation, and a powder of
compound chalk powder and hyd. c. cret. night and morning. From
this time to Sept. 21st the poor child was constantly ill from teething,
cough, or diarrhoea; it was wasted and pale, with a tumid belly and
enlarged cervical and submaxillary glands; cries and coughs a great
deal; the groins continue, however, to resist these unfavourable cir-
cumstances. Saw the patient in the above interval five or six times;
the left groin was uniformly close, firm, and resistant; the right
testicle continued a little enlarged, but varied in size with the condition
of the child's health, as did also the cervical glands. The empty sac of
the hernia could be felt in front of the cord at the upper part of the
scrotum, and seemed to be gradually contracting and shrinking upwards.
On carefully examining the child during a paroxysm of crying, I could
not detect any increase or swelling in the sac. The child was very
thin and ill at the time with cough. Dec. 6th.-On examining the
child to-day, I found him much improved in health and appearance,
much fatter and stouter. The testis has now returned to its normal
size, and the cervical glands nearly recovered. The mother states that

CASES XXXII., XXXIII.
297
two or three times, when the child was crying or coughing, while stand-
ing, and without the truss, she has observed a small protrusion below
and to the outer side of the former rupture, but not one-third its size,
and not descending into the scrotum; she states, moreover, that it
never appears when the truss is on, as it used to do before the operation.
Although the child cried much during my examination of the parts, I
could not detect any protrusion; the sac could be felt, and appeared to
have shrunken in size since my last examination. This case on this side,
then, may be considered as not completely satisfactory at the present
time; but it is reasonable to expect that the pressure of a proper truss
will complete the closure of the internal opening, as the operation has
done to the external part of the sac after a little time has elapsed.
March 16th, 1863.-To-day I saw the child again; his mother informed
me that there had been no return of the protrusion on the right side since
I had last seen him, however much the child cried. There was no pro-
trusion felt, on coughing without truss; the left groin remained perfectly
cured.
Case 32.-Richard Henry Terry, æt. 5, operated on at King's Col-
lege Hospital, July 20th, 1861, for a left congenital hernia, descending into
the scrotum freely. The operation was done by the rectangular pins, as in
Figs. 40 and 41. During the whole course of the case not a single
symptom worth recording occurred; the child not suffering in the least
from the presence of the pins. The spica bandage was removed three
days after the operation, and the lint five days after. At this time
there was no irritation whatever of the puncture, and throughout the
whole case only a little serous discharge. The pins were removed
without difficulty, and with little pain, on the 27th of July, when a
truss was immediately applied between the punctures, and the latter
dressed with dry lint. In six days more the punctures were quite
healed, and the patient left the hospital with instructions to wear the
truss constantly for two or three months, and to apply again if any
return was observed.
Case 33.-Charles Vellam, æt. 13, operated on at King's College
Hospital, Aug. 17th, 1861, for a left, oblique, scrotal hernia, of one
year's standing. In this case the larger rectangular pins were applied
longitudinally. From the straitness of the canal some doubt was en-
tertained whether the invaginating finger (the little finger was used) was
passed fairly behind the internal oblique muscle; and consequently,
whether the conjoined tendon was taken up in a satisfactory manner.
19th. No symptoms; no pain; bandage removed. 21st.-Lint and
straps removed; no suppuration. 24th.-Pins removed easily; a drop

298
APPENDIX OF CASES.
or two of pus followed their withdrawal. Has had no pain whatever
except when the parts were touched; bowels open three days ago by a
little castor-oil; to have middle diet, and half-a-pint of porter.
29th. Continues in good health; upper opening nearly healed; lower
admits the probe to the depth of three-fourths of an inch, and dis-
charges a few drops of thin pus daily; a hard cylindrical consolidation
evident in the track of the pins completely obscuring the external ring.
A little cedema of the scrotum, and slight enlargement of the testis is
apparent, with some tenderness; testis to be supported and fomented.
Sept. 1st.-Doing very well; testis still a little tender, but not larger;
lower puncture still discharging a drop or two of pus. 5th.-Lower
puncture healed; tenderness of testis diminished. 7th.-Tenderness
gone; upper opening still oozes serum, although a very minute point.
9th. Both punctures healed. 11th.-To-day the patient left the
hospital, wearing a truss fitting between the punctures. Sept. 21st.-
Exhibited to-day in the theatre of King's College Hospital. The groin
is firm and resisting; a slight bulging apparent at the upper puncture
when he coughs; the pressure of the truss has caused a blister over the
pubic spine; the truss was directed to be altered; but this being
neglected, on Oct. 21st he applied at the hospital with a swelling of the
testis and enlargement of the cord on the side operated on. The swelling
is tender on pressure, and gives the feel of varicose veins; no impulse
on coughing whatever. To take a dose of opening medicine, and to
leave off the truss altogether, and foment the parts. On the 26th,
the tumour was less tense, and could be felt to fluctuate from
fluid contained in the fundus of the sac. No impulse is felt on
coughing by the finger placed on the external ring; testicle less
tender, and more of its normal size; fitted with a light truss and
soft pad. Nov. 24th.-Brought to-day to my house. I find the truss
is so weak now as to be powerless. There is now very little enlarge-
ment of the testis, and the wormy feel of the cord has disappeared;
there is, however, more impulse in the canal than on my last examina-
tion; the bulging at the upper cicatrix, which always existed, is now
more directed in the axis of the canal. Probably, in this case the con-
joined tendon was not taken up by the pin; and the effusion in the sac
and enlarged spermatic veins, irritated by the galling of the badly-
fitting truss, have contributed to open up the hernial canal to some
extent; truss fastened so as to press more upon the internal ring.
Case 34.-Robert Headlin, æt. 5, operated on at King's College
Hospital, Aug. 24th, for a right, oblique, inguinal hernia, of six months'
standing. The external ring admitted easily the little finger, and the

CASE XXXV.
299
hernia descended freely into the scrotum upon the testis. The smaller
kind of pins were used in this case, and turned upon each other two
turns, so as completely to twist up the sac. 27th.-Has had no
symptoms and no pain whatever; bowels not opened; bandage re-
moved. 29th.-Dressings removed; no pus; slight chafing by the
point of the pin on the scrotum. Dressed with oiled lint; no bandage.
Sept. 3rd.-Pins extracted; a hard cord apparent in their track; no
suppuration whatever; no swelling or tenderness of the testis or
scrotum. 5th.-Doing extremely well; no pain whatever. 7th.-Punc-
tures very nearly healed. To have a soft light truss fitted between the
punctures, and to get up and walk about. 11th.-To-day the patient
was discharged with the punctures healed; a hard, firm groin; no cough
impulse; less impression on crying at the groin operated on than on the
opposite; consolidated band obscuring the external ring. To be brought
back to the hospital directly any change is observed.
Case 35.-Thomas Wheatley, æt. 57 (looking much older), operated
on at King's College Hospital, Aug. 24th, 1861, by the usual wire
operation, for the cure of a left oblique hernia, descending half way into
the scrotum, with a wide, loose, and patulous neck of the same diameter
as the fundus. It had been observed three months only, but was
rapidly increasing. Both groins very lax and bulgy. The patient had
a nervous, irritable, sallow look, with a yellowish tinge of skin. For a
week or two past has had a bad diarrhoea, which has weakened him
much. Was very anxious to have the operation done at once. Com-
plained, after the operation, of pain, and also of the tightness of the
bandage, which was thereupon slackened. Milk diet; pil. sapon. co.,
gr. v. every six hours. 26th.-Has been very restless; complains of
pain in the groin; respiration abdominal; no tenderness nor tympanitis
in the belly; pulse 72; tongue covered with a white fur; fomentations
over the bandage. 27th.-Much easier to-day and yesterday; no sick-
ness; takes his food with relish, and feels hungry; pain on pressure
over the groin operated on; respiration abdominal; tongue white;
pulse 72; some oedema of scrotum; bandage removed; scrotum sup-
ported by straps of adhesive plaster across the thighs. Continue the pills;
hst. ammon. acet. e. sp. æther. chloric., three times a-day. 29th.-Con-
tinues much easier; tongue still furred, drier, and slightly brown in the
centre; pulse 70, compressible; bowels not open since the operation;
dressings removed; considerable discharge of creamy pus; skin between
the punctures red and swollen, the redness extending upwards along
the groin. At the lower aperture a slough of the fascia is apparent,
and the odour is slightly foetid; the upper puncture is matted up

300
APPENDIX OF CASES.
round the wire by inspissated pus. Since the removal of the bandage,
the patient has moved about much in the bed, and the loop of wire
seems to have been caught in the bed-clothes frequently; wire un-
hooked, upper end untwisted and cut off short; dressed with strips of
wet lint and oilskin. The redness and oedema of the scrotum nearly
gone; testis slightly tender. To discontinue the opium, and take acid.
sulph. dil. mx., sp. æth. chloric. mx., and decoct. cinch. 3j. t. d. s.
30th.-Feels much better to-day, but complained of seeing spectra
during the night, and brooded much over some depressing family
matters. The night nurse reports that his mind wandered a little in
the night. He looks rather excited; tongue less furred; pulse 68,
compressible. On ordering 6 oz. of wine daily, I find that he has been
having every day since the operation 6 oz. of brandy without
my know-
ledge; it being my rule to administer no stimulants whatever in these
cases unless the symptoms decidedly require it. To have a chop if he
can eat it, and continue the brandy, but no wine. 31st.-Last night
the delirium returned much more severely; he became violent, got up
out of bed, tore off all the dressings, and tried to get out the wire, shouting
and gesticulating, and behaving exactly like a man in delirium tremens.
One drachm of laudanum, ordered by the house surgeon, was only par-
tially effective in diminishing the excitement; pulse 100; tongue
furred; respiration abdominal; no tympanitis whatever, nor tenderness
on pressure over the belly and groin. Little discharge from the
punctures, which show within a sloughy margin, and give out a
distinctly fœtid odour. Sept. 1st.-Last night the symptoms were
again very violent, much difficulty was experienced in keeping him in
bed, and he was constantly fingering and tugging at the wire. He
afterwards described the spectra he saw, as if the various articles of
furniture in the ward were dancing about him, and faces leering at and
mocking him. A drachm and a-half of tinct. opii was administered to
him, which had the effect of throwing him into an uneasy slumber or
stupor, in which state he continued at the visit in the middle of the
day. The breathing was sonorous; the countenance dusky; the nails
rather blue; free perspiration on the face; the pulse was 72, firmer and
quite regular in its beats. The skin about the punctures was livid, and
the discharge was scanty, serous, and foetid. The wires were completely
untwisted, but the attempt to withdraw them roused the patient from
his partly comatose condition, and he resisted so much with both
hands and feet, that it was deemed advisable to leave them in the
wound for the present; water dressings and bandages. 2nd.-The
patient remained eight hours in the state above described. At night

CASE XXXV.
301
half a drachm more of laudanum was given, and the brandy increased
to 10 oz. daily. He passed a quiet night, and in the morning felt
much relieved, and said he had slept well, without dreams or spectra;
pulse 74. Ordered to continue the brandy (10 oz. daily); and to take as
much strong beef tea as he feels inclined for, with a mutton chop and
eggs, and the following draught: quinæ disulph. gr. viii., morphiæ
hydrochlor. gr., sp. æther. chlor. mx., acid. sulph. dil. mx., aq. 3j., every
four hours. 3rd.-Much better to-day in every respect; tongue
moist, less furred, not brown; is perfectly self-possessed; no more
spectra or delirium; eats his food with relish; pulse 60, firmer;
bowels open freely to-day, but not purged. No tenderness, tympanitis,
or tumefaction whatever about the belly or groin; no sickness or
vomiting; no swelling, tenderness, or oedema about the testis, cord, or
scrotum. The punctures look much better; the sloughs are limited to
the margins of the openings, and are becoming separated by granula-
tions all round; they seem to have been produced chiefly by the
constant friction and working at the wires in his delirium. The dis-
charge is now plentiful, thick, and creamy, scarcely any fotor being
evident. The wires were to-day withdrawn, upward, very easily,
bringing away a small film of slough from their track. 5th.-Con-
tinues much better; quite free from delirium; eats and sleeps well;
pulse 72. Bowels open to-day and yesterday; a long, thin thread of
slough drawn out of the wire track; florid granulations freely spring-
ing up; discharge less profuse, thick, and creamy; continue water
dressing, and diminish the brandy daily by 1 oz.; continue the
quinine and morphia mixture. From this time he constantly and
uniformly improved, sleeping and eating well, and looking better every
day. On the 14th, he got up and walked about the ward, the openings
being filled by healthy granulations, and ceasing to communicate with
each other; pad and spica bandage.
On the 18th he discontinued the
23rd he was discharged. The
medicine and brandy; and on the
punctures were very nearly closed, oozing out a little serum; a great
deal of thickening in the canal; no impulse whatever on coughing. On
Oct. 18th, the patient presented himself for examination, not wearing a
truss, with a very favourable account of his increase of strength for work
since he was operated on. The groin was found to be bulgy and fuller
than the opposite one, but the cough impulse was arrested by the adhesions
at the upper cicatrix; promised to let me know if the groin got weaker.
The delirium in the above case was clearly due to the continuous
administration of brandy (6 oz. daily) to a man on low diet, unaccus-
tomed to its use, reduced by a previous diarrhoea, and troubled (as he

302
APPENDIX OF CASES.
explained to me afterwards) by family matters. The symptoms were
clearly those of delirium tremens, and were entirely allayed by the free
use of opiates. The restlessness and exertions of the patient tried
severely the immediate security of the sutures, but they resisted well,
although not assisted by a bandage, and the case made a rapid recovery.
Not a single abdominal symptom made its appearance in this case,
I hear from Mr. Kingdon, surgeon to the City Truss Society, that this
patient afterwards applied to him for a truss in Nov. 1862. Mr.
Kingdon states that the rupture had again reached as far as the external
ring, at which it protrudes. The patient stated that it reappeared six
weeks after the operation. In this case the structural weakness origi-
nally apparent in the groin was further increased by the sloughing
which followed the operation. Partly to this I attribute the ultimate
unsatisfactory result, and in part to his not having worn a truss after
the operation, to protect the newly-formed tissues during labour.
Case 36.-Mary Dobson, æt. 27, operated on in King's College
Hospital, for a right, oblique, labial hernia, of four months' standing.
The operation was a modification of the usual wire method without
transfixion of the sac, but simply twisting up the wire after the inner and
outer boundaries were secured in the loop. Operation performed
Sept. 21st, 1861. 22nd.-Very little pain; does not complain. 24th.
-Bandage removed. 28th.-Going on extremely well; tongue clean;
bowels open; no symptoms whatever. Oct. 1st.-Consolidation in the
wire track evident; very little discharge; no pain. 10th.-Wires re-
moved to-day without difficulty. Water dressing; bandage. 14th.-
Got up to-day and about the ward; discharge slight and serous. 17th.
-Punctures quite healed; much thickening; is in excellent health.
To have a truss fitted, and to be discharged. Nov. 30th.-To-day, the
patient presented herself for examination, wearing a light truss. A
hard cord blocks up the external ring, and extends quite up the canal.
A little bulging at the internal ring; no cough impulse whatever.
On the last occasion that I saw this patient, a few months ago,
the
bulging in the groin remained in the same condition, a slight impulse
being also felt when the patient coughed violently without truss. Re-
commended to continue the use of the truss so long as the weakness
remained.
Case 37.-John Smith, æt. 23, a prisoner in the Millbank Peniten-
tiary. Had a large, direct, scrotal hernia, of two years' standing, on
the left side, with a very lax internal opening, admitting three fingers.
Operated on October 5th, 1861, by wire in the ordinary way; during
the passage of the wire through the conjoined tendon it gave way and broke

CASE XXXVIII.
303
off; the needle was reapplied, but with less certainty as to the hold
upon the conjoined tendon and edge of the rectus. Milk diet; pil. saponis
co., gr. v. h. s. s. 7th.-Doing extremely well; no pain in the belly,
which is soft and compressible; tongue clean; pulse 72; skin open;
eats and sleeps well. Bandage removed; very little serous discharge;
leave off pills. 13th.-Doing very well; has not had an unpleasant
symptom; slice of meat, and wine ziv. daily. 20th.-Removed the
wire; very little discharge; induration not well marked; pad and
spica bandage. Nov. 4th.-During the last week, after he had been
up and about the ward for some days, while at the water-closet, straining
hard, and without truss, he felt something give way in his groin, and
the tumour reappeared; at first but slightly, and to the inner side of
the scar; but afterwards on the outer side also, after another sense of
something giving. The hernia, on examination, proved to be in the
same condition as before the operation. The patient much wished the
operation to be repeated. Accordingly, on the 28th of December,
1861, this patient was again operated on, by the wire operation figured
in Fig. 36, page 123, crossing the wires within the canal over the deep
opening, and using a broad boxwood compress to fix the wires at the
surface. 30th.-Patient doing very well; some swelling of the testis;
not a single bad symptom. Jan. 6th, 1862.-Doing very well; very
little discharge; testis enlarged, but not tender on pressure. 15th.-
Much induration in the canal and about the groin; wires untwisted
and pad removed; some slight febrile symptoms; a small abscess,
which had formed under the skin of the groin over Poupart's ligament,
was opened, and about a drachm of thick, yellow pus evacuated.
23rd.-Wires withdrawn with great ease; induration very extensive
and hard; punctures filled with granulations; no cough impulse was
apparent. From this time up to that of his discharge from the prison,
I was informed that no return of the rupture had occurred. When he
left, he wore a truss, and was recommended to apply to me if the
tumour returned, which he promised to do. I have not seen him since
that time.
Case 38.-James Perkins, æt. 18, operated on in King's College
Hospital, for a left, direct scrotal hernia, of twelve months' duration; the
finger passed freely into the abdominal cavity. The usual wire opera-
tion was performed, Oct. 19th. On the evening visit, he was found
asleep. 20th.-Tongue rather white; pulse 96; skin hot; no tender-
ness of the belly, but the testes rather tender, and the scrotum oedema-
A gonorrhoea has appeared since the operation; ardor urinæ
and discharge. To syringe warm water into the urethra frequently
tous.

304
APPENDIX OF CASES.
during the day.
Haust. effervescens 3j 4tis horis sum.; pil. saponis co.,
gr. v., n. m. que. 21st.-Better; oedema gone; no pain, hardness, or
tenderness in belly; tongue cleaner; pulse 95; much scalding. 22nd.-
Bandage removed; testis still tender and enlarged; much gonorrhoeal
discharge; tongue cleaner; pulse 96; no sickness; belly soft; eats
well, but does not sleep well. 23rd.-A good deal of fever to-day;
tongue white; pulse 100; has had pain across the back, but it is better
to-day; abdomen carefully examined; no tenderness or distension felt
on pressure, either deep-seated or otherwise, anywhere, except in the
immediate neighbourhood of the wounds; testicle still swollen, and
scrotum more oedematous; a small collection of matter had formed at
the lower puncture (which has nearly healed by the adhesive process).
This was evacuated and well pressed out; no sloughs or redness; the
scrotum is puckered up to the lower opening and obstructs the exit of
the discharge. Dressed with wet lint, and without bandage. To have
castor-oil 3ss. 24th.-Fever still continues; bowels not yet opened;
testicle still tender, but the cedema of scrotum has nearly disappeared;
gonorrhoeal discharge profuse. 28th.-Feels better; bowels freely
opened twice by the oil; tongue less furred; pulse 94; skin less hot;
more discharge from the lower puncture; very little from the upper;
testis less tender and swollen; wishes for meat. To have 4 oz. of wine
daily, and a slice of meat, if better, to-morrow. 26th.-Very much
better; pulse 92; tongue cleaner; more discharge from scrotal
puncture, and also from urethra; less thirst and fever; complains only
of scalding; eats his food with relish. 28th.-Continues much better
fever gone; pulse 86; tongue slightly furred; skin cool; no tender-
ness of abdomen, which is quite soft; less discharge from the punctures,
more from urethra. 29th.-Improving daily; complains only of scald-
ing. To have lotio plumbi injected five or six times a day, and nitric
acid and cinchona mixture. 31st.-Gonorrhoeal discharge much better;
swelling of testes nearly gone; induration very evident in the track of
the wire. Nov. 2nd.-Removed the wire to-day; doing very well;
very little discharge; gonorrhoea better; eats well. 8th.-Gaining
strength fast; no scalding. Got up to-day and about the ward. 14th.
-Punctures very nearly healed; to be fitted with a truss and dis-
charged. As the gonorrhoea still continues, to have a copaiba mixture
three times a day. Dec. 2nd.-Showed himself in the operating theatre
to-day. No impulse whatever on coughing; external ring completely
closed up; no enlargement of the testis; gonorrhoea well; to let me
know directly any change occurs. Feb. 2nd, 1862.-Came to the
hospital to-day, wearing a light truss. The parts are very firm; the

CASES XXXIX., XL.
305
superficial ring entirely closed; no impulse whatever; testicle normal
in size and feel. Is much stronger in the groin since the operation.
Will let me know if any change occurs.
Case 39.-Lewis Solomons, æt. 21 years, operated on by pins for a
large, congenital, scrotal hernia on the right side, Oct. 19th, 1861.
He is a very fat child, with a violent, petted temper, and cries a
good deal. 20th.-Pretty well to-day; has not cried much; bowels
moved freely; eats well; abdomen soft; some oedema of scrotum.
21st. More swelling of scrotum to-day; the end of the pin chafes the
skin there, and it is sore and painful, the dressing having been
wetted with urine and shuffled off. Bowels open; rather feverish.
Poultice to the scrotum and lint to protect the skin from the pin.
22nd. More restless last night; was sleeping when visited. Less
redness and swelling of the scrotum; slight oozing of serum; eats well;
bowels open. 23rd.-Feverish and fretful; skin covered with a red
rash, and a cough has appeared; considerable cedema of the scrotum and
prepuce; slight discharge of pus; passes his water well. On account of
the appearance of the rash, and the prevalence of scarlatina in the neigh-
bourhood, it was thought better to withdraw the pins to-day. Saline
mixture and poultice. 24th.-Fever and rash continue; swelling of
scrotum much less; a little discharge from the punctures; bowels open.
25th.-Much better; swelling nearly gone; very little discharge.
Nov. 4th.-There is now much induration in the canal; no cough impulse
whatever, though he cries and struggles a great deal when touched,
using much exertion; punctures nearly healed; to have a truss fitted.
11th.-Came to the dispensary to-day with a light truss on. Groin
in every way very satisfactory; scrotum shrunken in size; sac can be
felt empty and shrivelled. May 19th, 1862.-To-day the child was
shown in the operating theatre of King's College Hospital, and examined
by numerous visitors. No tumour whatever has appeared since the
operation. Child looks much better, and is stronger and more healthy
than before. Still wears a light truss. On taking off the truss,
and causing the child to stand up, no impulse whatever can be distin-
guished on coughing or crying; the superficial ring is well closed by
adhesions; scrotum much contracted; testis normal. Has been seen
since quite lately, and remains quite well.
Case 40.-John Bodal, æt. 25, an Irish bricklayer's labourer, applied
at King's College Hospital with an enormous direct inguinal hernia, on
the right side, which came suddenly after a bad fit of coughing, a fort-
night ago.
The rupture is of the size of two fists, protrudes readily,
and swells enormously on coughing. Operated on by the ordinary wire
X

306
APPENDIX OF CASES.
operation (page 109) Jan 11th, 1862. The bandage was kept on till
the 14th; the patient having slept well each night; very few or no
symptoms being present. On that day complained of more pain in the
groin; bandage removed. 15th.-Still complains of pain in the groin;
none in the belly; no tympanitis; bowels not open; very little dis-
charge; pulse 79. To have castor-oil. 16th.-Much more discharge;
less pain; pulse 80; bowels freely opened; poultice applied. 23rd.-
Has been doing very well; bowels open regularly; eats and sleeps
well. A small superficial slough at the lower opening. 27th.-Slough
removed; wounds look well; water dressing. 30th.-Much consolida-
tion; testis a little swollen. 31st.-Wires removed without difficulty;
canal filled by hard effusion. Feb. 10th.-The openings have now
entirely healed; no impulse or protrusion whatever on coughing; the
hernial opening seems to be quite closed. Discharged, wearing his old
truss. May 7th.-Applied to-day; has been working ever since his
discharge as a Covent Garden porter, lifting very heavy loads on his
back. Has had latterly, in addition, a very bad cough, which has
given him some pain in the groin. The superficial ring is now more
evident to the finger, but the cough impulse does not seem to affect it.
June 20th.-To-day he again applied, complaining that on taking off
his truss the other night, after a hard day's work, and a severe
coughing fit, a small tumour appeared in the groin. On examina-
tion the ring feels more patulous, but still the tumour does not at
once appear on coughing. The sides of the ring are hard and resisting.
Recommended to get a lighter employment, and to wear his truss night
and day while he has the cough. I have since seen this patient several
times; on one occasion a tumour of the size of an egg was evident when
he coughed very hard. The protrusion had evidently returned to some
extent, but was not a tithe of the size that it was before the operation,
and is now easily retained by the truss. Says it has appeared three or
four times to some extent, but never unless the truss was removed. Can-
not get a lighter employment. This case, in consequence of the poor
fellow's necessity of doing very heavy work for the support of his family,
and his violent cough so soon after the operation, has thus returned to
some extent. The directness of the opening into the abdomen, and, per-
haps, the adoption of the simpler operation for its cure, although so large,
have no doubt rendered the adhesions less efficient in retaining the rup-
ture. The powerful muscular development in the patient, especially of
the recti abdomines, has also aided in reproducing the rupture to the
limited extent which it now possesses. Another operation was proposed,
affording, as I believe, a very good chance of ultimate complete success,

CASE XLI.
307
but was declined by the patient for the present, on the score of his
necessity for daily provision for his family.
Case 41.-H. C., æt. 28, a surgeon in the Indian army, who has
himself many times successfully operated on natives in India by my first
method, applied to me for operation on an oblique inguinal hernia on
the left side, of eight years' duration. Has been on service in India the
last four years, and finds the rupture very inconvenient, often painful
when riding, and getting larger, notwithstanding the various trusses
by the best London makers which he has tried, and which sometimes
fail to retain it. The trusses he has worn have all had convex pads.
The rupture is now scrotal, and of the size of a duck's egg. The
operation was performed Feb. 28, 1862, by the use of wire in the usual
manner (page 109). Had some pain during the night, allayed by pil.
sapon. co., gr. V. The day after, he had a difficulty in passing water,
more from the painful effect of muscular contraction upon the groin
than from obstruction. A catheter was passed, and the water drawn
off. A slight enlargement of the left side of the prostate was observed.
Next day, an elastic catheter was passed, after which it was no more
needed. Some irritation, scalding, and discharge from the urethra
followed, but subsided in a few days. Five days after, some flatulent
distension of the abdomen was present, but no tenderness on pressure
anywhere but in the groin. No sickness or nausea. A dose of castor-
oil opened the bowels freely, and removed all uneasiness. Takes his
food well, with a glass of sherry daily. The testis began to swell a
little two days after the operation, remaining larger and a little tender
for three weeks, then resuming its natural size and feel. Moderate
suppuration was present after the fifth day. The wires were removed
easily and together, March 21st (three weeks after the operation). On
the 27th, the apertures were so far healed that he got up, wearing a
light truss of the horse-shoe pattern. An injection of ten grains of
tannin to the ounce of water was used, for a week before the final
closure of the punctures. On April 12th, both wounds were entirely
healed. On May 5th, the scrotum was much tucked
and the super-
up,
ficial ring closed by a hard cicatrix. A very slight bulge was apparent,
on coughing hard, at the site of the internal ring on both sides; but
not more on that operated on than on the other. Feels the side as
strong as the opposite one. The irritation of the urethra has entirely
disappeared. June 10th.-Parts remain unaltered, even during the
hard course of coughing the patient was put under. On July 1st, a
slight giving was observable at the site of the conjoined tendon, opposite
the superficial ring, when the patient made a violent voluntary com-
x 2

308
APPENDIX OF CASES.
pression of the recti, holding his breath at the same time. No bulging
whatever was, however, then felt at the internal ring; no cough impulse
whatever; feels very well and strong; no return of urinary symptoms.
Sept. 10th, 1862.-Nearly seven months after the operation, he called
on me previously to his departure for India. Has been married since the
last date, and travelled over Switzerland. Looks well, and feels in first-
rate health, and much stronger than before the operation. The side
operated on has not changed at all; no weakness, bulging, nor impulse
on coughing whatever, is felt during the examination, although making
considerable muscular efforts. The conjoined tendon seems to have
recovered its tone and resisting power perfectly. Close above the pubis,
at the inner side of the cord, a very small opening in the superficial
ring is apparent, not admitting the point of the finger, and giving no
impulse on coughing. Above, this is circumscribed by a firm, strong
band of adhesion, uniting the pillars of the ring. Testis and cord per-
fectly normal; no return of urinary symptoms; the patient is very
much satisfied with the result. Recommended to continue the horse-
shoe truss for some months longer.
Case 42.-William Stride, æt. 22, operated on March 29th, 1862, in
King's College Hospital. Has a double oblique inguinal rupture; that
on the left side has been observed five years; it is now scrotal, and of the
size of an orange, with lax orifices and wide neck. On the right side
is a bubonocele, lately appeared. Trusses inefficient in keeping up the
left rupture at his work, in the government factory at Woolwich. Left
side operated on by the usual wire suture. Slept the night after the
operation with the aid of pil. sapon. co. No tympanitis, nausea, or
swelling of the testis supervened. Bowels opened by castor-oil three
days after the operation; suppuration very moderate. Wires removed
on the fourteenth day. Walked about the ward three weeks after the
operation. Discharged three days afterwards with the punctures com-
pletely healed, and wearing a double horse-shoe truss. On May the 9th,
and again on the 19th, was examined; no change was observed. The
general impulse of the abdominal walls on cough was very markedly
arrested at the upper cicatrix, affording a strong contrast to the opposite
groin, in which it descended to the superficial ring. The ring on the
side operated on is completely filled by a firm cicatrix. Promises to
apply immediately any change occurs. Sept. 29th.-Saw this patient
to-day; no impulse whatever on the side operated on; complete
closure of the canal above the superficial ring. Still wears a truss
during the day. Feels stronger on the side operated on than the other,
which is unaltered in its appearance. Has since been shown in the
theatre of King's College Hospital several times. In February, 1863,

CASE XLIII.
309
this patient was again examined; no change whatever was apparent on
the side operated on; the external ring quite obliterated; cough
impulse arrested at the deep ring; tested freely by coughing without
truss. Still wears a double truss when doing work, to support
the opposite side, which feels now much weaker than the side
operated on.
-,æt.
Case 43.-W. B, æt. 32, a gentleman of exceptionably nervous
and susceptible temperament, a patient of my friend Dr. H. Stavely King,
of Brook-street, applied with an oblique scrotal rupture on the right
side, of the size of a large orange, which had been present for the last
three years, and was very difficult to manage with a truss. Has worn
trusses of every kind, all with convex pads. States that the rupture,
and the opening through which it passes, have been steadily increasing
in size, so that, at present, it passes directly out of the abdomen. The
truss at present worn (the most effective he has had) evidently presses
into and dilates the superficial ring. A decided varicocele is coexistent
in the cord of the ruptured side, and can be felt with the finger to
extend upwards into the canal. States that this increases enormously
in size when straining at stool, even though the truss keeps up the
rupture. The sides of the opening are slender and loose, and dilate
easily under pressure. Much pain is experienced in invaginating the
scrotum upon the finger into the canal. Is not in very good health,
having had oxalates in the urine several times, and latterly been troubled
with boils; is very anxious to have something done to cure the hernia.
Operation performed by wire in the usual way, March 12th, 1862.
The presence of the varicose veins in the canal prevented so high an
application of the sutures as might have been desirable, the bunch of
veins doubled up with the invaginated fascia into the canal, obscuring
considerably the internal opening and edge of the conjoined tendon.
The care required to avoid them with the needle contributed to prevent
a distinct perception of the transfixing of the conjoined tendon.
13th.-Had hiccough and retching during the night; some tympanitis
in the abdomen; pain at the site of the operation only; pulse 75;
bandage removed; water dressing; hot fomentations. 14th.-Fever
apparent to-day; borborygmi heard; pulse 75. 15th.-Suppuration
established; tongue white and furred; pulse 75. 16th.-Complains
much of flatulence; enema of oil of rue 3j. and gruel, which brought away
no results. 17th.-Had calomel and colocynth pill and black draught,
which results in a large motion of a very offensive character. 18th.-Had
a disturbed night; flatulent distension entirely disappeared; pulse 90.
Dressings at the lower wound discoloured by dark-coloured blood;
suppuration at upper wound favourable; water dressing. 19th.-Better

310
APPENDIX OF CASES.
night; pulse 75; tongue cleaning; slight oozing of blood at the lower
puncture continues; a few granulations apparent at the punctures;
complains of pain in the testis, which is slightly enlarged. Wound
syringed with tepid water. 20th.-Much disturbed by incessant visits
of friends; restless; pulse 95. On endeavouring to pass a stool, more
venous bleeding appeared at the wound. Repeated the pill and black
draught, which opened the bowels very freely; red lotion to the wound;
to have the wine increased. 22nd.-Reappearance of sanguineous stain
in the dressings; painful and spasmodic contraction of the cremaster
muscle, especially at stool, which results in an increase of the venous
bleeding; this was allayed by morphia. Punctures injected with a
solution of tannin, and a pledget of lint dipped in it applied. To have
tinct. ferri muriatis, with quinine; tongue cleaning steadily; sleeps
well with morphia. 23rd.-A small, black, hæmorrhagic point appeared
in the lower wound upon the cord; upon this a few drops of tinct. ferri
muriatis were dropped. Much disturbed by the visits of friends, in
spite of the emphatic warnings of Dr. King and myself; pulse got up
to 90. Continue iron, quinine, and wine. 24th.-Is better; pulse 85;
slight staining of the dressings still present; bowels not open since last
medicine. A warm aperient prescribed, with the effect of a copious
action of the bowels. 25th.-Bowels acted again; complains of much
pain in the rectum on voiding the motion, which was found, on
examination, to be caused by hæmorrhoids; shivered slightly a few
times; pulse 90 at night. 26th.-The communication of some news,
which could not be kept from him, and which led to an interview of
some hours' duration with a friend, in defiance of all remonstrance, has
had the effect of depressing the patient very much; pulse rises at night
from 90 to 110. Complains of much pain in the rectum; had an
enema of morphia and oil, which gave him great relief; slept for three
hours; on waking, his pulse was 85, at which it continued all day. To
increase the stimulus. 27th.-A bandage applied over the wire loop,
which, causing much pain, was removed after four hours. 28th.-Spasm
in the rectum continues at intervals, and flatulent eructations during
the day. Impossible to keep him quiet from visitors; after such in-
terviews the pulse rises to 100; respirations 25. 29th.-Wire removed
tolerably easily; very slight oozing of blood afterwards. Wounds have
not at all a favourable appearance; a great deficiency of action is
observable; discharge freely thin pus; pulse 120. Brandy and quinine
given freely. Slept during the day under the influence of solution of
morphia, after which the pulse was 98, and at night fell gradually to
85. During the night an increase of hæmorrhage occurred, following

CASE XLIII.
311
and induced by very severe spasmodic pains in the rectum, with fearful
straining and ineffectual efforts at stool. Ice applied assiduously
to the wound. Enemata of olive-oil and gruel bring away dark
scy balous masses, and a full dose of castor-oil, with henbane, afterwards
produces copious dark and offensive stools. The tenesmus continuing, a
suppository of morphia is applied, and the abdomen rubbed with oil and
morphia; passes a great deal of flatus; slept well during the night.
31st.-On firm pressure being applied to the sides of the upper
puncture, a considerable amount of thick, inspissated pus, mixed with
coagula, is pressed out. The nervous irritability of the patient has
hitherto prevented any pressure on the wound. A great want of action
is apparent in the wound. After this, no more oozing of blood occurred,
but the discharge was thin and unhealthy. The patient is evidently
labouring under some depressing influence, which seems to reside in
the close and confined nature of the room in which he lies, and the smell
of the new paint, which at this time pervades the house. The tongue is
dry and brown; the pulse frequent; the skin muddy; the patient
extremely irritable. It is accordingly determined to remove him to the
house of his friend, Dr. King. This was done in one of Alderman's
invalid couches, with a marked and immediate improvement in all the
symptoms. The wound assumed a much more favourable appearance,
and filled up gradually, but very slowly, the tannin injection con-
tinuing to be used with a view of consolidating the newly formed
adhesions. A slight return of the spasm from the hæmorrhoids was
successfully subdued by ung. gallæ co. Under quinine and generous
diet he gradually recovered; and on the 5th of April a spica bandage
and pad was applied, and he got up to the sofa. On the 12th, he went
to Brighton, and in about a fortnight afterwards the punctures were
entirely healed. The patient wore a horse-shoe truss-pad during the
day. He has been under observation constantly since, and the parts
appeared firm and resisting, until about three months afterwards.
About this time the patient had increased much in corpulence, and was
attacked by a violent cough, which affected him chiefly at nights, and
came on in violent fits while the truss was not worn. After this time,
a certain degree of weakness was observed at the superficial ring, indi-
cating a shifting of the adhesions of the invaginated fascia close to the
cord. The sloping rotundity of the conformation of the groin renders
the precise application of the truss-pad difficult to secure; and the
yielding during a violent cough-impulse has gradually increased, so that
at the present time there is, during coughing, a small protrusion of a
doughy feel, evidently composed partly of indurated sac, and partly of

312
APPENDIX OF CASES.
fat. This, however, is very small compared with the original rupture,
and is easily controlled by the truss. Dec. 3rd, 1862.-To-day Mr.
B came to me for examination, having worn a lever-spring truss of
the pattern given in Fig. 48. For the last two months the protrusion
has seldom occurred. On examination, it is found that the finger
cannot be made to pass the external ring, but there is some impulse felt
in that position on coughing. The scrotum has lost its swollen and
rounded appearance, but a small doughy tumour can be felt on cough-
ing. Testis of the normal size; feels strong and well, and wears the
truss with comfort and without under strap. In the foregoing case, the
state of health of the patient, his extreme nervous susceptibility, the
peculiarities of conformation, and the want of vigorous reparative action,
all combined to prevent the issue being as complete and satisfactory as
might have been desired.
Case 44.-William Rose, æt. 19, engineer at Woolwich Dockyard,
operated on in King's College Hospital, May 31st, 1862, for a con-
genital scrotal rupture, reaching to the size of a duck's egg.
Has worn
a truss from the age of fourteen years, which has been effectual in
keeping up the rupture. The superficial and deep rings were very
patulous, admitting easily of invagination. No symptoms whatever
supervened after the operation, which was done with wire in the
usual way. The bowels were opened by castor-oil four days after the
operation. Afterwards middle diet and one pint of porter; water
dressing and spica bandage over the wire loop. June 14th.-Wire
removed without difficulty. 21st.-Allowed to get up and move about
the ward with bandage and pad. July 10th.-Wounds all healed;
discharged with a firm closure of the rings; no impulse or bulging;
wearing a light horse-shoe truss. Since this time he has been shown
once or twice to the class in the theatre of the hospital, no change
having occurred in the groin.
Since
Case 45.-Henry Marsh, æt. 19, working in Woolwich Dockyard,
admitted into King's College Hospital, June 18th, 1862, for an oblique
inguinal rupture on the right side, descending into the scrotum.
Noticed two years and a half ago when lifting a heavy anvil.
then he has worn a double truss, as the left side is also weak and bulgy.
On removing the truss, the rupture drops at once into the scrotum.
The testicle on the ruptured side has not descended lower than the
upper half of the scrotum, and is atrophied so much as to be only one-
third the size of its fellow. The cord is short, and its veins very varicose;
the rings are large, with lax yielding sides; conjoined tendon very
evident; scrotum wide and flaccid. Operation done June 21st, 1862,

CASE XLVI.
313
in the usual manner with wire. In the night he had some nausea, and
slept little; complained next day of pain in the abdomen, which, how-
ever, was quite soft, and not tender on pressure. These symptoms
were entirely removed by a few doses of pil. sapon. co., with hot fomen-
tations, after the pulse had risen to 108, with a slightly furred tongue. On
the 23rd, the bandage was removed; and on the 25th, the bowels were
opened by castor-oil. He then slept and eat well, and there followed a
pretty free suppuration and much consolidation. On the 30th, the
atrophied testis was enlarged to above the size of its fellow, with some
oedema of the scrotum. On July 7th, half the wire was removed with
some difficulty, on account of a kink which had become entangled in
the tissues; wounds filling with granulations; discharge thin; eats and
sleeps well, and looks better in the face. 14th.-Remaining half of the
wire removed without difficulty; swelling of scrotum disappeared;
testis about the size of the opposite one. 16th.-Wounds nearly
closed; discharge small in quantity, and thicker; pad and spica
bandage; to get up and move about the ward. 18th.-A small
tender spot of redness, surrounded by a hard margin, apparent about
three inches above the pubis, the hardness being continuous with the
consolidation in the inguinal canal. A small opening being made,
evacuated a slight quantity of pus; poultice. 21st.-All redness and
tenderness gone; punctures nearly closed. On the 8th of August, he
was discharged, having waited nearly a week for his double horse-shoe
The groin operated on was very hard, firm, and resistant.
Aug. 30th.-Shown to the class in the theatre; no impulse, but a little
bulging at the deep ring; superficial ring firmly closed by bands of
adhesion; testis at present very little smaller than the opposite one;
very little remains of the yaricocele. Feels much stronger, and more
able to work than before the operation.
truss.
Case 46.-Charles Trotman, æt. 18, boiler-maker at Woolwich,
operated on in King's College Hospital, June 28th, 1862, for a right,
oblique, scrotal rupture, of the size of an egg, originating in a blow on
the abdomen seven years ago, for which he was rejected by a Government
medical inspector. Three years ago, his truss was broken by the fall of
some iron plates upon him, the rupture came down and was returned
with difficulty. Since that time, no truss has perfectly retained it, and
it is getting rapidly larger. Superficial ring very wide and patulous;
conjoined tendon very easily distinguished. After the operation, the
symptoms were so slight as not to merit notice. There was a slight
enlargement of the testis. July 2nd.-Discharge established moderate;
bowels opened by castor-oil. 3rd.-Nettle-rash on the arms. 7th.-Doing

314
APPENDIX OF CASES.
uncommonly well; eruption disappeared; discharge moderate; indura-
tion filling the inguinal canal. 14th.-Wires removed easily. 30th.-
Upper aperture quite healed; lower nearly closed. Discharged cured,
wearing a horse-shoe truss. August 30th.-Shown to-day to the class.
The rings are firmly closed; much of the induration has disappeared;
no bulging or impulse whatever on coughing; feels and looks very
well; is stronger than before the operation.
Case 47.-George Dunn, æt. 7 years, son of G. Dunn, of West
Bromwich, Staffordshire, was sent to me for operation by Mr. Lloyd,
surgeon, for an enormous congenital rupture, on the left side, dis-
tending the scrotum to the size of a large fist, and reaching halfway
down the thigh, nearly obliterating the penis by distension. The deep
opening at the neck of the sac was exactly opposite the superficial ring,
so that the rupture emerged close above the pubis at the edge of the
rectus muscle, as in a direct hernia, the conjoined tendon being altogether
wanting. The hernial apertures were so wide and patulous as to admit
easily the points of four fingers, and occupied the whole distance be-
tween the rectus muscle and Poupart's ligament. One finger could be
carried into the abdominal cavity so as easily to feel the common iliac
artery and aorta pulsating, and to reach as far upwards as the posterior
surface of the umbilicus. The sides of the opening were very lax,
loose, and dilatable. The bowels passed freely into the sac, and dis-
tended it enormously on the child making any effort. The sac was
thickened and hard, but permitted the peristaltic motions of the bowel
to be perceived at the surface. The rupture was easily and completely
reducible, returning immediately the pressure was removed. When he
winced under the pressure, the bowels emerged with a strong rush
which rendered it impossible to keep them in the abdomen except by
turning him upside down. This position was afterwards found to be
absolutely necessary during the operation, and subsequent dressings,
when his violent crying and struggles militated much against the main-
tenance of the closure of the hernial opening. No truss whatever had
sufficed to keep up the bowels for the shortest time. The rest of the
abdominal region was small and contracted, from the habitual extrusion
of so large a quantity of its contents. The boy was in strong, robust
health, and well nourished. This formidable case, appeared, at first,
almost a hopeless one, from its size and that of the hernial opening, and
the great deficiency of the abdominal walls. At the earnest desire of
the parents, however, I was induced to try the effect of an operation,
more with the object of diminishing the size of the opening so much as
to enable a truss to be worn with benefit, than with the hope of effect-

CASE XLVII.
315
ing a complete cure. On June 14th, 1862, in King's College Hospital,
an operation was done with a large pair of rectangular pins, the upper
and inner one passed through the tissues close to the border of the
rectus, but not including it, and the outer upwards through Poupart's
ligament. The pins were twisted and bound firmly down by strips of
lint and plaster. The laxity of the structures, and the distance of the
pillars at the pubis was such, that an opening remained after the twist-
ing of the pins just above the pubis, through which a knuckle of in-
testine escaped. This was returned after relaxing the pins a little, and
a pad held firmly over it by a spica bandage sufficed afterwards to
retain it, notwithstanding the violent struggles of the boy as the effect
of the chloroform passed off. The patient was placed in bed with the
shoulders low and the pelvis and legs raised upon pillows to relieve the
strain upon the pins. With the exception of the evening of the day of
the operation, when he cried a good deal, and a slight whitening of the
tongue for a few days, the symptoms were so slight as not to be re-
marked; there was no nausea nor even disinclination for food; nor did
he
cry much after the first day. The bowels were opened naturally
three days after, when the bandage was removed. The pins were then
found to have sunk into the swollen scrotum, and produced a deep
ulceration; though but little discharge, and that thick and healthy, was
apparent at the punctures. The oedema of the scrotum had extended
to the prepuce, which was much elongated, and affected with phymosis,
so as to interfere with micturition. The end of the prepuce was re-
moved, and its lining slit up with the scissors. The pins were at the
same time withdrawn; much thickening and consolidation being appa-
rent in the neck and fundus of the sac, obscuring the testis and cord.
The violent struggles of the little fellow, when the pins were withdrawn,
again protruded a knuckle of bowel close above the pubis. This was
returned without difficulty, a stout pad and spica bandage over a simple
dressing keeping it in its proper place. Much induration followed, filling
up
the whole anterior part of the sac, and producing a thickened and
resisting condition of the borders of the hernial apertures. The punc-
tures were both entirely healed by July 19th, when, on examina-
tion in the upright position, it was found that some protrusion still oc-
curred through the aperture, close above the pubis, and that it passed
down behind the thickened and twisted part of the sac into its posterior
portion, so as to distend the perineum behind the testis and cord.
At this date, the boy, being brought again under the influence of chlo-
roform in the theatre, was placed upon the table with the pelvis raised
very high. The posterior part of the scrotum behind the testis was

316
APPENDIX OF CASES.
then invaginated into the remaining hernial opening with the forefinger.
A large, common suture needle, armed with strong wire, was then
passed along the finger and made to transfix the attachment of Poupart's
ligament to the pubic spine. It was then carried, with its concavity
towards the finger, under the skin, and made to emerge near the root of
the penis.
The wire being drawn through, the needle was again
entered at the last-made puncture, and made to take up the attachment
of the internal pillar of the ring to the pubic symphysis. It was then
brought round the finger as before, but on the opposite side of it, and
made to emerge at the puncture first made. The wire being thus
drawn through under the skin enclosed the remaining portion of the
unobliterated sac in a circle, which included also the attachments of the
pillars of the ring to the pubis. Some difficulty was experienced, on
twisting the wire up tight, in keeping the bowel from protruding, as the
boy just then began to struggle violently. This was safely overcome by
keeping the finger plugged into the opening until it was embraced
closely by the wire loop, and then cautiously withdrawing it, twisting
the wire tight as this was done. A pad and spica passed across the
perineum pressed the wire firmly down upon the pubis behind the
testis. The latter with the cord and obliterated portion of the sac could
be distinctly recognised during the operation. No symptoms whatever
followed this operation; the boy ate his dinner next day as usual, and
the bowels were moved regularly. The wire was kept in fourteen days,
giving rise to very little suppuration, and much induration. It was
then removed, without difficulty, by dividing the loop with a fine
pair of cutting pliers passed through one of the punctures, and then
drawing it out by the twisted part. Firm pressure was then continued
by pads, sticking-plaster, and bandage, over simple dressing. By
August 8th the openings were completely healed, and the boy got up
and walked about the ward. On examination without bandage and in
the erect posture, a small degree of protrusion was still observed in the
neck of the sac behind the obliterated part when the boy coughed, but
the sac in the scrotum was completely obliterated, and contracted into a
hard mass. The protrusion could be felt to escape through a chink
left between the edge of the rectus muscle and Poupart's ligament above
the pubis. The little fellow was in capital health, eat very well, and
somewhat fatter than when first admitted. He had suffered so little
from the last operation which had proved so successful in its main
object, that I conceived that attempt might properly be made to
close the remaining opening. Accordingly, on August 13th, the boy
being placed under chloroform in the same position as in the last opera-

CASE XLVIII.
317
tion, the scrotum was invaginated up to the aperture or chink, and a
small curved hernia needle was carried through the scrotum without
previous incision, and passed through the edge of the rectus muscle a
little above its attachment to the pubis. The point of the needle being
passed through the skin of the groin in the usual way, a stout wire was
hooked on and drawn through into the scrotum. The needle was then
disengaged and passed in the usual way through the hard cicatrix in-
volving Poupart's ligament, and then through the skin aperture above.
The opposite end of the wire was then hooked on and drawn into the
scrotal puncture alongside the first. The two ends were then twisted
together and drawn up tight by twisting the loop above in the usual
manner. The rectus seemed to be fairly held by the suture and the
chink obliterated. A pad and bandage completed the operation. The
boy went on eating his food as usual, the bowels were regular, and not
a symptom supervened. Aug. 26th.-Sufficient induration being appa-
rent, with very little suppuration, the wire was this day removed. On
the 29th, the apertures were nearly closed. Sept. 10th.-After wear-
ing a stout compress and bandage up to this time in the recumbent
posture, the boy was examined in the erect posture without bandage.
On coughing, a small bulging is still apparent just above the pubis, but
no dilating impulse is perceptible in the thickened and amalgamated tissues
at the neck of the sac. The protrusion is apparently composed of a mass
of agglomerated sac, containing some omentum and bowel. The chink
which still remains is evidently due to the impossibility of drawing
close together the sides of the hernial opening, so widely separated at
their attachment to the pubis. An ovate truss pad, with a central per-
foration, adapted for direct hernia (Fig. 50), and composed of boxwood,
fits accurately upon the interval between the rectus and Poupart's
ligament, and effectually restrains any bulging in this situation under
any amount of coughing or exertion. The testis and cord of the side
operated on can now be perfectly distinguished, the former being a little
enlarged. The boy to wear the truss and move about the ward for a
week, to see the effect of the truss upon the parts when moving about.
He is then to be discharged. 30th.-Discharged; the truss keeps up
the small remaining rupture perfectly.
Case 48.-Charles Dunn, æt. four and a half years, the brother of the
last patient, admitted at the same time into the hospital, with a con-
genital scrotal rupture of the right side, as large as a small fist, which
no truss had ever retained. The coverings of the rupture are so thin
that the peristaltic movements of the contained intestines are distinctly
visible through them. It is easily and completely reducible. The

318
APPENDIX OF CASES.
abdominal openings are very large and lax, and placed directly opposite
each other, so that, as in the case of his brother, it has all the appear-
ance of a direct rupture, the neck being bounded internally by the
rectus muscle, and externally by Poupart's ligament; no conjoined
tendon being recognisable. Two fingers can be passed easily into the
cavity of the abdomen, feeling distinctly the pulsation of the iliac
vessels. On the 28th of June, 1862, the operation by the use of large
rectangular pins was performed in the usual way, the inner one trans-
fixing the tissues close upon the rectus muscle, and the outer one Pou-
part's ligament. The experience of the previous case led me in this
instance to place a couple of smaller pins transversely across the sac
behind the larger. The deeper of these was placed close to and on a
level with the upper border of the pubis, avoiding the spermatic cord
on the other side. The superficial one was placed a little higher, close
behind the larger pair. All protrusion below and behind the vertical pair
of pins was thus prevented. A pad and spica bandage applied pressure
over all. 29th.-In the night he has shuffled off the bandage and a
great part of the dressings, disengaging the small pair of pins from each
other. The ends of the pins have disappeared under the skin, and
could not be replaced, owing to the violent struggles of the patient.
The pins were left as found, and a pad firmly placed above them, the
spica bandage being stitched well to prevent future displacement. Con-
siderable ædema of the scrotum and enlargement of the testicle followed
the operation, but very little suppuration. The boy, with the excep-
tion of a slightly filmy tongue, continued unaffected in health; eat and
slept well. Bowels open naturally two days after. July 1st.-To-day
the pins were removed, the child being held up by his feet during the
dressing to prevent any strain upon the new adhesions during his
violent struggles. A stout pad held on firmly by sticking-plaster and
bandage. 7th.-The sac can be felt filled up to the neck by solid effu-
sion; apertures nearly closed; very little discharge; is in capital health.
14th.-A diminution is now apparent in the size of the solid tumour
about the neck of the sac. 16th.-To-day the child stood up without
bandage for examination. When he cried violently, a bulge was ob-
servable in the neck of the sac extending about three-fourths of an inch
downwards, the solidity of the fundus continuing firm and resistant. The
scrotum is much shrunk and thickened. The testis can be distinguished
somewhat enlarged. July 19th.-To-day, the aperture which remains at
the outer border of the rectus was closed up by a wire ligature carried
horizontally across by a common suture needle. One end of the wire
was passed close above the pubis and made to take up the insertion of

CASE XLIX.
319
Poupart's ligament, and the edge of the rectus tendon at its insertion.
The other end was passed under the skin across the neck of the sac a
little higher up, including the outer and inner pillars and conjoined
tendon. The ends were brought through the same skin puncture on
each side, and twisted tightly together down into each puncture, the
twists being then hooked on to each other over a cylindrical pad of lint
(see Fig. 38, page 127). After the operation, the child went on as
usual, very little suppuration ensuing. On the 30th, the indurative
action being considerable, the wires were untwisted and withdrawn.
The apertures healed up speedily, and on the 12th of August, when a
careful examination was made, the punctures were completely healed,
the parts much consolidated and well closed in, and no impulse or pro-
trusion whatever was apparent when he cried. The testis had nearly
recovered its normal size, the shrivelled and contracted sac could be
distinguished above it, not in the slightest degree affected by his crying.
An ovate, perforated, boxwood truss pad was fitted on, and the child
was taken home into the country by his father, looking fatter, if anything,
than when he came to the hospital. Since that time I have heard
many times from his father. The spring of the truss being rather too
strong, caused at first some swelling of the testis and scrotum, and some
excoriation of the upper cicatrix. This having been altered, the child
wore the truss with perfect ease. Not the smallest protrusion has since
occurred. Sept. 30th.-To-day, the child was brought to town for in-
spection. The hernial aperture remains completely occluded and firmly
resistant to the cough impulse; the sac can be felt in the scrotum
degenerated into a cord-like mass. The testis is of normal size and
shape. The truss he is wearing has a very weak spring, barely suffi-
cient to render support. March 13th, 1863.-Heard to-day from the father
(a very intelligent man) to say that both the boys remained in the same
condition in every respect as when they left the hospital. No return
whatever had occurred in the younger, and the slight protrusion of the
older boy was perfectly and easily retained by the truss.
Case 49.-Richard Humphreys, æt. 30, a puddler at Nant-y-glo Iron-
works, near Tredegar, Monmouthshire, sent to me by Mr. Jeffries, the
surgeon to the works, for operation, with a double, oblique, inguinal
rupture. On the left side is a large scrotal rupture of the size of the
fist, with a large lax abdominal opening admitting easily three fingers,
produced by violent coughing, seven years ago. On the right side is a
bubonocele, just making its way through the superficial ring. Has not
been able to wear a truss, from the left rupture slipping down behind it
while at work. Both sides are easily and completely reducible. Opera-

320
APPENDIX OF CASES.
tion performed, on the left side, in King's College Hospital, by the usual wire
method, July 12th, 1862; conjoined tendon not very evident. With
the exception of the loss of sleep for one or two nights, he suffered very
little after the operation. 14th.-Scrotum slightly edematous; testis
a little enlarged; no nausea or tenderness on pressure over the belly;
no tympanitis. 16th.-Complained of increased pain last night; feels
uneasy; bowels not open; bandage removed; to have castor-oil.
18th.-Bowels freely opened; feels quite right again; eats middle diet.
A spica bandage applied firmly over the wire loop to set up more action.
in the posterior wall of the canal. 20th.-Bandage caused more pain;
discharge moderate and healthy. 22nd.-Has little pain now; eats,
drinks, and sleeps well. Aug. 6th.-Wires removed without difficulty
(twenty-four days after the operation). 26th.-Progressing very well;
looks fat and well; wounds filled with red granulations; discharge almost
entirely ceased. 27th. The punctures have now entirely healed. The
superficial ring is completely closed by firm adhesions; scrotum
slightly tucked up; great induration in the inguinal canal; no bulging
or impulse whatever; discharged, wearing a double horse-shoe truss with
boxwood pad. Promises to let me know if any change occurs. This
case was kept longer under treatment and pressure, with the wires
unremoved, because of the want of certainty that the conjoined tendon
had been included in the ligature to a sufficient extent. The result of
the case so far is favourable to the practice in such cases.
October I received a note from Mr. Jeffries, of which the following is
an extract:-"You will be pleased to know that he has quite recovered
his health, and has gone to work; the cicatrix is hardly perceptible,
and altogether it is as neat a cure as any one would wish to look at.
He trusts that you will allow him to have the other side operated on
next spring."
On the 29th
Case 50.-Colonel Slade, æt. 10, a healthy-looking boy, operated on
at King's College Hospital, by the use of rectangular pins, in the usual
way, August 1st, 1862, for an oblique inguinal rupture on the left side,
reaching into the upper half of the scrotum. Observed after carrying
It is probable that, in
a pail of water, three weeks before admission.
this case, the sac was not interfered with. After the operation the
boy's health continued as usual. The bowels were opened naturally
three days after, shortly after which he resumed middle diet. On
August 9th, the pins were removed without difficulty, very little
discharge being apparent. A hard line of induration apparent along
the canal and track of the pins. On the 27th, the punctures were
entirely closed, and on examination in the standing posture, no bulging

CASE LI.
321
or impulse whatever could be detected on coughing. The superficial
ring was quite closed; testis and cord perfectly healthy and mobile.
Discharged wearing a horse-shoe truss. Ten days afterwards, he was
again examined after going about his work as usual. No change what-
ever was perceptible. Since heard of as remaining well.
Case 51.-John Day, æt. 11 years, operated on Aug. 28th, 1862, at
King's College Hospital, for a congenital rupture of the right side, of
very large size, totally uncontrollable by any truss which has been
tried. The pressure of the truss he has worn had produced much
excoriation, and latterly a large glandular abscess in the groin.
Unhealthy-looking child, with a tumid belly. Has suffered much from
diarrhoea and intestinal irritation from teething, on which account the
operation has been from time to time postponed, the rupture meanwhile
increasing rapidly in size. Two small rectangular pins were applied in
the usual way, the inner one including the thin border of the rectus,
which, from the great size of the deep opening, formed the inner
boundary of the neck of the sac. On the evening of the day of opera-
tion the child had bilious vomiting, and cried a good deal. The
vomiting continued at intervals during next day, when the scrotum
being œdematous, and the testis swollen, towards evening the pins were
removed, and a pad and spica bandage applied over the groin. At
night the vomiting had ceased, and the child slept under the influence
of mx. of tinct. camph. co. Next day the scrotum was very much
swollen, and a slight slough appeared at the lower puncture. A hard
swelling filled up the whole of the inguinal canal, and a little pus
escaped at both punctures. No impulse or dilatation was apparent
when the child cried. Simple dressing and spica bandage. To have
wine 2 oz. daily, and strong beef-tea. Two days after the operation the
bowels were opened naturally and freely. Sept. 5th.-Free discharge
from the punctures of healthy pus, very hard and large consolidation,
occupying the canal and scrotum; testis a little enlarged; child
improving rapidly in appearance.
9th. A small slough has come
away from the lower puncture. Scarcely any discharge from punctures,
which are rapidly closing. Testis diminishing in size; no impulse or
protrusion whatever on crying; an enlarged gland in the opposite
groin; and the tumid, hard belly showing a tendency to scrofula, the
child is put on two eggs, and a teaspoonful of cod-liver oil, three times
daily. 15th.-Looking wonderfully better; punctures entirely closed.
The consolidation diminishing in size, but increasing in firmness; testis
nearly its natural size. Runs about the ward wearing a pad and
bandage. To have a boxwood, horse-shoe truss fitted. From this time
Y

322
APPENDIX OF CASES.
he was kept in the house to watch the progress of the absorption of the
effusion in the canal. This diminished gradually, and at length dis-
appeared in a hard cicatrix, which closed the superficial ring and canal.
No impulse or protrusion whatever in coughing or crying succeeded.
Up to the present date (March 16th, 1863), I have many times seen the
child or its mother; no protrusion or impulse whatever has been seen, and
the child is in much better health than before the operation. The
symptoms observed after the operation, in this case, are due partly to
the chloroform, and partly to the bad state of the child's health at the
time. This was such that it was only the rapid increase of the rupture,
and impossibility of restraining it by a truss, that led me to operate,
especially in one so young as one year and a-half. This is the most
tender age at which I had hitherto operated. Notwithstanding the
short time that the pins were retained, the action set up was very
abundant, and the case was surprising from the rapidity and soundness
of the cure.
Case 52.-David Williams, æt. 34, operated on in King's College
Hospital, Sept. 5th, 1862, for a direct scrotal hernia, of the right side,
of two years' duration. The operation was done by the use of wire, as
described at page 109. The conjoined tendon was secured close to the
border of the rectus muscle. After the operation, the patient did not
lose a single night's rest, though he took no sedative, so little pain had
he. Sept. 8th.-Bowels opened freely by castor-oil. On account of
the cleaning going on in the hospital, the ward is at present much over-
crowded, and most of the sores in the room have assumed a sloughy
appearance. In this patient a slough has formed at the lower opening.
The testis is enlarged, and slightly painful on pressure; the bandage and
pad removed for the first time. 10th.-Looks pale and anxious, but
does not complain of pain anywhere; no sickness, nausea, tenderness,
or tympanitis whatever; discharge from lower puncture thin, sanious,
and fœtid. Has a cough, and states that the sputa are tinged with
blood. This, it appears, he has occasionally been subject to. Much
induration around the wires; slough separating a little; discharge thin,
copious, and foul at the lower, but purulent and healthy at the upper
puncture. Considerable swelling of testis, but little pain on pressure.
Discontinue bandage, and apply poultice to groin and scrotum; pint of
stout daily; quinine, sulphuric acid, and chloric æther mixture.
17th.-Several pieces of slough removed since last report. 22nd.-The
whole of the remaining slough removed to-day, appearing to include a
portion of the spermatic cord. Discharge from upper wound ceased.
26th.-On examination to-day, the testis is found to have diminished

CASES LIII., LIV.
323
considerably in size, but still gives its peculiar sensation to the patient
on pressure. Oct. 6th.-Upper wound entirely healed; truss with
ovate pad applied. 9th.-In consequence of irritation of the cicatrix and
considerable swelling in the scrotum, the truss has been discontinued for
the present. A hard, painful swelling is apparent in the site of the testicle.
10th.-An abscess which had formed in the scrotum has burst; the
swelling has entirely subsided after the escape of some matter. The
suppuration has evidently taken place in the interior of the testicle, the
size of which is now felt to be greatly diminished, and its normal sensa-
tion gone; the upper puncture is firmly cicatrized. Truss reapplied; to
get up and move about the ward. 11th.-Discharged to-day with a very
small wound still remaining in the scrotum; no impulse whatever at
the abdominal rings. 31st.-Came to show himself to-day. A slight
bulge in the upper part of the inguinal canal is the only evidence of a
rupture having existed. No impulse at the external ring whatever on
coughing. Testicle quite atrophied. Will let me know if any return
of protrusion occurs.
Case 53.-Robert Stephens, æt. 21 years, operated on at King's
College Hospital, Sept. 20th, 1862, for a direct scrotal rupture on the
right side, of the size of a hen's egg. The deep hernial opening is
placed close to the border of the rectus muscle, close above the pubis;
observed first a few days after birth; a bubonocele also observable on
the left side. Operated on by the use of three pins, two placed lon-
gitudinally, and one across, close to the pubis, and behind the other two.
Not a symptom occurred after the operation. His appetite and bowels
were regular; sat up and played on the bed the day after the operation.
Pins removed on the eleventh day, not having been meddled with
before. Much thickening in the canal; no suppuration whatever.
Oct. 8th.-Discharged with the punctures healed, wearing an ovate
truss pad. No impulse whatever when the child cries; much consoli-
dation in the canal. Seen again a month after; the consolidation had
then disappeared. No impulse or protrusion apparent on crying.
Case 54.-Charles E. B- æt. 21, operated on for an oblique scrotal
rupture of some years' standing, which no truss had been found to re-
tain, on account of the size of the deep opening and the great obliquity
of the pelvis. Operation done by wire in the usual manner, Oct. 7th,
1862. No symptoms of importance after the operation. Bowels
opened by castor-oil five days after. Some swelling of the testis;
discharge thick and scanty; bandage retained untouched for four days;
wires removed sixteen days after; much induration. 31st.-Both
openings nearly closed. Nov. 1st.-Removed from his lodgings to

324
APPENDIX OF CASES.
Lewisham, wearing a truss over the dressings; a slight return of the
swelling of the testis afterwards. 19th.-Called to-day after staying awhile
in the country; a hard mass remains in the site of the scrotal sac; testis
still rather enlarged. Dec. 2nd.-Came again to see me, having suffered
from a bad cough and rheumatism; thickening about the cord nearly
all gone; testis nearly of its normal size; no impulse whatever on
coughing. Jan. 14th, 1863.-Called to-day. The parts have resumed
a normal condition, all swelling and hardness having disappeared. No
impulse or bulging whatever; on the opposite side there is more im-
pression made by a cough than on the side operated on. Recommended
to wear a double truss for some time. March 4th.-Remains well.
Case 55.-Thomas H. Hewson, æt. 9, operated on by the use of pins
for a right, oblique, scrotal rupture of the size of a pigeon's egg, at
King's College Hospital; the result of a fall a fortnight before.
Operation done Oct. 12th. No symptoms whatever followed, the
patient eating and sleeping as usual. 22nd.-A slight discharge; testis
a little enlarged. 25th.-Pins removed without pain; a thick mass of
lymph fills up the canal. Nov. 3rd.-Ring-truss pad applied; moves
about the ward. 5th.-Discharged, both punctures healed. No impulse
whatever on coughing; no bulge at the site of the deep ring; superficial
ring quite closed. March 7th.-Seen to-day; parts unaltered.
Case 56.-William Piner, æt. 48, labourer, from Hounslow, operated
on by the usual wire method, at King's College Hospital, Oct. 18th,
1862, for a right, oblique, scrotal rupture, of the size of a large orange,
for which no truss had been available; no symptoms whatever after the
operation; wires removed sixteen days after; much consolidation;
wounds healed Nov. 13th; discharged on the 17th, with the superficial
ring closed, and no swelling or tenderness of the testis or cord.
Jan. 2nd, 1863.-Came to-day to show himself, having been at
labouring work in the interval. With a view of rendering the pad
more comfortable he has fixed some tow and folds of linen on the truss-
pad, which has displaced the pressure, leaving the canal entirely un-
supported; the result has been a partial return of the protrusion behind
the adhesions at the superficial ring. The truss-pad altered to bring
its pressure more fairly upon the canal.
Case 57.-Joseph J. Adams, æt. 19, a thin, sickly lad, subject to
epileptic fits, operated on in King's College Hospital for a right, oblique,
scrotal rupture, of some years' standing, with very wide open rings.
Operation done by wire, Nov. 1st, 1862; no symptoms followed the
operation. A week after had an attack of scarlatina, with sore throat,
and the usual eruption. The wounds suppurated freely, but did not

CASES LVIII., LIX.
325
seem much affected by the disease. Wires removed on the 17th. On
Dec. 3rd, the lower wound was entirely healed, and the upper one
nearly so; fitted with a horse-shoe truss-pad, and discharged. On the
14th, shown in the theatre; cough impulse firmly arrested at the deep
opening. On Jan. 26th, again examined (and also on March 16th),
having had several severe epileptic fits in the interval, in one of which
he cut his face very severely. The inguinal canal and rings quite un-
changed; a firm hard cicatrix in their site; no impulse or bulging.
The truss fitting rather loosely, was properly adjusted.
Case 58.-John Weller, æt. 42, a labourer, a stout, healthy-looking
man, sent to me by Mr. Hart, of Welbeck-street, with a double rupture.
Both ruptures were oblique, and enormously large; that on the right
side was nearly the size of a child's head, and of ten years' standing;
that on the left somewhat smaller, and of two years' growth, but gave him
much pain and uneasiness. No truss whatever would keep up either
rupture, and being thereby almost totally incapacited, he was urgent
that an operation should be done on the side that gave him most pain.
Operation done by cross wires (Fig. 36, page 123) on Nov. 9th, 1862;
wires fastened over a boxwood pad. Bandage removed on the 13th;
pad removed on the 15th; no pain, sickness, or tympanitis. Appetite
uninterrupted since the operation; was eating heartily the day after the
operation; the tongue barely whitened. 24th.-More discharge of a
healthy character; no pain whatever. A very large mass of consolida-
tion fills up the hernial rings, and extends into the sac in the scrotum;
some swelling of testis and cord; takes middle diet and a pint of stout
daily. Dec. 3rd.-Swelling of testis and cord entirely disappeared.
7th.-Wires withdrawn without difficulty; very little discharge; a
large amount of consolidation all over the groin. 10th.-Up and about
the ward to-day. 17th.-Discharged with a double truss with ring
pads, a large one on the right side, and a smaller on the side operated
This is effective in retaining also the side not operated on;
wounds healed. Jan. 26th, 1863.-Showed himself to-day; the truss
has shifted, and fails to keep up the large rupture when at work; there
is also some bulging of the side operated on, but he does not feel any of
the pain complained of before the operation. Truss to be readjusted to
the parts, and constantly worn.
on.
Case 59.-Captain G, æt. 42, operated on Nov. 14th, 1862, for
an oblique inguinal hernia of the left side, of some years' standing. It
is of considerable size, scrotal, and incapacitates him for active duty.
The ordinary wire method employed. Had no pain after the operation,
and slept at night without sedative; pulse and tongue unaffected.

326
APPENDIX OF CASES.
17th. Some oedema of the scrotum, and enlargement of the testis, but
no pain or tenderness; no discharge; bandage removed. 19th.-Bowels
opened by castor-oil; no pain; appetite better; complains of a little
bilious headache. 24th.-More discharge; consolidation very evident
in the canal, and in the fundus of the sac. Dec. 2nd.-Going on
without an unpleasant symptom; pressure applied by a bandage over
the wire loop. 6th.-Has continued the pressure up to the present
time, with the effect of a little increasing the size of the testis. Wire
withdrawn with ease; granulations apparent at the punctures; conso-
lidation in the canal very evident. 10th.-Walked about his room
with a pad and spica bandage. 14th.-Truss applied. 20th.-Left
to-day for the country. The external ring closed; some consolidation
still remaining in the canal, and a slight bulge, on coughing, at the site
of the deep ring. Will let me know of any change.
Case 60.-F. H, æt. 40, operated on Dec. 22nd, 1862, for a
right, oblique rupture of ten months' standing, of the size of a small
orange. At the bottom of the sac could be felt a roundish, hard mass,
apparently a portion of consolidated omentum adherent to the fundus.
No truss could be worn on account of the pain felt in this part, and all
other apparatus ineffective in keeping up the rupture. Operated on by
the wire method, care being taken to force up into the deep opening of
the canal the adherent omentum, and to apply the wires outside the
Although the patient had been previously in delicate health from
dyspeptic symptoms no bad symptoms whatever followed the operation.
The tongue remained clean, and the pulse unaffected, except an occasional
intermission for a day or two, the result, apparently, of the chloroform.
On Jan. 14th, 1863, the wires were removed without difficulty, and
water-dressing applied. On the 26th he left London on pressing
business with the wounds nearly healed, and wearing Bourjeaud's
apparatus. March 1st.-Have heard from this patient to say that the
parts are firmly closed, with no tumour or cough impulse, and that he
is wearing lever-spring horse-shoe truss pad.
Since the foregoing cases, I have operated on four cases in King's
College Hospital-two boys and one girl, by the method with pins; and
on a very large case of double scrotal hernia, in a man beyond the middle
age, at his own urgent request, by the crossed wire operation. Three of
the cases have been discharged cured; one, the girl, remains still in the
hospital. No constitutional symptoms have arisen in any of these cases.
THE END.

LONDON:
SAVILL AND EDWARDS, PRINTERS, CHANDOS STREET,
COVENT GARDEN.


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W. BONE&SON
FLEETSTLONDON EC
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