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Address in Surgery.

THE RADICAL CURE OF INGUINAL HERNIA.

By J. B. Wheeler, M. D., Burlington, Vt.

Mr. President and Fellows of the Vermont State Medical Society:

Few, if any ailments of a surgical nature are so often brought to the notice of the general practitioner, as hernia, and perhaps there is no other whose palliative treatment, when successful, affords so much relief, and, when unsuccessful, is attended with so much discomfort and risk to life. The perfect comfort which a well-fitting truss affords to a patient with a tractable sort of hernia, is familiar to every doctor, and so, too, is the miserable existence of the unfortunate whose hernia cannot be properly retained by a truss, but destroys its owner's comfort and endangers his life by its frequent descents.

It is with the idea of giving some account of what modern surgery can do for the commonest form of hernia, that I have chosen "The Radical Cure of Inguinal Hernia," as the subject of the address in surgery.

As a rule, a surgical operation is necessary for the cure of hernia, except in young children. In that class of patients, a cure can generally be effected

by the use of a

well-fitting truss, if persistently worn.

Among adults, such too seldom to place

a result is occasionally obtained, but any dependence on the truss as a curative agent, especially when we consider that the cases in which a radical cure is most to be desired, are the very ones in which a truss is of the least benefit. Operative surgery, then, must do its best to meet the want, and until operative techinque had reached its present state of perfection, the best that surgery could offer was bad enough. The mortality of operations which invaded the peritoreal cavity was so high that a conscientious surgeon could hardly feel justified in advising an operation on a reducible hernia, especially as the cure was far from certain, in those cases which were so lucky as to survive the operation. But since the mortality rate of all abdominal surgery has been so greatly reduced by improved technique, various operations for the radical cure of hernia have been devised, all of which have the low mortality rate, characteristic of modern, as compared with obsolete surgery, and some of which have a percentage of cures which abundantly justifies the operations. It is my purpose to describe briefly those operations which are finding the most favor among surgeons and to state, so far as possible, what may be expected from them in the way of cure.

Radical cure operations may be divided into two classes, those by which the inguinal canal is reconstructed and those by which it is obliterated. The first class is attended with less satisfactory results than the second. Every conceivable method of restoring the shape of the inguinal canal has been tried, but recurrence of the hernia has generally resulted because the surfaces approximated by the sutures were so narrow that the newly united struc

tures were too thin and weak to stand the strain put upon them by the abdominal contents. But when the canal is obliterated by sewing it up tightly, more resistance is offered to the vis a tergo, and recurrence is not so common.

The operations most commonly performed for the radical cure of hernia are MacEwen's, Bassini's and Halsted's. MacEwen's operation consists in isolating the sac and separating it from the inner surface of the internal ring, and then folding it upon itself until a pad is formed which is pressed into the abdominal cavity and stretched against the inner surface of the ring, thus occluding that opening. The canal is restored by stitching the conjoined tendon to Poupart's ligament over the spermatic cord. Although the canal is not obliterated in this operation, the results are excellent, especially in the hands of MacEwen himself, but they are attributable to the treatment of the sac rather than of the canal.

The operation which is most frequently performed in this country is the one which bears the name of Bassini, the professor of surgery in the University of Padua. The method which he employs is to isolate the sac, ligate it as high up as possible, after laying the inguinal canal open throughout its length, cut away the sac below the ligature, lift the spermatic cord out of the canal and obliterate the canal by stitching the internal oblique, transversalis and transversalis fascia to Poupart's ligament and the transversalis fascia. The spermatic cord is then laid upon the seam thus formed and covered by stitching the aponeurosis of the external oblique to Poupart's ligament.

Dr. Halsted of Johns Hopkins University, has devised an operation similar to Bassini's, but differing from it in the following respects. Instead of ligating the sac, he sews

it and cuts it away below the seam. He not only lays the canal open, but cuts through the abdominal wall upward and outward from the internal ring, until a point is reached where the muscles are thick enough to afford fairly broad raw surfaces of approximation. He then carries the cord up into this angle of the wound and obliterates the canal by sewing its walls together with stitches which include all the tissues except the skin. This leaves the cord on the outside of the aponeurosis of the external oblique, covered by nothing but skin. With the purpose of diminishing as much as possible the size of the cord and consequently of the hole through which the cord enters the abdomen, Halsted removes all but one or two of the spermatic veins.

The after treatment of these three operations is about the same. The patient is kept in bed, lying down, for three weeks. Some operators let their patients get up at the end of a week, (a plan which has been followed by Bassini himself), but as it is an established fact that healing by first intention is not perfect until three weeks have elapsed, it is safer to keep the patient in bed for that length of time. And I would here take occasion to remark, that if this rule were adhered to in other abdominal operations, we should probable hear less than we do of ventral hernia as a sequel of cœliotomy. No truss is worn after leaving the bed, as its pressure would tend to produce absorption of the cicatrix and weakening of the abdominal walls under the pad. The patient at first wears a snugly applied spica bandage, which may soon be replaced by a wellfitting abdominal supporter. This should be worn for several months at least.

The so called "open method" of operating, which was a good deal in vogue about five years ago, has been

practically abandoned. The best example of the open method is found in the operation devised by Professor McBurney of New York. In this operation, the inguinal canal is laid entirely open, the sac isolated and tied off, and then, instead of sewing up the canal, the edges of the skin are quilted to the deeper tissues and the canal is left to fill up with granulation tissue. The result is that the canal is obliterated by a cicatricial mass. After this operation the patient is kept in bed six weeks instead of three, and no truss is worn on getting up.

Although McBurney's operation is easy to perform and as safe as any other, it has not proved to be as effectual a cure as the other methods which have been described. In many cases the cicatricial tissue with which the canal is filled, gradually yields as time goes on and allows the hernia to descend again. For this reason the operation is seldom done nowadays, even by its distinguished originator.

In operating for radical cure, it is important not only to obliterate the canal, but so far as possible to divert inter abdominal pressure from the internal ring. A small depression of the peritoneum into that opening is gradually deepened by the pressure of intestine or omentum, forced into this little pocket by the frequent, and sometimes violent contraction of the abdominal muscles. The process goes on in this way until a hernia is fully developed. In order to guard against this danger it is necessary in operating to sew or tie off the sac as high up as possible, so as to render the inner surface of the parietal peritoneum smooth and leave no kind of a depression into which the abdominal contents can be forced. MacEwen's operation, which is by far the most successful of any method in which the canal is not obliterated, has always seemed to me to owe

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