March
THE RADICAL CURE OF HERNIA.
1899.]
93
Much of the discredit, into which the operation fell, was due to the indiscriminate manner in which it was formerly resorted to. The fact is not sufficiently recognised that, in
THE
Jiulian ^flodical diisoftc.
always
hernia, the actual exciting cause plaj^s important a part in the production of the affection, that unless some means be adopted many
MARCH, 1899.
cases
of
so
THE RADICAL CURE OF HERNIA.
to remove the
former,
operative
measures
are
not likely to be successful. When the open method of operating for the A few years ago Mr. Stanmore Bishop, in an the radical cure of hernia was first introduced, drew in important article on the etiology of hernia, comparative ignorance which tlien existed
led to special attention to the importance of this subof theject in relation to the question of operation. If an attention were paid to the causation of operation. It was believed that in this opera- greater would be fewer tion we had a certain cure for all cases of hernia, particular cases of hernia there and operations were undertaken indiscriminately failures. Another stumbling block in the way of this in all varieties of the affection. After the lapse lias been the great diversity of opinion operation of some 37ears it became evident that many cases which exists in regard to the principles upon had undergone relapse, and that the ultimate which its execution should be based. That there result of many of the early cases was extremely should be different methods of procedure is not
etiology of the affection over-sanguine estimate of the value to the
regard
unsatisfactory. These
facts,
is well
as
but that there should be so great a which divergence of opinion as to the principles upon and which these procedures are based is extraordi-
known, resulted
in
a
unnatural,
reaction unfavourable to the operation, became, for a time, very much discredited, the effects of this reaction cannot be said to have nary. We have on the one hand those who, like as yet entirely passed away. Ball of Dublin, maintain that the treatment of Much of this want of confidence is due to the the peritoneal stratum of the abdominal wall great divergence of opinion which exists regardalone is of importance, whilst the condition of ing the principles upon which the operation the muscular portion is of no significance. On should be based and the multiplicity of the the other hand we have those, certainly a majomethods which have been devised for its exerity, who consider that the treatment of the muscution. The list of these a
formidable
operations has already become
one, and threatens to
become still
more so.
The
sceptic,
not
unreasonablj',
declines to
ac-
knowledge the soundness of an operation which calls for such frequent modifications, and one upon the principles of which so much divergence of opinion still exists. However this may be, the recent reports of some of our most experienced surgeons show that, in suitable cases, the
great utility, and that large numbers of persons are permanent! and completely cured of this troublesome and dangerous is
operation
affection
one
by
of
means
of
operation.
The
publica-
tion of these
reports has tended, in a great to restore confidence in the operation, measure, and has shown that success depends not entirely upon the to
a
particular procedure adopted,
great
cases, and a
of
asepsis.
extent upon a
rigid
but also
careful selection of
attention to the
preservation
cular as
of the abdominal parietes requires and consideration as that of the portion. Mr. Ball, who has recently
portion
much
care
peritoneal published
account of
a modification of his so far as to goes operation, say that in inguinal hernia, all that is necessary is to efface the sac and "funnel-shaped an
method of
which leads to
it,
and that
depression"
no
attention need
paid to the condition of the muscular portion of the abdominal wall. On the other hand, in the operation of Mace wen and Bassini, the treatment of the two portions of the abdominal be
receive equal attention. We must confess to a difficulty in understanding the position of those surgeons who ignore the more careful and complete restoration of the
parietes
abdominal wall, such as is effected in the operations of Macewen and Bassini. The methods adopted by these two at the
surgeons attracted
appear to
have,
a
amount of attention than those of
greater
present time,
THE INDIAN MEDICAL GAZETTE.
U
other surgeons, and have found a larger number of imitators. The importance of a flaw in the muscalature of the abdominal wall, such as that from
resulting al of
a
cavity,
a
tumour, and the
liablity by hernia,
to be followed
cognised by flaw of the
of such is
the
remov-
an
abscess
condition
a
probably fully
re-
those who do not admit that
a
description situated
in
serious
more
a
laparotomy, or from or the healing of
inguinal region is of any consequence. one point regarding the operation
There is
for of hernia that does not appear to have received that attention which its imporWe refei to the method of dealing tance merits. the radical
with the
cure
prolapsed
omentum in cases
of
epiplo-
cele. It is
a
matter of
number of
largely,
if not
is strong O
a
great
of recurrent hernia the
cases
of the
tents
that in
experience
of omentum, and there that the mass of
entirely,
believe
to
reason
omentum sitself has
con-
found to consist
have been
sac
the chief
been
factor in
return of the hernia. In cases about bringing o o of inguinal hernia, whatever method of operation be preserved may be adopted, an opening must for the transmission of the cord, and into this opening before long a small portion of omena
insinuates
tum
action
larger
itself,
gradually
and
by
its
wedge-like
to the re-descent of
leads
a
mass.
The moral to be deduced from this fact is that in cases where a portion of omentum forms a
part
of the contents of
invariably routine
a
hernial sac, it should
If this
be removed.
practice, relapses
were
done
would be less
as a
frequent.
All surgeons appear to agree that whatever method of operation be adopted, primary union of the wound is essential to success. If suppuration occurs, the resulting cicatricial tissue appears slowly to yield to the pressure within. It is most unfortunate that this operation is so liable to be followed by deep-seated An
suppuration.
indefinite number of sutures of varying material may be introduced into the abdominal with
impunity,
and
Yet when sutures of a
operation
cavity
seldom heard of again. similar nature are used in
are
for the radical
cure
of
hernia, they not unfrequently induce suppuration. Various explanations have been given to account for this unfortunate
sarily
complication. That it is not necesa sceptic condition of the ligature certain; that it is often the result of
due to
appears
excessive tension is
extremely probable.
[Ma&cii 1890.
THE RADICAL CURE OF HERNIA.
1899.]
93
Much of the discredit, into which the operation fell, was due to the indiscriminate manner in which it was formerly resorted to. The fact is not sufficiently recognised that, in
THE
Jiulian ^flodical diisoftc.
always
hernia, the actual exciting cause plaj^s important a part in the production of the affection, that unless some means be adopted many
MARCH, 1899.
cases
of
so
THE RADICAL CURE OF HERNIA.
to remove the
former,
operative
measures
are
not likely to be successful. When the open method of operating for the A few years ago Mr. Stanmore Bishop, in an the radical cure of hernia was first introduced, drew in important article on the etiology of hernia, comparative ignorance which tlien existed
led to special attention to the importance of this subof theject in relation to the question of operation. If an attention were paid to the causation of operation. It was believed that in this opera- greater would be fewer tion we had a certain cure for all cases of hernia, particular cases of hernia there and operations were undertaken indiscriminately failures. Another stumbling block in the way of this in all varieties of the affection. After the lapse lias been the great diversity of opinion operation of some 37ears it became evident that many cases which exists in regard to the principles upon had undergone relapse, and that the ultimate which its execution should be based. That there result of many of the early cases was extremely should be different methods of procedure is not
etiology of the affection over-sanguine estimate of the value to the
regard
unsatisfactory. These
facts,
is well
as
but that there should be so great a which divergence of opinion as to the principles upon and which these procedures are based is extraordi-
known, resulted
in
a
unnatural,
reaction unfavourable to the operation, became, for a time, very much discredited, the effects of this reaction cannot be said to have nary. We have on the one hand those who, like as yet entirely passed away. Ball of Dublin, maintain that the treatment of Much of this want of confidence is due to the the peritoneal stratum of the abdominal wall great divergence of opinion which exists regardalone is of importance, whilst the condition of ing the principles upon which the operation the muscular portion is of no significance. On should be based and the multiplicity of the the other hand we have those, certainly a majomethods which have been devised for its exerity, who consider that the treatment of the muscution. The list of these a
formidable
operations has already become
one, and threatens to
become still
more so.
The
sceptic,
not
unreasonablj',
declines to
ac-
knowledge the soundness of an operation which calls for such frequent modifications, and one upon the principles of which so much divergence of opinion still exists. However this may be, the recent reports of some of our most experienced surgeons show that, in suitable cases, the
great utility, and that large numbers of persons are permanent! and completely cured of this troublesome and dangerous is
operation
affection
one
by
of
means
of
operation.
The
publica-
tion of these
reports has tended, in a great to restore confidence in the operation, measure, and has shown that success depends not entirely upon the to
a
particular procedure adopted,
great
cases, and a
of
asepsis.
extent upon a
rigid
but also
careful selection of
attention to the
preservation
cular as
of the abdominal parietes requires and consideration as that of the portion. Mr. Ball, who has recently
portion
much
care
peritoneal published
account of
a modification of his so far as to goes operation, say that in inguinal hernia, all that is necessary is to efface the sac and "funnel-shaped an
method of
which leads to
it,
and that
depression"
no
attention need
paid to the condition of the muscular portion of the abdominal wall. On the other hand, in the operation of Mace wen and Bassini, the treatment of the two portions of the abdominal be
receive equal attention. We must confess to a difficulty in understanding the position of those surgeons who ignore the more careful and complete restoration of the
parietes
abdominal wall, such as is effected in the operations of Macewen and Bassini. The methods adopted by these two at the
surgeons attracted
appear to
have,
a
amount of attention than those of
greater
present time,
THE INDIAN MEDICAL GAZETTE.
U
other surgeons, and have found a larger number of imitators. The importance of a flaw in the muscalature of the abdominal wall, such as that from
resulting al of
a
cavity,
a
tumour, and the
liablity by hernia,
to be followed
cognised by flaw of the
of such is
the
remov-
an
abscess
condition
a
probably fully
re-
those who do not admit that
a
description situated
in
serious
more
a
laparotomy, or from or the healing of
inguinal region is of any consequence. one point regarding the operation
There is
for of hernia that does not appear to have received that attention which its imporWe refei to the method of dealing tance merits. the radical
with the
cure
prolapsed
omentum in cases
of
epiplo-
cele. It is
a
matter of
number of
largely,
if not
is strong O
a
great
of recurrent hernia the
cases
of the
tents
that in
experience
of omentum, and there that the mass of
entirely,
believe
to
reason
omentum sitself has
con-
found to consist
have been
sac
the chief
been
factor in
return of the hernia. In cases about bringing o o of inguinal hernia, whatever method of operation be preserved may be adopted, an opening must for the transmission of the cord, and into this opening before long a small portion of omena
insinuates
tum
action
larger
itself,
gradually
and
by
its
wedge-like
to the re-descent of
leads
a
mass.
The moral to be deduced from this fact is that in cases where a portion of omentum forms a
part
of the contents of
invariably routine
a
hernial sac, it should
If this
be removed.
practice, relapses
were
done
would be less
as a
frequent.
All surgeons appear to agree that whatever method of operation be adopted, primary union of the wound is essential to success. If suppuration occurs, the resulting cicatricial tissue appears slowly to yield to the pressure within. It is most unfortunate that this operation is so liable to be followed by deep-seated An
suppuration.
indefinite number of sutures of varying material may be introduced into the abdominal with
impunity,
and
Yet when sutures of a
operation
cavity
seldom heard of again. similar nature are used in
are
for the radical
cure
of
hernia, they not unfrequently induce suppuration. Various explanations have been given to account for this unfortunate
sarily
complication. That it is not necesa sceptic condition of the ligature certain; that it is often the result of
due to
appears
excessive tension is
extremely probable.
[Ma&cii 1890.
