ARTICLE XLIV. IMPLANTATION OF SILVER FILIGREE FOR CURE OF LARGE VENTRAL HERNIA. BY HERBERT B. PERRY, M.D. OF NORTHAMPTON. READ JUNE 7, 1904. IMPLANTATION OF SILVER FILIGREE FOR CURE OF LARGE VENTRAL HERNIA. REPORT OF TWO CASES. THERE is no operation of reconstruction that the surgeon is called upon to perform that taxes more the resources at hand or promises less as far as restoration of function is concerned than large, ventral hernia of long standing, whether post-operative, congenital or acquired. The principle involved in the two cases I have the honor to detail to this Society is an old one, although the technique is of a later period than when silver wire was first used as a buried suture. In the evolution of suture materials silver wire has always been in evidence. Shede was the first to use it as a buried suture. His method was to include all the structures except the skin, as a preventive of subsequent hernia. A large impetus was given the silver wire suture when Credé published his discovery of the antiseptic properties of silver. In this country A. M. Phelps, of New York, was one of the first to use silver wire sutures in closing abdominal wounds, as well as its use in radical cure of hernia. The plan followed by him was to use a single strand, crossing and recrossing, to insure strength and solidity. The cases done by him were not, in the main, successful, owing, no doubt, partly to faulty asepsis, partly to the impossibility of using a single strand of wire without more or less strangulation of the tissues and, consequently, tissue necrosis. His use of silver wire began in 1892. From this time until 1900, when O. Witzel, of Bonn, published a report of a series of cases of hernia, giving results of the use of buried silver wire, very little progress was made, and the advance made since then is largely due to improved asepsis. Witzel's plan was to form a weave or net-work over the hernial opening with a single strand of wire. About the same time that Witzel reported his cases, R. Gopel, of Leipsic, reported a series of cases wherein a previously prepared silver filigree pad was sewed over the opening in the abdominal wall. This was the first account of the implantation of a silver filigree pad being used to cure large, ventral hernia. His deductions from his cases and claims of superiority for this particular method over that of Witzel's were as follows: First. The tissues bordering the hernial opening are less exposed to injury and constriction. Second. The time for operation is reduced. Third. The meshes with the ready-made wire pad are of equal and regular dimensions, and diastasis, even of small size, less frequently met with. Fourth. The amount of silver wire left is reduced to a minimum. In November, 1902, Dr. Willy Myer, of New York, reported, in the Annals of Surgery, three cases. In two of his cases previous attempts at repair had been made and were failures. The third case, owing to a large amount of adipose, seemed hopeless, except some means out of the usual line were attempted. His reports of the three cases were eminently satisfactory. The technique, as described by him, is the one employed in the cases to be reported. It will not be necessary for me to consume time by giv ing in detail all of the steps of the operation, but to say that it is identical as though an autoplastic repair were to be done, up to the point of closing the hernial opening. From that time the plan of procedure is as follows: The omentum should, if possible, be stitched to the margin of the hernial ring. The sac is cut away, except that sufficient is left to close over without much tension. This is done with a continuous silk suture. The fat is then excavated sufficiently wide to admit the silver wire pad and permit stitching its border to the muscles and fascia. This is done with a continuous silver wire suture of sufficient length to have its starting and finishing points together, thus reducing the rough points left to the minimum. This completed, the skin and fat is closed over all by interrupted silk-worm gut sutures. The silver pad should be of sufficient size to overlap the margins of the opening from onehalf to one inch. This plan is permissible only and indicated only in the classes of cases where autoplastic repair is impossible with any assurance of success, for any or all of the following reasons: First, the large size of the hernial opening; second, long existing hernia; third, atrophy through pressure and fatty degeneration of the adjacent muscular and fibrous tissues; fourth, and most frequently, previous unsuccessful attempts at autoplastic repair; and fifth, in fatty abdominal walls. The following cases are illustrative of two distinct types, the first a post-operative hernia having had an attempt at repair, the second an acquired umbilical hernia of many years' standing. CASE 1.-Mrs. A., age fifty-two, occupation housekeeper in a factory boarding house. In 1890 this woman was operated upon and a large ovarian cyst removed. A year later, as a consequence of vomiting violently after ether to reduce a Colles' fracture, a hernia in the ventral |