HISTORY OF HERNIAS
How is it possible that there are records that go back thousands of years documenting hernias in human beings? We are in luck because most hernias when left unattended become very large and obvious and can lead to complications many of which can be fatal. If an important individual of that time was afflicted with a hernia it was memorialized in some way. Because of the obviousness of very large hernias even unimportant individuals would have been noticed by observant scholars of the time and their hernia chronicled in someway.
HERNIA ORIGINS
One of the first images of an individual with a hernia is seen in the picture to the left Phoenician terra-cotta figure showing an umbilical hernia in a woman in the fifth or fourth century BC.
In the sixth dynasty of Ptah-hotep, the relief picture to the left shows workers in the field with umbilical hernias.
The shown at the left is of the Ankhmahor tomb at Saqqara at 2500 BC shows a relief showing reduction of an inguinal hernia.
The mummy of Pharaoh Meneptah who rain around 1215 BC shows complete absence of the scrotum but not the penis. It is surmised that an Egyptian surgeon attempted cure for a hernia. The mummified remains of Ramses V, 1157 BC, shows a massive inguinal hernia.
HERNIA DOCUMENTATION
The earliest written reference to hernias appears in the Egyptian papyrus of Ebers circa 1500 BC. In 300 BC in the corpus Hippocraticum hernias are mentioned as well as a few varieties and correlates them to certain occupations.
Praxagorus of Cos at around the fourth century BC is reputed to have attempted reduction of a strangulated hernia. Two others of that same time Herophilus of Chalcedon and Erasistratus of Keos are reputed to have performed hernia surgery.
Celsus lived in Rome in the first century A.D. He came from a wealthy family and wrote on many subjects including philosophy, warfare, agriculture and medicine. He gives an excellent description of the clinical signs of strangulation and the symptoms that can occur. He described the first surgical technique for hernias. Heliodorus or (sun’s gift) during the rein of Trajan describes a method of surgery for inguinal hernia. Claudius Galenus (shown on the left) who lived from 129 to 201 A.D. was a practitioner of medicine in the gladiator school. He was a prolific writer and published more than 100 books. He was a keen observer and commented that there was a deficiency in the two external abdominal muscles, which led to hernias.
Aretaios of Cappadocia lived sometime in the first century after Christ. He wrote a detailed description of a complication of a strangulation hernia. Aetius around 500 A.D. was a court physician to a Byzantine Emperor Giustiniano. He described a detailed surgical technique and also advocated that surgery was dangerous and should be avoided at all costs. In lieu of surgery he recommended prayers. Paul of Aegina from around 650 A.D. lived in Alexandria Egypt. He is responsible for a comprehensive surgical text describing scrotal and non-scrotal hernias. He suggested routine orchiectomy.
HERNIAS IN THE SECOND MILLENIUM
Albucasis was a Moorish surgeon circa 1000 A.D. he wrote a book which concentrated on procedures and instruments and was striving to revive the art of surgery as taught by the ancients. The picture on the left is an illustration from his book.
Avicenna from around 1000 A.D. was an Arabian physician who used auscultation to distinguish between hernia and hydrocoel. William of Salicet who lived around 1250 A.D. advocated preserving the testicle. Mondino de Luzzi was a professor of medicine in Bologna, around 1300 A.D. He revived the study of anatomy and came up for a radical cure for hernia. Guido Lafranchi from Paris, around 1350 A.D. advocated conservative treatment and was inspired by God to save the testicle! Roland of Parma from around 1383 A.D. treated hernias with with a position called Trendelenburg.
The image to the right shows an illustration from his book where the patient is positioned head down on a steep incline and uses gravity to help an incarcerated hernia reduce.
Guy de Chauliac (pictured to the left) lived in France in the 1300s. He wrote a magnificent book, Chirugia Magna. He was the first to note the difference between an inguinal and a femoral hernia. He also believed in manual reduction by Trendelenburg.
HERNIA SURGERY ADVANCES
Gabriel Fallopius
Gabriel Fallopius was a professor anatomy, surgery and botany and Padula around 1570 A.D. He studied with the famous Vesalius. He noted a high incidence of hernias in singers and monks.
Fabricius Aquapendente
Fabricius Aquapendente (pictured above) in the late 16th century debated the merits of medicine versus surgery and he preferred trusses to surgery. If that failed his second choice was Ferrum Candens!
Lorenz Heister
Lorenz Heister of Amsterdam first recorded description of a direct inguinal hernia. Pieter Camper of Leyden around 1750 AD described the surgical anatomy of the inguinal hernia and described the fascia named after him. Franz Hesselbach described the ligament that now bears his name and also the triangle that is the home of direct inguinal hernias. Antonio de Gimbernat (pictured below) described in enlarging the femoral ring by dividing the lacunar ligament as a treatment for incarcerated femoral hernia.
HERNIAS IN THE TWENTIETH CENTURY
Henry O Marcy
Henry O Marcy was a American general surgeon from Boston who practiced in the early 20th century. He performed high ligation of the hernia sac as well as closure of the internal ring to repair indirect hernias. This is a procedure that is still used widely today especially in pediatric patients.
Edoardo Bassini
Edoardo Bassini was an Italian surgeon from the early 20th century. Everyone considers him the father of modern herniorrhaphy. The procedure that he described is still in wide use throughout the world.
William Stuart Halsted
William Stuart Halsted was a prolific surgeon from Johns Hopkins in the early 20th century. He modified the Bassini procedure. He is also well known for championing aseptic technique and surgical education.
Chester Mcvay
In the late 40s Chester McVay popularized the use of the Cooper’s ligament for repair of inguinal hernias.
Henri Fruchaud
In the 1950s French surgeon and anatomist Henri Fruchaud clarified the preperitoneal anatomy. Based on his work prepare Preperitoneal approaches and laparoscopic approaches were realized.
Edward Shouldice
In the early 50s Edward Shouldice, Nicholas Obney and Ernest Ryan were performing a multiple layer repair of the posterior inguinal wall.
OPEN MESH REPAIRS
One of the first synthetic meshes used was Marlex. This was a poly propylene substance which revolutionized hernia repairs. This ushered in the era of tension free repairs. In 1965 Dr. Rives developed a hernia repair placing mesh in the pre-peritoneal space. He felt that all patients did not need this type of repair and consequently was very selective about using it. In 1984 Dr. Renè Stoppa used a large dacron prosthesis to reinforce transversalis fascia for complex hernias in patients who were deemed at high risk for recurrences. In the 1970’s Lloyd Nyhus, my chief and mentor (pictured to the left) from the University of Illinois and Cook County Hospital in Chicago and Robert Condon from the University of Wisconsin in Madison popularized the pre-peritoneal approach for repair of all inguinal and femoral hernias.
LAPAROSCOPIC HERNIA REPAIRS
In 1982 Dr. Ralph Ger performed the first Laparoscopic inguinal herniorrhaphy. A few years later Dr. Fitzgibbons would add mesh to the laparoscopic approach. This is but a brief review of the history of hernias based on the definitive text on this subject titled Hernia Healers by Rene Stoppa, George Wantz, Gabriele Munegato and Alfonso Pluchinotta, published by Arnette 1998.