Thursday, 28 July 2016

HISTORY OF HERNIA SURGERY



Friends, I hope you remember one of my most favourite senior colleagues Dr. H.S. Adenwalla. He has an unique ability of recreating the history of medicine in front of our eyes by his outstanding story telling abilities. This time he is telling us about Edoardo Bassini and the History of the Evolution of the surgery of the Inguinal Hernia. Enjoy it!
Edoardo Bassini was born in Pavia in Northern Italy and came from poor peasant stock. After he received his medical degree he joined up as a soldier under the revolutionary leader Giuseppe Garibaldi. During the war he suffered a saber cut in his right groin which led to a foecal fistula. This mishap is what focused this young surgeon’s attention on the anatomy of the groin. After he recovered from this injury he studied under Theodore Billroth in Vienna and then under Bernhard von Lagenbeck in Berlin and Joseph Lister and Spencer Wells in London. With Lister he learnt the principles of antiseptic surgery, which at age of 39 he brought to the famed university hospital at Padua. There he was given the chair of Pathological Anatomy. His first act was to convince his Superior Prof Tito Vanzatti that antiseptic surgery was of prime importance if surgical patients were to survive. When Vanzatti retired Bassini was elevated to Prof. of surgery at Padua.

Bassini was a tall well knit and athletic man, it is said he rose every morning at 4 AM to ride for an hour and a half and entered the hospital at 6 AM, where he worked late into the night. In his early years he lived in the hospital a Spartan existence.

The history of Inguinal Hernia therapy is a long one. The mummy of Pharoah Merneptals who reigned in 1215 BC showed a large scar in the groin with a scrotal swelling. The mummy of Ramesses V 1157 BC also showed evidence of a large inguinal Hernia. Three thousand years ago both operation and trusses were employed. The Babylonians advocated the ingestion of wolf’s bile in urine. The ancient Hindus laid heated cow dung upon ruptures. Celsus was a strong advocate of surgery but he worked on a wrong premise, he believed that the hernia resulted from a rupture of the peritoneum. There is no doubt that of all the workers of that age Celsur showed an advance in the knowledge of anatomy. He separated the sac from the cord structures and ligated the sac at its neck. His hernias however, recurred and he did not report as to how many of his patients died of shock or sepsis. Ambroise Pare after giving surgery a good try turned to the truss. With Pares’ abdication of surgery all responsible physicians gave up trying to operate on the inguinal hernia. All they had to offer was the truss. As a result millions of young otherwise healthy young men all over the world lived miserable lives. After a time Celsus’ operation was revived by Pierre Franco in France, Czerny in Heidelberg and John Wood in London. All their patients wore a truss after the operation and more than 90% of their hernias recurred. The results of surgery were obviously distressing.
Anaesthesia and antiseptic surgery set the stage for Edowardo Bassini’s monumental work, which was so simple that one wonders why no one had thought of it before. Bassini had devised his operation in 1884, by 1886 he had operated on 123 cases with a two year follow up and a 94% success rate. He however, refused to publish till he had operated on 250 cases, which he did in 1888.
A German physician by the name of Peter Gallman, a student of Virchow has left behind a firsthand report of what he saw at Padua in Bassini’s unit where the hernia operation evolved…. I quote from Gallman “A few days ago I arrived in Padua and visited the University Hospital. Things were different from what I had seen at Pavia and other Italian hospitals. I felt as I was breathing a different kind of air, clean and fresh, with a strong smell of carbolic acid and eucalyptus oil. When I asked to see Bassini I was guided to a plain white washed room with a few simple pieces of furniture. A tall strong looking man was seated behind a large desk. On the desk were a few open books and a couple of surgical instruments strewn around. He was in the act of writing something. His face was deeply tanned, his hair and beard dark with a few scattered threads of grey. As he rose to shake my hand his deep set sad eyes lit up with just a flicker of a smile. He spoke to me in fluent German without an accent. He said “I am pleased that you are interested in my work on the inguinal hernia. We are a young nation and it is difficult for people from the outside world to take us seriously” I noticed two things about him, that for an Italian he was sparing of gestures and unlike the German professors in my country he was soft spoken and was not at all formal. He continued “I have three patients with hernias for surgery tomorrow. I would be happy to have you witness them. Today you must see their antiseptic preparation that is most important.””Why today? I asked.” Bassini replied, “The day before the operation I put my patients in an isolated room, no visitors or unauthorised persons are allowed.” “I saw the patients being placed on rubber sheets and then after shaving began the most rigors sponging from neck to toe, first with soap and warm water and then with a carbolic solution, after this the patients were wrapped in a sheet dipped in carbolic solution and there they would remain till the next day when the operation would take place”. “This preparation was more stringent than what I had seen with Lister”. When I questioned Bassini he smiled and said”one can’t be too careful if infection sets in all is lost. ”
“Next morning I found a seat near the operating table. The first patient Ernesto Calzavare, was carried in still wrapped in the carbolic sheet. The patient was soon brought under chloroform anaesthesia. Bassini with one clean sweep of the knife opened the skin and the external oblique exposing the inguinal canal. The hernial sac bulged out. The vas and cord structures were separated. The contents of the sac were returned to the abdominal cavity. The sac was tied at the base and excised. I said to myself nothing new so far. Now came Bassini’s simple innovation. His assistant Tansini lifted the cord structures. Bassini then stitched the lower edge of the oblique abdominal muscle to Poupart’s ligament. Bassini had thus created a strong abdominal wall along the posterior region of the inguinal canal. He then nodded to one of his assistants, the doctor took a feather and tickled the patients throat, the patient gagged and coughed violently. The posterior wall of the inguinal canal remained firm. Bassini looked up and smiled. “That is all that there is too it, Gentleman. This patient can go back and dig in the fields or carry heavy loads, they will not be wearing a truss, and they will never get a hernia again”.

I stayed on in Padua for a month, saw many more hernia repairs and at least 40 patients operated on by Bassini a year or two ago, all of them doing hard manual work. Before I left Padua Bassini told me a poignant story. He said, “You remember Arturo Malatesta one of the operations you saw on the first day, after he was admitted there was an ugly scene in the ward which I was witness too. The girl he was betrothed to a slim beauty was standing over his bed and shouting at him and was telling him that she would not marry him. When she saw me approach she shouted “”I have told him time and again that it is all over between us. What do I want with a man who can’t even dance because his guts are falling out of his belly? A nineteen year old cripple! Does he think that I am going to spend the rest of my life buckling on his wretched truss?” “Isabella!” The poor man groaned and turning to me he said “Professor, tell her that you are going to cure me.” Bassini said, “I was so upset I placed my hand on the poor boy’s head and said. If she laughs at you son because you have this trouble, my boy, she isn’t worth marrying, you will find a better girl. I assure you. We shall do everything possible to cure you”.
Two years later Edoardo Bassini reached his first international audience. He published his method in the 40th volume of “The German Archives of Clinical Surgery” a report of 262 cases. It was a well documented paper, with a description of the method advocated and tabulated results. It was as though a long closed door was opening. Maccewen in England and Halsted in the United States were developing the same method more or less on the same lines. Padua became the Mecca for surgeons who were eager to follow the path that Bassini had blazed. Like most great innovations it was a simple one, but it required a genius who with single minded devotion gave mankind an answer to a problem that had defied the finest surgical minds of the world for centuries.
Edoardo Bassini died a celebrated surgeon immortalised by his hernia operation. He lies buried in his home town in Pavia in a family tomb in the “Cimitero Monumental” where are buried other renowned scientists like the Nobel Laureate Camillo Golgi, a neuro-scientist of great fame, Bartilome Penizza, a student of the great anatomist, Antonio Scarpa, who discovered that visual function lay in the posterior cortex, and Adelgi Negri, a pupil of Golgi a great pathologist renowned for his work on the pathology of Rabies. It is strange that all these men like Bassini studied and worked in the Universities of Pavia and Padua. The Anatomy museum at Pavia I believe is worth visiting. You will see the head and index finger of Scarpa in a jar, how it came about is another story.
There were six great Universities in the world Taxilla, Nalanda, Banares, Padua, Oxford and Cambridge. Taxilla and Nalanda perhaps the two oldest do not exist. It is said that the Government of India is trying to revive the University of Nalanda.

May I now add my bit to this lovely story. Every time I read these wonderful write ups, bejewelled with anecdotes and stories, I am amazed by your style of presentation and by your memory! How can you manage to remember so many finer details and then bring them out so eloquently and interestingly? My professor of General Surgery, Prof. P.C. Dubey also was a great history buff and told us stories about the surgeons of yesteryear and how surgery developed. I remember him telling us that Hernia comes from a Greek word ‘hernios’, which means bud or offshoot. He told us that in XIX century Heaton was performing injection of the mixture of white oak and morphine into the hernia sac to obtain its fibrosis! Czerny was performing the high ligation of the hernia sac and complete closure of the internal inguinal ring with sutures and Wood was double ligating the hernia sac to perform a natural plug and use it to close internal inguinal ring! Needless to say they all failed and recurrence was a rule along with very high mortality too! 

Bassini's landmark contribution in 1887 is written in golden letters in the history of hernia surgery and many surgeons copied his style. William Steward Halsted, after reconstructing the inguinal canal, left the spermatic cord in the subcutaneous position. It allowed for closure of the posterior wall of the inguinal canal with a very strong, transfixing sutures but he managed to perforate the urinary bladder in one of his patients and had a urinary fistula from the repair site! Zdzisław Sławiński in Warsaw did something even more peculiar - dissecting only the neck of the hernia sac, ligating and cutting it and leaving the cut sac in situ! It was McVay from Ann Arbour popularised his concept of inguinal hernia repair using Cooper’s ligament instead of inguinal ligament as a lower edge of sutures aimed at reconstructing posterior wall of the inguinal canal. Edward Earl Shouldice from Toronto advocated meticulous dissection, complete incision of the transverse fascia, sutures with monofilament rather than silk, oversewing of the posterior wall of inguinal canal by four layers of fascia and aponeuroses of oblique muscles and finally rapid ambulation of the patient. The Shouldice repair or the Canadian repair, as it was named, can be seen as a final, close to perfect state of Bassini method. It incorporates succinct changes, but the underlying concept is surely Bassini!