Women of Substance in Homeric Epic:

Objects, Gender, Agency Lilah Grace

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 OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi

WOMEN OF SUBSTANCE IN HOMERIC EPIC

OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi
 OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi

Women of
Substance in
Homeric Epic
Objects, Gender, Agency

LILAH GRACE CANEVARO

1
OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi

3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
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© Lilah Grace Canevaro 2018
The moral rights of the author have been asserted
First Edition published in 2018
Impression: 1
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a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
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address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
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for information only. Oxford disclaims any responsibility for the materials
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 OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi

Preface

Women in Greek epic are treated as objects, as commodities to be

exchanged in marriage or as the spoils of warfare. However, women
also use objects to negotiate their own agency, subverting the male
viewpoint by using the very form they themselves are thought by men
to embody. This book follows the ways in which women in Homeric
epic use objects to negotiate their agency, to express themselves,
and to contribute in their own way to the action. Female objects in
Homer can be symbolically significant and powerfully characterizing.
They can be tools of recognition and identification. They can pause
narrative and be used agonistically. They can send messages and be
vessels for memory.
This book brings together Gender Theory and the burgeoning field
of New Materialisms, combining an approach predicated on the idea
of the woman as object with one which questions the very distinction
between subject and object. This productive tension leads us to
decentre the male subject—and to put centre stage not only the
woman as object but also the agency of women and objects. This
book is an expression of a wider phenomenon, what Vital Materialist
Jane Bennett has called ‘attentiveness to things’. It uses a backdrop of
Thing Theory in its manifold manifestations to unpack the key ideas
of ‘object’ and ‘agent’, providing a model of agency which operates on
a sliding scale, governed by role in society and narrative and coloured
by gender. Male and female models of agency through objects are
teased apart in terms of narrative progression, boundaries, symbol-
ism, and chronology. Liminal women like Helen and Penelope, torn
between lives and outside normal kyrios control, are separated out as
a particular category with a striking degree of autonomy through
objects. Odysseus is highlighted as a unique male character with a
unique relationship to objects, subordinated for much of his epic by
the textiles of the women who seek to shape him, and foregrounded as
creator, repurposer, and manipulator of materials. Objects are shown
to be powerful, yet not infallible, as ultimately Homer reflects on their
limitations and establishes a hierarchy of memory in which mortals
and materials are outdone by epic poetry.
OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi

vi Preface
Attentiveness to things in Homeric epic has implications not only
for our reading of character and narrative, but also for our under-
standing of the role of women in Homeric society. The gender roles
and the human/object interactions explored have to mean something
to their audience, and in order for this to be the case the poet must be
reflecting, at least to some degree, cultural norms and social truths.
Combining anthropological and memory studies with gender studies,
this book reveals a nuanced awareness of the female role, codes, and
viewpoint on the part of Homer which is testament both to a poetic
sensitivity and to a social one. Gender Theory and New Materialisms
are brought together to reveal that Homeric women are not only
objectified but are also well-versed users of objects. This is something
that Homer portrays clearly, that Odysseus understands—but that
has often escaped many other men, from Odysseus’ alter ego Aethon
in Odyssey 19 to modern experts on Homeric epic.
 OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi

Acknowledgements

This book began as a postdoctoral project funded by the Alexander

von Humboldt Foundation at the University of Heidelberg. For that,
I have Jonas Grethlein to thank—my Humboldt sponsor, and a fellow
object enthusiast. Work on the book continued at the University of
Edinburgh under the aegis of the Leverhulme Trust, where I have had
the privilege of bringing together a dream team of scholars at a series
of conferences and panels. I learned a lot from visitors such as Jon
Hesk, Mario Telò, Nancy Worman, and Froma Zeitlin—and it is my
great fortune to continue to collaborate with Melissa Mueller. Drafts
have been shaped and reshaped in response to comments from Felix
Budelmann, Douglas Cairns, Michael Carroll, Deborah Lyons, Alex
Purves, and the readers and editors at OUP, and discussions with
Katharine Earnshaw have been invaluable in shaping my thinking on
things. I am grateful to Maureen Alden for guiding me to the book’s
cover image, and to Stephanie Winder for her help with the final
hurdles. A word of thanks also to James Corke-Webster, whose casual
mention of Object-Oriented Ontology set me on the path of theory.
I have taken particular pleasure in exploring questions of female
agency and identity while finding my feet in academia as a new
mother. Thanks to my son, Layton, for the company, the cuddles,
and the crash course in time management.
Finally, I dedicate this book to a woman of more substance than
she knows what to do with—my Mam.
OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi
 OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi

Contents

List of Illustrations xi
Abbreviations xiii

Introduction: The Proggy Mat 1

1. How Far Are We from a Hot Bath? 11
1.1. Women, Objects, Things 11
1.2. Society and Sandals 28
1.3. The Memory of Objects 43
2. The Politics of Objects 55
2.1. Words and Weaving 55
2.2. Stuck in the Middle with You 67
2.3. Managing the House, Managing the Narrative 84
2.4. Gathering the Threads 97
3. Object-Oriented Odysseus 109
3.1. Odysseus in the Middle 109
3.2. Tying the Knot 117
3.3. All Hands on Deck 129
3.4. Here’s One I Made Earlier 143
4. Beyond the Veil 167
4.1. Uprights and Subversions 167
4.2. Mortality and Material Memory 181
4.3. When the Gods Move Furniture 202
4.4. Architectural Anxieties 234
5. Uncontainable Things 245
5.1. When Is a Door Not a Door? 245
5.2. Cataloguing Women and Objects 259
Epilogue: Revealing Garments 275

Bibliography 281
Index of Passages 299
Subject Index 307
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 OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi

List of Illustrations

2.1 and 2.2. Drinking cup (skyphos) with the departure and recovery
of Helen. Painter: Makron; potter: Hieron; place of
manufacture: Athens, c.490–480 BC. Museum of Fine
Arts, Boston, Francis Bartlett Donation of 1912,
13.186. 78
4.1. John William Waterhouse, Ulysses and the Sirens,
1891, oil on canvas 100.6  202.0 cm, National Gallery
of Victoria, Melbourne, Purchased 1891 (p. 396.3–1). 168
5.1. Red-figure neck amphora attributed to the Owl Pillar
Group, c.450–430 BC. Depicting (possibly) Zeus
and Pandora/Elpis. British Museum, F147. 258
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 OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi

Abbreviations

Abbreviations of the names of classical authors and works are those

used in S. Hornblower and A. Spawforth (eds) (2012), Oxford Classical
Dictionary, 4th edition, Oxford.
Journal names are abbreviated according to the usage of L’Année Philologique.
The Iliad text used is the Teubner edition of M. L. West (vol. 1 1998, vol. 2
2000), and the Odyssey text is that of H. van Thiel (1991). The Theogony text
is West’s 1966 edition, and the Works and Days his 1978 edition. Texts of
the Shield of Heracles and the Catalogue of Women are taken from Glenn
Most’s 2007 Loeb edition.
OUP CORRECTED PROOF – FINAL, 14/7/2018, SPi
 OUP CORRECTED PROOF – FINAL, 13/7/2018, SPi

Introduction: The Proggy Mat

My Nana used to tell a story. The women were making their proggy
mats, exchanging scraps of textile and gossip both. That day, one of
the girls had rather a lot of fabric to use. ‘He’s gone off,’ she explained
succinctly. The fabric came from clothes that had been ‘his’—now
shredded, destined to be poked and progged, to festoon the floor and
be trodden down. The message was clear.
In this story, the objects say as much as do the women—if not
more. People and things communicate with and through each other.
There is a subtext to the textiles, encoded and decoded by the women.
In order fully to understand the story, we have to read object as well
as character; listen to what is not said but is expressed through a
material medium. We have to be attentive to things.
This is a story. But it is a true story, of real people and real objects.
It is also a story that takes place against a backdrop familiar to its
audience (there was probably a proggy mat on the floor when my
Nana was telling it). Interpretation is straightforward within its
context, minimal extrapolation required. What, then, happens when
we transfer our attention to things in a more complex and layered
narrative? What happens, first of all, when we do not have my Nana,
but rather a whole set of questions about authorship and tradition?
Second, what happens when the women and their objects are found
not in a living room in the north-east of England, but in a quasi-
mythical setting probably as unfamiliar to an original audience as to
subsequent ones? In taking my Nana’s story out of its cultural
context, we already run into difficulties of comprehension—how
many of this book’s readers actually know what a proggy mat is?1

1
A northern breed of rag rug, if you were wondering.
OUP CORRECTED PROOF – FINAL, 13/7/2018, SPi

2 Women of Substance in Homeric Epic

And third, what happens when the eyewitness account of objects seen
and touched is replaced by a poetic description of imagined things?
This book is concerned with women and objects in Homeric epic. It is
a book about materiality and about agency—but it is also a book
about the poetic representation of them.
The story of the proggy mat stars women, and was told by a woman,
to a female audience. None of this finds its parallel in the Homeric epic
tradition (unless, of course, you are Samuel Butler—more on him
later). And yet, what I shall call ‘the politics of objects’ pertains to
both stories. In being attentive to things, we can give voice to silenced
women; bring marginalized female characters into the spotlight;
reveal a complex code of communication and negotiation of agency
operating within gender constraints. It is not, of course, only Homeric
women who use objects: the Homeric male domain has its own
materiality too. But the relationship between objects and agency is
one that is coloured, influenced, even constituted by gender roles.
Chapter 1, ‘How Far Are We from a Hot Bath?’, sets the context
and parameters of the analysis, first by placing this book against a
backdrop of New Materialism—or, more accurately, New Material-
isms. This is a rapidly evolving field in philosophy, anthropology, and
the social sciences, and it is one with which I engage throughout this
book. It is a field which at its best productively engenders ‘attentive-
ness to things’, and I hope that this book will both show Homer to
have such attentiveness and encourage readers to develop this atten-
tiveness themselves. In Chapter 1.1 I use the framework of Thing
Theory in its various manifestations to unpack seemingly innocuous
but in reality surprisingly loaded terms like ‘object’ and ‘agent’, and
begin to define and locate agency, a key concept for this book. This
section relates the non- or post-Cartesian approaches of the New
Materialisms to Homeric epic, raising the question of boundaries: to
what extent does the Materialist slogan ‘Things are us!’ apply to
Homer? Most of the foundational studies in the field of object or
‘thing’ theory are concerned with the direct, real-world relation
between people and things, and comparatively little work has been
done on representations of that relation: that is, the relationship as
presented or as conceived in literature, in art, in drama, or through
other media. Drawing on the work of Alfred Gell, Chapter 1.1 argues
that this representational factor is of paramount importance, as it
makes a substantial difference to the status of objects and to the
location of agency. The section concludes with an exploration of the
 OUP CORRECTED PROOF – FINAL, 13/7/2018, SPi

Introduction: The Proggy Mat 3

productive tension between this book’s core approaches: Gender
Theory and New Materialism.
With Chapter 1.1 having laid the theoretical groundwork, Chapter
1.2 then addresses the historical and social ramifications of this book.
The importance of objects in elite male gift exchange is explored
through the complex example of the exchange of armour between
Glaucus and Diomedes in Iliad 6—a scene whose meaning has been
contested since Homer’s authorial comment onwards. This discus-
sion is balanced by a consideration of the importance of objects at the
other end of the social scale, through the scene of Odysseus’ meeting
with the swineherd Eumaeus in which objects proliferate. Most
importantly, the implications of ‘attentiveness to things’ for our
reading of Homeric society—and specifically the role of women in
Homeric society—are worked out. Chapter 1.3 then begins to draw
out some initial dichotomies and categories, starting with the differ-
ences between male and female interactions with objects. It focuses
on one function of objects that is intrinsic to both the context and
aims of the Homeric poems: that of memory and, more specifically,
memorialization. Using studies of cultural and collective memory and
anthropological studies of gift giving, this section broadly defines
male objects as operating on a continuum of memory. The idea of
the cultural biography of things is introduced, and objects of latent
power such as Agamemnon’s sceptre and Odysseus’ bow are used as
examples of items with provenance and lineage. Female objects, on the
other hand, are defined as primarily prospective, preserving memory
of the present for posterity—and the key factor here is that of creation.
Homeric women are foregrounded as producers of objects, and just as
they create an object and imbue it with a symbolic resonance, so too
do they handle memory in much the same way. The question of
boundaries is revisited, and a distinction made between men as users
of objects with permeable boundaries between person and thing, and
women as conscious of the creative process and thus linked to, yet at
one remove from, the objects they produce.
Chapter 2, ‘The Politics of Objects’, opens with a discussion of
different models and parameters of female agency. Iliadic and Odys-
sean women are differentiated in terms of their roles in war- and
peacetime respectively, and the ways in which Andromache and
Helen weave are used as case studies for ‘normal’ and ‘exceptional’
female characters. Chapter 2.2 engages more closely with these excep-
tional women, bringing together Helen and Penelope in terms of their
OUP CORRECTED PROOF – FINAL, 13/7/2018, SPi

4 Women of Substance in Homeric Epic

liminal position in society. Such a position, with the elevated auton-
omy it involves, is shown to be reflected in these women’s use of
objects, and in particular in their expressed awareness of kleos and the
mechanisms for achieving it. Each woman makes an explicit link with
the other, forging a connection through their lack of male guardian-
ship. Chapter 2.3 examines the guardian of the limen itself, Eurycleia,
and her agent objects: the door and the lock. This introduces, on the
one hand, female proximity to the house as a physical object: some-
thing which Penelope exemplifies throughout the Odyssey, as in many
of her appearances she is standing beside a pillar. Through her
opening and closing of doors onto the action, Eurycleia also intro-
duces the cinematic potential of epic objects, and the effect this has on
narrative pace. A narratorial focus or ‘zooming in’ on objects slows
the rhythm of the narrative. When the ‘camera’ is on the objects,
though we know the story is continuing, we cannot see it. The pace
necessarily slows in this material moment. When Penelope uses
textiles to pause time in Ithaca, the only object that can get time
moving again is her and Odysseus’ marital bed. Chapter 2.3 presents
the bed as a constitutive symbol with resonance for both genders. It is
inalienable, and a site of agonism for Penelope’s hand, for Odysseus’
identity, and ultimately for the dynamics of their reconciliation. The
bed and the raft are both objects made by Odysseus, but are starkly
contrasted, suggesting a corresponding female agonism: between
Calypso, who donates material for a sail, and Penelope, who, should
Odysseus ever arrive home, will recognize the material as a gift from
another woman. Such a message transmitted through textiles is one
example of the coded communication with which the rest of this
chapter is concerned. Drawing on feminist literature on female com-
municative channels and the potentially liberating power of technol-
ogy, this chapter takes these ideas back to before the jacquard loom,
before the telephone switchboard, and argues that such channels are
embedded in Homeric epic. Through the creation and distribution of
textiles, these supposedly ‘commodified’ characters create their own
kind of commerce, and their own way of communicating. This is the
politics of objects: material means of sending messages beyond the
household, promoting one’s own household and (in exceptional
cases) oneself, and mapping alliances through the distribution of
one’s household production.
Chapter 3, ‘Object-Oriented Odysseus’, turns to the eponymous
and exceptional hero. His relationship with objects is a unique one,
 OUP CORRECTED PROOF – FINAL, 13/7/2018, SPi

Introduction: The Proggy Mat 5

and one that deserves its own chapter even within a book on Homeric
women. The ways in which Odysseus uses objects raise questions
about the sliding scale of agency and how it relates to gender.
Chapter 2 showed how the bed allows Odysseus to reclaim both his
wife and himself: that is, the part of himself that is τέκτων, an
Odysseus who has been concealed under textiles for much of the
poem. Chapter 3.1 follows the string of women who try to use textiles
to shape Odysseus into what they want him to be. Odysseus is shown
to be a liminal figure, far from home, yet unable to put down roots
elsewhere, torn between women, their agent objects, and the potential
lives they represent. As a unique male character in the Homeric
poems, Odysseus expresses himself through objects in a unique
way. Being male, this expression can hardly come in the form of
increased agency; it manifests itself, therefore, with a twist. That this
twist is coloured by the female sphere points towards the parallels
between his liminal position and that of his wife, as well as the
homophrosynē that binds them. It also highlights the very cause of
his liminality: the many women between whom he is caught.
Chapter 3.2 focuses on one particular object: the chest given to
Odysseus by Arete in Odyssey 8. Close reading of this passage is
combined with research on psychology and the emotions, showing
this to be an example of Homeric nostalgia as the object triggers a
reverie which takes the narrator, the audience, and Odysseus himself
from Arete to Circe, Calypso, and Nausicaa. Crucially, and against the
expectations of both the psychological and Homeric scholarship, this
is an instance of nostalgic longing for something other than nostos.
Drawing on scholarship on entangled objects and the anthropology of
the gift, Chapter 3.2 suggests that in this striking passage Homer
reverses the ontological polarity of person and thing, as it is not the
object but Odysseus who has been passed from one possessor to the
next, and in the process he has become the gift upon which memories
are inscribed. Chapter 3.3 revisits the gendered model of creation,
focusing on handiwork and, more specifically, the hands themselves.
The hand is a contact point between person and thing, a point at
which the boundary becomes blurred. The transformative effects of
touch are explored, in terms of metonymy and hybrid agency and
focusing on Odysseus’ proximity to parts of his sailing vessels.
Chapter 3.4 then shifts from Odysseus’ creation of objects to his
repurposing of them, engaging with ‘Stuff Theory’ and exploring
the much-discussed theme of Odysseus’ fluid identity through his
Another random document with
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 Fig. 602 Fig. 603 Fig. 604

Congenital inguinal hernia. Infantile or encysted Hernia of the funicular

hernia. process.

In the female the canal of Nuck is a matter of minor importance,

containing only the round ligament. Nevertheless along it may
proceed an indirect inguinal hernia corresponding to that in the male.
The so-called acquired indirect hernia, according to the above
views, would not occur were it not for the opportunity—as it were, the
temptation—already afforded by some deviation of the peritoneal
arrangement in this locality. In these cases, however, the sac
appears to be new and is pushed along the inguinal canal anteriorly
to its normal contents. This may be the result of violent strain, or of
one which is apparently disproportionately small, but frequently
repeated.
Direct inguinal hernia is generally an occurrence of adult life, takes
place commonly as the result of accident, is a direct protrusion
through the abdominal wall at the triangular weak spot, whose outer
limit is the deep epigastric artery, with the obliterated hypogastric
artery to the inner side and Poupart’s ligament below, i. e., the so-
called triangle of Hesselbach. This hernia appears always at the
external ring, from which it may descend and become scrotal.
 Fig. 605

Scrotal hernia. (Richardson.)

 With complete or scrotal hernia there is usually little difficulty of
diagnosis (Fig. 605). An incomplete hernia, protruding at the external
ring, covered with considerable fat, and perhaps shifted a little in
position, is sometimes hard to distinguish from a hernia through the
femoral opening. The inguinal form escapes above Poupart’s
ligament, the femoral always below it, and Poupart’s ligament is to
be located by a line drawn from the anterior superior spine to the
spine of the pubis. The inguinal forms are usually nearer the middle
line. If the epigastric artery can be identified, either before or during
operation, the character of the hernia will be promptly demonstrated
by its relations to the neck of the sac.
Hernial protrusions give a familiar impulse on coughing unless the
incarceration of an epiplocele may mask this feature. By it they are
to be distinguished from hydrocele, varicocele, aneurysm,
undescended testicle, and the like.

Fig. 606

Hernia of liver through congenital opening in the umbilicus. (Richardson.)

Femoral Hernia.—Femoral hernia is much more common in women

than in men, and constitutes about one-tenth of all cases. This form
is also nearly always congenital in the above sense, and is
particularly liable to strangulation. It escapes through the femoral
ring into the femoral canal, to the inner side of the femoral vein, and
then, passing forward through the femoral opening, finds its direction
of least resistance upward. In consequence a loop of bowel thus
escaping from the abdomen may first pass downward, then forward,
and then upward, which will illustrate the futility of the ordinary
methods of taxis in the effort to reduce it by manipulation. These
hernias are usually small, hence their greater danger. These cases
have especially to be differentiated from psoas abscess, from
inguinal lymphatic enlargements, and tumors. If the sac be entirely
filled with omentum diagnosis is often difficult.
Umbilical Hernia.—Umbilical hernia is primarily permitted by failure
in obliteration of the opening at the navel for the omphalomesenteric
duct and for the urachus. Originally small, it may yet assume
enormous dimensions. Though actually of congenital origin, as just
stated, it may not be discovered until the later years of life. It occurs
much more commonly in females than males, and usually in
connection with a large deposit of fat in the abdomen, by which its
existence, or, at least, its limits and dimensions are masked.
Through the umbilical opening, which in the majority of cases is
small, may escape other of the abdominal viscera, as is shown in
Fig. 606, illustrating hernia of the liver. Fig. 607 illustrates the
pendulous form which many of these cases assume.
An infantile form (umbilical) is known, in which the actual
protrusion does not occur until the infant is several months old, and
which appears to be due to frequent strain, on a weak or
incompletely closed fenestrum, by coughing, crying, efforts to expel
urine through a strictured prepuce, and the like. These tumors at first
are small and always intestinal. It is often possible to so adjust a
small pad over these openings as to secure subsequent closure by
natural processes. On the other hand, the forms which come on in
later life, acquired during pregnancy, ascites, or in connection with
excessive obesity, assume sometimes relatively enormous size.
Here the hernial contents may be solely omental, but are usually at
least partially intestinal. Strangulation occurs in a large proportion of
these instances and incarceration is nearly always observed.
Naturally, in consequence, the patient complains of gastric
disturbances, as well Fig. 607
as of chronic
constipation, with
frequent colicky
attacks.[61]

[61] A rare form of

hernia into the umbilical
cord has been
described by Moran. It
has been known as
hernia funiculi
umbilicalis, and has
been held to be due to
abnormal persistence of
the vitelline duct, which
holds the loop of
intestine to which it was
attached inside the
abdominal wall, the
intestine continuing to
grow, the umbilical ring
remaining open and the
hernia thus enlarging. Umbilical hernia of pendulous form. (Park.)
Occurring in this way it
happens about the tenth week of fetal life. Such a hernia has no covering
except the peritoneum and the amnion—i. e., is without muscle or skin
covering. It would be probably first noted when the cord is about to be tied,
when at its loop, as a translucent tumor, varying in size from that of a small
cherry to a lemon, the cord being distended and assuming its own natural
size only after it has left the hernial tumor. The bloodvessels will run on one
side of the amniotic sac. Such sacs rupture easily, perhaps during crying
efforts or even during parturition. The condition is serious, and when
present no traction should be made on the cord. If easily reduced by taxis
an antiseptic compress should be fastened over the opening. Should
anything like strangulation occur operation is imperative and should be
done immediately.
Ventral Hernia.—Ventral hernia is of two types—the spontaneous,
usually epigastric, which is an omental escape in the middle line
above the umbilicus, occurring most often in fat women, in whom it is
likely to be mistaken for a hernia of ordinary umbilical type. By
fixation of its contained intestine and omentum there is more or less
dragging upon the upper abdominal viscera, with consequent
disturbance of function.
Postoperative Hernia.—Postoperative hernia often also spoken of as
ventral, occurs through the cicatrix of the wound which has permitted
it, whether this be in the middle line or elsewhere. It is an
unfortunately frequent sequel of laparotomy wounds which have
required drainage, but occasionally occurs in perfectly clean wounds
which have closed satisfactorily in the first place, but which have
subsequently parted because of unsatisfactory methods of bringing
together their deeper portions. (See p. 778.) Consequently it should
be sufficient here to remind the reader that the more accurate the
method of approximating the margins, layer by layer, and effecting a
complete and perfect union between them individually the less the
tendency to this unpleasant sequel.
Postoperative hernia may be so small as to be kept under
subjection with some form of abdominal support, or it may call for
operations for radical cure, as do other cases. They are subject to
the same dangers of strangulation of their contents.
Diaphragmatic Hernia.—Diaphragmatic hernia may be congenital, as
when occurring through a defect in this partition, or acquired, as
when under stress or strain some of the abdominal contents are
forced into the thorax, either through natural openings or through a
rent or tear. Such escape may include but a small portion of bowel;
in congenital cases one-half the abdominal contents have been
found within the thorax. The left side seems more often involved than
the right. Serious wounds of the diaphragm may be followed by this
condition. Under these circumstances the thoracic viscera are more
or less displaced, and the heart may be pushed considerably out of
place. In cases with a history of violent accident the surgeon may
more readily suspect and recognize the condition than in congenital
cases, where anatomical relations have long been disturbed, but
apparently more or less adjusted or compensated.
Pelvic Hernia.—In the lower part of the pelvis, under rare
circumstances, hernial protrusions occur either through the
sacrosciatic foramina, in which case they are known as gluteal or
ischiatic (Fig. 608), or through the obturator foramen, when they are
known as obturator hernias, the latter occurring more often in stout
women. Unless these constitute some form of recognizable tumor, or
produce acute obstruction by strangulation, they will pass quite
unrecognized. A perineal form of hernia is also known, which occurs
in Douglas’ cul-de-sac, behind the bladder or uterus, the levator ani
muscle being more or less disturbed, and the protrusion occurring
somewhere between the labium and the anus. In such hernial sacs
the ovary has been found, as well as intestinal loops, and the so-
called ovarian hernia includes some anatomical anomaly of this kind.

Fig. 608 Fig. 609

Ischiatic hernia. (Richardson.) Hernia into foramen of Winslow.

Lumbar Hernia.—In so-called lumbar hernia, which is very rare, the

hernia escapes along the outer border of the quadratus lumborum
muscle into the triangle of Petit. Such a tumor, usually small, may be
easily mistaken for lipoma or for cold abscesses.
Other anomalous types of hernia may occur in connection with
congenital defects of the bones or the less dense structures of the
pelvis proper.
Retroperitoneal and Properitoneal Hernia.—Retroperitoneal and
properitoneal hernia are types which seem to corroborate the views
already enunciated concerning the essentially congenital origin of
the ordinary forms. The former implies a protrusion into an internal
peritoneal pouch, and is usually found in the upper abdominal cavity
in the duodenojejunal fossa, although it may also occur lower down
on either side. It will not be recognized save by its effects, which will
usually be those of acute intestinal obstruction, and even then will
only be diagnosticated after the operation which the condition will
necessitate. Hernia through the foramen of Winslow has already
been mentioned in the chapter on the Small Intestines. (See Fig.
609.)
Properitoneal hernia implies usually the existence of a double sac,
with a common opening, its inner portion lying between the
peritoneum and the abdominal musculature, while its outer portion
takes the usual position of the hernial sac, either the inguinal, the
femoral, or the umbilical form. It may be suspected when reduction
which has been apparently successful has later evidently failed. It
occurs most often in the inguinal region, where it is usually referred
to as inguinoproperitoneal hernia, and where it was first recognized
by Parise, and later fully described by Krönlein. It may be with equal
propriety called interstitial hernia, and is often associated with
imperfect descent of the testicle, which perhaps has served to
deflect the descending hernia in an unusual direction. The
properitoneal sac is most often found between the internal ring and
the anterior spine, although it may be directed downward and inward
toward the bladder, or backward toward the iliac fossa. In size it is
usually small as compared with the external portions. Its existence
may be suspected when a patient with a hernia previously easily
reducible suddenly develops strangulation, which is apparently
relieved by taxis, only to recur a little later. So far as its radical
treatment is concerned all that is necessary is the extirpation of the
extra sac, with perhaps separate treatment of its neck, when dealing
with the greater and more completely filled pouch in front (Fig. 610).

Fig. 610

Properitoneal hernia. This illustrates also incomplete reduction of hernia.

(Richardson.)
 Littre’s or Richter’s Hernia.—These terms have reference to
strangulation of intestine in which,
nevertheless, the entire lumen of the bowel is not completely
involved, rather only a small area, which soon becomes sacculated,
or perhaps by a diverticulum becoming involved in the occlusive and
later gangrenous process. These forms are most frequently seen in
women and at the femoral ring. They are peculiarly dangerous in that
they produce symptoms which do not include those of total and
acute bowel obstruction, and hence are often allowed to go
unoperated until gangrene has already occurred. These forms, then,
will produce signs and symptoms of partial strangulation, with
incarceration, followed after hours or perhaps days by those of local
cellulitis, with perhaps necrosis; conditions which when opened may
expose gangrenous bowel and promptly become fecal fistulas.
Treatment of Hernia.—Hernia is treated for three different
purposes: for the relief of strangulation, i. e.,
as an emergency, for palliation, or for radical cure, according to the
nature of the case and the wishes of the patient.
The relief of strangulated hernia becomes a measure of instant
importance so soon as the condition is recognized, mortality being
due to delay, practically every case being curable could it be
recognized and operated promptly. The symptoms of strangulation,
as repeatedly indicated, are those of acute obstruction of the bowel,
including fecal vomiting with meteorism, and the local indications
which may be trifling, as in very small hernial protrusions, or
unmistakable, as in large hernial masses. The indication in every
instance is to restore the occluded bowel to the abdominal cavity.
Occasionally this may be effected by the method of manipulation or
by taxis, which should never be thought of save at the very outset,
and which may be aided by the local use of cold, or especially by the
Trendelenburg position, which may be exaggerated. Under these
circumstances, as Richardson has said, minutes are precious and
delay adds materially to the danger, so that usually all non-operative
methods are to be condemned.
 PLATE LIV

Strangulated Right Inguinal Hernia. (Richardson.)

The sac has been opened and its edges are drawn apart by means of forceps.
The inguinal canal and spermatic cord have been dissected.
 Taxis.—The principal danger in connection with taxis is that of
doing harm to the occluded bowel by rough manipulation. The
method includes a coaxing pressure in the proper direction, with
more or less compression of the external mass, the effort being to
gently persuade it back into the abdominal cavity. In this effort the
temptation, especially among the inexperienced, is to use too much
force, by which extravasation is produced, exudate increased, and
the local condition in every way made worse. That which is possible
during the first hour after strangulation has occurred may be
impossible a little later, when edema and exudate have distorted the
parts or cemented them together. The effort should not be
prolonged, but rather very brief, and if after a very few moments no
gain be made it should be discontinued.
Reduction “en bloc” is an unusual but ever-present danger. It
implies forcing back the peritoneal sac as well as its contained
intestine unreduced, so that while the external tumor is dissipated
the actual condition of strangulation is not influenced. Its effect would
be in no way to diminish the danger of the condition, but rather to
more seriously menace the patient, under the supposition that
reduction had been accomplished satisfactorily.
Two or three axioms in the treatment of strangulated hernia are
imperative:
Very little time, if any, should be wasted in manipulation or taxis.
Taxis failing or there remaining any suspicion of reduction en bloc,
open operation is imperative.
The time to operate is just after the diagnosis has been made and
the condition recognized. Every hour of delay increases danger of
obstruction and of gangrene.
Operations for strangulated hernia should thus always be done
early and before much exudate or local disturbance has occurred, as
when thus performed they may be combined with measures for
radical cure, which are hardly to be thought of when infection has
occurred. (See Plate LIV.)
Strangulated hernia, then, being always a dire emergency, is in
nearly every instance best treated by herniotomy, whose principles
are the same, no matter whether applied to inguinal, femoral, or
umbilical hernia. By a suitably planned incision the sac is exposed.
In the inguinal region this follows the general direction of the cord
and inguinal canal. In the femoral region it is best to raise a flap,
while in umbilical hernia, although the first incision may be in the
middle line, it will usually be found necessary to make an elliptical
excision of the overlying skin, in order that both it and the sac may
be removed. Under conditions of long existent hernia, plus
strangulation, the original anatomical conditions are much altered,
and it is not necessary to waste time in the endeavor to recognize
the various coverings of the sac. One cuts directly down upon it with
such care that he may recognize it as he comes upon it, usually by
its color and by the sensation of proximity to its strangulated
contents. This is ordinarily not a difficult matter; all bleeding vessels
should be secured before the sac is finally opened. Final and
complete identification may be made by finding that the sac itself
may be pinched up between the fingers or forceps, while the
underlying contents slip away. Only when parts are bound together
in exudate will there be difficulty in this regard. The surgeon should
still proceed with caution, although the sac will usually contain
sufficient fluid of transudation to protect against injury to the
enclosed bowel. Nevertheless the greatest care should be observed
not to wound the intestine, which sometimes lies very closely under
the skin, especially in the middle line of an umbilical hernia, although
there may be masses of fat on either side of it. Sometimes the sac
distended with discolored fluid is itself mistaken for the bowel. Error
can usually be avoided by following it upward and identifying its
continuity with the surrounding tissues.
When opened its contained fluid may be found quite clear, blood-
stained, purulent, extremely offensive, or even fecal, according to the
relative age of the condition and the degree and results of
strangulation. Under all circumstances it is advisable to disinfect the
sac and its contents before endeavoring to release them. This may
be done with dilute peroxide of hydrogen or with any ordinary
irrigating fluid.
Within the sac, when thus identified and opened, may be
imprisoned omentum or bowel, or both, in any degree of
preservation from that which is almost normal, and with circulation
but slightly disturbed, to that which is absolutely gangrenous.
Congested bowel will nearly always be more or less discolored. So
long as it is dusky or even almost black, but has not lost its luster, it
may probably be safely returned to the abdominal cavity; but if green
or if luster be gone, or if the contained fluid be distinctly putrefactive,
then serious doubt as to its viability will arise. In case of actual
perforation, gangrene, or fecal abscess there will be no doubt as to
the danger of returning such bowel, and other measures should be
adopted.
The viability of the bowel having been determined and the sac
disinfected the location and degree of tightness of the constricting
ring should now be determined. In inguinal hernia the constriction
may occur either at the external or internal ring; in femoral hernia it is
usually at the femoral ring; in umbilical hernia, at some portion of the
umbilical opening; while in all three forms constriction may occur
within the sac itself and with little reference to the ordinary hernial
outlets; all of which needs to be clearly kept in mind. This
identification is usually done with the tip of the little finger, gently
insinuated and used as a probe. The operator who is sure of his
methods does not necessarily need to expose the constricting ring in
order to nick it or divide it, but he who is not as proficient should
extend and deepen his incision until the parts are clearly exposed,
so that he may be sure of not doing more harm than good.
Ordinarily it is necessary only to nick at one or two points the
margin of the ring, which will feel much like a wire loop, and then to
use the finger as a dilator, stretching and perhaps tearing, i. e.,
making the knife do as little and the finger as much work as possible,
in order to so loosen up the constricted canal that by gentle taxis or
manipulation reduction can now be accomplished. The text-books on
anatomy give minute descriptions of the relations of these hernial
outlets to important bloodvessels, with which even the student
should be perfectly familiar. Nevertheless by following the subjoined
rule, and never departing from the principle thereby indicated, the
operator may safely proceed in practically every instance. This is to
cut in the direction of the patient’s nose. The knife used for this
purpose is ordinarily the herniotome, i. e., a blunt, slightly curved
bistoury, with but a small exposed cutting blade, whose dull point is
passed along the finger until the constriction is reached, and then, by
the sense of touch, beneath and beyond it, until the wire edge of the
ring rests upon the cutting part. The handle is then turned until this
edge points upward and is moved with a gentle sawing action always
in the above-specified direction, until the peculiar resistance is felt to
have yielded. It may then be turned a little and another nick be
similarly made. These nicks should not be more than one-quarter of
an inch deep, after which the knife is withdrawn and the finger now
made to dilate and tear. With these precautions there is very little
danger of dividing an anomalously placed vessel.
Dilatation of the ring being now sufficient it is well to pull the
hernial mass a little downward, in order that the condition of the
bowel at the point of constriction may be exactly noted. It should
therefore be gently coaxed into the wound, once more subjected to
inspection, and then to disinfection. The surgeon should now
determine what to do both with the bowel and the omentum.
Omentum which is covered with exudate or darkly discolored, or
surrounded by offensive material, should be first liberated, then
ligated, above the original point of constriction, and the undesirable
part removed, the stump being returned to the abdominal cavity. The
bowel, if decided by above indications to be viable, may then be
gently coaxed back if handled with care.
But gut which has perforated, or is so compromised as to be
threatening gangrene, should not be returned into the abdominal
cavity, but treated by resection, or by fixation and the formation of an
artificial anus, decision depending both upon the condition of the
patient and of the bowel. Some of these cases are too nearly
moribund when operated to justify such procedures as resection,
and are suffering too profoundly from the consequences of
obstruction to make it advisable to do more than open the bowel for
its immediate relief. Artificial anus is, therefore, the inevitable
necessity in some forms of strangulation. When the bowel is
gangrenous it is not necessary even to endeavor to draw it farther
down into the sac, but it may be simply opened in situ.
Intestinal resection and suture instituted under these
circumstances are essentially the same as those already described
in the chapter on the Small Intestines. With the formation of an
artificial anus there results the inevitable fecal fistula which will
require subsequent operation, probably secondary resection.
In non-septic and favorable cases, the reduction having been
accomplished, the operator then may proceed to extirpation of the
sac and the closure of the hernial outlet, i. e., operate for radical
cure, this being a modern extension and addition to the old operation
for relief.
If obstructive symptoms should persist after operation the
possibility of twisting of the intestine, or a possible reduction en bloc,
may be feared, which is not likely to occur if the open part of the
operating have been done thoroughly.
Clean cases of strangulation may be closed without drainage. In
case of doubt, however, it is advisable to provide at least a capillary
drain, while every case known to have been contaminated should be
perfectly drained.
 Fig. 611

Bassini’s operation. Ligation of the sac by means of a purse-string suture passed

through the internal surface of its neck. The cord is drawn to one side. The
aponeurosis of the external oblique is drawn apart with forceps. (Richardson.)
 Fig. 612

Bassini’s operation. Suture of the conjoined tendon to the internal surface of

Poupart’s ligament. Fortification of the posterior surface of the canal. (Richardson.)

Radical Cure of Hernia.—From the earliest times rude and crude

methods of endeavoring to effect a
radical cure of hernia have been in vogue. While sometimes effective
they have always been dangerous and always clumsy. Not until the
antiseptic method was introduced could they be regarded as in any
way safe or reliable. With the introduction of Listerism it became
practicable to do this work, upon principles simple in character and
ordinarily easy of performance, which may be summed up in the
formula: Isolation and obliteration of the hernial sac, with permanent
closure of the hernial outlet. Easy as such description may sound it
has been found more or less difficult in practice, and numerous
methods, apparently both simple and ingenious, have proved
defective and have called for the most pronounced modification.
Considerable space could be devoted to operations for radical cure,
but the intent here shall be to simplify the subject as well as the
method, and consequently but two or three will be described. Suffice
it to say that while all are based on the same principle they vary
somewhat in detail, and that some of these details have to be
adapted to the special requirements of individual cases.
With increase in experience has come enlarged confidence in the
operation, and it is now regarded as justifiable in nearly every
instance among individuals otherwise in good condition. It has a
double purpose—namely, the avoidance of the danger of sudden
strangulation and the riddance of necessity for wearing trusses, or
suffering the discomforts of hernia without any mechanical control.
Some modern methods include the utilization of some portion or all
of the sac, while in others it is entirely cut away. Consequently some
operators have endeavored to utilize such portion of the sac as could
be made available for either purpose, either as plug or suture
material.
The method of Bassini for relief of inguinal hernia, more or less
modified to meet individual demands, seems to have become of late
years the most popular and widely adopted. The incision is made
over the most prominent part of the tumor, extending as far
downward upon the scrotum as necessary, and upward to near the
anterior superior spine. Through it the external ring, with its pillars, is
exposed, and then the sac, by a dissection long and sufficiently wide
to fully reveal it. The exposure is made more complete by dissection
of the aponeurosis of the external oblique from the level of the
external ring upward and outward for an inch or so above the
external ring. By seizing the edges of the aponeurosis on each side
with forceps and retracting there is now afforded an excellent view of
the hernia proper. (See Fig. 611.)