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Spiritual Care and Therapy Integrative Perspectives 1st
Edition Peter L. Vankatwyk Digital Instant Download
Author(s): Peter L. VanKatwyk
ISBN(s): 9780889205727, 0889205728
Edition: 1
File Details: PDF, 9.83 MB
Year: 2003
Language: english
Spiritual
Care
and
Therapy

Integrative
Perspectives
This page intentionally left blank
Spiritual
Care
and
Therapy

Integrative
Perspectives

Peter L.VanKatiuijk

Wilfrid Laurier University Press

We acknowledge the financial support of the Government of Canada through the Book
Publishing Industry Development Program for our publishing activities.

National Library of Canada Cataloguing in Publication

VanKatwyk, Peter L., 1938-
Spiritual care and therapy: integrative perspectives / Peter L. VanKatwyk
Includes bibliographical references and index.
ISBN 0-88920-434-9
1. Pastoral counseling. 2. Counseling—Religious aspects—Christianity
1.Title.
BV40I2.2.V35 2003 253'.5 C2003-904093-3

© 2003 Wilfrid Laurier University Press

Waterloo, Ontario, Canada N2L 3C5
www.wlupress.wlu.ca

Cover design by Leslie Macredie, using a sculpture by Derek Green; text design by
P.J. Woodland.

PeterVanKatwyk's appendixes (1,2,7, and 8) can be reproduced and used by counselors

in a clinical context without express permission from the author or publisher.

Every reasonable effort has been made to acquire permission for copyright material
used in this text, and to acknowledge all such indebtedness accurately. Any errors and
omissions called to the publisher's attention will be corrected in future printings.

Printed in Canada

No part of this publication may be reproduced, stored in a retrieval system or trans-

mitted, in any form or by any means, without the prior written consent of
the publisher or a licence from The Canadian Copyright Licensing Agency (Access
Copyright). For an Access Copyright licence, visit www.accesscopyright.ca or call
toll free to 1-800-893-5777.
To Myra
This page intentionally left blank
 Contents

List of Tables and Figures ix

List of Appendixes xi
Acknowledgments xiii

Introduction I
PART I Spirituality in the Practice of Care 9
1 Spiritual Care in Ordinary Life 11
2 Spiritual Care in Clinical Practice 21
3 Cross-Spiritual Therapy 29

PART 11 Essentials of Caring 41

4 What to Know: Therapeutic Models 43
5 What to Say: Therapeutic Communication 53
6 What to Be: Therapeutic Relationships 65
7 The Helping Style Inventory: A Synthesis 75

PART III Contexts of Caring 85

8 Toward a Balanced Whole: The Family Connection 87
9 Textures and Threads: Life Cycle Transitions 95
10 Endings and Beginnings: Crisis and Loss 105
11 Parental Loss and Marital Grief: A Case Study 115

PART IV The Study of Spiritual Care 125

12 Supervision in Learning and Teaching Spiritual Care 127
13 Research Methods in Spirituality and Health Care 141
Thomas St James O'Connor

Conclusion 153
References 155
Appendixes 165
Index 193

VII
This page intentionally left blank
 List of Tables and Figures

Tables
3.1 Three Spiritual Perspectives 38
5.1 Three Styles of Therapeutic Communication:
A Table of Comparison 59
6.1 Two Models of Care: Compassion and Competence:
A Table of Differentiation 70
7.1 Four Styles and Four Images 80
8.1 Core Dimensions of Family Functioning 92

Figures
1.1 One's Place in the World 12
1.2 Dimensions of The Sacred 17
2.1 The "Self-in-the-World" Continuum 26
4.1 Therapeutic Strategies Map 46
4.2 Multiple Roles Map 50
5.1 Locating Counseling Responses 54
5.2 Locating Communication Styles 55
6.1 The Compassion Model 67
6.2 The Competence Model 68
7.1 Locating "What to Do" Responses 77
7.2 The Horizontal HSI Axis 78
7.3 The Vertical HSI Axis 79
7.4 The Helping Style Inventory 81
7.5 HSI Counseling Score 83
9.1 The Berg Genogram 98
9.2 The Coping Process 102
12.1 The Experiential Learning Cycle 128
12.2 The Experiential Learning Focus 130
12.3 The Helping Style Inventory 132
12.4 Student Helping Style Profile 137

ix
This page intentionally left blank
List of Appendixes

APPENDIX 1 167
The Three Core Care Conditions

APPENDIX 2 169
Assessment of Core Dimensions
of Family Functioning

A P P E N D I X 3 170
Genogram Format

APPENDIX4 173
The Stages of the Family Life Cycle

APPENDIX 5 174
Double ABCX Model of Family Stress

APPENDIX 6 175
The Flow of Stress through the Family

APPENDIX 7 176
Verbatim Report of Pastoral Conversation

APPENDIX 8 177
The Helping Style Inventory Map

APPENDIX 9 178
CAPPE/ACPEP: Code of Ethics
and Professional Conduct

A P P E N D I X 10 183
AAMFT Code of Ethics

xi
This page intentionally left blank
 Acknowledgments

SINCE MOST OF THIS BOOK has been previously shared, in print

and in the classroom, I have benefited from the responses of many people. I
experienced the immense value of feedback when I was deprived of it during my
sabbatical leave in 1999-2000. In splendid isolation in my native Holland, I
struggled with formulating and articulating ideas on which people thousands
of kilometres away needed to reflect. I began to better appreciate the meaning
of a learning community where knowledge is both unfinished and an ongoing,
shared process.
I am grateful to many of my students who enthusiastically participated in the
effort to define and develop concepts and practices of spiritual care. As a grad-
uate student, I was fortunate enough to have Howard Clinebell as my teacher and
thesis advisor. His generous openness to what the various therapies could offer
to human growth and his insistence on inclusivity have been a lasting legacy and
an inspiration to the integrative approach of this book. A true mentor, he cre-
ated a community where teaching and learning are interchangeable.
For over twenty-five years my life has been intricately connected with the
learning community made up from the Kitchener Interfaith Pastoral Counsel-
ing Centre and the Waterloo Lutheran Seminary at Wilfrid Laurier University. I
mention especially my friend and fellow faculty member Thomas St James
O'Connor, who kindly consented to write the last chapter of this book on
research in spiritual care and counseling, a topic in which he is eminently qual-
ified. Besides students, I thank colleagues who were dialogical partners in envi-
sioning a comprehensive and integrative approach in spiritual care. With special
fondness I think of Delton Glebe, who is always poised for wide-ranging the-
ological conversations both playful and profoundly pastoral. When principal
and professor of practical theology, he developed the Pastoral Counselling
Department of the Waterloo Lutheran Seminary into a leading institution for
pastoral counseling and marriage and family therapy programs in North Amer-
ica. John C. Henderson, former executive director of the Kitchener Interfaith
Pastoral Counseling Centre, inveterate student and teacher, supported me for
additional time in my sabbatical that made the writing of this book possible, and
Evelyn Marcon, long-time colleague at Interfaith and the Seminary, provided
helpful feedback on many of the chapters.
Family and friends have known how important it was for me to complete this
writing project. They have supported me with stubborn interest and, increas-
ingly, apprehension as the book gained the status of an overdue baby. My wife
Myra, a clinical professional in the field of child development and protection,
read with much faith and generosity everything I wrote and kept rewriting. Her

xiii
xiv ACKNOWLEDGMENTS

critical insight and good judgment have shaped all the pieces that came together
in this volume. She never doubted the eventual outcome of a published work.
To her I dedicate this book. Our children, Paul, Trish, Steven, and Martina,
who died unexpectedly as a young woman, have composed a rich and ongoing
family legacy that has guided me in drawing the contexts of caring (Part 3).
Some chapters have used material from previously published articles and
other chapters have subsequently been adapted for publication:
• Chapter 1 has been adapted to "Pastoral Counselling as a Spiritual Prac-
tice: An Exercise in a Theology of Spirituality," The journal of Pastoral Care and
Counseling, 56/2: 109-119. Summer 2002. It has also been adapted in the
chapter "Reconciliation and Forgiveness: A Practice of Spiritual Care" in The
Challenge of Forgiveness, Toronto: Novalis, 2001.
• Chapter 2 has been adapted to "Preparing A Place—A Theological Reflec-
tion on Pastoral Care," Consensus, 25/1: 55-66. Spring 1999.
• Chapter 4 has been revised to "What Is the Problem?—Problem Defini-
tions and Resolutions in Pastoral Counselling," The Journal of Pastoral Care,
53/4: 409-416. Winter 1999.
• Chapter 5 has been revised to "What to Communicate: A New Chapter in
Pastoral Care and Counseling?" The Journal of Pastoral Care, 54/3: 243-252.
Fall 2000.
• Chapter 6 utilizes parts of "The Helping Style Inventory: An Update," The
Journal of Pastoral Care, 47/2: 375-381. Summer 1995.
• Chapter 7 follows in part "Healing through Differentiation: A Pastoral Care
and Counseling Perspective," The Journal of Pastoral Care, 51/3: 283-292.
Fall 1997.
• Chapter 8 appears as "Towards a Balanced Whole: The Well-Functioning
Family, "The Journal of Pastoral Care, 55/3: 239-246. Fall 2001.
• Chapter 9 has been adapted to "Marital Therapy for Family Problems:
Pastoral Counseling Perspectives on the Process of Change in Construc-
tivist Couple Therapy," Pastoral Sciences, 20/1:143-157. Summer 2001.
• Chapter 10 incorporates parts of a previous article "A Family Observed:
Theological and Family Systems Perspectives on the Grief Experience," The
Journal of Pastoral Care, 47/2:141-147. Summer 1993.
• Chapter II was originally presented as "Parental Loss and Marital Grief:
A Pastoral and Narrative Perspective," The Journal of Pastoral Care, 52/4:
369-376. Winter 1998.
• Chapter 12 adapts parts of "The Helping Style Inventory: A Tool in Super-
vised Pastoral Education." The Journal of Pastoral Care, 42/4: 319-327.
Winter 1988.
 Introduction

THE TERM "SPIRITUAL CARE" is made up of two complex reali-

ties, each of which simultaneously connects us to, and disconnects us from, our
lives in the world. "Care," is the very essence of our humanity yet proves over-
whelming in its implications: caring involves feeling not only for one's own life
but for what happens in the lives of others and in the life of the world. Care is
energized by the anxiety of living in a finite and unpredictable world—a world
of decay and disappointments. To care evokes the defiance of not submitting to
such a world. To care seeks to transform this world to a safer and friendlier
place. To care strives to bring order and meaning to life. At the same time we
need to counter caring with non-caring. The words "I don't care" express that
we are disheartened by a world resistant to care, matched by our own inner
restraints to go on caring. At times we need to withdraw and disengage from life.
"Not to care" is as essential to life as "to care." Our caring is tempered in
moments of fatigue or depression, times when we need to recuperate from life.
In our daily life we experience health in the precarious balance between "caring"
and "not caring."
"Spiritual" poses another complexity, both placing and displacing us in the
world. The spiritual locates itself in the realm of the sacred. Our need to sepa-
rate the secular from the sacred, to differentiate the "worldly" from the "other-
worldly," demonstrates our felt incongruity of placing the sacred in the tangible,
ordinary experience of everyday life. Religion performs the task of constructing
places of the sacred for the faith community, focal points for the spiritual for-
mation of life. In religion the sacred is located in the public places, creeds, and
rituals of worship, and is associated with the traditions and discipline of reli-
gious practice. Presently, the two concepts of religion and spirituality are sharply
distinguished from each other. Religion is commonly depicted in terms of
organized or institutionalized expressions of faith in shared experiences of
commitment and devotion, while spirituality is often portrayed "as a highly
individualized search for the sense of connectedness with a transcendent force"
(Pargament, I997, 38). In much of the Western, post-Christian world the decline
of religion has been matched by a resurgence of spirituality as the profoundly
personal quest for enlightenment and meaning. Religion and spirituality can
both be contrasted and paralleled in the specific ways that each pursues the
quest for the sacred. In this book, both a person's religious resources and
unique spiritual orientation to life are seen as valid and active participants in the
practice of care.
The two ambiguous words, when united in the one designation spiritual
care, resolve some of the complexities of each word on its own. The two words

I
2 INTRODUCTION

need each other to be actualized. Each word interprets and expands the mean-
ing of the other: the sacred appears in acts of caring in a harsh world, and car-
ing constructs the sacred places where people connect and live the meanings of
their lives. The assumption of spiritual care is that, despite all evidence to the
contrary, the world is a place for caring. Spiritual care embodies the spirit in
ordinary human flesh and weaves the sacred into the rough fabric of everyday
life.
The term spiritual care narrows its focus and assumes a distinct meaning
when applied to the practice of caring in the mental health professions and
the health sciences. In a clinical context, the pairing of spiritual and care gains
additional ambiguity and complexity. Professional ethics detects an inherent ten-
sion between the two domains of the client's religious and spiritual life and the
caregiver's professional practice. Respect for the client's rights, convictions, and
values has generally marked religion and spirituality—whether the client's or
the counselor's—as private areas to be kept off limit in clinical practice. An
additional contaminating factor is the common association of religion with
spiritual guidance, charismatic leadership, moral instruction, and proselytizing
outreach—ways clearly incompatible with accepted clinical standards of prac-
tice. A legitimate concern is that spiritual care will become directive in exercis-
ing moral and spiritual guidance at troubled times when clients are vulnerable
to undue influence and lack free access to their own spiritual resources and
autonomous faculties.
The critical tenet for professional counseling is the clinician's awareness and
acknowledgment of the power differential between caregiver and client. The
potential abuse of the counselor's power is not limited to spiritual care but is
present in all therapy, often in direct proportion to the intimacy of the counseling
relationship. With regard to the power continuum of the helping relationship
(see chapter 7), this book underlines that helping relationships are intrinsi-
cally unequal and asymmetrical. This means that when the power of the helper
is disclaimed by the illusion that it is not in use, the client is most at risk. This
has special urgency for spiritual care as a professional practice that emphasizes
the personal dimension where both the client and the counselor share who
they are and what they value most as human beings. As in other types of ther-
apy, spiritual care practice mixes the personal and professional in the helping
relationship. An emerging consensus in the spiritual care literature stresses a
nondirective approach where counselors follow the client's direction in spiri-
tual sharing rather than the counselor's (Becvar, I996; Doherty, I999). This
also cautions therapists against self-disclosure of their own spiritual beliefs
without a shared context and clearly established boundaries. As one psychiatrist
notes: "Men and women who want to proclaim their private truths at the vul-
nerable and ill are not physicians" (Fleischman, as cited by Kathy Weingarten
in Walsh, I999, 256). This book focuses on the therapeutic relationship as the
place where the professional and the personal meet in the counseling interac-
tion. The Helping Style Inventory as the core metaphor of the book maps the var-
 INTRODUCTION 3

ious helping postures and proposes the context as the criterion for an appro-
priate and differential use of the counselor's self in the practice of care.
This book is largely autobiographical, reflecting my wandering vocational
journey as a caregiver. I came to America in 1961 as a young theology student
from Europe and began my ministry in a Canadian congregation composed of
mostly first-generation Dutch immigrants. My pastoral role often coincided
with social work in the practicalities of getting new immigrants settled and
adjusted to the new country. I encountered anxieties and conflicts that seemed
intimately bound to the immigration experience. I also began to wonder whether
these problems started with the displacement in the "new country" or whether
the immigration also reflected a prior displacement in the country of origin.
Conversations with parishioners indicated the post-war transition, financial
uncertainties, and family conflicts, as chief among other frustrations often
cited as contributors to the decision to migrate.
After eight years in two immigrant congregations, I came into contact with
immigrants of a different kind. I started graduate studies with a chaplaincy
residency in a psychiatric hospital, followed by more clinical education in a
women's prison and a halfway house for women parolees. In these institu-
tional settings displacement dynamics stood out. I began to view patient and
prisoner lives in the context of a person's place, or lack of it, in the world. After
completing graduate studies, my main vocational identity shifted to the area of
counseling. Further clinical education in marriage and family therapy contin-
ued to focus on how a person is located or situated in life—the person not as
a separate entity but as intricately embedded in and defined by a relational
context. Relational understanding of care is especially urgent for those most
vulnerable in life. This group increasingly includes all of us, and urges us to
social action and ecological stewardship in our threatened, deprived, and frag-
ile environments.
This contextual approach sits well with my other vocational home in pastoral
counseling. The tradition of the care of souls, cura animarum, centers on the per-
son in loco. In the Jewish-Christian tradition, the word "soul" is used to place the
person in a context of ultimate meanings where care is not so much organized
by the problems of life as by spiritual concerns. Historically it included a vari-
ety of helping acts "directed toward the healing, sustaining, guiding, and rec-
onciling of troubled persons whose troubles arise in the context of ultimate
meanings and concerns" (Clebsch & Jaekle, 1975, i, 4). The care of souls tra-
dition is wholistic in its emphasis on the total person: daily and ultimate con-
cerns, body and soul. Later in the history of religious care, the intimate unity of
body and soul slowly separated into a hierarchical configuration in which the
body represented the manifold ills and afflictions of this world, and the soul
symbolized one's eternal destiny in the world to come. The distinction between
body and soul became further entrenched in the modern period through the rise
of the medical model that claimed specialization in the physical reality of the
4 INTRODUCTION

body, leaving other dimensions of the human condition to be addressed mainly

by non-medical specialties of care. Current awareness that every aspect of
human life is present in the practice of care has provided a new appreciation for
the religious care of souls tradition. There is a return to the roots of spiritual care
where soul embraces the whole person in his or her interactions with the world.
The literature of spiritual care and therapy demonstrates a growing awareness
that our manifold connections in life are essential to the process of healing.
Recent studies (Walsh, 1999, Griffith & Griffith, 2002) show that most clients
want to share their spiritual concerns in the counseling interaction and resent
being split between body and soul: "Clients and persons who have participated
in our research have told us that they want to reflect on their spiritual experi-
ences in therapy and that they feel fragmented by attempting to delegate psy-
chological, relational issues to conversations with their therapist and spiritual
issues to conversations with their priest or pastor" (Griffith, 1999, 210). In the
broad definition of spirituality followed in this book, it is not possible to clearly
demarcate the spiritual from other parts of life. Spirituality is at the core of our
humanity and runs through all our life experiences and our history of signifi-
cant life cycle events. I will speak of spirituality not as an entity in and by itself
but as a differentiating perspective that simultaneously connects us to and dis-
connects us from all of life. Like the presence of soul, our spirituality is every-
where and nowhere (Anderson & Worthen, 1994). Similarly the discomfort and
challenge of such a broad definition of spirituality is that "a term that means too
much soon means nothing—and risks become everything" (Doherty, 1999,
180).
This volume differentiates between pastoral care and spiritual care. I believe
that there are good reasons at this time to go beyond the adjective pastoral, the
traditional term for ministry rooted in the Jewish-Christian heritage of reli-
gious care. The obvious one is that we live in a world that is ever more trans-
formed into a pluralistic and global community. Hospitals increasingly reflect
this new reality in shifting the description of their chaplaincy services from
providing pastoral care to spiritual and religious care. Another reason for reconsid-
ering the adequacy of the term pastoral is the phenomenal rise of the concept
of spirituality in the health sciences, clinical psychology, and therapy. The words
soul and spirit have re-entered the world of psychotherapy, highlighting the spir-
itual dimension of the therapeutic encounter (Becvar, 1996; Cornett, 1998;
Emmons, 1999; Moore, 1992; Griffith & Griffith, 2002; Plante & Sherman,
2001). The topic of spirituality is being included in many a therapy course cur-
riculum, some workshop seminars are marketing spirituality as the new fron-
tier in therapy, and an interdisciplinary array of counseling professionals now
incorporate the task of spiritual care into their own specialties of care, chal-
lenging pastoral counselors to rethink and broaden their own theology and
practice of ministry.
 INTRODUCTION 5

I argue for differentiating spiritual from pastoral care rather than just sub-
stituting the term spiritual for pastoral and assign it double duty. Pastoral care
and counseling has largely focused on care that is sensitive and responsive to
the Jewish-Christian religious traditions and spiritual resources in those who
seek the help of caregivers who represent their faith community. I will use the
term spiritual care for a pluralistic and inclusive practice that reflects on such
intrinsic qualities of the human spirit as the yearnings to give and receive love,
to find and fulfil one's vocation and potential in the world, and to be grasped
by transcendent beauty and transforming values. This sweeping scope radi-
cally broadens and democratizes spiritual care: it constitutes the daily expres-
sion of ordinary life rather than primarily a religious specialty of care or a
professional function of counseling.
The book is perhaps most autobiographical in voicing my personal incli-
nation, heightened by my immigrant experience, to cherish diversity. The book's
main ambition is found in its subtitle: Integraiive Perspectives. It defines the book's
inclusive structure of incorporating and networking a diversity of theoretical ori-
entations and practices of care. Rather than develop a distinct model of spiri-
tual care, I follow an eclectic approach that includes spirituality along the full
range of essential psychotherapies in individual, couple and family practice. The
clinical wisdom of pastoral care traditions and contributions from the rich and
extensive pastoral counseling literature are active participants without occu-
pying a position of undue dominance or special privilege.
This book has had earlier lives. Most of the chapters were assembled in a
course package, Spiritual Care: An Integratiue Counselling Manual, for a practicum
course which was part of the certification process in the Canadian Association
for Pastoral Practice and Education (CAPPE) and/or the American Association
for Marriage and Family Therapy (AAM FT). The inspiration for the manual was
to develop an adequate integrative knowledge base for a clinical education pro-
gram in spiritual care and counseling. The focus was to reflect upon the stu-
dent's clinical case materials in the light of the manual, the text for our seminar
sessions.
In another incarnation, I employed the same course package as a text in a
graduate course on the models of psychotherapy and spirituality. Again the
emphasis was on the text's subtitle: Intecjratiue Perspectives. Since integration is
about process, the book does not focus on content, on what the various coun-
selling theories specifically teach. It focuses, rather, on hou; a particular coun-
selling model fits into spiritual care. The assumption is that the reader has a
basic knowledge of the essential psychotherapies and/or that a good sourcebook
of the therapies goes along with the text (additional readings utilized in the
course included Gurman & Messer, 1995; Corsini, 1989; and Clinebell, 1995).
The present book shows this interaction between the theoretical and the
clinical, the interplay between conceptual diagrams and case examples (as a
Discovering Diverse Content Through
Random Scribd Documents
 Fig. 613

Park’s method of utilization of sac, showing its isolation and one way of
employment in making the suture further represented in Fig. 614.

By careful dissection the sac and cord are identified and isolated,
while the sac is opened and its edges held apart by forceps, after
which it is carefully separated from the other structures of the cord.
After thus isolating the sac, and with the least possible disturbance
of the cord and of the testicle, it is ligated as high as the internal ring,
or, if possible, higher yet. This leaves the cord uninjured; its size
should next be reduced by cutting away all superfluous tissue. Some
operators remove all the veins, but this seems unpromising and
dangerous.
 Fig. 614

Park’s operation. Continuous suture made with a long thin sac.

By all this dissection and reduction the inguinal canal has been
temporarily, cleared, and the sac having been elevated, ligated, and
cut away it becomes now a question of what to do with the cord. The
lower surfaces of the external oblique and of Poupart’s ligament are
next freed, the edge of the internal oblique, of the transversalis with
its fascia, the outer border of the rectus and the conjoined tendon
being all exposed to view by whatever dissection may be required,
all fat and areolar tissue being removed. The cord is finally disposed
of by holding it out of the way, usually by a loop of gauze, while the
deep layer of the external oblique and the external portion of
Poupart’s ligament are sewed to the muscle edges of the internal
oblique and transversalis, as appears in Fig. 612, by a line of sutures
which include the conjoined tendon, at the lower angle of the wound,
which should be affixed to the outer border of the rectus. In the
deeper portion of every such wound there is danger of injury to the
external iliac vessels as well as to the epigastric. For the escape of
the cord, and to avoid its undue constriction, an opening should be
left for it, i. e., a new internal ring, adapted for the purpose and not
too small. This is made by not suturing the upper part of the wound.
The cord being afforded this exit is now dropped, and the edges of
the external oblique are brought together over it, the sutures
extending well downward, but being omitted at the lower portion,
where a new external ring is thus left, only not of its original size, but
sufficiently large to accommodate the cord.
Such are the essentials of the Bassini method, which has been
modified by Halsted in such a way that the cord, reduced as much as
possible, usually by removal of most of its veins, is now not left
within the inguinal canal, but transplanted entirely outside of the
external oblique, escaping at the upper part of the incision and
requiring no further accommodation in its course toward the testicle.
In children, or even in adults with very small veins, he does not so
reduce the cord. After isolation, opening and transfixion of the upper
end of the sac, and its secure ligation, he drops the stump back into
the abdomen. The muscular and tendinous layers of the ring and
abdomen are united also, by layers, with quilted sutures.
 Fig. 615

Park’s method. Shoelace suture made with a sac split into two strips.

In these as in many other methods, much, practically everything,

depends upon the certainty and durability of the sutures used for
disposal of the inguinal canal. For some years surgeons used silver
wire, which has now been abandoned. The choice now seems to
depend on silk, thoroughly and freshly boiled, or animal sutures,
such as kangaroo or reindeer tendon. McArthur suggested to dissect
off a strip from the margin of the opening in the external oblique, or
from the aponeurosis, and to use this strip of the patient’s own tissue
for suture material. I have modified this method, as will be described
later. Kocher devised a method of isolation of the sac, without such
complete emptying of the inguinal canal, the sac being drawn up
through the canal, then through the internal ring, and finally through
an opening in the external oblique, over the internal ring, where it
was twisted and fastened, after which the external portion was
removed.
My own preference in operations for radical cure has been, until
recently, an exposure similar to that of Bassini’s, with complete
isolation of the sac, which is separated up to the level of the internal
ring or even higher. At this point it is drawn out through an incision
made in the external aponeurosis, twisted and fastened. The inguinal
canal is then closed, its deeper layers by a shoelace suture of
tendon, threaded into two stout curved needles, by which the deeper
margins of the canal are brought accurately together. Sometimes I
have transplanted the cord and again have dropped it back, the layer
of shoelace sutures closing the external aponeurosis over it. It has
not seemed to me to make any difference which method was
adopted, and I have practically never seen any atrophy or permanent
disturbance of the testicle.
More recently it has occurred to me to utilize the sac itself for
suture material, and this is the method which I now adopt in those
cases that permit of it.
Figs. 613 to 616 show the method of thus utilizing the sac. A long
thin sac may be twisted into a cord and used as an over-and-over
suture, by which the margins of the canal are brought together. If
found thick and unwieldy it may be trimmed down into a single
suture, or it may be split, with more or less trimming, into two
portions, by which the canal is then braided together or closed with a
shoelace suture, the ends being tied or fastened at the lower portion.
Fig. 616 shows how a short sac not otherwise available can be
lengthened and made sufficient for the purpose.
 Fig. 616

Park’s method. A short sac is so divided as to be elongated sufficiently for use as a

suture.

This again is utilization of the patient’s own tissue, he himself

furnishing his own animal ligature, which, being fresh and sterile,
may be regarded as reliable. The method, furthermore, has this
advantage, that there is reason to believe that tissue so utilized
becomes organized, in time, and that the union becomes more
reliable rather than otherwise. At all events in a considerable number
of cases it has yielded satisfactory results, and in no case has it
caused any disappointment.

Fig. 617

Radical cure of femoral hernia. Dissection of the saphenous opening. The sac of
the hernia has been tied. (Richardson.)
 Fig. 618

Radical cure of femoral hernia, showing method of application of purse-string

ligature to close saphenous opening. (Richardson.)
 Fig. 619

Radical cure of femoral hernia. Sutures applied to pectineal fascia, fascia lata, and
Poupart’s ligament. (Richardson.)
 Fig. 620

Obliteration of the femoral opening by purse-string suture. (Coley.)

Recurrence after these operations occurs less and less frequently

as operators gain in experience and technique is improved. At all
events the procedure has now become standard and
disappointments are relatively rare. It is useless to quote statistics of
individuals, for they necessarily differ. In general, however, it is
probable that from 90 to 96 per cent. of cases properly operated
suffer no recurrence.
In the female inguinal hernia is treated in practically the same way,
conditions being simplified by the absence of necessity for making
any provision for the blood supply of the testicle or cord. The canal
and rings may, therefore, in the female be absolutely closed.
Femoral hernia is radically treated on the same general principles,
but with greater difficulty, as anatomical conditions are less
favorable. A flap is raised below Poupart’s ligament, with its centre
over the tumor, and the sac exposed and completely dissected, then
opened, as in inguinal hernia. Its contents being reduced obliteration
of the sac and its utilization, if possible, are in order. It is rarely
difficult to separate it from its surroundings well up in the femoral
canal. It may be twisted and its neck ligated, or it may be possible in
some cases to either infold or reduce a sufficient portion of it to thus
form a plug, which, being pushed upward, serves as a means of
closing the femoral opening from above. Whatever use may be
made of it it should be obliterated as a pouch, and its descent
prevented by closure of the canal around it. This is difficult because
of the proximity of the femoral vein and the somewhat unyielding
character of the falciform and crural fasciæ. By some form of purse-
string suture, or by a little dissection and sliding of aponeurotic flaps,
it is usually possible to bring the surrounding structures snugly
together. Even here I have been able to apply my principle
enunciated above, and, by cutting away a strip of the sac, utilize it for
the purpose of closing the femoral canal; but it is not often that a
femoral pouch will be sufficiently large to afford tissues for this
purpose. Figs. 617, 618, 619 and 620 will save the necessity for
further description.
 Fig. 621 Fig. 622

Graser’s method of dealing with umbilical hernia.

In many inguinal and umbilical and in a few femoral hernias the

operator will be hampered by adhesions between the omentum or
between the bowel and the sac wall. These may be infrequent and
slight or extensive and dense. They are relatively unimportant so
long as they involve only the omentum, which may at any time be cut
away, the stump being dropped back into the abdomen, after being
suitably secured; but when bowel, especially large intestine, is thus
adherent, great care should be exercised, avoiding all possibility of
shutting off the blood supply while securing every divided vessel.
Particularly is this true in treatment of umbilical hernias, either
radical or under conditions of strangulation. In stout individuals,
usually women, umbilical sacs sometimes contain several feet of
bowel, and adhesions may be met at many points, difficulties arising
not only in their separation, but in the final disposition and
accommodation of all this bowel within the abdominal cavity, from
which it has been so long absent. Radical cure will in these cases
leave intra-abdominal viscera in a rather overcrowded condition.
The essential details of radical treatment of umbilical hernia are
the same, modified by the extent of sac which has to be removed,
and by the wisdom in many instances of a large elliptical excision of
the overlying skin and removal of much superfluous tissue. After
freeing the contents and reducing them, the sac wall being
completely separated, there is the choice of two or three methods of
closing the umbilical opening, either by overlapping of flaps, which
may be cut from the thickest portion of the sac, which will be close to
the outlet, or by dissecting them from the aponeurosis, as suggested
by Mayo, and turning the upper down over the lower, or by any other
expedient which individual peculiarities may suggest (Figs. 621 to
624). I have been able to employ, to apparent advantage, my
method of securing suture material for this deep closure from the sac
wall itself, this not preventing the employment of any other method or
improvement.
 Fig. 623 Fig. 624

Method by transverse closure of both deep and external incisions.

Ventral and postoperative hernias are operated on in essentially

the same manner as the forms above described. Adhesions may be
found in these cases, and plastic methods should be devised for
bringing together irregularly shaped openings and holding them in
the firmest possible manner. In any extensive abdominal hernia,
umbilical or ventral, it is advisable to use buried sutures, closing the
abdominal walls, layer by layer, and finally to insert at some distance
a sufficient number of through-and-through retention sutures,
guarded by plates or small rolls of gauze, these taking off tension
from the wound and affording protection against any special strain,
such as vomiting.
 CHAPTER LII.
THE LIVER.

CONGENITAL DISPLACEMENTS OF THE LIVER.

The congenital defects and displacements of the liver which
interest the surgeon are few. More or less transposition, sometimes
complete situs transversus, is encountered. The same is true of
more or less hernial protrusion into the chest, through a defect in the
diaphragm, or such displacement as may be permitted by some
defect of the abdominal walls or other viscera. Hammond has
recently shown that the left lobe of the liver is sometimes
congenitally enlarged to an extent sufficient to cause symptoms, a
condition alluded to by very few writers. In this way the liver may
cover the stomach and even extend over the spleen. Similarly the
right lobe may be affected, but giving a different train of symptoms.
Under these conditions mistakes may arise. Thus the left lobe might
be mistaken for a large spleen, from which, nevertheless, it should
be separated and differentiated by its free movement during
respiration. Hammond even reports one case of this kind where,
instead of removing the elongated portion of the liver, it was held up
against the abdominal wall by sutures. For a similar condition
Langenbuch has successfully resected a portion of this viscus. What
is said here pertains to a true congenital variety, and not to acquired
displacements or enlargements. In Fig. 625 is represented the case
of xiphopagous twins united by a band of liver tissue and operated
(by division of the band) by Baudouin.

WANDERING OR FLOATING LIVER.

The relations between congenital laxity of the natural supports of
the liver and certain morbid conditions, especially those produced by
marked enlargement followed by great reduction in size, to the so-
called wandering or floating liver are very indefinite. The term
“wandering” implies a Fig. 625
mobility far beyond
the normal, with more
or less yielding of
ligaments, especially
the suspensory,
which permits undue
displacement. We
often fail to realize
that the liver, which is
the heaviest of the
viscera, is
nevertheless, in man,
placed at their top,
and hence that it has,
in at least some
respects, very
meagre support. This
is one of the
disadvantages of the
upright position, and it
does not prevail in
animals. In addition to
this may be
mentioned the Xiphopagous twins, separated by division of a band of
peculiar enlargement common liver tissue. Case of M. Baudouin.
of the right lobe, very (Pantaloni.)
rarely of the left, so
often seen in connection with biliary obstruction, and often spoken of
as Riedel’s lobe. Floating liver is more common in women than in
men by four to one, and is often ascribable to the ill effects of tight
lacing. Repeated pregnancies, with the consequent relaxed and
pendulous abdominal walls which often follow them, also conduce to
the condition by weakening, in fact almost removing, its lower
supports.
Symptoms.—The symptoms produced are those of indigestion,
dyspnea, perhaps with cyanosis, nausea, vomiting,
and occasionally biliary obstruction and jaundice. In addition to these
the patient will show the ordinary physical signs of a displaced or
displaceable liver, noticeable in the upright or in the knee-elbow
position.
Treatment.—The treatment of milder cases will consist of support
from below by suitably adapted and well-fitting
abdominal binders or supports. Serious cases may necessitate
surgical relief. This consists of hepatopexy, i. e., fixation of the liver
to some of its upper surroundings. The operation is performed
through an incision such as that used for exposure of the gall-
bladder. The lower surface of the diaphragm and the upper surface
of the liver are scarified until they ooze perceptibly. The anterior
edge of the liver is then fastened to the abdominal walls, as also the
gall-bladder, if it can be utilized for the purpose. The patient is then
placed in bed with as much compression of the abdomen below the
liver as can be tolerated, in order that the scarified surfaces may be
kept in contact until adhesions result.

INJURIES OF THE LIVER.

By its size and construction the liver is made peculiarly liable to
certain injuries, while from others it is made more or less exempt by
its protected situation, especially by the ribs, which nearly enclose it.
From contusions it may undergo different degrees of laceration,
sometimes even to the degree of fragmentation and pulpifaction.
Again it is frequently involved in punctured wounds (stab, gunshot,
etc.), which may be inflicted from any possible direction, perforation
sometimes taking place from above and through the chest, and
involving the tissues beneath.
General indications of injury to the liver will be furnished by its
nature and location, the degree of collapse, and the consequent
abdominal rigidity, with the common signs of internal or intra-
abdominal hemorrhage. There is no doubt but that minor injuries of
the liver are nearly always repaired, and that they occur much
oftener than is generally appreciated; but a severe tear of the liver is
a source of great danger because of hemorrhage. In general, of
these injuries it may be said that any traumatism which produces
profound or increasing symptoms should be regarded as indicating a
careful exploration, done with every precaution at hand for carrying
out any possible indication. What the liver may safely bear in the way
of ligatures, sutures, and operative disturbance will be indicated
later. Many fatal cases show a period of a few hours of temporary
amelioration of symptoms which may have lulled to a sense of false
security, and during which internal mischief is still increasing.
Moreover, any blow sufficiently severe to rupture the liver may do
other harm. In such instances, then, it becomes a simple question of
whether there can still be sufficiently early intervention to save life.
To what extent this intervention may be required in stab and gunshot
wounds it is difficult to state. If hemorrhage and puncture of any
hollow viscus can be excluded and if no other serious symptoms be
present, it may be advisable to wait; otherwise the possible harm of
a judicious early exploration is so small, while the prospective
benefits are so great, that it is far the wiser course. Here, again, the
general rule may be applied. When in doubt operate. Further details
of operative procedures will be given below.

ABSCESS OF THE LIVER; HEPATIC ABSCESS.

While abscess of the liver is, like all other abscesses, due to germ
activity, it may yet definitely follow injury or be the result of a primary
disease, or an extension from some one of the adjacent tissues or
organs; as from above (empyema, pyopericardium,
subdiaphragmatic, spinal), from below (gall-bladder and ducts,
pancreas, stomach), from the portal circulation (superficial or
ulcerating piles, typhoid and other intestinal ulcers, peculiar or
tropical parasites like amebas), from the appendix, from the general
circulation (pyemic, metastatic), through the lymphatics (mesenteric
nodes), from the intestinal tube (ordinary round-worms and various
parasites), from cancer breaking down, as well as from degenerating
gumma or granuloma and from hydatid cyst.
Hepatic abscess may be acute or chronic, small or large, solitary
or multiple. The tendency is to enlarge and finally to kill. This they do
usually by rupture, e. g., either into the pleural cavity or the lungs,
after adhesions have been contracted, the pericardium, the
mediastinum, the peritoneum, any part of the upper alimentary canal,
or the biliary passages. Finally they may open externally and
perhaps be followed by spontaneous recovery.
A certain convenience of description is afforded by dividing these
cases into the so-called solitary abscesses and the multiple forms,
the latter being more commonly associated with tropical diseases of
the amebic type or with pyemic processes. In most solitary cases the
abscess is located in the right lobe, its extent varying within wide
limits, especially when the subphrenic space has been involved. Its
contents may be of almost any color and the pus is often thick and
foul in odor. (See Subphrenic Abscess.)
Symptoms.—Symptoms of the solitary type may be at the onset
acute, with or without history of previous sickness, the
patient being suddenly seized with severe epigastric or
hypochondriac pain, which is followed by prostration, with fever,
chills, and sometimes cough. Characteristic rigidity and tenderness
follow and the liver increases in size, the whole type of illness being
one of acute abdominal infection. The slower forms appear to come
on without early liver symptoms, patients complaining of cough and
discomfort in the chest, with loss of flesh and appetite. Gradually the
indications point to the hepatic region, while chills or intermittent
fever occur, the liver gradually increasing in size and becoming
tender. Again, in some cases, the trouble begins with irregular fever,
patients running down rapidly, yet showing few local signs until the
abscess invades the subphrenic region. In such instances
examination of the chest gives negative evidence, save that there
may be found elevation of the diaphragm due to accumulation below
it. In nearly all instances there arise, sooner or later, severe chest
pains, with enlargement of the liver, tenderness, and often
indications of fluid in the right pleural cavity, which on aspiration may
be found clear or purulent. Tenderness along the liver border will be
most marked among characteristic features. Sometimes there is
intercostal tenderness. Any indication of local peritonitis should be
taken as evidence of approach of pus toward the surface. Jaundice
is an occasional accompaniment. Previous malaria should be
excluded if possible and a careful case history is a great help.
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