the same rule prevails, the stitch entering a quarter of an inch below its point of exit and on a level with it. This converts the continuous suture into a mattress suture and secures a grip upon the muscular fibres themselves, instead of simply pulling on the areolar tissue, and thus is more secure. In this way the redundancy of the internal oblique and transversalis is taken up and at the completion of the work the thread is located near the point which once marked the outer part of the angle of the external abdominal ring. The needle is now carried through the aponeurosis of the external oblique muscle and the external abdominal ring is re-formed, only in much smaller proportions than it originally existed, care being taken not to make it so small as to unduly impinge the structures of the cord.

The wound in the aponeurosis of the external oblique muscle is then closed by a continuous suture which passes, of course, from the pubis upwards and outwards until the fibres have been united as far as they were severed. An extra turn of the thread is given here so as to prevent any possible loosening of the suture, after which a similar line of continuous suturing is carried from above downwards and inwards, matching carefully together the severed margins of the fascia. The thread is now located once more over the external abdominal ring and is now employed to bring together the margins of the skin by the subcutaneous method. The thread can be secured at the upper and outer end of the wound by bringing it out through the skin half an inch from the wound and securing it with a knot, after which the thread is to be severed. The appearance of the wound then is simply a fine scratch along the groin, two inches in length. No tissue has been impinged and not a single island of it has been completely surrounded by the thread except where the suture was first secured at the fixation of the sac in the abdominal wall. The employment of silk or silk-worm gut or silver has been found to be wholly unnecessary, especially where Kocher's method of shifting the sac has been employed, as there is no strain upon the stitches and no tendency of the hernia to return. The ordinary carbolized catgut is ample as a ligature. The continuous suture is adequate and the subcutaneous co-aptation of the margins of the wound all that could be wished for.

Attention should then be given to the pelvic terminals of the sympathetic nerve. All rectal difficulties, such as hemorrhoids, pockets, papillæ, fissures, etc., should be corrected, moderate dilatation of the sphincters practised and all abnormalities of the sexual apparatus properly dealt with. Phimosis is a very common concomitant of hernia and very frequently the meatus urinarius will

be found sufficiently small to account for much of the enervation of which the hernia is but the outward expression. Circumcision, meatotomy, snipping of the frenum and the passage of urethral sounds to further stimulate the sympathetic nerve and correct catarrhal conditions of the urethra, which are also frequently encountered in such cases, will be found serviceable measures in the cure of hernial cases. All general surgery prospers better when followed by conservative orificial work, and hernia cases especially so, as the anatomical displacement which constitutes hernia is nothing but a marked expression of enervation of the sympathetic nerve, upon which all nutrition depends.

Of course, the patient should always be consulted beforehand concerning pelvic work, as if he applies for treatment of the hernia alone and finds that some unexpected surgical work has been visited upon him, he is not likely to be pleased with the gratuity. The orificial work should not be forced upon a patient, but submitted to his judgment, and his wishes in the matter followed, and if he prefers to remain with the forms of irritation perpetually sapping his nervous reservoirs, after having been warned of what is taking place, the surgeon has dore his duty and the patient should be permitted to continue suffering the nervous loss if he prefers to do so. The patient should be able to secure the correction of the hernia without having other work-no matter how much he stands in need of it-visited upon him. The majority of patients, however, are quite reasonable, and if they understand that the pelvic work is an aid to the healing of the hernial wound and an insurance against recurrence, they are only too glad to be enlightened on the subject and obtain the full benefit of the surgeon's knowledge.

It is common in the operation for complete inguinal hernia to carry the external wound well down upon the scrotum. This seems to me unnecessary, a two inch wound opposite the internal ring being quite sufficient. It is common practice to sever the superficial external iliac and [the superficial external pudic arteries and veins. This, too, has seemed to me unnecessary and an undesirable mistake also, because the blood vessels are needed for subsequent repair of the wound. It is common practice to sever that part of the internal oblique and transversalis muscles which cover the inguinal canal and also the cremaster muscle. This has seemed to me an unnecessary mutilation of tissue and inadvisable, as it threatens a subsequent weakening of the parts. The sac is usually opened, whereas, in my estimation, this is seldom necessary. The Bassini method of shifting the location of the cord to a more superficial position than it naturally occupies is in common vogue, but

seems to me in every way less desirable than the Kocher method of treating the sac.

It is customary to close the wound by sets of deep and of superficial interrupted sutures, the deep ones being constructed of some unyielding material as Kangaroo tendon, silk-worm gut, silk or silver. This I have found to invite infection by obstructing the circulation and affording permanent lodgment in the tissues for foreign bodies. The continuous suture of carbolized catgut has served me so well for many years that I have found it thoroughly adequate to all requirements of hernial cases.

It is customary to overlook and completely ignore all orificial consideration; but, in my experience, the omission is a serious mistake.

To call attention to a small and properly placed incision, to the economy of the blood supply, to a saving of muscular structures and the advisability of handling the sac without opening, and to shifting its location by Kocher's method, to securing good capillary circulation for the inguinal wound by the use of the continuous suture of catgut, which remains in its integrity sufficiently long for healing purposes, and at the same time does not impinge tissue and thereby obstruct the circulation necessary to repair, and to call attention to the advantage of following the hernial operation with whatever orificial consideration the case may need, are my reasons for inviting your attention to so time-worn a subject as that of hernia; for, although the subject is an old one and text-book considerations are abundant, so long as one-fifth of the human race still remains subject to hernia, its consideration will never be out of place, especially so long as there is any possibility that prevailing practices are still sufficiently imperfect to furnish opportunities for improvement in the details of operative interference.

Apomorphia, one-fortieth of a gram hypodermically injected, has been successfully used for the cure of convulsions in children.

Hepar Sulphuris should be thought of when there is a sore on the body that is extremely sensitive to touch.

Manganum Met.-Cough; dry, constant irritation under the sternum; worse from talking, laughing, walking and deep inspiration; always better when lying down; stops when she lies down.

EUGENE H. PORTER. A.M., M.D.

ASSOCIATES.

EDITOR.

CEORCE F. LAIDLAW, M.D

WALTER SANDS MILLS, M.D.

Contributions, Exchanges, Books for Review and all other Communications Relating to the Editorial Department of the NORTH AMERICAN should be addressed to the Editor, 181 W. 73d Street. It is understood that manuscripts sent for consideration have not been previously published, and that after notice of acceptance has been given will not appear elsewhere except in abstract and with credit to the NORTH AMERICAN. All rejected manuscripts will be returned to writers. No anonymous or discourteous communications will be printed. The editor is not responsible for the views of contributors.

SCIATICA.

NE of the most intractable and distressing of maladies which the physician is called upon to treat is sciatica. For that reason a study of the disease presented in the Lancet of August 22 is of interest. The author is William Bruce, M.D., LL.D., and his paper is entitled "Sciatica: An Inquiry as to Its Real Nature and Rational Treatment Founded on the Observation of Upwards of Four Hundred Cases."

Dr. Bruce states that he has carefully noted the symptoms of four hundred and eighteen cases in the past thirteen years. Previous to that time he had seen about as many others. Of his recorded cases he found that the proportion of men to women was as 100 to 90. The greatest number of cases in any one decade was 128, found in persons between fifty and sixty years of age. The next greatest number, 105, was found in persons between sixty and seventy. No cases recorded younger than twenty. After that no age was exempt.

The writer says: "The symptoms of a typical case of sciatica are something like the following: To begin with there is some feeling of soreness in the hip and thigh, varying in degree from tingling or a feeling of 'pins and needles' to sharp pain. This pain is aggravated by movements of the leg, or it may attack the unfortunate sufferer in bed at night. Certain kinds of movement originate or increase the painful feelings, notably the exertion of getting into bed or the attempt to cross the affected limb over the sound one. Along with this latter symptom there may be a certain amount of powerlessness to execute this particular movement. The patient

almost always walks with a limp on the affected leg. When the pain is severe at night there is, as might be expected, a feeling of restlessness and, without actual startings, there are often small local cramps. A marked peculiarity of the pain is that after some time it comes to be complained of on the outer side of the leg, extending in some cases as low down as the heel. There are also occasional patches of anesthesia, generally on the outside of the thigh or leg."

In examining his patients Bruce asks the patient to lie on the back, dressed, on a firm even couch. He then bends the affected limb at the knee, and performs passive movements of flexion, external and internal rotation, and extension at the hip. If the case is recent he says one or more of these movements will cause pain. After this preliminary examination the patient is requested to undress and he inspects the gluteal region. He has the patient lie flat on the face with the muscles relaxed. He notes whether there is wasting in this region, or a diminution in the number of folds of the nates. The author says that in almost every case of sciatica there is softening or wasting and flattening of the hip mus cles and more or less obliteration of the natal folds on the diseased side. He then turns the patient on the sound side and inspects the capsule of the hip-joint. In some cases the affected joint is more prominent. In nearly every case will be found tenderness somewhere about the capsular ligament. He also follows the sciatic nerve to find if it is sensitive.

Bruce finds that tenderness over the sciatic nerve in sciatica is rare. Pain about the joint is often found. From these things the writer states his belief that sciatica is a hip-joint disease. He explains the distribution of the pains by giving the anatomy of the nerve supply to the parts. He does not believe sciatica to be a neuritis of the sciatic nerve. He believes the joint affection to be closely allied to the gouty or rheumatic diathesis.

His first indication for treatment is rest. In the beginning he does not believe in massage or electricity. Later on, perhaps, electricity and passive movements may be useful.

But the two main points in the paper are, first, sciatica is a hipjoint affection and not an inflammation of the sciatic nerve. Second, absolute rest in bed as the main factor in treatment.