dignified by mention of it. Still we must admit that cures are sometimes obtained by injecting hernial sacs with various substances. This plan of treatment is now happily largely relegated to quacks and empirics. That it is uncertain, painful, most dangerous and unscien tific none will deny.

LOUISVILLE, KY.

DISCUSSION.

Dr. John M. Foster, Richmond: About fifteen months ago it was my pleasure to be in New York City with Dr. Rodman, his business at that time. being to see the Bassini operation performed. I am glad he has profited by that visit, and I was somewhat anticipating the remarks he made, knowing that he was interested in the Bassini operation which he has described to you, but from which you can get a better understanding from the upper drawings which you see. My individual experience is limited to eight cases; only four of these had the radical operation. They were all operated on, and the method in all of them, with one exception, was the Macewen. In one of these the return of the hernia was due to violent exercise and failure to wear a truss. The hernia is very apt to return after Macewen's operation if every precaution is not taken. In a patient, twenty-one years of age, who had strangulated hernia eighteen hours, an operation was performed, and notwithstanding the violent exercise indulged in there was no return of the trouble. It is now two years since the operation was performed. In one case in which I operated, a child fifteen months old, with congenital hernia in which the sac could not be reduced, I followed the advice of a surgeon in Louisville who is connected with one of the hospitals there, and took out an elliptical piece of the sac, then sewed up the stump, and thereby reduced the size of the sac. While it has never been my good fortune to do the Bassini operation, I feel I understand the method as well as one can who must depend upon descriptions of it, yet the hernia operation is a good deal like the operation for laceration of the perineum; in order to fully understand any particular method it is best to see the work done in all of its details. While the pathology and etiology of acute and chronic hernia are different and should be considered separately, yet it is my belief the Bassini operation is well adapted to both. Dr. Rodman made no distinction between the two, although I can readily understand there may be recent acute cases of hernia, especially in young people, where such an extensive operation is hardly called for. Then, in a country practice, where we are very much handicapped by want of proper assistants and suitable surroundings and lack of facilities, we must even decline the Bassini operation when we know it is best adapted to the case, in order to do a more simple and less efficient one which consumes less time and

requires less assistance. I hope to profit by Dr. Rodman's experience by doing the operation in suitable cases.

With regard to the subject of trusses, I should like to have heard something more from Dr. Rodman as to the best time of adjusting a truss, and I hope he will bring out this point in his closing remarks. This subject comes home to me; even in the eight operations I have alluded to I have met with some of the difficulties that I know others have experienced, and I would like to have the doctor tell us the best time for adjusting a truss after the operation and how soon it may be applied. I would like also for him to give us an idea of the length of time consumed in the average Bassini operation as compared with other methods. I have had some bad results from failure to have trusses adjusted sufficiently early because of the efforts of the patients in coughing and straining. Those who have had experience with children under two or three years of age can appreciate what I say.

Dr. George S. Davis, Salvisa: A word first in regard to the time of operation. I think after three years of age that an operation for radical cure should be done; that whenever we do an operation for strangulated hernia trusses as a rule are not suitable in these cases after three years of age, and the ten-year limit is too great, as the doctor says.

Again, radical operation should be done in all cases of reducible hernia where a truss gives a great deal of pain, or where it is insufficient to keep up the bowel. In most cases of irreducible hernia the radical operation should be done, and a less radical operation should be performed in those cases where we have obstruction.

I will say one word in regard to femoral hernia before passing to the common form of inguinal. I wish to add a word of approval to the method where the doctor speaks of closing the wound with a flap from the tendinous muscle dissected up, at the same time dissecting up the periosteum in the horizontal ramus of the pubes, stitching both to Poupart's ligament, first having treated the sac with a puckering string with Macewen's method instead of dissecting it off.

In regard to inguinal hernia I pin my allegiance to Bassini's operation, which is the one universally recognized, as the essayist has said, unless it be Halsted's modification. There is one addition to this to which the essayist has called attention, and that is Dawbarn's plan of closing the rings and inguinal canal by transplanting the testicle between the muscles and the peritoneum, making a bed for it, which leaves no room at this end of the bowel. This new bed for the testicle is not uncomfortable, and I will say to those who think differently that an ounce of experience in these cases is worth a pound of theory. It is as different as possible from concealing the testicle within the canal. It takes but a few minutes longer, and I would say this. can be done in a few seconds longer with the finger by separating the peritoneal muscle by making a bed sufficiently large in which to drop it. In connection with Dawbarn's method of transplanting the testicle, I would advise dissecting freely the conjoined tendon of the internal oblique and

transversalis muscles, so that the edges will almost lie against Poupart's ligament without sutures. This is not done very often, but by having opened the canal freely it makes Dawbarn's plan easy. I would like to add that the testicle in its new bed is just as active as it was before operation, and lies surrounded by loose connective tissue, and I can conceive of no reason why it should not be active, being between the peritoneum and muscles instead of within the abdominal canal. In doing the operation all fascia should be dissected between the edges of the muscles and Poupart's ligament. By dividing the muscles and tendon and eliminating fat and fascia you have less chance of relapse.

In regard to sutures, while kangaroo tendon is an advantage, in that it is absorbed readily, still it is expensive, and silk-worm gut answers every purpose for deep sutures. For superficial sutures chromatized catgut answers the purpose well. Bassini, as you doubtless know, uses silk sutures throughout his operation; but one objection to silk is that it is difficult to sterilize.

I wish to raise one question in regard to drainage. The essayist says never use drainage. It takes but little time to insert a few strands of chromatized catgut in the lower end of the wound. If it is not needed it does no harm.

I believe the doctor gave statistics of two hundred cases without a death, and the cause of death in one case was not due to the operation per se, but to the anesthetic. This would seem to show that the mortality is nil in aseptic hands.

The gentleman who discussed the paper has raised the question of trusses. Recently I think the tendency is to discard trusses at the earliest moment possible, and especially if they are not particular in adjusting them. A truss adjusted too strongly is a disadvantage rather than an advantage.

Dr. H. J. Cowan, Danville: We all agree that in cases of strangulated hernia, where it is possible, an operation for radical cure should be done. In cases which can not be held by trusses, which are painful and give rise to inconvenience, we should advise the performance of a radical operation; but in cases where patients are getting along well with their hernia, in which the hernia is held up reasonably well with trusses, they want to know about what chances they will have some three years after operation, and the statistics presented in the paper were a great surprise to me. able to give statistics, but it is my impression that the reports of operations of radical cure for hernia after a sufficient length of time following the operation are bad. For instance, I remember the last report of Halsted in which there was a great number of relapses, and about twenty wounds suppurated in something like one hundred and fifty operations. I think probably that the difference between the proportion of bad results which I have gathered through general reading and the question of statistics reported by the essayist is, that most of those cases that have been reported are of

recent date. I believe that more operations have been done in the last two years than have ever been done before. The great majority of cases reported have been under observation for two years, and in the last series of cases reported by Halsted he reports recurrences after three years. We ought not to suggest an operation to a patient who is getting along well without giving him the assurance that the statistics will be a great deal better than they are to-day, and I believe the only cases upon which we should rely are those which have been under observation for three years or longer.

Dr. W. C. Dugan, Louisville : There is one point in connection with the incision of which I desire to speak. I do not think the old idea of cutting down on the constriction and introducing the "old Cooper knife" and cutting from within out is a good one. We ought to discard that, and simply cut down, expose the ring, the constriction, and with a delicate stroke of the knife cut the constriction from without. In that way we do not endanger the epigastric artery which the essayist has mentioned. Inguinal hernia in the female calls for an operation very early. The hernia is usually small and insignificant and calls for a small opening in operating.

I was surprised at the statement of the essayist that only one third of the cases under ten years of age were relieved by the use of trusses. Dr. Vance will speak on this point. He says he can cure nearly all of these cases, if brought to him early, by means of a truss. I do not wish to be understood as being opposed to operative interference in children. I operated a few days ago on a three weeks' old child. In these cases the social position should be considered, and some of these cases should be treated by means of a truss, provided it is not too painful.

With regard to ligation of the sac, I would go a little further than the essayist. He speaks of dissecting up the sac and cutting it off, placing it within the general peritoneum. It should be drawn down as McBurney advocates. It should be dissected away toward the ring, drawn down and cut off, so that when it is removed, instead of there being an infundibulum there will be a bulging at that point, making it much like the Macewen operation, or a modification of it.

In regard to the radical operation, the last speaker stated we could not say a patient was cured until about three years after operation. Statistics show that about 65 per cent of the cases that recur come on about the first six months; 85 per cent occur in the first year, leaving fifteen per cent that occur after that. If a patient is well at the end of the first year he has a pretty fair chance, there being only 15 per cent against him. I do not think the four-year limit should be enforced.

With regard to suture material, I prefer silk to catgut. I have had bad results following catgut, although I have taken precautions to disinfect it by means of boiling before operation. I prefer silk to silk-worm gut. The latter requires three or four knots to hold it, according to the statements of the essayist. That has not been my experience.

Now, as to the question of transplantation of the testicle. I have been advocating that for the last two or three years. I have stated before the Louisville Surgical Society that it was the future operation in all cases of this nature; and in my judgment in the very near future we will be lifting up the peritoneum and placing the testicle along where the ovary belongs in the female. There is no reason in the world why the testicle should not have been left there-why it should be brought down in the scrotum. It is in the way, constantly being crushed, and should have been left in the abdominal cavity.

With regard to Halsted's operation, there is a decided difference in my opinion between it and that of Bassini. I am partial to the Bassini operation, and have performed it in quite a number of cases with no bad results. If we bring out the cord through the entire thickness of the abdominal wall we have a direct opening and there is no projection against it as in the Bassini operation, so that we have the hernia coming directly through. That is the objection to the Halsted or Bassini operation as it is. We have a direct inguinal hernia following here. (The point of difference between the two operations was demonstrated by Dr. Dugan by means of Dr. Rodman's illustrations.)

Dr. Ap Morgan Vance, Louisville: With regard to the question of trusses, I believe the best cures we have ever had from hernia have been from the proper adjustment of trusses. Infantile congenital cases ought to be cured by this means, if they come under our treatment early enough after birth, and just in proportion to the age thereafter is the possibility of effecting a cure. Time and again I have cured young adults by trusses. I have a case in mind now of inguinal scrotal hernia that I treated during the last two years with a perfect result. The patient had only worn a truss for nine months. A good deal depends upon the intelligent application of the truss, and the proper conduct of it afterward. The patient should be taught what is to be expected of a truss, and should be seen often by the surgeon so as to keep up the treatment properly. I believe that no child ought to be subjected to the radical operation except where there is a tendency to incarceration or strangulation until the truss has been faithfully tried and for a continued length of time. I believe from early infancy up to the time of two years that a soft truss, made of cotton flannel, and the mother taught how to use it and cleanse it when soiled, is one of the best things we can use for the cure of hernia. All trusses that constrict the body and press upon the canal are faulty and do harm. They keep up a constant movement there. The truss should be in constant and unchanged relation to the part.

one.

Dr. H. H. Grant, Louisville: This subject is an exceedingly important Hernia is such a common affection that a very large proportion of the population in the country are more or less interested in what is to be done for it. If there was an illustration presented to this Society this morning to show the invalidity or unreliability of statistics, it would be