Buffalo only a few weeks ago rendered a verdict of $75.00 fine against a milk dealer who had put formaldehyde in his cream, and $50.00 against a grocer who was selling glucose for that wonderful transformation, the nectar of flowers, the product of the honey bee. These facts are encouraging indeed.

Another matter of special interest to physicians is the recent enactment of our legislature forbidding the unauthorised use of a certified label of milk. Its enactment was demanded as it was found that unscrupulous dealers were taking milk of any kind, marking it "certified" and by so doing imposing on the consumer, as well as the producer. It will hereafter be unlawful to certify to milk except under the authority of a competent person. Some may not understand what is meant by the term certified milk; it is milk produced on the principle that the natural fluid just as it comes from the healthy cow is in the best possible condition for human food if only we can keep it uncontaminated by the entrance of extraneous impurities, and having as a bacteriological standard not more than 30,000 bacteria to the cubic centimeter. This standard is reached by perfect sanitary conditions, cleanliness of stables, cows and milkers.

In closing this subject, I would not wish you to think me pessimistic, for I am optimistic as to the future benefits to be derived in the continued enforcement of the pure food law. Like all new laws it is not perfect; its practical workings will discover its weak spots; the courts will construe, but these constructions will, no doubt, reasoning from past experiences in the execution of our dairy laws, meet the requirements of the people and at the same time will not be unreasonable or harsh on the producer or dealer.

715 MUTUAL LIFE BUILDING.

An Analysis of Fifty Herniotomies.

BY MARSHALL CLINTON, M. D., Buffalo, N. Y.,

Attending Surgeon, Sisters of Charity, and Erie County Hospitals, Buffalo, N. Y.; Instructor in Surgery in the University of Buffalo.

D

URING the past few years it has been the author's privilege to operate over fifty hernias of all classes. In this group of cases are several points of interest. The first of the series was a strangulated inguinal hernia, which recurred with great promptitude. In the occasional cases operated during the next three years there are four recurrences; but for the last five years in a careful attempt to closely follow up all cases, I do not find a single

recurrence.

A large proportion of the cases in this series were emergency operations due to incarceration or strangulation and the majority were in men over 50. There are in the list five strangulated femoral hernias in women all of whom were over 50 years of age. All recovered and there are no recurrences. The gut was wounded in one case where the tight ring was cut with a sharp

CLINTON GLUTEAL LIPOMA AND INGUINAL HERNIA.

bistoury used in place of a herniotome, but this accident was repaired and was followed by no bad results.

One fatal case was that of a man 68 years old, in which the entire omentum was incarcerated and inflamed. After resection the

patient developed a hyperpyrexia and died in forty-eight hours. Ecchymosis into the scrotum was seen at times but was never troublesome. One internal ring was sewn up too tightly and caused pain by pressure on the cord. One patient was a cryptorchid and the testicle was removed during the operation.

The earliest of my patients were sewn up with silk after the method of Halstead, then in vogue. When infection appeared in the wound the effect of those buried septic silk sutures was such that they ceased to be used. With the betterment of general surgical technic and improvement in the technic of herniotomy, no cases of sepsis were seen and all cases were found healed at the first dressing.

There is some difference of opinion in regard to the proper method of applying sutures and the material to be used in bringing the internal oblique and transversalis to the shelving portion of Poupart's ligament. The whole key to successful operation, as Bassini suggests it, is in getting these layers properly separated and properly approximated without too great tension; otherwise gaping and recurrence is likely to follow.

Where the rings are very large, I have used kangaroo tendon with a double needle, sewing from above downwards; but where the edges approximate with ease I have had no hesitancy in bringing them together with properly prepared catgut, which will absorb in three weeks.

Teasing out the internal oblique and transversalis will aid in bringing together without tension the tissues mentioned. When this is done any absorbable, nonirritating suture that will hold the tissues in place until nature has given a firm scar will be found satisfactory. Occasionally, where the conjoined tendon runs in so far from Poupart's ligament that there is great tension on the structures when drawn together with sutures, it is better to tease out the structures to approximate than to rely wholly on some unyielding suture material. The tissues should lie without tension after the sutures are placed, in every case. When this is done there is no reason for not getting a good result and no need of a nonabsorbable suture material. The modern method of operating herniotomies in uncomplicated cases has no mortality, is free from danger, confines a patient three weeks, and sends him out with a permanent cure.

Among the peculiar cases is one shown in the illustration, at case of inguinal hernia with lipoma starting in the gluteal fold and pushing its way forward until it presented, as shown in the picture. The patient was discharged cured in three weeks.

CLINICAL LECTURE.

The Radical Cure of Inguinal Hernia.1

BY MAYO COLLIER, M. S., F. R. C. S.

[From The Polyclinic (London), August, 1904.]

GENTLEMEN-I have brought for your inspection today amongst other cases, one quite simple of diagnosis, but about which there is much to say and many points to discuss.

The patient as you see, is apparently a strong, healthy fellow, who comes to the hospital with the most absolute belief and faith that I can perform some simple operation on what he says is a rupture in the left groin, so that he will never have to wear a truss again, and never be troubled with a return of his complaint. In short, he wants me to perform the radical cure in the belief that the radical cure will do for him all that he thinks.

This is the general belief among the lay public on the subject of the operation for the relief of rupture. I need hardly tell you that this view is incorrect; and the approximate truth on the subject of the radical cure for hernia I shall endeavor to put before you today.

Now, the first question you must be prepared to answer is this: Why an operation at all? Why not a comfortable and well-fitting truss? This question must be answered from several points of view, and, firstly, there are seven classes of cases where a truss cannot be relied upon, and an operation is most certainly indicated, namely: (1) cases of irreducible hernia; (2) cases of strangulated hernia; (3) cases where the hernia is not controlled by a truss; (4) cases of hernia with ectopic testis; (5) cases where rupture unfits for the public service; (6) hernias in incompetent and ignorant people; (7) very large hernias hampering the movements and seriously threatening the personal comfort of the patients.

In all these cases it would be your duty to prefer an operation rather than outside mechanical supports. In other cases it is quite certain that hundreds and thousands of persons pass through their lives with comfort and safety with the assistance of a well-fitting truss, but I most certainly would not refuse to perform the radical cure for a person who was anxious to be relieved of his truss, and who, from a sentimental point of view, objected to the mechanical support.

Now, before you could honestly take upon yourself the responsibility of advising and operating on a patient for the cure of hernia, you must satisfy yourself, and in some cases your

1. Delivered at the Medical Graduates' College.

patient, as to the following facts, and you must be prepared with more or less exact knowledge on the subject:

(1) Can you assure him that the operation is a safe operation so far as his life is concerned, as well as free from risk of damage to his testicles?

(2) Does the term "radical cure" mean radical cure in the sense of permanency of cure? Is the operation a real cure or only a temporary palliative?

(3) Should very young people be operated upon? If not, within what age-limits should the operation be performed?

(4) Should a truss be worn after the operation? If so, for how long, and, if not, should any support or precaution be taken. to prevent return?

(5) You must satisfy yourself as to the best material for suture, and, lastly, but assuredly not least, the best form of operation to perform.

You see from this list of questions that you must answer either to the patient or yourself, that the procedure is not quite so simple as the public believe, and not quite so lightly to be undertaken as some would have us teach.

And, first of all, as to the safety of the operation. I think we may most certainly answer this question in the affirmative and say "the operation is perfectly safe, provided it is done by a skilled and competent operator with experience.'

Out of 104 cases in one practice there were only two deaths, both from zymotic diseases, and, in America, Dr. Coley, out of 160 operations, lost one case, from pneumonia.

These are just a few examples illustrating the freedom from trouble after this operation.

Next, is the testis in any danger from the operation? It most certainly is in the hands of the unskilled surgeon who endeavors to pull and drag and rend the layers, of fascia covering the hernial sac, instead of cutting straight down to the sac and gently peeling it from its nearest covering.

Atrophy of the testis, and inflammation with abscess and sloughing, have followed this operation in careless hands.

Next we come to the question, How far does the operation. bring about a complete or radical cure? Also, how far is this cure a permanent one? Please always safeguard your own reputation, and that of surgery in general, by telling your patients that many of the best and most promising cases lapse-that the hernia returns and requires a second operation or a truss. Tell your patient that only in some cases does the patient never require further assistance or treatment, but also tell your patient “that an operation will most certainly improve matters, that after an