canal, I have in a few cases passed the cord through the external oblique aponeurosis just above the middle of the canal, and instead of passing it between the taut edges of the coapted flaps, passed it through a transverse incision in the upper flap, thus strengthening the lower half of the posterior wall with the

Figure 5.-C-Inferior flap in place with two layers of the external oblique aponeurosis covering the upper third of the cord and one layer covering the middle third, while the entire length of the inguinal canal is covered with two layers of this aponeurosis. aponeurosis as Halsted formerly did the whole canal. A further modification was adopted from Andrews' method of passing the cord between the layers of the imbricated aponeurosis, giving still further obliquity to the canal and therefore greater valve-like pressure by infolding it, not throughout its whole course as in

Andrews' operation, but only in its middle third and passing it as before through an opening in the inferior or external flap. The technic of the operation is as follows:

First step: The skin and superficial fascia are divided from the spine of the pubis slightly beyond the internal abdominal ring. The external oblique aponeurosis is then divided to about the same point, leaving the lower flap of fairly good width. The sac is then carefully separated from the cord, opened to free it of intestine, transfixed, ligated high up and excised, when it will retract through the internal ring. (Figure 1.)

Second step: If there are varicose veins in the spermatic cord the largest of them are ligated and excised. The cord being held up out of the way, the transversalis fascia and internal oblique, including the conjoined tendon, are then stitched to the shelving portion of Poupart's ligament, two stitches being placed in the internal oblique muscle above the opening for the passage of the cord to gather up the muscle and fascia with a view of obliterating the inguinal fossa, care being taken to bring the cord well down to the lower border of the internal oblique, thus giving it considerable obliquity in passing beneath these muscles. (FigTre 2.)

Third step: Mattress sutures are then passed through the lower flap close to Poupart's ligament-that is, in the lower portion of the outer flap-catching the margin of the internal oblique and its fascia and the lower margin of the upper or internal flap, three such mattress sutures being placed in the upper part of the incision over the muscle and cord, the other four being passed beneath the cord as shown in Figure 3. A small incision, sufficient to make an opening large enough for the passage of the cord, is made in each flap; in the upper one at a point a half inch below that at which the cord passes out through the internal oblique, and the one in the lower flap at the junction of its lower and middle third.

Fourth step: The mattress sutures are then tied and the cord passed through the opening in the upper flap as shown in Figure 4. The lower flap is then carried upward over the cord (Figure 5) and stitched to the upper flap above the cord, except the lower third which is passed beneath the cord and stitched in like manner.

Fifth step: Both layers of the superficial fascia are then approximated and the wound closed with a subcuticular silkworm suture as in Figure 6.

The overlapping of the flaps is a part of Andrews' operation. The modification is the transmission of the cord, (1) through both flaps at different levels, and (2) through incisions rather than between the edges of the flaps, thus giving greater ob

Figure 6. Incision closed with subcuticular silk worm gut suture.

liquit to the canal and more valve-like value to the successive structures forming the anterior wall.

Ii there be any apprenension of weakening the aponeurosis by the incisions made in it for the passage of the cord, one may be reassured by thinking of the facility and completeness with which connective tissue regenerates, as illustrated in the regeneration

of the severed tendo-Achilles (for talipes equinus) and in the unimpaired strength of the reunited tendon. The end fibers in a measure reunite around the cord, making a more or less firm band. Certainly no resistance equal to it can be secured by adhesions between longitudinal fibers of the same tissue, or between muscle and tendon.

Should it be found by experience that these fibrous rings through the external oblique aponeurosis are not damaging to the cord, we believe that the method here described will prove to have special advantages in dealing with large oblique inguinal hernias, especially in cases in which the conjoined tendon is greatly weakened or partially obliterated and the rectus muscle narrow. By this method the posterior wall of the canal is strengthened and additional resistance to hernial protrusion is given at the point of the passage of the cord through the aponeurosis of the external oblique, partly by the strength of the fibrous rings themselves and also by the increased valve-like pressure insured on account of the greater obliquity of the new canal. The cord is abundantly covered in its upper two-third by the aponeurosis of the external oblique and below this by the layers of the superficial fascia, the adipose tissue, and skin.

DISCUSSION.

Dr. J. E. CONE, Youngstown: From the title of the paper, I expected to hear something in regard to the tremendous hernias we get in old men which we meet with constantly. I remember a case I had in '98. The man, who was some seventy years old, had a hernia which measured some twenty-three inches in circumference and extended down to his knees when he was standing up. This man became bedridden and could not get around at all. I advised in this case doing something that I do not know that I had any authority for, but I got his consent and did it. I told him if he would allow me to remove the testicle and cord, I could close it up with the probability of it not returning. I found a sac containing omentum, intestine and bladder. He had a cystitis which was giving more trouble than the hernia. Really, the excuse for operating was the cystitis. We removed a large amount of omentum, returned the bladder and intestine, and closed the wound complete, making a complete closure. This man lived several years and his hernia never returned, and it gave

him great relief from the bladder trouble. I think the Doctor's method is probably all right and I will probably try it; but I have always been getting good results from the Bassini-Andrews operation, and others. This is something we like to do, to save a man from a great amount of siffering and annoyance for many years, and I think these papers should be read oftener before our

Figure 7.-Transverse section of abdominal wall over inguinal canal. A-Integument. B-Adipose tissue. C-Imbricated aponeurosis of external oblique. D-Cord as transplanted in this operation. EInternal oblique muscle. F-Cord in its normal position. GFascia of transversalis muscle. G'-Conjoined tendon. H-Peritoneum. I-Epigastric artery. J-Epigastric veins.

county societies, and the people should be educated to the point where they will know they can be cured without wearing trusses. Then perhaps the time will come when we will not see in every drug store hundreds of trusses hanging around. They should