upon a rational scientific basis by his work, "Mechanical Vibratory Stimulation," published in 1903; a modest and unassuming volume, but none the less an epoch-making one, and the subject at once assumed a new dignity from the masterful presentation of unanswerable arguments, based not upon theories, but upon solid facts set forth in acknowledged authoritative standard works written by such authors as Landois and Stirling, Kirke and Foster, and facts further confirmed by actual practical experience. The subject at once assumed a new importance and great interest was excited thereby. In fact, this work heralded the birth of a practically new therapy.

To give some idea of the scope of vibration therapy a few paragraphs may be quoted from Pilgrim's work: "Treatment by mechanical vibratory stimulation has been found by practical. experience to be capable of: (1) Increasing the volume of the blood and lymph flow to a given area or organ; (2) Increasing nutrition; (3) Improving the respiratory process and functions; (4) Stimulating secretion; (5) Improving muscular and general metabolism, and increasing the production of animal heat; (6) Stimulating the excretory organs and assisting the functions of elimination; (7) Softening and relieving muscular contractures; (8) Relieving engorgement and congestion; (9) Facilitating the removal through the natural channels of the lymphatics, of tumors, exudates and other products of inflammation; relieving varicosities, and dissipating eruptions; (10) Inhibiting and relieving pain." Pilgrim disclaims any intention of lauding this treatment as a cure-all, but maintains that "for the purpose of effect-ing the changes above enumerated, there are no physical therapeutic agents within the writer's experience or knowledge that will render as effective service along these lines, with as few disappointments, as mechanical stimulation properly employed.

The general theory upon which this treatment is based is that all the functions and organs of the body are controlled by certain nerves or nerve centres, located principally in the spinal cord, and that in the course of disease, if these centres are reached and treated, restoration to normal actions may be expected in most cases to take place."

This claim of Pilgrim's can be substantiated by any one who has devoted careful attention to the details of treatment by mechanical vibration; it is no vain boast, and in many very obstinate affections vibration will be found one of the most useful measures within our reach, but it must be properly carried out and used in no mere haphazard fashion.

It will be quite impossible in the limits of a paper such as this to attempt to set forth all the conditions in which we may

count upon the assistance of mechanical vibration and brief reference to but a few must suffice.

In many forms of rheumatism it is of inestimable value, not only for the relief of pain and stiffness, but also in promoting the elimination of uric acid, hastening the absorption of effusion about joints and improving nutrition. In sciatica it is also of great use, and in rheumatoid arthritis it is a valued adjunct.

In chronic constipation, particularly when due to intestinal atony, it is likewise of great assistance, and is an admirable adjunct to electricity and suitable dietary.

In hemorrhoids internal or external its remedial action is frequently manifested quite promptly.

In many paralyses it is of great assistance, and its use affords much comfort, while in chorea it is one of the most valued remedies we possess.

In parenchymatous goitre it is often of considerable utility used in conjunction with electricity, and in many other condi tions it is of undoubted utility and well worthy of our confidence. 192 Bloor Street West, Toronto.

COMBINATION OPERATION FOR THE CURE OF INGUINAL

HERNIA.*

BY F. N. G. STARR, M.B. (TOR.),

Associate-Professor of Clinical Surgery, University of Toronto.

Mr. President and Gentlemen,-The subject of Inguinal Hernia and its radical cure is always interesting, and one over which there has been much controversy. While the number of operations is legion, it seems there are but two that are generally practised, namely, Kocher's and Bassini's. In the former the method of

dealing with the sac is certainly ideal, for it entirely obliterates the hernial protrusion and draws the peritoneum, in the neighborhood of the internal abdominal ring, upwards and fixes it in a direction opposite to the course of the spermatic cord. Kocher lays a good deal of stress on this point and claims that the "descent of a sac in the direction of the cord is rendered impossible."+ One has but to do a few of these operations to learn that "all things are possible," for one will frequently get recurrence, though Kochert publishes statistics gracefully granting to his own operation 100 per cent. of permanent cures, Bassins's (from only 7 cases) 37 per cent., McEwen's 66 per cent., and Kocher's modified by Landerer 80 per cent. In the face of such statistics one almost trembles to suggest what he considers a better method of dealing with the wall than that advocated by Kocher; however, to my mind, I think

* Read at a meeting of the Canadian Medical Association, Halifax, N.S., August, 1905. +Kocher's Operative Surgery, 4th edition, p. 239.

Kocher's Operative Surgery, 4th edition, p. 240.

that in Bassini's method we have a safer and better way of closing the canal, and I hope before I conclude to be able to demonstrate a still better method for selected cases. Coley and Bull,* of the New York Hospital for Ruptured and Crippled, who have had a very large experience with Bassini's method, report 450 cases in adults with seven relapses, and 800 in children with eight relapses.

It seems to me reasonable that a surgeon in search of the best might readily combine the good points in each of these operations and thus approach more nearly the ideal.

An incision is made over and parallel to the inguinal canal but extending beyond it above and below.

The superficial epigastric artery is divided and twisted, and the aponeurosis of the external oblique is exposed freely. The intercolumnar fascia, the lower fibres of the internal oblique (cremaster) and the infundibuliform fascia together with the aponeurosis are divided, thus exposing the whole of the inguinal canal. The divided edges of the aponeurosis may be grasped by forceps and this structure separated freely from the underlying strata: the lower edge of the internal oblique, the transversalis, and the conjoined tendon are then defined and separated by the finger from the peritoneum. Poupart's ligament, by the aid of the finger, is also fully defined. The sac is then isolated and freed as high up as required, some traction at the same time being used. It is now opened, carefully cleared of its contents, and is then seized at its fundus with long narrow curved forceps and invaginated backwards through the inguinal canal up into the abdominal cavity. "The point of the forceps is then forced against the abdominal wall, which is made to project just external to the internal abdominal ring. An incision one third c.m. long is made through the aponeurosis and muscles down to the parietal peritoneum, which, together with the invaginated hernial sac, is pushed through the opening. The parietal peritoneum is taken up with dissecting forceps and incised and the edges are grasped with artery forceps to prevent them from retracting. The whole length of the invaginated sac is forcibly pulled out;"t the empty forceps are taken out at the same time. The base of the sac is crushed with a pair of pressure forceps, transfixed with a chromic. catgut suture, and the two halves, together with the parietal peritoneum, are tied. The sac is cut off close to the ligatures, the stump pushed back under the fascia and the same suture is used to close the opening in the aponeurosis of the external oblique.

The lower edges of the internal oblique, the transversalis and the conjoined tendon are then united to the deep part of Poupart's ligament by means of a series of Mattress sutures of chromic catgut, care being taken that these sutures are not tied so tight that

*Progressive Medicine, June, 1905.

Kocher's Operative Surgery, 4th edition, p. 213.

the vitality of the parts be interfered with, just enough room is left at the inner end to allow the cord to emerge. In this way the cord is left undisturbed in its bed, which I consider an important precaution, for it seems to me that the less handling there is of the cord the less likelihood there is of unfortunate complications. There are certain cases of long standing in which there is a considerable redundancy of the aponeurosis, and in these the method of Bassini, namely, finishing the operation by suture, is hardly sufficient to ensure the integrity of the abdominal wall. It is in such cases that I commend to your attention the following method, namely, that the upper margin of the divided aponeurosis be sutured with a continuous chromic catgut suture to the superficial part of Poupart's ligament, beginning the running suture at the inner extremity and then where it terminates at the outer angle, by making a fixation cross the same running suture may be used to fix the lower divided edge of the aponeurosis, to the aponeurosis, above the level of the inguinal canal, and make the final fixation of that suture one half to one inch and a half above the external ring, its point, of course, depending upon the amount of redundancy of the aponeurosis. (See fig.) While I would insist on this as being absolutely necessary in all long-standing cases, yet a certain amount of overlapping of the aponeurosis may be secured in all cases and thus add materially to the strength of the abdominal wall. One must, of course, see to it that the cord is not unduly compressed, otherwise there may be swelling or more serious damage to the testicle. The operation is then concluded by a subcutaneous stitch of silkworm gut or heavy horse-hair, incuding in its bite the deep fascia as well as some fat, and by a subcuticular suture of horsehair, the ends emerging about half an inch above and below the extremity of the incision, and tied over a small roll of acetanild or iodoform gauze. These stitches are removed on the 9th or 10th day.

I have done this operation a number of times already and it has seemed to me rational and has given excellent results so far, and this is more than I can say of either Kocher's or Bassini's or any other operation in my hands. It is true the hands may be somewhat to blame, but I am prone to ask the method to share some of the responsibility.

Note: Since presenting this paper to the Canadian Medical Association I have discussed the operation with my senior colleague, Dr. Geo. A. Peters, and find that he has been doing practically the same operation for a number of years, while I have done it for not more than two years. The drawing was made for me by W. E. Gallie, M.B. (Toronto).

112 College St.