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kind of relapse that occurs after this "open" operation, that I was very much struck with the first patient who presented himself, on whom this operation had been performed. He had been operated on for inguinal hernia on both sides, and as in the case of these patients which Dr. Fowler has shown us to-night, his whole inguinal canal had been replaced by cicatrization. At the time I saw him, three months after the operation, the hernial tumors on the two sides were about as large as my fist, and the remarkable fact was that the cicatrix over these hernias had stretched to such an extent that you could almost see the movements of the intestines through them. I had no sooner observed this case than I read the statement of Dr. Ford at Washington. narrated the case of a patient with umbilical hernia in which a beautiful cicatrix had formed, but which at the end of six months was so thin that he could see the intestines through it. Now, the presence of such a condition must be a very unfortunate one for the patient, who has got to have something done for his relief when a relapse has actually occurred. It is very well to say that trusses are no good, that they never should be worn after operation, but what are the patients going to do when the hernia do relapse? The most enthusiastic operator is very glad to apply a truss then. Now, when these patients who have a thin cicatrix come to the truss man for a truss, he is much embarrassed. That thin cicatrix is pressed on the inside by the intestines, and on the outside by the truss, and it is in a condition very similar to that which exists in some cases of irreducible umbilical hernia, where the coverings of the hernia are thin and cannot stand the pressure of the overhanging clothes, and where the patients are in a deplorable condition. I have met with two cases operated on by the "open" method, who presented no relapse after several months. These patients came early for trusses, and I think if the operation is to be done it would be better to wear a light truss immediately afterwards.

I feel as if I had trespassed too long upon the time of the Society, and I thank you, gentlemen, for your kind attention.

Dr. PILCHER. I wish to express my own appreciation of the papers that have been presented here this evening, for the careful statements that have been given to us, and for the broad and comprehensive views which have been laid before us. I am sure there is none of us who can go away without feeling that he has received both information and stimulus for future guidance, and especially do I wish to express my appreciation of our indebtedness to our colleague from New York, who has been willing to give the results of his own ripe experience in this matter. I think this is a subject which may well occupy much of the thought and time of any practitioner of medicine.

It might be well for us to reflect for just a single moment upon the

continued presence of those who are afflicted by hernia among us, as well as the immense amount of disability and of suffering and of danger which this affliction entails upon the members of the community. If it is so that one out of every twelve persons is afflicted with hernia, the number of those who have hernia in this city of ours alone must exceed 60,000. If it is true, as is stated, and as was shown by the census of 1880, that over 600 deaths took place in one year in the United States from strangulated hernia, the possibility of death can never be dismissed from consideration by one afflicted with hernia. We are to remember that this is a disability which may develop in connection with the most robust at any period of life. This is well illustrated by the fact that, during the recent war of the Rebellion, from our own army alone in two years nearly 40,000 soldiers were invalided and discharged from the service in consequence of hernia developing after their enlistment, not to speak of the immense number of persons debarred from enlistment in consequence of hernia existing at the time of their application. Now, with all of this mass of danger and disability before us, it is not to be wondered at that the question of the radical cure of such a condition should have created so much interest and should have been so extensively discussed and experimented with in the past few years, since such experiments have been made comparatively safe in consequence of improved methods of operation. When the method of Heaton for the injection of irritating substances subcutaneously first attracted attention, I tried it in a very limited number of cases—two in all. The first case was cured and remains cured, I believe, until the present time, some ten years or more The second case relapsed within six months. I afterwards performed upon this second patient an operation for radical cure by the open method, during which I was able to demonstrate to myself the irritation and the condensation of tissue which had been produced in the inguinal canal by the injection, which made the operation for radical cure considerably more difficult than it otherwise would have been.

The question of the possibility of relieving this condition by the use of a truss has been referred to this evening. Observers who have given a very extensive investigation to this subject tell us that about twelve per cent. of those cases that are subjected to treatment by the truss are radically cured by the wearing of the truss. That is, as has been defined by Dr. Bull, they are apparently relieved of their hernia and pass years without any relapse, after having for a certain time worn a truss. We know that this is especially likely to take place in cases of hernia occurring in infants, and with any recent hernia in adults. If the hernial protrusion is not very great, and a truss is applied at once and is worn with a proper amount of intelligence and assiduity, the

hernia is prevented from returning, and the wearing of the properly fitting truss, unless the patient is subjected to great strain, is likely to bring about a fair immunity from further recurrence of the hernia. But notwithstanding all this, the other eighty-eight per cent. of cases of hernia still remain for us to condemn either to the perpetual wearing of a truss, or to be relieved by some means of radical cure. And it is certainly the case that at the present time no method of radical cure is spoken of that ought to be entertained by any intelligent surgeon except that by the open method, by the bloody wound. Various methods. have been mentioned this evening, and their merits and demerits pointed out. I do not wish to take up much of the time of the Society this evening, but I would say, that for operators in general, it seems to me that in this particular region the greatest amount of safety and security to the lives of our patients are to be obtained by adopting methods in which there shall be no danger of retention of secretions in the wound made. Therefore if the integument is to be drawn over it, that method in which is included the use of the drainage tube is to be preferred for the general surgeon, as entailing less danger of urinal disturbances and possible peritoneal involvement. It has seemed to me for this reason that the open method of McBurney was particularly free from danger, and in the number of instances in which I have used it, I have found perfect immunity from inflammatory complications. For that reason I think it would be the proper method to adopt in many instances. But after all, whether the method of McBurney, or the method of Riesel, or the method of McEwen, or Ball, or Barker, or any method which may be adopted, the main question is, when a patient presents himself to us with a hernia, whether we can urge upon that patient whether he should submit himself to the procedure of radical cure by an open method. In the earlier period of my thought upon this question I was inclined to be decidedly conservative and to restrict the operation only to cases first, in which strangulation had taken place, or in which the hernia was irreducible and was giving the patient extreme disability, or to cases that were with difficulty restrained by a truss, that were growing more dangerous continually and were seriously disabling the patient from the ordinary avocations of life. But as I had more experience with the operation, and as I reflected more upon the conditions which demanded the operation, I became convinced that it was only in the cases of the classes that I have mentioned that there was much danger from the operation. In some of these cases, indeed, the danger may be so great that it would be better not to attempt any operation at all, but simply to be content with such palliative treatment as the case might admit. With the great mass of cases of ordinary hernia, however, comparatively small, easily

reducible and easily kept up, which come to us-in these cases the operation is comparatively easy and simple to accomplish, being attended with little danger. I am logically driven, therefore, now to advise such people to submit to operation. As time passes on I am getting more and more on the ground which has been taken by the gentlemen who have spoken here this evening; that is to advise all persons who are the subjects of hernia to submit themselves to some operation for a radical cure, that is to say, provided a truss has been worn a certain length of time under proper conditions without cure.

Dr. WIGHT.—In reference to the question of relapse. We must remember first that our patient is in daily and I may say constant peril of strangulation. He knows not at what hour or at what moment he may be in danger of his life, perhaps before he can get a competent surgeon; he may wear a truss or not, as the case may be. That is one side of the question. The other side is this: after he has been operated upon for radical cure he may not be radically cured, but those conditions and circumstances which put his life in peril before have been mostly obliterated, and while he may possibly by that relapse which has been spoken of, have as much inconvenience as before, he is not in that daily peril and danger of his life. We are advocating this operation not because the trouble does not relapse, but because it relieves the individual of that constant peril that we have seen brought out by various reports of surgeons. That is one of the reasons I am in favor of these operations.

Dr. FOWLER.-I was struck by one or two points in Dr Bull's remarks in regard to the undesirability of allowing cicatricial tissue to take the place, for the purposes of security, of the immediate primary union of normal structures. I am willing to concede that this is true in all situations except in the case of the inguinal canal, but I am firmly convinced that the formation of cicatricial tissue in this situation serves a double purpose. In the first place, there can be no question in regard to the conditions as they exist after the operation, as shown by cases under my observation for nearly two years; the contraction of the cicatrix, the folding in of the edges of the elliptical shaped gap left by the open method of operating undoubtly insures, or conduces at least, to a smooth condition; certainly a concave condition of the peritoneal surface of the abdominal wall is not favored. I desire to impress that view now, because it may seem that I am advocating the open method and the formation of a cicatricial plug for the sole purpose of obtaining a stronger retentive tissue than that which can be obtained by the immediate union of the natural coverings of the canal. The obliteration of the inguinal canal itself I consider a very important factor in the McBurney operation for radical cure. Certainly no as

surance can be given that the inguinal canal is obliterated unless the edges of layers incised by the operation for the removal of the sac can be prevented from immediately uniting.

Dr. Bull spoke of the folding in of the edges of the skin and their adhesion to the transversalis fascia; that is partially true and partially not. The edges of the skin do not adhere immediately to the transversalis fascia. In fact a layer of granulation tissue springs up in the floor of the canal, and from this cicatricial tissue is formed; to this are attached the edges of the skin.

My experience in the operation for radical cure prior to the introduction of the McBurney method covered about eight cases, most of which were operated upon by the method of Socin, that of leaving a drainage tube in the canal and uniting the super-adjacent tissues. I have never thought it justifiable and have never advised that the entire super-adjacent structures should be immediately drawn together, and thus allow the inguinal canal to remain as a dead space, with no drainage provided for. The method of leaving a drainage tube in the canal, unless the open method is adopted, is to my mind the only other justifiable one. Therefore I am far from being prejudiced, but was rather favorably inclined theoretically to that method. The eight cases operated upon by myself truly are but a limited number, compared to the larger number mentioned by Dr. Bull, but they are quite sufficient to suggest to me the possibilities of that method. I may say furtherand this may perhaps invalidate my statement in regard to the possibilities in regard to radical cure by the method of Socin, that my patients were allowed to rise and walk about and wear a truss as soon as the wound healed. Six of these eight cases relapsed. I hardly like to trespass upon Dr. Bull's good nature, but I would like to ask concerning the after-treatment of his patients, and that of the parts themselves. Was the wearing of a truss insisted upon, and was the patient permitted to resume his occupation at once?

The point made by Dr. Wight in regard to the desirability of instituting some operation in most cases otherwise considered favorable for operation, for the sole purpose of preventing those dangers of strangulation and irreducible conditions which are so frequently found, at least with relative frequency in the cases not operated upon is well worthy of attention. That is to say, the instituting of an operation for the purpose of doing away with these conditions of the ring and canal, which predispose to strangulation, constitutes, of itself, a justification. for the operation for radical cure. I am in accord with him in that, and I believe the future will show that the number of relapses after an attempt at radical cure, relatively large and disappointing though they may be in many respects, will still leave us with a smaller proportion