sublimate; this has been demonstrated to be the most efficient of all germicides. That people should not drink it by mistake, the London Board of Health uses it as follows: "one-half ounce of corrosive sublimate, one ounce of hydrochloric acid, five grains of aniline blue, three gallons of water." As corrosive sublimate coagulates albumen, the acid is added to prevent that; and the blue color prevents it being mistaken for water. As dirt is the great breeder of the disease germs, the dust between the cracks of the boards should be well wetted to kill those lodged there.

These should be As before stated,

The contagion of typhoid fever is in the stools. disinfected before being thrown down the closet. boiling water kills every known disease germ. Three times the bulk of the stool of boiling water kept in contact with the stool for half an hour will destroy all the germs in the stool. It is sure, does not rot the pipes as many disinfectants do.

A new disinfectant is exciting some attention in Germany and England; it is creolin, a product of English coal. It ranks about with carbolic acid. It is superior to carbolic acid and iodiform from the fact that it is not poisonous and does not irritate the skin, and as a surgical dressing it will doubtless, in time, supersede these; as a germicide for the sick room it is valueless in comparison with corrosive sublimate. E. Merck, of William Street, New York, is the agent for it in this country.

After immersing threads on which were the germs of typhoid fever and others, with the Klebs-Loeffler bacillus and others, with the bacillus of scarlet fever, in a ten per cent. solution for thirty seconds all these germs readily propagated. While creolin has an assured value as a surgical dressing, it can hardly be used as a germicide in infectious. diseases. As flowing steam penetrates woolens and kills all known disease germs and their spores, the city should furnish a steam plant for disinfecting carpets, and also dry heat for pillows. A room large enough to hang carpets up without doubling should be had, because the more the folds the greater the difficulty of penetrating with the steam. New York City, under the advice of her bacteriologists, has made a start for such a plant.

Educate your families up to these facts, and particularly to the fact that woolens are the great holders and carriers of disease germs, and the question, that Dr. Storr's publicly asked at the meeting of the American Public Health Association, will be answered: "Why do these contagious diseases cling to the homes of the rich so much more than to the homes of the poor?" The winds of Heaven visit the homes of the poor and dissipate these disease germs, which cling to the carpets of the rich.

A FEW OBSERVATIONS ON THE RADICAL CURE OF

HERNIA BY SURGICAL OPERATION.

BY T. H. MANLEY, M. D.,
New York.

The great impetus given to operative surgery recently, by the introduction of antiseptics, has not been without making its impress on the surgical management of ventral protrusions, in various situations in the lower trunk.

If, in former times, conservatism was one of the most characteristic traits of the elder surgeons, its contrary is most noticeable in the younger generation of operators; and whether for "better or worse,' to day, when we find any portion of the abominal contents pressing beyond their natural boundaries, we hesitate not to force them back, and close the breach made by their exit, by various surgical measures; which, though somewhat different from each other in technique, have the same object in view, viz: the obliteration of the portal through which the viscus escaped; which is attained through the aid of an uninflammatory exudate; ultimately undergoing fibrous condensation, sealing up, and strengthening what had been, heretofore, defective.

As it is generally admitted now, that the vast majority of cases of abdominal hernia are readily, and rapidly, safely curable, by a simple surgical procedure, it becomes necessary to separate the different varieties; those curable, and incurable; those congenital and those acquired. Besides, in order that we may intelligently approach a case for operation, or condemn another as unfit, it is important that we examine briefly into the causes; the predisposing and immediate.

There can be no question that among the first, a faulty descent or development of the testes is, by all odds, the most frequent. Indeed,

I am convinced, from a careful series of observations made on the cadaver and from the faulty anatomical development found in every case in which I have operated, that the testicle is the agent which occasions all the trouble in nearly every case of strangulated or indirect inguinal hernia. It is only exceptionally that this is not so, I am quite sure. The testis may descend into the inguinal canal, and remain lodged there. It may descend partly into the scrotum, and lie anywhere from the inner margin of the outlet to the base of the

scrotum.

The testis in its transit downwards, after entering the peritoneal cavity, may contract adhesions with a fold of the mesentery, with the intestine, or with the inner surface of the pouch of peritoneum, the sac, the fascia-propria, the epididymis, or vas-deferens.

It may not even enter the internal ring though a perviou sslit in the aponeurotic tissues can be discerned, through which its lower fibrous cord, its pilot, the gubernaculum passes on its way to its place of temporary attachment, near the apex of the pubic-arch. This prenatal, fœtal type may remain through life, the canal never wholly closing on this strand of fibrous tissue, as it does around the spermatic cord after it has taken its normal position, and hence, a defect remains in the abdominal parietes.

Many cases have been recorded wherein the testis at birth was duly placed, but later entirely disappeared. In some instances becoming temporarily lodged in the inguinal canal, and re-appearing; in others, its habitat becoming uncertain and varied. Probably, in the majority of cases, if after birth, on the appearance of small hernia with imperfect descent of the testicle, no truss of any kind were applied, but the infant kept quiet on his back most of the time, nature would often effect a cure, by sending the spermatic gland well down and closing the canal, completing after birth, what it had imperfectly essayed to do before. But now, at this critical period, a truss is applied, with a view of preventing a further protrusion and effecting a cure-while in many cases it does precisely the opposite. By its constant, painful pressure, it produces an inflammation of the serous laminæ, in which the tender testis is enveloped, resulting in adhesions which will firmly anchor it, and in this manner make a complete and permanent descent of it impossible.

Not infrequently, even when the organ of reproduction surely reaches its destination, the inguinal canal never closes, or rather, there is such a disproportion between the cord and it, that a small fringe of omentum, may insinuate itself between them; and this, in the process of time, through pressure, overcomes the unyielding tension of the transversalis-fascia and fibrous parietes of the rings.

In all cases, in which this impediment to descent is noticed, or that the spermatic canal remains open and the bowel gravitates, the testis is improperly developed, or has undergone atrophy, as a consequence of vascular derangement, or inflammatory changes, attributable to pressure in its abnormal situation; or from being crowded aside by a firm, compact, old omental-hernia.

Other anatomical defects, besides those referable to the testis, contribute their share towards favoring, maintaining, and reproducing hernia. Among the most discernible, and pronounced, probably, is an abnormally elongated mesenteric-ligament. A varicosity of the veins in the folds of this tissue, or an excessive fatty deposit in its meshes, both alike, tending to drag and stretch it; thereby shifting the weight of the viscera, which it supports, from the spine to which they are connected

-not unlike the sail to a mast; to the abdominal parietes; to that region of the belly, weaker anatomically than any other and where in man, in obedience to the laws of gravity, they naturally impinge.

We see many internal serious derangements occasioned by these elongated ligaments, or mesenteries; as when the kidney or spleen have their appendages of abnormal length; the cæcum and its cul-desac; the colon, or even the rectum as well.

In the rarer species of rupture, as the direct inguinal and femoral, it is difficult to account for them in many instances; except on the presumption of the existence of structural defect, affecting the integrity of the conjoined tendon and the intercolumnar-fascia.

The sudden development of a femoral hernia is an impossibility. Owing to the manner in which the femoral vessels are invested by a prolongation of the iliac-fascia and the strong fibrous bands given off by the fascia-lata; a protrusion can occur in this situation only after the immediate, exciting cause has been operating over a considerable period of time.

Great varicosity or distension of the femoral vein, a condition so frequently associated with pregnancy, producing enlargement and weakening of the fibrous tissue which invests the vessels, diminishes resistance, and favors hernia. With that, as with other varieties of hernia, I am confident that the predisposing cause dates in nearly all cases from birth, with a very few, if any exceptions.

In the inguinal variety of hernia, the testis must be held responsible, and in the crural, the blood vessels. The treatment of hernia by surgery is palliative and radical; and it often requires a nice discrimination in the use of one's judgment to determine the cases appropriate for the one and the other.

With young children, when the testis is well down in its normal postion, accompanied by a protrusion on that side of moderate size, reducible, the truss may be worn with advantage, as a means of retention. Under like circumstances, the truss may be worn later in life, and also by those whose reduced state of health will not permit of operation.

The treatment of hernia by radical methods on an extended scale, was impracticable till within very recent times. It, however, is a very ancient operation, as is borne out by the writings of Celsus, who describes a plan of curing hernia by closing the distorted and disturbed. ring, by a plastic operation; by turning a flap of the integuments into the hiatus and firmly sewing it down to the peritoneum.

And so we find Wiseman in England, (Celsus vol. iii., p. 207, 6th ed.) and Ambrose Paré on the Continent, both at the same time, probably, in imitation of others long before them, doing essentially

the same operation, as many are innocent enough to suppose was originated in our own time. They aimed at obliterating the canal and destroying the sac. To secure this end, they employed what was in those times designated the royal stitch. It appears to have been an ordinary interrupted suture used for closing in the canal; often they cut away the protruding peritoneal porch. However, the operation soon became unpopular and was discontinued, though the majority operated upon were permanently cured, or died of the operation.

The agonizing pain always endured, when the operative procedures were tedious or difficult, the prospect of having a red-hot iron crowded deeply down into the denuded tissues of the groin, was indeed enough to deter all but the stoutest-hearted from submitting to the surgeon's manipulation.

Add to all this, septic infection, erysipelas in the areola, the fleshy tissues; and subsequent peritonitis; and we can all see what a formidable operation that for the radical cure of hernia in by-gone times must have been. It is only very recently that surgeons have undertaken to cure hernia as a deformity by a free cutting operation.

The results have, so far, been so gratifying that it is hoped that within no distant time, the occupation of the truss maker will be gone, and hernia of every species can be easily, and permanently remedied. by the surgeon.

Marcy, of Boston, McEwen, of Edinburg, and McBurney of New York, have each broken ground in this new field. Their operations are in many respects similar; but no one of them can be employed successfully in all cases. McEwen, after freeing the sac of adhesions, folds it up on itself and plugs the canal with it, adhesive inflammation following, a barrier is placed in the way of re-descent. Dr. Marcy aims specially at restoring the obliquity of the canal, and obliterating the sac by the buried suture. Dr. McBurney's operation consists essentially in opening up the canal to the internal ring, where he ligates off the sac, and then sews the cutaneous margins of the wound down to the sero-membranous lining of the peritoneal cavity, -commonly designated the fascia-transversalis--and depends on final and permanent closure of the gap by adhesion of all the tissues, and the formation of a solid scar.

No one of these operations will suffice in all cases however, without some modification to adapt it to individual cases. For instance, we cannot imbed the sac into the canal when there is no canal, as is always the case in old herniæ, as recommended by McEwen, nor can we ligate off the sac à la McBurney, when there is no sac, as is the case, with few exceptions, in congenital hernia, or those in which the bowel bursts through its peritoneal coverings, or slips down behind or