tion by purgation tends to lessen the occurrence of both hemorrhage and perforation.

In the late cases the indications are the same. If a vessel is already necrosed, hemorrhage is unavoidable; if not already necrosed, the way to prevent it becoming so is by removing the poison. With reference to this point I beg to refer to the paper in the Canadian Practitioner of April, 1893, or to the MEDICAL RECORD of March 10, 1894, where I have discussed this question at length. I still maintain the same conclusion, that purgation at no time causes perforation or hemorrhage, but at all times tends to prevent its occurrence. Misconception regarding this matter was the great barrier which interposed whenever an attempt was made to follow in treatment the indications furnished by study of the morbid process. So great was the dread of these two accidents that the fact that the great majority of fatalities were due, not to hemorrhage and perforation, but to toxæmia, was lost sight of. A study of the cases I have to report with reference to this point, will, I believe, convince the most sceptical that formerly a misconception did exist.

So much for meeting the indications furnished by consideration of what has been determined concerning micro organisms on paper or in theory. How does it work. out in actual practice? Precisely as it does in theory.

I have to report 172 cases with a mortality of five, or three per cent. No cases were excluded, late cases are taken as well as early. Forty-four of these were my own patients. Forty-one cases were treated at the Toronto General Hospital, to a considerable extent under my own direction, and in every instance under my observation. The remaining 87 cases were furnished me by several medical friends, with two exceptions resident in Toronto.

I have excluded none from my list, whether coming under eliminative treatment early or late, provided only that the treatment had been fairly carried out from that time. Concerning the cases received from others, I can only speak in general terms. All these cases were reported as having done well, with two exceptions, and the treatment gave results such as I have indicated in the papers published. One case died from hemorrhage and one from pneumonia during early convalescence. The hemorrhage case had been ill in the country while nursing a case of typhoid; returned to the city, and after two weeks' illness was again taken to the country. When seen she was comatose, had tympanites, and temperature of 104° F. Given saline in drachm doses every four hours, and shortly the temperature fell, tympanites disappeared, and consciousness returned. On the third day, at 12 A.M., she had a slight hemorrhage and the saline was discontinued. Next day, at 5 P.M., she had a severe hemorrhage and died

at once.

The case of pneumonia occurred in an alcoholic, and in my opinion it is doubtful whether he ever had typhoid. However, I have included his case in my list. In two other cases hemorrhage occurred, but treatment was persevered in with favorable results.

Coming now to my own cases, forty-four in number. I had one death from pneumonia, following a very severe attack, in a boy nine years of age. In this case, too, there was slight hemorrhage, which I thought might come from the rectal veins, as it was small and bright in color. The autopsy showed a remarkable condition of the intestine. Although death took place in the fourth week, two minute ulcers only were found in the ileum, but the intestinal glands throughout were swollen.

The forty-one hospital cases gave two deaths. One from hemorrhage, where the autopsy showed the presence of ulcers from the ileum as far down as the sigmoid flexure. She had been in the hospital eight days when death occurred. This case presented symptoms of severe infection, high temperature, distention, and a dusky expression. She did well until the hemorrhage occurred. This was slight at first. The purgatives were

discontinued and opium given until termination fatally from extensive hemorrhage.

The second fatal case occurred from hemorrhage from the stomach and nose with general purpura, hemorrhage in every part of the body. Autopsy showed a large number of ulcers, covered with black, dry sloughs. The patient died on the fourth day in hospital. These five cases make up the entire list of fatalities. Two died from pneumonia, after recovering from severe attacks of typhoid.

The two fatal hemorrhages occurred in cases coming under observation, certainly, in the third week of active illness. Both cases gave indications of profound and dangerous toxæmia, which disappeared as soon as elimination was secured.

Analysis of one hundred and seventy-two cases. Mortality of three per cent. No death from toxæmia, No perforation. Hemorrhage in eight cases, including the two fatal cases. My own single case of hemorrhage was so slight that I attributed it to rectal engorgement. In all the cases where I had opportunity of observing, except the two fatal cases, the amount lost was small.

Tympanites never developed in my own or hospital cases during treatment, and where present at first invariably disappeared as soon as elimination was freely secured. Delirium practically unknown after the first days, and I cannot recall a single instance where it was present after treatment became established.

Out of sixty-four charts in my possession, fifty-eight show that the highest temperature reached was in the first three days. That is, the temperature inclined toward normal as soon as elimination was secured. In many instances the chart shows decline in temperature as regular as a flight of stairs, e.g., charts Nos. 1, 2, and 3.

beg so pitifully to be allowed to escape if elimination is promoted in some other way.

In short, under this method of treatment the striking feature is the absence or speedy disappearance, in practically every case, of the classical group of symptoms, delirium or coma, tympanites, subsultus, and the extremely foul condition of the mouth and tongue. The two following cases are examples of speedy improvement:

CASE I.-Alice G, aged twenty-four, under Dr. J. E. Graham, was the first case treated in this way in the Toronto General Hospital, Dr. Graham kindly allowing me to supervise the treatment. When the treatment began she had already been seven days in the hospital. Had been given no purgative medicine whatever. She was dusky and drowsy, had decided

Diarrhoea, in my own cases, never required controlling treatment. The difficulty was rather the other way. In many instances it is not an easy matter to secure sufficiently free movement, and different purgatives and expedients must be resorted to. Sponging as routine treatment twice daily, but in my own cases never required for reduction of temperature. Lately, many who are warm advocates of the cold bath or Brant treatment, have arrived at an explanation of its action. It promotes elimination of toxin by the urine, increasing the toxidity of the urine five times. Very good; but why confine elimination to the kidneys? Bouchard has shown that in health the bile discharged into the intestine contains just six times the amount of toxin that is discharged with the urine. In the event of unusually toxic processes occurring in the intestine

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it is fair to conclude that the toxidity of the bile would be very greatly increased. If increased elimination of toxin is the great desideratum, one need not look far for a more direct method than that of immersing the sick man many times a day in a tub or a bed full of cold water. Besides, he is not likely to cry so loudly or

1 Burr: Chicago Medical Recorder, October, 1894, p. 229.

salts secured. Improvement every day. Tympanites completely gone on the 20th, and on the 24th the temperature became normal and continued so. At the same time a perfectly typical rash was present (Chart 1).

CASE II. Also a patient of Dr. J. E. Graham in the General Hospital. I was asked to see him in the absence of Dr. Graham. He had been ill for two weeks

and had been in the hospital five days. Temperature, 104.2° F., when seen on the evening of the fifth day (Thursday). At the time of my visit he was profoundly unconscious, with greatly distended abdomen, stertorous and rattling breathing, jaw fallen, tongue dry, tremulous and spasmodic conditions of muscles, subsultus, and picking at the bedclothes. In fact he seemed to be in extremis. I advised magnesia sulphate, half an ounce at once, and continued in drachm doses every hour, and plenty of fluid. In addition, in order to hold him until toxæmia should lessen, strychnine and whiskey were given at intervals. This was on Thursday evening, the 16th, and on Saturday morning he was quite conscious. Purgatives were continued vigorously. Condition continued to improve, and on the 22d the temperature became normal; subsequently it rose slightly, and again became normal on the 27th, to continue so.

In this case I am convinced the patient would have died in a very short time if the toxæmia had not been quickly lessened.

Charts 2, 3, and 4 are quite characteristic, and show the number of bowel movements daily. I have frequently been asked how much purgative should be given in a day. One can have no fixed rule. The idea is to give enough to secure elimination, and the amount required is a matter of experiment in each case. Usually three or four grains of calomel in divided half-grain doses, followed by a saline in three or four hours, will result in free elimination. If not, compound cathartic pill No. 2, followed by sulphate of magnesia or other saline, or else sulphate of magnesia alone in repeated doses. At any rate secure elimination quickly, it matters little how it is done. In many cases days are lost. The dose ordered to-day fails to purge. Next day another is ordered, still without result, no provision having been made in the event of the medicine ordered not being sufficient. In this way several days may go by, and while the patient may be taking purgative medicine he is certainly not receiving eliminative treatment. Indeed, I have known this condition of things to exist during an entire illness. Of course, treatment after that fashion must be due either to carelessness, or failure to grasp the principle in eliminative treatment.

THE AUSTRALIAN, OR O'HARA, OPERATION FOR THE RADICAL CURE OF HERNIA.

BY THOMAS H. MANLEY, M.D.,

NEW YORK.

In the spring of 1894, while making a tour through the London hospitals, it was my privilege to witness many surgical operations that I never before had seen, and a few that I had not even heard of.

The great attraction which British surgery had for me was the generally humane character of the aims which inspire the operator, and the pronounced conservatism which one sees extended to all cases, with few exceptions.

It was my purpose, particularly, to determine, as far as possible, just what the position of hernial surgery was, in those cases of non-strangulated variety; and endeavor, if possible, to gather some information of the details in technique of operating that might enable us to give our patient a better assurance of permanence of cure after operation than has been before possible. Happily, in this respect, my hopes were realized.

One afternoon, while in attendance on a clinic held by Mr. Golding Bird, a case of hernia was brought in for operation. My surprise was great when I saw him commence and go through an operation, of which I had no knowledge before, though of late years I had made a searching examination into all available literature on hernial operations, the ancient as well as the modern. The professor described the various steps of the operation, performed it with great skill and ease, and highly

commended it, but failed to mention the name of its originator or its history.

My impression of the operation was so favorable that, as soon after my return home as a case of reducible inguinal hernia came under my care, this particular operation was employed, and since the latter part of April, 1894, twenty one cases have been so treated by me, and in no single instance has there been a relapse, as far as I can learn. I have since learned that Henry O'Hara, M.R.C., S.I. senior surgeon to the Albert Hospital, Melbourne, Australia, first devised it. At the late meeting of the National Association of Railway Surgeons, at Chicago, on the invitation of Professor John B. Murphy, a surgical clinic was held by me in Cook County Hospital, on which occasion I was enabled to perform the O'Hara, or Australian, operation for the radical cure of reducible hernia, and demonstrated the various steps of its technique. Its simplicity and rationale so pleased those who saw it that a large number have since urgently requested me to publish a description of the operation, and so illustrate it that they might the better understand it. To fulfil this purpose, and, besides, recommend to the profession what has impressed me as the most desirable, safest, and most durable of all surgical cures of hernia, these few notes are submitted.

In the beginning it is necessary that we have a correct understanding of the precise etiological elements which enter into a hernia, in order that we may the better appreciate how far we may hope to deal with this infirmity by surgical measures; for it may be well to confess at the outset that there are several types of hernia quite beyond our power to cure.

The three anatomical elements which enter into the development of hernia are: 1st, Parietal; 2d, visceral; and 3d, mesenteric. Besides these, there are many other determining factors. The parietal only will be considered here, and only so far as may be necessary to discuss the special plan under consideration; for in that class of cases only in which the faulty development of structure is lodged in the walls, involving the canals of emergence, can we hope for or promise permanent results.

M. Paul Ségond, in his classical work on hernia,1 was disposed to take a pessimistic view of modern surgical operations for hernia; because he believed there was a certain mortality attending them. Of late, however, he has changed his opinion. In properly selected reducible herniæ, treated skilfully by the method here described, there should be no danger to life at all.

The technique embraced in the O'Hara operation combines some of the principles of the more ancient methods of Gerdy, Watzer, and Valette, with the more modern of Reisel, Macewen, and McBurney, i.e., invagination with obliteration of the lumen of the sac, to which is superadded the more modern procedure of the open incision.

It radically differs from all other modern operations inasmuch as it leaves the abdominal walls intact, the inguinal canal open, and the sac undisturbed in the scrotum. This is wherein its great strength lies; for in all cases, after treatment by this plan, we can give our patient an assurance that, if we should fail to accomplish a permanent cure, we still do not leave him in a state much worse than though nothing had been done, as is the case with many other current operations.

As will be seen, the ideal cases of hernia which are the most appropriate for the O'Hara operation are the indirect complete inguinal in the male, although with some slight modification it may be utilized with advantage in the femoral or inguinal of the female.

In order to derive the most satisfactory results with this operation, we should exercise discretion in selecting our cases; taking due care to exclude those which are very chronic, or have undergone extensive structural changes.

Hernial operations, in reducible cases, are underTraitement Chirurg. des Hernies, par M. Paul Ségond.

taken chiefly for three reasons: 1, To obliterate a deformity-cosmetic purpose; 2, to place a hernia in such a position that it may be more safely and comfortably supported by a truss; and, 3, to secure a definite cure. This operation, as far as my experience goes, fulfils the two latter in a larger measure than any other, and for its cosmetic results is equalled by none yet undertaken by the open incision.

The Various Types of Hernia for which the Australian Method is Best Adapted. It goes without saying that there are various ruptures that should never be operated on except in the presence of impending, or actual, strangulation. There are many others of such varied anatomical elements that no definite lines can be followed in dealing with them by operative methods; and thus it is that with the scheme here described there are certain types in which we must deviate from our regular course after an operation is begun.

Complete, Indirect, Inguinal Hernia in the Male.The most common variety of hernia, viz., the complete, indirect, inguinal, is that most suitable for the O'Hara operation, inasmuch as in this we have the sac well down in the scrotum, and are able to separate the neck or stalk as it emerges through the external ring.

In the female, when the viscera make their way out through, or by, the canal of Nuck into the labium majus, we may succeed equally well. It is well to remember, however, in this, which is an unusual form of hernia in women, that the extrusion commonly consists of some of the organs of generation, and that the inguinal canal with the female is very short and rudimentary.

Congenital Inguinal Hernia.-With cases of congenital inguinal hernia, as there is an absence of a free, peritoneal investment, and hence no sac, we may strip the fascia propria off the elements of the cord, and invaginate it in such a manner as to quite completely obturate the inner ring.

Bubonocele.-Bubonocele consists of a hernial arrest within the inguinal canal between the rings; or the apex of the sac may extend a short distance just outside the external ring. In genuine bubonoceles the anterior wall of the inguinal canal must be opened, when we will be obliged to invaginate the peritoneal pouch entire. When any part of the sac protrudes through the external ring, we may easily draw it down and free it from the cord, when it may be turned on itself and sent entire through the internal ring.

Femoral Hernia.-In femoral hernia of recent development we may utilize this method with advantage; though as all surgeons well know, owing to the intimate contact of the fascia propria with the great bloodtrunks, the utmost caution must be observed in the process of isolation, inversion, and anchoring the neck of the sac. If we keep close to the inner border of the falciform process and send our carrying-needle through the conjoined tendon, or Haselbach's triangle, we will avoid all danger of vascular damage.

Age. Seven of my cases were in children under five. In all this class, when they are over measles 4 and whooping-cough and have ruptures which are incoercible, the earlier they are treated the better. These little ones suffer but very slightly from the operation, and can be scarcely restrained from running about after the first few days succeeding the oper

ation.

the tissue is not so active, it usually requires about a fortnight for complete union.

Technique of Operation.-In order to endeavor to render the written description of this operation more comprehensive, I have had struck off the few diagrammatic sketches here inserted, although, as there is a great diversity in the pathological changes of the tissues which we encounter, and the extent in the alteration and changed relations of the anatomical structures, no description by pictorial illustration, however perfect, will convey more than the most elementary outlines for an operator.

The Extent and Site of the Division of the Tissues.In uncomplicated cases of reducible, indirect, inguinal hernia, we commence by making two incisions. The first, or inguinal incision, is made down on the neck of the sac as it emerges through the external ring. A two-inch incision carried downward over the long axis of the protrusion in the direction of the scrotum, or labium, according to sex, will give us ample space to reach the peritoneal envelope, completely detach it from the spermatic cord, lift it out of the opening, draw it well downward, transfix, ligate, divide, and invaginate it.

The position and extent of this incision must be modified according to the volume and site of the hernial descent.

The precise and exact manipulation of this incision, and what it exposes, constitutes the key to the operation.

In order to proceed with rapidity and safety it is not only necessary that we are familiar with the normal elements of the spermatic cord, but we must also fully understand the extensive alteration in structure which we may be prepared to meet in the generality of cases. In fully developed scrotal hernia of moderate volume our course is clear. The sac is adherent to the connective tissues of the scrotum, the infundibular process of the cord is quite free, therefore we readily expose and lift the neck out through the opening.

It will be remembered, however, that in some varieties of inguinal hernia the sac is quite free and elastic, following closely on the contained viscera in reduction; so that when we open down over the track, which but a moment before it occupied, we find nothing except the spermatic structures, for it has ascended to the internal ring, or at any rate it is within the canal,

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In another, not uncommon, form we will find no fascia propria of the cord.

The peritoneal pouch (Fig. 1) comes down not on our side, under or over it, but directly through its various strands, which cling to its walls with such tenacity that a delicate dissection may be recessary to free them before the sac is divided. After we have reached this and completely insolated it, our next step will be to be positively assured that it is empty of the viscera. If these are adherent to the internal surface we should open the sac and liberate them before division. Now we will pass the index-finger up the inguinal 3 canal and free the spermatic cord from the neck of the sac as far up as the internal ring. While the finger is in the canal the lip is gently pressed against the internal ring until this is somewhat dilated. We are now ready to make the second or iliac incision, which should be situated half an inch posterior and above the upper margin of the inner aperture.

This incision should not be more than one inch in length and should extend down to, but not through, the fascia transversalis. At this

After all hemorrhage is subdued and the wounds are rendered thoroughly aseptic, we close in both incisions hermetically with continued catgut suture and apply the usual dressings.

have nothing to fear from hemorrhage. The index-finger is kept in the canal, pressing the integuments outward and maintaining a support while we divide the tissues directly on it.

3

4

1

In femoral hernia in the male the lower incision is made external to the scroto-femoral fold; the upper, through the conjoined tendon extending down to the peritoneal reflexion, below the course of the internal epigastric artery.

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This completes the first stage of the operation. We begin the second by withdrawing the index-finger and raising the sac on a tenaculum (Fig. 2), and making tension from above downward. Then, with a needle carrying a double-looped suture, the neck is transfixed, and its lumen closed by a firm square knot, when tension is made from above and it is cut through with the scissors. The distal end is now drawn immediately downward and lost from sight by its own contraction, while the proximal end rises by contraction up the inguinal canal. Now, with a long needle perforated near its point and fixed in a handle, we carry each loop up separately through the inguinal canal, the internal ring, and out through the iliac incision through the parietal peritoneum. Each of these loops should emerge through the fascia transversalis about three lines apart. In performing this part of the operation we may introduce the needle from above or below (Fig. 3).

After the loops are both well drawn out, through above, and the neck of the sac is wedged in and anchored between the parietal peritoneum and sheath of the transversalis muscle, they are firmly knotted and cut off. We are now ready for the third and last stage.

1.

3.

4.

5

As this species of hernia seldom attains a considerable volume, we will not be obliged to very often vary the position or direction of the incision (Fig. 4). Although no opportunity has yet presented itself to me to apply this method on the female, still it is my conviction that it will prove equally efficient with her.

We will not, in this type, be embarrassed by the presence of the spermatic cord, as in the male; and therefore it should be performed with greater ease and rapidity, without the probabilities of relapse (Fig. 6).

The case illustrated by Fig. 7 was a boy, seven years of age, who since he was three years old had a rupture. For a long time he could wear no description of a truss with comfort, and the protrusion was steadily increasing in size. Although the hernia came well down into the scrotum after reduction, on dissection

it was found that the sac was drawn up so far into the inguinal canal that only its conical tip protruded through the external ring. This was

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FIG. 4.-Showing Relative Position of Incisions, for Inguinal Hernia-Right Side, Female. Relative Position for Incisions in Femoral Hernia, on Left Side, Female. 1. Incisions for inguinal hernia, in female; incisions for femoral hernia; 2. incisions for femoral hernia, closed; 3, neck of sac, drawn up and lodged;

4, sac.