These patients are merely introduced to demonstrate the condition of affairs after the McBurney operation; not as examples of radical cure, but rather as showing the method by which a radical cure may be brought about. Unless patients have been well advanced into the second year after the operation, I should not wish to use them in support of any oprative procedure for the radical cure of hernia.

More recently renewed attention has been directed to Bryant's operation the so-called method of interweaving the sac in the pillars. of the ring, but the advantages of this method are no greater than the ordinary procedure of securing the pillars of the ring and the edges of the skin in apposition by deep sutures. All of these operations have this objection, that no provision is made for preventing a subsequent concave condition of the peritoneal surface of the abdominal wall sac at the site of the internal ring; and unless some such provision is made there will be a "teasing" by the pressure of a knuckle of intestine coming in contact with this concave portion of the ring until the hernia recurs.

Dr. W. T. BULL, of New York. -I feel very much indebted to your President for the privilege of listening to the papers on hernia, and I am very sorry that I can make but a very poor return in the way of any remarks that I may make. I have had, however, an extensive experience in hernia, and I should be glad of an opportunity to present one or two facts gleaned from that experience for the consideration of the Society, and particularly because my experience has not led me to take quite the enthusiastic views with regard to the radical cure of hernia that you have already heard expressed.

I commenced to try to cure hernia radically something like ten years ago, when Heaton's method of radical cure was quite new. I performed that method in about fifty cases, which I reported in 1882 to the Surgical Society of the City of New York. In eleven of these cases improvement was reported; in five a cure was claimed, and in the balance the result could not be ascertained, because they were hospital cases and could not be traced. The Surgical Society, and apparently many of the profession, accepted the result as a valuable contribution to surgery, and I have found myself referred to in the surgical literature as one operating successfully for the radical cure of hernia by Heaton's method of injection. I sometimes think I have been wrong in not correcting that statement earlier. Five of these cases which were reported cured had not seen a return for periods of over a year, with but one exception, which died at the end of nine months. But I learned in the year following that all of the five experienced relapses. Every time that I have seen the statement made that there was something in Heaton's operation, and that I had accom

plished brilliant results by it, I have felt somewhat guilty for allowing this statement to remain in print. I mention this at some length, because I think that at the present moment we are too ready to accept testimony without looking into the nature of it. In other words, we are ready to accept statements of those who present statistics, without carefully looking into these statistics, to see how much ground or experience they cover, and over how long a period of years that experience has extended. Now, in a question like hernia, an experience of one year is a trifle. One must have an experience in operation that extends over five or six years or more, and when we consider that those cases which are ordinarily supposed to have been cured by any operative method, relapse all the way from five to forty years after the operation, we must approach the question with a great deal of hesitation and examine very closely the results of those who claim to effect a radical cure by any given method.

About 1883 the first important statistical contribution to the radical cure of hernia was made by Leisrink, of Hamburg; and it embraced a collection of 390 cases operated on by different surgeons, some English, some German. The mortality result was quite satisfactory-was so small that the result of that statistical contribution was to encourage surgeons generally to attempt the operation. The results shown by these statistics were not particularly satisfactory as far as cure was concerned. It is not necessary to mention them, but I would refer at once to the methods employed. The best showing was made by an operation introduced by a surgeon named Riesel, who claimed that it was desirable to ligate the neck of the sac at the highest point possible, and, in order to do this, he introduced that feature into the operation which has been referred to to-night-the splitting of the anterior wall of the canal, so as to ligate the sac of the hernia at its highest point, and then closing the inguinal canal with sutures. That was the form of operation which at that time gave the best results.

Another form of operation which has been referred to is that of Socin, which consists in drawing down the sac as far as possible, and ligating it at the highest point possible, and then suturing the integuments over a drainage tube, which is left in the canal. There is a direct and decided difference between these two operations. One claims to close the canal, the other leaves the canal open, without sutures.

In

It was on the strength of information gained by the perusal of these statistics that I commenced to operate at that time, and up to the present time I have reached a number exceeding one hundred cases. order to satisfy myself which method was the best, I adopted this plan : Feeling convinced that there was something in this point made by Riesel of ligating the sac as high as possible, I split open the anterior

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wall of the inguinal canal and tied the neck of the sac as high up as possible. In about one-half of the cases the canal was then sutured with catgut, and in the other half a drainage tube was left in, and the integuments sutured over it. One plan may be called the method of ligature and excision-simple ligature of the sac high up, and excision of the sac, without any suturing of the inguinal canal. The other method may be called ligature of the sac, and excision and suturing of the pillars of the ring. These two methods have been followed by myself side by side since 1883. Before stating what the results are as to cure I would mention, so far as details of the operation are concerned, that the sac has never been entirely excised unless it was of small proportions; where it was large it was always left in place and simply drained through the bottom of the scrotum. The number of cases I have stated to be something like one hundred, but the cases operated on within the last year, about thirty in number, I have not included in these statistics, because they have not run a sufficiently long period of time, as emphasized by Dr. Fowler. So I have material embracing seventy-two cases. Of these seventy-two cases, thirtyeight have been operated upon by the method of ligature and excision and suture of the rings, the method employed by Banks, of Liverpool. Thirty-four have been operated upon by the method simply of ligature and excision, without any suture (Socin). Three have died, and it is not necessary, I think, to make any reference to the mortality, since these were cases that died in the very earliest period of my operation, and were not proper ones for the operation, and would not in any subsequent series have been subjected to it. In order not to trespass too much upon the time of the Society I will not comment further, but would say in my individual opinion the mortality amounts to nothing. That leaves the number who recovered from the operation sixty-nine. Of these twenty-nine cannot be traced; forty, however, have been examined at periods of at least one year from the time operated on. The two methods show about the same result. Of the twenty cases subjected to the method of ligature and excision and suturing of the pillars of the ring, there have been twelve cures and eight relapses, and the figures are precisely the same for the other method.

I would say a word in reference to the word "cure." I think it is time we banished that expression altogether, because in view of the tendency of hernia to relapse, particularly in late periods of life, I think it is doubtful if we ever can call a case of hernia cured. It would be a better plan in reporting these cases if we simply reckoned them by the number of relapses. Of course the operation which showed at the end of a given period the smallest number of relapses would be the one entitled to the most confidence. I found in comparing these two

operations from various points of view, that there is very little to choose between them. In general the relapses have been somewhat more prompt after the simple method of ligature and excision of the sac without any suture of the pillars of the ring, than where the pillars of the ring have been sutured. On the other hand, the number of relapses at the end of the first year has been very much greater where the suture has been used than where it has not been used. But in general, and in order not to detain you with unnecessary details, I may say, that as a result of this personal experience, I think there is very little to choose between the two methods, but that I should prefer the simpler method of the two, and that is the method which Dr. Fowler spoke of as the method of Socin, of Bâle.

It may be proper to say one word in reference to the applicability of this operation. I am very glad to state that I share the enthusiasm of the gentleman who has written the paper in reference to the indications for the operation. I think it should be applied to every case of strangulated hernia where the intestine can be returned into the abdomen; and to all cases of irreducible hernia, except very large ones, which contain intestine; for the operation under such circumstances is an extensive laparotomy, the results of which in a number of operations have not been very good. They should be classed as cases that are contra-indicated. I should differ somewhat from the report of the Committee with reference to the application of any operation to children. I have certainly seen a great many patients who give in later years a history of wearing a truss in childhood, and in a majority of cases they did not show any sign of hernia. I believe, notwithstanding the present disposition to do away with the truss, that it has cured a great many people and is likely to cure a great many more, but these people are likely to be children to whom the proper truss is applied at the earliest period that the hernia is discovered. The simplest kind of apparatus in infants will frequently cure a rupture, and in children up to the age of five or six I should never despair of accomplishing the radical cure of hernia by means of a truss, and I should never willingly subject any child of that age to an operation, unless a very careful and experienced person in the management of trusses had had an opportunity to try to cure them. In general I am not disposed to advise operations on adults whose hernias are easily controlled by a truss.

If I would not be detaining the Society too long, I should like an opportunity to say a word with reference to a form of operation which I have no experience with. I venture upon that with some delicacy, because it is a form of operation to which, after a careful consideration, an experienced surgeon has given his approbation, and furthermore because it is a form of operation which my colleague, Dr. Mc

Burney, has carefully elaborated, and brought into such a state of perfection that it can but excite the enthusiasm of everybody who reads about it. I have not done this operation. In the thirty cases which make up the hundred to which I have referred, and which have been done during the last year, although during that time McBurney's operation has been before the public, I have not followed it, but have followed one of the closed methods. I find certain objections to it in theory, and have seen recurrences in practice. Theoretically I think the operation is founded on a principle which is false. I do not believe that the tissue left behind by the healing of an open wound is as strong, or can be made by any surgical process as strong, as the tissue left behind by rapid primary union. I think to hold that view is at variance with all our knowledge of wound-healing, and to act in accordance with it is contrary to the practice of all abdominal surgeons. Every surgeon who is a man of experience will say that those cases in which the abdomen has been opened in the median line and which have healed by granulation, are more likely to be followed by ventral hernia than those which have healed by primary union. This objection which I make to this operation is contradicted by some who advocate this operation and who state that this is not a granulation cicatrix, but that it is a carefully formed plug, made by sewing the skin to the transversalis fascia for the distance of the entire length of the inguinal canal. Now, the inguinal canal is protected by several layers of fascia, all of which are strong structures. Everyone of these is swept away by this effort to get up high and reach the neck of the sac, and the abdominal wall is reduced from its laminated condition to a simple mass, consisting of transversalis fascia and peritoneum, which is to be covered by this cicatricial layer. This I believe to be as insufficient as anything can be. These were the convictions which I had with reference to the "open" operation when it was first proposed. A number of surgeons have, however, adopted it and a good many operations have been done. The relapses are, however, beginning to appear. In the course of the last year at the Hospital for the Ruptured and Crippled, there have been about fifty cases of hernia that have relapsed after all forms of operation. All of these cases, although according to the statements of the patients they were radical operations for hernia, could not be literally taken for that. I could not use them for statistical purposes unless I could follow the patients in the hospital records. In this search I was able to follow twenty-five. Ten of these were operated upon by McBurney's operation in one year. I do not know whether there is a similar institution for the treatment of the ruptured in Brooklyn. If there be, I fear that similar cases will be met with there. I would like to say, furthermore, in reference to the