the responsibility that rests upon the profession in dealing with it. As Halsted has well said: "There is, perhaps, no operation which has so much of vital interest to both physician and surgeon as herniotomy, and there is no operation which, by the profession at large, would be more appreciated than a perfectly safe and sure cure for rupture."

The modern operation for radical cure dates from 1876 when Marcy' advocated and described the use of animal sutures to approximate the walls of the hernial opening. In 1878, Czerny sutured the pillars of the external ring in such a way as to narrow the opening and inguinal canal. In 1890, Halsted operated by transplanting the cord external to the aponeurosis of the external oblique muscle, and three months later Bassini, of Padua, operated by closing the transversalis and the internal oblique down against Poupart's ligament, thus transplanting the cord anterior to these muscles when it had formerly been beneath them, and thus closing the old inguinal canal. The Bassini operation or some modification of it is now used far more than any other. It consists in placing the cord anterior to the internal oblique muscle, which, together with the conjoined tendon, is sutured to Poupart's ligament, the external oblique aponeurosis being closed over it, thus restoring the anterior wall of the canal. Many operators place a suture through the internal oblique and transversalis just above the cord to obliterate the inguinal fossa and strengthen the wall at its weakest point, the internal ring. With this method, or a slight modification of it, Coley reports nine hundred and thirty-seven cases observed from six months to eleven years with nine relapses. Warren says that ninetyfive per cent. is probably a conservative estimate of cures following Bassini's operation when properly performed. Ninetysix per cent. of his cases healed by primary union. Roux traces three hundred and twenty-four of his cases beyond two years, of which number, fifty-four, or sixteen and seven-tenths per cent. relapsed .Of fifty-three of his cases operated upon by the Bassini method, thirty-five and eight-tenths per cent. relapsed. Of the cases that healed by primary union, all methods, fifteen and two-tenths per cent. relapsed; of those that healed by secondary union, twenty-two and four-tenths per cent. relapsed.

'Boston Medical and Surgical Journal, 1871.

For cases in which continuous pressure has attenuated, displaced and weakened the conjoined tendon, or those in which the internal oblique muscle seems to be thin and frail, the Halsted operation will probably give better results. His old operation is performed by making an incision upward and outward through the aponeurosis of the external oblique, the internal

Figure 3.-C-Superior flap of aponeurosis of external oblique. C'Inferior flap of same. Mattress sutures in place. A-Opening for passage of cord through upper flap. B-Same for passage of cord through inferior flap, when sutures are tightened and cord placed in new position. D-Superficial fascia.

oblique muscle, and the transversalis fascia to a point two cm. above the internal ring. The inguimal sac is then resected high up and the peritoneum sutured; the larger veins accompanying the cord are excised; the transversalis and internal oblique muscles and fascia and aponeurosis of the external oblique are

then stitched with mattress sutures beneath the cord to Poupart's ligament and lower flap of the aponeurosis of the external oblique.

Of four hundred and forty cases of all kinds, two hundred and sixty-one were traced from six months to nine and one-half years, and of this number there were seventeen relapses or six and five-tenths per cent. Of two hundred and thirty, healing by primary union, ten, or four and three-tenths per cent. relapsed; of thirty-one that suppurated seven, or twenty-two per cent. relapsed.

Atrophy of the testicle in this operation has been attributed to excision of veins. Whether this is true or not, the impression has tended to prevent the operation from becoming popular, though it doubtless has an important advantage over other operations in giving strength to the abdominal wall.

His method differs from that of Bassini chiefly (1) in division of the internal oblique muscle beyond the internal ring, making a new passage for the cord through the abdominal muscles, and (2) removal of the veins accompanying the cord. While there have been a few cases of injury of the cord from Halsted's operation, in the hands of different operators, Halsted reports that there have been no unfavorable results at Johns Hopkins Hospital, where the operation, slightly modified, but still including resection of large veins, is practiced as a more or less routine measure. O'Connors reports twenty per cent. of atrophy of the testis in one hundred and twenty-nine cases operated upon by Halsted's method. Bloodgood modifies the Halsted operation by leaving the cord posterior to the aponeurosis of the external oblique muscle, but retains important features of the Halsted method, namely, that of incising the internal oblique and transversalis fascia and removing the plexus of varicosed veins which acompany large hernias. He also utilizes the border of the rectus, exposed by incision of its sheath to strengthen the posterior wall, closing the several parts with mattress sutures.

Andrews overlaps the aponeurosis of the external oblique, transplanting the cord between its imbricated layers. This procedure is particularly serviceable in large hernias in strengthening

Medical Press and Circular, 1898. 9Chicago Medical Record, 1895.

the posterior wall of the canal. Dr. Eisendrath10 says: "The Andrews operation has been used by a number of Chicago surgeons in over 1000 cases, but no attempt has been made to re-examine this large number of cases." The same author says in support of this operation: "For those which are larger and of long duration, in which there is a marked muscular defect and a

Firgue 4.-C-Upper flap held in place by sutures. C'-Internal surface of inferior flap.

large internal ring, an operation like that of Dr. Andrews seems destined to become the ideal one."

There are probably on an average, from all methods, five to eight per cent of relapses. With the Bassini method Coley,

reports five hundred cases, with six relapses: Gallaezzi has collected thirteen hundred and thirty-four cases, with only two and sixteen hundredths per cent. relapses. These are usually in the large hernias or in those with correspondingly weak abdominal wall structures.

It must be evident that there is still room for improvement, notwithstanding in the hands of careful operators present methods give excellent results. Yet every operator finds special conditions in which he must resort to some new procedure to meet indications. These deviations from standard methods are likely to be employed:

(1) In cases of exceptionally weak conjoined tendon, and especially so if the rectus is at the same time narrow or poorly developed.

(2) In large hernias with the same structures displaced and partially obliterated by pressure.

(3) In cases in which previous unsuccessful operations nave destroyed these structures or resulted in adhesions which make the typical operation impossible.

An analysis of failures in such cases, or of failures in general will show (a) that after Bassini operation the recurrences result from weak union of the longitudinal fibers of the internal oblique to Poupart's ligament, and this, too, is a certain number of cases, notwithstanding great care has been taken to unite the transversalis and muscular fascia; and (b) that after the typical Halsted operation, there are occasional protrusions at the situation of the cord which passed directly out through the abdominal wall, and also that there are occasional cases of atrophy of the testicle. The latter effect has usually been attributed to the excision of too many veins, but I have thought it possible that pressure or impingement upon the cord by the tense fibers of the coapted flaps of the external oblique aponeurosis might be a factor in producing this result.

For most cases, even the most difficult ones, doubtless the Bassini, Halsted, Bloodgood, or Andrews method should be followed; but under especially unfavorable conditions, as assumed above, combination of methods, or new methods, may be worth trying. Believing that there might be in such cases advantage in transplanting the cord anterior to the aponeurosis of the external oblique and in giving more obliquity to the new