drop the material and assume the spiritual, and by our encouragement and counsel brighten the death chamber. And in this way exemplify the teachings of "The Man of Sorrows;" that we must "die to live again."

That, when we come down to the dark river, over which our souls are ferried by Charon, to that haven of rest promised to the faithful, it will be with the feeling: I did my best. And we hope to hear the voice of the Recording Angel on the other side say "well done, thou faithful servant; enter into the rest and rewards so long denied you."

And then will "unty, peace and concord," as Osler puts it, as well as a spirit of scientific progress, be the distinguishing features of the new era.

OPERATIVE SURGERY. For Students and Practitioners. By John J. McGrath, M. D., Professor of Surgical Anatomy and Operative Surgery at the New York Post-Graduate Medical School, Surgeon to the Harlem, Post-Graduate, and Columbus Hospitals, New York. Second edition, thoroughly revised. With 265 illustrations, including many full page plates in colors and half tone. 628 Royal octavo pages, extra cloth, $4.50, net; half morocco, $5.50, net. Sold only by subscription. F. A. Davis Company, Publishers, 1914-16 Cherry Street, Philadelphia, Pa.

In this volume an endeavor has been made to combine, in a practical manner, the subjects of surgical anatomy and operative surgery, because a knowledge of the one is essential to the proper study of the other.

Diagrammatic drawings have been used largely for the purpose of illustration, because these, in the author's judgment are the most satisfactory for teaching. An effort has been made to exclude all those anatomical consideratioins that are purely technical and not of practical value in the performance of surgical operations.

The arrangement of the subject is a very practical one and in accordance with the modern methods of teaching.

OPERATION FOR THE RADICAL CURE OF LARGE

INGUINAL HERNIA.*

BY JAMES U. BARNHILL, A. M., PH. D., M. D.

Professor of the Principles of Surgery and Clinical Surgery, Ohio Medical University; Surgeon to the Protestant Hospital,

Columbus, Ohio.

This paper is limited to the consideration of operations for the radical cure of large inguinal hernias in men. Under modern aseptic precautions, almost any of the leading operations are found successful for hernias of small size, but the number of relapses in cases of large hernias and those with defective abdominal walls is evidence that there is yet room for improvement in method in the radical cure of this class of hernias. The number of cases of hernia, especially those of large size, which go untreated, is evidence that the public, at least, still lacks confidence in our ability to effectually treat this class of hernias by operative procedure.

The danger to life should not deter from operation, for statistics show that the mortality from strangulation is greater than it is from operation for radical cure. The London Truss Company, reports a mortality from strangulation of one-half of one per cent., while we have many series of operations with a death rate of one-third of one per cent. or less. Bull reports fifteen hundred operations with four deaths, a rate of three-tenths of one per cent., and Coley, ten hundred and three operations with two deaths, a rate of one-fifth of one per cent.; Halsted, four hundred and forty cases with one death, or one-fifth of one per cent.

The widespread distrust of operations for the radical cure of hernia is due to the inefficiency of the older methods, especially before the days of aseptic surgery. This distrust is illustrated in the utterances, a few years ago, of leading surgeons still living. In 1873, Lawrence, said: "He whose hernia is reducible endangers his life to get rid of an inconvenience, and the operation

*Read before the Surgical Section of Ohio State Medical Association, May 11, 1905. Reprinted from The Ohio State Medical Journal. 1Holmes System of Surgery.

ΙΟ

affords no greater prospect of entire recovery than he had without it. For after he has undergone an operation at the hazard of his life, the complaint may return, and the only protection against relapse is to wear a truss." As late as 1893, Dr. Bull2 wrote: "Now that ten years have elapsed since the modern radical operations have been in vogue, we ought to hear of or have presented

Figure 1.-A-Stump of amputated hermial sac.

G-Transversalis

fascia. E-Internal oblique muscle. D-Spermatic cord. Aponeurosis of external oblique muscle. B-Adipose tissue.

C

to us patients who have been more than five years, at the least, without relapse. We could naturally expect to see such cases occasionally at a special hospital, but there are none such." And

2"Notes on Cases of Hernia which have Relapsed after Various Operations for Radical Cure." Bull.

Halsted said, in 1892: "Just now most of the so-called radical cure operations are under a cloud. They have not withstood the test of time."

While these same men, with many others, have demonstrated the possibility of curing a very large per cent. of cases and of reducing the mortality of cases operated upon below that of truss-treated hernias, there is still, in the profession and out of it, a misgiving about recommending operation for cases which can, for the time being, be controlled with a truss. Of course, there are incarcerated hernias that are inoperable, but there was a time (before incarceration) when they could have been successfully treated by operation. In the future fewer cases should be permitted to reach this condition. The large incarcerated hernias upon our streets, are a reproach to surgery. If we find safe methods for the radical cure of hernias, the public will not be slow to apply for relief. For none knows better than the sufferer himself that no truss relieves wholly the disability of hernia or insures against strangulation, and he knows that strangulation often causes death.

The results, under aseptic surgery, of the twelve or fifteen years, have commanded the confidence of the profession, and with that must follow the confidence of the public. "Little by little with the years," says Marcy. “I have broadened my view until there should be no hesitation in advising operation in cases with enlarging rings and protrusions less and less controllable by apparatus, if there be no concomitant circumstances to contraindicate it."

And Ferguson: "It seems now I almost unhesitatingly advise every individual suffering from inguinal hernia to be operated upon when the general conditions make such operable measures reasonably safe."

Experience has shown that results are good at almost any age, even in very large hernias, provided only that the conditions are such as not to endanger life.

3" Radical Cure of Inguinal Hernia in the Male." Johns Hopkins Hospital Bulletin.

Atlantic City Meeting A. M. A.

Operation for Inguinal Hernia, Transactions New York State Medical Association, 1898.

The importance of the subject is evident from the great number of hernias, and the disability, suffering and death occasioned by them.

One in every twenty of the soldiers of the Rebellion, according to a conservative estimate, suffer from hernia. Probably three per cent. of men between twenty-one and forty-five have inguinal

Firgue 2.-E-Internal oblique muscle sutured to Poupart's ligament. C-Aponeurosis of external oblique-retracted.

hernias, forty-one per cent. developing, according to Kingdon's tables," under thirty-five, and fifty-nine per cent. above that age.

The number of hernias, the usually life-long progressive disability which they entail, and the mortality that results from strangulation, emphasize the great importance of the subject and "John Burkett, Holmes System of Surgery.