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and so on down through the canal. He should then approximate the pillars at and above the external ring as closely as possible and close the outside tissues. Thus the operation which is made for the relief of the accident should be made. an operation for radical cure. It can be done more effectually at that time than at any other.

Again, the physician is called upon to make an operation for a radical cure; the patient comes to him complaining of the truss, which has become ineffectual, the hernia escaping in spite of it, and his life becoming a misery to him, and he asks if something cannot be done to make a radical cure. The answer is, "yes"; but the question is, by what method shall we make it? Choose the open operation, practiced with all antiseptic precautions. Cut down upon the parts, separate and dissect out as well as you can the neck of the sac, the hernia having been reduced; ligate the sac and cut out a portion. Thrust the stump back into the canal and approximate the pillars, closing them tightly and keeping the external ring tightly closed. So much for the method; now for the prospect of success. How much right have we to expect what might justly be called a radical cure? By the term radical, he meant permanent. In what proportion of cases can we expect to have a permanent cure, so that the patient will never have hernia again? What is hernia, and who have it? He thought he could safely say that the typical man never has hernia. When the true type in development has been attained and the abdominal walls closely woven together, they are proof against such accidents and there will be no hernia. Hernia is the result of the imperfect development of the abdominal muscles and aponeuroses. When that imperfect anatomical development obtains in the patient, the abdominal muscles are thin and flabby, and in such cases we get hernia.

Nor can we in such a case by an operation make a man better than his Creator made him, but if we can make him as good as he was we may congratulate ourselves. After we have operated and closed up this weak point as well as possible, the very best result that we can expect is that we have made the man as good as he was before he had hernia; but, if he was weak enough to have hernia from certain exciting causes, he will be weak enough to have it under similar circumstances again. If his hernia is brought on by lifting and straining, the same exciting cause will bring it on again, and under these circumstances a radical cure is only measurably radical. We should tell the patient after operation that if he will be more careful and take no violent exercise, he may hope for exemption from hernia.

In other cases, the patient has an old and immense hernia and cannot wear a truss; we operate upon him and can say to him that if he will be more careful and wear a truss, he can be tolerably comfortable for the rest of his life. Such, he apprehended, is the true aim and scope of operations for the radical cure of hernia; such are the precautions that should be given patients, as they must become our coöperators in order to make this operation a success; and with such coöperation and conscientious efforts on our own part, radical cure of hernia becomes a standard and important operation, as important as the subject itself, which, as we have seen, is of immense importance on account of the great dissemination of the disease.

DOCTOR E. F. WELLS said: Dr. Hamilton has certainly read a very interesting and extensive paper. There is one point in particular mentioned by the author, namely, that he advocates an operation in all suitable cases where an operation is not distinctly indicated. Every practitioner of large ex

perience must certainly have met with many cases in which the truss had been applied resulting in a cure, and he thought the truss should not be stricken entirely from the methods of obtaining a radical cure of hernia.

PROFESSOR HAMILTON in closing the discussion said he need not say that he was extremely gratified to find such substantial unanimity of sentiment as to the propriety of operation-nay, as to the necessity of operation, but there can be no doubt as to the necessity of further statistics on the subject. In regard to invagination, he thought a reading of the paper would not show that he advocated the method of invagination recommended by Gerdy. In the recent open method there is no invagination. Under the original Wood's method, the subcutaneous fascia only was pushed up under the ring; by the open method we cut down directly on the sac. This open method is really a combination method, because it brings together the pillars and takes care of the sac. Statistics are necessarily unreliable as to the ultimate permanency of the cure of these cases. The best statistics are those shown by the Swedish Hospital, where out of 300 cases a large percentage of recoveries is shown, and if statistics are worth anything in determining the success of a method, we must place some reliance on these. It would be well to have patients come back every year for the purpose of re-examination.

Professor Fenger, if he correctly understood him, speaks of the influence of suppuration in curing these wounds by letting them heal from the bottom, but in the various subcutaneous operations that is exactly what it is intended to avoid. There is no doubt that suppuration will make a radical cure of hernia if the patient's strength lasts, and the suppuration does not extend into the abdominal fascia. That was the method by which the old red-hot irons accomplished their purpose. The

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mineral acids produced a radical cure by the destruction of the tissue and healing from the bottom. The seton also performed a cure, but it has so many disadvantages that it is not to be compared with those procedures that stop the inflammatory processes short of the decomposition or death of the exudate. In regard to operating on children, he thought the argument cannot be regarded as sound that we should not operate on them on account of the difficulty of keeping a bandage on, for surely if any cases are to be benefited by an operation for radical cure, they are those in which the patient is young enough to grow-in which the tissues can be brought together and retained with great hope of a permanent cure. Everybody knows that cases do recover by the use of the truss, but the proportion, he believed, is less than by any other method. As stated by Professor Gunn, it is found that a majority of operations for strangulated hernia are, in effect, really operations for the radical cure, and there are more than five cures from operations to one after application of the truss. And when we remember that there are 250,000 trusses manufactured per annum in Philadelphia alone, he doubts very much if it can be shown that trusses have even a fair percentage of recoveries following their use.

PROFESSOR WM. T. BELFIELD reported a case of

SUPRA-PUBIC CYSTOTOMY WITH EXTRACTION OF LARGE CALCULI, AND CORROSIVE SUBLIMATE POISONING.

The patient was a feeble, emaciated man, 71 years old, who for nine years had suffered from cystitis of steadily increasing severity, caused, as was supposed by his various physicians, by prostatic enlargement. He had been sounded for stone a year ago under chloroform, but with negative result. For two years he had been unable to empty the bladder except by catheter. He refused permission to introduce the sound be

cause convinced that he had no stone, but was anxious to have an operation for the removal of the prostatic enlargement.

June 7, supra-pubic cystotomy was undertaken for the purpose of removing by galvano-cautery that portion of the prostate which was assumed to project into the bladder. The introduction of the sound under ether revealed a large stone; the usual incision was made; the finger in the bladder found two calculi, one behind the prostate, the other adhering to the fundus of the bladder, each about as large as a walnut. The first stone was crushed and the second with much difficulty removed entire. The patient was so collapsed that no attempt was made to remove the prostatic outgrowth, which could have been accomplished without much difficulty, and the following day the temperature was 100.5° F., the highest observed. On the third day it was normal and so remained. The wound was irrigated once daily with a bichloride of mercury solution. The progress was entirely favorable until the eleventh day, when there began a severe diarrhoea with much rectal pain and tenesmus, and later the evacuations were tinged with blood and the patient complained of a metallic taste. Sublimate poisoning was recognized and the solution discontinued. Temporary improvement followed, but death ultimately resulted on the thirtysixth day after operation. No autopsy was permitted, but a hasty examination of the abdominal contents was made. Peritoneum, kidneys and bladder were normal, except that the latter was much hypertrophied. The intestines could not be opened; the calculi weighed 2 ounces and 6 drachms.

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