In the anatomic or typical operation the sac is tied on. Why? To restore the rotundity of the peritoneum, the transversalis fascia is sutured nicely around the root of the cord. Why? In order to obliterate a pathologic infundibuliform process, and make a new internal ring. The internal oblique muscle is sutured to Poupart's ligament at least two-thirds the way down which is the usual attachment found in the female. Why? That a congenital defect be rectified and the muscle be allowed an opportunity to protect the internal ring; and the aponeurosis of the external muscle is then sutured and the skin coapted, for the reason that they may occupy their normal place in this region. It will be noticed that no step is taken without a valid anatomical reason. ("A Typical Operation," etc., Journal A. M. A., April 11, 1899.) When the hernia is a direct one, or the conjoined tendon deficient, an additional procedure is often required, and that is to split the sheath of the rectus muscle, and sew it over to Poupart's ligament, across the weak point. Should, however, the entire inguinal area be deficient, thinned out, atrophied, or degenerated, I have not hesitated to transplant a portion of the sartorius muscle to this region.

FISTULE AND METHYLENE-BLUE

It has been my practice for some time past to stain all fistula with methylene-blue before attempting their removal, and I have found it of the highest practical value. A branchial fistula is sometimes difficult to follow with a probe or by sight on account of its small and frail nature. If, however, methylene-blue is forced into it, staining of its lining membrane takes place, and there is then no difficulty whatever in following the blue trail, however serpentine it may be in its course. Take, again, a horseshoe anal fistula, with its friable inner surface, and crooked course, how often have we been perplexed in trying to differentiate the limitations of the disease. Methylene-blue forced into the fistula. just before operating stains it perfectly, and defines its extent; thereby the operative procedure is simplified, and not

more tissue is removed than necessary, such tissue being clearly manifested by the stain.

In several cases of fecal fistula when I employed the methylene-blue I was able to trace them with accuracy and great ease. Over a year ago I was invited to hold a clinic at Michigan University, and of the cases produced there was one with three fistulæ, two fecal and one biliary; the bile came through one of the fecal openings, all following operations for suppurative appendicitis. The methylene-blue staining converted what would have been a formidable, tedious, and difficult task into a comparatively safe and easy one. The stain followed a small fistula among adherent coils of small intestine to the upper portion of the jejunum, from which the bile escaped, and the clearness with which its course was demonstrated was marvellous. Another blue streak was followed, and it brought us on to a large and chronically inflamed and perforated appendix, situated far in and behind the cecum and colon. The other fistula were in the large bowel and easily detected. Just a short time previous to this, I operated on a similar case, referred by Dr. Gunn, of Clinton, Ont., Canada, in which the bile escaped through the orifice of a fecal fistula in the large bowel, following an operation for appendicitis. A separate, tortuous, fistulous track led to the upper small bowel, which gave a passage-way for the bile, which could not have been readily traced were it not for the methyleneblue stain. The appendix was hidden behind the large bowel.

In dealing with the different varieties of rectal, vesical, vaginal, and ureteral fistulæ, the aid of methylene-blue, as above described, is invaluable.

By staining an impassable stricture of the urethra by injecting methylene-blue into the penis, the small tortuous stricture is colored blue, and then the Wheelhouse operation is facilitated, and the course of the stricture followed by sight from before backwards.

In bone surgery it is equally useful. Cavities in the long. bones are more accurately cleaned out when they are thus

stained. In performing a mastoid operation, upon making a small opening through the bone, if methylene-blue is forced into the suppurating cavity, the various directions in which the disease extends are made obvious.

I have written so much about the next disease that I shall devote but a few words to it, lest its importance might be forgotten. I refer to

NEPHRITIS

A great deal of thought and work have been given to the surgical treatment of nephritis since the appearance of my first article on this subject (March 18, 1899). While decapsulation of the kidney has been performed upwards of 200 times, by different surgeons, still there are many unsettled questions concerning it. The immediate and remote benefits that are derived from decapsulation and puncture, as well as from decapsulation and nephrotomy, or from nephrotomy alone, are no longer questioned by those of experience in this line. In cases of decapsulation and nephrotomy, the other kidney frequently improves so as to excrete normal urine, for which I venture no explanation. We make bold now to declare that nephritis, interstitial, parenchymatous, or diffuse, is purely a surgical subject, and that in its treatment internal medication is a sad failure. Chronic Bright's disease, once permanently established, is as much a surgical problem as is the inflamed appendix, gall-bladder, or hypertrophied prostate. It must be remembered, too, that chronic interstitial and parenchymatous changes, or both, have been going on a long time before the disease is detected or makes itself manifest by producing ill-health. It is not consistent with common-sense, reason, or accrued knowledge to say that interstitial nephritis is chronic from the start, as many authors would have us believe.

Although I feel that I am your welcomed and privileged guest to-day, and would be allowed to say a good deal more, I must, however, respect your kindness and endurance, but permit me to point out briefly a few of the many other important branches not yet mentioned.

We have within a few years seen the operation of pros

tatectomy generally adopted the world over for the relief of prostatic hypertrophy, and in that time the Bottini operation has had its initiation, rise and fall. We enjoy brilliant achievements in ureteral surgery. The artistic hand of the surgeon has been successfully laid upon the wounded heart, diseased lung and fevered brain. While much has been done surgically for the liver and biliary tracts, the stomach and the intestinal canal, there are still many unsolved problems connected with them that are attractive to the inquirer. The vicious circle is not yet cleared away; whether we do a gastroenterostomy anteriorly or posteriorly, it is not always prevented. In addition to this, we can anastomose the proximal with the distal arm of the loop of bowel, and still it comes. We may then tie off the proximal arm, close to the stomach, as advised by Fowler, and say to ourselves, "Now I have got you"; but I am not so sure of that, for I have seen a case that continued to vomit, and died after Finny's operation, just as they often do with a viciuos circle. A partial explanation may be that the secretions from the stomach, duodeum, liver, and pancreas are sometimes so abundant that a shocked and paralyzed bowel cannot evacuate them per vias naturales. Diseases of the pancreas are being successfully treated by drainage, and so I might go on and on, and hint at many other things that may yet be accomplished by surgery, as in certain forms of diabetes, obscure brain lesions, and in pneumonia.

PNEUMONIA

This last disease is so fearfully fatal, and medication is so futile, that one is impelled to do almost anything that offers even a ray of hope for recovery. I believe that a person should not be allowed to die of pneumonia without removing a rib and draining the lung at the seat of origin of the disease, before the person is too much poisoned, on the one hand, or before the opposite lung is put out of commission, on the other. This is food for thought. The idea is not at all new with me, and I have two cases in support of my belief; one a case of inflammation of the right lung

with complete consolidation and some pleuritic fluid of a whitish nature which I then (1888, Winnipeg General Hospital) believed to be pus. Judging empyema to be the condition, I removed a portion of the seventh rib in the midaxillary line, and finding no empyema I proceeded and explored the consolidated lung in search of an abscess, but in vain. I used a large trocar and canula, inserted my finger into lung tissue, and finally drained the lung with gauze. My object then was to check any bleeding that might follow. I was abashed at my procedure, but the patient made one of the most rapid recoveries I ever saw. Resolution began to take place immediately, and I received extravagant praise for my work. The other case I refer to was one of a tubercular pneumonitis (of the middle lobe of the right lung), published by me about three years ago, in which a recovery took place after drainage of the lung parenchyma and insertion of iodoform. The consolidation cleared away within a short time and I considered drainage contributed largely to the gratifying result.

Now I must close, and thank you.