gauze dissection. When the sac is entirely freed, to the highest possible point, it should be freely opened, and if the reduction of contents may be facilitated by so doing, the sac should be split clear to the neck. After the reduction of devitalized contents, or removal, as may be necessary, the sac may be conveniently ligated at the highest point by twisting it to a slender stalk. As this twisting is executed, intestine and omentum are forced out and are prevented from slipping into the neck, to be caught in the transfixing needle. By this twisting of the sac, all of the slack of the peritoneum is taken up, so that when the ligature is applied and the sac cut away, the stump springs back through the internal ring, leaving no pocket to favor a recurrence. If a distinct varicocele exist, it will always be advisable to excise at least a part of the veins of the cord.

As to the transplantation of the cord, it seems to be a matter of relatively little importance whether it is transplanted or not. Surgeons seem more and more inclined not to transplant it. In somewhat more than one hundred Bassini operations for inguinal hernia I transplanted the cord, and had no reason to regret it, but lately have not transplanted the cord, and have had results as good as in those in which the cord was transplanted. The method of drawing the internal oblique abdominal muscle and transversalis to the ledge on the under surface of Poupart's ligament over the cord closes the inguinal canal firmly and permanently, and leaves the tissues of the spermatic cord undisturbed.

In an examination of twenty-nine male and twenty-five female normal adult cadavers Drs. A. H. Ferguson and R. C. Turck, of Chicago, finding the average length of attachment of the internal oblique to Poupart's ligament to embrace the outer two-thirds of the ligament, stated their belief that a smaller extent of attachment greatly favored the development of an oblique inguinal hernia through taking away one of the anterior supports of the internal abdominal ring. Most anatomists, for example, Gray, Henle and Eisendrath, found the internal oblique to be normally attached to the upper half of Poupart's ligament only. However this may be, Dr. Ferguson's observations in this direction led him to develop his so-called anatomic operation of attaching the in

ternal oblique to Poupart's ligament over the cord, leaving the cord untorn from its bed upon the transversalis fascia, and, at any rate, the practice of Ferguson's operation has convinced many that it makes very little difference whether the cord is transplanted or not, and thus this apparently unnecessary step has been quite generally dropped.

Dr. Ferguson originally used a running suture of carbolized catgut to unite the internal oblique to the ledge under Poupart's ligament. He also used a running suture of such catgut to close the slit in the aponeurosis of the external oblique. Most surgeons, however, who employ the Ferguson method, use interrupted sutures of chromic or iodized catgut. It will be seen that the Ferguson operation aims to restore normal anatomic conditions by the union of the internal oblique and transversalis to Poupart's ligament in front of the cord.

The original Bassini operation, as is well known, sought to strengthen the naturally weak posterior wall of the inguinal canal by suturing the internal oblique and transversalis muscles to the inner aspect of Poupart's ligament behind the cord.

Coley reduced the space left at the upper angle of the wound for the passage of the cord and its vessels by inserting a suture above the cord, thus slightly modifying the original method.

In the so-called imbrication, or lap-joint, operation of Dr. E. Willis Andrews, a third layer is added to those which are placed behind the cord by the Bassini method; that is, with kangaroo tendon mattress sutures the inner portion of the external oblique aponeurosis, internal oblique and transversalis are all drawn deeply under Poupart's ligament, while the cord is held up. The cord is now dropped upon the fascia of the external oblique, and Poupart's ligament is sutured over it so that the cord now lies in a new inguinal canal, whose posterior wall has three layers, one of which is the powerful aponeurosis. Its anterior wall is composed of one layer of the same strong character. The Andrews operation is strongly advocated for use in cases of large hernia of long duration, where there is marked muscular defect and a large internal ring. Halsted originally sewed all layers, including the external oblique, to Poupart's ligament behind the cord, but

21-Ind. Med. Assn.

placed no protecting fascia in front of the cord, and funiculitis was a common sequela. The present Halsted operation, in use at the Johns Hopkins Hospital, leaves the cord in its bed. The veins are ligated when large and the vein stump dropped back. The suture with which the hernia sac is ligated is carried far out under the internal oblique muscle, passed through this muscle and tied. The cremaster muscle is now drawn with mattress sutures of black silk to the posterior surface of the internal oblique. The edge of the internal oblique as well as the anterior sheath of the rectus at the lower angle is now drawn under Poupart's ligament with similar sutures, and, lastly, the external oblique edges are overlapped, as in the Andrews operation. It will be seen that Halsted buries black silk. He claims that black silk is more readily seen against the tissues than white silk. It is also claimed that the aseptic technic at Johns Hopkins Hospital is such that it has not been found necessary to remove these sutures. Halsted closes the skin wound with a subcuticular silver wire stitch and applies a silver foil dressing. To secure immobility, the patient is placed in a plaster of Paris cast, extending from the umbilicus to the knee on the involved side. This elaborate method of suture used by Halsted appeals to most surgeons as unnecessary, excepting in very unusual cases, a more simple suture being efficient in almost all cases of inguinal hernia.

By the use of McArthur's autoplastic suture, which suture represents simply a narrow ribbon of the aponeurosis of the external oblique split off from each side of the wound, and with which almost any method of closing may be followed, it is unnecessary to introduce any foreign material whatever deeply into the wound. This operation is not quite so easy of execution as most others, and it is, perhaps, for this reason that it has not been more generally adopted.

As before stated, those who employ the Andrews modification of the Bassini operation regard it as ideal in cases with large ring and extensive muscular defect. The advantages of overlapping the aponeurotic and muscular structures are, according to Eisendrath, that the former, while elastic, possess great strength and are not so likely to pull away from Poupart's ligament. It is

claimed, also, for this operation that the sutures placed just above and below the cord enable one to so decrease the size of the large internal ring that it becomes unnecessary to resect the veins unless they are very much enlarged. The reinforcing of the internal ring, however, should perhaps not be regarded as peculiar to any method, as presumably everybody does this if it is found neces

sary.

In closing the external ring, likewise, no doubt in cases of defective or small conjoined tendon the sheath of the rectus muscle or even the belly of the muscle itself has been long drawn over by surgeons to fill in this defect. Bloodgood, however, now systematically exposes the sheath of the rectus by retracting upward and inward the aponeurosis of the external and internal oblique muscles. The sheath is incised for a distance of five centimeters upward and outward from the symphysis. The muscular fibers are then sutured to Poupart's ligament. The writer has never practiced this modification, but has frequently simply drawn the sheath of the rectus over to Poupart's ligament, believing that it is the fascia which gives to the abdominal wall the strength to contain the abdominal viscera, while the muscle itself really only provides elasticity and motility. Muscle belly is frequently found forming part of the hernial contents; fascia, never.

Everywhere surgeons are beginning to realize the importance of getting patients, out of bed much more promptly than has heretofore been regarded as safe or desirable. While this may be in the main true of surgical operations generally, in case of plastic operations, like the radical operation for hernia, it is not wise to have the patient up before tolerably firm union is established, which means not earlier than the fourteenth day, as a rule. Every movement of the limb must to some extent disturb or displace the parts included in the sutures, and this is especially true of the aponeurosis. This layer being continuous all over the abdomen, groin and thigh, and the slit at the hernia representing simply a break in the contiguity of this extensive and important layer, it will be seen that movements of the trunk or limbs may do considerable damage.

When recurrence presents itself after operation for hernia, it

will usually be found that faulty asepsis is responsible for the accident. Since rubber gloves have been used, the percentage of recurrence has been lowered in the experince of nearly every operator who has dealt with a large number of cases. No matter what the method, hernia will not often recur if the operative technic has been aseptic. Very often the break in the chain of asepsis has come because of the introduction of nonaseptic absorbable sutures. An absorbable suture is never more than relatively aseptic, which means that it is not aseptic at all. On the other hand, the burying of nonabsorbable sutures is fraught with some danger, so that, aside from Halsted, who uses the black silk, and Phelps, who buries silver wire filagree, and Harris, who uses silver wire, introduced in such a way that it may be removed after union has taken place, very few operators are willing to trust to nonabsorbable sutures.

Diagram showing manner of introducing single tier suture for Ferguson's anatomic coaptation of layers. Internal oblique is drawn and held under the ledge of Poupart's ligament, and edges of slit in aponeurosis of external oblique are overlapped with linen suture which also closes skin wound.