considered a duly qualified medical man. Mr. C. H. Nicolson, P.M., gave it as his opinion that a case had been made out against the defendant, but as the justices were in a majority against him, he would have to dismiss the case. Dr. Mullen stated that he would make an application for an order to have the decision reviewed before a higher court.

BIRTHS.

BRAY.-On the 5th March, at Euroa, the wife of Percy Dean Bray, M.R.C.S. Eng., of a daughter.

HARBISON.-On the 10th April, at Shepparton, the wife of J. W. Harbison, of a

daughter.

LIDDLE.-On the 8th April, at Surrey Hills, the wife of Percy H. Liddle, M.B., B.S., M.R.C.S., of a daughter.

PINNIGER.On the 18th April, at Beechworth, the wife of W. B. Pinniger, M.B.,

of a son.

RIORDAN.-On the 27th August, 1894, at 122 Nicholson-street, Fitzroy, the wife of T. F. Riordan, M.D., of a son.

Ross. On the 10th April, at Dimboola, the wife of W. Chisholm Ross, M.B., Ch. B.,

of a son.

SCHLESINGER.-On the 24th April, at Monaro, Wellington-street, St. Kilda, the wife of R. E. Schlesinger, M. B., M. Ch. Univ. Edin., M.R.C.S. Eng., of a daughter.

SUTTON. On the 26th April, at Terang, the wife of Dr. C. S. Sutton, of a daughter. WELD. On the 6th April, at her residence, Lascelles-street, Hopetoun, the wife of Dr. J. C. Weld, of a daughter.

MARRIAGES.

ELLIOTT-CURTIS.-On the 7th March, at Clapham, London, Nicholas P. Elliott, M.R.C.S. Eng., L. R.C.P. Ed., L.M., late of Brunswick, Melbourne, Victoria, and Sydney, New South Wales, to Frances Curtis, second daughter of F. A. Heighton, Esq., of Harringworth, Acton, England.

ERSON-HUCKELL.-On the 4th March, at Perth, W. A., by the Rev. J. Greerer, Dr. Leger Erson, of Dublin, to Florence Isabel Margherita Huckell, eldest daughter of J. C. Huckell, of Toronto, St. Kilda, and granddaughter of the late Richard D'Alton, Architect, City Councillor, and old colonist,

MARTELL-WHYTE.-On the 9th May, at East Melbourne, by Rev. Dr. Strong, Horatio Percy Martell, Moonee Ponds, to Margaret, second daughter of the late Patrick Whyte, East Melbourne.

SKINNER-KENNY.-On the 7th May, George Henry Skinner, M.R.C.S. Eng., L.R.C.P. Lond., to Sarah Margaret, second daughter of P. Kenny, Esq., J. P., of Broadford.

ZICHY-WOINARSKI-BRIND.-On the 17th May, at the Cathedral Church, Ballarat, by the Lord Bishop of the diocese, assisted by the Very Rev. the Dean and Canon Carlisle, of North Melbourne, Victor Zichy-Woinarski, M.B. et Ch. B., fourth son of the late G. ZichyWoinarski, Esq., to Gertrude Mary, only daughter of Henry Brind, Esq., of Ballarat,

Contributors of Papers to the Australian Medical Journal can have copies re-printed in pamphlet form by communicating with the Publishers before the issue of the Journal.

THE

Australian Medical Journal

JUNE 20, 1895.

Original Articles.

ON THE PALLIATIVE AND RADICAL TREATMENT OF INGUINAL HERNIA.

By R. B. DUNCAN, M.D.

Senior Hon. Surgeon, Kyneton Hospital.

The great frequency of inguinal hernia, as well as the dangers it entails, have rendered it at all times one of the most important of surgical affections. That its palliative treatment has been of great, and in many instances of lasting benefit, is apparent on every hand. The various measures, however, which have been brought forward of late years for its radical "cure," have to a certain extent overshadowed the benefits to be derived from a well-fitting truss.

The tendency to adopt operative practices has undoubtedly been extreme. One has only to glance at the formidable number of cases claimed by numerous operators in every country, to realise how great the change has been. While the adoption of operative measures has not as yet perhaps lessened the general belief in the value of judicious and carefully selected palliative treatment, there is reason for thinking that the ever-increasing desire for operative interference on the part of some surgeons may lead to this most undesirable result.

It must be apparent to those who have carefully considered the matter, and who have had any experience in the treatment of hernia, that in the vast majority of instances no operation whatever is required. The dangers to a person the subject of hernia, who wears a properly-fitting and carefully-adjusted truss, are slight, or even non-existent. Those who become habituated to "truss life," and who are careful in the use of such an apparatus, have really nothing to fear. Palliative treatment then, by the use of a well-fitting truss in cases of medium-sized reducible hernia, is all that is required, and all that should be attempted. The method itself is so well known to every surgeon, that it is needless to speak of it at length.

The question of operating with the view of radically "curing' a hernia is a wide one, and embraces many points of importance. VOL. XVII. No 6.

S

The indications for radical interference, however, are now much clearer than they formerly were. It is not very long since opinions firmly prevailed as to the feasibility of radically curing herniæ by subcutaneous operation. One has only to search the surgical annals of the past, to perceive what ingenuity and labour has been expended in the direction of subcutaneous surgery as applied to hernia. In England, the operation of Wood, and in our own country that of FitzGerald, may be regarded as typical representations of this particular method of surgical procedure. Both surgeons claimed a large measure of success, but the plans proposed have not been followed to any extent by others, nor has the subcutaneous injection of irritating fluids, with the view of causing closure or narrowing of the inguinal canal, been any more successful. A more intimate knowledge of the anatomical conditions prevailing in hernia, and especially the influence of the peritoneum, has led to much clearer conceptions regarding radical treatment. At present, no middle course exists between the protection which a truss affords and the open method of operating.

The patients suffering from hernia, and labouring under conditions demanding operative interference, fall into several classes, which can only be defined in a general sort of way. One easily defined class is that of the youth who may wish to enter a Civil Service, or the Army or Navy, where a hernia is an insuperable barrier to such admission. But a very important question here arises. Would a young man of means or position, who could take up another career, be justified in submitting himself to operation for such a purpose? I would answer such a question in the negative. To the many whose choice may be restricted, the question is not so easy of solution. It has been attempted, though fortunately not by any recognised authority, to put this particular operation on the same level as that for varicose veins of the extremities and varicocele. A moment's consideration will show that nothing could be more inapposite than such a comparison. There is a second class of case, in which the answer as to what should be the proper procedure can present no difficulties, viz., those wearing a well-fitting truss which keeps the hernia in position. Should rupture at any period of life be interfered with, which can be satisfactorily retained in place by a truss? The answer to this should, in my opinion, clearly be in the negative. It may be urged that the patient lives a long way

from medical assistance, that the truss might break or become unfitted for use. Whilst admitting the weightiness of such an argument, it must be borne in mind that the radical “ cure "is still, in the most careful hands, a risky and uncertain operation.

One would imagine there would be little difficulty in coming to a decision in the class of cases which includes the manual labourer; there the risks under the most careful palliative measures are obvious enough. Anyone engaged in duties which demand almost constant muscular exertion, of the most varied character, but especially that kind connected with heavy lifting, undoubtedly runs daily risks of no light kind, be the precautions what they may. It is precisely in this class of cases where palliative protection is in a great many instances totally inadequate. When it is borne in mind the large share which chemists take in fitting trusses, in connection with the working classes, the added risks from this source are obvious enough. Those engaged in the most exacting kinds of manual labour, even when they receive the most careful attention at the hands of a surgeon are, as said before, from the very nature of their occupation placed in daily peril, a peril difficult to estimate, but none the less real. That this danger is considerably increased by the use of unsuitable trusses is a matter of almost daily experi ence. With some reservations, the manual labourer belongs essentially to the class to which modern operations of a radical kind are most applicable, and will most largely benefit. Were it intended or even possible to divide the subjects of hernia into clearly defined classes, the definitions above given would be quite inadequate. So much depends on the patient's personality, his age, history, and environments, not to speak of the varied peculiarities of the hernia itself, its position, size, and contents, that divisions, except of the most general kind, are well nigh an impossibility. Were this not so, the subjects of "large hernia," on the mere question of size alone, would invite attention and comment as an easily distinguishable class, and if the definition be narrowed down to those who have "copious" hernia, which no truss, however well fitting, is able to retain in position, the decision in regard to what procedure ought to be adopted becomes easy enough. Irreducible herniæ furnish another important class. Here the dangers are so constant and so imminent that scarcely two opinions can exist as to the correct method to pursue. Especially so is this the case when the sac is the seat of retained

omentum. Palliative measures can scarcely be said to exist in such cases, and operation is the only remedy.

Although constantly liable to inflammation, strangulation, and obstruction, it is wonderful how a patient at times survives such a variety of dangers. The writer had a patient whom he attended occasionally during a period of ten years, during which time inflammation and obstruction alternated with great regularity. The patient finally succumbed after an operation to relieve strangulation, performed when too late. The plan of endeavouring to make such hernia reducible by rest and dieting has little to recommend it.

As exemplifying the early age at which such a condition may supervene, a colleague of mine lately operated on an irreducible hernia in a infant aged one year and eight months. It was a large inguino-scrotal hernia, the size of the shut fist. The operation resulted in perfect cure. The question of surgical interference in the case of hernia of children of tender years is necessarily a wide one. Palliative treatment by means of a truss is open to many objections, not the least being the length of time required, and the ever watchful care demanded to ensure success. The chief objection raised to operating on the very young, is the difficulty in dealing with the dressings, a difficulty I think, from personal experience, more imaginary than real. The fact, however, that a truss can accomplish so much, and in many instances effect a complete cure, has no doubt exerted considerable influence against operative interference in the case of those of tender years. uncertainties of radical "cure" when applied to this or any variety are readily apparent, when the large number of different operations now in practice are taken into account. This might be a matter of surprise were the physical alterations which a hernia induces a fixed quantity, capable of mathematical definition. From the failures that too frequently attend any form of operation, it is becoming daily more apparent that there are undetermined elements connected with hernia which have not, so far, been appreciated. Statistics, so far as they are available, prove conclusively that there is a very large percentage of failures under any plan at present in vogue.

The

"Radical treatment of reducible hernia," says a well-known modern surgeon, "is a preferable term to 'radical cure.' It is by no means always a cure, and so to speak of the operation is to surround it with a specious attractiveness." With this statement