Report of 233 herniotomies performed in Professor Halsted's clinic in the past two years, out of which 49 were per formed under local anaesthesia. Almost all cases of hernia, with the possible ex ception of those in young children, could undoubtedly be subjected to the radical operation under similar local methods. but, when a general anaesthetic can be safely administered, for various reasons it is much to be preferred by both patient and operator. In cases of strangulation, where the vomiting and shock from the absorbed toxins is great, the use of a general aniesthetie is contra-indicated. It is in border-line cases of this sort that local anesthesia gives the best chance of recovery. In just such cases do we often meet with death under or rapidly follow ing the general amesthetie. Schleich's 1 to 1000 cocaine-muriate mixture for infiltration anesthesia used. The solu tions of eueaine-B, suggested by Braun, have no advantage, while the duration of the eucaine anesthesia is not quite as great. For anesthetizing the individual nerve-trunks a V,: to 1-per-cent. steril ized solution of eucaine-B or cocaine is used. It is injected directly into the nerve.
The patients are prepared for operation by accustoming them to confinement in bed and getting them used to evacuating the bowels and passing the urine without getting up. One-tenth or V. grain of morphine is injected three-fourths of an hour before the operation, and repeated just before it is commenced. Its disad vantage is the confining of the bowels. The patients are often shaved and pre pared on the table. The skin is infil trated in the line of the incision. The tissue is found to he very vascular, and all bleeding is stopped, as it is essential to the dissection. It is unnecessary to anesthetize the panniculus. Nerve-fibres may be encountered in it, and veins that will cause pain if resected. The wound should be deepened to the aponeuiosis at the upper angle near the external ring. The aponeurosis is then opened in the line of the fibres from the external ring, and the ilio-hypogastric and inguinal nerves immediately cocainized with a 1 per-cent. solution. This produces anaes thesia of the whole lower operative field if the high incision is employed and the scrotum not opened. The ilio-inguinal and genital branches should be carefully displaced in the lower angle of the wound. The closure of the wound does not require any further anesthesia. if the subcuticular silver suture is employed, the skin edges will still be sufficiently anaesthetic to permit of its introduction. Sometimes a few inhalations of chloro form, not enough to produce unconscious ness, are necessary if the patient becomes very nervous or a sensory nerve-fibre is cut. No post-cocainization pain has been
complained of, while the infiltration has not interfered with primary union under one dressing generally in ten days. (Annals of Surg., Jan., 1900).
Kocher's method of radically treating hernias is the only one which stands in the same class with the method prac ticed by Bassini. Kocher lays particular stress on the careful isolation of the hernial sac, especially its neck. He at taches but little importance to strength ening the abdominal walls. He elimi nates the hernal sac without splitting the inguinal canal. The cord is freed at its point of exit from the external ring, and, after splitting the cremaster muscle and the common vaginal tunic, the sac is separated from the cord as high as possible. A short cut, half a centimetre long, is then made through the external oblique fascia, one or two centimetres to the outer side of the ex ternal ring. This opening is deepened down through the peritoneum. A closed forceps is introduced into the peritoneal cavity and along the sac of the hernia until it grasps the end of this sac. By traction upon the forceps the hernial sac is invaginated, and its end is drawn through the small wound made over the outer portion of Poupart's ligament. The edges of the peritoneal wound through which the invaginated sac has been drawn are picked up by three or four pairs of forceps and secured either by suture or by ligature, together with the sac. A couple of sutures secure the remainder of the wound, and the opera tion is completed, unless it seems ad visable to close the canal by one or two sutures.
The mortality of MOO operative cases treated by the Bassini method is less than of 1 per cent., while Kocher had no mortality in 191 cases. Hence both operations can be regarded as devoid of danger.
As to the permanence of cures, Franz notes, of 593 cases of Bassini operation, the histories of which have been fol lowed, that there was recurrence in less than 5 per cent. The author, out of 67 of his own cases, notes recurrence in less than 2 per cent. Kocher, of 33 cases treated by the invagination method, notes a recurrence of less than 2 per cent.
In regard to the choice of operation, it is noteworthy that in nearly all Kocher's cases the hernias were small; hence the abdominal walls were not greatly weakened. When the hernias are very large, however, simple ablation of the sac cannot possibly insure a per manent healing. Under such circum stances the abdominal wall must be re constructed, and here the Bassini opera tion is indicated.