The results of operative treatment of femoral hernia are quite as satisfactory as those of inguinal hernia. The opera tion consists in freeing the hernial sac up to Poupart's ligament, and suturing or ligaturing it at this point. The femoral canal is then closed by suturing Poupart's ligament to the pubic crest or the peetineal fascia.
Kocher treats the sac of a femoral hernia by invaginating as described in the treatment of inguinal hernia.
Where, after laparotomy. the peri toneum, the muscles, the external apo neurosis, and the skin have each been separately sutured, there is no likeli hood of hernia.
The umbilical hernias are treated by a total extirpation of the sac and of the umbilicus. The sheath of the reams muscle is then split, after which the peritoneum and posterior layer of the rectus sheath are sutured; next the bellies of the rectus muscles are op posed; and finally the aponeurosis is sutured. Of 10 cases thus operated upon, 2 recurred.
Kocher, after extirpation of the sac and navel, closes the opening by a con tinued silk suture passing through all the structures except the skin. Rotter (Therap. Gaz,, from Therap. Monats., II. 1, 1901).
The brilliant results of Macewen have not been generally obtained by other sur geons, while the transperitoneal method very recently introduced by Dr. George R. Fowler, which may be, in some re spects, preferable to other methods, is as yet too recent to warrant passing judg ment upon.
In radical operation for hernia six weeks in bed and two weeks more of abstinence from physical exertion should be the minimum period allowed. Kocher (Corr. f. Schweizer Aerzte, Sept. 15, '92).
In any operation aiming at radical cure it is necessary to support and strengthen the fascia transversalis. The most frequent cause of recurrence after some of the recent operations is owed to neglect of this point. Heuston (Brit. Med. Jour., Apr. 18, '96).
A method has been employed in about 60 cases by Bull and Coley during the past eight years, which they have named "suture of the canal without trans plantation of the cord," the other steps being identical with Bassini's operation.
The results, thus far, have been nearly, if not quite, as good as in Bassini's, though the number is as yet too small to estimate its comparative value; its only advantage lies in the direction of greater simplicity in the technique.
All methods in which the sac is allowed Results of Operation.
It must now be admitted that hernia can, for a considerable time at least, be cured by operation. Whether these cures will prove permanent cannot, as yet, be stated positively, for a permanent cure, strictly speaking, would mean freedom from relapse until the death of the pa tient. Although no definite time-limit can be laid down beyond which relapse may not occur, nevertheless a careful study of eases operated upon up to the present time enables us to arrive at cer tain fairly-definite conclusions.
There were 360 cases of relapsed her nia following various methods observed at the Hospital for Ruptured and Crippled. An analysis of these cases throws much valuable light upon the question as to when relapse is most likely to occur. In SO per cent. relapse occurred during the first year after oper ation; 64.5 per cent. during the first 6 months after operation; 11.9 per cent. occurred after a period of 2 years; 5 occurred from 10 to 22 years after oper ation. There were 31 femoral cases and 329 inguinal. Bull and Coley (Annals of Surgery, Nov., '9S).
In view of these facts it may be stated in a general way that, if a rupture is sound at the end of one year after opera tion, there is a strong probability of per manent cure, while, if it remains well for two years, the chances of relapse are very small. Ninety-five per cent. is a conserv ative estimate of cures following Bas sini's operation if the operation has been properly performed. This estimate pre supposes a judicious selection of cases.
[Some operators openly state that they never select their cases. There is no field in surgery, I believe, in which there is greater need for the exercise of good judgment than in that of opera tions for the radical cure of hernia. WILLIAM B. COLEY.] The practice of operating upon all cases of hernia, irrespective of the age to remain behind to be disposed of in various ways should be abandoned. If the sac is left behind there is less chance of securing primary union, and it affords no additional security against relapse.