Radical Operation for the Cure of already stated, this is now advised as a routine in all young subjects. The operation is modified in many details in the hands of different surgeons and in endless ways to meet the conditions found present in a given case and according to whether it is situated in the inguinal or the femoral ring or at the umbilicus or other weak spot in the abdominal wall. Thus for the cure of a hernia in the inguinal region an incision is made through the skin along the inguinal canal, the aponeurosis of the external oblique is divided, and the sac is separated from the cord up to the internal abdominal ring. The isolated sac is either invaginated into the inguinal canal by a ligature attached to its fundus, which is then drawn up through the inner ring into the abdominal cavity, the ends of the ligature being brought out through the abdominal wall; or the neck of the sac is ligatured by trans fixion, the ends of the ligature being brought out through the abdominal wall and tied, after the sac below the pediele has been cut away. Leaving an opening either above or below for the cord in males, the inguinal canal is then obliterated by stitching the internal oblique and trans versalis to Poupart's ligament, the upper lip of the incision in the external oblique being also separately stitched to Poupart's ligament, after which the skin incision is dosed by sutures.
After a satisfactory and successful operation for hernia no truss should be worn unless subsequent signs of bulging occur. This is usually due to weakness of internal oblique and transversalis at or just behind the conjoint tendon. Further operation is contra-indicated unless an attempt I e made to darn the muscle with silk.
After an operation care should be taken that no active muscular exertion be permitted for several weeks after the patient has commenced to move about.
The radical operation for femoral hernia is conducted upon the same lines. After the exposure and opening of the sac it is ligatured by trans fixing its neck; the portion of the sac below the ligature is then cut away. Each end of the ligature threaded into a long curved needle is passed through the femoral canal, and the point of the needle made to appear externally after perforating the abdominal wall, and the ends are tied together. Usually it is necessary to occlude the femoral canal by stitch ing the pectineus muscle, fascia and Poupart's ligament together, as formerly carried out, or, as suggested by Dowden, to use the extra peritoneal fat as a plug above the crural canal to prevent descent of another sac.
In all cases of hernia where a truss is employed to keep ,up the pro lapsed bowel or omentum it is of vital importance that the appliance should fit the patient properly, otherwise it becomes an additional menace to his safety, especially if the pad permits the hernia to descend behind it or by its side. This may arise from the weakness of the spring of the instrument. When the services of an experienced truss-maker are obtainable they should always be requisitioned, and the surgeon should see that the pad is of the proper shape and size, and that the spring of the instrument is neither too strong nor too feeble. As a rule it may be discarded after assuming the horizontal position at night, but it should be adjusted in the morning before the patient leaves his bed.
It is always advisable to have two trusses, so that the one in reserve may be employed while the ordinary one is being recovered or repaired. Some patients provide themselves with a waterproof instrument for use when bathing.
When the patient cannot interview an instrument-maker the surgeon should supply him with measurements from which a well-fitting truss may be fashioned. Ready-made cheap instruments are often unsatis factory and sometimes dangerous. The size of a tape passed round the pelvis at a level of half-way between the iliac crest and the great tro chanter and meeting at the hernial opening should be supplied, together with an estimate of the size of the latter, stating the side on which the hernia is situated and whether in the femoral or inguinal region.
The writer has several times witnessed arrested development of the testicle following the continuous application of a tightly fitting truss in young subjects. This is liable to occur in rapidly growing boys when the instrument has been worn for too long a period without being replaced by a larger one. The mortality of the radical operation being now, thanks to aseptic methods, almost nil, such a risk should never be per mitted, and after the failure of cure by the truss, operative measures should not be delayed, even in the case of infants.