Its application according to the following steps can be warmly recommended: I. The incision is made as high as possible, going upward from the inguina] ring, in order to keep away from the region of the abdominal openings.
2. The skin incision having been continued to the fascia, the index finger of the right hand inverts the scrotum with the hernial sac, pushing the latter forward to the skin incision, so as to bring it into view.
3. The neck of the hernial sac is caught, freed all around with a blunt instrument, and placed in front of the skin incision.
4. The tunica vaginalis eommunis is dissected and the neck of the hernial sac isolated with a blunt instrument. This should be done as rap idly as possible, as otherwise the tender structures arc apt to become dry, which renders the separation exceedingly difficult. The isolated fibrous structures of the cord are caught with a ring forceps, collected and dis sected off from the hernial sac. Should there be difficulty in dis secting it, the contents are replaced, the hernial sac is cut through, and the tip is left in connection with the other parts. The central stump is ligated.
5. Next, the isolated sac or its ligated stump is invaginated accord ing to the method of Kocher. The beak of the invaginating forceps is passed carefully upward along the peritoneal wall so as to avoid engag ing an intestinal loop. The invaginated hernial sac is drawn through the peritoneal wound, perforated and ligated, the superfluous flap dissected off, the central stump buried, the peritoneum and fascia being closed with the same suture. In this way the peritoneum is drawn upward from the funnel toward the inguinal ring.
6. An assistant catches hold of the testicle in the scrotum, drawing it downward. This serves to tighten the seminal cord in the inguinal ring and to allow an inspection of the lumen of the canal. Should this be too wide, two interrupted sutures will be sufficient to narrow it.
7. The skin is closed with metal clamps, silk sutures being apt to carry infections material into the wound. The wound is painted with tincture of iodine and a resinous solution, and covered with a small plaster bandage. The larger the bandage, the greater is the difficulty
to keep it clean.
S. The child is placed on a frame (Fig. 37c), which is so constructed that it fixes the chest, back, and legs, but leaves the abdominal openings free. The frame is slung up in the cot so that a small pan can be placed underneath to receive the stools and urine.
0. The child remains on this frame until the fifth day, when the skin clamps are removed and the bandage renewed with a perforated small plaster to drain the wound dry. When there is no further danger of infection, the child can be removed from the apparatus and sent home. Older children are able to leave the bed on the eighth day.
The frame is, of course, intended for infants who can not yet con trol their excretions. It does away with all trouble of bandaging and answers all requirements of hospital practice in keeping the wound clean. Children may be carried about on the frame without danger, which constitutes a great advantage in ease there is danger of pneumonia.
The time required for operation according to this method is very short, four minutes being sufficient under favorable conditions, while eight minutes are sufficient for difficult dissections and extensive hernne. A few drops of ether are sufficient for anesthesia. Nurslings are not ant sthetized at all, in order to avoid the digestive disturbances, which arc frequently serious. The operation is so insignificant that even weak and atrophic children may he subjected to it. It is just. this class of children that do not bear skin bandages well, while the rapid growth of the hernia urgently demands interference owing to muscular insufficieneym function.
It will be understood from this description that Bassini's operation should he t bought of in infants only when the hernial contents are broadly adherent to the hernial sac (efecal hernia) and in those forms of incar cerated hernia in which it is necessary to incise the sac up to the ring. I give the preference to Bassini's plastic method also in very large herniee with a very wide hernial ring in the case of older children.