BY EDWIN A. LEWIS, M.D., Professor of Anatomy, Long Island College Hospital. Read before the Medical Society of the County of Kings, October 15, 1889. It is neither necessary nor appropriate, before an audience of this First, then, the anatomy. We start with a tumor in the region of perhaps constitutional disturbances or even stercoraceous vomiting. Rather rarely this class of symptoms is all there is to guide the surgeon. This happens when a very small portion of gut is occluded in the ring -so small that no tumor or swelling is perceptible. These cases are obscure. The diagnosis of intestinal obstruction is not difficult, but it is almost impossible to be certain that hernia causes the obstruction. Happily, also, these cases are rare. well-defined swelling. Is it hernia? ciently easy, but not always. In the vast majority there is a We have to remember certain lymphatic glands, which may render the case doubtful. I have seen one operation for hernia which developed only an enlarged lymphatic, and have known of others. On one occasion I called a consultation to satisfy myself that I had only a glandular swelling to deal with, so doubtful was the case. If this was a hernia, it needed immediate attention; if not, the usual course of an enlarged gland would be followed. Foreign growths may prove deceptive-fibrous or adipose tumors, sebaceous, cystic, or malignant tumors, even a psoas abscess, pointing where a femoral hernia would naturally show itself. Hydrocele, varicocele, and sarcocele have to be excluded. Still, in the vast majority of cases, the history and the aggregation of symptoms, subjective and objective, will guide to a correct opinion. The condition which is most deceptive is the presence of an enlarged lymphatic. These often appear suddenly, particularly below Poupart's ligament, at the point where a femoral hernia might be found. When sure that the tumor is hernia, the next question is, What variety is it? Much of success in treatment, either by reduction or operation, depends on a correct answer. Remember that the tendon of the external oblique muscle, from the anterior superior spine of the ilium to the spine of the pubic bone, is the ligament of Poupart. Remember that the external pillar of that triangular opening, called the external ring, is attached to this spine of the pubes, while the internal pillar is attached at the symphysis, this inner pillar being also a part of the external oblique tendon. Thus it is plain that the external ring is almost in the median line of the body. Remember that the internal ring lies at the middle of Poupart's ligament and only half an inch above it, the inguinal canal being about an inch and a half long. If the hernia can be traced through this external ring, we are sure of inguinal hernia. Often this cannot be done, particularly in fleshy subjects: there is a tumor in the region of the groin, which is surely a hernia, but the external ring and the inguinal canal fail to serve as guides. Neither can the origin of the tumor be shown to be below Poupart's ligament, when it would surely be femoral; nor above Poupart's ligament, when it would as surely be inguinal. We remember that the femoral ring is larger in females; but still the landmarks are not plain enough to make a diagnosis certain: i. e., the hernia cannot be shown to be in the scrotum or labium majus; it cannot be shown to emerge near the median line from the external ring, nor be traced into the inguinal canal; it cannot be proved to distinctly originate either below or above Poupart's ligament. In such a case, reduction or operation must be proceeded with without an absolute diagnosis. We may suspect femoral hernia from the sex and the indefinite character of the tumor, but not be sure of it. If the doubtful character of the hernia is remembered, efforts at reduction and methods of operation need not be interfered with seriously. The landmarks thus far mentioned are few: Poupart's ligament, the external and internal rings, the inguinal canal, all with reference to distinguishing the variety of hernia to be dealt with, i. e., as between. femoral and inguinal. If we can trace the hernial tumor to or through the external ring, of course there is no question. If, on the other hand, we find the external ring and the inguinal canal free, and can map out Poupart's ligament above the protrusion, the diagnosis is established. Suppose we are sure of the general variety of the hernia. It is inguinal. We next inquire, Is it external or internal? gastric artery, coming up from the external iliac, is the important landmark. The epi Remember that this artery lies normally just to the inner side of the internal ring, and, if the hernia is recent, we may almost surely find the relation of the protrusion to it. We can determine, with reasonable certainty, either that the tumor makes its way from the inner ring obliquely through the canal, or that it presses directly out from behind the external ring. In the one case the hernia is oblique inguinal and external to this epigastric artery; in the other it is direct inguinal and internal to the artery. But if the hernia is an old one, the anatomical relations are usually much changed. The canal is obliterated; the inner ring is dragged down and in, and is enlarged and apt to lie almost directly behind the outer ring. Now, it is impossible to say whether our hernia is external or internal. If we can be sure that it is external, we cut upward and outward in enlarging the ring, to relieve the constricted gut: that is, we cut away from the artery; if, on the other hand, we can be sure that it is internal, we cut upward and inward. Being in doubt, we must cut directly up ward, parallel to the epigastric artery, to avoid injury to this important landmark. Damage to this artery would prove a serious complication. The important landmarks in femoral hernia surround the femoral or crural ring. Through this the gut emerges on its way out to the saphenous opening in the fascia lata. Remember that the crural canal is very short- -a bare half inch. Remember that the crural ring lies under Poupart's ligament; remember that it is almost surrounded by vessels. Outside, femoral vein; epigastric artery above and external; a communicating branch in front; in close proximity, above and to the inner side, the spermatic cord with its important structures. The inner side is occupied in many cases-about one in four-by the large obturator artery, skirting the edge of Gimbernat's ligament. To avoid all these structures, the ring must be divided very cautiously upward and inward, the knife-edge being dull and sparingly used. Depend on the finger to enlarge the ring, by stretching to a sufficient degree to allow the gut to be replaced. The sharp edge of the iliac portion of the fascia lata must not be forgotten. Remember that this falciform process, or Hey's ligament, is attached above to Poupart's ligament and the spine of the pubic bone, being continuous with Gimbernat's ligament. Femoral hernia presses directly against this sharp fixed edge as it emerges from the saphenous opening and turns upward toward the abdomen. At this point you may find the constriction, instead of farther up in the crural ring. Your attention has thus been called to the more important anatomical landmarks and the relations they bear both to diagnosis and treatment. To diagnosis, as they assist in determining the variety of hernia to be dealt with; and to treatment, as they need to be remembered and avoided. It is, however, the fact that, after applying all the anatomical knowledge which can be brought to bear on certain cases, they are not entirely clear until the surgeon's knife has exposed the parts to view, so that the absolute relations of the parts can be seen. In considering the technique of herniotomy, I call your attention, for the purposes of this paper, as already set forth, not to the operations step by step, any more than I have already done to the detailed anatomy, but rather to some of the more important steps in operating —perhaps I ought to say to certain precautions, not to be omitted, which are as important as the actual incisions. Remember, first, that the abdomen is to be opened just as truly as if a laparatomy for ovarian tumor was about to be performed. To be sure, the extent of the peritoneal incision is not great, but that membrane rebels against any careless handling even when but slightly inter fered with. Therefore let the surroundings be as favorable as possible, and all antiseptic precautions taken. When the home surroundings are not good, and hospital advantages can be procured, the patient should be advised to take advantage of them. In fact, I believe that, in the majority of cases, the patient will have a better chance for a favorable result in any well-ordered hospital than at home. The abundance of light and air, and the number of trained attendants to be found at a hospital, cannot be elsewhere provided except in the homes of the wealthier classes. This course is often either impossible of attainment or peremptorily declined. Do not begin the operation until arrangements are made for plenty of hot water, plenty of suitable soft towels or cloths or large flat sponges, and competent assistants to keep them hot, for the purpose of keeping the bowel, when exposed, and the parts in the vicinity of the operation both aseptic and at a proper temperature. I cannot urge this point too forcibly. I am confident that I have seen lives saved by careful attention to the keeping of the exposed parts well protected by hot aseptic cloths frequently renewed-particularly keeping any exposed gut well covered. I am just as positive that I have seen patients exposed to serious risk by the failure to observe this precaution. The danger of subsequent peritonitis or septic poisoning is thus reduced to a minimum. Let the region of the body to be operated on be carefully cleansed and shaven. Methods of antisepsis do not form a part of this discussion. The preparations are to be made the same as for any capital operation. Instruments should be placed in a strong carbolic-acid solution. The usual irrigating fluids should be ready. These and other preparations are not special to this operation. First incisions may be liberal. Hæmorrhage in either inguinal or femoral operations is seldom a serious complication, except as accident happens to the two considerable sized arteries, already mentioned in discussing the landmarks. After dividing the skin and superficial fascia, we fail to recognize the layers of covering, we learned so, carefully, when students. The successive layers that we do find are to be divided on a director until the sac is reached. These layers may be many or few. They will be many in fleshy persons and in those who have worn a truss for some time. The irritation of a truss causes local thickening of the tissues. They will be few in cases of recent hernia, particularly in thin patients. When these are divided, we come to the sac. It may not be difficult to recognize this by its tense rounded appearance, the filamentous character of the membrane, and the arbores |