1913 BMJ (Clinical Research Edition)  
and no alm-otunt of pullinig down or twisting will separate it from tllese strtuctures. If this is not successfuLlly done the dimple remiiains, and tlle predisposing eauLse remains, no miiatter hlow carefully the abdominal walls and external ring may be repaired. Aniotlher difficuilty miief witlh in the ordinary metlhods of operating is to find tlle sac and separate it, emnbedded as it is among tlle tissues sturroundinig tlle cord, a process often causing miuch-tearing and separation of
more » ... paration of structures. I suggest, tlierefore, the following miiethod, wlichl will obviate all tllese difficulties: Tlje sliin incision begins just internal to and above the spine of the pubis, and runs upwards parallel to tlle fibres of the aponeurosis of the external oblique froiim wlhichl tlle skin anid subcutaneous tissue is raised. Tlle pillars of tlle ringa lavinga been clearly defined, the external oblique is split-up far enoughl to -give sufficient room. The cord alndl structtures coverinig tlle sac is seen lying in its place and miiust not be touclhedl. The lower ml-argin of tlle internal oblique is now seen and is retracted upwards. The peritoneumiii (not tlle sac) is now opened from the intternal rin1g upwvards. In almnost all the eases operated upoln the internal ring, is very miuiich approximated to the external by tlle dragging of the lherniated gut, so that there is plenty of roomi above it, btit if tlhere is not enough the incision of peritoneum may be carried dcowni on the outer sidle of the ring. Wlhen the abdomilinal cavity is openied the neck of the sac can now be seen from the inside. If omentum or other structures are adherent they can easily be separated or drawn out of the sac. The lower end of the incision througlh peritoneum is now carried down to the neck of the sac and round it, so that the abdominal peritoneum is now entirely separated from the sac, just as the hand of a glove would be separated from a finger if the latter were cut off at its junction to the palm. The abdominal peritoneum is now closed with continuous suture as in any other abdominal operation. The sac has now to be dealt with, and the neck may hiave to be carefully dissected off the fibrous ring I spoke of. The left finger is passed down into the sac, wlhich is drawn up round it with forceps by the assistant and can easily be dissected or swabbed out of its bed with very little disturbaince of surroundiug tissues. The position of the deep epigastric artery must not be forgotten in dealing with tlle neck. I usually suture the edge of the internal oblique down into the groove of Poupart's ligament as far as I am able. Whetlher this is ilulch real use I am not prepared to say. The edges of the external oblique are drawn together with a continuous mattress suture and overlapped or not according to the fancy of the operator. I think, where the muscles are very lax, overlapping is certainly useful in making a thicker and stronger wall. As I have said, I do not claim that tllis method has never been used before, but I have been adopting it for some time, and I like it better than any other I have tried. It is much more rational, I thiink, as one is able to see all the time what one is doing-instead of working in the dark. This is especially useftul in those cases wlhere the fibrous ring is present of wlhich I lhave spoken, and wlliclh I do not think it is possible to obliterate otherwise. THE aninual report of the Surgeon-General of Trinidad and Tobago for the year 1911-12 states that the total population at the last census (1911) of the colony was 333,552, as compared with 273,899 at the census of 1901. The Indian community accounts for nearly one-third of the total population, and increases apparently at a relatively greater rate than the general population. The birth-rate was 34.65, and the Indian birth-rate exceeded that of the general population by 2.31. The gross death-rate recorded was 23.36, and there was a difference here of 4.03 in favour of the general population as comnpared with the Indian section. Froml the reports furnislhed by the inedical officers, and frolml those of the wardens on the health of their several districts, the medical year appears to have been uneventful, epidemic disease was absent, and there were no featutres of special interest recorded. The total number of patients treated in the medlical institutions of the colony was 16,934, as against 15,896 during the previous year, and there was a daily average of 2,121 patients under treatment in them. The Colonial Hospital has accommodation for 320 beds, and aW small isolation hospital in two sections has been provided. During the period under reviewv 6,539 cases were treated, 5.511 were discharged, and 718 died. PRESIDENT'S INTRODUCTORY REM1ARKS. AFTER a fewv initial observations the President said: Tlho first duty of your Commiittee was to draw up a programime for the tlhree days of meetings of tllh Section and to fix oIn subjects for discu-ssion. After careful consideration we chose for to-day's discussion the technique and aftertreatment of the radical mastoid operation. This is a subject which, althouglh of the greatest intcrest to us, has, curiously enough, not been set down for formal discussion at this Section of the Britislh Medical Association for many years. Modifications of the techlnique are frequently being introduced, varying metlhods of dressing suggested, new drugs brought forward to hasten the healing by stiimulating the growth of epithelium and sc on ; we therefore thouglht that a discussion on all suclh points could not fail to be most interesting andl instructive, With regard to the subject for Thursday, there seem's to be in the minds of several members of the Section som-Ie misgiving or doubt as to whether it is of sufficiently wide scope or sufficiently great interest and importance to be worth a formal discussion. I have been asked tlhe question, "What is there in ' The Care of Patients after Nasal Operations' to discuss?" I am quite willilng to take upon myself the responsibility of having suggeste(d tlle subject to youLr Committee, and I should like briefly to touch on somiie of our reasons for selecting it. In the first place, we all know from bitter experience that after a slight operation on the nose undertaken to relieve a comilparatively trivial disconmfort, slight interference witlh nasal respiration, etc., the patient does lnot always luake an ulneventful and uninterrupted progress to recovery, btut that unfortunately somle of these trivial operations have very serious consequences. For examuple, Miss H. T., aged 25, on whom I had operated for tonsils and adenoids, began to complain of lheadache and of pains in the feet on the seconid day, then followed pain and swelling in tllc anlkles, knees, wrists, elbows, anid so on, and pericardial efftusion. Tlle patient was in bed for twc months, and miore or less an invalid for long after hit return to her-home in the country. Again, Miss A., aged about 30, had suffered from lnasal obstruction as long as she could remember. I removed the anterior and posterior ends of bothi inferior turbinals, and gtuillotined the tonsils. For a few days things went perfectly smootlhly, then pain was complained of in the back, temperature rose, anid soon an abscess in the left lung developed. And againi, a child on wlhom I had operated for adenoids was, in spite of my orders, allowed out on the third day after operation, got a chill, and developed a most alarming and painful illness, temperature reachling 1070 F. on one occasion. I have cited these three cases because they illustrate the gravity of tlle conditions that may follow comparatively trivial nasal and naso-pharyngeal operations, andl also because they illustrate the fact that the error may be made before, during, or after the operation. Thus, in the first case one may say tlhat the error was made before the operation, and consisted in not obta-ining accurate enough informnation as to the patient's constitution, history, and state at the time. Had I known thler what was afterwards told me by the patient anld hler doctor, I should either have ref-used operation altogether
doi:10.1136/bmj.2.2751.728 fatcat:mqoz6x6qq5frzd44brhzz36oqm