the cord are found rather closely around the cord and the cord usually lies below and behind the sac so that should the operator aim to carry his needle point along rather high in the canal he will be least likely to encounter these vessels. It is not to be forgotten that the veins of the cord are particularly likely to be somewhat dilated in these cases of hernia and the operator is taking more or less of a hazard in neglecting the suction technic outlined. It is not safe to trust to the fact that the paraffin is injected in a solid state as is asserted by some operators. It is true that paraffin in a liquid state is more likely to flow into an opened vein than the paraffin in the solid state, yet it is possible to throw a very small amount of solid paraffin into a vein if no precaution is taken to prevent it, and while a very small mass thrown directly into a vein would be harmless in nearly all instances it might do considerable damage should it be so unfortunate as to lodge in certain vessels.
FACTORS TO BE CONSIDERED IN DEALING WITH INGUINAL HERNIA.
The inguinal canal gives passage to the spermatic cord. It is an oblique canal extending from a point one-half an inch above the center of Poupart's ligament to the spine of the pubes. The cord emerging from the external ring continues into the scrotum, and the most definite manner of finding the external ring is by picking up the cord in the scrotum and following it with the index finger until the point of the index finger is pressed into the canal, the scrotum being invaginated at the same time. In scrotal hernia when the patient is placed in the recumbent posture the contents of the hernial sac may be pressed into the abdomen and the finger following the receding hernial contents will slip into the opening of the external ring.
OPERATOR MUST BE SURE HERNIA IS REDUCED.
A hernia should always be completely reduced before any operation is attempted and the size and situation of the external ring definitely determined. The larger and the longer a hernia has been allowed to go unreduced the shorter the inguinal canal will be, as the inner margin of the internal ring is gradually forced toward the median line of the body, and in very large hernia the external ring is stretched somewhat outward so that an opening exists directly through the abdominal wall. This character of hernia is such that three fingers may easily be pressed directly into the hernial interval and as a rule so much of the abdominal contents have been outside the abdomen for so long that the hernia cannot be overcome without decidedly increasing abdominal pressure. These cases in which hernial contents can be pressed into the abdomen by force and which markedly increase the intra-abdominal pressure
when reduced are unsuited for any operative treatment which does not include excision of a quantity of omentum.
The average case.
In the average case the examination of the external ring will not show a canal so greatly dilated and it may be taken for granted that it has not been shortened to a considerable extent by the giving of the internal margin of the internal ring toward the median line. Under these circumstances the operator may decide that he has a canal of from two to three inches in length and lying parallel to Poupart's ligament and slightly above this structure.