APPENDIX 131 



through and through all tissues at the base of the 

 diverticulum in such a manner that the entire mass is 

 comprised within the grasp of the sutures which really 

 constitute multiple ligatures. 



Where herniotomy is to be done, general anesthesia 

 with chloroform is necessary. The field of operation 

 should be carefully cleansed, shaved, dried and painted 

 with tincture of iodin, and a large sterile towel or 

 cloth placed over the abdomen with an opening of 

 sufficient size made in it to expose the hernia. An ellip- 

 tical piece of skin and underlying fascia or other tissue 

 is then removed in just enough quantity to allow per- 

 fect apposition of the skin with sufficient tension to 

 reinforce the structures underneath. 



The opening exposes to view the margins of the ab- 

 dominal aperture. If much cicatricial tissue result- 

 ing from previous interference exists, it may be neces- 

 sary to remove some of it with a scalpel or with heavy 

 dissecting scissors. If the opening is circular, it is 

 advisable to remove a triangular portion of the mar- 

 ginal structure at the anterior and posterior parts, 

 making the opening near oval and permitting of more 

 nearly perfect approximation of the margins. Scari- 

 fication of the edges of the opening serves to increase 

 local inflammation and promote early adhesion of the 

 joined tissues. 



Apposition of the margins of the subcuticular open- 

 ing by means of interrupted sutures of heavy chromic 

 gut or silk is effected. The sutures are set well back 

 of the margin and include peritoneum and all muscu- 

 lar structures. Tincture of iodin is applied to the 

 sutured tissues and the skin and fascia are joined by 

 mattress sutures of heavy silk. With careful technic, 

 primary union results. 



