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(4.) Pain is often caused by the pressure of the spring, just where it turns inwards beneath the anterior superior iliac spine. If this is the case, the spring may require to be sharply bent inwards at this point.

(5.) Care must be taken that the spring is so shaped that the pressure is exerted equally by the whole breadth of the spring; otherwise the upper or lower border, as the case may be, exerts an undue amount of pressure, and so causes pain.

These remarks as to the spring refer to all inguinal trusses, no matter what variety of pad is used. For a bubonocele or a light scrotal hernia, a pad of the ordinary shape keeps the hernia up, but there are several points to which attention must be paid regarding the adjustment of the pad. Firstly, the pad must exert the whole of its pressure over the position of the external ring and the inguinal canal, and should under no circumstances press upon the pubic bone. Pressure on the bone is the cause of two evils—(a) It causes pain, and (b) the pressure is borne by the bone and not by the anterior wall of the inguinal canal; hence, while the hernia may not be able to escape through the external ring, it is still able to pass through the internal ring and so enter the canal. It is hardly necessary to lay stress on the danger of such a state of affairs, Secondly, if the patient has an overhanging abdominal wall, the pad must be so adjusted as to look upwards and backwards, instead of directly backwards. If this is not done, the upper border of the pad exerts far too much pressure, while the hernia escapes beneath the lower border. For a heavy scrotal hernia, and indeed for many light ones as well, the so-called “rat-tail” pad is necessary. This pad is larger than the ordinary one, and is continued downwards over the pubes by a triangular prolongation, which gradually narrows into a strap, which is carried over the perineum to be attached to the spring posteriorly. It is most important that the tail of the pad should be made of strapping only and that it should not contain any metal. Hence the metal part of the rat-tail pad must be the same shape as that of the ordinary pad, though it should be slightly larger; as in the case of a scrotal hernia

the canal and rings are more dilated than in the case of a bubonocele. It can easily be seen that if, as is often the case, the metal is continued into the tail, then pain is caused by pressure on the pubic bone, while the wall of the inguinal canal is not supported in the proper manner.

Even with the use of a rat-tail pad, a heavy scrotal hernia will sometimes escape to the inner side of the pad. To prevent this the “fork-tongue” pad is useful. This is the same as the rat-tail pad, with the addition of a projection inwards towards the middle line The metal of the pad is continued into the projection, to which a strap is attached and fastened at its other end to the spring on the opposite side.

Whatever the shape of the pad used, many scrotal herniæ are difficult to keep up. If the hernia at first comes down, while the truss is on, the patient should be instructed to reduce the hernia each time it escapes, and to wear the truss night and day. If these directions are followed, then, in a few weeks, the hernia becomes easily manageable. If it does not, then another careful examination should be made, so as to make quite sure that there is not an irreducible string of omentum adherent to the bottom of the sac.

In the Child.-In treating an inguinal hernia in a young child by means of a truss, it must be borne in mind—(1) That the hernia is seldom so heavy as to make its proper keeping-up by a truss a difficult matter, and (2) that it is generally considered possible to cure an inguinal hernia in a young child by means of a truss. As regards the weight and size of the hernia in a child, the above statement generally holds true; but, certainly, cases are occasionally met with in which the hernia is so heavy and large that no form of truss is really efficient.

In treating a hernia in an infant by means of a truss, it is most important to pay special attention to the child's digestion and nutrition—to the former, so as to prevent distention of the abdomen, due to accumulation of intestinal gas, and also to prevent straining due to constipation; and to the latter, in order to render the abdominal muscles strong, for on their


strength depends the strength of the walls of the inguinal canal. The application of a truss to the abdomen of an infant, who is habitually constipated, and whose intestines are distended with gas, is quite useless. Again, of course, it must be ascertained whether or not circumcision is required.

In applying an inguinal truss to the hernia of a child, the same rules must be observed as regards the position of the pad as in the case of adults. In the case of an infant who does not yet crawl about, the worsted truss is generally efficient and, if found to be efficient, is, on the whole, the best to

It is applied as follows:-Have the patient lying on his back; reduce the hernia, and hold the one end of the skein of wool over the position of the inguinal canal. Then carry the rest of the skein round the pelvis, passing first round the right side, if the hernia be on the right, and round the left side if the hernia be on the left. Having now brought the free end of the skein right round the pelvis, thread it through the loop of the first end, then pass it over the perineum and fasten it by tapes to the band of wool as it crosses the back of the pelvis.

This truss keeps in position well, does not chafe the skin, and is so cheap that each truss can be thrown away directly it becomes soiled. Though generally very efficient, the worsted truss is not reliable if the hernia be very large and heavy, and is certainly not to be depended upon if the child crawls or walks. In either of these cases the spring truss, completely covered with rubber, should be used. Then comes the question-Can an inguinal hernia in a young child be cured by the use of a truss? It is impossible to correctly answer this question, because it is never possible to say with certainty that a hernia is cured. However, if treatment be begun in infancy, if the patient's nutrition and digestion are good, and if the greatest care be taken to ensure that the hernia never comes down, it is at all events highly probable that a cure can be effected. But to render a cure possible, the following instructions must be given to the nurse :

1. The truss is to be worn night and day

2. When the truss is removed for washing the child, the finger must be pressed over the position of the inguinal canal, until the truss is re-applied.

Even if the hernia has not been down for many years, a truss should be worn until after the age of puberty. In fact, to be absolutely on the safe side, a light truss should be worn for the rest of the patient's life. In other words, though, if an inguinal hernia in a child be treated in the way above described, it is improbable that the hernia will be seen again after the child is 9 or 10 years old; yet a cure is never so assured as to make it absolutely safe to entirely leave off the use of a truss.




THE early recognition of cancer of the larynx, when it is still limited to that part of the interior of the larynx from the ventricular bands downwards, followed by the operation of thyrotomy, is generally productive of the best results. The possibility of effecting complete removal of the disease by this operation depends on an early diagnosis.

When cancer is extrinsic to the larynx, involving the aryteno-epiglottic folds, the arytenoid cartilages, the epiglottis, or the posterior wall of the cricoid cartilage; and in cases where the originally intrinsic cancer has become extrinsic, infiltrating deeply with infection of neighbouring lymphatic glands; then a much more extensive operation is required for its removal.

The mortality from such operations, involving complete or partial extirpation of the larynx, has been high, but the brilliant results achieved by Gluck in Berlin, through improved methods, have proved that it is possible in skilled hands to enormously increase the percentage of successful cases.

In a recent original communication in German (Wien. klin. Woch., 5th May, 1904), Dr. Koschier gives an account of fourteen cases of carcinoma of the larynx on which he has operated during the last four years. He inquires into the causes of death in the past after the operation for extirpation of the larynx, and discusses recent improvements in the technique of the operation and in the after treatment.

From the statistics of Sendziak on extirpation of the larynx for carcinoma it appears, he remarks, that as a cause of death, “aspiration” pneumonia accounts for more than half of the fatal cases.

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