abates or disappears; the pulse becomes very feeble and intermittent; collapse deepens, and delirium is usual. It is a safe clinical rule that in strangulated hernia cessation of pain without the relief of constriction or the use of opiates. means that gangrene has begun. In a pure omental hernia strangulation produces similar but less decided symptoms. In Littré's hernia only a portion of the circumference of the bowel is constricted, usually in the femoral ring. In a strangulated Littré's hernia constipation is rarely absolute and the tumor is often undiscovered. In some cases of strangulation there are muscular cramps in the legs (Berger). In children convulsions are not unusual.

Treatment. In treating strangulated hernia place the patient upon his back, bend the knees over a pillow, and rigidly interdict the administration of food. An attempt is to be made to effect reduction by gentle manipulation or taxis. In applying taxis to a femoral or inguinal hernia, flex and adduct the thigh of the affected side. In applying taxis to an umbilical hernia, both thighs should be flexed upon the abdomen. Always lower the shoulders and head and raise the pelvis, and accomplish this by lifting the foot of the bed and placing pillows under the pelvis. Grasp the neck of the sac with the fingers and thumb of one hand, and employ the other hand to squeeze the hernia and urge it toward the belly. In direct inguinal hernia the pressure should be backward and a little upward; in umbilical hernia it should be backward; in oblique inguinal hernia it should be upward, outward, and backward; in femoral hernia it should be downward until the hernia enters the saphenous opening, and then "backward toward the pubic spine" (MacCormac). If the bowel is reduced, it passes from the hand with a sudden slip and enters the belly with an audible gurgle; omentum, when reduced slowly, glides back without gurgling. Taxis is never to be continued long, and it is not even to be attempted in cases of great acuteness, in cases where strangulation has lasted for several days, in cases known to have previously been irreducible, in cases associated with stercoraceous vomiting, or in an inflamed or gangrenous hernia.

If taxis fails, obtain the patient's permission to operate. Anesthetize; try taxis again while ether is being dropped upon the hernia to cause cold; if it fails, at once perform herniotomy. Taxis possesses certain dangers it may rupture the bowel; it may rupture the neck of the sac and force the bowel through the rent; it may strip the peri

toneum from around the hernial orifice and force the bowel between the detached peritoneum and the abdominal wall; it may reduce a hernia into the belly when the bowel is still strangulated by adhesions; it may reduce the hernia en masse or en bloc, the sac and strictured bowel being forced together into the abdomen. By reduction en bissac is meant the forcing of a congenital hernia into a congenital pouch or diverticulum. In any of the above accidents strangulation may persist after apparent reduction by taxis, and this condition calls for instant laparotomy-in most instances through the hernial aperture. If taxis is successful, put the patient to bed, apply a pad and bandage, allow the patient to take no food until vomiting ceases, merely permitting him to suck bits of ice, and keep him on a liquid diet for several days. At the end of the first week give solid food; if the bowels have not acted by this time, administer an enema, following it by a dose of Epsom salts if there is no pain and no disposition to vomit. Some surgeons advocate inversion as a valuable aid to taxis.

Herniotomy.-The instruments required in herniotomy are a scalpel, a hernia-knife and director (Fig. 242, B), hemostatic and dissecting-forceps, blunt hooks, scissors, a dry dissector, partly-curved needles, and a needle-holder. Drainage-tubes should be ready. In the operation the patient lies upon his back with the shoulders raised, the surgeon standing to the patient's right side. In oblique inguinal hernia it has been the custom since the days of Scultetus to raise a fold of skin at right angles to the axis of the external ring and transfix it, the wound which results being extended until it becomes three inches in length. This incision possesses no special merit. It is better to cut from without inward, and to make the same incision as for the performance of a radical cure in a non-strangulated case. The tissues are divided until the sac is reached, and no attempt is made to specially identify them. The sac is known by the fat which usually covers it, by the arborescent arrangement of its vessels, by the fact that it can be pinched up between the finger and thumb and the layers rolled over each other, and by the fluid within the sac. Should the sac be opened? In very recent cases it is usually unnecessary, but if there is any doubt as to the condition of the bowel, or if a radical cure is to be attempted, open the sac and be certain as to the condition of its contents. The general rule should be to open the sac. The sac is opened and the contents examined for fecal odor (which is not unusual) and for gangrenous smell;

the thickness of the bowel is estimated, and the color and luster are determined. In oblique inguinal hernia nick the constriction upward and outward, as shown in Fig. 246. In direct inguinal hernia the cut is made upward and inward. Always pull the bowel down and examine the seat of constriction to see what damage has been inflicted at that point. If the bowel glistens, if the proper color comes back after irrigation with very hot water, and if there are no spots of gangrene, restore the bowel to the abdomen, and do a radical cure. If the bowel is in a doubtful condition, fasten it to the incision, apply a dressing, and watch the development of events. If the bowel is gangrenous, our action depends upon the condition of the patient. If the patient is in good condition, resect the gangrenous portion, and perform end-to-end anastomosis by means of a Murphy button. If the patient's condition is bad, make an artificial anus, and at a later period perform anastomosis. An arti

ficial anus can be made by the method of Bodine (page 695). In most cases do not open the bowel at once, because it may recover in a day or two, when it can be restored to the belly; or it may slough and form an artificial anus. In such a doubtful case, fasten the bowel to the belly-wall with sutures, dust it with iodoform, dress it with hot antiseptic fomentations, and await future developments. Gangrenous omentum requires ligation and resection. If the bowel is fit to reduce, push it just inside the ring, irrigate the parts, insert a drain, and stitch. In most cases perform a radical cure. In femoral hernia we can make the incision one inch internal to, and parallel with, the femoral vessels, and crossing the tumor and ligament (Barker); but it is better to make the incision of Fabricius for radical cure. Divide the constriction by cutting upward and a little inward. In umbilical hernia make a slightly-curved incision a little to one side of the middle of the tumor, open the sac, separate adhesions, and divide the constriction by cutting upward or downward, and sometimes also laterally.

After an operation for strangulated hernia put the patient to bed; bend the knees over a pillow; give no food by the mouth for thirty-six hours (MacCormac), only allowing the patient bits of ice to suck; give nutrient enemata containing

brandy; and use morphin hypodermatically. If the bowels have not acted by the end of the first week, give an enema and follow this by a saline. Remove the drainage-tube on the third day. At the end of about three weeks, if a radical cure has not been attempted, get the patient up, first applying a pad and a spica bandage to the groin, and later a truss. If a radical cure has been made, the patient should stay in bed for one month. A truss should not be worn if a radical cure has been made.

Anatomical Varieties of Hernia.-In direct inguinal hernia the bowel passes out through Hesselbach's triangle internal to the deep epigastric artery. It enters the inguinal canal low down, and passes outside the conjoined tendon or forces the conjoined tendon before it or splits through the tendon. The neck of the sac is internal to the deep epigastric artery. The coverings of this hernia, when it passes external to the conjoined tendon, are the same as for indirect inguinal hernia; when a direct hernia pushes before it the conjoined tendon, its coverings are skin, superficial fascia, intercolumnar fascia, conjoined tendon, tranversalis fascia, subserous tissue, and peritoneum. In indirect inguinal hernia the bowel passes through the internal abdominal ring external to Hesselbach's triangle and external to the deep epigastric artery. It passes down the inguinal canal and emerges from the external ring; it may enter the scrotum or labium (scrotal or labial hernia), or it may not. The neck of the sac is external to the deep epigastric artery. Its coverings are skin, superficial fascia, intercolumnar fascia, cremaster muscle, infundibuliform fascia, subserous tissue, and peritoneum. Congenital or encysted inguinal hernia is a hernia into an unclosed vaginal process. The bowel in congenital hernia has one layer of peritoneum in front of it. The testicle is posterior. In funicular hernia the vaginal process is closed below and open above, and a hernia takes place into the unclosed funicular process. The bowel has one layer of peritoneum in front of it. The testicle is posterior. In infantile hernia the vaginal process is occluded above, and not below, and the septum of occlusion is pushed down by the hernia. In infantile hernia the bowel has three layers of peritoneum in front of it. The testicle is in front. Always remember that congenital hernia may not appear for several months after birth. Congenital hernia conceals or buries the testicle; acquired hernia does not. In femoral hernia the bowel descends along the femoral canal, and the neck of the sac is at the femoral ring. The neck of a femoral rupture is always external to the pubic spine;

sac.

the neck of an inguinal rupture is always internal to the pubic spine. Femoral hernia is never congenital. Its coverings are skin, superficial fascia, cribriform fascia, crural sheath, septum crurale, subserous tissue, and peritoneum. Umbilical hernia may be congenital (the ventral plates having closed incompletely), infantile (the citatrix of the umbilicus having stretched), or acquired. Ventral hernia is a protrusion at any part of the anterior abdominal wall except at the umbilicus or above it. Epigastric hernia is a protrusion of peritoneum in the space bounded by the ensiform cartilage, the ribs, and the umbilicus. The sac of peritoneum may be empty, may contain omentum, or omentum and bowel. The stomach very rarely passes into the The protrusion is usually, but not invariably, through the linea alba. Properitoneal hernia is a sac between the peritoneum and transversalis fascia. This form of hernia is sometimes produced by making taxis on an inguinal hernia, when the internal ring is small or is blocked by an undescended testicle. In properitoneal inguinal hernia, which is the most common form, there are two sacs detectable, one in the scrotum, the other parallel with Poupart's ligament, and as one sac is emptied the other distends (Breiter of Zurich). Obturator hernia passes through the obturator membrane or the obturator canal, and is felt below the horizontal ramus of the pubes, internal to the femoral vessels. Lumbar hernia occurs at the edge of, or through, the quadratus lumborum muscle. Sciatic hernia passes through the great sacrosciatic foramen. In diaphragmatic hernia some viscera of the abdomen pass through a natural or an accidental opening into the thorax. Pudendal hernia protrudes into the lower part of the labium. Perineal hernia presents in the perineum, between the rectum and the prostate gland or between the rectum and the vagina. Hernia into the foramen of Winslow is very rare.

XXVIII. DISEASES AND INJURIES OF THE RECTUM AND ANUS.

Hemorrhoids, or Piles.-There are three varieties of varicose tumors of the rectum, namely: internal, which take origin within the external sphincter; external, which take origin without the external sphincter; and mixed hemorrhoids, which are a combination of the two.

External hemorrhoids are covered with skin. Internal