74 SURGERY. 



ceous. The countenance is pale and anxious, the skin cold and 

 clammy, and the pulse, which was at first lull, now becomes rapid and 

 indistinct ; gangrene has taken place, the pain subsides in the tumour, 

 which feels doughy and crepitant upon being handled. The vomiting 

 may cease, and the patient will appear more comfortable, although 

 he is actually sinking. It may be that the integuments and cover- 

 ings of the intestine may inflame and slough with the intestine ; 

 and, after a copious feculent discharge, the patient may recover by 

 artificial anus. 



When the tumour is small and recent, and the constriction tight, 

 a few hours may produce death, if no relief is afforded ; when the 

 hernia is old and large, days may elapse. 



Many of these symptoms may exist in other diseases, as in colic 

 or ileus, but inquiry or examination should always be made as to 

 hernia. 



Treattnent. — The great object is to relieve the strangulation. In 

 the first place taxis should be resorted to, and an effort made to 

 reduce the contents of the sac. In order to facilitate this object, 

 bleeding, warm bath, purgatives, enemata, opium, and cold applica- 

 tions to the tumour will be found of use. A tobacco injection, made 

 with 3j to Oj of water, may be of use, but requires great caution in 

 its use, on account of its prostrating effect. These remedies may so 

 relax the system that the reduction can be effected ; at any rate they 

 will diminish the inflammation if judiciously used. If not successful, 

 the knife must be used. 



INGUINAL HERNIA. 



Bubonocele is a common name for this variety of hernia, which 

 consists of a tumour in the groin, made by a descent of the gut or 

 omentum through what are called the rings of the abdomen. These 

 are the weak spots at which the protrusion takes place. 



Before studying the operation for strangulated inguinal hernia, 

 it will be proper to examine the anatomy of the parts in their natural 

 condition, and then the varieties of the disease. 



For anatomy of inguinal hernia refer to Anatorny-, page 75. 



Oblique, or indirect inguinal hernia, occurs thus : — The intestine, 

 or omentum, first pressing against the parietal peritoneum, distends it 

 and forms it into a sac ; this sac, containing the intestine, then presses 

 against the fascia transversalis at that portion where it is thin, and 

 passes from the abdomen to the cord, which spot is called the in- 

 ternal abdominal ring, although it is not a hole. The sac, covered 

 by the fascia transversalis, which is now thickened by pressure, 

 then descends the inguinal canal, behind the transversalis and in- 

 ternal oblique muscles, and when it reaches the external ring it 

 is covered by the cremaster, which may be considered as a con- 

 tinuation of these muscles; thus covered, it escapes at the ex- 



