312 Inguinal Hernia 



hernia of old standing may so drag down the epigastric artery as to 

 lie close to the pubes ; he may then mistake it for a direct hernia. In 

 every inguinal hernia, then, whether diagnosed as oblique or direct, the 

 strangulation is to be eased by an upward incision in the neck of the sac. 



A strangulated inguinal hernia does not necessarily require a 

 cutting operation ; the surgeon may be able to return it by taxis (rnt?, 

 an arrangement): he lays the patient supine, with the pelvis raised, 

 and he flexes the thigh and inverts it, to relax Poupart's ligament and 

 the abdominal wall ; then, taking the neck of the sac between the 

 fingers and thumb of his left hand making them into a sort of funnel 

 he endeavours to squeeze back the contents of the tumour. Years ago, 

 the patient was prepared for taxis by emetics, hot baths, tobacco 

 clysters, and even venaesection, with the view of diminishing general 

 and local resistance ; ether has happily rendered this treatment 

 obsolete. Before using taxis the patient should be kept on his back, 

 with pelvis raised, in hopes that, the vessels of the bowel being emptied 

 to the utmost, the mesentery may draw back the protruding knuckle. 



Reduction en masse is the thrusting of the peritoneal sac and its 

 contents bodily within the abdomen,the strangulation not being relieved. 

 So symptoms persist ; and perhaps a tumour may be felt deep in the 

 iliac fossa. Moreover, the scrotum is found empty of sac. In such a 

 case the inguinal canal has to be opened up, the peritoneal cavity 

 explored, the mass brought down, the strangulation relieved, and the 

 bowel returned. Sometimes the sac and its contents get pushed up 

 between the peritoneum and the abdominal wall 



If the constant wearing of a truss fail to prevent the descent of 

 a hernia, the radical treatment may be contemplated. The old 

 methods of performing the so-called radical ' cure ' were as complicated 

 in description as they were ingenious in execution ; they have now 

 given place to straightforward and simple operations on the principle 

 of occluding the neck of the peritoneal sac and partly closing the 

 external abdominal ring : an incision is made down the axis of the 

 tumour from the external ring, through skin and superficial fasciae, 

 intercolumnar, cremasteric, and infundibuliform fasciae, till the sac is 

 reached ; its contents are then returned, its neck, isolated from the 

 elements of the subjacent cord, is tied as high up as possible, and the 

 sac is cut away below the ligature. The wide mouth of the canal is 

 then partially occluded by lace sutures securely passed through the 

 pillars of the external ring. 



The radical treatment is also usually performed after operating for 

 the relief of a strangulated hernia. 



FEMORAL HERNIA 



The external iliac vessels are continued into Scarpa's triangle, 

 beneath Poupart's ligament, between a prolongation of the transversalis 





