The Abdomen 291 



several minutes by vain attempts to return the organs without open- 

 ing the sac. When the latter alternative had finally to be adopted 

 it was found that adhesions had effectually prevented the efforts 

 from being crowned with success, and in one case the presence of a 

 diseased uterus was laid bare. 



But it sometimes happens that the size of the ring prevents re- 

 duction of the contents. In this case it must be enlarged by means 

 of an instrument specially designed for the purpose, or if the latter 



No. 58. Hernlotome. 



be not at hand a probe-pointed bistoury guided by a grooved director 

 will answer the purpose almost as well. The enlargement must be 

 made with due regard to the proximity of vessels. 



The contents being returned, the sac is next removed. This 

 should be pulled well out, twisted, and excised after first applying 

 either a simple, multiple, or purse-string ligature to its neck as high 

 up as possible. The stump is then pushed within the abdominal 

 wall. ~ The next step comprises closing the opening in the wall. 

 This is accomplished, as in celiotomy, by suturing the margins. 

 The skin wound is closed as in celiotomy. The subcutaneous ap- 

 plication of tampons with the object of giving additional support is 

 unnecessary, if not useless for the purpose for which it is intended. 

 Neither need supporting bandages be employed. The best suturing 

 material to use during the various stages is silk. 



In strangulated hernia, treatment, to be effectual, must be 

 undertaken in the early stages, as the lesion is quickly fatal, usually 

 within twenty-four to twenty-eight hours. The sac is opened, the 

 ring enlarged by cutting, and the bowel slightly drawn out and the 

 entire mass carefully examined. Congested bowel, even if dark-red 

 in color, usually possesses sufficient viability for complete recovery 

 and may be safely returned, and the operation completed as already 

 described, but if any part is found to be gangrenous recourse must 

 be had to resection. 



ABDOMINAL HEKNIA IN PARTICULAR. 



Umbilical Hernia. Umbilical hernia occurs either congenitally 



