The Abdomen 297 



sac up to the inguinal ring by blunt dissection of the cellular tissue 

 connecting it with the skin. Some practitioners make a V-shaped 

 incision with its apex towards the anterior extremity of the sym- 

 phisis pubis, and the flap of skin supporting the inguinal mamma is 

 then turned over. There is no advantage to be gained by this pro- 

 ceedure as the canal can always be reached when the incision is made 

 beside the median line. In any event, there is usually a certain 

 amount of redundant skin to be removed. Next open the sac and 

 endeavor to reduce the contents. Sometimes this is easily accom- 

 plished, but at other times it is impossible. In the latter case the 

 ring must be enlarged by incision. The incision should be at the 

 extremity of the ring furthest from the median line, in order to 

 avoid wounding the external pudic vessels which make their exit 

 from the cavity towards the inner extremity. It should also be made 

 to avoid the peritoneum. If the bladder forms the contents and 

 is irreducible, it may be punctured to facilitate matters. When the 

 gravid uterus forms the protrusion, and is irreducible, removal of 

 the fetuses must be effected by Cesarean section or the entire pro- 

 truding portion may be excised, the stump being returned to the 

 cavity. In case the latter alternative is adopted the corresponding 

 ovary should be drawn out and also removed. Fetuses contained 

 in the opposite cornua are not necessarily disturbed by such extreme 

 measures, but may continue to develop till full term. Hobday has 

 recorded an instance, and Nauraux has experienced equally favor- 

 able results where the remainder of the uterus has been conserved. 



The next step is ablation of the sac. The latter should be 

 twisted and ligated as near to the ring as possible, cut off on the 

 occluded side, and the stump returned tO' the cavity. The ring 

 should then be sutured, three or four sutures usually answering the 

 purpose. By using mattress sutures and at the same time slightly 

 inverting the edges, the ring can be permanently obliterated. Par- 

 ticular care must be exercised against wounding the pudic veins 

 which stand out very prominently. It may sometimes be found 

 advantageous to ligate them. Redundant skin should be removed. 

 Healing generally takes place by second intention, chiefly owing to' 

 the large subcutaneous cavity which must of necessity be left in the 

 groin, and post-operative infection which it is difficult to prevent. 



Inguinal and Scrotal Hernia in the Male. In the male the 

 inguinal form of hernia is relatively uncommon. It may occur, as 



