STRANGULATED.-A strangulated fem oral hernia may sometimes be reduced by taxis when the thigh is flexed and ro tated inward, which position causes the saphenous opening to be relaxed periph erally. No excessive compression or upward pressure should be exercised, however, operation being less hazardous than such a proceeding.
Radical Operation for Femoral Hernia. —Until very recently femoral hernia has been regarded as less amenable to radical cure than inguinal; but the statistics would tend to disprove the correctness of this idea.
Numerous methods have been from time to time brought out; many of them are complicated and the majority of them have been supported by a very small number of cases. The inguinal method for the cure of femoral hernia, in which the opening is made in the inguinal canal and the femoral opening closed within the abdominal cavity, has been employed by a number of surgeons. It is, I be lieve, unnecessarily complicated, and, as long as almost perfect results can be obtained by the simpler methods, I think it should have no place in surgery. There is the additional risk not only of having a recurrence in the femoral region, but through the opening made in the in guinal canal. Various osteoplastic oper ations have been introduced by means of which the femoral opening is closed by a bony flap. Most cases of femoral her nia, I believe, can be cured by one of the two following methods: 1. Pulse-string suture of kangaroo-tendon. This suture is introduced first through Poupart's lig ament, the outer part of which forms the roof of the crural canal, then passes through the pectineal fascia, the fascia over the femoral vessels, and lastly up ward through Poupart's ligament, emerg ing about '/, inch from the point of entrance. When this suture is tied it
brings the floor of the canal into contact with the roof and completely closes the opening. It is very important to thor oughly free the sac before applying the ligature. I have employed this method in 25 cases with not a single relapse, and 10 cases were traced from 2 to 6 years. This method I believe sufficient for fem oral hernia in children and the great majority of adults.
If the opening is very large Bassini's method, which has given such admirable results for femoral hernia, may be em ployed.
An incision is made parallel with Pou part's ligament and over the centre of the tumor. This is the same incision that I employ in the purse-string suture. The sac is dissected free from the canal and ligated as high up as possible; with a curved needle six or seven sutures are inserted so as to unite Poupart's liga ment with the pectincal fascia, thus accomplishing the same object that the purse-string suture does. The first suture is placed near the spine of the pubis; the second half a centimetre ex ternally; the third one centimetre from the femoral vein, and the remaining sutures are so placed as to bring together the anterior and posterior walls of the canal.
Umbilical Hernia.
–Three forms of umbil ical hernia are usually recognized: the congenital, due to faulty union of the vis ceral plates in the middle line; the infan tile, which occurs soon after birth as a result of yielding of the umbilical cica trix after separation of the umbilical cord; and the adult, which usually pre sents itself late in life in women who have borne many children.