01 all symptoms, vomiting is the most important. Vomiting is always persist ent, occurring at longer or shorter inter vals. At first the vomitus consists merely of the contents of the stomach; if the hernia is not reduced, it contains bile, mucus, and finally becomes stereo raceous. Complete constipation is al ways a symptom of great importance. In rare cases diarrhoea may occur as an early symptom. There is always an increase in the pulse-rate and usually slight ele vation of temperature, especially in the early cases. Later on temperature may become subnormal.
In strangulated omental hernia, with strangulation of omentum alone,—an extremely rare condition,—all of the symptoms are milder in character. Con stipation may or may not exist.
El have recently observed one case of acute strangulated omental hernia in which operation was performed on the third day. WILLIAM B. COLEY.] Twenty-five operations in such cases in children under one year of age since May, 189S. There was only 1 death among the 25 cases. In addition, the 100 cases previously tabulated by the author indicate beyond all question that infants: endure this operation very well. The report of a case is given in which the intestine had almost slipped back into the peritoneal cavity, leaving no palpable tumor, although the strangula tion persisted. The operation was done
on account of the symptoms and his tory. The child left the hospital on the eighth day. The records indicate that delay in interpreting the symptoms or reducing the hernia by taxis have been the greatest danger, while early opera tion has been the greatest safeguard. C'. N. Dowd (Med. llecord, Oct. 12, 1901).
Diagnosis of Strangulated Hernia.— There is no condition likely to be met with in surgical practice in which it is more important to make an early and correct diagnosis than in strangulated hernia. In typical cases, fortunately, the diagnosis is attended with little diffi culty. In a hernia previously irreducible, the condition of obstruction or inflam mation of the hernial contents may cause one to suspect strangulation. In ob structed hernia, however, the impulse is usually present; pain is less acute and the other symptoms are much less marked than in the case of true strangulation.
The same is true of inflamed hernia. Strangulation sometimes occurs syn chronously with the development of a hernia; I have observed two such cases. Given a patient with the symptoms of intestinal obstruction, careful examina tion should be made of all the sites at which a hernia might occur.