situated at the upper part of the hernia, opposite the tendon of the transversalis muscle, or in the sac itself. When this is the case, slit up the abdominal ring, hook up the abdominal muscles, and draw them upward toward the abdomen, then pull down the hernial sac; the stricture is thus exposed. Then divide the stricture in the centre and cut directly upward, let the hernia be where it may, and the danger of wounding the epigastric artery will be avoided. The intestines should be returned piecemeal to the cavity of the abdomen, and then the omentum will follow them.

Direct Inguinal Hernia.—In operating on these cases it must be borne in mind that the spermatic cord is placed on the other side; that the hernia is covered by the fascia of the cord, by the cremaster partially, and is contained in a sac, formed by the tendon of the transversalis muscle, assisted by the fascia transversalis, beside a peritoneal sac. The division of the stricture must, therefore, be directly upward.

Congenital Hernia.-The seat of stricture will be usually found under the edge of the transversalis muscle, or at the internal ring, when it should be divided in the same manner as in other cases of hernia.

Femoral Hernia.-The first incision is made in the course of Poupart's ligament, along the tumor, extending from one side to the other; the second cut is made at right angles to the first, toward the umbilicus, so that the two incisions resemble the letter T inverted. The flaps are then dissected off and reflected. This exposes the superficial fascia, which is next divided, and the fascia propria is then brought into view; cut through this and the peritoneal covering presents itself. Then make an incision, with the greatest care, and introduce a director, to ascertain the seat of stricture. Having opened the hernial sac and exposed the intestine, divide the stricture directly upward and inward, a little inclined to the umbilicus. The seat of stricture is at the posterior edge of the crural arch, just where the intestine leaves the abdomen; therefore, in dividing the stricture, after introducing the director, a bistoury, blunted at the point, is to be put on it and placed against the stricture; in this way there is no danger of wounding the intestine. The bistoury is next gently raised, and, with a slight touch of the instrument, the fibres give way.

Umbilical Hernia.-First make an incision across the tumor and then another at right angles, so that it will resemble the letter T inverted. The integument being divided, the corners of the incision are to be turned aside, by which the sac will be brought into view. This being carefully opened, the finger is to be passed into the orifice of the sac at the umbilicus and a blunt-pointed bistoury introduced. The stricture is to be divided upward, in the direction of the ensiform cartilage.

Treatment after the Operation.--The patient should be kept in the recumbent position with his knees flexed over a pillow. As soon as he has recovered from the effects of the anesthetic an injection of morphia should be given. No food should be allowed for at least thirty-six hours. A little ice may be given to relieve thirst, and if there be much prostration the strength may be supported by enemata of beef tea, with a small quantity of brandy. If there is abdominal pain, give a hypodermic injection of morphia. Keep the bowels quiet until the seventh day; if they have not spontaneously acted by that time, and all the symptoms are favorable, administer an enema. drainage tube may be removed at the end of forty-eight hours, and the sutures should be taken out on the third or fourth day.

FIG. 19.

SPICA RETAINING PAD.

The

Generally the antiseptic dressings may be discontinued on the tenth day, and the wound then treated with iodoform or boracic acid. The patient should be kept in bed for at least three weeks, and at the end of a month, if required, a truss may be applied. The patient must not rise without a truss or a properly applied pad or bandage.

DISLOCATIONS.

A dislocation is the removal of the articulating portion of a bone from that surface to which it is naturally connected.

DISLOCATION OF THE LOWER JAW.

A blow on the chin when the mouth is widely opened will cause this dislocation. Yawning will also produce it.

Symptoms. Both condyles are advanced between the surface of the temporal bone and zygomatic arch; the mouth is open, and the patient is not able to shut it by pressure made on the chin; the lower teeth are on a line anterior to the upper; the appearance is that of a person yawning; the pain is severe; the saliva is increased and dribbles from the mouth.

If the lower jaw is partially dislocated one condyloid process only advances, while the other remains in its articular cavity.

Reduction. If recent, this dislocation is reduced by wrapping a handkerchief around the thumbs, placing them on the coronoid processes, and depressing the jaw, force it backward as well as downward, and the bone suddenly slips in its place. If this does not answer, the following method is to be tried: The patient being seated, his head supported by an assistant, the surgeon, standing in front, introduces his thumbs into the mouth, as far back as possible upon the molars, and places the fingers of each hand under the chin and base of the jaw. Using his thumbs as fulcrums, the back part of the jaw is forcibly depressed, to disengage the condyles from the zygomatic fossæ, and at the same moment the chin is elevated by the

FIG. 20.

DISLOCATION OF THE LOWER JAW.

surgeon's fingers. The thumbs of the operator are to be thoroughly protected by the folds of a handkerchief or napkin.

If the dislocation has existed some time, the better plan is to place some yielding substance, like cork, behind the molar teeth, on each side of the mouth, and then raise the chin over them.

DISLOCATIONS OF THE CLAVICLE.

The sternal end of this bone may be dislocated forward, and also back. ward; more frequently forward, when it is thrown upon the upper part of the sternum.

When the dislocation is in front of the sternum, the reduction is easily effected; place your knee against the spine, draw the shoulders backward,

and the clavicle will assume its natural position; then apply the clavicle bandage, placing a pad on the displaced end of the bone.

The dislocation behind the sternum is a very rare occurrence; it may be produced by curvature of the spine; if so, there is no mode of reducing it.

The outer extremity of the clavicle is most frequently dislocated upward on the acromion; it is, more correctly speaking, a dislocation of the acromion from the clavicle, where the bone is thrown upon the upper surface of the acromion, or upon the anterior part of the spine of the scapulæ. It is usually caused by violent falls upon the shoulder.

FIG. 21.

DISLOCATION OF THE ACROMIAL
END OF THE CLAVICLE.

Symptoms.-There is a distinct prominence, formed by the displaced bone, upon the upper surface of the acromion, which disappears on raising the arm; the limb hangs closely along the trunk, the shoulder is somewhat flattened. The facility of reduction, and the prominence of the clavicular portion of the trapezius muscle, indicate the nature of the accident.

Treatment. Reduction is effected by raising the shoulder, drawing it backward and carrying it outward by placing a pad in the axilla and bringing the elbow well to the side. After reduction, the treatment is the same as for fracture of the clavicle. A thick pad, with the base directed upward, is placed in the axilla, and the arm and forearm must be well secured to the chest; direct pressure must be made by means of a pad and gutta-percha plate laid on the projecting clavicle, and strapped tightly down by a band passing parallel to the arm and under the flexed forearm. This is retained in position by being attached to a strap passed round the opposite axilla.

DISLOCATIONS OF THE HUMERUS.

First Dislocation.-Downward into the axilla, which is most common. Symptoms. The arm is lengthened; a hollow is felt under the acromion; the shoulder is flattened externally; the elbow sticks out from the side and cannot be made to touch the ribs; the head can be felt in the axilla.

Second Dislocation.-Forward beneath the clavicle, upon the second rib, the coracoid process being on the outer side.

Symptoms.-The arm is slightly shortened; elbow projects backward; the acromion seems pointed; the depression of the deltoid is more considerable than in preceding case.