Citations for re- rior temporal lobe; and isolated areas in more posterior areas view articles are provided on these topics for readers who (Levin et al 10 mg accupril with visa. Skull fractures occur in approximately desire more in-depth reviews of each of these areas discount accupril 10 mg otc. Children more frequently present with diffuse injury and cerebral Epidemiology swelling (44%) resulting in intracranial hypertension than adults order 10mg accupril amex. Reviews of advances and challenges in the understand- stituting a major cause of death and disability in the United ing of the pathophysiology of pediatric brain injury as well as States (Langlois et al. The male-to-female incidence initial assessment, management, and treatment of pediatric rate ratio is approximately 1. Higher incidence rates higher in young children, among whom the incidence is ap- have been found to be related to median family income proximately 10% (Yablon 1993). Elevated rates of psychiatric disorder are consis- infant, toddler, and young child brain injury are related to tently found in cohorts of epilepsy individuals who have assaults or child abuse and falls. Antiepileptic drugs injury, by severity, ranges from 80% to 90% for mild, 7% to may positively influence behavioral or psychiatric presen- 8% for moderate, and 5% to 8% for severe brain injury. Etiology and Pathophysiology School Sequelae Focal injuries including subdural, epidural, and intracere- bral hematomas occur with a higher incidence in adults Academic functioning within the school environment is (30%–42%) than in children (15%–20%). There is an antero- the childhood equivalent of occupational functioning for 439 440 Textbook of Traumatic Brain Injury adults. Special ical study involved a birth cohort studied at age 5 and then education services are necessary for various problems in- again at age 10 (Bijur et al. The study found that cluding poor academic function related to 1) skill deficits children who went on to sustain injuries (e. The term novel psychiatric disorders has been coined to de- Psychiatric Disorders scribe two possible scenarios. These disorders are varied, thus demonstrating that behavioral outcome after brain in- Methodological Concerns jury is not a unitary construct. This categorical classifi- Study design is critical to the determination of the quality cation system of new/novel disorders has value because it and generalizability of data generated. The second stage in this evolution is the examination data from studies with major design flaws. Therefore, unless other- it is likely that different disorders will have different psy- wise indicated, this review refers only to accidental injury. In fact, understanding of phenotypically similar disorders in chil- there have only been two prospective studies of consecu- dren who have not experienced brain injury. The only prospective psychiatric predictor of novel psychiatric disorders in one study was studies that have used standardized psychiatric inter- preinjury family function (Max et al. Preinjury family life events Preinjury family function or stressors and immediate postinjury coping style emerge Socioeconomic status as significant variables later in the follow-up. The impor- Preinjury intellectual function tance of novel psychiatric disorders for family functioning is evident at 6, 12, and 24 months postinjury. The direc- whether these disorders were present before the injury can- tion of these effects is as expected (worse outcome with not be overstated. Furthermore, investigators have demonstrated ten- dren developed new-onset psychiatric disorder was simi- tative support for bidirectional influences of child behav- lar in one study (Brown et al. Table 28–2 provides a summary of current lesion-behavior 2002) rates of new-onset psychiatric disorder compared correlates for specific psychiatric disorders and symptom with uninjured control groups of children in four studies. The labile, aggressive, and disinhibited than the families of injured control children, and this was subtypes are common, whereas the apathetic and paranoid more closely linked with postconcussive symptoms than subtypes are uncommon (Max et al. Summary of lesion findings in psychiatric disturbances after pediatric traumatic brain injury Disorder Lesion correlate (timing of outcome) Source Attention-deficit/hyperactivity disorder Right putamen, thalamus (12 months) Gerring et al. An overlapping study of attention- while affective regulation problems initially associated deficit/hyperactivity symptoms found a similar relation- with superior frontal lesions may decrease as other gray ar- ship with severity and also found that overall attention- eas subsume this function, such plasticity in the face of le- deficit/hyperactivity symptoms were associated with sioned white matter tracts does not yield improved func- poorer preinjury family functioning (Max et al. The item numbers correspond to numbered items on the Neuropsychiatric Rating Schedule. Increased severity of injury, frontal and temporal lobe of investigators (Levi et al. Lengthy episodes and similar frequency of ir- even after controlling for ethnicity, social disadvantage, and ritability and elation may be characteristic. Posttraumatic symptoms at 1 year postinjury otherwise specified, adjustment disorder with depressed were predicted by preinjury psychosocial adversity, prein- mood, or adjustment disorder with mixed anxiety and de- jury anxiety symptoms, injury severity, as well as early pressed mood. Follow-up for 2 years revealed that 7 of these postinjury depression symptoms and nonanxiety psychiatric 9 children at some point displayed a clinically significant diagnoses. In fact, of 5 children who ing” was associated with a lower lesion fraction in the right developed a depressive mood disorder in the first month af- limbic area, specifically the cingulum. E, Max, “Depressive Disorders After Pedi- were associated with left temporal lesions and absence of left atric Traumatic Brain Injury. No statistically signif- Psychosis icant increase has been demonstrated in any single anxiety disorder compared with preinjury frequencies, but there Only two cases of new-onset nonaffective psychosis have was a trend in this regard for overanxious disorder (Vasa et been reported in studies of consecutive admission of 224 al. A more recent large study of that severity of brain injury and postinjury level of stress the association of multiplex schizophrenia and multiplex were associated with mood/anxiety disorders (Luis et al. Lesions of the superior frontal gyrus were signifi- higher for those with a diagnosis of schizophrenia, bipolar cantly associated with postinjury anxiety symptoms, where- disorder, and depression than for those with no mental ill- as frontal white matter lesions were associated at a trend ness (Malaspina et al. Four of 50 children (8%) from a pro- multiplex schizophrenia pedigrees does not appear to be a spective study of consecutive children hospitalized follow- phenocopy of the genetic disorder. A significant component of his that should frequently enter the differential diagnosis. After the injury she went through a period of appropriate mourning not complicated by de- Postconcussion Symptoms pression. Her friends and family noticed this dif- irritability and anger but no violent outbursts. This made ference and accepted that she had begun to take on more home life miserable. The syndrome had that accidents can happen easily and this was why she resolved after approximately 1 month postinjury. There were no signifi- need not necessarily be related to the direct effects of brain cant psychosocial stressors in the first month after injury. The syndrome did not depend on ir- it is a syndrome dominated by a new onset of potentially ritability for the diagnosis. He was sad and persistently drew pictures of graves and tombs, expressed hopeless- severe affective instability, aggression, or disinhibition/ ness, and had vegetative signs of depression. He thus re- markedly impaired social judgment and occasionally by ceived a diagnosis of postconcussional syndrome as well apathy or paranoia. A child age 5 years 3 months presented 29 months after be- ing involved in a motor vehicle accident. He was strapped in his car seat 446 Textbook of Traumatic Brain Injury and cried loudly immediately upon impact and then sucked development (Goldman 1971).
The commonest cause generic 10 mg accupril with visa, in Vascular malformations can be venous discount accupril 10 mg free shipping, capillary generic accupril 10mg otc, an adult, of a non-healing ulcer of the lip is a squa- arterial, lymphatic or mixed (see Chapter 5), and mous cell carcinoma. Aetiological factors include are clinically and histologically distinct from the exposure to sunlight, immunosuppression and pipe haemangiomata that affect neonates. The main differential diagnosis is a basal sified as high- or low-flow malformations. The sites are: Management lower lip – 95 per cent Surgical excision with a 5-mm margin of nor- upper lip – 5 per cent mal tissue taken in all dimensions around the oral commissure – 5 per cent. Metastatic disease is uncommon but when it The surgical defect is then reconstructed to does occur it involves the lymph nodes in the sub- maintain the muscular and sensory function of mental triangle and then the jugular chain. The mouth is in the centre of the face and ulcer is infected these lymph nodes may be enlarged it is essential that the lip be restored with tissues by inflammation. Larger defects may need local flap A simple punch biopsy is usually sufficient to con- reconstruction. Metastatic lymph nodes in the neck can be treated by block dissection with or without radio- Imaging therapy. However, nodes, as this is more sensitive and specific than the best results require fractionated treatments, clinical examination alone. Diagnostic pitfall: salivary gland tumour If there is no history of intermittent swelling, or if Mucocele the lesion is hard and not cystic on palpation, and particularly if it is in the upper lip, the swelling may A mucocele results from the extravasation of mucin be a minor salivary gland tumour. This triggers an inflammatory reaction which walls off the mucin with a fibrous Mucoceles can be excised through the mucosal lining, so forming a cyst. They are very rare in the surface of the lip, taking care to avoid any fibres of upper lip. Salivary gland tumours require a wider margin of surgical excision to ensure com- plete removal. Investigation Clinical diagnostic indicators Fibroepithelial polyp The diagnosis is clinical. Mucoceles present as a localized lower lip swelling which varies in size Fibroepithelial polyps are benign hamartomata. The swelling They consist of all the normal components of oral 272 The mouth, tongue and lips mucosa in a pedunculated lesion. They are thought It is possible to reduce the bulk of the lips surgi- to be caused by trauma as most arise on the lateral cally (cheiloplasty) if the medical approach fails. Symptomatic polyps can be removed by simple surgical excision This condition results from staining of the gums with local anaesthesia. Orofacial granulomatosis The process is most common in the mucosa lining Orofacial granulomatosis is diagnosed by finding the buccal aspect of the dento-alveolar processes of giant cell granulomata in a biopsy of a swollen lip. The lesion is blue- It is an allergic condition related to various food grey with an indistinct border. It is commonly affected, and it is rare to find lesions on more common in the upper lip. Investigation Conservative management is appropriate unless there is doubt about the diagnosis, when surgical Blood tests excision may be used for the purpose of obtain- It is associated with inflammatory bowel disease ing histological confirmation of the diagnosis and so it is important to obtain a full blood count and treatment. Malignant melanoma Tissue biopsy The oral mucous membranes are thinner than skin The histological diagnosis is made from a biopsy and lack the thick layers of epidermis and dermis. As of the mucosal surface of the lip, deep enough to a consequence the rich lymphatics of the submucosa sample the full depth of the submucosa. Satellite Angio-oedema is acute-onset swelling after contact tumours are common, and the regional lymph with an allergen. If inflammatory bowel disease is revealed and Investigation treated the oral symptoms will usually improve. A cinnamon- and benzoate-free diet should be Clinical diagnostic indicators tried if there is no obvious cause. Mucosal melanoma most commonly affects the Corticosteroids and other immune modulators palate. A C colour black and variable with darkening significant proportion of sublingual tumours are of pigmentation malignant. D diameter enlarging Management Tissue biopsy If the ranula is symptomless it does not need A biopsy, preferably excisional, should be obtained treatment. Partial excision or deroofing, a simple procedure Fine needle aspiration cytology can be used to that can be carried out with a local anaesthetic, will confirm the presence of lymph node metastases. Persistent recurrent lesions are best treated by Imaging excision of the sublingual gland. Exostosis Management An exostosis is a bony hard swelling arising from Surgical treatment of these difficult tumours should the cortex of the mandible or maxilla, of no known be planned at a meeting of the appropriate surgical cause and consisting histologically of normal bone. They are commonly found in the midline of the Excision of the tumour with a wide surgical hard palate (torus palatinus) and on the lingual margin is essential and may require major recon- aspect of the mandible (torus mandibularis) where struction. Their bony hard consistency is diagnostic and There is no cytotoxic drug regimen of any value. Conservative treatment is appropriate for the majority as they are usually symptomless and present as incidental clinical findings. A ranula is a mucus-containing cyst in the floor Odontogenic cysts of the mouth, usually in young people, caused by damage to the ducts of the sublingual salivary A wide variety of the pathological abnormalities gland. Clinical diagnostic indicators Dental cysts are relatively common and produce A ranula has the same bluish tinge as a mucocele of radiolucent swellings within the jaws. Dentigerous cysts arise from the follicle that surrounds the enamel of unerupted teeth. They Investigation have an epithelial lining that sheds cells into the Imaging cyst cavity, which then degenerate to produce a cholesterol-rich content. Plain radiographs may show the multilocular Odontogenic keratocysts arise from the oral ‘soap bubble’ appearance of an ameloblastoma epithelium that gives rise to the dental follicles. Management The presence of multiple keratocysts is a car- Surgical excision is the preferred treatment. The dinal feature of basal cell naevus syndrome (an entire lesion with a surrounding cuff of normal bone autosomal dominant condition which is character- must be removed. In the mandible, reconstruction ized by keratocysts, calcification of the falx cerebri, may be required. Lichen planus (white and red patches) Investigation Lichen planus may be found anywhere in the Imaging mouth without associated skin desease. Malignant Many odontogenic cysts present as incidental find- transformation is rare. Investigation Clinical diagnostic indicators Tissue biopsy Lichen planus frequently appears as lacy white Larger swellings should be biopsied as they might patches on a red background (striate type). Diagnostic pitfall: ameloblastoma It may be symptomless or be painful after eating Ameloblastoma can be misdiagnosed as a dental cyst. Although the clinical appearance of lichen pla- Management nus is often diagnostic, particularly when the lesions Infection is treated initially with antibiotics. Ulcers 275 Tissue biopsy important to make sure that the patient has good Incisional biopsies are for diagnosis not treatment, oral hygiene and does not wear any removable but if there is doubt about the true diagnosis it may dental prosthesis at night. This situation arises most often with an asym- Lesions on the tongue have the highest risk. Surgical metrical area on the tongue, where there is a high excision has the advantage that the whole lesion is possibility of cancer.
The ure- consists of tiny best buy accupril, saclike acini that secrete milk thral opening is a small tubular structure that during lactation buy accupril 10 mg cheap. The perineum is merging to form larger ducts as they travel the space between the rectal opening and the toward the nipple 10mg accupril with mastercard. Numerous sebaceous ing the urinary, vaginal, and anal openings and glands dot the surface of the areola. The greater these glands lubricates the areola, helping pre- vestibular glands (or Bartholin’s glands) lie on vent dryness and cracking during breastfeeding. Estrogen is are born with a fixed number of immature ova responsible for the changes that occur during housed inside thousands of ovarian follicles puberty, including breast development; depos- within the ovaries. The Puberty tends to begin earlier in females than fallopian tubes transport ova from the ovaries in males, at about age 9 or 10. The first sign of to the uterus; fringelike projections at the outer puberty in girls is breast development followed ends, the fimbriae, propel the ova into the tube. At about age 12 the first menstrual the ovum, which lives approximately 24 hours period (menarche) arrives. Beginning in adolescence and continuing until The uterus is a hollow, pear-shaped organ menopause, a woman’s reproductive system located between the urinary bladder and the undergoes cyclic changes called the reproductive rectum. The major portion of the uterus is cycle each month as it prepares for the possi- called the body; the cervix is the narrow portion bility of pregnancy. The ovarian and menstrual endometrium that is thickened by estrogen and cycles are interrelated with activities in both progesterone. Fundus of Isthmus of Ovarian Endometrium Uterine tube Myometrium uterus uterine ligament (Fallopian tube) tube Ampulla Infundibulum Uterine cavity Ovarian follicles Fimbriae Broad ligament Ovary Corpus Ovarian luteum vessels Internal os Fornix Uterosacral ligament Cervical canal External os Cervix Vagina Figure 11–2 Internal female reproductive tract. Estrogen and progesterone allows palpation of the posterior aspect of the secreted by the ovaries drive the menstrual cycle. During a pelvic examina- The reproductive cycle begins on the first day tion, a sample for a Papanicolaou (Pap) test may of noticeable vaginal bleeding or menstruation. D&C may be used in the estrogen and progesterone that promote thicken- diagnosis of endometrial cancer and treatment ing of the endometrium. As the follicle matures it migrates to reproductive system and can aid the diagno- the surface of the ovary. The fimbriae sweep the ovum into the fallo- female reproductive organs (Figure 11–3 and pian tube. After ovulation, estrogen levels decline Figure 11–4 ), colposcopy is used to visualize the rapidly. Once the ovum has been released from cervix, and the uterine lining can be inspected the ovary, the empty follicle is converted into the with hysteroscopy. These visualization techniques corpus luteum, which secretes large amounts of can be used to diagnose some cancers, dysmen- progesterone. Other laboratory tests that may and progesterone cause the reproductive cycle to be performed include urinalysis and blood tests begin again. Diagnostic Tests and Procedures Physical examination of the female reproductive Diseases of the Female system begins with a pelvic examination. A pelvic examination can detect certain cancers in their Reproductive System early stages, infections, and other reproductive system disorders. Chapter Eleven Diseases and Disorders of the Reproductive System L 225 Laparoscope Fallopian tube Ovary Uterus Light source Figure 11–3 Laparoscopy. Cervical Cancer Cervical cancer is a malignant neoplasm that Figure 11–4 Photograph taken during a laparoscopic proce- forms within tissues of the cervix. Women with early cervical cancers usually Endometrial Cancer have no signs or symptoms until the cancer Endometrial cancer forms in the tissue lining the becomes invasive and grows into nearby tissue. Other types of cancer can form in the When this happens, the most common signs uterus, but they are much less common than and symptoms are abnormal vaginal bleeding, endometrial cancer. The average age of diagno- approximately two-thirds of all cervical cancers sis is 60. Imaging tests may ment therapy, never having given birth, family be used to aid in staging the cancer. The 5-year history of uterine cancer or Lynch syndrome, relative survival rate for localized cervical cancer and obesity. The 5-year relative survival rate bleeding after menopause, abnormal bleeding, for all stages combined is 70%. Treatment for abnormal vaginal discharge, pelvic pain, and precancerous lesions may include cryosurgery pain during intercourse. The etiology of endo- (freezing), cauterization (burning), and laser sur- metrial cancer is idiopathic. Treatment for cervical cancer may include cancer cells possess receptors for estrogen, surgery, radiation therapy, and chemotherapy. Prevention of cervical cancer includes regular Diagnosis requires a medical history, pelvic Pap tests to find precancers before they can turn examination, hysteroscopy, removal of endo- into invasive cancer. Removing the cancer via surgery is the Cervical cancer screening information from the most common treatment for endometrial cancer. Endometrial cancer Academy of Pediatrics recommends that all girls cannot be prevented, but screening can identify and boys between the ages of 11 and 12 receive early cancer. Chapter Eleven Diseases and Disorders of the Reproductive System L 227 Fibroid Tumors of the Uterus birth, and a personal or family history of ovarian, breast, or colorectal cancer. Fibroid tumors (leiomyomas) are benign tumors Signs and symptoms may include bloating, of the smooth muscle of the uterus. Fibroid pelvic or abdominal pain, trouble eating or feel- tumors are the most common tumors of the ing full quickly, and changes in urinary urgency female reproductive system, affecting 20–40% of or frequency. About 20% of ovarian cancers tor for developing uterine fibroid tumors is being are found at an early stage, but most ovarian a woman of reproductive age. Treat- do occur, signs and symptoms include excessive ment options include surgery, radiation therapy, vaginal bleeding, pelvic pressure, abdominal and chemotherapy. If detected early ovarian can- pain, abdominal enlargement, and pain dur- cer has a 5-year survival rate of approximately ing intercourse. Treatment for uterine fibroid tumors no effective screening and an unknown etiology, depends on severity of signs and symptoms and ovarian cancer remains unpreventable. Oral contraceptives may decrease the bleed- Breast Cancer ing caused by uterine fibroid tumors. Uterine Breast cancer is a malignant tumor that forms artery embolization shrinks uterine fibroids by in tissues, ducts, or glands of the breast. Focused ultra- cancer is found mostly in women, but men can sound surgery destroys uterine fibroid tumors get breast cancer. Endometrial 2013 approximately 232,340 cases of invasive ablation destroys the endometrium and reduces breast will be diagnosed and 39,620 women the amount of bleeding during menstruation. One-third of hysterectomies per- nosed with breast cancer and 522,000 died of formed in the United States are due to uterine breast cancer worldwide in 2012. Unfortunately, these common affects women of all ages, although the aver- tumors cannot be prevented. Risk factors include age, never having given birth, having your first child after age 35, beginning menopause after Ovarian Cancer age 55, genetic risk factors, being overweight or Ovarian cancer is a malignant neoplasm arising obese after menopause, lack of physical activity, in tissues of the ovaries.
Plasma or plasma Surgical Factors tachycardia best purchase for accupril, hypotension 10mg accupril overnight delivery, poor senso- expander is given quickly to restore the Postoperative drains helps to drain the pus or rium buy accupril master card, confusion and shrunken eyes. Nasogastric aspiration with Ryle’s tube of allowing it to spread all over the abdomen. The signs clammy skin, dry tongue, drawn and anx- prevents vomiting and gives rest to the and symptoms will vary according to location, ious face, called Hippocratic facies. Analgesics should not be administered to there is associated tachycardia and fever. The source of peritonitis is located and rated peptic ulcer, leakage following biliary Posterior approach is no longer advocated appropriate surgical procedure is done e. Rarely infection occurs from hematog- Currently anterior or lateral subcos- • Repair of perforation for perforated enous spread or direct spread from a chest tal approach is more favored and it is wise peptic ulcer. Clinical Features be assessed by subsequent ultrasound assess- • Resection and anastomosis of bowel for Subphrenic abscess usually follows general- ment or sinogram. Straight duce frequency or urgency while that of X-ray shows multiple gas-flled loops with Signs the rectum will give rise to diarrhea and fuid levels. Tese are • In late cases a palpable mass may be felt Diagnosis is confrmed by per rectal exami- subphrenic abscess and pelvic abscess. Abscess is sur- cavity collapses afer a few days Postoperatively phragm above and the transverse colon with rounded by sharp echogenic wall. Chapter 41 The Peritoneum Tuberculous Peritonitis • Umbilical hernia or congenital hydrocele iii. Traumatic rupture of the gallbladder or The incidence of tuberculosis has declined appears in children due to increased its ducts due to gunshot, wound or closed over the past several decades. Nephrectomy (Right) Source of Infection In this variety ascitic fuid is present in one b. Right hemicolectomy Tuberculous peritonitis is always secondary quadrant of the abdomen which is sealed c. Clinical Features sible sites of primary are: Other cystic swellings in the abdo- • The patient usually presents with signs i. Pulmonary tuberculosis men such as pseudocyst of the pancreas, and symptoms of difuse peritonitis with ii. Intestinal tuberculosis mesenteric cyst, and retroperitoneal cyst are a degree of shock. Fibrous Peritonitis Treatment In most of the cases tuberculous peritoni- In this variety, there is no ascites but there is • Laparotomy is required to deal with tis results from reactivation of latent primary extensive fbrosis, which results in dense adhe- the underlying condition following peritoneal form. It produces the following pathological • It is seen in females as a complication of changes. Exudation with minimal fbroblastic reac- genital tract and there is always a second- from a suture line. Extensive fbroblastic reaction – plastic or on intestines or biliary tract, when a patient fbrous peritonitis. Fibroblastic with secondary infection – Tis consists of antituberculous chemotherapy. Surgery is needed for the relief of intesti- The condition is ofen difcult to diagnose nal obstruction from adhesions. Ascitic Form Oliguria may be an early indicator of post- Etiology • It is common in children and young adults operative peritonitis. Following biliary surgery-Damage to • Leak or abscess cavity is confrmed by extensive fbrosis. A hernia is an abnormal protrusion of the hernia whole or a part of a viscus through an open- Less common hernias include 1. It is in between the lateral crus attached to the pubic tubercle and the medial crus attached to symphysis pubis, derived from the external oblique aponeurosis and the base is formed by the pubic crest. The deep inguinal ring is lateral (a) Anterior-Skin, superfcial fascia, to the inferior epigastric artery external oblique aponeurosis and Chapter 42 Hernia feshy fbers of the origin of internal • Neck of direct hernia is medial to the Hernial Contents oblique in its lateral 1/3rd. Hernias are named variously according to the (b) Posteriorly-Fascia transversalis along nature of the hernial content, e. Omentum-When the hernia is called ing it from extraperitoneal fatty tis- omentocele. A loop of intestine-When the hernia is half there are conjoined tendon and It is a herniation of abdominal contents called enterocele. Meckel’s diverticulum-Tis is called (c) Superiorly-Tere are arched fbers inguinal canal. Two loops of intestine in the manner of (d) Inferiorly-Inguinal ligament and outside within viz. Obliquity of inguinal canal (in children According to the extent of hernia three types Irreducibility may be due to: it is straight)-Tis favors the apposi- are found i. Omentocele as the omental fat gets rise of intraabdominal pressure thereby ally young and presents with an inguinal adhered to the sac. During straining or coughing, the con- vaginalis closes just above the epididymis. A huge hernia, ofen called scrotal joint tendon contracts and as it forms So the contents of the hernia can be felt abdomen. Presence of solid fecal mass (incar- boundaries; it closes the inguinal canal the hernia. Tis usually occurs in adults ceration) in the lumen of the colon producing a shutter or sphincter like and a long-standing history is received in occupying a hernial sac. Complete (scrotal type) hernia-Here the ible hernia containing intestine which is muscle pulls up the spermatic cord hernial contents descend upto the bottom obstructed from outside or within but there into the canal and plug it during rise of of scrotum. The testis is felt posterior to is no interference of blood supply to the intraabdominal pressure. Strangulated hernia-A hernia is said to be -Boundary: being continuous with tunica vaginalis of strangulated when the blood supply of its Laterally-Inferior epigastric artery. It is a congenital hernia, com- contents is seriously impaired, rendering the Medially-Lateral border of rectus monly seen in children but it may appear contents ischemic. Sac, (b) Contents of the sac, (c) Coverings 6 hours afer the onset of frst symptoms. The sac and its coverings has been strangulated hernia is usually tense, tender the inferior epigastric artery. Direct hernia is more common in Afer the reduction of hernia deep ring the elderly people while indirect hernia is is occluded by the pressure of the thumb Direct Inguinal Hernia more common in younger and adult life. Clinical Examination of indirect hernia and the test is said to be • Usually bilateral and acquired. Inspection • Index fnger is kept at the deep ring, • The neck of the direct hernial sac is wide i.