ness, chronic coughing, constipation, diarrhea, sudden strain, or blows on the abdomen.

Symptoms.-Rupture first appears as a fullness or swelling, more noticeable on standing, lifting, coughing, or straining. It may disappear entirely on lying down or on pressure with the fingers. In the beginning there may be discomfort after standing or walking for any length of time, and later there is often a dragging pain or uneasiness complained of, or a sensation of weakness or griping at the seat of the rupture. In case the rupture cannot be returned, it is called irreducible and is a more serious form. The great danger of hernias is the likelihood of their being strangulated, as the term is; that is, so nipped in the divided abdominal wall that the blood current is shut off and often the bowels are completely obstructed. If this condition is not speedily relieved death will ensue in from two to eight days. Such a result is occasioned, in persons having rupture, by heavy lifting, severe coughing or straining, or by a blow or fall. The symptoms of strangulated hernia are sudden and complete constipation, persistent vomiting, and severe pain at the seat of the rupture or often about the navel. The vomiting consists first of the contents of the stomach, then of yellowish-stained fluid, and finally of dark material having the odor of excrement. Great weakness, distention of the belly, retching, hiccough, thirst, profound exhaustion, and death follow if the condition is not remedied. In

some cases, where the obstruction is not complete, the symptoms are comparatively milder, as occasional vomiting and slight pain and partial constipation.

If the patient cannot return the protrusion speedily, a surgeon should be secured at all costs-the patient meanwhile lying in bed with an ice bag or cold cloths over the rupture. The surgeon will reduce the protrusion under ether, or operate. Strangulation of any rupture may occur, but of course it is less likely to happen in those who wear a well-fitting truss; still it is always a dangerous possibility, and this fact and the liability of the rupture's increasing in size make a surgical operation for complete cure advisable in proper subjects.

Treatment. Two means of treatment are open to the ruptured: the use of the truss and surgical operation. By the wearing of a truss, fifty-eight per cent of ruptures recover completely in children under one year. In children from one to five years, with rupture, ten per cent get well with the truss. Statistics show that in rupture which has been acquired after birth but five per cent recover with a truss after the age of fifteen, and but one per cent after thirty. The truss must be worn two years after cure of the rupture in children, and in adults practically during the rest of their lives. A truss consists of a steel spring which encircles the body, holding in place a pad which fits over the seat of hernia. The Knight truss is one of the best. The truss is most satisfactory in ruptures

which can be readily returned. In very small or large hernias, and in those which are not reducible, the action of the truss is not so effective. In irreducible ruptures there is likely to be constipation and colic produced, and strangulation is more liable to occur. A truss having a hollow pad may prove of service in small irreducible ruptures, but no truss is of much value in large hernias of this kind. Every person with a reducible rupture should wear a proper truss until the rupture is cured by some means. Such a truss should keep in the hernia without causing pain or discomfort. It should be taken off at night, and replaced in the morning while the patient is lying down. In cases where the protrusion appears during the night a truss must be worn day and night, but often a lighter form will serve for use in bed. To test the efficiency of a truss let the patient stoop forward with his knees apart, and hands on the knees, and cough. If the truss keeps the hernia in, it is suitable; if not, it is probably unsuitable. Operation for complete cure of the hernia is successful in 95 cases out of 100, in suitable subjects, in the ruptures in the groin. The death rate is but about 1 in 500 to 1,000 operations when done by surgeons skilled in this special work. Patients with very large and irreducible hernias, and those who are very fat and in advanced life, are unfavorable subjects for operation. In young men operation—if it can be done by a skillful surgeon and in a hospital with all facilities-is usually to be recommended

in every case of rupture. Umbilical hernias and ventral hernias, following surgical operations, may be held in place by a wide, strong belt about the body, which holds a circular flat or hollow plate over the rupture. These have been the most difficult of cure by operation; but recent improvements have yielded very good results-thirty-five cures out of thirty-six operations for umbilical rupture, and one death, by Mayo, of Rochester, Minn.-and they are usually the very worst patients, of middle age, or older, and very stout.

Umbilical rupture in babies is very common after the cord has dropped off. There is a protrusion at the navel which increases in size on coughing, straining, or crying. If the rupture is pushed in and the flesh is brought together from either side in two folds. over the navel, so as to bury the navel out of sight, and held in this position by a strip of surgeon's plaster, reaching across the front of the belly and about two and one-half inches wide, complete recovery will usually take place within a few months. It is well to cover the plaster with a snug flannel band about the body. The plaster should be replaced as need be, and should be applied in all cases by a physician if one can be secured.

VARICOSE VEINS.-Varicose veins are enlarged veins which are more commonly present on the legs, but are also seen in other parts of the body. They stand out from the skin as bluish, knotty, and winding cords which flatten out when pressure is made

upon them, and shrink in size in most cases upon lying down. Sometimes bluish, small, soft, rounded lumps, or a fine, branching network of veins may be seen. Oftentimes varicose veins may exist for years —if not extensive-without either increasing in size or causing any trouble whatsoever. At other times they occasion a feeling of weight and dull pain in the legs, especially on long standing. When they are of long duration the legs may become swollen and hard, and eczema, with itching, is then not uncommon. This leads to scratching and sores, and these may enlarge and become what are called varicose ulcers, which are slow and difficult of healing. Occasionally an old varicose vein may break open and give rise to profuse bleeding.

Causes. Varicose veins are more frequent in women, especially in those who stand much, as do cooks. Any obstruction to the return flow of the blood from the veins toward the heart will produce them, as a tight garter about the leg; or the pressure of the large womb in pregnancy upon the veins, or of tumors in the same region. Heart and lung diseases also predispose to the formation of varicose veins.

Treatment. Varicose veins are exceedingly common, and if they are not extensive and produce no discomfort they may be ignored. Otherwise, it is well to have an elastic stocking made to come to, or above, the knee. The stocking should be put on and removed while lying down. Cold bathing, outdoor exercise, and