By A. Lukar. American University of Hawaii.
Plaque erosion has been more commonly found in gency rooms in less than 2 hoursthe golden time women younger than 50 years buy caverta 100 mg otc, and is highly associated period for reperfusion therapyunderscoring the need with cigarette smoking purchase caverta 50mg fast delivery. Heart and Estrogen/Progestin Replacement Study Aspirin has been shown to be of benefit in females cheap caverta 100mg line. Both strategies have shown benefit in that younger buy discount caverta 100mg line, nondiseased vascular tissue may be more women and men. Women con- 10,000 pregnancies, with slightly less than half the cases tinue to show higher death rates, higher transfusion being caused by cholesterol plaque. Spontaneous coro- rates, and higher rates of vascular complications after nary thrombosis (clot formation) without underlying percutaneous intervention. Furthermore, women less fre- Increased vascular reactivity during pregnancy may also quently received stents than their male counterparts. Use of oxytocin (Pitocin), which is used to induce labor, may play a role as well. This ominous complication of Lifestyle change, regular exercise, weight loss, and pregnancy is thought to occur because of hormonally quitting cigarette smoking are very important in pre- mediated biochemical and vascular changes occurring venting heart attacks. Over the past several decades, we have nancy or oral contraceptive, must not be ignored. The Framingham Heart Study is partic- cially efficacious as an initial treatment strategy in ularly useful because, unlike many other older medical females because of the increased risk of hemorrhagic studies, it included women from its beginning in 1948. This is particularly the case given the longer no longer has a meaningful role to play. The reasons for the female advan- tage remain unclear but cholesterol levels appear to play Suggested Reading some role. While hormone replacement therapy replacement therapy and cardiovascular disease: A statement for healthcare professionals from the American Heart Association. This appears to be particularly the case in the disability in developed countries. This makes hypertension of lipids, the majority of cases of elevated levels of the most prevalent of risk factors with over 80 million cholesterol result from lifestyle factors. These include Americans defined as having high blood pressure (tra- sedentary lifestyle, obesity, and diets high in total and ditionally defined as a reading of 140/90 mm Hg as saturated fats. Initial medical studies of antihypertensive treat- as less than 40 mg/dl for men but a level less than ments clearly demonstrated a benefit of treatment in 50 mg/dl is considered a marginal risk factor for women men as well as elderly women with insignificant effect and frequently is a marker of the metabolic syndrome. This was Dietary modification by reducing fat intake and likely because most trials did not include sufficient increasing fiber content is often the first step in therapy numbers of women to come to a reliable conclusion. In for those with elevated cholesterol levels and should fact, 3 of the 10 major older clinical trials (a type of be used in conjunction with drug therapy when this medical study) excluded women. Highly effective and potent medications, recent studies that clear benefit for women was demon- namely, the statin class of drugs, are now available strated. Western societies contains between 50 and 100 g of fat Most recently, the Heart Protection Study enrolled and 0. Patients treated with sim- lipoproteins lead to elevated levels of cholesterol and vastatin had a 27% reduction in major coronary events. While some individuals have This benefit was similar in both sexes and was, inter- genetic abnormalities that lead to impaired metabolism estingly, irrespective of initial cholesterol level. As is the case in patients with male patients can significantly reduce cardiovascular diabetes, management of those with the metabolic syn- complications. This is largely due to the increasing prevalence Cigarette smoking is the most important pre- of obesity as well as the aging of the population. It remains the major pre- morbidity and mortality of diabetes is mostly due to ventable cause of early death, disability, and health atherosclerosis. Estimates suggest that 11% appears that diabetes confers a higher degree of risk on of deaths in women are attributable to smoking and females than males. The number of ciga- betes have an absolute risk for coronary events similar rettes smoked per day is directly related to cardiovas- to diabetic men. Smoking as few as 14 or 514 cigarettes The metabolic changes in diabetes are complex a day increases the risk of coronary events two- to and a major reason for the increased risk is the alter- threefold. In addition, smoking is a major contribu- diabetes have a more abnormal lipid profile, which may tor to the incidence of stroke and peripheral vascular explain their particular susceptibility to atherosclerosis. Along with aggressive con- The need and benefits of smoking cessation cannot trol of the blood glucose level, other risk factors such be overemphasized. Stopping cigarette smoking is a dif- as hypertension and lipid abnormalities should be opti- ficult task and often requires a multifaceted approach mized. The target blood pressure in a patient with dia- including patient education, pharmacologic agents as betes is no more than 130/80 mm Hg as measured with well as a close partnership between the patient and the a blood pressure cuff. This is particularly important since A syndrome in which multiple cardiac risk factors data suggest that smoking cessation techniques are less are present, so-called syndrome X or insulin resis- effective in women and that women have higher tance syndrome, is marked by truncal obesity (waist of relapse rates. The National that this protein serves simply as a marker of the pres- Institutes of Health Consensus Panel on Physical ence and extent of atherosclerosis instead of playing Activity and Cardiovascular Health recommends that a a causative role. Some of the same medications used person accumulate at least 30 minutes of moderate in the treatment of elevated cholesterol levels also intensity physical activity on a daily basis. Smoking, hypertension, between elevated levels of homocysteine in the blood and diabetes were associated with a 2. This could be one of the major reasons why Hypertension, Nutrition, Smoking people seek plastic surgery. Both men and women feel the pressure to look their best, and more men are seek- Suggested Reading ing plastic surgery because of this very fact. How we feel about our- Expert Panel on Detection, Evaluation, and Treatment of High Blood selves affects how we relate to others. Journal of the American Medical many people who might be considered homely are per- Association, 285, 24862497. Mayo Clinic Proceedings, with ones self-image and allow healthy self-confidence 73, 157165. Risk factors that attenuate a psychological evaluation may be suggested prior to the female coronary disease advantage. The choice of surgeon can be the most important prevention of coronary heart disease in women. If the plastic surgeon is board eligi- Risks and benefits of estrogen plus progestin in healthy post- ble, it means that he/she has completed education, but menopausal women. In addition, a lot of the plastic surgeons have their own webpage, which can educate you about that particular person. Cosmetic Surgery Cosmetic surgery (also called Asking other patients about your surgeon can provide plastic surgery) is used both to correct true deformities very valuable information. In our culture, not cover cosmetic surgery, so checking with your there is a tremendous emphasis placed on our personal insurer is very important as well. No one ever sees a should carefully consider the risks and benefits before 200 Couples Therapy undergoing any procedure. Undergoing cosmetic assess how strong the boundaries are around the couple surgery involves a large commitment on the part of and around each individual. Suggested Resources Intergenerational Therapy as developed by Murray Website: www. Goals of therapy are to help the couple through insight, understand their family of origin issues so they are less Couples Therapy All individuals have a basic likely to repeat them. At the same time, we also have a basic need such theorists as Albert Ellis and Neil Jacobson focuses to be separate and develop our individual potential. The cognitive therapist helps Balancing these conflicting needs is the central issue of the couple pinpoint how they act toward each other to intimate relationships and helping couples establish or try to control each other in order to get their needs met. This is addressed by understanding how the destructive behavior and the beliefs that support that couple manages, respects, and accepts differences. Accepting differences supports individual development Solution-Focused Therapy as developed by Steve and frees partners to be truly intimate by reducing the DeShazer and his colleagues proposes that a couple inevitable power struggles which emerge when chang- does not need to understand a problem to develop a ing a partner takes precedence over acceptance. The focus of the work is identifying Couples therapy can address the needs of married strengths and resources to be adapted to create a solu- couples, same-sex couples, premarital couples, or cou- tion. Goal setting is central to the approach and is ples in a committed relationship who have chosen not accomplished by identifying specific behaviors and to marry.
In one week discount caverta 100 mg visa, all his dental work was done; we omitted to record in his file what was done discount caverta 50 mg otc, however caverta 100mg otc. Somehow caverta 100 mg generic, he continued getting copper, in spite of moving to the copper-free motel. Nevertheless, tumor activity was stronger than before, in some respect, since the alk phos was up. We increased his glutathione to 500 mg, eight a day to help the liver detoxify everything. By the end of the second week, May 18, he was still frequently Positive to copper; he had to switch motel rooms again. And he was given caster oil packs to place in the groin area every night, both to ease pain and provide immune stimulation. Although the blood test showed some improvement from the time of ar- rival three weeks ear- lier, his best news was tucked under his arm as he brought in his new ultrasounds. Its contour was now rough; it was beginning to fragment judging by density change. And with the admonition to do a scan or ultrasound once a month till it was all gone and a blood test that included serum iron. Little could we perceive that obtaining these elementary data records would not be easy even in a country like Canada with a May 27 tumor down to 4. But after that, a new tumor grew in the empty location where the kidney had been (called the renal fossa). He had started the parasite program eleven days ago, but still had iso- propyl alcohol built up in him. Calcium was too low, due to malonic acid and other toxins appearing in the parathyroid glands. A generous level of triglycerides and enough cholesterol would cer- tainly help him succeed. But there was no time to gloat over his good health; there was a tumor to shrink, and he had come many miles to do this. He was ad- vised to move into a mobile home with plastic water pipes tempo- rarily while his plumbing got changed. All supplements had to be procured from us to be sure they had been tested and were free of the common tumor-causing pollutants. On June 26 although copper and fiberglass were now Negative, he still tested Positive for Staphylococcus at the kidney location. He had just begun dental cleanup, but hadnt been using white iodine to brush; he was quickly started on it. In case the calcium should go too high, the albumin is present to sponge it up and take it out of action in the bloodstream. Although calcium had come up significantly, it was still low, a parathy- roid problem. Testing at the parathyroid showed copper and vanadium Negative there, but glutathione, biotin, and glutamine were also Negative. With glutathione Negative, this tipped us off that a heavy metal was still present or a malonate. An ultrasound of the kidney tu- mor was scheduled since it had been six weeks since he began the cancer program. The radiologist, not being able to see anything at the left kidney site (remember it had been surgically removed) thought the patient must be mistaken so he took the ultrasound of the right kidney instead. When the patient returned, the missing ultrasound of the left side was seen as an error so the patient was sent back to the radiologist. But the radiologist explained to the patient there was nothing to take, since the kidney was gone, so why spend the money? It seemed unfair to send him a third time just to get the missing tumor namely, nothing on record. Remi and his family were pleased and convinced, although only the radiolo- gists word could ascertain that the tumor in the left kidney fossa was gone. Tumor gone, was this rotten tooth By now we had begun to suspect dental plastic as the the culprit? He was advised to have it all re- viewed, tested by the staff with scrapings or chipping of the plastic; and some of it replaced, again! He prom- triglycerides 214 251 170 ised to send an ultrasound cholesterol 171 182 204 from home in August. This time to request an ultrasound of the location of the space where the left kidney had once been. It started as non-Hodgkins lymphoma, but a year ago there were several brain lesions found by scanning. One was removed surgically and was diagnosed as diffuse large cell non-Hodgkins lymphoma, intermediate grade. She then got ten radiation treatments to the head, which brought two of the remaining lesions down to 1. She began going to sleep for half hour periods during the day, her balance was bad, and her eyes werent focusing so she couldnt read any- more. We reviewed her scan on May 8; we could see what looked like a disor- ganized tangle in the thalamus filling the depression that hangs down and mushrooming above it. If the tumor could be shrunk in a permanent way, she would not need to recover from anything. The calcium level was too low, showing that the metabolic problem in- volved the parathyroid gland. Iron showed some depression (it should be about 100), but not enough to interfere with red blood cell formation. Al- though her blood fats (triglycerides) were much too low, cholesterol level was excellent. She was reminded that her urine would look bluenot to worry about turning into a blueberry. The next day, though, May 4, she was still testing Positive for copper at the brain and liver; it was found polluting the dilantin pills she was taking. They had already moved twice to different rooms in their motel, each time bringing the tap water in to test for copper. It would mean sitting in a long line of border traffic each day, but at least the copper problem would disappear. Her blood test, done May 16, showed the typical drop in uric acid as it becomes unmasked by folic acid and other supplements. This results in almost no purines (nucleic acids) being formed or used (catabolized) and hence a low uric acid. The contrast medium brings in all the lanthanide elements, causing serious immune lowering. Until we know which part of her treatment program was responsible, we do not understand it and can- not abbreviate it in any way. Certainly her iron level had become normal (about 100), indicating the absence of com- peting heavy metal, specifically copper [and germanium]. She would now be able to make more red blood cells and improve her immunity so deadly bac- teria could no longer live in her brain lesion. They were getting ready to leave as a happy couple again feeling, as we all did, that their mission had been accomplished. But a marble-like lymph node had popped out at the left side of her neck near the collar bone. Her toxin test showed she was getting toluene on a daily basis; this would certainly go to her brain. She was not drinking commercial beverages, so toluene was suspected in the pre- scription pills and capsules she was taking. We gave Karl the malonate-free food list; his determination was greater than ever. She was Positive for Staphylococcus aureus at the lymph nodes; we knew the problem would be dental since the lymph nodes at the neck drain the mouth fluids.
When you look at 1 Peter 1:23 in this context cheap 100 mg caverta fast delivery, it becomes strongly sug- The Impact of Zoe on The Human Body gestive of something order caverta 100 mg visa. There is a perishable sperm - you can grind a mans sperm to death; a plants seed can be ground to death caverta 100 mg amex, but the sperm of God 50 mg caverta amex, by which you were born again, is imperishable and in- destructible, Hallelujah! When you were born again it was the seed of God that came to you and produced life in you. If truly we have Gods life (Zo) in us, that brings life to our spirit, soul and body, where then is the place for sickness? No wonder Isaiah prophesied concerning us, saying, Those that live therein (in Zion) shall not say, I am sick (Isaiah 33:24). You can have your life marked in the right direction only; the direction of success, prosperity and the good life. The epidemic was so contagious that mere touching of those already in- fected could lead to an infection. When asked about it, he replied that another kind of life was at work in him and that if the disease germs came in contact with his body, this life in him would burn them up and destroy them. They took a sample containing these germs and dropped some on the back of his hand. They actually viewed his hand underneath a microscope to ensure the germ cells were alive. After a few hours, they checked under the microscope again and the germ The Impact of Zoe on The Human Body cells had stopped moving. Everyone there looked on at him, expect- ing him to swell or suddenly fall down dead. But Paul just shook off the viper into the fire and no harm came upon him (Acts 28:1-6). When you are Zo-conscious, no germ cell, no matter what it is called, can have a home in your body or dominate your body. More often, people ask the lepers question, who questioned not Gods abil- ity, but His willingness to heal. They even know Hes done it for others and can relate the testimonies of other people If Thou Wilt... He was not only sick in his body, he was an outcast, isolated from the society because of his contagious disease. But he had heard of Jesus and was desperate enough to want to find out if this Teacher from Nazareth would want to do something about his condition. I believe that day He must have known He was answering the ques- tion in the heart of not only people who were then present but also that of generations to come. With a lot of com- passion, He stretched forth His hand, touched the leper and said, I will: be thou clean (Mark 1:41). If you read the next verse you will discover that the man actually got healed as soon as Jesus spoke the word, not as soon as He touched him. Verse 42, And as soon as he had spoken, im- mediately the leprosy departed from him, and he was cleansed. There is a record of another sick man who didnt even have enough sense to know it was the Creator of the universe who was standing before him. During one of our healing crusades - Night of Bliss - a young man came up to share his testimony. Of course, that woke him up to discover he had been instantly healed by the power of God! God said, Beloved, I wish above all things that thou mayest prosper and be in health, even as thy soul prospereth (3 John 2). If society has made you an outcast because of your sickness; if your infirmity has isolated you from the mainstream of life, from living life in health and abundance; if youre sick and wondering if God can ever do something about it, I want you to know that God is more willing to heal you than you are willing to be healed. Just like the disciples asked Jesus concerning the blind man, Who did sin, this man, or his parents that he was born blind? God Somebody said, God put that sickness on me because, Knid He knew if I was not sick I would have done such-and- of such. The same fellow who said God put the sick- ness on him to make him humble goes straight to the doctor to take away what God put on him to make him humble. He says its Gods will to make him sick because God wants him to be humble, but then he starts taking drugs to take away what God put on him to make him humble. Some people give the examples of the Egyp- tians to illustrate that God actually put sickness on people to make them humble. The only problem is those people have forgotten that the Egyptians were not the people of God. The Bible lets us know there are indeed clay pots fitted for destruc- tion, but this doesnt refer to the children of God! Some people are so hypocritical, they will criti- cize any minister who preaches prosperity and di- vine healing. Never criticize a christian or a minister of the gospel who teaches divine healing or prosper- ity. The same people who criticize such ministers would go to work six days a week but wouldnt open their Bibles or pray just as often. In fact, if such people had a fever during the week, they would still drag themselves to work. And just the one time they come to Church, they say, I wish the Pastor would talk about righteous- ness and holiness and leave prosperity and divine healing out. No one can pretend to go to work every- day of the week just because he loves his boss or be- cause he loves the nation. Do you know after Jesus healed a man who had had an infirmity for thirty-eight years at the pool of Bethesda, the Pharisees complained? Accord- ing to their understanding, no work was supposed to be done on a Sabbath day. And because Jesus told the man, Rise, take up thy bed, and walk they consid- ered carrying his bed to be work. This man had suffered for thirty-eight long years; no one remembered the sabbath all that time. It wasnt a day of sitting at home, it was a day of rejoicing, a day of rest from trouble, rest from worry and pain and rest from disease and infirmity of the body. Nobody ever told that man the truth, and just on the day Jesus gave him rest from pain, they all came shouting, Its the Sabbath! We were not even born when Jesus went to suffer for our sins on the Cross and took our pains upon Himself. What more could our God have don to demonstrate His desire for our complete well being? You have to realize that sickness is destroyed Sickness cannot have a home in your body. Her daughter was grievously oppressed by the devil and she went to the Master for help. And he laid his hands on her: and immediately she was made straight, and glori- fied God. The Lord then answered him, and said, Thou hypo- crite, doth not each one of you on the sabbath loose his ox or his ass from the stall, and lead him away to watering? And when he had said these things, all his ad- versaries were ashamed: and all the people rejoiced for all the glorious things that were done by him. God doesnt want us bound by Satan, nor does He want any of the diseases of the Egyptians on us. If this womans only claim to divine healing was her decendancy from Abraham, we have more. Jesus died for our sins and sicknesses on the Cross so we dont have to be sick again. Healing Is Not Coming To You, Its Already Yours Beyond Gods willingness to heal us and heal- ing being part of our inheritance as children of Abraham, is another wonderful truth - Healing is not coming to us, its already ours! Listen to me, healing al- ready came to us at the Cross, before Jesus was raised again to life. Now that Hes been raised to life, the Bible says, Likewise reckon ye also yourselves to be dead indeed unto sin, but alive unto God through Jesus Christ our Lord (Romans 6:11). But he was wounded for our transgressions, he was bruised for our niquities: the chastisement of our peace was upon him; and with his stripes we are healed. So Isaiah was looking forward to the Cross where he knew we would receive our healing.
Open the inguinal area about 2cm distal to the inguinal If the testicle swells (not uncommon after a difficult ligament and try to clamp the vein on both sides of the hernia repair) order 50mg caverta, this is usually due to thrombosis of the hole buy caverta 100 mg with mastercard. This usually settles and leaves a normal fine 4/0 or 5/0 monofilament set 1mm apart; otherwise use testis discount 100mg caverta amex. It is then worth using an The leg will be oedematous postoperatively order 50mg caverta visa, but this is antibiotic. Do not tie the saphenous or profunda femoris veins, because these will not control If the testis atrophies, you have probably interrupted the bleeding from the femoral vein. If you think that you have injured the bladder, You will not be able to revive the testis, so remember the repair its mucosa, and its muscle with absorbable suture. If urinary retention develops, insert a urinary catheter; remove the catheter when the patient is eating, walking, If you find an inflamed appendix in the hernial sac and pain free. If you have used a mesh and infection persists, you may have to remove this to allow the infection to If a piece of bowel has a white ring on it, settle. This will prove to be a messy and difficult a (Garr) stricture may develop later at the site of the ring operation, so have some blood ready and take your time. So, if you can, resect this The result will be a severe weakness in the inguinal area, segment of bowel. If a loop of bowel escapes into the peritoneal cavity, If a faecal fistula results, you have injured the bowel. If you find a Meckels diverticulum in the hernia sac (Littrs hernia), amputate the diverticulum and close the bowel with absorbable suture. This is unusual, 500ml air every alternate day progressively into the and occurs with a hernia previously already strangulating peritoneal cavity through the linea semilunaris (18-3) bowel (18. Isolate the loop of bowel trapped in This will allow easier return of abdominal contents. If groin pain radiating to the scrotum persists Proceed as for a simple hernia repair (18. One way of reducing the risk of scrotal haematoma is to use tape to secure the empty floppy scrotal sac for 48hrs to the anterior abdominal wall with 2 pieces of gauze 18. It used to be said that there were two kinds of inguinal hernias in the tropics: those above the knee and those below it! If it is not completely obliterated it abdominal content that reduction back into the abdominal can leave a number of abnormalities (18-15). Note that a cavity may cause excessive pressure on the diaphragm and congenital hydrocoele is simply an indirect hernia subsequent respiratory distress. If you want to see it, If a patient has a very large indirect inguinal hernia, find some way to make him cry or laugh! It will be difficult to repair, and much more Unlike umbilical hernias, they do not become smaller likely to recur. Inguinal hernias seldom divide and transfix the spermatic cord just below the strangulate in childhood because the neck of the canal is internal inguinal ring, so that you can close it and reinforce fairly wide and the canal is so short, but they often become the posterior wall of the inguinal canal more securely. However, in 30% of You must increase the abdominal volume pre-operatively premature babies these hernias will strangulate and these to accommodate all the contents of the hernia: this you can babies are most easily missed. Herniotomy is one of the do by progressively injecting air into the peritoneal cavity. In young children, simply open the sac There is a 50% chance that it will reduce spontaneously, (herniotomy), and tie it off. Make a 3cm incision in the skin crease above the inguinal ligament, more medially and superiorly than you would for an adult. Cut through the subcutaneous tissues, and pick up and tie the small superficial epigastric and external pudendal vessels with haemostats. A, when it remains completely open, a complete inguinal hernia To find the hernial sac, which should be anterior to the forms. Gently separate tissues off the cord vaginalis becomes narrow, but does not disappear, fluid passes down which appears as a distinctly blue structure and thereby it from the peritoneal cavity and forms a hydrocoele around the testis. You should then be able to get behind it with a vaginalis, it may form a hydrocoele of the cord. Operate on a finger and so hold it between the thumb and index finger congenital hernia and on a congenital hydrocele: tie and divide the of your left hand. Wait to operate until a baby is 6 or preferably 9 months old, when anaesthesia and surgery will be easier. Always also look for maldescended or absent testes Otherwise, divide the sac and transfix its neck with 3/0 (27. If you find bilateral inguinal hernias in girls, look for signs of ambiguous genitalia or intersex state. If there is a strangulated hernia as a neonate, (1) Make sure you are cutting the sac only. You can easily the sac will be very friable and will not take sutures; cut the vas, because it is adherent to the posterior surface be content to close the internal ring by approximating the of the sac. If you do so accidentally, apply fine haemostats to the parts of the sac that are free If the testis atrophies later, you have probably interfered and try to separate the sac off its underlying structures; with its blood supply. The parents, who may have difficulty accepting that one testis can function as efficiently as two, If you have pulled the testis out of the scrotum, will not be pleased. The other testis should however be be sure to return it properly, or else it may adhere in the normal, so reassure them. You can relieve a strangulated inguinal hernia and resect Try to put your finger though it into the peritoneal cavity. If it is big enough to let you insert your index finger Unlike a femoral hernia, there is usually no need to open (the internal ring is >1cm wide), it probably needs the abdomen through a separate incision to get better herniorrhaphy. Put the tip of your finger through the hole in which the stump of the sac has retracted. Feel the margins of the hole, put a haemostat on its medial Suggesting torsion or inflammation of an inguinal margin, and lift it forwards. A retained edges together with 3/0 absorbable sutures, so as to wrap testis is often associated with an interstitial hernia (into the the transversalis fascia snug round the cord. You may have to open the inguinal Suggesting inflamed inguinal nodes: the swelling is canal for about 5cm to get access to the internal ring: more diffuse, there is sometimes redness and oedema of cut upwards and laterally from the external ring in the the overlying tissues. Vomiting and abdominal pain are direction of the fibres of the external oblique aponeurosis minimal or absent. If there is a hernia and a hydrocoele that are separate, An inguinal hernia which has only been irreducible for a proceed as above, and open the tunica distally by pushing short time, and is not very tender to touch. Be especially careful, Use morphine and put the patient in a steep Trendelenburg as you search for something to sew together, that you do position. If it does not, use gentle manipulation, to close the defect internally via a laparotomy. This is a curved probe with a cutting edge on its perform a laparotomy via a midline incision. You may need more than one haemostat and congestion make identifying the overlying structures transfixion suture. If there was obvious perforation, drain the canal Pick up layer by layer in forceps, and carefully incise each through the scrotum. Attach a Babcock forceps to If presentation is very late with oedema, cellulitis or the bowel or omentum to prevent them slipping inside the abscess formation on the abdominal wall or scrotum, abdomen. If you can insert (1);in the inguinal region, where the prognosis is better, an instrument through it and nick its lateral margin, do so. Alternatively, push your little finger (2);in the scrotum, where the prognosis is worse. Open the groin, and identify the strangulated loop of Gently deliver the contents of the sac. If it extends to the bowel; doubly ligate both ends tightly with 2 silk as close scrotum, it may be easier to deliver the testis also. Curette the fistula track, taking care not to damage any (2);Do not incise the medial side of the internal ring, or local structures. Make sure the patient is well A femoral hernia is more likely to strangulate than an re-hydrated and his potassium deficit is corrected. It is rare where people, Then perform a laparotomy: make a midline incision and especially children, walk barefoot because the resulting apply non-crushing clamps on each loop (proximal and enlarged femoral nodes close the defect. Keep the clean laparotomy wound clear of the disease, the sex incidence of femoral hernias is more groin and explore this as above if you havent already nearly equal, with femoral hernias only marginally more done so).