Hernia in Infancy AND ITS CORRECT TREATMENT. BY A L EX A ND ER DA LLAS, 4k D., NEW YORK. REPRINTED FROM THE INTERNATIONAL JOURNAL OF SURGERY, February and April, 1892. Press of E. P. Coby & Co., 21 Platt St., N. Y HERNIA IN INFANCY AND ITS CORRECT TREATMENT. By Alexander Dallas, M. D., New York. Consulting Surgeon to the Bayonne Hospital. The increasing interest shown in the treatment of hernia is an encouraging sign and warrants the in- ference that the days of apathy and neglect are pass- ing away and that, ere long, this important subject will receive the care and attention it deserves. The indifference of the profession in the past has been most calamitous ; its further continuance will prove suicidal, for the time is rapidly approaching when the medical attendant will be held to as strict ac- countability in the treatment of hernia as he now is in a case of fracture or other serious injury. Here, as elsewhere, success can only be attained by intelli- gent, persistent effort, and every case of hernia de- mands and should receive the physician's best atten- tion. Particularly is this the case in children, in whom hernia is quickly responsive to treatment, and the physician who, through neglect or ignorance, allows a child to grow up to manhood handicapped by so serious a disability, is guilty of criminal care- lessness. Only those who are interested in this subject fully realize the immense amount of pain, discomfort and despondency, altogether unnecessary and avoidable, from which these patients suffer, and no amount of effort is too great to arouse the body of the profession to their clear -duty in the matter. Our teachers, naturally, are looked to as the expo- nents of all advances in medicine and become, to a large extent, the moulders of professional opinion in the special branches to which they devote themselves, but, unfortunately, our teachers in hernia are either silent or give forth a very uncertain sound. 2 A few months ago an article appeared in one of our medical journals, written by AV. B. De Garmo, M. D., Professor of Special Surgery (Hernia) in the N. Y. Post-Graduate Medical School, under the cap- tion " Hernia in Infancy and its Treatment," in which the author distinctly states that "it is the intent and scope of this paper to give to the general practitioner a few hints that may aid him in the diagnosis and treatment of this class of cases." As " one of them," I venture to dissent from some of the hints contained therein, and while the article contains much that is good, it also contains state- ments that, in my judgment, are misleading. Using it as a text, I will endeavor to emphasize the good and eliminate what appears to me to be the evil. About one half of all abdominal hernias occur dur- ing the first five years of life and, as they can almost all be cured under proper treatment, the importance of the subject can be readily appreciated. Generally these cases first come under the care of the family practitioner and he, to avoid trouble and evade' re- sponsibility, prescribes a truss and hands the case over to the nearest druggist or instrument maker, taking no further interest in it. The surgeon who would prescribe a splint for a fracture and expect the splint-maker to apply it would be justly condemned by the whole profession ; and, yet, the one is just as rational as the other. No truss maker, however skillful a mechanic he may be, can be expected to give that intelligent service which the case demands, nor has any physician the right to evade his own re- sponsibility in the matter. Hernia in infancy may bo divided into congenital or acquired, the congenital being due to causes opera- tive at birth, such as preternatural openings etc., although the hernial protrusion may not show itself for years. The acquired form is always due to forci- 3 ble effort of some kind. The varieties of hernia met with are four, the inguinal, umbilical, ventral and diaphragmatic. Femoral hernia is never found at this period of life. Diaphragmatic hernia is very rare and is usually congenital, although one or two cases of the acquired form are recorded, due to trau- matism. It is a protrusion of the abdominal viscera into the pleural cavity, through an opening in the diaphragm. Ventral hernia is a protrusion of the viscera through some part of the abdominal walls, generally in the linea alba. It also is somewhat rare. To say that " congenital hernia refers to a protrusion of the viscera into the cavity of the tunica vaginalis," as our author states, is somewhat misleading and can only refer to one form of congenital hernia (inguinal). Inguinal hernia is the most common of all the varie- ties of infantile hernia. It is more frequent in boys than in girls. In 1,516 cases, there were 1,409 males to 107 females. It is also more frequent on the right side, due to the pressure of the liver and the slightly lower attachment of the mesentery on that side. It is a more serious affection in boys and, unless care is exercised, much trouble may result. In girls, it is not so serious and is more easily cured, unless com- plicated by prolapse of the ovary. When this occurs, the ovary should be returned at once ; if irreducible it should be removed. The formation of congenital inguinal hernia is usually rapid. After passing through the inguinal canal, it drops to the bottom of the scrotum, lying in front of, and obscuring the testicle, the separation between the two being often difficult to make out. The thickening of the cord, referred to by the author as a strong diagnostic point, I have not met except as due to pressure. The acquired form of inguinal hernia is generally slow in its formation. Beginning as a bulging over the upper part of the canal, it gradually descends along the cord into the scrotum, 4 carrying before it a true hernial sac formed of peri- toneum. Here the outlines between the testicle and tumor can readily be defined. Umbilical hernia is the next most frequent form of infantile hernia, and is a protrusion of the viscera through the umbilical aperture. It may be congen- ital or acquired. The author states that " it is about equally divided between males and females," but, as a matter of fact, it is much more common in girls. This is attributed to the larger size of the umbilicus in the female sex, a condition recognized by the ancient sculptors, as seen in their statuary. In infancy, the contents of the hernial sac are* almost invariably intestinal, omentum being rarely found. This is said to be due to the proportionately longer mesentery, but, perhaps, more to the poorly developed condition of the omentum. Among the predisposing causes of hernia, arrest or want of development is the most efficient. In the umbilical form, the non-closure of the opening for the transmission of the omphalo-mesenteric vessels is the most frequent cause. In the inguinal variety, among the more prominent may be mentioned the- incomplete or delayed descent of the testicle, leaving a patulous tunica vaginalis, and the incomplete for- mation of the internal oblique, transversalis and cremaster muscles. Inherited predisposition is claimed to be a very common cause, especially under twelve months of age. Age, also, is said to exercise a very material influence. In the first year after birth, hernia occurs in the proportion of 1 in 21, in the second year, 1 in 29, in the third year, 1 in 37, gradually decreasing in frequency up to the thir- teenth year. Race, too, has some influence. Hernia is less frequent in the negro than in the white man, except in the ventral form. Lascars seldom have it. The Irish suffer less from it than the French or Ger- mans, while the Jews are very prone to it. The in- 5 fluence of an abnormally long mesentery is somewhat doubtful. In the monkey and other animals, where a long mesentery is the rule, hernia is almost un- known. A patulous funicular process is looked on as one of the most frequent causes of hernia and, yet, man is about the only animal in whom it normally becomes obliterated. A tight bellyband may occa- sionally act as a predisposing cause. Among the ex- citing causes may be mentioned constipation, over- distension of bowels, crying, coughing, vomiting, straining from a contracted prepuce, etc. The diagnosis of infantile hernia is usually easy. The appearance of a tumor at one of the openings, its elastic feel and ease of return, its increase in size in the erect position or during crying or straining, its disappearance in the recumbent position, and, usually, its absence after rest in bed, its impulse on coughing, all point to hernia. Then there is the sharp, violent pain when the hernia appears sud- denly ; or, when it comes more gradually, the dull, aching, recurring pain or soreness always present when distension of a natural canal occurs. But there are conditions simulating hernia where the diagnosis is extremely difficult and can only be arrived at by exclusion. In umbilical hernia, we may have dropsy of the funis, malignant growths or cysts. In inguinal hernia, the conditions are some- times very puzzling, but in all cases the examiner should first assure himself of the presence of the testicles in the scrotum. If absent from the scrotum, it may be found lodged in the canal or lying just outside the external ring, where it is often mistaken for hernia, especially as it appears to be reducible into the cavity of the abdomen. If it can be brought out of the canal, a light truss should be applied over the internal ring and the testicle encouraged in its descent to the scrotum. Such marked retraction of the testicle as the author mentions I have never 6 seen, but the history of the case should rapidly clear up any doubts. Hydrocele of the tunica vaginalis can readily be recognized by the fact that it is cir- cumscribed, irreducible, elastic and translucent, and from its slow growth from below upward. Congeni- tal hydrocele, or " windy rupture," is much more difficult to differentiate. In this condition we have a tumor in the scrotum which can readily be reduced, but which quickly reappears on assuming the up- right position. The absence of pain or tenderness, the lack of swelling or enlargement at the external ring, and the imperceptible reappearance of the tumor while the finger is held over the canal, will help to distinguish this condition. It is important to diagnosticate this, as it materially interferes with the cure of the hernia and cannot be retained by truss Hsematocele is readily distinguished from hernia by its history of traumatism. " In discussing hernia of early life, it is important that we should have a clear understanding of 'irreducible,' 'incarcerated,' and 'strangulated' hernia; " but the author omits to give the data for a clear understanding of the subject. When from its shape, the existence of adhesions, or its very nature, a hernia cannot be returned into the cavity of the abdomen, it is called " irreducible " hernia. Intestinal movements are not obstructed nor is the circulation arrested. Irreducible hernia is rare in childhood. When adhesions do occur, they are readily broken up and the hernia reduced. An " irreducible " hernia occasionally becomes ob- structed through the accumulation of flatus, impacted feces, etc , then constituting the condition termed " incarcerated " hernia. The term is also used to denote a partial strangulation of the gut without much pain or intestinal obstruction. This condition, if seen early, is not serious, but if neglected, may rapidly become so. Hence, the advice given by the 7 author is dangerous and, if followed, may end in disaster. He says : " I have found that these cases need cause no uneasiness so long as urgent symptoms are not present; usually after the child sleeps, or dur- ing sleep, the mother can by gentle pressure reduce the tumor." "Urgent symptoms " are liable to de- velop at any moment, and mothers, as a rule, are not sufficiently expert in diagnosis to be depended on. In "strangulated" hernia, the constriction is so severe as to arrest circulation, paralyze the nerves, and cause intestinal obstruction. If complete, gan- grene rapidly supervenes; if less complete, linear ulceration of the parts compressed occurs. Fortu- nately, it is not a common occurrence in infancy and can readily be overcome without surgical interfer- ence. One or two doses of the mixture which has invariably proved successful in my hands will rapidly effect reduction and will prevent the possibility of re- duction f'en bloc." (See Medical News Nov. 28, .1891). If necessary, it can be used per rectum. In infants, it is generally advisable to use an anaesthetic to quiet their struggles. In adults it is not necessary. In cases of intestinal obstruction, it must not be for- gotten that a hernial tumor may be found at one of the usual outlets and, yet, it may not be the cause of obstruction. In such cases, reduction by taxis, with- out relief of the symptoms, will prove that the cause must be sought elsewhere. In the cure of hernia in infancy, mechanical treat- ment unquestionably occupies the first place. In adults, questions of expediency or necessity may de- mand operative interference, but in children surgi- cal measures are unnecessary and uncalled for. Mechanical treatment, properly applied and per- sistently carried out, will cure all cases of infantile hernia, with scarcely an exception, and the cures 8 will be as permanent as by any operation and with- out risk. " Statements that operations are advisable on child- ren, because trusses cannot be worn, are born of absolute ignorance of the mechanical treatment of hernia ; as a matter of fact, infants tolerate truss- pressure better if that pressure is intelligently applied, than do adults." Even at the risk of being classed amongst the ignorant, I believe there is a good deal of truth in the claim, as trusses are ordinarily applied: the second part of the quotation is contrary to all teaching. Physiology tells us that the nervous system is much more developed, proportionately, in children than any other, and is more sensitive to impressions than at any other period of life. Daily experience confirms the findings of physiology and proves, beyond a doubt, that children react to pres- sure, or irritation of any kind, more readily than adults. The fact is that symptoms of irritation from improperly applied and unduly severe truss pressure can be found m all these cases, but, heretofore, they have been wrongly attributed to other causes. The author states that "there is no lack of good trusses in this country." Unfortunately, he does not name some of them. He condemns all side trusses, those where the pad is placed on a descending arm, all soft trusses, and the so called French and German styles of truss. The "cross-body" truss which he so highly recommendsis, in my judgment, particularly objectionable. It is a single truss, whereas in inguinal herniain children, the truss should always be double, as the predisposing causes to hernia exist alike on both sides. Then the constant motion to which all side-spring trusses are necessarily subjected through muscular contractions, bodily movements, etc., is here intensified on account of the longer arm of the lever ; excoriation of the skin is unavoidable ; the point of the greatest pressure is outward, against 9 the weakened external pillar of the ring, and down- ward, increasing the compression of the spermatic vessels between the pad and the pubic bone. The following quotation represents the most ad- vanced teaching of the present day and explains itself : " Only a light pressure is required if its location is at the right spot. A very common, almost universal error in applying trusses is in putting the pad too low. If the pad rests over the pubic bone its efficiency is at once destroyed. It should be borne in mind that the design of truss-wearing is to keep the bowel entirely within the abdomen, and inorder to accom- plish this in a thorough manner, the supporting pressure must be very nearly over the internal ring. The descent of a hernia may be stopped at the external ring ; and while it may in this way be kept out of sight, it still occupies the upper part of the canal, and a cure will never result. A truss pad that rests against the bone cannot thoroughly protect the upper part of the canal, it is held atvay from it, and the child is made uncomfortable. When the truss is fitted high, the parts back of the pad are soft and yielding, and it is worn with comfort?' Here we have some truths and some misleading statements mixed up. Light pressure only is required if the truss be applied and retained over the right spot, and there is only one right spot, directly over the internal ring. The bowel cannot be retained thoroughly within the abdomen by applying the pad nearly over the internal ring. When the pad rests over the pubic bone, its efficiency is at once .destroyed, and the child is made uncomfortable. Here are two truths, the importance of which cannot be overestimated, and the full recognition of which by the profession will mark an era in the correct treatment of hernia. The trusses now in use all impinge upon the pubic bone. Even when applied over the internal ring, they soon sink down until they rest upon the bone. An attempt is 10 made to overcome this tendency to droop by increas- ing the strength of the spring, but the receding abdominal walls, muscular contractions, and the force of gravity are obstacles too great to be overcome. In the so-called elastic trusses, the pad is anchored over the bone by the perineal band, while, in the lever truss, the pressure is applied from below upward, thus dilating the upper portion of the canal. The evil effect of these trusses is intensified by the shape of the pad used. In the majority of cases, this is round or conical, and its projecting surface, driven by the powerful spring, bores its way into the opening and actually enlarges it. The flat pad, while not dilating the opening, increases the pressure at its lower edge. Now, why is the child made uncomfortable when the truss rests on the pubic bone, as it invariably does ? A glance at the anatomy of the parts will at once reveal the cause. Passing out of the inguinal canal and over the sharp edge of the pubic bone, we find the vas deferens, spermatic arteries and veins, nerves and lymphatics, here covered only by integu- ment and superficial fascia. Right over these impor- tant vessels is placed a steady pressure of 2 to 4 lbs., in some cases double, kept on continuously for six months or a year or more. Apply this pressure for the same length of time over any other portion of the body, and only one result will follow : pain, nervous irritability, atrophy, loss of function, etc. So it is here, but more marked, on account of the important organs involved and the peculiarly susceptible con- dition of the nervous system in children, resulting finally in a lowered vitality which renders them an easy victim to any intercurrent attack. To deny the existence of these symptoms is to gainsay plain facts, proven by analogy and experience. In the past, they have been attributed to other causes, to the " teeth " or " colic/' &c., &c., or looked on as unavoid- able and due directly to the rupture itself. Remove your presszire over the pubic bone and the disagreeable symptoms ivill soon disappear. 11 In assuming the care of a case of hernia in infancy, two questions at once present themselves : 1st, when shall treatment commence ; 2d, what form of truss should.be employed ? The answer to the first question is perfectly clear. As soon as the hernia shows itself, treatment should at once commence. The idea that the child will out- grow its disability, or that it is too young to bear treatment is utterly erroneous, and much harm is often caused by the delay. In regard to the second question-what form of appliance is best-opinions differ. In the treatment of all forms of inguinal hernia in my own patients, I have, for some time, been using a truss devised by myself and shown in the accompanying cuts ; and the results have been most gratifying and satisfactory both to the patients and myself. PART II. Fbont View. An examination of the drawing will at once show how much it differs from the trusses now in use. The belt is made of light material and is covered with leather or hard rubber. (Soft rubber tubing should 12 never be used for this purpose). It rests firmly upon the crest of the ilium, an immovable support, and is not affected by the movements of the body or con- tractions of the muscles. As a result, there is no interference with movement, no incessant motion of the pad, no excoriations to heal up. The belt passes down the sides of the abdomen, closely hugging the abdominal walls, thus breaking the lateral recoil of the intestines which causes the protrusion, and acting as an auxiliary to the pad. The pad itself, of hard rubber, is small, somewhat diamond shaped, its lower outer angle cut off to fit into the fold of the groin, its surface slightly concave to adapt itself to the convex abdominal walls. Running from the centre of the face of the pad to its lower edge is a gradually deep- ening groove, which prevents compression of the vas deferens, and spermatic vessels and nerves. The pressure exercised by this truss, being applied from above downward, is slight, comfortably borne and directly over, not " near," the internal ring ; not because " the parts back of the pad are soft Back View. 13 and. yielding, and it is worn with comfort," but because that is the only place where pressure should be applied and retained. Another important feature in this truss is its ease of application. Once properly adjusted, it can be taken off by the patient and reapplied, without fear of displacement-a fact which cannot be said of any other truss with which I am acquainted. As all spring trusses should be removed at bedtime, the importance of this will be readily appreciated. In umbilical hernia, a flat disk, kept in position by a simple binder or fastened with plaster, is usually sufficient to effect a cure in the early months of life. Later, a flat pad with a spring may be necessary, or a rubber ring with diaphragm is an excellent appliance. The use of a ball or the conical pad usually employed is a serious mistake, as it presses into and dilates the ring, aggravating the very object for the cure of which it is applied. In ventral hernia, the same principles of treatment should be employed, varying the appliances with the varying condition and location of the protrusion. Now, having applied a truss, most physicians seem to think that their work is done. On the contrary, the real treatment of the case has just commenced if a cure is desired. The patient should be kept under the physician's supervision and should be carefully examined at regular intervals, to assure himself of the 14 perfect retention of the hernia, as well as to provide for the rapid growth of the child. Perfect cleanliness should be preserved, and all causes that operate to prevent nature in her efforts at repair should be re- moved. The digestion should be carefully looked after. Constipation should be prevented. Vomiting from overfeeding or improper food should be checked. Straining from diarrhoea or from a- constricted or adherent prepuce, as well as persistent cough from any cause, should be removed. The persistence of any of these causes may hinder, or even completely destroy, all chances of cure directed solely to the hernial pro- trusion. At the same time, efforts should be made to develop and strengthen the weakened muscles by massage, electricity, and gymnastic exercises of various kinds. There is one point in the treatment of these cases to which I wish to call special attention. No spring trusses should ever he worn in bed. In the large majority of cases, it is quite unnecessary, and in all cases, it is harmful. When necessary, as in the case of infants, the truss should be removed at bed- time, and replaced by a " hank " truss or a home made bandage. It is in these night cases that the lately much vaunted " hank" truss will find its proper field of usefulness. The length of time during which truss pressure should be kept up will vary in different cases, but should not be less than one year at least, counting from the time of last protrusion. After six months, the pressure should be gradually lessened until, at the end of the year, it is merely nominal, while the efforts made to strengthen the parts should, at the same time, be increased. Of the complications mentioned in the earlier part of this paper, there are two which demand special attention, viz : congenital hydrocele and non-descent of the testicle. Congenital hydrocele or " windy rupture," is pre- 15 sent in the majority of cases of congenital hernia. It is due, I believe, in many cases to improper truss press- ure, for it usually does not appear until some time after treatment has begun. Care must be taken in these cases not to confound it with a return of the hernia. If the quantity of fluid should become so large as to inconvenience .the child, or if it persist for any length of time, the cure can be accelerated by the use of the Heaton method of injecting a few drops of an irritant solution in the canal. This will excite sufficient adhesive inflammation to retain the fluid in the abdominal cavity, while truss pressure is kept up to prevent protrusion of the gut. Non-descent of the testicle is very frequently over- looked. It demands careful attention and judicious management. When the testicle is in the canal, a concave pad should be applied over it, not only to prevent irritative pressure, but also to encourage its passage outwards to the external ring. As soon as it emerges'from the canal, a pad should be applied over the internal ring. In the extremely rare cases of infantile hernia, where properly applied mechanical treatment fails to effect a cure, then surgical measures have to be re- sorted to. In these cases, almost any form of opera- tion will meet with success, and, if performed with proper antiseptic precautions, the risk is slight. The McEwen operation as modified by Bennett, is unquestionably the best yet advanced, but each operator has his own method of attempting to effect a cure. For myself, I prefer a transverse incision through the skin, and after reducing and fastening the sac as high up as possible, so as to bring a fresh portion of the peritoneum over the opening, I am more anxious to approximate the external portion of the anterior and posterior lips of the internal ring, than in drawing together the pillars of the ring 16 which has little effect in preventing, of itself, a re- currence of the hernia. For it must be remembered that the internal ring is not a ring at all, but a "slit" or separation between different layers of tissue ; and, while we cannot close up the inner portion of this " slit " on account of the vessels passing through it, by removing the fossa above the internal ring, which invites the descent of the bowels, and by clos- ing up the external half of the "slit" through which the protrusion occurs, we will succeed better than by any other method. Here, as elsewhere, the more closely we imitate nature, the more successful pur efforts will be. 65 West 36th Street.