Observation of 1000 eases of lapa rotomy done in the hospitals in Berlin, showing that nearly one-third of all the eases sutler from ventral hernia. In some eases the hernia does not develop for one or two years after the operation. Winter (La Semaine Med., June 15, '95).
In regard to the treatment of such cases, much depends on the age of the patient, as well as upon the character of the abdominal wall. As a rule, these patients are young adults with good abdominal muscles, little accumulation of fat, conditions the contrary of which is usually found in umbilical hernia and which so often contra-indicate operation.
The results of operations for epigastric hernia are very satisfactory. The same is true of cases following appendicitis. Of four cases not one relapsed, though the immix were of large size and adhe sions were present.
Owed Hernia.—This form of hernia is far more frequent than is generally sup posed. I have observed it 16 times in 531 operations. In a number of cases the ace= could be reduced, but the appendix could not, on account of adhe sions to the sac. Ctucal hernia occurs usually on the right side, but may be found on the left. I have operated upon one left inguinal hernia in which the sac contained a large, vermiform appendix.
The patient was 10 years old. In the of cases, especially in young subjects, the hernia is congenital.
Strangulated hernia of the eteemn in any form is infrequent, the number of cases met with in a large series of 5i15 herniotomies amounting to only 1.59 per cent. Extreme rareness of uncompli cated cases of this form of strangulated hernia noted. two instances only being found in this same series. The very high rate of mortality (MG per cent.) was clearly due to the critical condition of the majority of the patients at the time of operation. Bennett (Lancet, Feb. 1. '90).
Rare Forms of Hernia.—DrAritn.to MATIC HERNIA.—This form may be con genital or acquired. The congenital form is due to imperfect closure of the phragm and the protrusion into the pleu ral cavity of a portion of the abdominal contents. This occurs by the side of the ensiform cartilage, between the xiphoid and costal portions. A diagnosis of this condition is hardly obtainable.
Case of diaphragmatic hernia in male child, 3 'A years of age, showing the fol lowing points of interest: 1. The phys ical signs in this case were identical with those of empyema. 2. The frequent high temperatures, for which there was no ap parent cause except constipation. Lynde (Archives of Pediatrics, Dee., '89).
Case of congenital diaphragmatic her nia diagnosed during life. The patient was 14 months old. Percussion was dull on the left side of the chest and vesicu lar murmur was absent; posteriorly on the left side interstitial gurgling could be heard at times. When the child was inverted the lower part of the left chest became tympanitic and the note on per cussion varied between tympanitic and dull, with variations in positions at dif ferent times. In consequence of the de velopment of vomiting, constipation, and collapse it was thought that some strangulation had possibly occurred and abdominal section was performed. All
the intestines were found in the left chest. but were not strangulated. The child died. There was a semicircular de ficieney in the posterior part of the left leaflet of the diaphragm 2 inches long. The spleen was in the left. pleural cavity: the left lung was completely un developed. The peritoneum was contin uous with the pleura round the opening. JefTreys Wood (Lancet. Apr. 13, '991.
The acquired form may be due to rupt ure of the diaphragm through violent effort, direct violence, or penetrating wounds. The penetration through the opening thus formed suddenly creates dvspncea and asphyxia, besides other manifestations which the displacement of organs give rise to according to the site of the tear or laceration in the dia phragm. Excessive thirst has been noted by Bryant as a prominent symptom.
Case of diaphragmatic hernia in which the author performed laparotomy. Nearly the whole sigmoid flexure and the large omentum had disappeared through the diaphragm. .All the efforts to effect a replacement were useless, either through the stomach turning on its axis or the sigmoid flexure. The pa tient died the day after the operation. G. Naumann (Hygeia. Aug. S, 'SS).
Pneumothorax, the affection with which diaphragmatic hernia is likely to be confounded, results from pulmonary tuberculosis in 90 per cent. of all cases, and in probably all of these is speedily followed by effusion of serum or pus into the pleural sac. The affection de velops without the history of an injury. In the remaining 10 per cent. nearly all result from traumatism, and in most of these inflammation of the pleura speed ily follows with effusion of fluid, though in a very few there may be no infection and the air may be absorbed without causing any effusion. In pneumothorax dyspncea may come on suddenly or gradually and one may often hear am phoric respiration, especially in expira tion, which may be either intense or feeble and which disappears when fluid rises high enough to cover the opening into the air-passages. When fluid and air are present in the pleural cavity, metallic tinkling may often be heard during the respiratory acts and distinct splashing sounds may be obtained by shaking the patient's body while the ear is applied to the chest. The heart is constantly crowded to the opposite side, where it remains without varia tion. Diaphragmatic hernia is congeni tal or occurs through congenital de fects in about 3S per cent. of the cases that have been recorded, and in many of these it does not cause marked symptoms unless the hernia becomes strangulated. In about GO per cent. of eases the affection is traumatic, and therefore the history is quite different from that of pneumotho•ax. The dyspnma in hernia may come on sud denly and as suddenly subside, whereas that of pneumothorax is more continu ous. E. Fletcher Ingals (Jour. Amer. Med. Assoc., June 22, 1901).