INGLINAL HERNLA, ABDOMINAL HERNIA, DIAPHRAGMATIC HERNIA Nature and Etiology.—Abdominal herniae belong in general to the sphere of surgery. They deserve, however, a brief consideration in a work on children's diseases, because the characteristic hernial sacs result either from congenital conditions, errors in the fcetal develop ment resulting in separation of the abdominal wall, or through openings or canals which have a congenitally larger dimension than normal. The child also acquires hernia from other causes, such as weakness of the tissues at certain predisposed regions, as in adult life. Hernia in children is almost always hereditary or clue to congenital conditions and is therefore a disease of childhood.
This is especially true of inguinal hernia. This form of hernia is caused by complete or incomplete opening of the proeessus vaginalis peritonei (henda vaginalis congenita s. vaginalis). This non-closure is not sufficient for the formation of the hernia. It is due to the abnormal size of the inner abdominal ring and its position directly back of and above the external abdominal ring. This gives a wide entrance, and a short, as well as direct course to the inguinal canal, a peculiarity of childhood which disappears with the growth of the child. These two characteristics, the shortness of the inguinal canal, and the location of the inner abdominal ring, together with the pockets in the infundibuli form fascia, predispose to the congenital, as well to to the acquired hernia in the child. Both kinds of inguinal hernia. are therefore attribu table to an hereditary, tendency. These conditions manifest the same symptoms and are differentiated only after opening the hernial sac. Congenital predisposition is also met with in other, though rare herniae in childhood.
Of umbilical hernia it is not necessary to speak at length in this place.
Diaphragmatic hernia results from the partial or complete failure of the diaphragm or from abnormal enlargement of the normally exist ing foramina (places of predilection, the foramen of Morgagni, between the pars sternalis and costalis; foramen Bochdaleckii, between the pars costalis and vertebralis of the diaphragm; ancl lastly, openings for the aisophagus or the TICI'Vlts sympatheticus).
The abdominal hernia passes medially through congenital gaps in the linea alba or laterally through an hereditary muscular defect, or the abdominal widening of the triangle of Petit or that of Lesshaft.
The congenital tendency of hernize in children indicates also the time of their occurrence. Femoral hernia, seldom occur in childhood. John Langton saw only one crural hernia among thirteen thousand observed in children. These develop in the growing pelvis ancl the enlarging thigh, and therefore usually appear just before or after puberty, and especially among girls. Inguinal hernia, on the contrary, is by far the most frequent in the first year of life, and almost always the indirect, which occurs from the widening of the inguinal canal, and in the majority of cases appears in boys on the right side (the right testicle descends last). Kocher never saw clirect internal inguinal hernim in children, Demme very seldom.
hernim observed in early childhood, or whose origin must be attributed to that period and diaphragmatic or abdominal hernhe clue to congenital defects of the musculature, bring us to the conclusion that all the herniai of childhood are traceable to hereditary causes. In contradistinction to the causes of hernia in adults all other causes play an unimportant part in the hernia of children. These causes are clearly a part of childhood. The distention so frequent with gastric disturbances in childhood cau.ses a tension in the abdomen, increases the abdominal pressure, and is the chief reason for the protrusion of the viscera and expansion of the hernial sac. The crying and pressure present in these disorders have a place among the causes of hernia, not wholly imagi nary. Whether phimosis and the frequent bearing down pressure play the sante part seems to me by the rarity of cases of true phimosis to be uncertain.