The following treatment has given Inc excellent results in chil dren: After a warm bath the child is slightly etherized, lifted by the legs to a vertical position and, by shak ing the hernial sac, an attempt is made to replace its contents into the abdominal cavity. The traction of the mesentery will render considera ble assistance in this position.
Strong manual pressure should be avoided, especially if the incar ceration has existed for a long time. If the hernia proves irreducible by these light manoeuvres, herniotomy should be at once performed. The hernial ring is exposed by an in cision, the sac isolated in as high a position as possible, and opened at the top. (Microscopical examina tion of the hernial fluid.) The strangulated loop is pulled forward and it is often possible to reduce it without enlarging the hernial ring. Should this, however, prove impossible, the latter should be opened, which means enlarged layer by layer. After a careful inspection of the stran gulated loop, the intestine is replaced if still viable, and the hernial ring is closed by some method of radical operation.
The question whether the intestine is still reducible greatly taxes the experience of the operator.
Very young children, especially nurslings, bear an intestinal opera tion very badly, particularly if the general condition is weakened. On the other hand, the tissues of infants have considerable .power of regener ation. The decision would, therefore, be in favor of reducing a danger ous looking loop rather than resorting to large resections, which nearly always have a fatal result. I have had to do so only once in thirty cases.
Should the hernia prove irreducible, resection should be done only in the absolutely healthy. Older children will bear the operation. Younger ones will not be spared the danger of resection by constructing an artificial anus, because, as the child becomes debilitated through the intestinal fistula, resection will in most cases have to be done to close the fistula.
b. Treatment of Reducible order to avoid the danger of strangulation, the inguinal ring should be kept closed, which can be done either by constantly wearing a truss or by early radical operation. Opinions as to the selection of these methods do not agree. I am abso lutely in favor of early operation, and in our clinic no trusses have been used since 1900. The disadvantages of the truss are: 1. If constantly worn, and not otherwise, it prevents the possibility of the bowels entering into the hernial sac. But one single hour at night,
one paroxysm of coughing, may destroy the work of years.
2. It may cause the walls of the abdominal sac to become agglu tinated while the hernial predisposition persists unabated. Not a single case is known where by wearing a truss real obliteration of the hernial sac has occurred, but many cases are known where, in spite of apparent cures, the hernia reappeared later.
3. The truss causes the sphincter musculature of the hernial ring to become atrophied through the pressure of a pad, thereby depriving the organism of a natural protection.
-1. Physical education is prevented not only in children who wear a truss for existing hernia, but also in those in whom the hernial predis position persists after discarding it. Improvement of physical vigor, increasing the power of resistance and facilitating the battle for exist ence, is rendered impossible by the continuance of the pathological tendency.
5. The only advantage of the truss is the possibility of deferring the radical operation beyond the first years of childhood without danger, but this involves a great deal of inconvenience, such as constant watch fulness, injury to the skin, eczema, etc., furthermore impairing the natural closure of the ring and consequent diminishing of the chances of a successful result of the later operation.
The only disadvantage of operation lies in its danger, and upon this depends the decision for or against early operation.
Only a large number of cases can give proper information on the question of danger.
Campel reports 305 operations with 3 per cent. mortality, Gross mann 111 with t per cent., Clogg 130 and Carmichael 152 cases with 1 death each, de Carmo 119 with no death. In my department 1100 cases were operated without a death that could be directly attributed to the operation. (See Mortality, p. SS, and also compare Cooley and Billilmann.) The majority of the reported (leaths are due to complications, many of which are attributable to disturbances occasioned by prolonged anaesthesia. If it is possible to simplify the operation to such an extent that, without detracting from its efficiency, it can be carried out under very short anaesthesia, then this slight surgical interference, which (lops not require more than a few minutes, must be considered devoid of danger and vastly superior to the wearing of trusses.