bar spine, a condition unquestionably conducive to prolapse of both the abdominal and pelvic viscera. The patient's clothing is investigated, and peremptory orders are issued that tight bands shall be at once discarded.

The next day, if the condition is such that the patient is able to be about, dynamometer tests of the various groups of muscles are taken, and a physical chart or graphic representation is made, which at once shows the weak spots in the patient's nervomuscular apparatus and also the degree of weakness. The physical coefficients, based upon the mathematic data obtained by the dynamometer, indicate at once whether the patient should gain or lose in flesh, and

FIG. 6.

Showing the effect of heavy skirts and a bad position in a woman aged twenty-four years.

the kind and amount of exercise required. In cases of special interest, outline tracings of the front and side profiles are made, as a record of symmetry and habitual pose. Examinations of the blood and the urine are made, and, if it is necessary to determine the digestive capacity, a test-meal is given. The examination being completed and a careful record made, the treatment is usually outlined as follows:

A week's program of baths, consisting of one or two vaginal douches daily of such a temperature as is adapted to the patient's condition, sitz baths (80° to 90° F.), the ordinary shower-bath, spray, and douche,

the Scotch douche, salt glows, electric-light baths of three to five-minutes' duration, tonic applications of faradic electricity in the form of general faradization, the sinusoidal electric current with slow alternations applied to specially weak groups of muscles, applications of the galvanic current to the spine and the sympathetic centers of the neck and abdomen, general massage, special massage of the abdomen, pelvic massage, manual Swedish movements daily, mechanical Swedish movements, Swedish gymnastics and light calisthenics in the gymnasium, and, in appropriate cases, swimming, bicycle riding, boating, and other light exercises, and such other specific treatment as individual cases may require. If the patient is thin, careful attention is given to the application of such dietary measures as will be conducive to the most rapid gain in flesh. If the patient is obese, reducing measures are employed. In case the patient habitually sits or stands with the spine abnormally straightened, thus encouraging visceral prolapse by diminishing the obliquity of the pelvis, she is subjected to a special course of training and instruction to correct this injurious attitude. In many cases an abdominal supporter is employed. (Fig. 7.) A more specific description of some of the measures employed may be of interest:

Baths. In addition to sitz, shower, and other baths, various local applications are made, such as fomentations to the spine, hot sponging, or hot and cold applications to the spine, fomentations, hot bags, and compresses over the abdominal or pelvic regions, foot baths, hot and cold applications to the head, effervescing or carbonic-acid-gas baths, electric, Russian, and Turkish baths, etc. The electric-light bath continued just long enough to produce slight moisture of the skin and followed by a cool shower bath I find a most excellent tonic measure. Showers, and all forms of sprays and douches are employed with apparatus so constructed that absolute accuracy in regard to time, temperature, and pressure may be easily secured. Experience shows that it is only by the employment of accurate measures that definite and reliable results may be obtained.

Electricity. The era during which electricity was considered a panacea for all human ailments and especially for maladies peculiar to women has passed. The number of over-enthusiastic electrotherapeutists is certainly much smaller than it was a few years ago. It is now, I think, generally conceded that electricity is actually curative when employed by itself alone in but a very small proportion of cases of pelvic disNevertheless, it is an exceedingly useful palliative. For the relief of ovarian and other forms of pelvic pain I find the rapidly alternated sinusoidal current superior to all others. The slowly alternat

ease.

ing sinusoidal current furnished by the apparatus shown in Fig. 8 is a most efficient means of developing weakened muscles. It produces powerful contractions without pain, a contraction occurring at each alternation of the current. Both forms of the current may be used for internal or external application, or in combination.

Massage.-General massage is of great value as a means of improving the patient's general nutrition, but I attach great importance to abdominal and pelvic massage used in connection with general massage. During a good many years I have given attention to the development of these special forms of massage, and have seen most excellent results from their employment. I shall not occupy space in this paper to describe fully the methods of abdominal and pelvic massage, but I have endeavored to consider the subject fully in my work, "The Art of Massage."

Massage of the Abdomen.-The following rules should be carefully observed in abdominal massage: 1. General abdominal massage should not be administered until two hours after eating.

2. The bladder should always be emptied just before abdominal massage.

3. In obstinate cases of fecal accumulation, a coloclyster (large enema taken in right Sims' or kneechest position) of warm water should be administered, the water being allowed to pass off before treatment. 4. The patient should be taught to relax the ab

pain or other disagreeable sensations, as such disturbances create rigidity of the abdominal muscles, thus seriously interfering with the effects of the manipulations.

10. In employing massage of the abdomen, the operator should stand over the patient, so as to aid his hands as far as possible by the weight of his body, taking care, of course, to graduate the pressure to the requirements of each individual case.

II. All deep-kneading movements in massage of the abdomen should be slower than for other parts of the body, to allow time for the movement of the fecal mass.

The different procedures to be employed in abdominal massage may be briefly discussed as follows:

Reflex Stroking.-With the ends of the fingers make very light strokes in a circular or semi-circular direction about the umbilicus. Begin very close to this point, gradually extending outward, then return and repeat. Also make vertical strokes along the sides in the mammary line and parallel with the rectus muscle. Strokes may also be made over the fourth, fifth, and sixth ribs at the sides of the chest. In sensitive persons one-sided contraction of the abdominal muscles or a twitching at the epigastrium will be noticed as the result of these so-called abdominal and epigastric reflexes. This procedure is strongly exciting; some patients are not able to endure it. The profound reflex which results in patients who are very sensitive or ticklish is evidence of the

well drawn up, the legs being supported so that the anterior abdominal wall will be relaxed as much as possible. The patient's hands should be by her side, and all the muscles of the body in a state of rest. Only gentle pressure should be employed, and the application continued but two or three seconds at each point. In many cases it will be found that extreme sensitiveness exists at the points indicated, which is evidence of an excited or hyperesthetic state of the abdominal sympathetic. Continuous

gentle pressure may be beneficial by setting up a series of vital activities which result in the restoration of the nerve to its normal condition.

Vibration. (a) Strong vibration applied to the abdominal contents has been shown to be one of the most powerful means of stimulating the nervous reflexes, circulation, glandular activity, and peristalsis. Either one or both hands may be used. The flat palm of the hand is applied to the surface, with the arm extended, and fine vibratory movements are executed in such a manner as to throw the whole abdominal contents into vibration. The same movement, may be beneficially applied to the liver. (b) A more vigorous shaking movement is communicated to the abdominal contents by making intermittent pressure either with one hand, or with one hand reinforced by the other, or by both hands in alternation, the movements being made with sufficient rapidity to produce a decided motion of the abdominal contents. The effect of this procedure is very marked in cases in which the abodminal walls are considerably relaxed. (c) A third method of applying shaking is by placing the palm of the hand upon the abdomen, the arm slightly flexed, then making a rapid rotary movement without allowing the hand. to slide upon the surface. The direction of the movement is alternated, half a dozen in one direction, and then an equal number in the opposite direction.

Percussion. This is unquestionably the most powerful of all the stimulating means which can be applied to the viscera through the abdominal wall. All the different modes of percussion, viz., tapping, spatting, clapping, hacking, and beating may be usefully employed.

Digital Kneading.-(Fig. 10.) Standing face to the patient's feet, with the fingers very slightly flexed, place the finger-tips, the hand being reinforced by the other hand placed above it, upon the abdomen low down upon the right side. Crowd the finger-ends backward, pressing with as much force as possible, without giving the patient inconvenience, against the cecum. Carry the hand upward in the direction of the ascending colon as far as permitted by the ribs. Repeat the movement four or five times. Execute similar movements on the left

side, beginning above instead of below, and pressing the fingers upon the abdominal wall at a point close under the ribs on the left side. Then carry the hand downward, turning toward the median line at the conclusion of the movement so as to follow as closely as possible the course of the sigmoid flexure of the colon.

(To be continued.)

THE MANAGEMENT OF HERNIA IN INFANCY

AND CHILDHOOD.'

BY WILLIAM B. COLEY, M.D.,

OF NEW YORK;

ATTENDING SURGEON TO THE NEW YORK CANCER AND POSTGRADUATE HOSPITALS; ASSISTANT SURGEON TO THE HOSPITAL FOR RUPTURED AND CRIPPLED.

THE importance of understanding the best methods of treating hernia in infancy and childhood is evident when we consider the relative frequency of this affection during the earlier years of life. At the Hospital for Ruptured and Crippled, New York, during the six years from October 1, 1890, to October 1, 1896, there were treated 26,388 cases of hernia. Of these, 6586, one-fourth of the entire number, occurred in children under the age of 14 years. Of 22,362 inguinal herniæ, 5554 occurred in children under 14 years of age; almost exactly one-fourth. Of 21,000 cases of hernia observed at the London Truss Society, 3433 were in infants under the age of 1 year.

I believe that many herniæ observed in youth, and even in adults, are due to lack of treatment or to imperfect treatment during infancy.

Some writers advise against the use of a truss during the first year of life, trusting that Nature will effect a cure, or believing that no harm will result from the delay. Such teaching should be strongly condemned. In this I am in most hearty accord with Mr. Macready, who says, "directly the rupture is discovered the truss should be applied. Some have imagined that very young children cannot wear a spring truss, but this is an error." The experience with the light spring truss in infantile hernia at the Hospital for Ruptured and Crippled entirely agrees with Macready's. I have yet to see an infant, save possible three or four suffering from extreme malnutrition, that could not wear a properly constructed

and well-fitting steel truss. Such a truss should

cause very light pressure, and should be daily removed to permit of careful washing and cleansing of the parts. I regard the steel truss as much superior to the various substitutes, e.g., the "worsted" truss, and this opinion is based upon a careful trial in a large number of cases.

Duration of Treatment.—It is very difficult to lay 1 Read before the Section on Pediatrics at the last meeting of the American Medical Association.

down any hard and fast rule as to how long a truss should be worn, but it is safe to say its use should seldom be discontinued until two years have elapsed since the hernia was last observed. The younger the patient when the treatment is begun the shorter the time necessary to effect a cure is true in the majority of cases. If the use of a truss is discontinued too soon relapse is likely to occur, and then a much longer time will be required to effect a cure, if, indeed, it be ever attained. Strangulation, though rare during the first year of life, occasionally occurs and furnishes an additional reason for early treatment. I have operated seven times for strangulated hernia in children under two years of age; three of them under one year.

Umbilical Hernia.-This variety is very common during the period in question, 2043 cases in patients under the age of 14 years having been observed at the Hospital for Ruptured and Crippled during the six years previously referred to. The method of treatment which we have employed as a routine measure consists in placing a simple wooden button, about one inch in diameter and first covered with rubber plaster, directly over the umbilical opening, and fixing it in this position by means of a strip of rubber plaster, two inches wide, which completely encircles the abdomen. This is changed about every ten days, and seldom causes excoriation or undue irritation. Nearly all of these patients with umbilical hernia are cured within a short time by some such simple means of support, and it is extremely rare to find a child who has reached the age of puberty with the hernia persisting. Therefore, it follows that it is bad judgment to advise operative treatment in this class of cases.

Epigastric Hernia.-There are occasionally seen hernia which closely resemble the umbilical variety, but careful examination makes clear the fact that the hernial opening is not at the site of the umbilicus, but slightly above, or more rarely, on either side of this point. Such herniæ are due to congenital defects in the linea alba, or in the lineæ semilunares, and if the opening is very large, e.g., of a size that will admit the thumb, mechanical treatment will seldom effect a cure, and such cases may very properly be subjected to operation. Out of a total of 565 hernia in this region in children under 14 years of age, but 19 of this variety were observed during the period previously mentioned.

Femoral Hernia. -This is seldom found in in fancy and early childhood. Of 1424 cases of femoral hernia treated at the Hospital for Ruptured and Crippled during the six years referred to, only 43 occurred in patients under the age of 21 years, and but 17 under the age of 14. Macready's tables, compiled from

the records of the London Truss Society, show that out of 1658 cases of femoral hernia only 27 occurred in children under the age of 10 years, and only 5 under the age of 5 years. In other words, out of a total of 21,000 cases of inguinal and femoral hernia, only 5 cases of the femoral variety were observed in children under 5 years of age! I have operated upon 8 cases of femoral hernia in children under the age of 10 years, and 15 under the age of 14 years, the youngest having been a male infant just 2 years of age, with a double femoral hernia of large size. An operation was performed upon both sides with an interval of two weeks between the operations. The sac of the right hernia contained the

cecum.

This is the only case in which I have found this organ in a femoral hernia.

Treatment of Femoral Hernia. -The mechanical treatment of femoral hernia in infancy and childhood can be dismissed with a few words, as the best authorities admit that it is practically incurable by means of a truss. In regard to this point, Macready states that "femoral hernia so seldom recedes in either sex that it must be deemed incurable. It is well known from pathologic observations that these herniæ become obliterated, but the instances are so few that they give no ground for hope of a favorable issue in general." This fact furnishes a sufficient reason for urging early operative treatment, provided, of course, that it may be shown that such treatment is both safe and effective.

Personally, I have had but one relapse subsequent to operation for femoral hernia, either in children or adults. I have operated upon thirty-eight patients presenting this affection, and the oldest is now well upward of six years. The one case which relapsed, that of an adult, was the only one in which primary union was not obtained. The methods I have employed were two, as follows: (1) A very high ligation of the sac and a closure of the canal by means of a "purse-string" suture of kangaroo tendon. The wound is closed with fine catgut suture, and is not drained. Eight patients were operated upon in this manner. (2) Bassini's operation for femoral hernia was employed in the treatment of the remainder, and consists of a closure of the canal by two layers of interrupted sutures. In this operation I likewise used kangaroo tendon for the buried sutures. A truss was not employed after operation in any of these cases and, in all, the wounds healed by primary union.

Treatment of Inguinal Hernia in Children, and the Probability of Cure from Mechanical Treatment. -It will be at once seen that this is a most important point, for upon it depends the whole question of the operative treatment of hernia in children.