VOL. XLV, No. 10 WHOLE NO. 1071. J

YEARLY SUBSCRIPTION, $1.00

Original Articles.

UMBILICAL HERNIA; MAYO'S OPERATION A CLINICAL LECTURE.*

BY N. B. CARSON, M. D., ST. LOUIS, Professor of Clinical Surgery in the Medical Department, Washington University; President of the St. Louis Medical Society.

THE

'HE CASE I present to you to-day is one of umbilical hernia upon which I propose to do Mayo's operation. In referring to your text books you will find that this form of hernia is divided into three classes, the congenital, infantile and adult. The congenital, which is fortunately rare, occurs during embryonic life, and is due to improper development of the abdominal walls. As Malgaigne very properly says,it should not be considered as a hernia, for it is concerned "not with viscera that have escaped from a cavity, but with viscera that never have entered it." The tumors in these cases vary in size from a slight projection at the umbilicus containing only a loop, or a part of a loop of the intestines, to a tumor of quite large size containing the entire abdominal contents. Scudder reports a case operated upon by J. C. Warren, which contained the liver. J. H. Warren, in his work on hernia, refers to cases containing the bladder and

womb.

The diagnosis of these cases is not difficult, and is made simply by the tumor. As I have said, this tumor is sometimes small and when the cord is ligated is sometimes included in the ligature, and there results either a fecal or urinary fistula, or death, depending altogether upon the amount of intestine involved. The coverings of this form of hernia consist of the constituents of the cord. In some cases ulceration of the coverings takes place, followed by a fatal peritonitis. As I have said, it is exceedingly rare, and Lindfors estimates its frequency as one in every 5,184 births. At the Hospital for the Ruptured and Crippled, in a period of five years, only two *Delivered at St. Louis Mullanphy Hospital, Jan. 25

1902.

such cases presented themselves, and they came in the same week.

As to treatment, statistics seem to be in favor of operation. McDonald reports 31 cases; of these, 12 were treated expectantly, with 9 deaths, and 19 were operated upon with 2 deaths.

The second form, infantile hernia, is the most common, and one that no doubt in your practice you will be often called upon to treat. This is an acquired form and not congenital, and the contents of the sac are always intestine. The tumor varies in size from a very slight projection to a tumor as large as the end of the thumb; very seldom larger. This condition is generally brought on by crying or straining. The coverings of the sac are from without inward, skin superficial and deep fasciae, and peritoneum. The diagnosis is very easily made, as we have the tumor which is readily reduced, and which goes back with a perceptible gurgle. The treatment consists in placing a pad over the hernia after reducing it. A nickel or cent-piece, enclosed in adhesive plaster, makes a most excellent truss. The tendency is to a spontaneous cure. It is very seldom that they are found in adult life, although McCready claims to have seen one in a young man 25 years of age which had existed from infancy.

The third form, the adult hernia, to which this case belongs, is also an acquired hernia, and is generally the result of strain, or accident, or childbirth. Petit holds that it is not an umbilical hernia proper, but that the protrusion is outside of the umbilical ring. J. H. Warren and others agree with Petit, while Sir Astley Cooper has disproved the correctness of this assertion. With him Malgaigne and some other authors agree. The symptoms are simply the tumor presenting in the umbilical region, which may attain enormous size. Its contents generally consist of folds of omentum, but frequently we have the intestine; the transverse colon, very often forms part of the contents of the sac. When the contents

the omentum and intestine, and the omental sac contains the loop of intestine. There are, however, exceptions to this rule, so that when we operate, we should act as if the intestine was in constant danger. According to authors, this form of hernia occurs more frequently in females than in males; and of all hernias it occurs in the male in 5.46 per cent, and in the female 27.34 per cent. The tendency of the contents of the sac is to inflame and form adhesions, so that unless seen immediately after occurrence, it is almost impossible to accomplish a reduction.

Now, I will here make a digression, so far as to say that in the text books you will see it recommended, in all forms of hernia after the sac has been opened, and the stricture relieved,

FIGURE II.

will result fatally when this practice is followed than if the intestines are allowed to remain in situ until it is positively determined whether they will return or not to the normal condition. I also wish here to advise you very strongly against much manipulation, and the use of force or violence in attempting reduction in any form of hernia, as the result will be much more unfavorable when such practice is resorted to, than when the cases are promptly operated upon.

When we review the pathology of this condition, we find that it generally occurs, as in this case, in large fleshy persons, where the muscles are attenuated and relaxed. The abdominal cavity has become contracted on account of the mass outside, and the umbilical opening has become stretched until it attains a very large di

than the original hernia. An old writer says that an extruded viscus has lost the right of habitation, and, therefore, Wheaton, with others, recommends the bed treatment preceding the operation. He says that although the hernia may return in six months, benefit has resulted, because the right of habitation has been re-established and if the second operation is done it will in all probability result successfully.

Coley does not agree with those who assert that the status of the patient is better after operation than before. On the contrary he says the patients are left in a more pitiable condition after the operation than before.

The treatment is altogether operative, as it is impossible in the great majority to accomplish a reduction and when reduced, owing to

FIGURE IV.

De Forest Willard reports a case of a very large hernia, in which he made a plug of the stump of the amputated omentum, and closed the fasciae, layer by layer over it. Others have advised the use of silver or gold wire netting, but the results of these cases wherever the wire has been used have not been reported. McCosh, of New York, used celluloid in one case with success, and although nearly three years have elapsed, he says that the patient is perfectly comfortable and with. no sign of irritation from the plate, nor evidence of hernial protrusion.

Of all the operations which I have seen recommended for the cure of these cases, the one devised by W. J. Mayo, of Rochester, Minn., appeals to me most favorably and is the one that I shall demonstrate to you to-day upon

this case. Before proceeding with the operation, I will explain to you the different steps by means of the drawings before you, which I had made from cuts taken from Mayo's reports. Mayo claims to have done the operation nineteen times successfully, although in some of the cases sufficient time had not elapsed to demonstrate certainly the ultimate cure.

Three surgeons, widely separated (Mayo and two Italian surgeons) devised this operation independently, but to Mayo unquestionably belongs the priority. Ochsner, of Chicago, has done the operation seven times, as he claims, successfully, although the interval is too short to determine the ultimate results.

The first picture that you see, marked number one, represents a transverse incision through the skin, and fasciae, down to the ring which has been divided, showing the omentum which forms the contents of the sac. After dividing the skin and fasciae down to the aponeurosis,this is separated in all directions to the extent of one inch and a half, which is shown in the second picture. Here we also have the cut in the peritoneum closed. Having dissected away the fat from the aponeurosis, the sac at the neck is opened and if it contains bowel this is returned and the sac with its contents removed. If much intestine is contained in the sac, a corresponding amount of omentum should be amputated, to make room for the intestine returned. An incision is then made on each side of the ring to the extent of an inch.

The situation of this incision should depend on the direction in which we intend to close our wound, whether transversely or longitudinally, and this should also depend upon the readiness with which the margins of the ring can be brought together. If we are going to close our wound transversely, the aponeurosis (of the upper flap) should be dissected from the peritoneum to the extent of an inch. These incisions are shown in the third picture. This picture also shows the mattress sutures placed one inch above the margin of the upper flap. A sufficient number of mattress sutures are introduced, the loops of which include the edge of the lower flap, so that when they are tightened the lower edge of the ring is invaginated into the pocket made in the upper flap. The free margin of the upper flap is then fixed by a continuous suture,

MAINE'S JUMPING FRENCHMEN. Physicians who practice along the Canadian border of the New England States are familiar with a class of persons known as "jumpers." These individuals are neurotics and their particular neurosis is dignified with the designation "Miryachit," a term of Russian derivation, signifying "to make a fool of one's self." The disease is thus described in Quain's Encyclopedia:

"This is the term applied in Russia and Eastern Siberia to a morbid condition, which, however, is met with under different names in various parts of the world. The term itself is part of a verb meaning 'to fool' or 'play the fool,' and the victim of the disease, if it may be named, has a desire, apparently irresistible, to imitate whatever action is carried out in his presence, and also to repeat whatever is said to him or in his hearing. The condition, according to Dr. Jankovsky, is chronic, but subject to spontaneous remission, and is not usually of such a character as to interfere with an ordinary occupation. The tendency is not infrequently hereditary, and is usually induced by contact with a miriasha—a person affected in this way; and amidst a neurotic community in places where it is prevalent. the influence of such a person is in the highest degree disturbing. An exactly similar condition, according to Dr. Neale, is met with in Java under the name of Lata. On the northern frontier of Maine, between the United States and Canada, there exists the curious of so-called 'jumpers,' who resemble in some points the sufferers from miryachit. But instead of imitating action or repeating words, the sufferers from this condition are characterized by their inability to disobey any sudden sharp order which is given to them. Thus a man ordered to take hold of a red-hot stove was impelled to do so, although the effect was disastrous. A similar condition has been described by Dr. Bennett as existing in Griqualand among the natives and

those of mixed race, who suffer from an irresistible impulse to dance, shout or grimace on the occasion of any sudden or peculiar sound; and like the 'jumpers,' they also will obey any sudden order, oblivious of consequences.

"Under whatever name or in whatever part of the world it is met with, the condition is essentially a physical disturbance, and it affects chiefly those who are on the outskirts of civilization. On the whole, men are more subject to it than women, and in the form met with in Africa men are apparently the only victims. In the Russian form, on the other hand, men are less frequently attacked than women. The condition has many resemblances to the great dancing epidemics of the middle ages, and almost seems like a relic of them. Like them, it spreads like contagion; and its manifestations are similarly the result of irresistible impulses, and are displayed among a class emotionally unstable and destitute of the self-control which is necessary in a well-ordered community. By some, the Canadian form is ascribed to the excessive indulgence in tickling to which the classes affected are addicted; but it is more likely that both this and its supposed effect are the expression of the same underlying instability."

By the foregoing the reader will be better enabled to understand the following story, which appeared in a newspaper recently, and which seems to be uncommonly accurate:

That a "jumping Frenchman" is a dangerous person to have was demonstrated in a Maine lumber camp last week, when, at the sudden command of a would-be joker, one of these strangely afflicted creatures struck a fellowworkman a fearful blow over the head with a sled-stake.

The blow nearly fractured the skull of the victim of the "joke," and it will be weeks before he can get out of his bunk.

The "jumper" was whittling the stake with a big knife, and the other woodsman stood watching him, when the joker came along and suddenly yelled out:

"Smash him!"

Instantly the "jumper," mechanically respon sive to any quick command, felled the man in front of him to the floor.

The "jumping Frenchman" has long been known as one of the peculiar institutions of Northern Maine, and a few of his kind are to

be found in the factory towns like Lewiston and Biddeford. These "jumpers" seem to have no control over their nerves or muscles when taken off their guard or startled in any way and while there is a certain drollery at times in their antics, the humorous element is, to thoughtful persons, overshadowed by the tragic possibilities. A "jumper" is liable to kill a man at an instant's notice, and be no more responsible for his act that would be a mad bull or a runaway locomotive.

In some towns severe punishment awaits the man who is caught "jumping" one of the poor wretches, and on several occasions the friends of the "jumper" have taken the law into their own hands and visited just revenge upon the jokers. A "jumper" will do at once whatever he is suddenly commanded to do. He will strike any person who may chance to stand in front of him, put his own hand into the fire, or even jump overboard from a boat or wharf.

"Jump in!" yelled a stevedore on a Bangor wharf to a "jumper"-and into the Penobscot the poor fellow dived like a flash. As the time was April, the river was full of floating ice, and it was with great difficulty that the "jumper" was rescued.

A "jumper has been known to leap from a train running at full speed because a drunken river driver yelled "jump off!" and the story is told that a "jumper" created a scene at his own wedding by frantically embracing the bride on the way down the church aisle in response to a yell of "hug her!"

The most famous "jumper" that Maine ever knew was Preston B. Jones, who for 20 years was one of the most interesting characters in Bangor. "Pres" Jones, as he was commonly called, had been a soldier in the Union army. and became a nervous wreck from the booming of the big guns before Petersburg.

Unlike others "jumpers," Pres Jones jumped and shouted at the same time, and was as likely to do that on his own account as when startled. He did whatever came into his mind.

Once, when Sheriff Jerrard was trying to do in Bangor what Sheriff Pearson was trying to accomplish in Bangor-shut up all the barrooms and stop the sale of liquor-the officers were making a search of premises in lower Broad street, directly opposite the little shop of Pres Jones.