CASE REPORTED.

BY DR. W. G. WEAVER, WILKES-BARRE, PA.

READ MAY 4, 1904.

Gall-stones removed from common duct. Mr. M., age 48. The specimen I exhibit to-night is a large gall-stone taken from the commonn duct. Five years ago the patient was admitted to the Wilkes-Barre City Hospital as a medical case. At that time he was not thought to be a subject for operation. After his discharge from the institution an exploratory operation was performed by two Wilkes-Barre physicians, but, according to the concurrent testimony of those present, including the etherizer, no calculi were found.

The scar indicates a very extensive incision (patient exhibited). You notice the relatively small incision made in the second operation. This operation was performed by me on January 7th, 1904. I was ably assisted by Dr. Fell, to whom I owe much for his experience and advice. The operation was very difficult on account of the extensive adhesions from the first operation. No stones were found in the gall-bladder, but after extensively breaking up adhesions, the large stone exhibited was found in and removed from the common duct. The exquisite polish of the lower end of the stone was produced by its contact with another stone further down, near the entrance of the duct to the duodenum. This second stone was removed with considerable difficulty.

The patient exhibited evidence of such cachexia as to warrant a belief that malignant disease existed. He had numerous attacks of hepatic colic, but during last summer had improved so much as to be able to work most of the time in the mines. As cold weather approached, however, the attacks of colic were frequent and severe, and the resulting jaundice was nearly continuous, so that it was difficult to find a favorable opportunity for operation.

The gall duct was closed with cat-gut sutures, but as a further precaution, gauze drainage was also used. Very little leaking occurred and the wound was completely closed in three weeks. The recovery was without incident. The patient has gained about twenty pounds in weight, and his color, as you observe, is good.

I exhibit the patient and the removed calculus on account of the history of the former, and the size of the latter.

A SYMPOSIUM ON HERNIA.

READ MAY 17, 1904.

AETIOLOGY AND VARIETIES.

BY DR. S. M. WOLFE, WILKES-BARRE, PA.

The subject before us this evening is one of the most important ones that the physician has to deal with, and one that we cannot be too well informed upon. In many cases of hernia, an exact knowledge of the condition and prompt action on the part of the medical attendant will save a human life, and a lack of the same will be very embarrassing to the physician and very disastrious to the patient.

What is hernia? I find the simpliest and best definition in the American Medical Dictionary, by Dorland, who describes it as being a protrusion of a loop or knuckle of an organ or tissue, through an abnormal opening. In speaking of hernia, however, we usually refer to some type of the abdominal variety. In the aetiology of hernia, we have the following points to consider.

Heredity: Macready says that in twenty-five per cent. there is a hereditary history; Kingdon places the percentage at thirty-four. This is more particularly true of congenital hernia.

Sex is another important factor, inguinal hernia being six times as frequent in the male as the female.

Hernia may occur at any age; in a large percentage of cases, it develops during infancy, and the cases that develop at this time are twice as frequent in boys as girls. The cause at this time is usually some congenital defect. After infancy, the greatest number of herniae occur between the ages of fifteen and fifty years. This is due to the fact that the average person is more active and does harder work at that period of life.

Occupation is an important factor. Those people whose work requires severe muscular strain, are particularly liable to develop hernia.

Operation, or traumatism of the abdominal wall, followed by scar tissue, may be a predisposing cause.

Child-birth, especially in fat women with flabby abdominal walls, may cause herniae, especially of the umbilical variety.

A large proportion of all hernia occurring in adult life may be traced to a sudden and severe strain. It does not necessarily follow that a hernia must appear immediately after such a strain. It may be days, weeks, or even months, before the patient detects a slight fullness over the affected area, which gradually increases until a more or less fully developed hernia appears. Other causes of hernia, given by various authors, are elongation of the mesentery, contusion, obesity, ascites, muscular atrophy, rapid loss of flesh, whooping-cough, stricture, constipation, tight-lacing, playing on wind instruments, jumping, running, vomiting, etc. Whatever may be the exciting cause of hernia, in the great majority of cases there is some hysical imperfection of the structures about the hernial orifice. For this or some other reason, there is a tendency for patients suffering from a single hernia, especially of the inguinal type, to develop the same condition on the opposite side.

Various writers estimate that this happens in from twenty to forty per cent. of such cases.

The clinical varieties of abdominal hernia are the reducible, the irreducible, the obstructed, the inflammed and the strangulated.

The anatomical varieties consist of the inguinal, which may be either of the oblique or indirect variety, or the direct. These are distinguished from each other by their course through the abdominal wall, and their relations to the epigastric artery.

In oblique hernia, the neck of the sac is external to the epigastric artery and crosses it at right angles.

In direct hernia, the opening is a new one, and the hernia protrudes below the epigastric vessels and to their inner side.

In oblique hernia, in the male, the sac is always directly in front of the spermatic cord. I speak of this, because twice. inside of the last few years, I have seen an operator look inside of the sac for the cord. The spermatic cord was never found inside a hernal sac. We can readily understand this, when

we remember that the testis in the process of formation, is never intraperitonal.

Oblique inguinal hernia in women rarely descends into the labia.

Next in frequency and importance is the femoral variety, which is a protrusion through the crural canal. This sort of hernia is always acquired. It rarely happens before adult life, although a case of double femoral hernia in a child of two years is reported; umbilical hernia may be either congenital or acquired, the great majority of these cases occurring in infants. Interstitial hernia is another variety, where the sac may lie between the transversalis fascia and the parietal peritoneum, or beneath the aponeurosis of the external oblique muscle, or between the external oblique muscle and the skin. This last variety is the most common of interstitial hernia. I had a case of this variety a few months ago—an enormous mass appeared after a severe vomiting attack; it extended from Poupart's ligament about three inches upward, and its lateral measurement was six inches or more. In this case there was an undescended testicle and I find that the condition is usually present in these cases.

Ventral hernia may occur at any point in the abdominal wall, other than the locations already described. It is usually due to some congenital defect, operation, incision, injury, ascites, or the like. Other varieties of hernia, less frequently met with, are the obturator, ischiatic, diaphragmatic, pudendal, perineal, rectal, retro-peritoneal, foraminal, mesenteric, lumbar, vesical, sciatic hernia and hernia into the foramen of Winslow. It is said that every organ of the abdominal cavity, excepting the pancreas, has been found in hernial sacs.

There are other varieties of hernia that might be mentioned, but as the gentlemen who are to follow me are obliged to treat all the varieties described, I will, out of consideration for them and the society, bring my part of this program to a close.

I thank you for your attention.

INFANTILE HERNIA.

BY DR. A. G. FELL, WILKES-BARRE, PA.

These may be either congenital or acquired. The most common varieties are the umbilical and inguinal, which are caused by a delayed or incomplete development of the parts, causing a weakness, or in the inguinal congenital, a want of closing the tunica vaginalis after descent of the testicle, which usually takes place in the male child before birth. The inguinal hernia is more common in the male than the female, in consequence of the anatomical construction of the parts. The testicle before birth in the foetis, is situated in the lumbar region, back of the peritoneum, and in its descent carries a portion of the peritoneum into the scrotum, forming the vaginal tunic which entirely surrounds the testicle. If there is a proper closure of this prolongation the tunica vaginalis is cut off from its extension into the abdomen, but if the opening is not obliterated we then have the proper condition for the congenital hernia. It must be borne in mind a congenital hernia is not an acquired sac, but it is a sac which should have been obliterated. This sac may be distended with intestine, omentum, appendix or any abdominal viscera in the neighborhood.

Femoral hernia is never congenital and is very rare in infants; in female children the ovary has been found along the course of the sac in the canal.

The most common hernia of infant life is umbilical. The umbilical aperture is always open at birth, but usually closes on ligating the cord, but at times this fails to close and the parts are ready to take advantage of the weakness. Almost fifty per cent. of ruptures occur before thirty-five years and very few occur between infancy and about eighteen to twenty years.

In acquired hernia, given a naturally weakened part, long and severe crying or straining of the abdominal walls may cause the parts to break, forming the hernia. One of the most persistent symptoms of hernia in an infant is the colicy cry, and we should always examine colicy children to see