if a hernia does not exist before giving drugs. The presence of hernia is ascertained by the usual symptoms.

Treatment.-Infantile hernia, congenital, tends to cure itself, especially if some assistance is rendered in keeping it reduced. The first thing to do after ascertaining that a hernia exists is to reduce it and keep it so. And if the parent or nurse will give it the requisite attention during the early age it will, as a rule, be cured. What is required after reduction is some mechanical appliance to keep it reduced. The same principle applying in a child as in an adult; if the hernia comes down in spite of the appliance remove the dressing, again reduce the hernia and again apply the apparatus.

What should we use? In umbilical hernia, the best and simpliest thing is the ordinary wooden button, which may be placed over the umbilical ring and held securely by adhesive strips. All other appliances fail for the reason that it is impossible to keep them in their position, and this renders them useless. The button must be removed every few days to examine the skin and to change the location of the adhesive strips, avoiding irritation of the tender skin of the infant.

"The zinc oxide plaster is least likely to cause irritation."

In the inguinal variety the adjusting of a well fitting hard rubber truss is the best, but care must be taken that the size be changed to accord with the increasing age of the child. This style of truss is preferred, because it is easily cleaned and non-absorbent, not offensive and easily adjusted, with constant pressure on the parts. Care must be taken that the pad is not too small, but of sufficient size not to cause an enlargement of the ring, and firm enough not to allow the viscera to protrude. A very useful and inexpensive truss may be formed by using a skein of wool yarn-passing it around the body and passing one end through the looped other end, and then extending the end passing through the loop down under the perineum and bringing it up and attaching it to the encircling skein on the back. Care must be taken that the loop is directly over the internal ring. The skein must be repeatedly changed from being soiled. This can be readily washed. If the skein

of yarn is either too long or too short, it may be readily rewound, making it the proper length.

In femoral hernia use a hard rubber truss.

These measures failing either through neglect of parent or nurse, or through the improper fitting of the truss, the advisability of an operation presents itself. The operation upon an infant is attended with more danger than in an adult. An infant cannot be made to understand the consequence of interfering with the dressing and cleanliness, and this must be taken into consideration in operating upon the child. Therefore, the dressing must be such that the child cannot reach the wound, and such that it cannot come off but will remain fixed. Plaster paris dressing over the regular dressing affords the best means in accomplishing it. This must also be protected so that the dressing does not become soiled with the excretions from the bowel and bladder. In operating on congenital inguinal hernia, and in fact all inguinal hernia in children, look for the vasdeferens, remember that it is small and not so prominent as in an adult, and that it lies close to the sac.

Now, what may be the reasons for operation on an infant for hernia?

I. Certain cases of adherent omentum.

2.

Cases complicated by reducible hydrocele.

3. Cases that are not successfully cured after faithfully trying mechanical treatment, or through neglect.

4. Cases that are not reducible or strangulated.
5. Umbilical hernia should rarely be operated upon.

MECHANICAL TREATMENT OF HERNIA.

BY DR. C. R. GROSSER, WILKES-BARRE, PA.

By mechanical treatment of hernia is meant the attempt to control the rupture by means of some form of truss or bandage. A truss consists essentially of a pad and spring. The pad may be made of hard wood, celluloid, hard rubber or other material.

Two of the best trusses on the market are the Hood, or frame truss, and the Crossbody.

A good truss should so fit the pelvis as to exert an even pressure on all parts and it should retain its proper place in every position of the body. The application or proper fitting of a truss requires considerable experience and mechanical knowledge. The matter should not be left entirely in the hands of dealers in trusses as they put well fitting trusses on buboes varicocele and hydrocele of the cord sometimes. In large hernia and in hernia difficult to control, the water pad will often prove effective where hard pads have failed; usually, however, too large pads are used. The pad should be no larger than sufficient to completely control the hernia.

A pad one-half inch in diameter is large enough for the majority of cases. Before applying a truss the hernia should be completely reduced while the patient is in the recumbent posture. In adults, the truss should usually be left off at night and applied before rising in the morning. In infants and children the truss should be worn constantly, day and night, for the reason that in this class of cases there is ground to hope for a permanent cure, hence the necessity of avoiding any chance of reopening a partially closed sac and canal. In inguinal hernia the pad should rest over the internal ring as nearly as possible and never upon the pubic bone. The steel band should encircle the pelvis on a level with the upper border of the sacrum behind and just below the crest of the ilium, on the sides. In many cases, particularly in those persons with fat and pendulous abdomens, it is difficult to keep a hernia reduced except by using a spring of such force as to produce great discomfort, besides incurring a risk of developing a rupture on the other side. Under such conditions it would be better to apply a double pad truss, thus affording support to both sides of the abdomen. The double pad is of course necessary in cases of double hernia. If the pad of the truss produces chafing, as it is apt to do in warm weather, the surface should be washed with alum water or diluted alcohol.

As a test for the efficiency of a truss it is advised that the

patient be directed to cough, while sitting on the edge of a chair leaning forward, and with legs extended and widely seperated. If the hernia does not slip down behind the pad under these circumstances, the truss many be considered satisfactory.

Mechanical treatment of umbilical hernia. Nearly all forms of belts and pads are of little value in young children, as it is almost impossible to keep them in place. The single narrow strip of adhesive plaster which tends to draw the skin together for small hernial openings, the two-inch wide strip of adhesive plaster with a small pad or wooden button covered with plaster or linen, are the most useful. In umbilical hernia of adults, the best result we can hope for by means of mechanical support is to control the hernia so that it does not increase in size nor become adherent. These hernia when left to themselves usually become adherent and irreducible, and attain great size. When this condition is reached it is almost impossible to give more than partial relief by mechanical means.

For femoral hernia there is a possibility of a cure, but it occurs so very rarely that it may fairly be disregarded.

All that can be reasonably expected of a truss is to control the rupture enough to prevent it becoming adherent and irreducible.

Results of mechanical treatment. The great majority of all cases are in infants under the age of one year. The statement that all children are cured of hernia by mechanical means is not supported by facts. Of 15,000 adult cases observed at the Hospital for Ruptured and Crippled, 700 developed the hernia during infancy or childhood, this may seem to be a small proportion, yet we must take into consideration the large number of children (ruptured) that die from various causes before attaining adult life. More men are cured than women. More girls than boys. A cure by this means does not usually occur after the age of twenty or thirty.

THE RADICAL CURE OF HERNIA.

BY DR. W. S. STEWART, WILKES-BARRE, PA.

In taking up the subject of Radical Cure of Hernia, as assigned to me, I propose only to discuss the inguinal variety, for it would require too much of our time to discuss the operations for all the different varieties of hernia. What are the indications and counter-indications for the radical cure of hernia as given by Coley.

They are in children:

First.

Cases of adherent omentum.

Second. Cases complicated with reducible hydrocele.
Three. Cases irreducible and strangulated.

Four. Cases unable to obtain the care and attention requisite for successful, mechanical treatment.

Fifth. Cases over four years of age, when mechanical treatment has been faithfully tried for a number of years without benefit.

In adults, the younger the patient, the better the chances of radical cure. Operation is indicated in all young adults, in as much as there is little prospect of cure by a truss after the age of maturity. The operation in skilled hands is attended by almost no risk and the chances of a cure without the further need of truss are excellent. All cases of irreducible omentum in patients that are fit subjects for an abdominal operation. The contra-indications are those cases with very large irreducible hernia in stout persons, these as a rule, should not be operated upon. The risks are larger and there is little prospect of a permanent cure. Now, we naturally ask ourselves whose method of operation will give us the best results?

That question must be answered by the operator himself, and he naturally will select the one he is most familiar with, and the one that gives him the best results. The four methods of oper ation that are most prominent and in the order in which they are most popular, is Bassini's, which was given to the profession in 1888, and first done by Bassini in 1884.

Halstead's, which is a modification of Bassini's in 1890.