fluid. The consequence is, in not a few cases, severe inflammation, followed by suppuration, and the formation of an abscess; many instances of this are on record, and we have ourselves met with a number. The entire substance of the female mamma has, in this manner, been occasionally destroyed.

The intumescence of the breasts in young infants would appear to be the result of a subacute inflammation, attended with serous infiltration into the cellular tissue of the part. Occasionally, the inflammation extends to the substance of the mamma; the skin by which the gland is covered becomes then very tense, shining, and of a dark-red color. Even this aggravated form of the disease will very generally give way in a few days to the simplest treatment. We do not recollect to have ever seen a case which was attended with any degree of trouble, or great or prolonged suffering, certainly no one which showed any tendency to terminate in suppuration, excepting when the tumor had been subjected to the rude and unjustifiable processes adopted for the removal of the supposed stagnant milk.

All that would seem to be required, in the generality of cases, is to anoint the tumor daily with a little sweet oil, or fresh lard, and to cover it with a piece of tolerably thick, soft muslin. When, from any cause, considerable inflammation, pain, and swelling of the breasts take place, the case should be treated by a few leeches, and the application of soft emollient poultices.

A weak solution of the hydrochlorate of ammonia in diluted vinegar, has been proposed as a prompt and certain application in the ordinary form of this affection; we have never used it ourselves, but we have no doubt that it will prove beneficial.

R.-Hydrochlorat. ammoniæ, 3ss.
Aquæ,

Acid. acet. impur. aa 3ij.-M.

To be applied warm, by moisteuing pieces of soft linen rag with it, and laying them upon the affected parts. (Eberle.)

It would be well for the practitioner himself to examine daily, for the first three or four days after birth, the breasts of the infant, in order to detect immediately any swelling that may occur, and when it does appear, to direct the proper measures to be pursued for its removal.

11. Ruptures.-Herniæ.

Hernia is, by no means, unfrequent in early infancy. Children have been born with an umbilical, inguinal, or scrotal hernia, or even with two or more hernial protrusions. More commonly, however, the protrusion takes place within the first few days or weeks after birth, and it is important that it should receive early attention, as well to protect the infant from suffering or danger, as from the circumstance, that by proper treatment, a radical cure may then, in many cases, be effected, and thus the patient saved, in after life, from all the serious consequences invariably attendant upon this infirmity, in whatever region of the abdomen it may be located.

The most frequent form of hernia met with in the infant is that at the umbilicus (exomphalus). This results from the circumstance of

the base of the umbilical cord, in early foetal life, forming a portion of the anterior parietes of the abdomen, and containing the greater part of the intestinal tube. In proportion as the development of the foetus is perfected, the base of the cord contracts, the convolutions of intestine, at the same time, retire within the cavity of the abdomen, and an aponeurotic sheath surrounds, and further contracts the base of the cord, allowing only a sufficient opening for the passage of the latter, with the urachus and umbilical vessels. In some instances, however, the commencement of the cord remains of a large size, and some of the convolutions of intestine continue within it, forming at birth a hernial sac of a round or rather conical form; the summit corresponding with the proper commencement of the cord, and the base to the circumference of the aponeurotic ring at the umbilicus, which is of larger size than natural. The hernial sac is composed in these cases of the peritoneum with the skin and cellular tissue more or less condensed.

The hernia, though strictly congenital, may not be detected until some days after birth, when the intestines become distended by aliment, and crowded downwards towards the umbilicus by the contractions of the diaphragm during inspiration, and in the act of crying. The bulk of the protrusion varies very much; ordinarily, it is about the size of a hickory-nut, but may increase to that of a walnut, or even beyond. It generally contains a convolution of intestine, but may contain only omentum. Dr. Friedberg, of Prague, has called attention to the frequent connection between phimosis and hernia in infancy. The constriction of the urethra caused by the phimosis, gives rise to difficulty in urinating; to overcome this the child strains forcibly, and a rupture is the consequence. Of 111 cases of hernia occurring in children under one year of age, the males were 62 per cent. in excess of the females. Of the boys 27.7 per cent. suffered from congenital phimosis. The number of cases in whom more than one hernia was presented was nearly double in those who were affected with the most aggravated form of phimosis. After the removal of the phimosis by operation the hernia speedily disappeared, the more quickly in proportion to the early age of the child. And a cure was often effected even without the aid of a truss. (Prag. Vierteljahr., No. 1.) It is always larger and more tense when the infant cries or coughs. Upon relaxing the abdominal muscles, and using gentle pressure, the contents of the sac may be readily forced back into the cavity of the abdomen, when, through the parietes of the empty sac, an aperture into which the point of the finger can be inserted is perceptible in the linea alba.

Until the separation of the cord, and the cicatrization of the navel, it is unnecessary to do anything more than to apply, in addition to the usual bandage, immediately over the umbilicus, a compress formed of a few folds of soft linen. As soon, however, as cicatrization is completed, a more effectual course of treatment must be commenced; and the earlier this can be done, the greater will be our chances of effecting a radical cure. The object is to keep the protruding bowels completely and permanently within the abdomen, so as to permit the closure of the opening through which they had escaped to take place. A good

means for effecting this is to cover a portion of gum elastic of a conical shape, and about an inch in thickness, with soft muslin, and then to stitch it to the centre of the ordinary belly-band. The apex, which should not be larger than the umbilical opening, is to be accurately applied over the latter, and the band fastened in the usual way. This compress should be kept on constantly, for it is only by long continuance that we can expect any benefit to result from its employment. In proportion as the infant advances in age, the umbilical opening contracts, while the intestines acquire a greater volume, so that they cease to pass through it, when the use of the compress and bandage may be discontinued. We have, in numerous instances, effected a complete cure by the means here described.

Another mode of treating umbilical hernia in infants, and one that will no doubt be found admirably adapted to produce the desired result, is described by Dr. Maunsell. It consists in the application of a graduated compress, formed of white leather, spread with adhesive plaster, over the opening, and above this, the common flannel roller. The apex of the compress, which is to be applied next the navel, should be, as nearly as possible, of the size of the opening. The compress should consist of three or four pieces, the largest being about three inches in diameter; a double stitch should be passed through these and knotted externally, so as to keep each piece in situ. We should always adjust the compress with our own hands, as great care is necessary to insure the complete return of the hernia. Unless the child exhibits marks of uneasiness, it should not be removed until the plaster loses its adhesive quality, when a new one should be immediately applied. In conducting the case, patience will be greatly exercised, as months will be required for the completion of the cure, a fact that should be explained to the friends at the beginning. It has been recommended by A. Cooper to apply a section of an ivory ball over the umbilicus, and retain it there by adhesive plaster and a bandage. To maintain an equal and constant compression, an elastic belt and pad might be found useful, in all cases.

The following plan, originally adopted by Mr. Woodroofe, of Cork, answers, we are informed by Dr. Maunsell, very well, when there is a small opening with a considerable elongated sac. After reducing the contents, the pouch is to be firmly held between the fingers, and a narrow strip of adhesive plaster wound around it, commencing as close as possible to the abdomen, and continuing to the apex. By this plan an adhesion of the walls of the sac will be brought about, thus forming a natural truss, and preventing protrusion through the opening in the linea alba: it cannot be employed, however, when the hernial tumor is broad and flat. It was proposed by Desault and Dupuytren to apply a ligature around the base of the tumor, with the view of inducing inflammation and adhesion of the sides of the hernial sac. This plan, which is the one described by Celsus, though apparently well adapted to effect a permanent cure, has been abandoned by most modern surgeons, in consequence of the liability of the patients in whom it has been tried, to a return, subsequently, of the hernia.

In the male, congenital inguinal hernia is, by no means, unfrequent. It may exist upon one or both sides. In passing out of the abdomen of the foetus, through the abdominal ring, the testicles always carry with them a portion of the peritoneum, by which they become enveloped, and which also forms the vaginal sac in which they are contained. This sac may become perfectly closed at its upper part, so as to cut off all communication between it and the cavity of the abdomen; often, however, it remains partially or entirely open, so as to allow a convolution of intestine, or a portion of omentum, to descend into it, the protruded bowel being in contact with the testicle, and becoming sometimes adherent to it. The communication between the vaginal cavity of the scrotum and the abdomen, may, however, exist without giving rise to hernia; and it is possible for a portion of intes tine or omentum to descend to the bottom of the sac, while the testicle still remains within the abdomen, or has descended no farther than the ring. Ordinary, non-congenital, inguinal hernia, with strangulation, has been observed, according to Lawrence, in an infant of fourteen months.

It is no uncommon occurrence for a testicle, at the period of birth, to be arrested at the ring, or to have just passed through it, forming a hard rounded tumor in the groin; we must be cautious not to mistake this for hernia, and as the testicle may remain in this position even while a portion of intestine has descended into the sac, this fact must always be kept in mind, as no truss should ever be applied, until the testicle has passed fully into the scrotum.

Scrotal hernia should not be confounded with hydrocele, which is of common occurrence in infants. The latter may be distinguished by the transparency of the tumor, and by our being unable to feel the cylinder of the intestine rolling under our fingers, within the sac. The fluid distending the vaginal sac of the scrotum, we are to recollect, may, in many instances, be returned into the cavity of the abdomen; when this is the case the size of the hydrocele will be increased when the infant cries or coughs. With a very little care such swellings may very readily be distinguished from congenital or accidental hernia. As a general rule, there can be no positive certainty as to the existence of the latter until the testicle has descended into the scrotum.

A curious case is related by Billard, of congenital inguinal hernia. in a female infant. There existed in the left inguinal region, a rounded tumor about the size of a filbert, rather hard to the touch, and incapable of being returned into the abdomen or diminished by pressure, neither was it enlarged by the crying of the child. The tumor was directed obliquely towards the labium of the same side, but did not quite reach to it. The child died from pneumonia, when it was found that the tumor was a real hernial sac, containing the left ovarium, with the fimbriated extremity of the Fallopian tube, a little reddened and swollen. These had descended and passed through the inguinal canal and ring-which latter was much larger than it usually is in the female infant-and were contained in a sac formed of a prolongation of the peritoneum, with the cavity of which it communicated. There were no convolutions of intestine adhering to the surrounding

parts; the right ovarium was in its usual situation; the round ligament of the uterus on the side at which the ovarium had descended, was much shorter than that on the opposite side, and terminated in the labinm by an aponeurotic expansion, instead of losing itself in loose filaments, as usual. Hence, it would appear, that the shorter and more firmly attached ligament had first caused the uterus to incline towards the left side of the bladder, and then drew with it the ovarium through the inguinal ring.

In the treatment of congenital inguinal hernia, the same objects are to be had in view, as in the treatment of that of the umbilicus, namely, to retain permanently the protruding bowel within the cavity of the abdomen, and to favor the natural closure of the ring. The child should be kept as tranquil as possible; it should be restrained by every means in our power from violent paroxysms of crying, and from all exertion likely to increase the protrusion.

When the hemia is present at the period of birth, or appears soon after, it should be at once reduced, and a temporary bandage applied, with a small compress upon the abdominal ring. But little compression, however, should be at first resorted to, and the bandage and compress should be frequently changed, as well from a due attention to cleanliness, as to prevent the irritation of the skin, which would otherwise speedily result from their being constantly wet, and soiled by the natural discharges.

From the smallness of the pelvis, before the end of the first year, and the difficulty of keeping the straps from being continually wet, and causing, in consequence, chafing of the parts with which they are in contact, it is scarcely possible to get any truss to fit, or to keep it on sufficiently constant, previous to that period. We have seldom seen much good result from a truss, or any other retentive apparatus, excepting a simple bandage and compress, before the third or fourth year. Attention should be paid to preserve the bowels of children affected with hernia freely and regularly open.

If the hernia becomes the seat of inflammation, indicated by increased tumefaction, pain, and tenderness upon pressure, leeches should be immediately applied, in numbers adapted to the age and strength of the child; the warm bath should be employed; the tumor covered with a light emollient poultice, and the bowels freely evacuated by castor oil or mild laxative enemata. Should the hernia become strangulated, which is a rare occurrence in young children, if we are unable to reduce the tumor by the ordinary means, an operation will become. necessary.

Cases are recorded in which the operation was performed by Mr. Curling, in a boy twenty-one months old (London Med. Times, 1853), and by Mr. Rayner, in an infant seven weeks old. In the latter case there was stercoraceous vomiting. (London Lancet, 1857.) In both cases the operation was successful, and the children revived. Fergusson has operated successfully on an infant only seventeen days old.

Besides the hernia resulting from the escape of a portion of the bowels at one or other of what are termed the natural openings in the walls of the abdomen, they may also be produced by a congenital