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Incarcerated hernia in infancy
INCARCERATED
HERNIA
IN INFANCY *
CASE REPORT CHRISTOPHER
J.
MCCORMACK,
M.D.
Assistant Attending Surgeon, St. Francis Hospital HARTFORD,
CONNECTICUT
T
sanguineous fluid. On deIivery of the sac contents these were discovered to be the head of the cecum, the proxima1 iIeum and the appendix, which was Iying free in the sac. A perforation was noted in the appendix at about its midpoint. The appendix was removed by tying with catgut and cutting the mesoappendix, tying the base of the appendix with catgut and removing with the cautery. The stump was not inverted but was repIaced in the abdomen and 2 Gm. of suIfaniIamide powder were sprinkIed over the stump, into the abdomen and into the wound. The hernia1 sac was divided at the interna ring, the proxima1 segment cIosed with catgut and in order to save time the dista1 portion was Ieft. The conjoined tendon was brought to Poupart’s Iigament with catgut and the externa obIique fascia was closed with catgut. The cord was not transpIanted. Interrupted siIk was used in the skin. The whoIe procedure took about forty-five minutes. The report of the pathoIogist was as foIIows: Macroscopic: The specimen is an appendix 3.5 by 0.4 cm. The serosa is 3 pIus injected. A segment, 3 mm. Iong, in the center appears necrotic in a11 coats and there is a smaI1 perforation. The waI1 is soft, mucosa hyperemic in the remainder of the appendix. The Iumen contains mucoid ffuid. Microscopic: Sections represent an acute, suppurative and necrotizing appendicitis. Diagnosis: Acute appendicitis with perforation. Post-operativeIy the chiId had a stormy course. His temperature rose to 106’~. that evening, his respirations were 48 and his puIse 140. An infusion of 200 cc. whoIe bIood and IOO cc. of saIine was given by specia1 needIe into the marrow of the right tibia, >/a gr. sodium IuminaI was given for restIessness and external heat was appIied to the abdomen. The next day he was given tea by mouth and a soapsuds enema. SuIfadiazine, $1 gr. was given every four hours and gIucose and
HIS case is being reported for the foIIowing two reasons: (I) the age of the patient, and (2) the unusua1 complication associated with the incarcerated hernia. CASE
REPORT
J. P. N. entered St. Francis HospitaI at I I : 13 A.M. on May IO, 1943, with the foIloWing history: He had been deIivered normaIIy at term in Februaiy, 1943, and deveIoped normaIIy. His weight at birth was 5 pounds and 12 ounces. The chiId had been we11 unti1 March 13, 1943, when loose stooIs containing some bIood were noted. He recovered sIowIy from this and was weII untiI noon May 9, 1943, when it was noted he had a fever of 100%. At the same time a sweIIing was noted in the right scrotum. Examination at the time of admission reveaIed a dehydrated child, drowsy and IistIess. His temperature was 99.6”~. and his weight was 7 pounds 4 ounces. The abdomen was distended and tender to touch in the right Iower quadrant. The scrotum was red and there was a mass about 4 by 4 by 8 cm. in the right scrotum extending into the right inguina1 canal. At the time of admission the baby vomited a moderate amount of bile stained materia1. The right testicIe was not feIt and the mass did not transmit Iight. The fontaneIs were depressed. Examination of the heart and Iungs was negative. A diagnosis of an incarcerated right inguina1 hernia was made and he was brought to the operating room about two hours after entering. Under vinethene and ether anesthesia, a right inguina1 incision about ~$4 inches Iong was made 45 inch above and paraIIe1 to Poupart’s ligament. The externa1 obIique fascia was divided, the inguina1 cana opened and the mass delivered. The sac was opened and contained a moderate amount of sero-
* From the Department of Surgery, St. Francis HospitaI, Hartford, Conn. 116
saline were given into the right tibia. The second day he was put on a formula of equal parts of skimmed milk and tea, 4 ounces at each feeding every four hours. The formula was changed the nest day to skimmed milk, ‘; ounces, whole milk, 5 ounces, water 12 ounces and divided equahy for six feedings. On May 14, 1943, the formula was changed to whole milk 12 ounces, water 12 ounces. On XIay 15, 1913, the temperature was normal, the sulfadiazine was discontinued and the formula was whole milk 14 ounces, water IO ounces. Dextro-maltose I ounce, DrisdoI and cevatamic acid were added. On the eighth day, iLIay 18, 1933, the skin sutures were removed and there was a moderate amount of serous drainage from the wound. This persisted until May 25, 1943, the fifteenth postoperative day. He was dismissed from the hospital May 30, 1943, twenty days after
entering and weighed 8 pounds and I ounce. At examination on March 15, 1944, the scar was firm and we11 healed, there was no evidence of a recurrence of the hernia and the child was apparentIy healthy and weighed 13 pounds, 8 ounces.
An incarcerated inguinal hernia in infancy is not uncommon. Thorndike and Ferguson,’ reporting on 906 patients with a diagnosis of incarcerated or stranguIated inguina1 hernia during a ten-year period in a series of 1,740 operations for inguinal hernia in patients under tweIve years, stated that the greatest incidence of incarceration occurred during the first six months of Iife, and after the age of eighteen months there was a steady faI1 in the incidence of incarceration up to the age of six. The predominance of maIes as we11 as the predominance of the right side is verified in the present case. They found that 80.2 per cent involved the right side. There is an exceIIent discussion of the differentia1 diagnosis of incarcerated hernia in infancy and chiIdhood in this paper and anyone interested shouId consuIt this ar;icIe as the author of the present articIe does not believe that he can add anything new. According to WakeIey,2 hernia of the appendix is a we11 known cIinica1 entity
and amounts to over I per- c~ent ()I’ all hernias. He reports sixteen cases of herniated appendices in 2,000 cases of hernias of aI1 ages. However, only one case was in the age group of one year, and in this patient, the appendix was not ruptured. The average age of the sixteen patients was approximately forty-fix-e years. Remsen” reported a case which closely simulated the one in the present report in many ways. However, the appendix was not perforated and there was an associated hydrocele. This patient was sixteen days oId. The whole appendix was not in the hernial sac. GoIden and HamiIton’ reported a veq interesting case of a strangulated hernia in an infant of five weeks. In the sac was found an acutely inflamed appendix. The appendix was not ruptured but associated with the acute appendicitis was an acute testicuIar inflammation. HoIzeI” reported the postmortem findings in a thirty-two days old infant which showed a ruptured appendix in a hernia1 sac. However, there was no sign of an incarceration although cIinically from the history there verv IikeIy was a loop of bowel in the right mguinal region. If one considers the anatomy- and embryoIogy of this condition, he is at a loss to expIain Its occurrence. Surgeons who have had a great deal of experience agree that the appendix in an infant usually Iies high in the abdomen. Because of this in acute appendicitis, I usually make my incision, which is the BattIe or the right rectusmuscle inward retracting incision, higher than normal in infants or children. There is no doubt about the congenital origin of the hernia, but it is difficult to explain the presence of the appendix in the hernial sac at the age of three months. CONCLUSIONS I. Incarcerated hernia is not uncommon in infancy or chiIdhood. 2. Appendicitis or ruptured appendicitis is aIs not uncommon in infancy or chiIdhood.
118 American
Journal
of Surgery
Puppel,
Morris-Carcinoma
3. Incarcerated hernia containing a ruptured appendix is exceedingIy uncommon in chiIdhood and infancy. 4. A case of an incarcerated hernia containing a ruptured appendix in a chiId three months oId is reported with a favorable resuIt. I was unabIe to find a simiIar case in the Iiterature. I wish to thank Dr. EIIen P. O’FIaherty of the Department of Pediatrics of St. Francis HospitaI for her help in the preparation of this paper and for her capable handling of the postoperative feeding probIem this patient presented.
WHILE stomach
carcinoma
of
the
is one of the captains
duodenum
of Ileum
OCTOBER. rg‘$.&
REFERENCES I. THORNDIKE, A. JR. and FERGUSON, C. F. Incarcerated inguinal hernia in infancy and childhood. Am. J. Surg., 39: 429, 1938. 2. WAKELEY, C. P. Hernia of the veriform appendix. A record of sixteen persona1 cases. Lancet, 235: 1282, 1938. 3. REMSEN, C. M. Appendicitis in an infant sixteen days old with appendix in an inguinal hernial sac. Ann. Surg., 56: 91 l-914, 1912. 4. GOLDEN, J. L. and HAMILTON, H. H. Strangulated inguinal hernia, with unusua1 complications, in an infant of five weeks. New England J. Med., 210: 857-858, 1934. 5. HOLZEL, A. Appendicitis in the hernial sac of a nursling. Kinder&L Praxis, 7: 502, 1936.
is exceptional,
carcinoma
of the
of the men of death. Four thousand persons die annuaIIy from this disease in Britain, and nine thousand in America (Sherren). MaIes are twice as often affected as femaIes. From “A Short Practice of Surgery” by HamiIton BaiIey and R. J. McNeiII Love (H. K. Lewis & Co. Ltd.).
HERNIA
IN INFANCY *
CASE REPORT CHRISTOPHER
J.
MCCORMACK,
M.D.
Assistant Attending Surgeon, St. Francis Hospital HARTFORD,
CONNECTICUT
T
sanguineous fluid. On deIivery of the sac contents these were discovered to be the head of the cecum, the proxima1 iIeum and the appendix, which was Iying free in the sac. A perforation was noted in the appendix at about its midpoint. The appendix was removed by tying with catgut and cutting the mesoappendix, tying the base of the appendix with catgut and removing with the cautery. The stump was not inverted but was repIaced in the abdomen and 2 Gm. of suIfaniIamide powder were sprinkIed over the stump, into the abdomen and into the wound. The hernia1 sac was divided at the interna ring, the proxima1 segment cIosed with catgut and in order to save time the dista1 portion was Ieft. The conjoined tendon was brought to Poupart’s Iigament with catgut and the externa obIique fascia was closed with catgut. The cord was not transpIanted. Interrupted siIk was used in the skin. The whoIe procedure took about forty-five minutes. The report of the pathoIogist was as foIIows: Macroscopic: The specimen is an appendix 3.5 by 0.4 cm. The serosa is 3 pIus injected. A segment, 3 mm. Iong, in the center appears necrotic in a11 coats and there is a smaI1 perforation. The waI1 is soft, mucosa hyperemic in the remainder of the appendix. The Iumen contains mucoid ffuid. Microscopic: Sections represent an acute, suppurative and necrotizing appendicitis. Diagnosis: Acute appendicitis with perforation. Post-operativeIy the chiId had a stormy course. His temperature rose to 106’~. that evening, his respirations were 48 and his puIse 140. An infusion of 200 cc. whoIe bIood and IOO cc. of saIine was given by specia1 needIe into the marrow of the right tibia, >/a gr. sodium IuminaI was given for restIessness and external heat was appIied to the abdomen. The next day he was given tea by mouth and a soapsuds enema. SuIfadiazine, $1 gr. was given every four hours and gIucose and
HIS case is being reported for the foIIowing two reasons: (I) the age of the patient, and (2) the unusua1 complication associated with the incarcerated hernia. CASE
REPORT
J. P. N. entered St. Francis HospitaI at I I : 13 A.M. on May IO, 1943, with the foIloWing history: He had been deIivered normaIIy at term in Februaiy, 1943, and deveIoped normaIIy. His weight at birth was 5 pounds and 12 ounces. The chiId had been we11 unti1 March 13, 1943, when loose stooIs containing some bIood were noted. He recovered sIowIy from this and was weII untiI noon May 9, 1943, when it was noted he had a fever of 100%. At the same time a sweIIing was noted in the right scrotum. Examination at the time of admission reveaIed a dehydrated child, drowsy and IistIess. His temperature was 99.6”~. and his weight was 7 pounds 4 ounces. The abdomen was distended and tender to touch in the right Iower quadrant. The scrotum was red and there was a mass about 4 by 4 by 8 cm. in the right scrotum extending into the right inguina1 canal. At the time of admission the baby vomited a moderate amount of bile stained materia1. The right testicIe was not feIt and the mass did not transmit Iight. The fontaneIs were depressed. Examination of the heart and Iungs was negative. A diagnosis of an incarcerated right inguina1 hernia was made and he was brought to the operating room about two hours after entering. Under vinethene and ether anesthesia, a right inguina1 incision about ~$4 inches Iong was made 45 inch above and paraIIe1 to Poupart’s ligament. The externa1 obIique fascia was divided, the inguina1 cana opened and the mass delivered. The sac was opened and contained a moderate amount of sero-
* From the Department of Surgery, St. Francis HospitaI, Hartford, Conn. 116
saline were given into the right tibia. The second day he was put on a formula of equal parts of skimmed milk and tea, 4 ounces at each feeding every four hours. The formula was changed the nest day to skimmed milk, ‘; ounces, whole milk, 5 ounces, water 12 ounces and divided equahy for six feedings. On May 14, 1943, the formula was changed to whole milk 12 ounces, water 12 ounces. On XIay 15, 1913, the temperature was normal, the sulfadiazine was discontinued and the formula was whole milk 14 ounces, water IO ounces. Dextro-maltose I ounce, DrisdoI and cevatamic acid were added. On the eighth day, iLIay 18, 1933, the skin sutures were removed and there was a moderate amount of serous drainage from the wound. This persisted until May 25, 1943, the fifteenth postoperative day. He was dismissed from the hospital May 30, 1943, twenty days after
entering and weighed 8 pounds and I ounce. At examination on March 15, 1944, the scar was firm and we11 healed, there was no evidence of a recurrence of the hernia and the child was apparentIy healthy and weighed 13 pounds, 8 ounces.
An incarcerated inguinal hernia in infancy is not uncommon. Thorndike and Ferguson,’ reporting on 906 patients with a diagnosis of incarcerated or stranguIated inguina1 hernia during a ten-year period in a series of 1,740 operations for inguinal hernia in patients under tweIve years, stated that the greatest incidence of incarceration occurred during the first six months of Iife, and after the age of eighteen months there was a steady faI1 in the incidence of incarceration up to the age of six. The predominance of maIes as we11 as the predominance of the right side is verified in the present case. They found that 80.2 per cent involved the right side. There is an exceIIent discussion of the differentia1 diagnosis of incarcerated hernia in infancy and chiIdhood in this paper and anyone interested shouId consuIt this ar;icIe as the author of the present articIe does not believe that he can add anything new. According to WakeIey,2 hernia of the appendix is a we11 known cIinica1 entity
and amounts to over I per- c~ent ()I’ all hernias. He reports sixteen cases of herniated appendices in 2,000 cases of hernias of aI1 ages. However, only one case was in the age group of one year, and in this patient, the appendix was not ruptured. The average age of the sixteen patients was approximately forty-fix-e years. Remsen” reported a case which closely simulated the one in the present report in many ways. However, the appendix was not perforated and there was an associated hydrocele. This patient was sixteen days oId. The whole appendix was not in the hernial sac. GoIden and HamiIton’ reported a veq interesting case of a strangulated hernia in an infant of five weeks. In the sac was found an acutely inflamed appendix. The appendix was not ruptured but associated with the acute appendicitis was an acute testicuIar inflammation. HoIzeI” reported the postmortem findings in a thirty-two days old infant which showed a ruptured appendix in a hernia1 sac. However, there was no sign of an incarceration although cIinically from the history there verv IikeIy was a loop of bowel in the right mguinal region. If one considers the anatomy- and embryoIogy of this condition, he is at a loss to expIain Its occurrence. Surgeons who have had a great deal of experience agree that the appendix in an infant usually Iies high in the abdomen. Because of this in acute appendicitis, I usually make my incision, which is the BattIe or the right rectusmuscle inward retracting incision, higher than normal in infants or children. There is no doubt about the congenital origin of the hernia, but it is difficult to explain the presence of the appendix in the hernial sac at the age of three months. CONCLUSIONS I. Incarcerated hernia is not uncommon in infancy or chiIdhood. 2. Appendicitis or ruptured appendicitis is aIs not uncommon in infancy or chiIdhood.
118 American
Journal
of Surgery
Puppel,
Morris-Carcinoma
3. Incarcerated hernia containing a ruptured appendix is exceedingIy uncommon in chiIdhood and infancy. 4. A case of an incarcerated hernia containing a ruptured appendix in a chiId three months oId is reported with a favorable resuIt. I was unabIe to find a simiIar case in the Iiterature. I wish to thank Dr. EIIen P. O’FIaherty of the Department of Pediatrics of St. Francis HospitaI for her help in the preparation of this paper and for her capable handling of the postoperative feeding probIem this patient presented.
WHILE stomach
carcinoma
of
the
is one of the captains
duodenum
of Ileum
OCTOBER. rg‘$.&
REFERENCES I. THORNDIKE, A. JR. and FERGUSON, C. F. Incarcerated inguinal hernia in infancy and childhood. Am. J. Surg., 39: 429, 1938. 2. WAKELEY, C. P. Hernia of the veriform appendix. A record of sixteen persona1 cases. Lancet, 235: 1282, 1938. 3. REMSEN, C. M. Appendicitis in an infant sixteen days old with appendix in an inguinal hernial sac. Ann. Surg., 56: 91 l-914, 1912. 4. GOLDEN, J. L. and HAMILTON, H. H. Strangulated inguinal hernia, with unusua1 complications, in an infant of five weeks. New England J. Med., 210: 857-858, 1934. 5. HOLZEL, A. Appendicitis in the hernial sac of a nursling. Kinder&L Praxis, 7: 502, 1936.
is exceptional,
carcinoma
of the
of the men of death. Four thousand persons die annuaIIy from this disease in Britain, and nine thousand in America (Sherren). MaIes are twice as often affected as femaIes. From “A Short Practice of Surgery” by HamiIton BaiIey and R. J. McNeiII Love (H. K. Lewis & Co. Ltd.).