536 



TREATMENT OF UMBILICAL HERNIA. 



(b) Removal of the sac by clain. The clam acts like multiple 

 ligation and is most useful in hernia with a broad base ; but, although 

 this method is simpler than ligation, it usually prevents healing 

 by first intention. To prevent the clam falling off too soon, needles 

 are passed through the sac below the clam, or a clam with serrated 

 edges may be used. With this object in view, Bordonnat constructed 

 the iron toothed-clam shown in Fig 392, and Combe invented a 

 perforated clam (Fig. 393), which allows the passage of ligatures or 



392. — Bordonnat' s clam. 



strong needles through the sac. After reducing the 

 hernia, the clam is applied to the neck of the sac, 

 as near as possible to the under surface of the belly, 

 and in the direction of the linea alba, and fastened 

 by screws, or, as in castration, by a cord. What- 

 ever the method employed, the following symptoms 

 almost always appear : — During the first few hours 

 after operation there is slight colic. Next day signs 

 of inflammation become apparent : the umbilical 

 region is swollen and painful ; the hernial sac is 

 cold, purple in colour, and insensitive ; appetite is 

 in abeyance and fever is present. Towards the fourth 

 day the skin becomes necrotic ; the clams separate 

 and fall about the twelfth to the fifteenth day, 

 leaving a considerable wound and much local swelling, 

 which disappears slowly. In three weeks to a month 

 the umbilical opening should be obliterated. In 



cases of very wide umbilical ring, however, recurrence of the hernia 



has been noted even after the above treatment. 



The chief points in using clams are to grasp sufficient skin, and 



to fix the clam evenly and firmly, though not tight enough to induce 



immediate necrosis. Iron clams provided with screws are preferable 



to wooden clams, because they can be gradually tightened and more 



evenly applied. 



In using wooden clams, Degive recommends, especially for large 



hernia?, the application of two clams, one above the other ; the upper 



Fig. 393. 

 Combe's clam. 



