(EDEMA OF THE UMBILICUS. 



731 



secured and placed on its back. The skin over the rupture is drawn 

 together by the fingers in a flat fold, corresponding with a central longi- 

 tudinal line through the abdomen {linea alba), and elevated from the parts 

 beneath, in order to cause the intestines or omentum to descend. The 

 clam is then put over the skin, as close to the abdomen as possible, and 

 the screws tightened. The pressure must not be too severe, or the parts 

 will drop off too soon, and possibly the intestines may escape. The 

 operation, therefore, requires to be carefully watched." 



Sutures are frequently employed, and there are various ways of using 

 them. One method is the "twisted " suture, which is applied as follows : 

 The hernial sac is included between two round pieces of hard wood or 

 iron, which are drawn tightly together by whipcord passed round their 

 extremities before and behind ; double sutures are then passed through 

 the sac, one of which is tied to the piece of wood on one side, and the 

 other to that on the other side — so that the sac is completely invested 

 between the wood and ligatures, which divide it into two portions. 

 Another procedure by suture is to make a thick longitudinal fold of the 

 skin covering the hernia, to pass the suture needle — armed with a waxed 

 thread or cord — as near to the muscles as possible, and about three to 

 four inches from the ring, from before to behind, or one side to the other ; 

 the needle is again passed through in the contrary direction, about half 

 an inch from the first perforation, and the two portions of suture firmly 

 tied, so as to draw the skin together like the mouth of a sac. Sutures 

 are then passed through the sides of the pedicle and tied, so as to include 

 the whole of the skin in the multiple loops. A cure by this procedure is 

 usually effected in about fifteen days. The only objection to the opera- 

 tion appears to be the danger of wounding the intestine by the needle. 

 To obviate this, some operators, after reducing the hernia, pull the empty 

 sac well away from the abdomen, and pass it through a partially split 

 piece of lead which is applied close to the belly ; then the needle can be 

 used without risk, as the lead — which is secured in situ — forms a shield 

 as well as a truss, and prevents the descent of the intestine until adhesion 

 has taken place. 



When the hernia is irreducible or strangulation has taken place, then it 

 will be necessary to carefully open the sac. Should adhesion have taken 

 place between the latter and the intestine, or between the skin and per- 

 itoneum, this must be broken up ; if the umbilical ring has to be incised 

 in order to return the viscus, this may be effected by a probe-pointed 

 bistoury. The incision should be no longer than is absolutely requisite. 



The after-treatment of operation for hernia must be conducted on 

 surgical principles, and according to the necessities of the case. 



CHAPTER V. 



CEdema of the Umbilicus. 



* 

 Tumefaction, or rather " oedema " of the umbilical region, is not at all rare. 

 Often it is simply due to an effusion of serum in the connective tissue of 

 the umbilical cord, and sometimes to an infiltration of blood in this part 

 and the surrounding connective tissue. 



This accident is usually produced by contusion and laceration during 



