HERNIA. 



761 



taken singly may prove but an indifferent dia- 

 gnostic, but in the aggregate they establish such 

 distinction that it must be the result of sad in- 

 attention or of actual ignorance if any serious 

 mistake is committed. 



It has been stated that a varix of the saphena 

 vein may present symptoms and appearances 

 strongly resembling crural hernia, inasmuch 

 as the tumour disappears under pressure or in 

 the horizontal posture, and returns again imme- 

 diately on these influences being removed, and 

 also as it receives a certain degree of impulse 

 from coughing or sneezing. From anatomical 

 considerations it would almost seem impossible 

 that such an error could be committed, and at 

 first sight the observation seems to have been 

 made for the purpose of creating nice distinc- 

 tions and rendering the subject apparently com- 

 plete rather than for any practical utility. A 

 case, however, is related by Petit, who distin- 

 guished the real nature of the tumour by its 

 dark-coloured appearance and by the general 

 varicose state of the remainder of the vein. If 

 difficulty is experienced in any particular case, 

 it may be easily resolved by making pressure 

 on the trunk of the iliac vein above Poupart's 

 ligament, when the tumour will re-appear, even 

 although the patient maintains the horizontal 

 posture. 



" Fatty tumours are not unfrequently found 

 on dissection occupying the exact situation of 

 crural hernia. I have not had an opportunity 

 of seeing any case of this kind in the living 

 body, but have had occasion to remark at least 

 five or six instances of it every season in the 

 dissecting room, from which I presume such 

 tumours are more common than is generally 

 suspected. In all those instances the fatty tu- 

 mour was connected with or rather seemed to 

 grow from the outer surface of the peritoneum 

 lining the crural ring; and the inner surface of 

 this membrane when viewed from the abdomen 

 had a contracted, wrinkled, and thickened ap- 

 pearance, resembling very closely the appearance 

 of a reduced hernial sac. Whether the perito- 

 neum had been protruded in these instances 

 I cannot pretend to say ; nor can I venture to 

 lay down the symptoms which should guide us 

 in our diagnosis in the living body. This 

 much at least is obvious, that these steatoma- 

 tous tumours will not be accompanied by 

 symptoms of strangulation/'* 



Umbilical hernia. The navel is the remnant 

 of an aperture that had been situated nearly in 

 the centre of the front of the belly, but nearer to 

 the pubis than to the ensiform cartilage: it is 

 placed in the linea alba, and of course Its edges 

 are tendinous. During foetal life it serves for 

 the transmission of the umbilical vein and arte- 

 ries, but its size is greater than would merely 

 suffice for the passage of these vessels, in order 

 that the circulation of the blood through them 

 should suffer no interruption by accidental com- 

 pression ; and in a foetus of seven months the 

 edge of the aponeurotic opening is still thin, 

 weak, and unresisting. After birth, when the 



* This passage is copied from Colles's Surg. Ana- 

 tomy, p. 84. 



navel string (as it is called^) has dropped off, 

 the umbilical aperture begins to close, until 

 finally that puckered cicatrix is formed, the 

 appearance of which is so familiar; but the 

 periods at which this process commences and is 

 completed, and the circumstances that may 

 occur to interfere with it, are of some importance 

 with reference to the phenomena of hernia. 

 Scarpa says that it begins immediately, and that 

 if the finger is passed up the peritoneal wall of 

 the abdomen in a child two months afterbirth, 

 not only will the navel be found firmly formed 

 and completely cicatrised, but there will be a 

 knot or elevation felt at this spot, shewing that 

 it is then really stronger than most other parts 

 of the abdominal parietes. Lawrence states 

 that the contraction commences about the third 

 or fourth month after birth, and thence inculcates 

 the necessity of an infant being tolerably accu- 

 rately bandaged anterior to that period in order 

 to prevent the occurrence of umbilical rupture 

 from its struggles or its cries. It is not of 

 much consequence which of these opinions 

 may be correct : probably both are so to a cer- 

 tain extent, for the opening is larger in some 

 infants than in others, and will require a longer 

 time to close, and the process of obliteration 

 does not commence in all exactly at the same 

 period after birth. Whatever variety may 

 exist in this respect, when the process is com- 

 plete the umbilicus can never afterwards be 

 called an aperture; it never again re-opens; and 

 when ruptures are observed in after-life seem- 

 ing to occupy this situation, it will be found on 

 examination that some neighbouring parts of 

 the linea alba have given way, and the disease 

 more strictly belongs to the ventral than to 

 umbilical hernia. 



It appears then that by the salutary provi- 

 sions of nature the front of the abdominal pa- 

 rietes is well supported, and the contained 

 viscera protected from protrusion ; and even if 

 the operations by which the umbilicus is closed 

 should be accidentally suspended or interfered 

 with, (as by the presence of a hernia for in- 

 stance,) the disposition is not lost, and the aper- 

 ture preserves its tendency to close and become 

 obliterated for the first five or six years of 

 childhood. Thus at any time within that period 

 there may be a reasonable probability of obtain- 

 ing a permanent cure of umbilical hernia; 

 whereas after the age often or twelve years this 

 disposition ceases to operate, or at least is 

 greatly impaired, and there is little or no chance 

 of so fortunate an occurrence. 



The condition in which the umbilicus exists 

 at and after birth divides the herniae that occur 

 in this situation into different orders according 

 as they may appear at the period of birth or 

 afterwards. Scarpa considers the disease to 

 consist of only two species, the congenital and 

 the adventitious the congenital being that 

 which appears in the infant when born, and the 

 other occurring at any subsequent period. 

 Lawrence speaks of three kinds, the congenital, 

 that which appears at birth, and in which the 

 protruded viscera are lodged in the umbilical 

 cord; the umbilical hernia of children occur- 

 ring after the navel has been formed, but pro- 



