762 



HERNIA. 



trading through the original deficiency in the 

 linea alba; and the hernia of adults, which has 

 some peculiarities that shall be noticed here- 

 after. 



The congenital umbilical hernia seems to 

 depend rather on a deficiency of the anterior 

 walls of the abdomen than on any other cause, 

 and in the cases in which it is observed, the 

 aperture at the navel is much larger than it 

 should naturally be, and its tendinous edges 

 excessively thin and weak. The deficiency of 

 the abdominal parietes ranks amongst natural 

 malformations, and it is astonishing to what an 

 extent it has been observed. The entire of the 

 tendinous front of the belly has been found 

 imperfect, and nearly the whole of the viscera 

 displaced, thus forming an immense rupture 

 covered at its base and for some extent farther 

 by the skin and superficial investments of the 

 body, and in its remaining part by the transpa- 

 rent spongy substance of the umbilical cord. 

 The contents of these ruptures are greatly varied : 

 the liver or a portion of it, the spleen, the 

 stomach, the greater and the lesser intestines 

 have all been occasionally found thus circum- 

 stanced, but more particularly the omentum, 

 which, as might be anticipated from its situation, 

 is observed to constitute a part of almost every 

 umbilical hernia both in the old subject and in 

 the young. Whenever there is such a defi- 

 ciency in the abdominal parietes, the pressure 

 an infant undergoes in coming into the world 

 materially contributes to the production of 

 hernia, and accordingly it is observed most fre- 

 quently after a protracted and difficult labour; 

 and if it is large, and the contents of the ab- 

 domen extensively deranged or displaced, it is 

 in general fatal, the infant seldom surviving 

 beyond two or three days, and perhaps not so 

 long. In this affection there seems to be a 

 want of correspondence between the size of the 

 viscera and that of the abdominal cavity, the 

 former appearing enlarged and swollen ; and 

 there is seldom a possibility of returning the 

 rupture, or of maintaining it so if reduced. 

 There is in general also in these cases some 

 other malformation or incomplete development 

 to account for the fatality that so uniformly 

 attends them. But if, on the other hand, the 

 hernia is small, the case is by no means neces- 

 sarily attended with danger: the rupture may 

 be reduced, but it has a tendency to return when- 

 ever the child cries or makes any other exertion, 

 and it is extremely difficult to restrain it by a 

 bandage ; but if it can be kept up for a few 

 months, the umbilical aperture closes as it 

 would have done if there had been no pro- 

 trusion, and the cure is permanent and com- 

 plete. 



If, before the navel has become cicatrized and 

 closed, a portion of any viscus should happen 

 to be protruded through it, and its progress 

 towards obliteration thus interrupted ; or if the 

 contraction has been delayed longer than usual, 

 and an aperture thus left ready to favour the 

 escape of a part of intestine from its natural 

 situation, the rupture will be of the second 

 form mentioned, namely, the umbilical hernia 

 of the child. This differs from that of the 



infant inasmuch as it is covered by the skin and 

 the cicatrized knot of the navel, and does not 

 lie within the cord ; and from that of the adult, 

 so far as, if replaced and prevented from again 

 protruding, the aperture will gradually contract, 

 and thus a permanent cure be obtained, which 

 is scarcely to be expected at a more advanced 

 period of life. It has been already mentioned 

 that Scarpa considered the perfect contraction 

 of the umbilicus to be completed in about two 

 months, and at the end of that time that it is 

 even firmer than other parts : he moreover 

 seemed to think this part materially strength- 

 ened by the remains of those vessels which 

 before birth made up a part of the cord. The 

 umbilical vein passing from the navel upwards 

 towards the liver, and the hypogastric arteries 

 passing downwards, are at the umbilicus united 

 by a cicatrix to the skin and to each other, and 

 contribute to prevent the yielding of the part as 

 soon as they become ligamentous. The point 

 of union of these vessels must be pushed 

 forwards as well as the integuments in adven- 

 titious hernia, and hence it happens that when 

 the umbilical aperture is only of its natural 

 size, the rupture that takes place (if any) is 

 small; and in cases where it is large and the 

 abdominal parietes deficient in this point, the 

 tumour is natter and more compressed than 

 might have been otherwise expected, and some 

 of these vessels are found lying on it and 

 forming a part of its covering. 



In persons more advanced in life in whom 

 the opening in the tendon had been perfectly 

 closed, Scarpa denies that it ever becomes 

 relaxed again, and therefore states that the rup- 

 tures which occur from over-distension, from 

 pregnancy, or as the sequelae of dropsy, are 

 not situated in the original umbilical canal, but 

 in some part of the linea alba that has more 

 recently given way, and of which the umbilicus 

 happens to form a part. lie states further that 

 the linea alba is not equally strong and firm in 

 all its parts ; that above the navel it becomes 

 gradually thinner, and in women vho have 

 borne many children it is uneven in consistence, 

 and in some parts so weak as to be liable to 

 yield and tear on a very slight exertion. Hence 

 it happens that these ventro-umbilical ruptures 

 generally occur rather above the navel; and the 

 almost obliterated remains of this cicatrix (for 

 by the distension it becomes nearly smooth) is 

 scarcely ever observed to occupy the centre of 

 the tumour, but is found to one side and almost 

 placed inferiorly. In the dissection of these 

 tumours a laceration or fissure is constantly 

 met with in the linea alba, sometimes transverse, 

 but more generally longitudinal, and this is one 

 reason why the umbilical ruptures of old per- 

 sons are not susceptible of a radical cure, for 

 there is a great difference between a natural 

 opening, the tendency of which is to contract 

 and close, and one made by the yielding and 

 laceration of part of the linea alba or other 

 tendinous portion of the abdominal parietes, 

 which certainly cannot be supposed to be en- 

 dowed with strong reparative properties. 



There was a question formerly raised as to 

 whether umbilical hernia possessed a peritoneal 



