HERNIA. 



763 



sac, and it was generally believed that no such 

 investment had any existence in the disease. 

 Garengeot in his paper on singular species of 

 herniae expressly states that ruptures of this 

 kind were deficient in this particular, and he 

 was followed by Petit and almost all the elders 

 of our profession, who, to spare themselves the 

 labour of investigation, copied from each other 

 errors as well as truth. It is really curious to 

 observe how a mistake could have so long 

 maintained its ground that could have been set 

 at rest by half-an-hour's dissection ; and indeed 

 it is in some respects surprising how such an 

 opinion came to be entertained at all. In every 

 case of umbilical hernia there must of neces- 

 sity be a sac, because the peritoneum is not 

 deficient at the navel, and the vessels that pass 

 within the cord do not enter the cavity : they 

 lie anterior to it, and are partly invested by the 

 membrane, which is entire and complete behind 

 the navel, and neither intestine nor omentum can 

 be protruded without pushing it out before it, 

 and thus constituting a proper hernial sac. It 

 may be that in large umbilical herniae the peri- 

 toneum shall have become very thin, so that the 

 peristaltic motions of the intestines may be 

 easily perceived through it from without; or it 

 may have been burst accidentally, and in either 

 of these cases there will be an appearance as if 

 there had been in reality no sac. And more- 

 over, the peritoneum immediately behind the 

 navel is not connected to it by the same loose 

 and distensible cellular tissue that unites it to 

 other parts : it is here very closely joined, and 

 consequently in small ruptures only occupying 

 this spot there will be no appearance of a sepa- 

 rate and distinct sac, although the peritoneal 

 covering is really there notwithstanding. It 

 must be borne in mind, however, that invest- 

 ments of umbilical ruptures are always very 

 thin, and a proportionate degree of caution is 

 requisite in cutting through them during ope- 

 ration. There are no distinct layers of fascia 

 here as in other ruptures, no laminae to sepa- 

 rate one by one and one after another. In the 

 congenital species the contents of the sac are 

 merely covered by the peritoneum and the 

 sheath of the cord. In the infantile, the 

 coverings are the skin and cicatrix of the navel 

 and the peritoneum ; and in the adventitious 

 kind or ventro-umbilical we meet the skin, then 

 the superficial fascia, which is very thin and 

 weak on this part of the abdomen ; next the 

 cellular tissue that had united the peritoneum 

 to the adjacent structures, and which may have 

 become condensed so as to form a kind of 

 fascia propria ; and lastly, the peritoneum or 

 hernial sac itself. 



In almost every case of umbilical hernia 

 occurring in the adult, omentum has formed 

 part of the contents of the sac, at least the ob- 

 servation has been so universally made that the 

 rule may be considered as established. In 

 general it lies before the intestine in such a po- 

 sition as to conceal it altogether and make it 

 appear as if no other viscus was engaged ; but 

 sometimes the intestine makes a passage through 

 it and presents first when the sac is opened : or 

 both these structures may be coiled and twisted 



together in such wise as to render it difficult to 

 unravel and separate them one from another, 

 and highly perilous to return them in that con- 

 dition into the cavity lest strangulation should 

 take place within. From the circumstance 

 also of containing omentum, umbilical ruptures 

 frequently become irreducible, this structure, 

 when protruded, becoming thickened and en- 

 larged and occasionally loaded with fat, so as 

 to preclude the possibility of its being again 

 returned through the tendinous opening. Or 

 adhesions may have formed between the 

 omentum and the intestine, or between either 

 or both of these and the sac : in short, the 

 rupture may become irreducible from any of 

 the causes already mentioned as capable of 

 producing such a condition of parts, but the 

 one first alluded to, namely, the thickening and 

 alteration of the omentum, is the one most 

 generally observed. 



This altered condition of the omentum has 

 also a paramount influence on the case even at 

 a more remote period. Let it be supposed that 

 symptoms of strangulation have supervened, 

 and an operation been deemed necessary to 

 preserve existence, the presence of this mass 

 will be likely to prove extremely troublesome. 

 Every surgeon is conversant with the different 

 opinions that have been entertained as to the 

 manner in which irreducible omentum should 

 be dealt with. Some* speak boldly enough of 

 cutting it off and returning any part that might 

 remain, or allowing it to slip back into the 

 abdomen without feeling any apprehension 

 from the possibility of haemorrhage. Some 

 have tied a ligature around it to cause it to 

 slough, and Mr. Heyf employed a ligature in 

 another way and with a different view, namely, 

 by applying it so tight as gradually to cut 

 through the omentum by the process of ab- 

 sorption, but without entirely destroying the 

 circulation through the included part. ScarpaJ 

 left the omentum, merely covering it with the 

 sides of the hernial sac and dressing it lightly 

 until suppuration appeared, when, he said, the 

 pedicle by which it hung might be safely tied 

 and the mass cut away. I notice this diver- 

 sity of opinion not for the purpose of incul- 

 cating any one line of practice, but to shew 

 that the omentum cannot be left there with 

 safety. It is at all times and under every cir- 

 cumstance not very highly organized or able to 

 sustain disease; still less so is it when altered 

 from its natural arrangement, converted into an 

 unwieldy mass of fat, and exposed to the in- 

 fluence of the atmosphere in an open wound. 

 Sometimes it runs into tedious and unhealthy 

 suppurations with profuse and wasting dis- 

 charges ; more generally, if the patient is old 

 and debilitated, into mortification, which may 

 (if the subject lives sufficiently long) pass on 

 to the unaltered omentum within the abdomen, 

 nor cease until it has reached the stomach. 



* Pott, op. citat. p. '6. Petit and Ponteau, 

 Mem. de 1'Acarl. Royale de Cbir. torn. vii. p. 338. 

 Colles's Surgical Anatomy, p. 100. 



t In this he was anticipated by Moreau, Mem. 

 de 1'Acad. Roy. de Chir. t. vii. p. 344. 



t Op. citat. p. 420. 



