192 Anatomy Applied to Medicine and Surgery. 



mer, i.e., congenital, is very infrequent (one in five thou- 

 sand cases), and is due to a want of closure at the umbili- 

 cus, whereby the foetal intestinal canal is not separated 

 from the original umbilical vesicle. This congenital form 

 causes a fusiform appearance of the cord near the umbili- 

 cus and, if care be not taken, the intestinal protrusion may 

 be included in the ligation of the cord. The infantile 

 form of umbilical hernia, on the other hand, is due to a 

 yielding of the umbilical cicatrix, and generally occurs 

 some weeks after birth, but it disappears, as a rule, before 

 puberty. Umbilical hernia of adults is usually met with 

 between the ages of thirty and fifty, and, generally, in 

 females, especially those who are stout and have borne 

 many children. The coverings in this form are : (1) Integu- 

 ment; (2) superficial and deep fascia; (3) the stretched 

 umbilical cicatrix (occasionally this is pushed aside) ; (4) 

 the trans versalis fascia; (5) subserous tissue, and (6) the 

 peritoneum. The hernia generally makes its appearance at 

 the upper part of the umbilical ring, since the lower part 

 is strengthened by the remains of the umbilical 

 arteries and the urachus the less dense vein go- 

 ing to the upper part of the ring. Taxis may 

 be employed, but the protrusion is generally irre- 

 ducible from union occurring between it and the peri- 

 toneal wall, or, from the deposition of fat, and, as it is 

 always a source of danger, unreduced, the radical opera- 

 tion may be attempted. In this operation, after excision 

 of the elliptical portion of the tissues over the hernia, the 

 peritoneum is sutured, then the deeper tissues in front of 

 the peritoneum, and, lastly, the skin. Another method 

 that is sometimes employed is Gersuny's. In this, tihe 

 peritoneum first, is sutured, then the edges of the recti 

 muscles, and then, after the suturing of these structures, 

 the superficial portion of the wound is packed with gauze 

 so as to cause it to heal by granulation. 



