Umbilical Hernia 299 



scar for that tissue is strong and resisting but through the linea 

 alba either above or below the navel most likely above it, but possibly 

 to one side of it. When a hernia takes place exactly at the navel 

 itself, it is generally through the upper part that is, above the level 

 of the urachus and the obliterated hypogastric arteries for this is the 

 weakest part of the scar. 



The coverings of an umbilical hernia are peritoneum, sub-peritoneal 

 fat, transversalis fascia, and integuments ; but these tissues in time 

 become fused together into a single, thin layer. Umbilical hernia 

 occurs more frequently in women, and especially in those in whom the 

 umbilical region has been stretched and weakened by pregnancy, and 

 in those whose viscera are encumbered by the deposit of a large 

 amount of fat. 



The abdomen may be mapped out into nine regions, as follows : 

 A line is drawn around the body at the level of the two anterior 

 superior iliac spines, and a second, parallel to it, over the ninth costal 

 cartilages. These three zones are subdivided by two lines, parallel 

 to the linea alba, from the middle of Poupart's ligament to one of the 

 costal cartilages probably the eighth. 



These nine areas are, from above downwards, in the middle 

 line, epigastric (eTrt, over ; yaa-r^p, stomach), umbilical, and hypogastric 

 (VTTO, below) ; at the sides, hypochondriac (wro, xoi/Spot, cartilages), 

 lumbar (lumbi^ loins), and inguinal (inguen, groin) or iliac (;'//#, 

 flanks). 



The viscera contained in each region are liable to variation ; for 

 instance, when the stomach is distended the colon is pushed far down, 

 and when that piece of intestine is distended it may ascend high 

 behind the ribs ; but, for the most part, the contents of each region are 

 as follows : 



Highest Zone. 



Right hypochondriac. Liver and gall-bladder ; pyloric end of 

 stomach (?) and duodenum. Hepatic flexure of colon and upper part 

 of right kidney, supra-renal capsule, and, probably, pancreas. (The 

 fundus of gall-bladder lies behind the ninth costal cartilage.) 



Epigastric. Part of liver and stomach ; transverse colon and great 

 omentum. Pancreas ; the large abdominal vessels and some of their 

 branches ; solar plexus. 



Left hypochondriac. Cardiac end of stomach, tail of pancreas, 

 spleen ; splenic flexure of colon ; upper end of kidney, supra-renal 

 capsule, and perhaps some of left lobe of liver. 



Median Zone. 



Right lumbar. Ascending colon, descending duodenum, kidney ; 

 coils of small intestine, ureter. 



Umbilical. Transverse colon and duodenum, great omentum ; 



