SURGERY. 
724 
vein is pressed upon above Poupart’s ligament. A psoas 
abscess may be known by the fluctuation of the matter, the 
preceding pain in the loins and shivering, and the absence 
of intestinal complaints. 
The term umbilical hernia has been applied, not only to 
protrusions of the bowels through the opening of the navel, 
but to all other tumours of a similar nature, which present 
themselves any where in the vicinity of that aperture ; the 
majority of them take place in the linea alba, either above 
or below the precise situation of the umbilicus. 
The congenital exomphalos sometimes affects the fetus 
in utero, and of course exists at the time of birth; the viscera 
protruding out of the umbilical ring itself, and passing into 
the cellular substance, which connects the vessels of the cord 
together. It may commence in any of the stages of gesta¬ 
tion ; for it is observed in the embryo, and in the fetus 
which has not yet acquired its full size, as well as in that 
which is completely grown. 
According to all appearances, the principal cause of the 
congenital exomphalos is a slow and imperfect developement 
of the abdominal muscles. As the umbilical ring in the 
fetus is the weakest point of all the parietes of the abdomen, 
the viscera must be very liable to protrude at this opening, 
and gradually make their way into the cellular substance, 
which connects the vessels of the cord together. 
Children born with umbilical herniae generally live but a 
short time, because they are simultaneously afflicted with 
other malformations. 
The true umbilical hernia, which is formed subsequently 
to birth, presents itself in children after the separation of the 
funis, and is generally attended with the following particulari¬ 
ties :—The swelling is either of a round,cylindrical, or conical 
shape, with a circular base. No vestige of the cicatrix of the 
navel can be discerned upon it, except that near the apex, or 
upon one side of the tumour, a small portion of the skin 
seems paler and thinner than the rest Underneath the com¬ 
mon integuments another covering is found, consisting of a 
cellular substance, and of that delicate fascia which is spread 
over the surface of the abdominal muscles. When this 
second investment is opened, the true hernial sac is seen, 
which is thin, semitransparent, and in every respect similar 
to the rest of the peritoneum, as in other herniae. It usually 
contains a noose of intestine, and never, or but very rarely, 
omentum; a circumstance which Scarpa accounts for by the 
natural shortness of this membrane in young children. 
The occurrence of exomphalos in children always implies 
an imperfect closure of the umbilical ring. The quickness 
with which the navel is closed after birth, and especially the 
retraction of the cicatrix by the umbilical ligaments, as the 
growth of the body proceeds, greatly promote the efficacy 
of bandages, and, in young children, facilitate the radical 
cure of this species of hernia. A disposition to such protru¬ 
sions is very common during the first three or four months 
after birth, but moderate compression suffices for the removal 
of the swelling, and for keeping the parts reduced. 
The exomphalos of the adult subject is a hernia in the 
linea alba. Scarpa lays down, with great accuracy, the dis¬ 
tinguishing characters both of the true umbilical hernia, and 
of other cases which occur in the linea alba near the navel. 
The first disease, says he, whether met with in the infant or 
the adult, has a circular neck, or pedicle, at the circum¬ 
ference of which the tendinous margin of the umbilical ring 
can be felt with the end of the finger. Whatever may be the 
size of the tumour, its body always retains nearly a spherical 
shape; nor can any wrinkle of the skin, nor any thing at all 
resembling the cicatrix of the navel, be observed either upon 
the convexity or upon the sides of the swelling, the skin 
being merely a little paler and thinner at some points than 
others: on the contrary, in a hernia of the linea alba, the 
neck of the swelling is of an oval shape, like the fissure 
through which the protrusion has taken place. The tumour 
itself is .also constantly of an oval form. When the finger 
is pressed deeply round its neck, the edges of the aperture in 
the linea alba are perceptible; and if the hernia be very near 
the navel, the umbilical cicatrix may be seen on one of the 
sides of the swelling, a sure indication that the viscera, do 
not pr.otrude through the umbilicus itself. 
Herniae of the linea alba, when left to themselves, are 
much slower in their progress than true cases of exomphalos. 
On account of their small size they are frequently unob¬ 
served, especially in corpuleut subjects, or when situated at 
the side of the ensiform cartilage. However, they bring on 
complaints of the stomach; habitual colics, particularly after 
meals; and the patient may be troubled for a long while 
with such disorders before their true cause is detected. On 
the other hand, a true umbilical hernia may be known from 
the earliest period of its formation, both by the changes which 
it produces in the cicatrix of the navel, and by the rapidity 
of its increase. 
These two species of hernia require similar modes of treat¬ 
ment ; but the cases which happen in the linea alba are more 
difficult of cure than the exomphalos. 
The treatment of reducible hernia is sufficiently simple: 
it consists merely in returning the bowel into the belly, and 
placing a truss on so adjusted that its pad presses fairly on 
the opening. The same sort of truss serves for crural and 
inguinal hernia, and except in particular cases, the com¬ 
mon one answers perfectly well. Trusses for umbilical her¬ 
nia have merely a large concave pad to lie over the umbili¬ 
cus, secured by a broad belt that passes round the waist. 
With respect to irreducible hernia, if the incapacity for 
reduction be of recent standing and no untoward symptoms 
are present, we may frequently get it back, by desiring the 
patient to take some brisk purges, live low, and use the re¬ 
cumbent posture for a few days. But ordinarily there are 
adhesions formed before the surgeon is applied to, and all 
that can be done is to support the hernia and prevent its fur¬ 
ther protrusion, by using a suspensory bandage. 
Hernia is a complaint only formidable to life when it be¬ 
comes strangulated: that is to say, when the viscus pro¬ 
truded through the abdominal opening swells and cannot be 
returned, so that inflammation spreads into the contents of 
the abdomen, while at the same time the passage of the 
faeces is stopped, and the strictured bowel becomes inflamed 
to a degree that threatens speedy gangrene. The symptoms 
of strangulated hernia are thus described by Sir A. Cooper. 
—“ The patient first complains of pain about the region of 
the diaphragm. He will describe the sensation to be as if 
he felt a cord bound tightly round the upper part of the sto¬ 
mach. The next symptom is constant eructation, owing to 
the great quantity of air rising from the intestines to the sto¬ 
mach. The patient is next troubled with vomiting, accom¬ 
panied with costiveness. He has a great disposition to have 
motions, but cannot succeed in his attempts to expel the 
faeces. There is some pain in the swelling, and a good deal 
at the part where the stricture is situated. These symptoms 
attend the first dawn of strangulation. The abdomen after¬ 
wards becomes considerably distended with air, not at first 
from inflammation, but in consequence of the accumulation 
of flatus in the intestines. This is evident, because the pa¬ 
tient does not at first complain of pain on pressure of the 
abdomen. The vomiting becomes more frequent, and fe¬ 
culent matter is rejected from the stomach. A clyster will 
sometimes bring away a portion of feculent matter; but the 
quantity will be extremely small. During the time that the 
abdomen is in this tense state, but unaccompanied with 
pain, and while there is frequent vomiting of the faeces, the 
pulse is hard, frequent, but very distinct; but in the next 
stage of symptoms, when the abdomen is not only tense but 
painful to the touch, you will find the pulse extremely small 
and frequent; so small that it can scarcely be felt; so fre¬ 
quent that it can hardly be counted. The vomiting and 
eructations continue, and the patient is pale, and covered 
with a cold perspiration. The tumour becomes very tense, 
hard, and in general a little inflamed on the surface of the 
skin. The next change in the symptoms of strangulated 
hernia is, that in addition to the vomiting, which is not less 
frequent, hiccough supervenes. Hiccough was formerly con¬ 
sidered to be a sign of the presence ot gangrene, but it is 
now known not to be so. Patients have had hiccough for 
