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 mariner 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 hemorrhage. Some have tied a ligature around it to cause it to slough, and Mr. Ileyf 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. Scarpa: 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 he 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 sliew 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.
The symptoms of umbilical hernia are easily understood by referring to those points in which it differs from ruptures situated else where. In the infant the tumour appears long and thin, according to the quantity of viscera protruded through the aperture of the navel, and projects downwards on the belly : its coverings are almost transparent. In the more adult subject, if the patient is thin the tumour is of a pyrifurm figure, and when permitted to in crease without restraint becomes very large and hangs pendulous towards the pubes. If lie is fat it may form a less circumscribed swelling, broad and flat, apparently extending in every direction round the umbilical aperture. The sensation imparted to the finger is of a soft and doughy tumour slightly moveable under the skin, but sometimes in consequence of the presence of intestine in the rupture it may possess some elasticity. Occasionally, after an omental hernia has remained for years without producing much inconvenience, it sud denly enlarges towards the centre and assumes a conical chape, the apex being soft and elastic, the base hard and more solid : in this case there has probably been a fresh protrusion of intestine which has burst through the omentum and requires instant attention, as so circum stanced it is extremely liable to fall into a state of strangulation. The collateral symptoms,
such as nausea, flatulence, colicky pains, &c., are more severe and more frequent in umbilical than in any other form of hernia, a circum stance that has often given rise to the idea that the stomach formed some part of the protrusion, but perhaps it is unnecessary to resort to such a supposition, for probably the herniae of the linea alba that have been described as con taining part of the displaced stomach were in no wise different from ordinary umbilical ruptures as to their contents, for the omentum being protruded will be sufficient to account for every aggravation of symptom.
When the hernia is strangulated, it is said that the symptoms are less severe and less urgent than in other species of ruptures, a cir cumstance that has also been accounted for from its so often containing omentum alone. Sir A. Cooper states that more cases of stran gulation occur in the seasons when green vege tables are plenty than in others, which would seem to favour the idea of its being often caused by the use of flatulent or indigestible sub stances. But (except with reference to pre vention) it is of little consequence how it may be caused, or whether its progress is rapid or not. When once formed, it must be reduced ; and it runs its course with sufficient rapidity to render it extremely alarming. It has destroyed a patient in less than eighteen hours, and although such severity is not generally to be expected, yet in this or in any other kind of hernia the smallest unnecessary delay can never be justified.
" Sometimes a small mass of indurated fat, situated between the peritoneum and its union with the aponeurosis of the abdominal muscles, makes its way insensibly through the separated fibres of the linea alba, and is at last elevated externally in form of a tumour which seems to have all the characters of an omental hernia. The existence of this species of tumour through the linea alba is not only a certain fact and de monstrated by several observations made on the dead body by Morgagni, by Klinkosch and several others, but it is also proved that it makes its appearance in other parts of the linea alba besides that to which the umbilical vein corresponds internally. It may occur that a person in whom a similar small tumour has existed for a long time in the course of the linea alba may be attacked from a quite diffe rent cause by violent colic, with nausea, incli nation to vomit, and interruption to the alvine excretions. The surgeon, in similar circum stances, is easily led into error," (and Scarpa committed the mistake himself,) " presuming that the tumour is a true incarcerated hernia of the linea alba, subjecting the patient to an ope ration which has no connexion with the cause of the disease." Never having seen any similar tumour, I have copied the above passage from Scarpa : they are probably of the same nature with those described by Mr. Colles as occa sionally presenting at the crural ring. The resemblance must be strikingly obvious to every reader.
( William Henry Porter.)