ADULT UMBILICAL HERNIA.—This variety of hernia protrudes through the linea alba, not far from the umbilicus, and is generally observed in stout people, especially in women.
Umbilical hernia in the adult may attain enormous proportions, hanging down like a large pouch if allowed to go untreated. The omentum, transverse colon, and small intestines may all be found in it.
Treatment. — When reducible, the hernia is held with difficulty by trusses, especially in large subjects. A broad belt with a pad fastened to it is sometimes more effectual. It is frequently irreduci ble, however, and is prone to inflamma tory manifestations. When it cannot be reduced, it is best to protect it by means of a cup-shaped pad held in position by a bandage or a belt.
This variety of hernia is also liable to become obstructed, a complication occa sionally leading to strangulation. There is local disturbance and sometimes pain; vomiting sets in and the other manifes tations of strangulation already described present themselves.
Taxis should be tried and, if care be taken to empty the hernial intestines of all gas by gentle pressure, often succeeds. If it should not, however, the proclivity of the hernia to rapidly become gan grenous, owing to compression of its vas cular supply, renders an immediate herniotomy advisable.
When operation becomes necessary, the skin should be divided over the ori fice, remembering that the sac is exceed ingly thin and that it may readily be penetrated. Adhesive inflammation often causes the contents to be adherent, an other complicating circumstance. To overcome the constriction without open ing the peritoneum should be the first aim; if this is impossible, a couple of shallow incisions through the fibrous ring at its lower border from the inside of the sac will generally make it possible to reduce the strangulated loop. The adherent omentum should then be liber ated, ligated, and removed, and its stump returned. After freshening the pillars of the ring and suturing. the wound
should be closed and drained. Should the gut be gangrenous an artificial anus is the only resort.
The radical cure of umbilical hernia in adults has been so unsatisfactory that most writers still advise that the hernia should be retained by a pad if still re ducible, and supported by a suspensory bandage if irreducible, radical cure only being attempted when operation is neces sitated by strangulation. The unsatis factory results are due to the great ten sion which attends the closure of the ring, it being impossible in many cases to oppose at all the fascia constituting the margins of the ring. The best results have been obtained by splitting longi tudinally the inner margins of the sheaths of both rectus muscles and sub sequent suture of the abdominal wall in layers, the peritoneum and overlying fascia being first united, then the two reeti muscles, then the anterior sheaths of the latter, and, finally, the skin. This is the operation described by Tillmanns. It must be remembered, however, that in many cases it will be found impossible to unite the anterior sheath of the rectus muscles after splitting in the way de scribed, or at least such union would be possible only under great tension, which in all probability would defeat the ulti mate success of the procedure.
It might be found possible to modify the operation detailed above by dividing the anterior sheaths of the reetus Inns cies vertically an inch or more from the ring borders. The strong fascia obtained in this way would then be turned over across the aperture, the inner sides of the flaps becoming the outer sides as they were sutured in place. The freed recti muscles could then be brought in apposi tion as before. Closure could be effected in this way without any tension. The wall over the recti muscles would be weakened; but as the rectus has here a posterior sheath, this weakening would not be serious. J. B. Bullitt (Annals of Surg., Nov., 1900).