UMBILICAL HERNIA (See Knopfelmacher, vol. ii.) Etiology.—The abdominal walls become closed before birth, with the exception of the ring that must remain open for the umbilical vessels to pass through. After the cord has fallen off and the umbilical vessels have become obliterated, the gap becomes gradually smaller until it is closed, although in nearly all infants during the first few weeks it can still he felt about the size of a goose-quill. The fatty deposits which later advance from all sides toward the umbilical ring play, in my opinion, an essential part in its closure. In atrophic children umbilical hernia is far more frequently present. This place certainly offers opportunities for eversion of the peritoneum; in fact, traction of the cord may have previously pulled it out into a funnel-shape. Crying awl straining may facilitate forcing the abdominal contents into this funnel, and the seine effect may have been produced by an abnormal position in titer°. (Per sonal case.) Pathological Anatomy.—The outward appearance of an umbilical hernia is that of an enlarged umbilicus which may assume varying dimensions. The wall consists of the eicatricial skin and the peritoneum, which, together with the transverse fascia, have prolapsed through the ring formed by the superficial fascia. Skin and peritoneum arc closely adherent to the tip of t he tumor and in large herniae may be reduced to the thinness of a transparent membrane. In most eases there is also a more or less extensive gaping of the reetus muscles.
The contents of extensive herniae consist of the small intestine, and they are easily reducible by pressure, with the well-known gurgling sound. In small there is usually only a slip of omentum that prevents complete closure; it is generally adherent to the tip of the sac.
Symptoms.—An umbilical hernia rarely causes any disturbance in the well-being of the child. By exaggerated intra-abdominal pressure, however, it may considerably increase in size—for instance, in disorders of digestion and micturition (constipation, tenesmus, phimosis), coughing, and, later on, pregnancy—so that its earliest possible removal seems advisable. The earlier the operation, the more resistant will be the sear.
open ring may undergo spontaneous closure, provided care is taken that the hernia never prolapses. This requires great attention on the part of the nurses, since a single prolapse will destroy the work of weeks in the endeavor to retain the hernia. If from careless nursing or owing to the extent of the hernia permanent reten tion is not achieved after six weeks of palliative treatment, radical operation should be resorted to.
The palliative measures consist in the application of adhesive band ages to exert pressure on the hernia and thereby prevent a prolapse. In doing so, the natural process should be imitated, approximating the margins of the hernia after its emit cnts have been reduced.
The only way to effect this is the following: I hernia or umbilicus, as the case may be, should be embedded bet ween two longitudinal or transverse folds of the skin and retained in this position by an adhesive plaster bandage applied over the folds. It is not necessary to wind the bandage around the body, as this would exert exaggerated pressure.
The insertion of pads into the bandage or the application of hard discs to repress the hernia is not nearly so efficacious, because these devices do not approximate the margins. The insertion of conical pads is objectionable, because unphysiological. Leather or rubber bandages obtain but little hold on the round body of an infant and will be found unsuitable and useless with prolonged application.
The most practical kind of treatment, is operative. With eonser vative operation and a little practice it constitutes a mode of surgical interference which is singularly free from danger.
It need only be considered that there exists a biological intention of closing the ring and that nothing but the constant protrusion of the contents prevents it. In the newborn, therefore, we may confine our selves to the closure of the hernial ring without resorting to any plastic measures, which would unnecessarily prolong and complicate the opera tion on an infant.