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Show 214 OPLKA'UON roa FEMORAL Bream. UMBILICAL HERNIA. the intestine may be emptied without further incision, and then be reduced. But let us not conceal the possibility that this internal edge of the ligament of the thigh may be the sole or princi= ple cause of strangulation; and that it must be cut. It is a will cut the cord; nor outwards, where the epigastric artery 215 is before the knife. The reduction of the gut, the circumstances regarding the omentum, the dressing, and the precautions after the opera; tion, are the same in this case as in the bubonocele. firm tendon, unlike the cause of the internal stricture of the bubonocele. If it be distinctly felt, cord-like, and running OF THE UMBILICAL HERNIA. across, the neck of the sac need not be cut, but the directory should be put over the neck of the sac, and the history carried along the directory, until the probe-point is just beyond the margin of the ligament ; when by gently depressing the handle of the instrument, the edge near the point rises upon the ligament so as to cut it. If no more of the ligament be cut than is absolutely neces sary, there will be no danger to the epigastric artery or the spermatic cord. Still we should recollect 110w very near these parts lie to the edge of the knife. This being the situation of the parts- Miami 1 THE umbilical hernia (exomplzalos) is very seldom strangulated. If, however, it should, and the gut be included, .making it an urgent case, then the young surgeon should be aware of the difficulty of keeping the parts reduced, when the whole tumour has been laid open, and the parts pushed back, as the opening is generally very wide, and compres sion is with difficulty applied to a soft, yielding part, like the fore-part of the belly, and which is naturally protruded and retracted with every respiration. We ought not then (if the unpleasant necessity appears) to draw the knife over the face of the tumour, and lay it completely open; but only make an incision semicircularly on the base of one side. Then, with the same precautions of dissecting oh" the outer lamina, endeavour to get within the margin of the tendon, which being cut by the probe-pointed history, the hernia may be reduced, or the last portion of the intestines, which has perhaps fallen into the interstices of the old contents, may be returned. If upon this the large circle of the neck of the sac does not so dilate as to relieve the contents, that part of the sac embraced by the stricture may also be cut, so as to admit the finger. By this operation, the terrible consequence of having a portion of the bowels among the hands, which cannot be re‘ In this plan, A, is the hernia. B, the spermatic cord. C, the course of the spermatic cord, marked by dotted lines above the ligament. D, the course of the epigastric artery ; duced, may be avoided. But this I conceive to be the peculiar character of the umbilical hernia-there is often a predisposition to the discase from the great width of the opening. For this reason, so that E is the course of the incision ; and that it must be and from the opening being direct, as well as free, it is less straight upwards is evident ; neither inclining inward, for we subject to strangulation than the other kinds of rupture. , , mm Mossm '- |