natural tendency of the umbilicus, in early life, to close; but such occurrences are so rare that the surgeon is not warranted in leaving cases to the unassisted efforts of nature.

UMBILICAL HERNIA IN ADULTS.

This is rarely met with in males, but more frequently in females. Pregnancy is one of its most usual exciting causes; hence its comparative frequency in females who have borne many children. In almost all cases of umbilical hernia in adults, omentum forms some part of the hernia, and to this has been attributed the fact that in the greater number of instances in which strangulation occurs, the symptoms are less urgent than in most other species of hernia. An umbilical hernia may be reducible, irreducible, or strangulated; and in each of these conditions the treatment should be conducted according to the principles laid down in the general doctrines of hernia. The coverings are very thin, consisting merely of the cicatrix of the navel, the hernial sac formed of peritoneum, and the very thin layer of cellular tissue by which they are connected together. In performing the operation, it should be remembered that these coverings are often exceedingly thin, and that although every umbilical hernia has originally a peritoneal sac, yet when the hernia is large, the sac becomes so thin by dilatation, or absorption, or both, as scarcely to be perceptible. When the peritoneum becomes exceedingly thin and adherent to the skin, the covering is often found to present the appearance of being formed of only one layer. The coverings may be divided by a longitudinal or any convenient form of incision, and the stricture may be divided by cutting upwards and to the left side.

IV. VENTRAL HERNIA.

By a ventral hernia is understood one through any part of the front of the abdomen, except the inguinal canal, the femoral canal, or the umbilicus. Cases belonging to this class should be treated according to the general principles already laid down.

Such are the various classes into which herniæ in accessible situations are divided. Occasionally, however, they are found in inaccessible situations, for example, in the diaphragm, the obturator foramen, or the greater ischiatic notch; constituting diaphragmatic obturator, or ischiatic hernia. Sometimes cases occur of a mixed class; for example, a perineal hernia, which consists of a descent between the bladder and the rectum, the swelling presenting itself in the perineum; or a vaginal hernia, in which the tumour projects into the vagina. Examples of hernia in inaccessible situations are, happily, of rare occurrence; they cannot be made the subject of surgical treatment; and their existence. only becomes a matter of certainty after death.

I shall conclude this section on hernia with the following remarkable case of strangulation, caused by a diverticulum. I recorded the case in the number of the "Edinburgh Monthly Journal of Medical Science," for July, 1849:

David White, seventeen years of age, a fine-looking young man, had always enjoyed excellent health until the 22d of April; on which day,

while walking in the street, he was suddenly seized with sickness, vomiting, and violent pain in the abdomen; the pain being constant, but attended with frequent paroxysms of aggravation.

At the commencement of the attack the belly was not tumid, nor was there any tenderness on pressure-on the contrary, the patient had an inclination to compress the belly with his hands, especially during the paroxysms of pain, and to turn himself round in bed. In the course of five or six hours, however, the abdomen became tender to the touch, and ultimately so much so that the slightest touch occasioned pain and vomiting; the belly gradually became tumid; and the patient was obliged to preserve his body as motionless as possible in order to prevent the aggravation of pain.

Such is the history of the symptoms, as given by my friend, Dr. George Morrison, who attended him from the commencement of the attack.

My colleague, Professor M'Robin, and I saw the patient for the first time twenty-four hours previous to his death. His symptoms, when we saw him, were-distension of the abdomen; constant violent pain, with paroxysms of aggravation like the tormina of ileus; tenderness on pressure; sickness, urgent vomiting of a greenish liquid; no stool after the commencement of the attack; pulse one hundred and thirty, small and feeble; features collapsed, and the countenance expressive of great exhaustion.

These symptoms continued for twenty-four hours, without undergoing any material change, death taking place within sixty hours from the commencement of the attack.

The suddenness with which the symptoms appeared, their history, and the absence of swelling in any of the usual sites of hernia, produced a strong impression on the mind of Dr. Morrison, Professor M'Robin, and myself, that the symptoms were caused either by intussusception, or by internal hernia, or by some internal cause of strangulation; in short, that it was a case of enteritis, occasioned by some internal mechanical

cause.

I made a post-mortem examination twenty-four hours after death, in presence of the medical gentlemen above mentioned. On opening the abdomen, a small quantity of sero-sanguineous fluid was found in the cavity of the peritoneum; the stomach, and a great part of the small intestine, were greatly distended with flatus; the distended portion of the intestine was much inflamed, and there were slight adhesions of lymph in some parts. The lower third of the ilium and the whole of the great intestine were collapsed, and of a perfectly healthy appearance. On displacing some of the convolutions of the small intestine, a portion of the ilium, twelve inches in length, was found greatly distended, strangulated, and in a state approaching to gangrene; the part of the intestine to the gastric extremity of the strangulated portion being violently distended and inflamed, and that to the rectal extremity being comparatively collapsed, and of a perfectly healthy appearance; the strangulation being effected by a diverticulum of the ilium, having very peculiar relations and connexions.

Fig. 167 of the accompanying drawings gives a front view of the

strangulated intestine and stricture. Fig. 168 gives a posterior view. Fig. 169 presents an appearance of the natural relations of the diverticulum, obtained after emptying the intestine, and withdrawing it from underneath the diverticulum by which it was strangulated.

The diverticulum was an inch and a-half in length, and terminated in a slightly-dilated cul-de-sac; from the extremity of which a membranous band was sent off, one extremity of which was evidently continuous with the serous coat of the diverticulum, and the other as evidently not merely attached to, but becoming continuous with, the anterior lamella of the mesentery. Through the aperture formed by the diverticulum, mesentery, and the portion of the intestine, from which the diverticulum

is continued, twelve inches of intestine had passed at the commencement of the attack, and became strangulated.

The above cannot but be regarded as a very curious and extremely unusual case-not that it is rendered so by the mere existence of a diverticulum, which is itself a rare formation, but the presence of a diverticulum being the occasion of strangulation.

There is on record one case bearing a striking resemblance to the above. I allude to a preparation in the museum of St. Bartholomew's Hospital, of which I subjoin the description as extracted from the published catalogue of that valuable collection:

"Portion of small intestine, from which a diverticulum is continued.The extremity of the diverticulum is adherent to the contiguous part of

Fig. 167. Anterior view of the strangulated intestine and stricture ;-a, gastric extremity; b, rectal extremity.

Fig. 168. Posterior view of the strangulated intestine and stricture;-a, gastric extremity; b, rectal extremity.

the mesentery, so as to form a circular aperture or ring. Through this aperture a portion of intestine, twelve inches long, passed, and became strangulated. The patient, a lad subject to constipation, died four days after signs of strangulation of the intestine."

It will, however, be seen that, in one point at least, the cases differ: in that of St. Bartholomew's Museum, the fundus of the diverticulum is adherent to the contiguous portion of the mesentery-whereas, in the case I have described above the fundus of the diverticulum is connected with the mesentery by the serous coat becoming contracted into a membranous band, and expanding into the anterior lamella of the mesentery. In the catalogue of the museum of the Royal College of Surgeons in Ireland, there is a description of a preparation in which a diverticulum, four or five inches long, caused strangulation of several feet of intestine; but the relations of the diverticulum, as well as the mode in which it effected strangulation, were very different from the case described above.

Fig. 169. An appearance of the natural relations of the diverticulum to the intestine: a, gastric extremity; b, rectal extremity.

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CHAPTER XIV.

WOUNDS OF THE ABDOMEN.

ALTHOUGH the doctrines respecting the treatment of wounds generally is applicable to wounds of the abdomen, yet as these are particularly dangerous and require certain peculiarities of treatment, it is necessary to give a fuller account of the different sources of danger and of the treatment required in wounds of various kinds in that part of the body. There have been instances in which both the fixed and the floating viscera have been wounded, in which balls and sharp instruments have passed through the body, and yet the patient has recovered; but still when wounds of the abdomen are accompanied by injury of the contained viscera, they are extremely dangerous, and in the majority of instances fatal. The chief sources of danger are hemorrhage, fatal depression of the nervous system, extravasation of visceral contents, and peritonitis.

Hemorrhage may prove fatal, either very speedily from the loss of blood, as when any large vessel in the abdomen is wounded, or when there is an extensive deep wound of such organs as the liver or spleensuch cases presenting the usual symptoms attendant on profuse internal hemorrhage; or when the loss of blood is not of sufficient extent to produce death, by its occasioning inflammation of the peritoneum, which quickly leads to the most unfavourable results.

Depression of the nervous system, although generally attendant in a greater or less degree on wounds of the abdomen as well as on blows on that part, more rarely occurs to a fatal extent in the former than in the latter case; yet sometimes it terminates in death, the sudden shock given to the nervous system causing the failure of the heart's action,a result which has been supposed by some to occur more frequently after wounds of the stomach and duodenum than of the other viscera.

Extravasation of visceral contents does not occur so often as might be expected; indeed, it is astonishing how seldom such effusion takes place in cases of a small wound of the intestine; extravasation being in such cases prevented, in the first instance, by the constant equable pressure which the abdominal viscera exert on each other, the various surfaces being constantly in close contact, and by the tendency to protrusion of the mucous membrane, which plugs up the orifice, and afterwards by exudation of coagulable lymph on the exterior of the wound, by which and by adhesion to surrounding textures the breach becomes permanently repaired. By this process both hemorrhage and extravasation of intestinal contents are often prevented; but if the viscus be full, or the wound very considerable, effusion of visceral contents into the sac of the