Umbilical Hernia 
IN THE ADULT. , 
BY 
WILLIAM WARREN POTTER, M.D, 
OF BATAVIA, N. Y. 
REPRINTED FROM THE BUFFALO MEDICAL AND SURGICAL JOURNAL, JANUARY, 1879. 
BUFFALO: 
Baker, Jones & Co., Printers, 222 Washington St. 
1879. Umbilical Hernia 
'■IN THE ADULT. 
BY 
WILLIAM WARREN POTTER, M. D„ 
OF BATAVIA, N. Y. 
A paper read before the Medical Association of Central N. Y. at Rochester, Nov. 19, 1878, 
That species of rupture in which the abdominal viscera are pro- 
truded through the round opening of the linea alba which trans- 
mits the umbilical blood-vessels of the foetus, has been named 
umbilical hernia. The terms Exomphalos and Omphalocele have 
also been applied to the malady; exomphalos especially being quite 
frequently used by many of the older authors. Mr. Samuel 
Cooper* remarks that “custom appears to sanction the extension 
of the terms exomphalos, omphalocele, and umbilical hernia, not 
only to protrusions of the bowels through the opening of the navel, 
but to all other tumors of a similar nature which present them- 
selves anywhere in the vicinity of the aperture, and the majority 
* First Lines in Surgery. Ed. of 1822. Vol. II, p. 2. 2 
Umbilical Hernia—Potter. 
of which actually take place in the linea alba either above or below 
the precise situation of the umbilicus.” 
Sir William Lawrence* asserts that the term exomphalos can be 
applied with propriety to that rupture only which occurs at the 
umbilicus, while any displacement of the viscera through the linea 
alba, in the neighborhood of the navel, should be classed with ven- 
tral hernia. 
J. L. Petit was the first observer to point out the distinction 
between true exomphalos, and hernia of the linea alba in the imme- 
diate vicinity of the umbilicus; for before his time, says Mr. S. 
Cooper,! all umbilical hernia were supposed to protrude directly 
through the navel. Thrf*question appears to have been a point of 
controversy among writers at the close of the last, and beginning 
of the present century, some holding to the one view and others of 
equal acumen assisting the contrary opinion. The opinion of Sir 
Astley Cooper is quoted in support of the view, that umbilical her- 
nia usually takes its course through the navel Sir 
William Lawrence J seems to have reached the gist of the matter 
when he declares “ that the anatomical facts will furnish us with two 
pathological inferences. First; that infancy is more subject than 
any other age to umbilical hernia, properly so called, when the vis- 
cera are protruded through the navel itself. Secondly; that adults 
may be more exposed to that species of the complaint in which the 
hernia takes place in the vicinity of the umbilicus.” And again, 
the same author asserts § that whether the protrusion takes place 
most frequently in the former or in the latter of these two situa- 
tions (that is, directly through the navel or in the immediate vicinity 
of that part), can be a matter of no practical consequence whatever, 
although it might perhaps influence the name of the complaint. 
To acquire an accurate knowledge of the malady now under con- 
sideration, it should be studied under its three principal forms: 
first, congenital exomphalos; second, exomphalos of the young sub- 
ject; and finally, umbilical hernia in the adult. It is with the 
latter sub division of the disease that we have to do, more espe- 
♦Lawrence on Ruptures, p. 407. 
+ First Lines. Vol. II. p. 9. 
i Lawrence on Ruptures, p. 108. 
§ Ibid, p. 407. Umbilical Hernia—Potter. 
3 
cially, to-day; and, with your permission, I will here introduce a 
brief clinical history of a case of strangulated umbilical hernia, 
which, not very long ago, happened to fall under my observation. 
After supplimenting the account with some remarks pertaining 
especially to the case itself, I will submit some observations ger- 
main to the whole subject. 
Case.—Mrs. 0. residing near Corfu, Genesse county, aet 39 years, 
height 4 feet 10 inches, weight 195 pounds, very obese, married, 
mother of two children aged ten and eight years respectively, was, 
on the 19th of January 1877, at seven o’clock A. M., seized with 
great distress in the umbilical region, which she readily referred to 
the descent of an old hernia. The tumor had often before given her 
similar trouble, and as often had she been able to reduce it herself; 
but now, finding her efforts in that direction unavailing, she sum- 
moned her physician, a homeopathic practitioner residing a mile 
away. He soon reached her bedside and remained in constant at- 
tendance until five o’clock P. M. without, however, affording his 
patient any substantial relief. Her sufferings had now become so 
extreme as to alarm the friends, and Dr. A. H. Crawford of Corfu, 
a very skilful practitioner was called, and to whom the attending 
physician relinquished the charge of the case and departed. Dr. 
Crawford diagnosed strangulated umbilical hernia, and prescribed 
opium, hot fomentations, etc. The use of the taxis proving un- 
successful, he advised further counsel, suggesting the probabilities 
of an operation; and, in obedience to a telegraphic summons, I 
visited the patient at 10,30 o’clock, P. M. 
Finding a tumor of the umbilicus, about the size, shape, and 
“feel” of a large turnip, which was still the source of great pain, 
we administered half a grain of Sulph. Morphia, supplimenting it 
with inhalations of chloroform, hoping thus to control or abridge 
the sufferings of our patient in order to obtain a further examina- 
tion of the tumor. After some delay this was accomplished, though 
with no little difficulty, on account of the embonpoint of the pa- 
tient and the great tenderness of the swelling, when Dr. Crawford’s 
diagnosis wras confirmed. The remote symptoms were not yet 
urgent, so we decided to postpone the further consideration of 
operative measures, an alternative wrhich now seemed inevitable, 4 
Umbilical Hernia—Potter. 
until morning, in order to obtain the advantage of daylight; mean- 
while continuing the hot applications to the entire abdomen. 
Morphia was also given in half grain doses, at intervals varying 
from half an hour to two hours, throughout the night, suppli- 
mented, as in the first instance, with inhalations of chloroform at 
frequent intervals, to allay the very anguish of misery in Avhich 
the patient was tossing about the bed whenever its use was sus- 
pended for a lengthened period. Nausea, which had existed from 
the first, towards morning became a troublesome factor, and finally 
enormous quantities of nearly pure bile were ejected, and the pa- 
tient complained of feeling sick “ all over.” Morning, at last, 
brought an ominous relief from pain and great prostration withal, 
but the condition of the hernial tumor was unchanged, it still feel- 
ing as dense, hard, and inelastic as ever. 
Deeming further delay as now inexcusable, at 0 o’clock, A. M., 
twenty-six hours after the seizure, the patient was etherized, and 
Dr. Crawford assisting me, I operated by gastrotomy in the linea 
alba, at the lower margin of the tumor. I first endeavored to re- 
lieve the stricture outside the sac, but failing in this the sac itself 
was opened, by a small incision, when an ounce or more of serum 
escaped; its contents were found to consist of omentum, intestine, 
and a portion of the liver had also thrust itself into this insatiable 
maw. Passing the finger into the opening and down to the seat 
of the stricture, which had a sharp, cutting “feel,” a guide was 
thus made for the passage of an ordinary hernia knife, with which 
the structure was readily relieved by division obliquely downwards 
to the left of the linea alba. The external wound, not larger than 
three inches, was closed by two deep interrupted sutures, and 
dresssed in the usual manner. Bile was largely vomited during 
the first hour following the operation, after which it ceased 
altogether; union by adhesion resulted, and in two weeks, she was 
upon her feet and in the enjoyment of her usual health. It is 
proper to add that menstruation ensued three days subsequent to 
the operation. 
Kemakks:—Two or three points of interest in this case seem to 
demand notice before dismissing it altogether. 
The pain, it will be observed was ol an unusually severe charac- Umbilical Hernia—Potter. 
5 
ter from the very outset, resisting every effort to relieve it unaided 
by chloroform, and requiring the almost constant exhibition of 
that drug, after the first twelve hours. The frequent vomiting of 
large quantities of pure bile is also a noticeable circumstance, ac- 
companied as it was by the general malaise, which the patient often 
alluded to, as causing her to “ feel sick all over.” She explained 
her use of the expression, saying, that heretofore whenever the 
hernia had been incarcerated she had not felt as now—that in ad- 
dition to the pain about the swelling, she experienced an inde- 
scribable misery, an unusual pain reaching through to the spine— 
that she felt sick “all over” as she had never felt before. The in- 
carceration of a portion of the liver within the hernial sac becomes 
a feature of peculiar interest in view of the infrequency of its oc- 
currence; and this no doubt offers an explanation of the strange 
and unusual feelings of the patient, and accounts as well, for the 
large quantities of bile ejected. The rapid recovery, without un- 
toward symptoms, seems due, in a large measure, to the fact that 
the operation was made early, before the vitality of the parts be- 
came seriously impaired, and particularly before the patients 
strength became exhausted. My only regret is that we did not see, 
and operate upon this patient in the P. M. of the day before, thus 
abridging her sufferings by -several hours. 
Sir James Paget in a lecture upon hernia very aptly remarks, 
u that for every case in which an operation has been avoided by 
waiting, there have been two cases in which lives have been lost by 
waiting too long.” Mr. J. Cooper Forster in “ The Lancet ” for 
February 1872, says, “ two cases (of umbilical hernia) came under 
my care not so very long ago in which the medical gentleman iii 
attendance showed an amount of intelligence which was quite 
delightful. I saw both of the cases within four hours—one within 
two—of the descent of the hernia, and in both I operated within an 
hour of seeing them, and they both got well—a very unusual thing 
in cases of umbilical rupture.” Again, Mr. Le Gros Clark remarks 
(in the British Medical Journal, April 1872,) “ if gentleness and for- 
bearance were more generally adopted in applying the measures 
undertaken to afford relief, and purgatives and procrastination— 
often self-inflicted—were eliminated from the treatment, I believe 6 
Umbilical Hernia—Potter. 
that the statistics of the operation for strangulated hernia would 
present a far more favorable aspect than is at present the case.” 
I am well aware that it is not always possible to draw a sharp line 
between the laying down of other remedial measures, and the taking 
up of the knife, but a considerable observation has convinced me, 
as I presume it has most of you, that failures in the operation for 
strangulated hernia are mainly due to procrastination. While I 
would not condemn the judicious and moderate use of the taxis 
in appropriate cases, I am yet of the opinion, that as much harm 
as good comes of it, in the long run. It is a method, at once, very 
potent for good, and very powerful for harm, its employment sum- 
moning all the attributes of the clever surgeon—patience, courage, 
caution, firmness, gentleness, skill—these and perhaps others which 
I have not mentioned will be necessary, and then, unhappily, its 
use will be looked back upon regretfully in many instances. 
Fortunately in the case related, the taxis had been employed 
moderately and with skill by my colleague, leaving nothing for 
me to determine in regard to it, after my arrival. 
L1TERATU11E. 
Most writers on umbilical hernia appear to pass over the subject 
very carelessly, and whoever attempt an examination of the litera- 
ture of this form of rupture, will be confronted at the outset by 
the fact that much less attention has been paid to perfecting our 
methods and procedures in respect to it, than to the other varieties 
of the disease. This is due, no doubt, largely to the fact that it is 
of much less frequent occurrence than the inguinal or femoral 
forms of rupture; though Sir Astley Cooper says that if he had 
followed the orders of frequency of occurrence in his description 
of the several species of hernia, he should not have hesitated to 
place the umbilical next in order to the inguinal. 
The earlier authors of treatises upon Surgery, speaking generally, 
devote more space to the consideration of this subject, than do 
those writing at a later day and within our own time. Mr. Samuel 
Cooper in the second decade of the present century, occupies 
eighteen pages in the discussion of exomphalos, while Mr. Liston 
and Mr. Dewitt, writing one and two decades later respectively, dis- Umbilical Hernia—Potter. 
7 
miss the subject with a few short paragraphs. Mr. Fergusson 
writing about the same time as Mr. Dewitt, makes no mention spe- 
cifically of umbilical hernia. Sir Astley Cooper* writing in the 
beginning ol this century, discusses the subject in his masterly 
style in a chapter of forty pages. But of all the writers of the 
first quarter of this eventful century for medicine, Sir William 
Lawrencef has given us, in a chapter of twenty-six pages, perhaps, 
all things considered, the most clear, concise, and scholarly account 
of the malady under consideration. I have, in the course of this 
paper, quoted his opinions and sayings largely, as indeed, I have 
most of the other authors mentioned. 
In our own country the venerable and ever to be venerated 
Gross, in his admirable treatise on Surgery, has devoted as much 
space as was consistent with the comprehensive nature of his work, 
to a succinct and practical detail of the more salient features of 
umbilical hernia; while Hamilton writing about the same period, 
gives his views in a few trite and terse paragraphs, extending 
through a page and a half of his unique and valuable volume— 
epigrammatic in style and full of practical teachings. 
These, and other authors—contemporaneous with them, but 
whom I must omit to mention specifically for lack of time, may be 
examined with pleasure and profit in the investigation of this in- 
teresting subject. 
The causes of umbilical hernia in the adult, may be, in the main, 
classed under three heads : First, pregnancy and laborious partur- 
ition; Second, obesity; and Third, straining at stool. 
It is more often a disease of woman ; and pregnancy, with its 
attendant phenomena, is the most common cause of the malady in 
the adult female.\ This cause operates chiefly in the more ad- 
vanced months of gestation, the mechanical pressure of the gravid 
uterus, as it rises upwards, carrying the intestines before it, en- 
croaches upon and narrows the space appointed for the abdominal 
viscera, thus aggravating the complaint if it has already existed, or 
CAUSES. 
* See Sir A. Cooper on Hernia, page 259, et seq. 
t See Lawreuce on Ruptures. Am. Eel. 1843, p. 406. et seq. 
$Sir A. Cooper on Hernia. Ed. 1844. p. 263. 8 
Umbilical Hernia—Potter. 
becoming the source of it, as the case may be ; and the tumor gen- 
erally becomes larger with every pregnancy, as might readily be 
anticipated. “Women often also ascribe this disease to laborious 
parturition.”* 
Sir William Lawrencef remarks that “ the distension of ihelinea 
alba by the gravid uterus so strongly favors the occurrence of ex- 
omphalos, that the number of females afflicted with this rupture 
greatly exceeds that of males.” 
• The second most common cause of this malady in the adult is obe- 
sity. According to Mr. S. Cooper,J dropsical and corpulent indi- 
viduals of both sexes are frequently seen afflicted, and Sir William 
Lawrence§ alludes to the fact that excessive corpulency in both 
sexes acts, by weakening the navel or the immediately surrounding 
fibres of the linea alba, to produce umbilical hernia. And again, 
Sir Astley Cooper|| declares that a “ very frequent cause of this 
complaint is an extraordinary degree of obesity, which, by enlarg- 
ing the omentum and mesentery, renders the abdomen less capable 
*of retaining its contents.” 
Straining at stool is referred to by Gross as one the causes which 
operate to produce umbilical hernia in the adult, though, I opine, it 
is a very infrequent one. It is, however, highly probable that any 
sort of straining, excessive in degree, as in pulling or pushing at a 
heavy load, or lifting a weighty burden, may, in a previously weak- 
ened or imperfect state of the parts, operate to protrude the abdom- 
inal viscera at or near the umbilicus. 
The statistics of hernia, always full of interest to the profession 
in general, form a favorite field of study for the practical surgeon, 
and it may not be out of place to introduce here, such as bear more 
especially upon the branch of the subject under consideration. 
During a period of 28 years, the City of London Truss Society 
relieved 83,584 cases of rupture, of which 3,439, or a fraction less 
STATISTICS. 
♦Sir A. Cooper on Hernia. Ed. 18-44, p. 268. 
tLawrence on Ruptures, 1843, p. 411. 
JFirst Lines in Surgery, 1822. Vol. II, p. 14. 
§Lawrence on Ruptures, 1843, p. 410. 
j|On Hernia, p. 263. Umbilical Hernia—Potter. 
9 
than L in 25, were of the umbilical variety. Of these 3,439 cases 
of umbilical hernia, 6G4 were men, and 2,275 were women—more 
than four times as many women as men. Of 2000 ruptures ob- 
served by Monikoff, 78 were exomphali.* Camper saw at Amster- 
dam, 1,968 cases, of which only ten were umbilical hernia. Of 
seventy-one cases reported by Soemmering, in Holland, (all umbil- 
ical hernia,) seventeen were men and fifty-four were women. 
In Yol. Ill, St. Thomas Hospital Eeports, 1873, Mr. Croft gives 
the statistice of 2,401 cases of hernia, of which 104, or one in 
twenty-three, were umbilical ruptures, and of this number forty- 
twro were males, and sixty-two females. 
The Medical Statistics of the Provost Marshal General’s Bureau, 
compiled by Surg. J. II. Baxter,f furnish some interesting data in 
this connection. An examination of table XIX of this report ex- 
hibits the iact that of 334,321 “recruits, substitutes, drafted, and 
enrolled men of various nativities,” 17,296 were rejected on account 
of hernia, a ratio per 1000 of 50.554. Of the 17,296 rejected for 
hernia of all kinds, 317 were so rejected by reason of umbilical 
rupture, a ratio per 1000 of .948. For the purpose of showing the 
relation umbilical hernia bears to the white and colored races res- 
pectively, I have extracted from table XVII (p. 433, vol. II,) the 
following data. Of 341,569 Whites, Colored and Indians, examined 
306 were rejected on account of umbilical hernia, 315.620 were 
White, of which number 125 were rejected lor umbilical rupture, a 
ratio per 1000 of .396. 
25.828 were Colored, and 181 rejected, a ratio of 7.008 per 1000. 
121 were Indians, and none were rejected for this disease. 
The fact that umbilical hernia is more frequent in the Colored 
race than in the White, as here shown, is probably owing, in part, 
to want of care in adjusting the umbilical bandage after birth,J and 
also, in part, to the fact that the negro babies are more neglected 
during infancy ; they being allowed to cry excessively before the 
abdominal parietes become perfected.§ 
♦Sir W. Lawrence, p. 2L 
tWashington Gov’t Printing Office. 1875. 
$Med. Statistics, P. vi. G. Bureau, Yol. 1, p. 349. 
§Med. Statistics, P. M. G. Bureau, Vol. 1, p. 372. 10 
Umbilical Hernia—Potter. 
ANATOMY'. 
A few of the anatomical characteristics of umbilical hernia may 
with propriety be noticed now. The shape and size of the tumor 
are variable, according as the subject is obese or the reverse ; in 
the fat subject it is spherical, broader at its base and less prominent; 
in the thin person it is usually free and pendulous. These hernia 
sometimes attain an enormous size, particularly may they do so in 
women, who, from having borne many children, have pendulous 
abdomens. 
It was formerly supposed that exomphalos was devoid of a true 
hernial sac, many of the older surgeons of great renown having 
denied its existence. But it has been clearly demonstrated that 
umbilical hernia is not only furnished with a true peritoneal sac, 
but it possesses also a more superficial investment, derived from a 
condensation of the surrounding cellular tissue.* It is, however, 
often the case that the coverings of this hernia are so thin, and par- 
ticularly in old cases, portions of the sac become so absorbed as to 
make it difficult to trace on the front of the tumor; circumstances 
which should caution the surgeon in operating for umbilical hernia ; 
otherwise he may wound the intestine with the first stroke of the 
knife. In exomphalos the sac usually contains both omentum and 
intestine, rarely intestine alone, and still more rarely the liver or 
other abdominal viscera. 
Sir Astley Cooperf asserts that he has never seen the umbilical 
hernia in the adult, but that it contained omentum, though Sir 
William Lawrence reports a case upon which he operated with suc- 
cess, which contained small intestines only.j; 
“ The transverse arch of the colon is the bowel most frequently 
protruded ; but the small intestines are also frequently found in 
the sac, and in some unusual instances the coecum.Ӥ Mr. Holmes 
states that he has seen nearly the whole intestinal canal in the sac 
enveloped by omentum. 
DIAGNOSIS. 
The diagnosis of umbilical hernia cannot, ordinarily speaking’ 
be attended with great difficulty, ft usually begins as a very small 
♦Lawrence on Ruptures, p. 109. 
I'Sir A. Cooper on Hernia, 1814, p. 261. 
JLawrence on Ruptures, 1813, p. 411. 
§S. Cooper, First Lines, 1822. Vol. II, p. 11. Umbilical Hernia—Potter. 
11 
tumor at the navel, which is easily returned, but re-appears upon 
removing the pressure and directing the patient to cough. As it 
increases in size it gravitates and becomes pendulous in the thin 
subject, and its boundaries can be readily defined. In the obese 
individual, however, the case is not quite as simple, since the tumor 
may become buried in the fat, and extend itself between the integ- 
ument and muscles, without causing external swelling. Gross re- 
lates a case of this sort which became strangulated, and was over- 
looked, but the autopsy proved it to have been the cause of 
death. 
Sometimes, says Mr. S. Cooper,* a tumor grows from the navel, 
and puts on the appearance of an umbilical hernia ; also a large 
collection of hydatids within the liver, or upon its surface, some- 
times give rise to a tumor at the side of the navel, which is liable 
to be mistaken for an exomphalos. 
“ Scarpa,” says Mr. S. Cooper, alays down with great accuracy, 
the distinguishing characteristics of both the true umbilical hernia, 
and of other cases which occur in the linea alba near the navel. 
The first disease, says he, whether met with in the infant or the 
adult, has a circular neck, or pedicle, at the circumference of which 
the tendinous margin of the umbilical ring can be felt with the 
end of the finger. Whatever may be the size of the tumor, its 
body always retains nearly a spherical shape; nor can any wrinkle 
of the skin, nor anything at all resembling the cicatrix of the 
navel be observed, either upon the convexity or upon the sides 
of the swelling, the skin being a little paler and thinner at 
some points than others; on the contrary, in a hernia of the 
linea alba, the neck of the swelling is of an oval shape, like the 
fissure through which the protrusion has taken place. The 
tumor itself is also constantly of an oval form. When the finger 
is pressed deeply round its neck, the edges of the aperture in 
the linea alba are perceptible; and if the hernia be very near 
the navel, the umbilical cicatrix may be seen on one of the sides of 
the swelling, a sure indication that the viscera do not protrude 
through the umbilicus itself.”f 
* First Lines. 1822, p. 12. 
tCooper’s First Lines. Ed. 1822, Vol. II, p. 11. 12 
Umbilical Hernia—Potter. 
Before the time of Petit, as I have before remarked, all umbili- 
cal hernia were supposed to protrude through the opening of the 
navel. While asserting this fact still to be true with regard to in- 
fants, he says : “ I would not wish to be understood to assert, that, 
in adults, the parts never issue out of the umbilicus ; but as I 
haye seen this sort of case only twice in my life, this small number 
compared with the great opportunities I have had for seeing um- 
bilical hernia, authorizes me to state that out of one hundred of 
these ruptures, not two happen through the opening of the navel, 
but the protrusions take place above, below or on one side of that 
part.”* Mr. S. Cooper believes that in adults, the protrusion hap- 
pens more frequently above than below the umbilicus, which, ac- 
cording to Scarpa, is due to the fact that the upper half of the 
linea alba, extending from the xyphoid cartilege to the navel, is 
naturally broader and weaker than the lower half, while the recti 
muscles also become situated nearer together as they descend from 
the navel to the pubes, f 
PROGNOSIS. 
When the umbilical hernia becomes strangulated it is the almost 
universal opinion among authors, that the prognosis is much more 
unfavorable, than in the inguinal or crural varieties. “ Several of 
the best practical writers all concur,” says Mr. S. Cooper, “ in one 
important statement, which a prudent surgeon should constantly 
recollect, viz: that the exomphalos and hernia of the linea alba 
are less subject to true strangulation than the generality of other 
ruptures ; but, that when it unfortunately takes place, the symp- 
toms are more intense, and the accession of gangrene more rapid 
than any other species of hernia.”^ 
M. Demarquay, says, in a paper published in the Bulletin de 
Therapeutique for Oct. 30, 1874, that he has never seen recovery 
follow the usual operation performed after attempts at reduction, 
which are ordinarily futile in consequence of the numerous old 
adhesions. 
* Petit. Treatise on Surgical Maladies. Vol. II, p. 250. 
+First Lines Surgery. Ed. 1822. Vol. II, p. 11. 
jFirst Lines. Ed. 1822. Vol. II, p. 16. Umbilical Hernia—Potter. 
13 
This unusual fatality may be accounted for, in part, because of 
the subjects more commonly affected, such persons being unfavor- 
able for operations; and in part, because of the general intestinal 
disorder, which exists with, or is speedily produced by the rupture; 
and again, in part, because of the proximity of the stomach, to which 
irritation and inflammation are readily propagated; but more par- 
ticularly, as I opine, because of the too frequently great and inex- 
plicable delay in making the operation for the relief of these cases. 
TREATMENT. 
The treatment of umbilical hernia in the adult resolves itself 
under three different heads, corresponding to the three several con- 
ditions under which the malady may be observed; that is to say, 
whether it be in the reducible, irreducible, or strangulated state. 
To the relief of the latter condition we shall deem it proper to 
restrict our observations at this time. 
Now, as always, the chiefest factors in the treatment of strang- 
ulated hernia, are the taxis, and the knife. Whatever other thera- 
peutic measures may be resorted to, can only be regarded in the 
light of aids to these two potent remedies; nor is it too much to 
assume, that their timely and skilful employment will bring suc- 
cessful results, in the vast majority of cases. The first object, then, 
in the treatment of a strangulated umbilical hernia, as indeed is 
the case in other varieties, is to attempt its reduction by the taxis. 
So much has been written and said of late in regard to the methods 
of its employment, that it would be a mere work of supereroga- 
tion on my part, to enter into an extended detail of when and how 
to use the taxis; neither would it comport with the scope and limits 
of this paper to do so. But I may with propriety suggest a single 
rule of action which will apply to the vast majority of strangulated 
exomjjhali, viz: to make, under chloroform, one decided effort with 
the taxis, and be prepared to operate if it should fail to reduce the 
hernia; for nothing does more harm in such cases than repeated 
unsuccessful attempts at reduction. It has become a rule now-a- 
days with many eminent surgeons, never to employ the taxis except 
with an ansesthetic; for they believe that more harm than good 
comes of its use, unless all muscular resistance by the patient be 14 
Umbilical Hernia—Potter. 
put out of the question. It would be well, in my humble 
if this principle was more universally taught in our schools. I 
need not stop to condemn prolonged attempts at reduction—the 
violent or forcible use of the taxis in the “ reduction at all hazards ” 
plan—since it can have no place in the treatment of strangulated 
umbilical hernia; for surely here, if anywhere, should the surgeon 
be gentle and self-restraining in handling the delicate structures, 
ever mindful of the fact that he may do them infinite harm. 
In case the tumor be inflamed, with tender and painful cover- 
ings, the taxis will be wholly inadmissible, and the case passes at 
once under the domain of the knife. If perchance the symptoms 
either remote or local, be not urgent and some delay becomes advis- 
able, while waiting it may be proper to make use of hot fomenta- 
tions, enemata, or opiates; but the tobacco glyster of Sir Astley 
Cooper; gymnastic postulations with the head downwards and the 
feet “in the air;” cupping glasses and puncture of the intestine; 
these and other like and unlike things which have been so aptly 
styled by Sir James Paget as “ingenious wrong doings, more dan- 
gerous than the operation which they are intended to avert,” may 
be put aside as worse than useless in the management of the con- 
dition now under consideration. 
“ Purgatives” adopting the language of Sir James Paget, “ I be- 
lieve, had better not be thought of, if there be any marked signs 
of strangulation. There are no clear indications for determining 
the cases in which they might possibly be useful ; and if they do 
no good, they may do grievous harm.” 
The operation for strangulated umbilical hernia has been at- 
tended with great and unusual fatality from the earliest period of 
its history. Sir W. Lawrence affirms * that “ the greatest practical 
writers have strongly represented the frequent fatality*of the oper- 
ation for strangulated exomphalos, and declares that the results 
of his own experience coincide entirely with their statements.” 
He further asserts that the majority of operations he has made 
himself, or seen done by others, have ended fatally. There appears 
to liave been, among the older surgeons, a great dread of the early 
operation, for they pretty generally advise delay, and constantly 
* Lawrence on Raptures, Ed. 1843, p. 428. Umbilical Hernia—Potter. 
15 
warn of the probably fatal termination of cases in which operative 
measures are finally resorted to. Scarpa however strongly opposes 
this doctrine and advised that the operation be made early; 
attributing its ill success to its beiDg performed too late. Sir 
Astley Cooper seems to have concurred in the opinions of Scarpa, 
judging from his practice, but he does not speak emphatically in 
regard to the matter. Authorities in our own time do not differ 
from those referred to in regard to the fatality of the operation. 
Hamilton declares* that the statistics of this operation present a 
more unfavorable result than do the statistics for either inguinal 
or femoral hernia. He further asserts that when it has been neces- 
sary to open the sac the result has generally been fatal. Gross 
says f “ when we consider how disastrous have been most of the 
operations that have hitherto been performed for the relief of 
strangulated umbilical hernia, we can scarcely lay too much stress 
upon the protracted and judicious employment of the taxis.” 
That there are certain circumstances peculiar to this variety of 
rupture which render the operation often unsuccessful, cannot be 
doubted, the large size of the tumor, its free and direct communi- 
cation with the abdomen, the immediate proximity of the stomach, 
and the condition of the patients who often suffer with the malady, 
are all unfavorable to success, and surround the operation with 
peculiar dangers. These, however, seem to me, arguments in favor 
of the early operation, rather than reasons for procrastination. To 
jeopardize to results of an operation, already singularly hazardous, 
even though with but a single jot of additional danger ought to 
be reprehended; and I am sure that in these days of improved 
abdominal surgery the statistics of this operation can be brought 
up to a much better showing than unhappily is at present the case, 
if the knife be appealed to earlier than has been the usual practice 
amongst surgeons, both ancient and modern. 
Says Colles, “there is something peculiar in these hernias that 
causes peritoneal inflammation sooner than others; they are ex- 
tremely different from all other hernias, and in nothing more so 
than in the severity of the mischief arising from them, and the 
* Prin. and Practice of Surgery 1st Ed. p. 744. 
t System of Surgery, p. 714. 16 
Umbilical Hernia—Potter. 
rapidity with which they run their course.” Sir Astley Cooper 
mentions a case which run its course and ended fatally I7i hours 
from the commencement of strangulation. 
As to the method of the operation little need be said, since one 
may cut up, or down, or sidewise and not be wrong; for the dan- 
ger in this operation, according to Sir Astley Cooper, is in wound- 
ing the intestine, and not the blood vessels. 
In the case reported, I chose the lower margin of the tumor for 
the incision as being more convenient and simpler in execution. 
In a larger and more pendulous hernia, the upper side would pos- 
sibly be preferable, though I should say, speaking generally, that 
an incision through the abdominal walls in such immediate juxta- 
position to the stomach is to be avoided if possible. Since the mouth 
of the sac is always, according to Sir James Paget, the seat of the 
stricture, the middle of the first incision may, with propriety, be 
right over it; and it may be made at the most convenient point 
upon the circumference of the tumor—above, below, or to one side, 
as the case may be—an opening from two to three inches long being 
usually sufficient. Caution should be observed in making the first 
incision, lest the intestine, owing to the thinness of the external 
coverings, be wounded by the first stroke of the knife. When 
practicable, the stricture may be divided outside the sac, but this 
is generally difficult, for the sac is thin, and there may be little tis- 
sue between it and the fibrous ring. 
Gross strongly advises division of the stricture without opening 
the sac, “experience,” he says, “having shown that its division is 
fraught with the greatest danger, from its liability to be followed 
with fatal peritonitis”; but if the operation be made early, this 
liability will be greatly diminished. Sir James Paget suggests the 
propriety, in large umbilical hernia, of making two incisions at 
opposite borders of the ring. If the attempted division of the 
stricture external to the sac be unsuccessful—and the trial should 
not be prolonged, since it is a good thing to succeed in, but a bad 
thing to fail in—the sac itself should be opened by an incision 
large enough to admit the passage of the finger, along which an 
ordinary hernia knife is introduced, and the stricture divided ac- 
cording to the usual rules governing the operation for strangulated Umbilical Hernia—Potter. 
17 
hernia. “ In dividing the orifice of the hernial sac and the linea 
alba,” says Sir Astley Cooper,* “ there is no risk of cutting through 
any vessel of sufficient consequence to endanger lift ; for it is re- 
fining upon anatomy to mention the umbilical vein or arteries in 
this operation, as the latter two are mere cords, and the former, 
even if it were opened and divided, would be readily closed by a 
dossil of lint.” 
Strangulated umbilical hernia is liable to occur, as might be ex- 
pected, during gestation; and pregnancy, according to Sir Astley 
Cooper, does not appear to add to the risk of the operation. Sir 
William Lawrence has operated successfully in the well advanced 
pregnant state, considering it not an objection, but rather an ad- 
ditional reason for rescuing the patient as quickly as possible from 
the imminent danger of her rupture.f 
M. Demarquay, who has paid considerable attention to umbilical 
hernia of late, alludes, in the paper hereinbefore noticed, to the al- 
most universally fatal issue of operations for strangulated exom- 
phali, and describes a new operation by which lie has been enabled 
to save one out of the four patients upon whom he has put into 
force. He extends an oblique incision from the middle portion of 
the tumor towards and on to the left side of the abdominal wall. 
He avoids the right side on account of the proximity of the um- 
bilical vein ; the middle line, also, as presenting an objection in the 
linea alba. The cellulo-adipose tissue is then divided, layer by 
layer, until the pedicle of the hernia sac is reached, when a small 
incision is made at the lower part of its left side ; through this the 
left index finger is introduced until its end rests upon the orifice 
of the hernia. Along the finger a falciform bistouy is guided, and 
an incision is made implicating the left side of the circumference 
of'the sac, and extending entirely through all the substance of the 
abdominal wall at this point. The aim of the operation is to re- 
lieve the strangulation by a debridement of three or four centime- 
tres, and then if the intestine has not been too much compressed, 
and it, as well as the omentum, are still only in a state of conges- 
tion, the parts concerned will become disgorged and their functions 
♦Sir A. Cooper on Hernia. Ed. 1844, p. 294. 
tLawrence on Ruptures. Ed. 1843, p. 431. 18 
Umbilical Hernia—Potter. 
re-established, even though there be a little herniary peritonitis. 
It is difficult, however, to understand what the precise advantage 
of this plan is, and particularly is this the case when we consider 
the large percentage of failures.* 
Mr. Thos. Annandale proposes f a somewhat novel method of 
operating for the relief of strangulated hernia, particularly appli- 
oable, as he thinks, to exomphalos in the adult, especially if the 
coverings are thin or ulcerated, or the hernia large. To quote his 
words, “ The principle of this method consists in making a small 
incision through the abdominal walls and opening the abdominal 
cavity near the hernia, instead of cutting into the hernial sac itself 
or exposing it. One or more lingers are then to be inserted into 
tbe abdominal cavity, and the protruded structures contained in 
the hernial sac drawn back from within.” He applied this method 
to a case of umbilical hernia in a male aged 61 years, in which 
symptoms of strangulation had existed three days. He made an 
incision three inches long midway between the xyphoid cartilage 
and the navel, and opened the abdominal cavity to the extent of 
an inch and a half. The hernial protrusion consisted of several 
inches of small intestines adherent to the sac, but these easily gave 
way, and the whole contents of the sac were brought out through 
the abdominal wound and examined. He also freely divided the 
hrm neck of the sac with a probe-pointed knife introduced through 
the wound, returned the intestines and closed the incision in the 
usual manner. Three hours after the operation the patients bow- 
els opened freely; the next day he was weak, though free from 
pain; but, says the operator, the exhaustion continued, and he died 
somewhat unexpectedly (?) forty-eight hours after the operation. 
But, this paper has already exceeded the proper limits, and 1 
must bring it to a close, leaving many points of interest in this 
important subject still untouched. 
Therefore, in conclusion, permit me to remark that, while no 
originality has been essayed in the presentation of this subject, I 
have, on the other hand, merely sought to draw attention to a 
somewhat neglected species of hernia, by massing some of the sa- 
♦See Med. Times & Gazette, Dec. 5th, 1874; and London Med, Record, March 17th, 1875, 
tSee Edinburgh Med. Journal, Sept. 1873. Umbilical Hernia—Potter. 
19 
lient features in the teachings, writings, and opinions of recognized 
authorities thereupon, and finally, to advocate, in general, the early 
operation for the relief of strangulated umbilical hernia in the 
adult.