Hernia of liver through congenital opening in the umbilicus. (Richardson.)
Femoral Hernia.
—Femoral hernia is much more common in women than in men, and constitutes about one-tenth of all cases. This form is also nearly always congenital in the above sense, and is particularly liable to strangulation. It escapes through the femoral ring into the femoral canal, to the inner side of the femoral vein, and then, passing forward through the femoral opening, finds its direction of least resistance upward. In consequence a loop of bowel thus escaping from the abdomen may first pass downward, then forward, and then upward, which will illustrate the futility of the ordinary methods of taxis in the effort to reduce it by manipulation. These hernias are usually small, hence their greater danger. These cases have especially to be differentiated from psoas abscess, from inguinal lymphatic enlargements, and tumors. If the sac be entirely filled with omentum diagnosis is often difficult.
Umbilical Hernia.
—Umbilical hernia is primarily permitted by failure in obliteration of the opening at the navel for the omphalomesenteric duct and for the urachus. Originally small, it may yet assume enormous dimensions. Though actually of congenital origin, as just stated, it may not be discovered until the later years of life. It occurs much more commonly in females than males, and usually in connection with a large deposit of fat in the abdomen, by which its existence, or, at least, its limits and dimensions are masked. Through the umbilical opening, which in the majority of cases is small, may escape other of the abdominal viscera, as is shown in [Fig. 606], illustrating hernia of the liver. [Fig. 607] illustrates the pendulous form which many of these cases assume.
Fig. 607
Umbilical hernia of pendulous form. (Park.)
An infantile form (umbilical) is known, in which the actual protrusion does not occur until the infant is several months old, and which appears to be due to frequent strain, on a weak or incompletely closed fenestrum, by coughing, crying, efforts to expel urine through a strictured prepuce, and the like. These tumors at first are small and always intestinal. It is often possible to so adjust a small pad over these openings as to secure subsequent closure by natural processes. On the other hand, the forms which come on in later life, acquired during pregnancy, ascites, or in connection with excessive obesity, assume sometimes relatively enormous size. Here the hernial contents may be solely omental, but are usually at least partially intestinal. Strangulation occurs in a large proportion of these instances and incarceration is nearly always observed. Naturally, in consequence, the patient complains of gastric disturbances, as well as of chronic constipation, with frequent colicky attacks.[61]
[61] A rare form of hernia into the umbilical cord has been described by Moran. It has been known as hernia funiculi umbilicalis, and has been held to be due to abnormal persistence of the vitelline duct, which holds the loop of intestine to which it was attached inside the abdominal wall, the intestine continuing to grow, the umbilical ring remaining open and the hernia thus enlarging. Occurring in this way it happens about the tenth week of fetal life. Such a hernia has no covering except the peritoneum and the amnion—i. e., is without muscle or skin covering. It would be probably first noted when the cord is about to be tied, when at its loop, as a translucent tumor, varying in size from that of a small cherry to a lemon, the cord being distended and assuming its own natural size only after it has left the hernial tumor. The bloodvessels will run on one side of the amniotic sac. Such sacs rupture easily, perhaps during crying efforts or even during parturition. The condition is serious, and when present no traction should be made on the cord. If easily reduced by taxis an antiseptic compress should be fastened over the opening. Should anything like strangulation occur operation is imperative and should be done immediately.