and covered with granulations that bled very easily, and when handled a little roughly, profusely; and as a consequence her general health was very much reduced. In this case I suggested an operation but she would not consent to it. I put her on the usual course of treatment, both local and general. She rapidly recovered, became pregnant, had a healthy male child at term, and has had none of her trouble since. But of course parturition did not remove or cure the rupture. This is not an isolated case. I could give a number from my note-book, but it will add nothing to the facts in the case. I give the above, as it is a typical case and shows that if an operation is advisable it is certainly not often necessary.

CASE OF UMBILICAL HERNIA.

A. A. HAMILTON, M. D., MARION, IND.

On the evening of the 8th day of March, 1880, I was called to attend Mrs. Charles Atkinson in confinement. Upon my arrival at the house I at once made an examination per vaginam, and found the os well dilated, and the head of the child presenting. The labor progressed rapidly, and without any accident to the mother, and in less than one hour a female child, of medium size, was born into the world. Upon throwing back the bed clothes, for the purpose of ligating the cord, I was momentarily startled by the sight of a large, fleshy mass protruding from the abdomen in the region of the umbilicus. A hasty examination enabled me to pronounce this tumor an umbilical hernia. This hernia was slightly pyriform in shape, measuring about twenty-six centimeters in circumference at the base, and about twenty-seven centimeters at its greatest circumference. Measured longitudinally, the distance from the base to the most prominent part was perhaps twelve and a half centimeters. It was covered by a thin, translucent membrane, part of which seemed to be the distended sheath of the cord, the remainder more nearly resembling the peritoneum. The upper part of the tumor had a soft, doughy feel, and appeared to contain folds of intestine, distended by flatus, but upon making deep pressure, a hard, resisting mass could be felt, which I decided to be some of the solid viscera-either the liver or spleen. Repeated efforts were made to reduce this tumor, but its contents could not be forced back into the abdomen. The umbilical cord was at

tached near the base of the tumor, and a little to the left side. It was normal in appearance, and of the usual size. Aside from the rupture, the child was well developed, and apparently healthy. An unfavorable prognosis was given at the time, but the nurse was directed to maintain as steady pressure as possible by keeping the child's bandage tightly drawn. At first the child was very fretful and restless, and refused to nurse. About the third day it began to improve; was less fretful, nursed tolerably well, and discharged urine and feces regularly. It had been noticed from the first that when the child cried the tumor seemed to become more full and tense; but this, I thought, was owing to the pressure behind the tumor, caused by the contraction of the abdominal muscles. On the fourth day a broad strip of rubber adhesive plaster was drawn tightly over the enlargement, and the nurse was directed to tighten the plaster from day to day in case the tumor seemed to diminish in size, which, however, it did not seem inclined to do.

On the 11th day I visited the case again and found the rupture somewhat reduced in size and covered with small ulcerated patches, which were discharging a terribly offensive matter. An ointment of oxide of zinc and vaseline was prescribed and the plaster reapplied. The case seemed to do well until the 4th day of April, when the child was suddenly taken with convulsions, and died in about eighteen hours.

The tumor had decreased in size somewhat in its longitudinal diameter, owing, as I supposed, to the fact that the intestines had returned to the abdominal cavity. The sac was still as large as before in its transverse diameter, but seemed to contain only the hard resisting mass before alluded to.

At the post mortem, held eighteen hours after death, the following notes were taken by Dr. William Lomax:

"Cadaver somewhat emaciated. Right leg and foot slightly edematous. A large, prominent exomphalos presented. The most prominent portion was covered by a thin epithelial tissue, very similar to the prolabia and about the same color. Shallow patches of ulceration were scattered upon it. This discolored epethelial surface was circular in form and some nine centimeters in diameter. The skin was perfect up to this border, which was

well marked by the arrest of development. On opening the abdomen it was found that the deficiency of development extended to the parietes, leaving an opening in the walls answering to the discoloration of the surface. This opening was occupied by the liver, to which the thin cutaneous pellicle was adherent. The liver was large, weighing about one-half kilogram. Two deep fissures were found on the under surface of the left lobe. The lobus quadratus was large and projecting. The border of the right lobe was a thickened, semi-cylindrical rim. Stomach and bowels empty. All the viscera except the liver normal. This was a case in which the deficiency could only have been remedied by detaching the walls of the abdomen from the thin intervening substitute and bringing them together and securing them by sutures-a most heroic, hazardous and unwarranted operation. Death from convulsions, not directly from abnormity of the abdomen."

REMARKS.-After having carefully examined a number of the latest and best works on surgery, with a view of ascertaining the frequency of this affection, I am forced to believe that, while small or moderately large tumors, containing one or more folds of intestine, are comparatively common, umbilical tumors of the size and character of the one just described in your hearing are extremely rare, and therefore of interest to physicians.

Tumors of the umbilicus may be congenital or acquired, and while the affection is most common in children, it is occasionally found in adults-especially in women who have given birth to a number of children.

CAUSES. In the fetus these tumors generally depend upon, or are accompanied by, a defect in the walls of the abdomen, caused by an arrest of development; but whether this deficiency is primary, permitting the viscera to protrude, or whether the tumor is first formed by the forcible expulsion of its contents, owing to violent efforts of the child in utero, thus preventing the closure of the abdominal walls, are questions which I am not prepared to answer.

In the child, after birth, and in the adult, hernial tumors are generally caused by a succession of violent muscular contractions (as crying; severe and protracted labor; straining at stool, etc.), forcing the abdominal contents continuously against the thin and

weakened abdominal walls in the umbilical region. In the adult these tumors are generally found in persons with enlarged and pendulous abdomens, in whom the muscles are thin and relaxed. Congenital umbilical herniæ of large size are frequently accompanied by an arrest of development in other parts of the body, as hare-lip, bifid spine, etc. When the rupture is congenital and of large size, the sac is usually formed by an expansion of the thin, translucent covering of the cord, together with the peritoneum. In children and in adults the hernia, when acquired, is generally covered by the cuticle or true skin. In these cases the contained viscera are forced through the muscular ring, pushing onward the skin, superficial facia and peritoneum, thus forming a sac.

VARIETIES-Umbilical tumors may be divided into several varieties, according to their situation, their size and their contents. In regard to situation it may be said that while the exomphalos is generally contained in a single sac, protruding from the abdomen at the umbilical opening, rare cases occur in which the hernia, after passing through the ring, insinuates itself between the muscles and the skin. In other cases the tumor may be situated to one side of the mesial line; and, again, cases have been reported in which there was a double sac-one containing omentum, the other intestine, etc. As to size these tumors vary greatly, some being no larger than a marble, while others extend as low down as the pubes. With reference to their contents, we may remark that ordinarily they contain folds of small intestine alone, or accompanied by the cecum, colon or omentum. Tumors of large size may contain the liver, spleen, or, in rare cases, the stomach; and in the adult female even the gravid uterus may be found contained in a hernial tumor.1

PROGNOSIS.-If the tumor contain only intestine, and is of small size, and especially if the patient be young and otherwise healthy, and the hernia reducible, the prognosis is generally favorable. In such cases, if reduction be maintained by proper appliances for a suitable time, nature will accomplish a cure by the contraction and final occlusion of the umbilical ring. On the other hand, if the hernial protrusion be of large size, and its contents some of the solid viscera confined in a sac formed only of peritoneum and the

(1) Gross' Surgery, Vol. II., p. 713.