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Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.

Umbilicus (1916): 1 Umbilical Region Embryology | 2 Umbilical Region Anatomy | 3 Umbilical New-born Infections | 4 Umbilical Hemorrhage | 5 Umbilicus Granuloma | 6 Omphalomesenteric Duct Remnants | 7 Umbilicus Abnormalities | 8 Meckel's Diverticulum | 9 Intestinal Cysts | 10 Patent Omphalomesenteric Duct 1 | 11 Patent Omphalomesenteric Duct 2 | 12 Bowel Prolapsus at Patent Omphalomesenteric Duct | 13 Abdominal Wall Cysts by Omphalomesenteric Duct Remnants | 14 Omphalomesenteric Vessels Persistence | 15 Umbilical Inflammatory Changes | 16 Subumbilical Space Abscess | 17 Umbilicus Paget's Disease | 18 Umbilicus Infections | 19 Umbilicus Abnormalities 2 | 20 Umbilicus Fecal Fistula | 21 Umbilicus Round Worms | 22 Umbilicus Foreign Substance Escape | 23 Umbilical Tumors | 24 Umbilicus Adenomyoma | 25 Umbilicus Carcinoma | 26 Umbilicus Sarcoma | 27 Umbilical Hernia | 28 The Urachus | 29 Congenital Patent Urachus | 30 Urachus Remnants | 31 Urachal Remnants Producing Tumors | 32 Large Urachal Cysts | 33 Anterior Abdominal Wall Abscesses | 34 Urachal Cavities | 35 Umbilicus Acquired Urinary Fistula | 36 Urachal Concretions and Urinary Calculi | 37 Urachus Malignant Changes | 38 Urachus Bleeding into the Bladder | 39 Patent Urachus Tuberculosis | Figures
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Chapter X. A Patent Omphalomesenteric Duct

Historic sketch.

Appearance of the umbilicus.

Condition of the child.

Treatment.

Cases of patent omphalomesenteric duct.

In 1817 Poussin reported the case of a child three years old. On the fifth day after birth the nurse made traction on the cord, as it had not yet come away. "Inflammation" followed, and a small opening developed at the umbilicus. Sometimes this would close for three weeks or more, but never for a much longer period ; from time to time the child passed round worms through it. At the umbilicus was a projection the size of a hazelnut, which showed at its center an opening from which feces escaped. The fistula was due to a patent omphalomesenteric duct.

Brun, in 1834, published a remarkably clear article on this subject, and described several cases that had been observed by Dupuytren.

King, in 1843, reported a case observed by Parsons and Gunthorpe. In this case a portion of the small bowel had turned inside out through the fistula, and lay as a sausage-like mass on the abdomen. This case is reported in detail on page 233.

Eves, in 1845, reported the case of a child, one month old, who had a red, funguslike tumor, about the size and shape of a raspberry, attached to the umbilicus. At its apex was a small opening, from which occasionally feculent liquid would issue in jets and through which a probe could be passed directly backward for two inches. On investigation it was found that the cord had separated at the end of a week, and fecal matter had then commenced to come from the umbilicus.

Schroeder, in his inaugural dissertation on the formation of intestinal diverticula, published in 1854, said that in the Pathological Museum of Prague is the record of a six-months-old child who showed an embryonic omphalomesenteric duct which passed from the umbilicus to the ileum as a canal of gradually increasing size.

Lannelongue and Fremont, in their treatise on the varieties of congenital tumors, said that umbilical fistulae of this origin had been observed by Sandifort, F. Schulze, Tiedemann, Ludwig, and Tilling.

A patent omphalomesenteric duct is by no means common, but Brun was able to publish three cases from Dupuytren's clinic, and Quaet-Faslem five cases from Petersen's clinic. A fairly complete summary of the cases scattered throughout the literature will be found toward the end of this chapter.

Sex. — In 13 of the cases here recorded we have no data as to the sex, but of the remaining 35, 31 were in males and only 4 in females, showing conclusively that the patent omphalomesenteric duct occurs almost exclusively in the male.

Age. — For the 35 cases in which we have data as to the age at which the patient came under observation we have the following figures:

Under one year old 22

Between one and ten years old 8

From ten years of age and over 5


Holmes' patient and the one observed by Leisrink and Alsberg were ten years old. Fitz's patient was twenty-one years of age, and Kehr's, twenty-eight years old. Park's patient was an athlete, his exact age not being given.

The Umbilical C o r d . — In many cases no mention is made of the condition of the cord at birth, but in quite a number the records show that the cord was very large at its base, in some cases being fully twice as thick as usual near the abdomen. Pratt, for instance, said that for an inch and a half from the abdomen the cord was double its usual thickness. Many of the cases were handled by midwives and no definite records made. I feel sure that future reports will demonstrate that the cord near the umbilicus is invariably thicker than usual, when a patent omphalomesenteric duct is present.

In Hansen's case the cord was very large, bluish green, and abnormally broad. It came away on the eighth day.

In the cases in which the cord has been very thick, as a rule, the ligature has been applied farther away from the abdomen than usual.

Appearance of the Umbilicus

When the cord comes away, an abnormal condition at the umbilicus is generally detected at once. The umbilical depression is occupied by a bright-red nodule. This may not be larger than a pea, but is frequently the size of a hazelnut (Fig. 121, p. 206) or of a cherry. In some instances it is much larger. In Ardouin's case, for example, its diameter was as large as that of the little finger, and the growth was 2.5 cm. long (Fig. 115, p. 192). In Hansen's case it was cylindric, snout-like, and curved. On its convex surface it was 3 cm., and on its under and concave surface 2 cm., in length. In Battle's case it was l 1 ^ inches long. In Shepherd's case it looked like a penis and was 1}4, inches long. In Roth's case it formed a cylindric tumor 2 cm. in length (Fig. 120, p. 205). In Morian's case, when the cord came away, a red, sausage-like mass was left (Fig. 119, p. 202); in Deschin's case a mushroom-shaped mass the size of a walnut was found. Figs. Ill, 112, 113, and 1 14 give a very good schematic representation of the various forms of a patent omphalomesenteric duct.

In Jacoby's case, when the cord dropped off, the umbilicus was occupied by a raw area the size of a silver dollar. In Quaet-Faslem's case of a boy, nine days old, there was a long, pear-shaped tumor, 8 to 10 cm. in length. These tumors, whether large or small, are bright or dark red in color, and are covered over with typical intestinal mucosa. This occasionally, as was noted in one of Weiss's cases, may be covered over with brownish crusts. On examination of the summit of the tumor, an opening will be found. This may be exceedingly fine, or several millimeters in diameter. A probe introduced into the fistula can be passed directly into the small bowel.

On microscopic examination the surface of the projection or of the fistulous tract will be found to be covered with mucosa similar to that of the small bowel (Fig. 75, p. 134; Fig. 123, p. 207; Fig. 125, p. 209).

In these cases the omphalomesenteric duct has remained open, as it was in the early months of fetal life (Fig. 3, p. 3; Fig. 5, p. 5). Consequently, the appearance of the umbilical growth after the cord has come away will depend on how far away from the abdomen the cord has been ligated. The greater the amount of omphalomesenteric duct left behind, naturally, the longer will be the protrusion. In those cases in which a large, relatively flat area of mucosa is found, the duct has probably been present as a cystic dilatation, and this has flattened out when the cord ligature has cut through.

In this connection the case observed by Prestat and cited by Ledderhose is of interest. In an autopsy on a male infant at term, Prestat demonstrated an intact



Fig. 111. — A Patent Omphalomesenteric Duct. (Schematic.) The lumen is of rather small diameter, and yet occasionally the bowel may prolapse through a lumen even smaller than this.



Fig. 112. — A Patent Omphalomesenteric Duct with a Polypoid Formation at the Umbilicus. (Schematic.)

The lumen of the duct diminishes markedly in size a short distance from the small bowel. Its outer end projects more than a centimeter beyond the surface of the abdomen. The outer surface of this polypoid projection is covered over with mucosa, which is directly continuous with that lining the omphalomesenteric duct and the small bowel.



Fig. 113. — A Very Short Omphalomesenteric Duct. (Schematic.) Usually the convex loop of small bowel is several centimeters away from the umbilicus, but occasionally, when the duct is very short, it may be almost directly attached to it. In the sketch here shown the greater part of the duct lies in the abdominal wall, and in the center of the polypoid nodule which projects outward from the umbilical depression.



Fig. 114. — A Patent Omphalomesenteric Duct with a Polyp-like Formation at the Umbilicus. (Schematic.)

The omphalomesenteric duct is relatively short, and at its intestinal end is a sort of valve. Just above the umbilical opening of the duct is a polyp covered over with intestinal mucosa which, on the one side, is continuous with the skin, and on the inner side with the mucosa lining the omphalomesenteric duct.


umbilical cicatrix. On opening the abdomen he found a cord the size of a goosequill. This was 2J^ inches long, and communicated with the small bowel. On pressure fecal matter passed into the fistula, and at the umbilicus a small tumor projected from the cicatrix. This opened, and on moderate pressure fecal matter escaped. In this case there was nearly a fistula. If the patent omphalomesenteric duct had extended just a little farther out, it would have been constricted by the ligature and left open when the cord dropped off.


The Discharge From the Fistula. — ■ This varies greatly. When the opening is very small, a little mucus may come away. In some cases this has a fecal odor; in other cases, as in Salzer's case, this is lacking.

Where the fistula is a little larger, liquid feces may escape every day, or, as noted in Pratt's case, every three or four days. In some cases the escape of feces was detected only when the child cried or when pressure was made upon the abdomen. In other cases the bowel contents escaped in large quantities from the umbilicus. The amount of the umbilical discharge will depend almost entirely on the size of the fistulous opening.

Skin.- — ■ The skin around the fistula often shows irritation. This again will depend on the amount of feces escaping, and on the irritating or non-irritating qualities of the contents of the particular intestine. Furthermore, the nearer the diverticulum is to the cecum, the less irritation one would expect.

CONDITION OF THE CHILD.

In many cases the children were in good physical condition, but others were weak and frail.

Billroth's patient was very weak; Broadbent's had congenital syphilis; Morian's child cried a great deal and lost weight; Leisrink and Alsberg's patient frequently had abdominal pain; Nicaise's patient was pale and emaciated, as was also one of those observed by Quaet-Faslem; Weiss's patient had had abdominal pain, diarrhea, and vomiting; Roth's patient died suddenly when six months old.

TREATMENT.

Various methods have been adopted to effect a closure of the umbilical opening. The most satisfactory results have been obtained from the use of caustics or the actual cautery, or from the application of a ligature to the umbilical growth. Many of the fistulse closed permanently; others opened up again as a result of coughing, as in Weiss's case. Leisrink and Alsberg's patient was operated upon and died of intestinal obstruction. King's patient underwent a plastic operation, which successfully closed the umbilical end of the fistula, but the child died later of intestinal obstruction.

Removal of the umbilicus and the fistulous tract has given the best permanent results. This is the only method to be considered at the present day. An incision should be made encircling the umbilicus down to and through the peritoneum; if traction is then made, the fistula and the loop of small bowel can be readily brought out of the abdomen. The fistula should then be removed in precisely the same manner as in dealing with an appendix.

CASES OF PATENT OMPHALOMESENTERIC DUCT. Other cases of patent omphalomesenteric duct are referred to in Chapter XI (p. 214), on Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct; and "in Chapter XXI (p. 328), on Worms.

Radical Operation in a Case of Persistent Omphalomesenteric Duct. — Alsberg's * patient was eighteen weeks old. When the cord came away, healing did not occur, a red, moist area remaining. This became more prominent, and a small, horn-like projection, 1 cm. long, developed. This projection was red in color and had an opening from which, yellow fluid escaped.

  • Alsberg, A. : Ueber einen Fall von Radicaloperation eines persist irenden Ductus omphalomeseraicus. Deutsche med. Wochenschr., 1892, xviii, 1040.



On admission the child was found to be well developed. At the umbilicus was a flat tumor, the size of a bean, with an abundance of fluid escaping from an opening in it. The line of junction between the skin and mucosa was sharp. A bougie could be passed for 20 cm. into the opening.

Operation. — -The omphalomesenteric duct was cut off near the small bowel and the stump turned in. The child died on the twelfth day from peritonitis.

Patent Omphalomesenteric Duct. Extirpation. Recovery.* — The child was born September 14, 1906, and was seen on October

5th. He was then twenty-one days old, and presented a fecal fistula at the umbilicus. The parents thought that the woman, who had had charge of the tying of the cord, had applied this ligature to an intestinal loop, but the history shows that there was no room for criticism of the midwife. The boy was well nourished.

At birth the person who tied the cord, 5 or 6 cm. from the umbilicus, noted that it was large at its base. In the course of three days the cord came away, and in its place was a tumor the size of a little finger in diameter, and 2.5 cm. in length. It was red in color, and from it a few days later there was a considerable amount of hemorrhage.

On October 1st, the sixteenth day, the family noticed for the first time an escape of intestinal material and gas. At the same time the bowels moved regularly.

Ardouin saw the child five days later, and the tumor presented the picture seen in Fig. 115. It was red, like a cherry, and resembled intestinal mucosa which had been irritated. The tumor was limited at its base by a cutaneous elevation at the umbilicus. The surrounding skin was reddened and ulcerated at some points. At the summit of the tumor was a depression, from which fecal material and gas escaped. Ardouin recognized the condition as one of persistent omphalomesenteric duct. There were no other malformations.

Operation. — A lozenge-shaped incision encircling the umbilicus was made and the peritoneum opened. The tract was clamped off at the point of junction with the intestine, and cut across with the thermocautery, just as in the removal of an appendix. The opening in the bowel was closed, and the child made a perfect recovery.

Extroversion of Meckel's Diverticulum. — Battle's patient was a girl eighteen months old. She was fairly well nourished, but had a pear-shaped tumor at the umbilicus. This was noted shortly after birth, and had been increasing in size.

  • Ardouin, P.: Persistance du Diverticule de Meckel ouvert a l'ombilic. Fistule stercorale.

Omphalectomie. Extirpation du diverticule, guerison. Arch. prov. de chir., Paris, 1908, xvii, 1. t Battle, W. H.: Clin. Soc. Trans., London, 1893, xxvi, 237.



Fig. 115. — A Patext Omphalomesenteric Duct. (After Ardouin.) A probe has been introduced into the tract in order to show its permeability. 1, the diverticulum; 2, the umbilicus; 3, the surrounding collar of skin; 4, the point of attachment of the diverticulum to the intestine; 5, the probe passing through the length of the fistulous tract.




It was one and a half inches long, and covered with red, smooth mucosa, which bled on manipulation. There was a sharp line of demarcation between the tumor and the skin. At the free end the diameter equaled that of a cherry, and at its narrowest point was reduced by one-half. At its extremity was a hole through which a probe could be passed inward for two inches. There was a thin, rather feculent discharge, and the tissues surrounding the tumor were eczematous. The stools were normal. The protrusion could be reduced only very slightly by pressure. It increased in size when the patient cried or stood erect.

Operation. — The abdomen was opened; the diverticulum was cut through transversely, and the stump invaginated. The next day scarlet fever developed, and the child died on the eleventh day.

At autopsy the abdominal condition was found to be perfectly normal. The death was due to scarletfever. The distance of the diverticulum from the ileocecal valve was ten inches.

A Patent Omphalomesenteric Duct.* — The boy, fourteen weeks old, had had a fecal umbilical fistula since birth. Projecting from the umbilicus was a growth half an inch in length from which a small amount of fecal matter escaped from time to time. Billroth thought that this represented an omphalomesenteric duct that had remained open (Fig. 116).

The growth was tied off with the hope that the fistula might close, but when the suture came away, it remained open. Billroth thought of closing the fistula later with sutures, but the child was very weak, and was taken home by its parents. It soon died.

A Patent Vitelline Duct. — Broadbent f showed the specimen. The child had occasionally passed fecal matter from the umbilicus, but as it was a subject of congenital syphilis, no surgical procedure was undertaken. At autopsy a coil of intestine was found in contact with the umbilicus, and there was a slender tube passing from the intestine to it.

A Patent Meckel's Diverticulum. J — A boy, six months old, was brought to the hospital June 3, 1894. He had a pear-shaped tumor 4 cm. long, with a pedicle about 1 cm. in diameter, at the umbilicus. Its surface was covered with a bright-red mucosa, resembling that of a prolapsed rectum. In the center was an orifice from which there escaped a mucous liquid. Nothing resembling fecal matter had ever been noted. A probe was easily introduced into the center of the orifice, and passed into the abdomen.


Fig. 116. — A Patent Omphalomesenteric Duct. (After Billroth.) The patient was a boy, fourteen weeks old, who had had an umbilical fecal fistula since birth. Projecting from the umbilicus was a growth, half an inch in length, from which a small amount of fecal matter escaped from time to time.


  • Billroth: Chirurgische Klinik, Berlin, 1869, 294.

f Broadbent: Med. Times and Gaz., 1866, ii, 45.

JBroca: Persistance du diverticule de Meckel ouvert a l'ombilic et invagine au dehors. Revue d'orthopedie, 1895, vi, 47. 14


Operation, June 9, 1894. — Broca made a circular incision around the umbilicus, going down to the peritoneum. The growth communicated with the intestine by an opening that would admit a probe. The opening in the ileum was closed, and the child made a good recovery.

Patent Omphalomesenteric Duct. — Bureau records another observation made by Broca.* A boy, aged ten months, was admitted to the hospital on October 21, 1897. In the center of the umbilicus was a small red tumor, about 2 cm. long, consisting of the everted diverticular mucosa. At its summit was an orifice into which a probe could be passed. There was a serous discharge from the fistula. On October 21st the fistulous tract was resected. The child made a good recovery.

Prolapsus of the Omphalomesenteric Duct. — Bureau f says that diverticular entero-umbilical fistulse are always due to the persistence of Meckel's diverticulum or to remains of the omphalomesenteric duct. Open diverticula at the umbilicus are rare, and prolapsus of the diverticulum complicating the fistula is still rarer. Broca observed one case in 12,000 patients examined at the Hopital Trousseau during two years. J The danger is from intestinal occlusion. The modes of treatment are compression, ligation, cauterization; laparotomy followed by resection of the diverticulum and closure of the bowel should be employed.

Patent Omphalomesenteric Ducts. — Brun's § article, published in 1834, is a remarkably clear one. He records three cases coming under the care of Dupuytren and a fourth observed by Poussin. In three of the four cases there was an umbilical fecal fistula, and in the other there was no fistula. Brun said that Dupuytren had never seen a case before 1833, and then in short succession the three patients were admitted.

C a s e 1 came under Dupuytren's care. The child was twenty-eight days old. At the umbilicus was a tumor the size of a cherry, red, and covered over with mucosa. The tumor was irreducible; it was narrowed at its base and had a perforation in its center from which fecal matter escaped. In this case the cord had dropped off on the fifth or sixth day, and shortly afterward the condition had been noted. The child's general health was good. A sound could be carried one and a half inches into the fistula. Finally the growth was tied off with a silk ligature. It sloughed off after fifty-four hours and the wound healed.

C a s e 3. A boy, who came under Dupuytren's care, had a large cord at birth. This was tied at a point five fingerbreadths from the umbilicus. At the end of the fifth day the cord had not yet come away, and a new ligature was applied nearer to the abdomen. On the ninth day, when the cord sloughed off, there were two small red tumors at the umbilicus. These were about the size of a finger-tip, and projected half an inch. They were roundish and covered over with mucosa. The one was opposite the other, and both were in the same horizontal plane. The right was smaller than the left. The left one was perforated in its center, having an opening one ligne (2.25 mm.) in diameter. A probe could be carried for more than an inch into this opening, and fecal matter escaped from it. The child also had normal stools. Neither of the tumors was reducible on pressure. Both were tied with silk and dropped off on the third day, with perfectly satisfactory results, the fistula remaining closed.


  • Broca (Quoted by Bureau): These de Paris, 1898, No. 257, 32.

t Bureau, J. : Prolapsus ombilical du diverticule de Meckel. These de Paris, 1898, No. 257, 14.

% Broca: Rev. d'orthopeYlie, 1895.

§ Brun, L. A.: Sur une espece particuliere de tumeur fistuleuse stercorale de l'ombilic. These de Paris, 1834, No. 238.


A Patent Omphalomesenteric Duct.* — Deschin's patient was a boy five months old. A tumor was noted at the umbilicus when the cord came away. To the left of the umbilicus was a walnut-sized, mushroom-like tumor, bright red in color, and reminding one of the mucosa of the large bowel. In the middle was an opening which led into the bowel. Feces escaped from it. The surface of the growth was alkaline in reaction.

The abdomen was opened, and the fistulous tract found to be 3 to 4 cm. long. It passed to the small bowel. The tract, together with the umbilicus, was removed. The child took the anesthetic badly and died several hours later. At autopsy it was found that the fistula was 49 cm. above the cecum. It was lined with intestinal mucosa.

A Case of Diverticulum Ilei Communicating with the Umbilicus. f — W. D., aged one month and four days, had a red, fungus-like tumor, about the size and shape of a raspberry, attached at the umbilicus. At its apex was a small opening from which occasionally feculent liquid would issue in jets and through which a probe passed directly backward for two inches. The child was in good health and the bowels moved in a natural way.

On investigation it was found that the cord had separated at the end of a week, and fecal matter had then commenced to come from the umbilicus.

A ligature was tied firmly around the base of the umbilical projection. This sloughed off in a few days. The canal became obliterated, and the discharge ceased completely. Eves refers to his case as one particularly favorable for palliative treatment.

Intestinal Obstruction Due to a Patent Omphalomesenteric Duct. — Fitz J refers to a case observed by Dr. John Homans, of Boston. A man, twenty-one years of age, met with a severe fall February 8, 1884. He had always been healthy, with the exception of a congenital umbilical sinus, which was vaguely supposed to communicate with the intestine. His mother was confident that portions of food (seeds and the like), after being swallowed, had escaped at times from the sinus, and that the latter had been closed since October, 1882.

"Four days after the fall he was seen by Dr. John 0. Dow, of Reading, Mass., who found him suffering from absolute intestinal obstruction, tympanites, tenderness, and pain. Three days later — a week after the accident — frequent vomiting of an offensive, so-called fecal, material took place. Dr. Homans was summoned in consultation, after another interval of three days, and found the patient vomiting, every few minutes, an exceedingly offensive brown fluid. The abdomen was distended, tympanitic, and tender. The eyes were bright, and the countenance intelligent. Pulse feeble, about 130.


  • Deschin: Zur Frage der chirurgischen Behandlung bei dem Vorfall des Dotterganges.

Centralbl. f. Chir., 1895, xxii, 1154.

t Eves, A: The Lancet, London, 1845, i, 101.

t Fitz, R.: Persistent Omphalomesenteric Remains, their Importance in the Causation of Intestinal Duplication, Cyst-formation and Obstruction. Amer. Jour. Med. Sci., 1884, lxxxviii, 30.



"A dark-colored urine was drawn from the bladder and a director introduced into the sinus. A little fecal matter seemed to escape. The opening was enlarged laterally, especially to the left, sufficiently to admit the finger. The incision may have been an inch and a half long, and the finger entered the peritoneal cavity. No obstruction was felt near the umbilicus within reach of the finger. A loop of intestine was seized, sewn to the skin, and an opening, about half an inch in length, was made through its wall. No fecal or intestinal contents escaped until after the junction was completed, when an offensive, brownish fluid material and gas were freely discharged.

"On the day following the operation the temperature was 100.4° F.; the pulse, 108. The vomiting had ceased, and there was some relish for food. Occasional twinges of pain in the right groin were complained of. There was but little abdominal distention, and Dr. Dow was able to detect a circumscribed enlargement in the vicinity of the ileocecal valve. Two days later the temperature was normal; pulse, 108. The swelling and tenderness in the groin were much diminished, and there were no twinges of pain. Solid food was desired. On the next day the temperature was 96.2° F., pulse, 120. Restlessness, distress in the back, and ringing in the ears were the prominent symptoms, and were attributed to insufficient nourishment. Injections of beef-tea were given, and were followed by marked relief, the pulse falling to 108 and the temperature rising to normal. His strength gradually failed, however, notwithstanding that food was given by the mouth and rectum. The temperature became persistently lower, and the pulse weaker, with increasing frequency. His death took place one week after the operation. On the day preceding a passage from the bowels occurred, although Dr. Dow was of the opinion that the contents of the stomach never passed beyond the intestinal fistula.

"An autopsy was made twenty-six hours after death by Dr. G. E. Putney, of Reading, who has furnished the following interesting report :

"He found the body considerably emaciated and the abdomen flat. A probe inserted into the congenital opening passed downward, forward, and to the right, at an angle of 40 degrees with the median line.

"The parietal peritoneum was glistening, of a dark, reddish-slate color. Its blood-vessels were prominent, especially around the umbilicus, within a radius of four inches. There was no lymph. The small intestine was of a very dark, drabred color. The large intestine and the colon were of about two-thirds the normal size. The artificial opening into the intestine was 52 inches below the pylorus. Its edges were thickened, ragged, and sloughing, and had failed to unite with those of the abdominal wound.

"A diverticulum four inches long and half an inch in diameter arose from the ileum four feet above the ileocecal valve, and extended to the umbilicus. The ileum below its origin was three-quarters of an inch in diameter. The tissues of the diverticulum appeared normal, with the exception of the muscular coat of the distal three-quarters of an inch, which was thrice the normal thickness. A tendinous cord the size of a darning needle and 4 inches long proceeded from the mesentery along the diverticulum and became lost in the tissue surrounding the umbilical opening. In its course along the diverticulum it appeared as if ensheathed.

"The contents of the small intestine resembled dark pea-soup; those of the large intestine were pultaceous, resembling yeast. There was no evidence of any existing constriction at the time of autopsy.

"There seems to be no reasonable doubt that the above case is one of intestinal obstruction from persistent omphalomesenteric remains. The autopsy gives no evidence of the manner in which the obstruction occurred."

Fitz's article is one of the most readable in the English language. A Patent Omphalomesenteric Duct.* — ■ The boy was five

years old. When the cord came away, an enlargement the size of a hazelnut was noted at the umbilicus. This nodule was red and discharged a clear liquid, which at times was blood-tinged. Up to the fifth year the tumor had occasioned no serious



Fig. 117. — A Patent Omphalomesenteric Duct. (After Froelich.) The umbilicus was particularly prominent, owing to a definite projection. This had existed since the cord came away. For its relative size and position see Fig. 118.


Fig. 118. — A Patent Omphalomesenteric Duct. (After Froelich.) The umbilical growth seen in Fig. 117. S, S, is the sound, which passed down a certain distance and then directly into the abdomen, as indicated by the dotted line. The entire growth was removed. Its inner portion was continuous with a pervious cord which opened into a loop of small bowel.


trouble. When the child came under observation, an elongated projection was noted at the umbilicus (Fig. 117). At its center was an opening from which a clear liquid escaped. The tumor was bright red and resembled intestinal mucosa. It was soft in consistence, but on pressure could not be reduced in size. The patient's movements did not cause any alteration in its size. A probe introduced into this fistula could be carried downward and came in contact with the lower part of the mass, but a curved probe directed toward the umbilicus passed into the abdomen. The fluid escaping was alkaline. The condition was one of patent omphalomesenteric duct with partial eversion of the outer portion.


  • Froelich, R. : Du fungus ombilical du nouveau-ne, a l'occasion cl'une operation de prolapsus ombilical du diverticule de Meckel. Rev. mens, des maladies de l'enfance, Paris, 1902, xx, 517.


The omphalomesenteric duct was excised from a point about 0.5 cm. from the intestine, and the stump turned into the bowel. Microscopic examination showed that the surface of the umbilical nodule was covered with intestinal mucosa.

A Patent Omphalomesenteric Duct.* — The patient was a boy two and one-half years old. From the time that the cord had come away fecal matter had been noted at the umbilicus. In time a granular tumor the size of a cherry developed at this point. There was some prolapse of the mucosa of the fistulous tract.

The fistulous tract was dissected free as far as the bowel and then removed. The patient made a good recovery.

A Patent Omphalomesenteric Duct.f — At birth the cord was very large near the umbilicus. It was bluish-green in color, and fell off on the eighth day. There remained a red, snout-like mass, 2 cm. in length. This secreted much pus, and, when the child cried, there was some bleeding. Later on gas-bubbles and feces escaped.

At examination there was noted at the umbilicus a cylindric, somewhat conic, snout-like mass, which hung downward and to the left. The left, which was the under side, was 2 cm. long. The right, the upper side, was 3 cm. long. At the bottom the growth was 2 cm. in diameter.

The skin was drawn upward upon the surface of the tumor on the right side for a distance of 1.5 cm.; on the left for a distance of 0.75 cm. The remainder of the tumor was covered with bright-red mucosa. In the center was a funnel-shaped opening. A sound passed upward and to the right 7 cm.

Operation. — Two threads having been passed through its base to prevent its giving way, the tumor was excised. Three small vessels were caught. On account of the friable mucosa it was impossible to suture it, and the stitches were taken at some distance away. The peritoneum was not seen. The skin ring of the umbilicus was removed, and this area was drawn over the stump and closed. The child made a good recovery. The wound healed perfectly, and the umbilical ring, which was previously 2.5 cm. in diameter, contracted down until it was very small.

The microscopic picture showed typical intestinal mucosa. The condition was due to a patent omphalomesenteric duct.

A Fecal Concretion Discharged at the Umbilicus. J — Heaton presented a patient in whom, after a short illness, a large fecal concretion had been discharged from the umbilicus. This patient, before his illness and since he left the hospital, had been in perfect health. There was no history nor any evidence of tuberculosis. Heaton suggested that perhaps a concretion had become impacted in Meckel's diverticulum, had set up an ulceration there, and, fortunately for the patient, had been discharged from the umbilicus.

Probable Persistence of the Omphalomesenteric Duct.f — The patient was a female child, four months old, who had a red, velvety, cylindric projection at the umbilicus. This was three-quarters of an inch long, stiff and tense, and constricted at its base. Its end was covered with a thin slough. It bled readily, but no aperture could be detected. It had existed since the cord had come away. The mother said she had noticed a little moisture having the odor of feces, but no fecal matter could be detected.


  • Gevaert, G.: Fistule ombilicale diverticulaire chez un enfant. Ann. de med. et de chir.,

- iv, 1. f Hansen, J. A. : Ein Beitrag zur Persistenz des Ductus omphalo-entericus. Inaug. Diss., Kiel I "

% Heaton, G.: Brit, Med. Jour., 1898, i, 627.

§ Hickman: Persistent Vitelline Duct, Trans. Path. Soc. London, 1869, xx, 418.



Hickman says that usually, in these cases, eversion of the mucous membrane leaves a canal extending into the bowel through which the feces occasionally pass. In this case no canal could be found.

[The fact that there was a fecal odor here seems to indicate clearly that an opening existed, although Hickman did not find it. A reference to other cases will show that, although no definite connection with the bowel was detected, at operation the canal was found to be patent.]

Patent Omphalomesenteric Duct. — Holmes* had a patient who gave a history of having had a warty growth at the umbilicus during his first year. This was ligated. Holmes saw him when he was ten years old, and at that time he had a constant but not copious discharge from the umbilicus. This fluid, macroscopically and chemically, resembled bile. Later vegetable matter escaped, showing that a definite fecal fistula existed.

A Patent Omphalomesenteric Duct, f — The patient was a poorly developed male. The midwife, when tying the cord, noticed its unusual breadth, but nevertheless put the ligature at the usual point. When the cord dropped off on the third day there was left a raw area, the size of a thaler, which was prominent and moist and from which fluid escaped. Within a few days the surrounding parts became erythematous, and on the sixth day the mother observed feces coming from the umbilicus. The greater part of the intestinal contents, however, still passed by the rectum. The child had no pain in the lower abdomen, but the parents were greatly distressed.

After several physicians had treated the child without success, an old nurse put on an occlusion apparatus and then applied pressure. As a result the feces were held back and the ring closed rapidly and became flatter. By the sixth week the child had improved greatly and soon only a small amount of feces escaped from the umbilicus. Three or four weeks later the umbilicus had healed completely and the child was strong and healthy.

A Patent Omphalomesenteric Duct.J — The patient was a man, twenty-eight years old, who had a patent omphalomesenteric duct. At the umbilicus was a reddish mass, the size of a cherry, showing at its top a depression from which a mucous secretion escaped; no feces, however, were noted. The patient had suffered from obstipation, and felt as if there were something in the umbilical region which prevented the feces from passing. He had had severe colic. On account of the foul odor his comrades avoided him, and his condition had rendered him melancholic.

Operation. — The duct was removed at the bowel and the opening in the ileum closed with two rows of sutures. The patient made a good recovery, but three weeks after operation he committed suicide at his home.

  • Holmes, T. : Surgical Treatment of Diseases of Children, London, 1868, 181.

t Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, xiv, 202. Jacoby also reported this case in Jahrb. f. Kinderheilk. u. phys. Erzieh., 1878, xii, 144.

X Kehr, H. : Ueber einen Fall von Radicaloperation eines persistirenden Ductus Omphalomeseraicus. Deutsche med. Wochenschr., 1892, xviii, 1166.


A Patent Omphalomesenteric Duet

The child was six months old. At the umbilicus was a red, smooth, moist tumor, the size of a hazelnut. When the child cried or when pressure was made on the abdomen, the tumor increased in size. At its most prominent part was an opening, hardly the size of a linseed, into which a sound could be introduced for from 5 to 8 cm. There escaped from the fistula a clear green fluid, with a slightly yellowish tint. Under light narcosis the surface was seared with the cautery and a bandage was applied. At the end of eight days nothing but a small opening remained. It was suggested that the child be taken home for a time. When Kern reported the case, the child was more than one year old and had improved, but a fistula remained.

Operation.- — Professor Kraske later excised the diverticulum and the child made a good recovery.

A Patent Omphalomesenteric Duct . — -Kirmisson f says that persistence of Meckel's diverticulum with an opening at the umbilicus is a rarity. His patient was five and one-half months old. The father was not a strong man. When the cord came away on the third day the mother noticed a whitish swelling, which, eight days later, became reddish in color. The swelling was the size of a strawberry. Its mucosa was smooth, and on its surface were two small, teat-like projections, and in its upper portion a small orifice into which a probe could be carried 3.5 to -i cm. The mucosa of the nodule merged directly into the skin surrounding the umbilicus. When the child cried or moved, the tumor became larger and larger. Feces were not detected.

The tract was dissected out and removed. It communicated with the small bowel. The fistula was about 5 cm. long and tapered off; its larger end was at the bowel, the smaller, at the umbilicus. The child made a good recovery.

Microscopic Examination. — The mucosa at the umbilicus resembled that of the intestine. Its surface was covered with cylindric epithelium and the glands were tubular.

A Patent Omphalomesenteric Duct. — Kortet quoted Deschin as saying that 1.8 per cent, of autopsies in children have shown remains of the omphalomesenteric duct. He then reports the case of a boy, fifteen months old, who had at the umbilicus a tumor resembling a penis. When the child cried, this became larger than a finger. Its reduction was difficult. Usually the nodule was the size of the tip of a finger.

The child suffered with intestinal catarrh. Attributing this to the open umbilicus, Korte inserted an iodoform drain into the fistula. Later he resected it down to the bowel. The child made a good recovery.

Patent Omphalomesenteric Duct. — Lannelongue and Fremont! refer to the cases of fistulse observed by Sandifort, Schulze, Tiedemann, Ludwig, and Tilling, all of which were analyzed by Cazin.

They also say that Bruce reported several instances in which a small hernia of

  • Kern: Leber das offene Meckel'sche Divertikel. Beitrage z. klin. Chir., 1S97, xix, 353.

t Kirmisson, E.: Persistence du diverticule de Meckel ouvert a rombilic avec prolapsus de la rnuqueuse intestinale. Revue d'orthopedie, 1901, xii, 321.

{ Korte: Ein Fall von Extirpation des persistirenden Ductus omphalo-mesentericus. Deutsche med. Wochenschr., 1898, xxiv, 103.

§ Lannelongue et Fremont : De quelques varietes de tumeurs congenitales de l'ombilic et plus specialement des tumeurs adeno'ides diverticulaires. Arch. gen. de med., 1884, 7. ser., xiii, 36.


the umbilicus was included in the cord, and when the cord dropped off, a small orifice was left from which feces and gas escaped; later, granulation developed at the umbilicus, and after a variable time these openings closed. After considering all the facts Duplay (they say) came to the conclusion that these were hernial diverticula.

Intestinal Obstruction Due to a Patent Omphalomesenteric Duct.* — The patient was a boy, ten years of age, who was said to have had an open umbilicus. The physician who saw the boy first when he was three years old said it was nearly closed at that time. Nevertheless, it would become prominent, finally flatten, and discharge a few drops of yellowish fluid (odor not given). The child had good health, but frequently complained of abdominal pain.

After eating three apples he was suddenly seized with abdominal pain, signs of obstruction developed, and an operation was performed fourteen days later.

Operation. — When the abdomen was opened, a cord was found passing from the umbilicus back into the abdominal cavity. It resembled intestine, and was the size of a finger. Near the umbilicus it looked fibrous, but in the deeper portion resembled bowel. It had encircled a loop of distended bowel and completely occluded it. Peritonitis followed, and the patient died. The cord was found -to be the omphalomesenteric duct, which was adherent to the umbilicus.

Case of Perforate Umbilicus. f — The patient was a male child. Projecting from the umbilicus was a tumor the size of a hazel-nut. It was bright red in color, and was perforated at its apex by an orifice from which there was a continuous mucous discharge. This opening led into a long canal. There was no escape of urine. The fluid looked like and smelled like fecal contents. The mucous membrane was dissected away and the wound closed.

Marshall said that, although the outer opening could be closed, there would always be a risk of some of the contents of the intestine passing into the canal and setting up irritation and suppuration in the region of the umbilicus.

A Patent Omphalomesenteric Duct.J — The boy was born with an umbilical hernia. On the fourth day, when the cord came away, a red, sausage-like tumor was seen, from which feces and air escaped in small quantities. The boy also passed stools by the rectum. He cried and lost weight. The tumor was covered with mucosa, was the thickness of a thumb, and projected, somewhat like a twisted horn, 3 cm. from the distended umbilicus (Fig. 119). A sound could be introduced into it for 6 to 7 cm. and passed obliquely upward.

When the child was five weeks old, the abdomen was opened and the diverticulum removed. The child made a good recovery. Morian gives a table of the cases of patent omphalomesenteric duct.

A Patent Omphalomesenteric Duct

Nicaise § reports an observation made by Patry. After ligation of the cord the child cried, was greatly agitated, vomited, and suffered from constipation and abdominal distention. These symptoms persisted for four or five days and did not cease until the ligature of the cord came away, leaving a large aperture through which an abundance of greenish liquid escaped. The child seemed to be very much relieved. Patry saw the infant for the first time at the eighth month. He was then much emaciated. The umbilical opening easily admitted a probe. It was surrounded by a collar of mucosa the margins of which were raised, round, and reddish in color. From the opening there escaped a quantity of fecal material almost equal to that passed by the rectum. After feeling assured that the fecal material could all escape by the intestine, Patry closed the umbilical orifice. He was able to obtain healing of the fistula by cauterization and compression after a term of two months.


  • Leisrink und Alsberg: Einklemmung seit 14 Tagen, Laparotomie. Einschniirung durch

einen off en gebliebenen Ductus omphalo-mesaraicus; Resection des eingeschniirten Darmstuckes mit dem schnlirenden Strang ; Darmnaht. Tod nach 6 Stunden. Langenbeck's Arch. f. klin. Chir., 1882, xxviii, 768.

t Marshall: Med. Times and Gaz., 1868, ii, 640.

t Morian: Ueber das offene Meckel'sche Divertikel. Langenbeck's Arch. f. klin. Chir., 1899, lviii, 306.

§ Nicaise: Ombilic. Dictionnaire encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv, 159.



A Patent Omphalomesenteric Duct.* — ■ The patient was a child thirteen days old. At birth an unusually thick cord was noted. When it came away on the ninth day a red, moist surface was left behind. This rolled out



Fig. 119. — A Patent Omphalomesenteric Duct. (After Morian.) The boy was born with an umbilical hernia. On the fourth day, when the cord came away, a red, sausage-like tumor was seen. It projected 3 cm. from the umbilicus, and was covered with mucosa. It was a patent omphalomesenteric duct, with some prolapsus of its mucosa.

during the next two days. Projecting from the umbilicus, which was prominent, was a red growth 1 cm. long, and covered with mucosa. At the tip of the projection was a small opening the size of a pin-head, into which a probe could be introduced for 8 cm. A mucoserous fluid escaped, but no feces.

The condition was diagnosed as a persistent omphalomesenteric duct with slight prolapsus of the everted intestinal wall. It was not thought to open into the bowel.

Operation. — The abdomen was opened and the duct was found attached to the convex surface of the small bowel. It was severed, and, with the umbilicus, removed intact. The child made a good recovery.

A Patent Omphalomesenteric Duct. — Park's f patient (Case 2) was a college athlete who gave a history of always having had some discharge from the navel. A probe could be passed downward through a small opening for a distance of three inches. A median abdominal incision was made, and the operator found a tubular communication with a loop of small bowel. The fistula was exsected and the opening in the bowel closed. The patient made a good recovery.


  • Xeurath, Rudolf: Zur Casuistik des persist irenden Ductus omphalomesaraicus. Wien.

klin. Wochenschr., 1896, ix, 1158.

+ Park, Roswell: Clinical Lecture on Congenital Fistula? and Sinuses at the Umbilicus. Med. Fortnightly, 1896, ix, 9.



A Patent Omphalomesenteric Duct. — In Pernice's Case 142* it was noted at birth that there was an abnormal thickening of the umbilicus. The cord came away on the ninth day. The umbilicus did not contract down and close as usual, but a greenish, thick discharge from it was noted; this gradually became yellow and then whitish and turbid. "When seen at seven months of age, the boy had at the umbilicus a growth suggesting " proud flesh," which was open in its center. The umbilicus swelled out markedly whenever the child cried. The skin in the vicinity was reddened and excoriated, and the skin papillae were somewhat enlarged. In the middle of the umbilicus was a broad-based, reddish, mucuslike excrescence, and in the vicinity a funnel-like depression which also had a reddish wall. A probe could be passed down this funnel for 6 cm. toward the pelvis. The canal was broad and easily admitted a No. 12 bougie. When the child cried, the funnel filled with a secretion resembling mucus, which was turbid, alkaline in reaction, and contained particles of fecal matter.

The inner surface of the canal was lined with cylindric cells. The canal was curetted with a sharp spoon several times, and after five weeks it remained closed.

A Patent Omphalomesenteric Duct.f — The patient was a male child, three years old. His parents were in good health. On the fifth day after birth the nurse made traction on the cord, as it had not come away. "Inflammation" followed, and a small opening developed. Sometimes this opening would close for three weeks or more, but never for a much longer period.

On examination the mother was surprised to see a worm, half an inch long, crawling along the child's abdomen. The child, who had been ill, rapidly recovered. Several weeks later two worms similar in character were extracted from the umbilical fistula.

Between intervals of abdominal pain the child enjoyed good health, except for occasional pain due to the worms. At the umbilicus was a slight projection the size of a hazelnut, with an opening in the center which discharged contents resembling feces.

On several occasions a physician was called to see the child when in great pain and removed lumbricoid worms from the fistula.

A Patent Omphalomesenteric Duct.* — The umbilical cord was unusually thick, for an inch and a half from the abdomen, being more than double the caliber of the rest of the cord. The ligature was applied distally to this thickening, the resultant stump being unusually tense and hard. On the ninth day the covering at the top sloughed, revealing a red, granular projection. At the end of a month the outer covering had disappeared, and a firm, smooth, red tumor remained. This was one and a half inches long, pyriform in shape, and attached to the umbilicus by a short but thick pedicle. Its outer extremity pre

  • Pemice, L.: Die Nabelgeschwiilste, Halle, 1892.

f Poussin: Observation sur l'expulsion de l'abdomen, par une ouverture a l'ombilic, de plusieurs vers ascarides-lombricoides. Jour, de med., 1817, xl, 81.

t Pratt, J. W. : A Remarkable Case of Umbilical Tumor. The Lancet, London, 18SL ii, 1142.

seated a central orifice from which a watery fluid exuded more or less constantly. There was no evidence of hernia. The growth was not painful, but bled when handled, unless treated gently with oiled fingers. It became vascular when the child cried. Toward the end of the third week after birth fecal matter commenced to escape. This phenomenon was noted every three or four days during the following month. The child's general health was good.

"When the child was seven weeks old, a strong silk ligature was tied around the pedicle of the growth. Three days later, on removal of the. dressing, the growth was found detached. The raw area was dressed with zinc ointment and a pad applied. In a few days nothing but an induration was noted around the umbilicus. The child was well a few days later. There was no return of the fistula.

An Omphalomesenteric Duct so Nearly Patent that Moderate Pressure was Sufficient to Force Intestinal Contents Through the Umbilicus. — In a male infant at term Prestat* demonstrated an intact umbilical cicatrix. On opening the abdomen he found a cord the size of a goose-quill, 2^ inches long, and communicating with the small intestine. This opening was oblique and passed from the convex side of the bowel. When pressure was exerted on the small bowel, fecal matter passed along the fistula and caused a pouting out of the umbilical cicatrix. This readily yielded, allowing feces to escape, thus demonstrating conclusively that the omphalomesenteric duct was practically patent along its entire course and merely sealed over at the umbilicus.

A Series of Patent Omphalomesenteric Ducts. — Quaet-Faslem f gives a very good resume of the literature on the origin of the omphalomesenteric duct, and then reports five cases of persistent patency. The first case had been already recorded by Hansen in his inaugural dissertation (Kiel, 1885).

In Case 2 of his series a boy, nine days old, was admitted to the hospital, on January 4, 1888, because feces were escaping at the umbilicus. At the navel was a long, pear-shaped tumor, 8 to 10 cm. long, with an opening in the center. A sound could be passed through it into the abdomen.

The tumor was cut off with scissors and the opening closed with catgut. The boy made a satisfactory recovery. The fistula was a patent omphalomesenteric duct.

Case 3 (1892). A ten-months-old male child presented a prominent umbilicus with a small opening from which mucus escaped. The tumor was removed and the wound successfully closed.

Case 4 (1885) was that of a boy two days old in whom a blackish-green cord still remained. There was also a conic, red umbilical tumor, showing at its summit a small opening from which mucus escaped. When the child coughed or moved, small fecal masses came away. The tumor was removed and the lumen closed, with good results.

Case 5 (1895). A girl, five years old, was admitted because the umbilicus had never healed and secreted fluid. Around the umbilical opening was a reddening, and at the umbilicus was a hernia the size of a nut, from the center of which a yellowish secretion escaped. The child was very thin and pale. A diagnosis of persistence of the omphalomesenteric duct was made.

  • Prestat (quoted by Ledderhose) : Chirurgische Erkrankungen des Nabels. Deutsche

Chirurgie, 1890, Lief. 45 b.

t Quaet-Faslem : Das Offenbleiben des Ductus omphalo-mesentericus. Inaug. Diss., Kiel, 1899.



Operation. — The tract was dissected out, cut off, and the hole in the bowel closed. The results were satisfactory. It is unusual to find so many cases reported from the same clinic (Petersen's). The cases, though perfectly clear, are fragmentary.

A Patent Omphalomesenteric Duct with the Central Portion Partially Closed, Preventing the Further Escape of Feces.* — The patient (L. P.), eleven months old, had a small, smooth projection half an inch long and oneeighth of an inch in diameter at the umbilicus. This was red, cylindric, and covered with mucosa. There was no aperture leading to the abdominal cavity. The mother stated that for some months after the birth of the child there had been a very foul discharge from the navel. This was fecal in character. Xow there was no escape of feces, and only occasionally moisture.

The projection was ligated and nipped off, and the child left the hospital three days later in good condition.

On microscopic examination the umbilical polyp was found covered with intestinal mucosa. In some places the covering had been rubbed off. Railton comments on the closure of part of the fistulous tract, thereby shutting off the escape of feces. The closure was probably caused by new connective-tissue formation.

A Patent Omphalomesenteric Duct. — Roth (p. 383), f in the description of Case 3, refers, to a boy, nearly a month old, who exhibited an unusual outgrowth at the umbilicus after the cord came away. The tumor was cylindric, red in color, and about the size of the last phalanx of a small finger. The cord was unusually large and came away on the eighth clay.

When the child was brought to the hospital, this projection was 2 cm. long, and a sound could

be introduced 4 cm. downward. The surface of the tumor was velvety. From the fistula bile, yellow grumous masses, and vegetable matter escaped, showing conclusively that it was a fecal fistula. The child died suddenly when six months old.

From a loop of small bowel the diverticulum extended to the umbilicus. From the mesentery a delicate fold passed over the intestine and was adherent to the umbilical ring (Fig. 120, b). In this fold several vessels were seen. The diver


Fig. 120. — A Patext Omphalomesenteric Duct. (After Roth.) A longitudinal section through the patent duct and the surrounding tissues, a is the valve-like flap of mucosa where the omphalomesenteric duct opened into the small bowel, b indicates the point of attachment of the duct to the peritoneum of the anterior abdominal wall. Just beneath it is the omphalomesenteric artery, c is the edge of the peritoneal fold just above the diverticulum. It will be noted that the outer portion of the duct really formed a penile projection extending downward from the surface of the abdomen.


  • Railton, T. C: Prolapse of Meckel's Diverticulum (Omphalo-mesenteric Duct). Brit.

Med. Jour., 1893, i, 795.

t Roth, M.: ITeber Missbildungen im Bereich des Ductus omphalo-mesentericus. Virchows Arch , 1881, Lxxxvi, 371.


ticulum was 58 cm. above the ileocecal valve. It gradually became smaller as it passed from the small bowel to the umbilicus. There was a definite valve (Fig. 120, a) where the diverticulum passed from the intestine outward.

A Patent Omphalomesenteric Duct.* — In May, 1903, a strong five-months-old girl was brought to the clinic with a history that, soon after the dropping off of the cord on the sixth da} r , there had been observed a small red tumor at the umbilicus. An odor had been detected only a little while before admission. The tumor had an opening at its tip, and from this now and then drops of clear mucus were discharged. It had not increased in size, but wheu the child cried or when pressure was exercised, it became a little more prominent .

The umbilical nodule was about the size of a pea. It was reddish and velvet -like, with a fistulous opening in the middle through which a sound could be easily passed for 2 cm. into the abdominal cavity (Fig. 121). The tumor was somewhat pedunculated. The mother said that there had never been any discharge of fecal matter from the fistula, and that the child's



Fig. 121. — A Patent Omphalomesenteric Duct. (After Salzer.) /' is the tumor: .V, the attachment to the abdominal wall; D, the opening into the bowel. For the low-power picture see Fig. 122. For the high-power see Fig. 123.


Fig. 122. — Paht of a Patent Omphalomesenteric Duct. (After Salzer.) Fig. 122 shows a longitudinal section of Fig. 121, on one side of the fistulous tract. The entire outer surface of the tumor is covered over with typical intestinal mucosa. MD indicates a point where the glands show some branching. E shows the squamous epithelium. The line of junction between the skin and the mucosa is sharply defined. For the high-power picture see Fig. 123.


stools had always been regular. From the history there was no doubt that the condition was due to persistence of the omphalomesenteric duct. The only question was as to whether the fistula was complete or partial.

Operation, June 26, 1903. — An elliptic incision was made, encircling the umbilicus, and a cord was found passing from the navel to the convex side of the small bowel. This cord was 2 cm. long and 0.5 cm. thick. It was covered with

  • Sulzr;r, H.: Ueber das offene MeckePsche Divertikel. Wien. klin. Wochenschr., 1904, xvii,

614.


peritoneum on all sides. Blood-vessels passed from the mesentery over the bowel to this cord.

The diverticulum was cut off at the bowel; the bowel was closed, and the child made a perfect recovery.

The tumor was hardened in Muller formalin solution and then in alcohol of different strengths and embedded in paraffin. Serial sections were cut in such a manner that they ran parallel with the course of the diverticulum throughout. In some sections it was possible to see that the lumen of the intestine was open and


Fig. 123. — Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Omphalomesenteric

Duct. (After Salzer.) Fig. 123 shows a small portion of Fig. 121. At M.D. is a large gland. On being followed downward, its branches are clearly seen. D.D. indicates goblet-cells. The surface of the mucosa shows some degeneration, evidently on account of coming in contact with the clothing.


communicated with the umbilical fistula. Some of the sections were stained with hemalum-eosin and some by the van Gieson method. The peritoneal covering of the diverticulum was seen to be directly continuous with that of the intestine as far as the abdominal wall.

The nerve elements of Meissner's and of Auerbach's plexus were found in their normal positions in all portions of the diverticulum. The mucosa of the diverticulum presented points of much interest. In its free abdominal portion, as well as in the region of the abdominal wall, it was identical with the normal mucosa of the small intestine. But where it lay free on the surface of the prolapsus on the abdomen, the character of the glands was markedly changed. The gland tubules were smaller than Lieberkiihn's crypts. They often showed bifurcation or numerous branches and were tortuous (Fig. 123). The gland-cells were clear, finely granular, polygonal in shape, and showed a nucleus resting on the base. They took the eosin weakly, and the glands themselves did not pass as deeply as those of Lieberkiihn.

Professor v. Ebner and Professor Schaff er, who examined the specimens, said that all these glands bore some resemblance to those of the cardiac end of the stomach. At the point where the mucosa passed into the skin, the Lieberkiihn glands with numerous goblet-cells were again visible (Fig. 122). A portion of the duct resembled, as Professor Ebner said, the mucosa of the large bowel.

Salzer says that, to epitomize the findings, we have a case of a patent omphalomesenteric duct.

A Patent Omphalomesenteric Duct.* — J. W., about ten months old, was brought to the clinic on February 27, 1896. On the fifth day after the cord had come away a granulation was noted at the umbilicus. This had an opening the size of a darning-needle. It was surrounded by reddish walls, and by making pressure the midwife could bring away sausage-like masses of fecal matter from the umbilicus. The reddish walls became higher and thicker, and as the fecal discharge did not cease, the child was brought to Dr. Noder, July 31, 1895. Noder was able to introduce a sound fully 10 cm. into the abdominal cavity, and at once greenish, soft fecal matter and greenish-colored fluid escaped. By gradually pressing inward, as one would do with a prolapsed anus, he could diminish the size of the tumor. As a result of four applications of the cautery, the fistula became so constricted that only mucus and watery fluid escaped from it.

As the child was not in very good physical condition, he was brought to the hospital. Projecting from the umbilicus was a sausage-like body, 4.5 cm. long, which spread out over the abdomen (Fig. 124). From its form and also its color it was easily seen that it was divided into two portions. The first was in intimate connection with the abdominal wall (Fig. 124, a). It was 2.5 cm. long, about the thickness and roundness of a man's finger, and covered over with a prolongation of the abdominal skin. Sitting on this like a cap was a second portion. It was red, strawberry-shaped (Fig. 124, b), and covered over with a shiny red mucosa which secreted an abundant quantity of mucus. Where the first mass joined the second, there was a rather deep depression. No opening could be made out. There was, however, at the top of the red tumor a slight depression (Fig. 124, c), but a probe could not be introduced.

On pressure the two portions of the tumor were found to differ in consistence; the first was hard and cord-like; the second was softer and could be pressed together somewhat, but, nevertheless, was firm and uniform. On pressure both developed some gurgling and could be reduced in size. When the child took a long breath the entire mass was pushed outward and then receded again.

The abdominal walls were excoriated. Digestion and defecation were normal. The fluid was alkaline in reaction and contained mucin. There was no evidence whatever of urine at the umbilicus. The case was diagnosed as one of a Meckel's diverticulum reaching to the umbilicus and originally communicating with the surface.


  • Sauer, Felix: Ein Fall von Prolaps eines offenen Meckel'schen Diver tikels am Nabel.

Deutsche Zeitschr. f. Chir., 1896-97, xliv, 316.




Operation. — When the peritoneum was opened, it was found that the tract had communicated with a loop of the small bowel. The diverticulum was cut off, the end turned in,, and the growth removed. The diverticulum was 3 cm. in length. The child developed peritonitis and died on the third day.

Sauer then goes on to give a careful description of the microscopic findings. He sums up as follows: At a point 53 cm. d above the ileocecal valve is the Meckel diverticulum which extends through the umbilical ring. g After the dropping off of the um




Fig. 124. — An Umbilical Polyp and a Fibrous Nodule at the Umbilicus. There was Originally a Patent Omphalomesenteric Duct. (After Sauer.) a is a portion of the prolapsus covered with skin; 6, the outer end of the omphalomesenteric duct, covered over with mucosa and formerly opening into the bowel; c indicates the depression whence the fecal matter had at one time escaped. The opening was closed by means of the thermocautery. For the microscopic picture see Fig. 125.


Fig. 125. — Longitudinal Section through the Entire Center of a Partially Closed Omphalomesenteric Duct. (After Sauer.)

For the general appearance of the umbilical tumor see Fig. 124.

a, a portion of the tumor lying on the abdominal wall. The tumor, b, is covered over with skin and consists of tissue of the abdominal wall; c, the tumor covered over with mucosa; d, the prominent hypertrophied mucosa of the diverticulum; e, the depression where communication with the diverticulum opening into the bowel had formerly taken place; /, line of junction between the skin and the mucosa; g, blood-vessels; h, the portion of Meckel's diverticulum communicating with the bowel; i, a portion of Meckel's diverticulum has been nipped off and scar tissue has formed as a result of cauterization; k, marked thickening of the mucosa; I, scar tissue where the lumen formerly existed.


bilical cord the diverticulum becomes adherent to the abdominal ring. Through mechanical pressure feces escape, then prolapsus of the diverticulum takes place.

By means of the thermocautery the outer portion of the opening was closed. Fortunately, there was no prolapse of the intestine. The opening was still closed at the end of about three months. The solid portion of the tumor is shown in 15


Figs. 124 and 125, and consists of fibrous tissue. The reddish tumor is covered with typical intestinal mucosa.

A Patent Omphalomesenteric Duct. — Schroeder * says that in the Prag. Path.-anat. Museum (Protocol 479, 1849) is the record of a child six months old. The embryonic omphalomesenteric duct was present. It passed from the umbilicus to the ileum as a canal increasing in size until it joined the bowel.

A Patent Omphalomesenteric Duct. | — The patient was a strong, healthy boy three months old. He was admitted to the hospital with a fecal fistula at the umbilicus. At birth the cord was thicker than usual. The ligature came away on the fifth day, and on the following day the nurse noticed flatus escaping from the umbilicus; later, feces were discharged in large or small quantities. A few days after the cord came away the umbilical growth protruded more markedly.

At the site of the umbilicus was a protrusion which was the size of, and had the appearance of, a child's penis. This projection was V/^ inches long and had at its extremity an opening which looked very much like a preputial orifice. The growth was covered over with mucosa and bled easily. For three or four inches around the umbilicus the skin was raw, red, and eczematous. A probe could be introduced into the projection, and feces escaped. The fistulous tract was large enough to admit easily a pair of artery forceps.

Operation. — The abdomen was opened; the diverticulum was cut off, and the hole in the bowel closed. The child made a good recovery.

A Patent Omphalomesenteric Duct. J — A boy, aged seven, was brought to the hospital on account of a lumbricoid worm which was protruding from the umbilicus. MacSwiney says: "I at once proceeded to deliver it in an artistic way, and I had to exercise some caution in the operation lest it should break ; as there was considerable tension on the creature, and it was evident that its body was tightly compressed in a tract or sinus through which it was slowly making its way out."

The father said that since birth there had been a fistula at the umbilicus and that it constantly discharged. There was never, however, any sign of blood, bile, or feces. The discharge was clear yellow matter with no fecal odor. MacSwiney, and his friend, Dr. Kelly, thought the case to be one of an unclosed vitelline duct.

A Patent Omphalomesenteric Duct.§ — A male child, two months old, was admitted June 1, 1896. The labor had been normal. The old midwife said that in her long experience she had never seen so large an umbilicus in the new-born.

When the cord came away, the mother had noticed at the umbilicus a reddish tumor from the point of which intestinal contents were discharged. Since birth the tumor had grown but very little. The child was well developed and healthy. At the umbilicus was a tumor the size of a hazel-nut. In form it resembled a penile

  • Schroeder, G.: Ueber die Diverlikel-Bildungen am Darmkanale. Inaug. Diss. (Erlangen),

Augsburg, 1854.

t Shepherd, F.: Umbilical Fecal Fistula in an Infant Cured by Radical Operation. Arch. of Pediatrics, L892, ix, 55.

% MacSwinev, S. M.: Ascaris Lumbricoides extracted from an Umbilical Fistula. Proc. Path. Soc. of Dublin, 1873-75, vi, 251.

\ Stierlin, R. : Zur Casuistik angeborener Nabelfisteln. Deutsche med. Wochenschr., 1897, xxiii, 188.


gland. It was dark red in color, velvety, glistening, and reminded one of intestinal mucosa. At the point of the tumor was an opening which admitted a sound; at the base was a ring of indurated tissue, 4.5 mm. broad, which surrounded the tumor as a cuff. When the child cried, the tumor was a little more prominent. If pressure was made on the abdomen, there escaped a small quantity of gas and fluid fecal matter from the umbilicus. A metallic sound passed 6 to 8 cm. downward; an elastic catheter, 25 cm. and farther, without any difficulty. Defecation and urination were normal. Stierlin came to the conclusion that he had to deal with a diverticulum.

The skin ring at the umbilicus was split upward and downward. It was then easy to separate the tumor from the surrounding structures. On making traction and continuing the dissection Stierlin found that the fistula passed to the convex side of the small bowel. The diverticulum was 6 cm. long (Fig. 126).

While the dissection was being made, it was noted that an artery had been injured. This was isolated, tied, and dropped back into the abdomen. It was a persistent omphalomesenteric artery. The base of the diverticulum was now clamped, and the diverticulum removed. The opening in the bowel was closed with two continuous silk sutures. The child made a good recovery.

Strangulation of Intestine by Diverticulum Ilei. — Wilks* reported a case of obstruction caused by Meckel's diverticulum. The child had previously undergone a successful plastic operation for fecal fistula at the umbilicus.

A Patent Omphalomesenteric D u c t . f — ■ Peter M., three weeks old, had an umbilical fistula which had been noted soon after the cord came away. A great deal of fecal matter escaped. Surrounding the opening was a small fungous wall. Caustics were applied to the fistulous tract, and a bandage was put on, but without success. Several years later the child was brought back. The fistula had become smaller, but fecal matter still escaped tried, this time with success.

A Patent Omphalomesenteric Duct. J — Frederick W., seen by Wernher, was a twin child eleven weeks old, and well formed. The parents said that the child had had intestinal obstruction. At other times there would be abdominal pain and diarrhea. He cried a good deal and vomited. On examination the umbilicus was found to be prominent. Surrounding the margin of the fistula was a fleshy wall which bled readily and was covered with brownish crusts. Wernher lost track of the child, but it was brought back three months later. The



Fig. 126. — A Patent Omphalomesenteric Duct. (After Stierlin.) A diverticulum, springing from the convex surface of a loop of small bowel. It was 6 cm. long, and ended in a mushroom-like extremity. It was cut off at the line indicated by a-a and inverted just as one would do with an appendix.


Caustics were again


  • Wilks, Samuel: Trans. Path. Soc. London, 1865, xvi, 126.

f Weiss, Eduard : Ueber diverticulare Nabelhernien und die aus ihnen hervorgehenden Nabelfisteln. Inaug. Diss., Giessen, 1868. X Weiss, Eduard : Op. cit.


212 THE UMBILICUS AND ITS DISEASES.

projection at the umbilicus was hard, and when the child cried, a few drops of brownish fecal matter escaped. Cauterization was tried and the amount of fecal discharge diminished. Eight days later the opening was closed and the bowels were regular.

Six months later the child was again admitted. A week before admission it had coughed a great deal, and as a result of the coughing a prominence was noticed at the umbilicus. The digestion had been disturbed for some time, and there were diarrhea and colic. As a result of severe coughing the umbilical scar broke and yellowish fecal matter and some blood escaped. The child soon died.

Autopsy. — A Meckel's diverticulum was found extending from the convex side of the bowel; it had a mesentery of its own. The mucosa of the diverticulum of the ileum was much injected. It opened at the umbilicus by a small passage.

Literature

LITERATURE CONSULTED ON PATENT OMPHALOMESENTERIC DUCT.

Alsberg, A. : Ueber einen Fall von Radicaloperation eines persistirenden Ductus omphalo-meserai cus. Deutsche med. Wochenschr., 1892, xviii, 1040.

Ardouin, P.: Persistance du diverticule de Meckel ouvert a l'ombilic, fistule stercorale, omphal ectomie, extirpation du diverticule, guerison. Arch. prov. de Chir., 1908, xvii. Barth, A. : Ueber die Inversion des offenen Meckel'schen Divertikels und ihre Complication mit

Darmprolaps. Deutsche Zeitschr. f. Chir., 1887, xxvi, 193. Battle, W. H.: Extroversion of Meckel's Diverticulum. Clin. Soc. Trans., London, 1893, xxvi,

237. Billroth: Chir. Klinik, Berlin, 1869, 294.

Broadbent: Patent Vitelline Duct. Med. Times and Gaz., 1866, ii, 45. Broca, A. : Persistance du diverticule de Meckel ouvert a l'ombilic et invagine au dehors. Revue

d'orthopedie, 1895, vi, 47. Bureau, J.: Prolapsus ombilical du diverticule de Meckel. These de Paris, 1898, No. 257. Brun, L. A. : Sur une espece particuliere de tumeur fistuleuse stercorale de l'ombilic. These de

Paris, 1834, No. 238. Deschin: Zur Frage der chirurgischen Behandlung bei dem Vorfall des Dotterganges. Centralbl.

f. Chir., 1895, xxii, 1154. Eves: A Case of Diverticulum Ilei Communicating with the Umbilicus. The Lancet, London,

1845, i, 101. Fitz, R.: Persistent Omphalomesenteric Remains, their Importance in the Causation of Intestinal

Duplication, Cyst-formation, and Obstruction. Amer. Jour. Med. Sci., 1884, lxxxviii, 30. Froelich, R.: Fongus ombilical du nouveau-ne, prolapsus ombilical du diverticule de Meckel. Etude de chir. infantile, Paris, 1905, 85. Du Fongus ombilical du nouveau-ne, a l'occasion d'une operation de prolapsus ombilical du diverticule de Meckel. Rev. mens, des mal. de l'enfance, Paris, 1902, xx, 517. Gevaert, G.: Fistule ombilicale diverticulaire chez un enfant. Ann. de med. et de chir., 1892,

iv, 1. Hansen, J. A.: Ein Beitrag zur Persistenz des Ductus omphalo-entericus. Inaug. Diss., Kiel,

1885. Heaton, G.: Fecal Concretion discharged at the Umbilicus. Brit. Med. Jour., 1898, i, 627. Hickman: Persistent Vitelline Duct. Trans. Path. Soc. London, 1869, xx, 418. Holmes, T.: Surgical Treatment of Diseases of Children, London, 1868, 181. Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, xiv, 202; Jahrbuch

fur Kinderheilkunde und phys. Erzieh., 1878, xii, 144. Kehr, II.: Leber einen Fall von Radicaloperation eines persistirenden Ductus omphalomese raicus. Deutsche med. Wochenschr., 1892, xviii, 1166. King, T. W.: Fajculent Discharge at the Umbilicus from Communication with the Diverticulum

Ilei. Guy's Hospital Reports, 1843, i, 2. series, 467. Kern: Ueber das offene Meckel'sche Divertikel. Beitrage z. klin. Chir., 1897, xix, 353. Kirmisson, E.: Persistance du diverticule de Meckel ouvert a l'ombilic avec prolapsus de la muqueuse intestinale. Revue d'orthopedie, 1901, xii, 321.


Korte: Ein Fall von Extirpation des persist irenden Ductus omphalomesentericus. Deutsche med. Wochenschr., 1S9S, xxiv, 103.

Lannelongue et Fremont: De quelques varietes de tumeurs congenitales de l'ombilic et plus specialement des tumeurs adenoides divert iculaires. Arch. gen. de med., 1884, 7. ser., xiii, 36.

Leisrink und Alsberg: Einklemmung seit 14 Tagen, Laparotomie. Einschntirung durch einen offen gebliebenen Ductus omphalo-mesaraicus; Resection des eingeschniirten Darmstiickes mit dem schniirenden Strang; Darmnaht. Todnach 6 Stunden. Langenbeck's Arch. f. klin. Chir., 1S82, xxviii, 768.

Marshall: Case of Perforate Umbilicus. Med. Times and Gaz., 1868, ii, 640.

Morian: Ueber das offene Meckel'sche Divertikel. Langenbeck's Arch. f. klin. Chir., 1899, lviii, 306.

Xicaise: Ornbilic. Dictionnaire encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv 5 159.

Xeurath,. R. : Zur Casuistik des persist irenden Ductus omphalo-mesaraicus. Wien. klin. Wochenschr., 1896, ix, 1158.

Park, Roswell: Clinical Lecture on Congenital Fistula? and Sinuses at the Umbilicus. Med. Fortnightly, 1896, ix, 9.

Pernice. L.: Die Xabelgeschwiilste, Halle, 1892.

Poussin: Observation sur l'expulsion de l'abdomen, par une ouverture a l'ombihc, de plusieurs vers ascarides-lombricoides. Jour, de med., 1817, xl, 81.

Pratt, J. W.: A Remarkable Case of Umbilical Tumor. The Lancet, London, 1884, ii, 1142.

Prestat: Ledderhose, Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lieferung 45 b.

Quaet-Faslem: Das Offenbleiben des Ductus omphalo-mesentericus. Inaug. Diss., Kiel, 1899.

Railton, T. C: Prolapse of Meckel's Diverticulum (Omphalo-mesenteric Duct). Brit. Med. Jour., 1893, i, 795.

Roth, M.: Ueber Missbildungen im Bereich des Ductus omphalo-mesentericus. Virchows Arch., 1881, Lxxxvi, 371.

Salzer, H.: Ueber das offene Meckel'sche Divertikel. Wien. klin. Wochenschr., 1904, xvii, 614.

Sauer, F.: Ein Fall von Prolaps eines offenen Meckel'schen Divertikels am Nabel. Deutsche Zeitschr. f. Chir., 1S96-97, xhv, 316.

Schroeder, G.: Ueber die Divert ikel-Bildungen am Darmkanale. Inaug. Diss. (Erlangen), Augsburg, 1854.

Shepherd, F. : Umbilical Faecal Fistula in an Infant Cured by Radical Operation. Arch, of Pediatrics, 1892, ix, 55.

MacSwiney, S. M.: Ascaris Lumbricoides extracted from an Umbilical Fistula. Proc. Path. Soc. of Dublin, 1S73-75, iv, 251.

Stierlin, R.: Zur Casuistik angeborener Xabelfisteln. Deutsche med. Wochenschr., 1S97, xxiii, 188.

Wilks, S.: Strangulation of Intestine by Diverticulum Ilei. Trans. Path. Soc. London, 1S65, xvi, 126.

Weiss, Eduard: Ueber diverticulare Xabelhernien und die aus ihnen hervorgehenden Xabelfisteln. Inaug. Diss., Giessen, 186S.



Umbilicus (1916): 1 Umbilical Region Embryology | 2 Umbilical Region Anatomy | 3 Umbilical New-born Infections | 4 Umbilical Hemorrhage | 5 Umbilicus Granuloma | 6 Omphalomesenteric Duct Remnants | 7 Umbilicus Abnormalities | 8 Meckel's Diverticulum | 9 Intestinal Cysts | 10 Patent Omphalomesenteric Duct 1 | 11 Patent Omphalomesenteric Duct 2 | 12 Bowel Prolapsus at Patent Omphalomesenteric Duct | 13 Abdominal Wall Cysts by Omphalomesenteric Duct Remnants | 14 Omphalomesenteric Vessels Persistence | 15 Umbilical Inflammatory Changes | 16 Subumbilical Space Abscess | 17 Umbilicus Paget's Disease | 18 Umbilicus Infections | 19 Umbilicus Abnormalities 2 | 20 Umbilicus Fecal Fistula | 21 Umbilicus Round Worms | 22 Umbilicus Foreign Substance Escape | 23 Umbilical Tumors | 24 Umbilicus Adenomyoma | 25 Umbilicus Carcinoma | 26 Umbilicus Sarcoma | 27 Umbilical Hernia | 28 The Urachus | 29 Congenital Patent Urachus | 30 Urachus Remnants | 31 Urachal Remnants Producing Tumors | 32 Large Urachal Cysts | 33 Anterior Abdominal Wall Abscesses | 34 Urachal Cavities | 35 Umbilicus Acquired Urinary Fistula | 36 Urachal Concretions and Urinary Calculi | 37 Urachus Malignant Changes | 38 Urachus Bleeding into the Bladder | 39 Patent Urachus Tuberculosis | Figures

Reference

Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.

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