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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 XI. A Patent Omphalomesenteric Duct — continued

The opening of a patent omphalomesenteric duct on the side of the umbilical cord before the cord drops off: Report of cases.

Prolapsus of the bowel through a patent omphalomesenteric duct opening on the side of the umbilical cord.

Escape of meconium into the liquor amnii through the umbilicus.

An omphalomesenteric duct opening into the abdomen and discharging feces into the abdominal cavity.

A patent omphalomesenteric duct associated with defective development of the rectum or anus.

In this chapter are considered several cases of patent omphalomesenteric duct that presented some rather unusual features.


THE OPENING OF A PATENT OMPHALOMESENTERIC DUCT ON THE SIDE OF THE UMBILICAL CORD BEFORE THE CORD DROPS OFF.

A glance at Fig. 10, p. 10, Fig. 11, p. 11, Fig. 12, p. 12, in the chapter on Embryology, will show that in the early months of fetal life a large part of the intestine lies in the exoccelomic cavity of the cord. As the embryo develops nearly all the intestine is found in the sac, but finally the bowel recedes into the abdomen and this sac becomes obliterated.

That the sac occasionally remains open, and contains a patent omphalomesenteric duct, is clearly demonstrated by the following cases:

Peake, in 1811, in a new-born child observed a tumor at the umbilicus. It was larger than a walnut, and the skin grew over it for a quarter of an inch. The tumor had the appearance of intestine protruding into the umbilical cord. The cord was ligated at a point three or four inches from the umbilicus. At the lower part of the tumor Peake noticed a fissure, and soon a thin, dark material escaped from the opening. The child died on the third day, and at autopsy the ileum was found protruding at the umbilicus.

Auvard, in 1889, observed a tumor at the umbilicus in a newly born child, Accordingly the cord was tied at a point 8 cm. from the umbilicus. The tumor measured 3x4 cm. In the anterior portion of the cord, 3 cm. from the umbilicus. was an opening which had everted margins and measured 3 to 4 mm. It was reddish in color, and meconium escaped from it. Both the mother and the midwife said this opening existed when the child was born (Fig. 127, p. 216, Fig. 128, p. 216). The child's bowels moved regularly, but it sometimes vomited fecal matter.

When the cord came away, a red tumor the size of a walnut remained, which was continuous with the opening. At autopsy a patent omphalomesenteric duct was found (Fig. 129).

(iampert, in 1893, reported a case in which the cord was larger than usual. It was accordingly tied at a point 9 cm. from the umbilicus. Five days later, although the cord was still attached, yellowish material began to escape from its base. The

214


A PATENT OMPHALOMESENTERIC DUCT. 215

cutaneous umbilical orifice was prominent, and formed a collar around the tumor occupying its center. This tumor was 1 cm. in diameter and irreducible, and in its center was an orifice from which gas and feces escaped. A sound could be carried for 3 or 4 cm. into the fistula. The surrounding skin was slightly irritated. On the tenth day a slight prolapse of the mucosa occurred. Fearing prolapsus of the bowel, Gampert cauterized the canal, applied a ligature to the tumor, cut off the excess, and applied pressure. In this way the fistula was successfully closed.

Guthrie, in 1896, recorded the case of a child that had had no movement for three days after birth. Feces then began to escape from an opening in a colorless, bladder-like projection, which had existed at the umbilicus since birth. This protrusion was attached to the cord. It became red and inflamed, ulcerated, and then disappeared.

For a month after birth some feces were passed by the rectum, and then all escaped through the umbilicus. Later there occurred a prolapse of the bowel through the opening, which, however, finally disappeared spontaneously. At autopsy the patent omphalomesenteric duct was found at a point 12 inches above the ileocecal valve.


CASES IN WHICH THE OMPHALOMESENTERIC DUCT OPENED ON THE SIDE OF

THE UMBILICAL CORD.

A Patent Omphalomesenteric Duct Opening to the Side of the Umbilical Cord.* — In this case the midwife noticed a tumor at the umbilicus. The cord was tied distally to this, at a point 8 cm. from the insertion at the umbilicus. When the child was seen by Auvard, there was a cylindric tumor, measuring 3x4 cm., at the umbilicus. This was included in the membranes of the cord and covered with amnion. The cord was free for about 6 cm. from the umbilicus. In the anterior portion of the cord, at a point 3 cm. from the umbilicus, was an opening, the margins showing an eversion. This opening was reddish in color; it measured 3x4 mm., and from it there escaped a greenish liquid, rather thick, and of the character of meconium. The midwife and the mother said that this opening had existed at the time of the child's birth (Figs. 127 and 128). The bowels moved regularly. All the generative organs were normal.

This boy was transferred on the fourth of January to La Charit?. By January 8th the cord had not yet come away, but a small quantity of greenish liquid was escaping from the opening. The discharge was sometimes yellowish. The patient vomited frequently, and the fecal matter was sometimes green. On January 10th the cord came away, leaving a red tumor, the size of a walnut, continuous with the opening above described. A sound introduced could be passed into the cavity without difficulty, and carried inward 6 cm. The child's weight continually diminished.

On January 12th the child was presented at the Obstetrical and Gynecological Society of Paris. The members present, particularly Lucas-Championniere, were of the opinion that the tumor represented a hernia of the diverticulum of the intestine. The child's weight continued to diminish, and he died on February 3d, apparently from weakness. The umbilical tumor had diminished in size. At autopsy it was not larger than a pea. When the abdomen was opened, a loop of

  • Auvard: Travaux d'obstetrique, 1889, Paris, i, 331.


216


THE UMBILICUS AND ITS DISEASES.


small bowel was found extending toward the umbilicus, and a diverticulum opened from the loop through the umbilicus (Fig. 129). The diverticulum entered the small bowel at a point 42 cm. from the cecum.

A Patent Omphalomesenteric Duct Opening on the Side of the Umbilical Cord.* — • The cord at the umbilicus was larger than usual. The ligature was applied at a point 9 cm. from the umbilicus. On February loth, five days after birth, the midwife called Gampert, because the cord did not come away and because at its base a yellowish material was escaping. This discharge resembled fecal matter. The stools passed normally by the rectum.



Fig. 127. — A Patent Omphalomesenteric Duct Opening at the Base or the Umbilical Cobd. (After Auvard.) This sketch was made four days after the birth of the child. The cord was ligated at a point about 8 cm. from the umbilicus. In the anterior part of the cord, 3 cm. from the umbilicus, was an opening admitting the little finger. The margins were raised, and there was some eversion, the everted portion being reddish in color. From the orifice a greenish material, having the characteristics of meconium, escaped. There was frequent vomiting.



Fig. 128. — A Patent Omphalomesenteric Duct. (After Auvard.) This picture was obtained eleven days after birth. The cord came away on the seventh day, and left a pinkish tumor the size of a walnut, with the opening as shown. The child became weaker, and died after a month. For the appearance four days after birth see Fig. 127. For the intra-abdominal picture see Fig. 129.



Fig. 129. — A Patent Omphalomesenteric Duct as Seen fbom the Abdominal Cavity. (After Auvard.)

This picture was obtained at autopsy. A loop of small bowel lies near the inner umbilical opening, and from it a diverticulum passes directly to the umbilicus. It opened on the surface. Passing from the mesentery over loops of small bowel to the umbilicus was a fine fibrous cord, evidently a remnant of an omphalomesenteric vessel.


When seen, the child was large and well developed, and the cord was still adherent to one-half of the circumference of the umbilicus. The cutaneous umbilical orifice was prominent, and formed a large collar around the tumor which occupied the center. This tumor was about the size of the little finger, and cylindric in form and shape. It was 1 cm. in diameter and irreducible. It had in its center an orifice from which yellowish material and gas escaped. A sound could be carried in to a depth of 3 or 4 cm. The skin around the umbilicus was slightly irritated.

On the tenth day, when the child cried, a slight prolongation of the mucosa showed at the orifice. Fearing prolapsus of the bowel, Gampert cauterized the

  • Gampert: Fistule entcTo-ombilicale diverticulaire chez un nouveau-ne. Rev. med. de la

Suisse romande, 1893, xiii, 356.


A PATENT OMPHALOMESENTERIC DUCT. 217

canal and used pressure. The tumor diminished, and tannic acid powder and vaselin were used. A silk ligature was applied, and the excess of tissue was cauterized. When the ligature came away, the opening was closed and remained so.

A Case of Patent Meckel's Diverticulum into which the Posterior or Distal Wall of the Ileum Became Intussu seep ted, Forming an Umbilical Tumor; Death.* — A male infant, six weeks old, was admitted to the Paddington Green Hospital on April 25, 1892. At birth it weighed seven pounds and three ounces. After three days, during which there was no stool, the child began to defecate through an opening in a colorless, bladder-like projection, which had existed from birth at the umbilicus and to which the cord was attached. The cord separated on the ninth day.

The colorless protrusion subsequently became red and inflamed and finally ulcerated; it disappeared a few days before admission. For about a month after birth some portion of the feces came from the rectum, but later all passed through the umbilicus. Micturition was normal.

On admission the child was puny and emaciated. Protruding from the umbilicus was an elongated mass, V/2 inches long by 1 inch in breadth. It was of a dull red color, and had the appearance of intestinal mucosa. Near its superior extremity there was an opening through which feces were discharged, and a catheter could be passed upward and to the right. There was also a small dimple on the inferior end of the protrusion. This would not admit a probe.

On April 29th the protrusion increased to the length of six inches. It became somewhat tightly constricted at the umbilicus. It was much congested, and resembled an intussusception. Taxis failed.

As the patient was too weak, the hernia was let alone. Two days later it disappeared spontaneously, but the child died of exhaustion May 2d.

Autopsy. — The fistula was 12 inches above the ileocecal valve. The upper opening led to the somewhat dilated ileum; the lower opening to the collapsed small and large bowel. The entire large bowel was not bigger than a lead-pencil. The cecum was reduced to the size of the first joint of the little finger. The large bowel apparently had never contained feces. There had been a prolapsus of the bowel through the patent omphalomesenteric duct.

Case of Preternatural Anus Found in a Portion of Ileum Protruded at the Umbilicus. — J. Peake,f a member of the Royal College of Surgeons, London, found, on delivering a woman of a healthylooking boy, that the child had a tumor at the umbilicus. This was larger than a walnut, and the skin grew over it for a quarter of an inch. At the upper part the umbilical vessels passed over the tumor but seemed altogether distinct from it. A ligature was tied around the cord where it appeared normal, that is, at a point three or four inches from the umbilicus.

Peake goes on to say that the tumor had the appearance of a protruding portion of the intestine within the umbilical cord, and at its lower part he could observe a fissure. Soon a thin, dark material escaped from this opening; it was probably meconium.

Shortly after birth the child vomited frequently, and was evidently ill. It

  • Guthrie, L. G.: Pediatrics, 1896, ii, 1.

t Peake, J.: Edinb. Med. and Surg. Jour., 1811, vii, 52.


218 THE UMBILICUS AND ITS DISEASES.

had many convulsions, and died on the third day. The food that was given it was either directly brought up again or afterward passed through the aperture at the navel. Nothing seemed to pass along the regular course of the intestine. Just before death a little mucus and meconium escaped by the rectum.

Autopsy. — The passage from the stomach to the umbilicus was normal. A portion of the ileum protruded at the umbilicus. The bowel below was much smaller than normal.

PROLAPSUS OF THE BOWEL THROUGH A PATENT OMPHALOMESENTERIC DUCT OPENING ON THE SIDE OF THE UMBILICAL CORD.

Prolapsus of the bowel through a patent omphalomesenteric duct is discussed at length in Chapter XII. The case recorded by Gibb is the only example known to me in which prolapsus of the bowel occurred on the side of the cord during the first few hours of life. In Guthrie's case the omphalomesenteric duct opened on the side of the cord, but prolapsus did not occur until several weeks after the cord came away.

Unique Congenital Malformation, Associated with Umbilical Hernia and a Pendulous Artificial Anus.— Gibb * reports a rather unusual condition noted a few hours after the child's birth. The upper part of the cord had dilated, forming an umbilical hernia containing intestine. Attached to the side of the sac was a blood-red body with villous surfaces, looking like intestinal mucous membrane. Meconium passed from both ends of this body. From the anus feces passed on the third day. At autopsy the large bowel was found to be diminished in size. Gibb thought that the mass was a portion of the cecum and the ileum. [This picture (Fig. 130) presents the appearances typical of a prolapse or inversion of the small bowel through the patent omphalomesenteric duct in association with an umbilical hernia.]

ESCAPE OF MECONIUM INTO THE LIQUOR AMNII THROUGH THE UMBILICUS.

If Auvard had been present when the child, whose case he reported, was born, he would probably have found meconium in the liquor amnii, as the omphalomesenteric duct lay open on the side of the cord. In other words, at birth there was a direct connection between the lumen of the small bowel and the amniotic cavity.

The only case in which it is definitely stated that meconium escaped through the cord into the liquor amnii is the one mentioned by Brindeau.

A Patent Omphalomesenteric Duct, with Fecal Matter Escaping into the Liquor Amnii. f — The patient, an eight months child, died on the fifth day after birth. Its weight was two pounds and three ounces. Meckel's diverticulum was 22 cm. above the cecum. The omphalomesenteric duct was open, and traction had drawn the gut outward at a sharp angle. The portions of the intestine immediately above and below the duct were thus easily drawn together, like the barrel of a fowling-piece.

Meconium before birth had passed into the liquor amnii. The intestine above the diverticulum was dilated; below, it was very small.

  • Gibb: Trans. Path. Soc. London, 1856, vii, 216.

t Brindeau: Nouv. arch, d'obstet. et de gyn., Fevrier 25, 1895, 45.


A PATENT OMPHALOMESENTERIC DUCT.


219


AN OMPHALOMESENTERIC DUCT OPENING INTO THE ABDOMEN AND DISCHARGING FECES INTO THE ABDOMINAL CAVITY.

Weiss* said: "Notwithstanding the fact that in dead-born children diverticula are found in the umbilical cord, there has been no example of death due to an out


Fig. 130. — Inversion of the Bowel Through a Patent Omphalomesenteric Duct Opening on the Side or the

Umbilical Cord. (Redrawn after Gibb.) At a is a hernial dilatation of the cord. This sac was filled with intestines. At 6 is the opening of a patent omphalomesenteric duct. Through this the small bowel had prolapsed, turning inside out. At c and d are the bowel openings. As the bowel had turned inside out, its mucosa was, of course, congested and dark red.


pouring of fecal matter into the abdominal cavity." This was probably true at that date, but Orthf says: "I recently made an autopsy on a new-born child and found a diverticulum split longitudinally below the umbilicus and adherent to the

  • Weiss: Inaug. Diss., Giessen, 1868.

t Orth: Lehrbuch der spec. path. Anatomie, Berlin, 1887, i, 765.


220 THE UMBILICUS AND ITS DISEASES.

anterior abdominal wall in such a manner that meconium could escape into the abdominal cavity. A large quantity of meconium lay between the abdominal wall and the thickened omentum."


LITERATURE CONSULTED ON THE OPENING OF THE PATENT OMPHALOMESENTERIC DUCT ON THE SIDE OF THE UMBILICAL CORD OR IN THE ABDOMINAL CAVITY.

Auvard: Travaux d'obstetrique, 1889, Paris, i, 331.

Brindeau: Nouv. arch, d'obstet. et de gyn., Fevrier 25, 1895, 45.

Gampert: Fistule entero-ombilicale divert iculaire chez un nouveau-ne. Rev. med. de la Suisse romande, 1893, xiii, 356.

Gibb: Unique Congenital Malformation Associated with Umbilical Hernia and a Pendulous Artificial Anus. Trans. Path. Soc. London, 1856, vii, 216.

Guthrie, L. G. : A Case of Patent Meckel's Diverticulum into which the Posterior or Distal Wall of the Ileum became Intussuscepted, forming an Umbilical Tumor. Death. Pediatrics, 1896, ii, 1.

Peake, J.: Case of Preternatural Anus found in a Portion of Ileum protruded at the Umbilicus. Edinburgh Med. and Surg. Jour., 1811, vii, 52.

Weiss, E.: Ueber diverticulare Nabelhernien und die aus ihnen hervorgehenden Nabelfisteln. Inaug. Diss., Giessen, 1868.


A PATENT OMPHALOMESENTERIC DUCT ASSOCIATED WITH DEFECTIVE DEVELOPMENT OF THE RECTUM OR ANUS.

Anderson's patient was a child born at the seventh month. There was no anus, and the rectum and sigmoid were lacking. The omphalomesenteric duct was patent.

Cheyne's patient was a three-weeks -old child. The omphalomesenteric duct was patent. The anus ended in a blind pouch, one inch within the sphincter. The child was still alive when the case was reported to the medical society.

Nicolas's patient was a child six days old. The omphalomesenteric duct was patent. The anus was open, but an obstruction was found several inches above it.

A Case of Fecal Fistula at the Umbilicus with Nondevelopment of the Sigmoid Flexure and Rectum.* — The patient was a male child delivered at the seventh month. After tying and cutting the cord, the physician noticed a red tumor of nevoid aspect at the line of section, and perceived that the proximal end of the cord was considerably enlarged. On the following day meconium escaped from the umbilical stump. There was no trace of an anal orifice. The edges of the umbilical orifice became red and everted. The child lost flesh, and died on the twenty-third day after birth.

At autopsy prolapsus of the ileum through the umbilicus was found. This was 134 inches from the cecum. The short portion of the ileum extending to the cecum was empty. The sigmoid and rectum were wanting.

[The opening undoubtedly represented a patent omphalomesenteric duct.]

A Patent Omphalomesenteric Duct Associated with an Imperforate Rectum. — • Mr. Cheyne f showed an infant, aged three weeks, with congenital umbilical fecal fistula, and asked for suggestions as to treatment. The child was rapidly losing weight. The anus was present, and a sound

  • Anderson, William: Trans. Path. Soc. London, 1891, xlii, 128.

f Cheyne, Watson: Umbilical Fecal Fistula. Brit. Med. Jour., 1892, i, 815.


A PATENT OMPHALOMESENTERIC DUCT. 221

passed in about an inch. The umbilical aperture seemed to lead into a canal. The general impression seemed to be that operative intervention was undesirable.

Patent Omphalomesenteric Duct Associated with an Imperforate Sigmoid. — -Nicolas* (Obs. 12) refers to a boy six days old who was observed in Marjolin's clinic. At birth there was a purulent discharge from the umbilicus, and nothing had passed by bowel. The child had vomited fecal matter several times. On rectal examination the anus was found to be patent, but there was an obstruction at a point several centimeters higher up, so that not even gas could be expelled by the rectum. Two days later an artificial anus was made, but the child died forty-eight hours later.

Autopsy. — -The small bowel was large for so young a child. At a point 80 cm. from the pylorus it was 23^ times the normal in diameter. It suddenly dilated and became 4 to 5 cm. in diameter. Meckel's diverticulum was 3 cm. long.

Had it not been for the open omphalomesenteric duct these children would have succumbed a few days after birth. The open duct was in reality a safety valve. For those desiring a more extended knowledge of the subject of patent omphalomesenteric duct associated with faulty development of the bowel, a careful perusal of Ahlfeld's splendid monograph is to be recommended.

In these cases it would be necessary to establish the continuity of the bowel before attempting to remove the omphalomesenteric duct.

  • Nicolas, P. : Sur deux varietes de fistules ombilicales, Paris, 1883.


LITERATURE CONSULTED ON PATENT OMPHALOMESENTERIC DUCT ASSOCIATED WITH DEFECTIVE DEVELOPMENT OF THE RECTUM OR ANUS.

Anderson, Wm.: A Case of Fecal Fistula at the Umbilicus with Non-development of the Sigmoid

Flexure and Rectum. Trans. Path. Soc. London, 1891, xlii, 128.

Cheyne, Watson: Umbilical Fecal Fistula. Brit, Med. Jour., 1892, i, 815.

Nicolas, P.: Sur deux varietes de fistules ombilicales, Paris, 1883.

Ahlfeld: Zur yEtiologie der Darmdefecte und der. Atresia ani. Arch. f. Gyn., 1873, v, 230.



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.

Historic Disclaimer - information about historic embryology pages 
Mark Hill.jpg
Pages where the terms "Historic Textbook" and "Historic Embryology" appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms and interpretations may not reflect our current scientific understanding.     (More? Embryology History | Historic Embryology Papers)

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