Book - Umbilicus (1916) 12
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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.
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Chapter XII. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct
Prolapsus of the bowel.
Findings at autopsy.
Cases of prolapsus of the bowel through a patent omphalomesenteric duct.
In 1843 King reported an observation made by Parsons and Gunthorpe in which the small bowel had prolapsed through a patent omphalomesenteric duct and was recognized as a sausage-like mass lying on the abdomen in the umbilical region. From time to time since then an isolated case has been observed. We shall now refer briefly to certain conditions which may be found associated with this abnormality.
The Cord. — In some of these cases, when the child is born, the cord near the umbilicus is unusually thick. In one case, reported by Gesenius, this thickened area gave a crackling sensation when it was grasped between the fingers.
Age. — The condition has been noted as early as the third day and as late as six months after birth. In nearly half of the cases it occurred within the first two weeks. In Lowenstein's case the child was three months old; in Helweg's, four months; in Kolbing's, nineteen weeks; in Huttenbrenner's and in Weinlechner's case, five months, and in Blin's case, six months.
Development of the Umbilical Fistula. — In considering these cases we must remember that the omphalomesenteric duct has remained patent from the intestine through the umbilicus, and out for a variable distance into the cord. If it has remained open to the point where the cord has been tied off, of course, a fecal fistula will be present just as soon as the cord drops off. When the fistulous tract is very small, it may be impossible for feces to escape for some days. Should the duct be patent just to the umbilicus, a small umbilical polyp may present itself in the umbilical depression and no fistula will for the time being be noted.
It may be interesting to trace the development of the fistula in the individual cases.
In Barth's case, when the cord came away, there was a red nodule 1 cm. in diameter at the umbilicus, and in the center of this a fistula, into which a probe could be introduced for 4 cm.
In Gesenius's case a small polyp was noted when the cord came away. Next day this showed an opening in its center, and two days later the projection had increased in size and looked like a raspberry. The opening now admitted a catheter for six or seven inches, and feces escaped from it .
In Gevaert's and in Golding-Bird's cases the fistula was noted when the cord came away.
In Basevi's case, when the cord dropped off, it was apparent that the umbilicus had not healed, a reddish, moist wound remaining. Feces did not escape until later.
In Lowenstein's case, after the cord came away, an "inflammation" was noted at the umbilicus. On the fourteenth day a fistula developed. Lowenstein urged operation, which was refused. Later the opening became as large as a 50-pfennig piece, and three weeks after this as large as a plum.
In Arndt's and in Ophuls's case a small umbilical polyp was found in addition to the fistula, and in Blin's case there were two small polyps as well as a minute fistulous opening.
In Theremin's Case 1 the cord came away on the eleventh day. In the center of the umbilical ring was a reddish tumor, conic in form, and resembling an umbilical polyp. There were small ulcers on the surface of the tumor, and on the twenty-third day a superficial hemorrhage occurred.
In Theremin's Case 2 the cord came away on the eighth day, leaving at the umbilicus a conic red polyp, 1.5 cm. long and 1 cm. broad. There was no vestige of an opening. Twelve days later the polyp had receded; it was not over 5 mm. long, but had an ulcer in its center, from which a few drops of blood escaped. On the following day the polyp showed a small central opening.
In Holmes' patient, who was born prematurely, the umbilical cord bifurcated three inches from the abdomen. It was tied off below the bifurcation. A fecal fistula was noted after two weeks.
In the following cases a small reddish tumor had been noted at the umbilicus, but the fistula did not develop until this umbilical polyp had been tied off.
Helweg's patient, a boy four months old, had a penis-like tumor at the umbilicus. This was not present at his birth. It was covered with mucosa, and had in its center a canal into which a sound could be introduced, but no feces escaped from it. The tumor was tied off with silk. It became necrotic in four days; shortly after prolapsus of the bowel was noted.
In King's case an umbilical polyp was removed by means of caustics. When it came away feces escaped.
In Robbing's case a polyp existed at the umbilicus. This was tied off and removed. Later there was prolapsus of the bowel through the patent duct.
From the evidence here adduced it is perfectly clear that in some cases the fecal fistula develops just as soon as the cord comes away. If the opening be of sufficient caliber, feces escape readily, but if very small, only mucus may be discharged for a time. In other cases the outer end of the omphalomesenteric duct has not extended to the point at which the cord has been ligated, but as a result of ulceration or gangrene the intervening barrier may be broken down and the fistula established. In a few cases the removal of the umbilical polyp has been sufficient to establish a patent vitelline duct.
PROLAPSUS OF THE BOWEL.
Inversion of the bowel does not necessarily follow when a patent omphalomesenteric duct exists. This will be clearly seen if the reader refers to Chapter X on Patent Omphalomesenteric Duct (p. 188). In that chapter are recorded a large number of cases in which the bowel manifested no tendency to prolapse.
Several factors are probably necessary to bring about prolapsus: (1) a duct
THE UMBILICUS AND ITS DISEASES.
that is of good caliber throughout, or at least at its intestinal attachment; (2) an excessive amount of abdominal pressure, such as is produced by crying or by the paroxysms of whooping-cough, as was noted in Hiittenbrenner's case, or by the cough of a bronchitis, as was noted in the case recorded by King. Whether a
Fig. 131. — Patent Omphalomesenteric Duct of Large Diameter
The lumen of this duct is directly continuous with that of the small bowel, and at the umbilicus its intestinal lining extends out a short distance upon the surface of the umbilicus. When the lumen of the omphalomesenteric duct is wide, there is always great danger of the bowel prolapsing and turning inside out through the duct, following the direction indicated by the arrows. For the subsequent stages of such a prolapsus see Figs. 132, 133, 134, and 135.
Fig. 133. — Partial Prolapsus of the Small Bowel through the omphalomesenteric duct. The wedge of small bowel has extended partly through the abdominal wall. The loop is now divided into two definite portions, the dilated and proximal, and the contracted and distal portion. The proximal portion is naturally dilated, because there is already a barrier to the adequate escape of the fecal contents. The distal portion is, of course, contracted, because nothing is passing into it. For the subsequent steps of the prolapsus see Figs. 134 and 135.
Fig. 132. — Commencing Prolapsus of Small Bowel through Patent Omphalomesenteric Duct. The lumen of the duct is large, and the small bowel, on its mesenteric side, is forming a wedge, as indicated by the arrow. This wedge will gradually pass out through the duct, as shown in Figs. 133, 134, and 135.
Fig. 134. — Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct. The small bowel has prolapsed still farther through the omphalomesenteric duct. The proximal loop has become more distended, and the distal loop has become contracted still more. The lumina of both loops can be traced out to the surface of the abdomen. The mucosa of the bowel has now extended out so far that it forms a definite, roundish projection, elevated above the surface of the abdomen, and naturally covered over with intestinal mucosa, because it is the inner surface of the small bowel. Between the proximal and distal contracted loops of bowel the peritoneum is carried outward beyond the level of the abdomen, as indicated by x. At this stage only a small amount of fecal matter can escape from the umbilicus, and signs of obstruction will soon develop. For complete prolapsus see Fig. 135.
weakly and emaciated child is more prone to the prolapsus is problematic, as some of the patients were strong, others very frail.
Just prior to the prolapsus some of the children have had stoppage of the bowel for several days. In other cases the first intimation of alarming trouble was the presence of the inverted bowel on the abdomen. A careful study of Figs. 131, 132, 133, 134, 135, and 136 will clearly show the reader the various stages in the
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 225
development of the prolapsus of the bowel through the patent omphalomesenteric duet.
A glance at Fig. 137, p. 227, Fig. 138, p. 228, Fig. 140. p. 230, and Fig. 141, p. 232, will give a very good idea of the prolapsed bowel. Lying on the surface of the abdomen is a red or dark-red, sausage-like mass. This may lie transversely on the abdomen; it may be S-shaped, or appear as two horns forming a semicircle, as in Theremin's Case 1. The mass varies in length from a few inches to one and a half feet, as noted in Violbing's case. As the tumor is nothing more than a portion of the small bowel that has turned inside out through the fistula, its surface consists of intestinal mucosa. At each end is an opening; these represent the upper and
Fig. 135. — Complete Prolapsus of the Bowel through the Patent Omphalomesenteric Duct.
For the early stages of the prolapsus see Figs. 131, 132, 133, and 134. The proximal loop of bowel is now markedly distended, and the distal loop is correspondingly small. Lying on the surface of the abdomen is a sausage-shaped mass. This is naturally reddish or dark red in color, because it is covered over with the mucosa of the small bowel. It has an upper opening corresponding to the lumen of the proximal loop of small bowel, and a lower opening — the lumen of the distal loop of bowel. A loop of small bowel is trying to pass outward in the chink between the proximal and distal loops, as indicated by the arrow. That this can take place is shown in Fig. 136.
Fig. 136. — Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct, and ajn- Umbilical Hernia Between the Loops of Prolapsed Bowel. In order that the reader may satisfactorily unravel this picture, he should consult Figs. 131, 132, 133, 134, and especially 135. The loop of small bowel that in Fig. 135 was near the chink between the distal and proximal loops has now succeeded in passing between them and occupies the cavity (x) noted in that picture. The lumina of the distended and contracted loops are visible, and the now enlarged and rounded mass would give a note of tympany. The interloping loop of bowel, as a result of its constriction, now has a distended and contracted portion.
lower ends of the lumen of the bowel. Usually the openings are very small, but in Weinlechner's case they were large enough to admit the tip of the finger. Where the prolapsus is small, the picture reminds one very much of a prolapsus of the rectum or of an intussusception. The tumor is usually elastic to the touch and tends to bleed on manipulation.
If the child lives long enough, the mucosa covering the prolapsed bowel may become necrotic. The children, however, usually soon go into a state of collapse, and die in from a few hours to two or three days. After the prolapsus has developed, nothing but mucus escapes by the rectum. There is in reality complete obstruction of the bowel, as practically nothing can escape through the constricted abdominal tumor. 16
226 THE UMBILICUS AND ITS DISEASES.
RESULTS. Some of the children were so ill that no operation could be undertaken. Others were operated upon, the abdomen being opened, the bowel drawn back, and the fistula closed. All these died. In only one case have we any record of a success. This was in King's case, in which no operation was undertaken. The bowel was reduced, and the fistula cauterized. Finally it closed. The child died later, probably of pulmonary tuberculosis.
FINDINGS AT AUTOPSY.
In Basevi's case Chiari found a fibrinopurulent exudate at the umbilicus, and a small abscess between intestinal loops.
In Gesenius's case, in which no operation had been performed, the omentum and intestine were adherent near the umbilicus. The intestinal loops were adherent and covered with a reddish exudate.
In Theremin's Case 1, no inflammation existed in the abdomen, but the prolapsed bowel was markedly infiltrated.
The variability in the location of the omphalomesenteric duct was very clearly brought out. In Lowenstein's case it was just above the ileocecal valve; in Gesenius's case the diverticulum was 1 cm. long and 9 inches above the valve; in King's case, 5 inches long and 18 inches above the valve; in Blin's case, 3 to 4 cm. long and 25 cm. above the valve; in Ophiils's case, 35 cm. above the valve, and in Theremin's Case 2, 60 cm. above the ileocecal valve.
A careful study of these cases clearly demonstrates that when the omphalomesenteric duct is patent, the wisest plan is at once to make an incision encircling the umbilicus, draw out the loop of bowel, and treat the fistulous tract as one would an appendix.
Newly born children are only fair risks, yet, on the other hand, if one waits until prolapsus has occurred, death is almost certain, as the child has so little reserve force.
In those cases in which prolapsus has already occurred the same procedure may be adopted, but in such a case, after the fistula has been closed, a loop of bowel just above the attachment of the diverticulum should be drawn out and opened, even if there be a remote possibility of prolapsus occurring through this enterostomy wound. We are all familiar with cases of strangulated hernia in which the bowel has been obstructed for several days. In these, even if the obstruction is relieved, death is liable to follow from the absorption of products of decomposition that have been accumulating in the bowel. The same principle also applies here, and we must allow free drainage of the bowel contents.
CASES OF PROLAPSUS OF THE BOWEL THROUGH A PATENT OMPHALOMESENTERIC DUCT.
Three other cases of prolapsus of the bowel through the vitelline duct, those of Gibb, Guthrie, and Peake, are recorded in Chapter XL
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 227
A Case of Prolapsus of the Small Bowel Through the Patent Omphalomesenteric Duct. — Arndt * reports the case of a boy sixteen days old. The midwife was struck by the thickness of the umbilical cord at the time of labor. The father said that, shortly before admission, when the child vomited, "pus" escaped in a stream from the umbilical region. The child was poorly nourished, and at the umbilicus was a tumor the size of a walnut, reddish in color, which on manipulation bled slightly. It was apparently covered over with mucosa. On the right and also on the left upper portion of the umbilical projection was an opening, into which a sound could be passed for a long distance. From both openings intestinal contents escaped when pressure was made, or if the child cried. Because of the prolapsus a diagnosis of patent omphalomesenteric duct was made. Three days later there was stool by bowel. Five days after admission two tumors could be seen — one was sausage-shaped, the other round. The former was 9 cm. long (Fig. 137). It doubled in length in four days, became S-shaped, and both ends had openings. The opening in the upper end was about the size of a pea; the lower opening was half as large. Pressure on the child's abdomen increased the size of the tumor. The second tumor was situated in the upper margin of the umbilical ring. It was solid and as large as a hazelnut.
At operation Professor Runge found that the tumor with the two openings was an inverted portion of the small bowel that had passed through the patent omphalomesenteric duct. When the bowel was replaced in its normal position, a hollow channel was found passing from the small bowel to the umbilicus. This opening was about the size of a pea. The fistulous tract was removed. The child unfortunately died of peritonitis, as the sutures did not hold properly.
Arndt says: "In this case we have to do with prolapsus of the small bowel through the omphalomesenteric duct." Microscopic examination of
the solid umbilical tumor showed that it was an enteroteratoma (an umbilical polyp).
This case was also reported by Ophlils in his monograph.
Prolapsus of the Small Intestine Through a Patent Omphalomesenteric Duct. — Barth'sf patient was a child, nine days old, who was brought to the clinic on account of a tumor at the umbilicus. The mother said that this tumor was noted immediately after the cord came away: The cord itself did not present anything unusual, so far as the mother or midwife could
Fig. 137. — Prolapse op the Small Bowel through an Open Omphalomesenteric Duct. (After Arndt.)
The sausage-like mass ivas 9 cm. long. It had doubled its length in four days. At both ends were openings. These represented the lumen of the bowel. The smaller, polyp-like mass, seen in the upper part of the picture, was covered with mucosa and attached to the upper part of the umbilical ring. Histologic examination showed that it was covered over with intestinal mucosa. It was a so-called adenoma or umbilical polyp.
- Arndt, C: Ein Fall von Dunndarmprolaps durch den offen gebliebenen Ductus omphaloentericus. Arch. f. Gyn., 1896, lii, 71.
fBarth, A.: Ueber die Inversion des offenen Meekel'schen Divertikels und ihre Complication mit Darmprolaps. Deutsche Zeitschr. f . Chir., 1887, xxvi, 193.
228 THE UMBILICUS AND ITS DISEASES.
tell, but through the opening at the umbilicus fecal matter had been discharging for several days. The bowels in the meantime had moved regularly, and the urination was normal.
The child was a well-formed boy, and apart from the umbilical trouble was apparently normal. At the umbilicus was a tumor about 1 cm. long. This was of a blood-red color, and was covered with injected mucosa. On its surface was an opening. The tumor was 1.5 cm. in breadth and firmly fixed at the umbilicus. A sound could be passed into the canal without difficulty for 4 cm. There was no change noted in the tumor when the child cried. Barth, having seen a similar case in Danzig, came to the conclusion that this was an inversion and prolapsus through a patent Meckel's diverticulum. The small tumor was covered with iodoform gauze, a compression band was applied, and the child was brought to the polyclinic daily. For the next few days there was no change. The child digested well, and there was very little discharge from the umbilicus.
Fig. 13S. — Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct. (After Barth's Fig. 1.
Redrawn by August Horn.)
a is the point at which the bowel has prolapsed and turned inside out through the umbilicus; c and 6 are the points at
which probes could be introduced into the bowel lumen.
Five days later Barth was surprised to see that the small tumor had been transformed into a reddish, sausage-like tumor, as shown in Fig. 138. At the umbilical ring there was now a tumor 2.5 cm. long and 1.75 cm. thick. This was continuous with the sausage-shaped cylindric tumor b-c, which was 7 cm. long and varied from 1 to 1.5 cm. in thickness. The entire tumor, pedicle, and sausagelike mass were dark red and covered over with a slightly hemorrhagic mucosa. At b and c the mucosa was continuous in the openings. The opening (6) led through a canal into the pedicle (a), and through the umbilical ring into the abdominal cavity. From the opening (6) fecal matter escaped. The opening (c) led into a canal toward (b), but nothing came out of it. When a sound was introduced, a wall could be made out between the two openings.
From this description it is seen that there was a prolapsus of the inverted intestine. The child was at once brought to the hospital. His general condition was good. There was no pain, and the child's digestion was good. From the open
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 229
ing yellowish fecal matter escaped. From the rectum nothing but mucus came. Dr. Schmid, who saw the patient, thought of reducing the prolapsus. Just as soon, however, as this was attempted, the child commenced to cry and more loops of the intestine came out at the umbilicus. These were seen to be covered with peritoneum. Other loops now presented themselves (Fig. 139).
Operation. — One of the intestinal loops passed directly into the prolapsed and inverted bowel. When traction was made on it, it could be drawn back. The intestine was supported only by a small pedicle. This was cut and the bowel was reduced. When reduction had been effected, the intestine showed an oval opening 1.5 cm. long. One of the assistants who was holding the intestine tore it, and fecal matter came out. The wound was at once closed with catgut. The diverticulum was removed, and the intestine closed. The child died on the third day after operation. The autopsy showed a small abscess in the upper portion of the abdominal wall and a circumscribed adhesive peritonitis. A short convolution of small intestine had become attached to the abdominal wall.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct.* — -A well-nourished child, twelve days old, came under observation on account of non-healing of the umbilicus. At the umbilicus was a reddish, moist wound. The surrounding tissue was normal. In this case the cord was thicker than usual and had come away on the tenth day. On the nineteenth day, when the child cried, a reddish cone, 4 cm. high, appeared. This showed no opening, and there was stool by the bowel daily. A few nights later the child suffered from discomfort ; the tumor increased in size, gradually became necrotic, and the child died. In this case there were prolapsus and inversion of the small bowel through a patent omphalomesenteric duct (Fig. 140).
On opening the abdomen Dr. Chiari, who made the autopsy, found the small bowel attached to the umbilicus by a fibrmopurulent exudate, and there was an abscess the size of a walnut between intestinal loops.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct, f — A child six months old was brought to the Hotel
Fig. 139. — Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Secondary Complications. (After Barth's Fig. 3. Redrawn by August Horn.) This illustration by Barth is a diagrammatic representation of a hernial protrusion that may be associated with the prolapsed omphalomesenteric duct. & is a proximal portion of the bowel that has prolapsed; c, the distal portion of the loop. The portion lying on the abdomen has turned inside out, and is naturally covered with mucosa. A probe can be readily introduced into the extra-abdominal portion, either from above or from below. At x-y the bowel has been markedly constricted by the abdominal wall. The loop of bowel (d) has prolapsed to a certain extent through a small hernial opening above the omphalomesenteric duct.
- Basevi, Settimio: Jahrb. f. Kinderheilk. u. physische Erziehung, 1878, xii, 275.
fBlin: Diverticulum de l'intestin ileum chez tin enfant de 6 mois; anus contre nature a rombilic, issue d'une anse intestinale par rorifice ombilical; etranglement ; debridement; mort; autopsie. Mem. de la Soc. de biol., Paris, 1853, 1. ser., iv, 131.
THE UMBILICUS AND ITS DISEASES.
- : V
Dieu (Jobert's clinic). At the umbilicus was a cylindric tumor lying transversely on the abdomen. This tumor was reddish brown and was evidently an intestinal loop. Below this were two small elevations, the size of peas. These were not so red as the large tumor; they were resistant on pressure and adherent to the skin.
The mother said that these two small nodules had been noticed since the cord came away, and that below one of the small nodules was a minute opening from which a little fecal matter escaped at first, but later only mucus. Suddenly, on the day of admission, during straining, the tumor noted escaped from the abdomen.
Reduction was impossible. An incision was made in the ring, but the child died in two days.
At autopsy a diverticulum, 3 to / 4 cm. long and of the diameter of a
penholder, was found. This was 25 cm. above the cecum.
Inversion of the Small Bowel Through a Patent Omphalomesenteric Duct.* — The patient was a well-nourished boy. The umbilical cord near the abdomen was thicker than usual, and on pressure a rumbling, crackling sound was heard. The abdominal wall below the cord presented a furrow, as if the muscles had not come together properly. The cord was tied about four inches from the umbilicus, and came away on the ninth day; the umbilicus then appeared to be normal. On separation of the folds, however, a small, red, fleshy wart, resembling an umbilical polyp, was seen. On the following day, instead of the elevation, there was an opening with reddish walls, and two days later, after the child had cried a good deal, a projection the size of a raspberry was noted. This had at its summit an opening which admitted a catheter for from six to seven inches. From this opening a little yellow fluid escaped. The child took the breast well. The urine passed normally, and the stools were regular. About eight days later the child was brought back, but the condition was greatly changed. It was very fretful, and cried continuously. For three days it had had no stool. At the umbilicus was a brownish-red, glistening tumor, which was distended like a sausage. It was three inches long, with blunt ends, and attached to the umbilicus by a sort of pedicle. Its covering was undoubtedly intestinal mucosa, and at either end was an opening into which a sound could be introduced for nearly an inch.
1 i ii ins: Inversion des Dlinndarmes durch ein am Nabcl off en gebliebenes Divertikel. Jonr. f. Kinderkrankh., 1858, xxx, 56.
Fig. 140. — Prolapsus and Inversion op the Intestine through a Patent Omphalomesenteric Duct. (After Basevi.)
A square piece of the anterior abdominal wall, with the umbilical ring in its middle, has been removed. Above and to the left is the cecum, with the valve-like opening passing into the small bowel. On the right is the ileum. The bowel has become inverted through the patent omphalomesenteric duct, forming a somewhat sausage-like mass on the surface of the abdomen. At either end is an intestinal opening. The one on the left shows up clearly.
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 231
Around the so-called pedicle was a reddish ring, firmly fixed and preventing the introduction of a sound at this point. There was evidently a diverticulum with an inversion through it.
The child became more restless, collapsed, and died after forty-eight hours. At autopsy, after the omentum and intestine near the umbilicus had been loosened up, the intestine could be pulled back and there remained a diverticulum, 1 cm. long, 9 inches above the cecum. The intestines around it were stuck together by a reddish exudate. In this case there was a patent omphalomesenteric duct, through which the intestine had prolapsed.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct.* — This child was six weeks old. At the umbilicus was an elongated cylindric tumor, tense and reddish purple in color. It was 12 cm. in length, soft and elastic. In this case, when the cord came away, a fecal fistula existed at the umbilicus. There was an inversion of the intestine through the fistula, like an inversion of the uterus or prolapsus of the bowel through the anus.
Operation. — The bowel was reduced and the fistula closed, but the child died ten hours after operation.
A Case of Intussusception Through a Patent Meckel 's Diverticulum, f — -A male infant, four weeks old, when seen, was almost in collapse. When the cord had separated four days after birth, the stools had begun to pass through the navel. During all this time there was a red lump or projection at the umbilicus, and it was through the end of this that the discharge took place. Twenty-four hours before admission a more pronounced protrusion was observed, and the bowels ceased to move by the rectum, discharging only at the umbilicus, and not through the apex of the projection, but at its base, where it seemed to emerge from the original swelling.
The tumor was elongated and about the size and length of a little finger. It depended from the umbilicus, and was inclined toward the left groin. It was covered with bleeding mucosa. It was firm, and looked like an intussusception. Around its base was a rolled collar or cuff of mucous membrane, out of which emerged the protrusion described. The protrusion was separated from the collar by a sulcus, from one part of which yellow fecal matter exuded. A probe inserted into the apical opening passed in three inches and met with an obstruction. A probe, inserted into the basal groove, whence yellow fecal contents were coming out, passed without obstruction for several inches. There was in this case a prolapsus or intussusception of some of the small bowel through a patent omphalomesenteric duct. The child was too ill for operation and died.
Prolapse of the Bowel Through an Originally Partially Patent Omphalomesenteric Duct.} — A boy, four months old, had a penis-like tumor at the umbilicus. This projection was not present at the time of his birth. It was covered over with mucosa, sharply differentiated from the umbilical skin, and at its end was a canal, into which a sound
- Gevaert, G.: Inversion intestinale a travers 1'onibilic. Chirurgie infantile, Charon et Gevaert, deuxieme edition, Bruxelles, 1895, 251.
t Golding-Bird, C. H.: Clin. Soc. Trans., London, 1896, xxix, 32.
t Hehveg, Kr.: Aabent Diverticulum ilei, Invagination, Prolaps, Inkarceration. Hosp. Tidende, 1884, ii, 705.
THE UMBILICUS AND ITS DISEASES.
could be introduced for one inch beyond the abdominal wall; nothing escaped from the opening. The stools were normal.
The tumor, which was hard at its base, was tied off with a silk ligature. It became necrotic in four days. As a result of violent coughing, prolapse of an S-shaped piece of intestine with a dark-red mucous lining took place (Fig. 141). It was attached to the umbilicus by a short pedicle. The portion of intestine
lying on the abdomen was eight to nine inches long, and as thick as the small intestine of an adult. At both free ends was a canal. After loosening up the tumor at the umbilicus the operator found that two pieces of small bowel had passed out of the umbilical ring into the horns of the prolapsus. After making traction on the intestine he was able to draw back both horns, but there remained an opening in the bowel the size of a mark. This communicated with the umbilicus and was the patent omphalomesenteric duct. The bowel was closed. The child died a few hours later.
At autopsy a beginning peritonitis was found around the umbilical region. The omphalomesenteric duct was 18 inches above the ileocecal valve.
Prolapse of the Bowel Through a Patent Omphalomesenteric Duct. — Holmes* described a specimen that had been sent to him by Dr. H. Whiteman. It was from a male infant which had been born prematurely with a bifurcated cord. The bifurcation began three inches from the abdomen. The cord was tied below it. At the end of two weeks feces were coming from the umbilicus, and the surrounding tissues were inflamed. The intestine rolled out, and, when Holmes saw the patient, a loop was hanging out of the abdomen and feces were coming from it. There was evidently some defect in the closure of the umbilical opening, probably due to a fissured cord, and Holmes thought that the nurse had probably retied the cord after Dr. Whiteman had tied it well away from the abdomen, and that she had tied off the end of the bowel. Attempts were made to push the bowel back in order to use Dupuytren's clamp method. The child did well for several days, but the bowel came out again and death occurred. In this case, until prolapse of the bowel took place, the feces passed by the rectum.
[The history of the case leaves no doubt that a patent omphalomesenteric duct existed and that the nurse was in no way responsible for the injury.]
Fig. 141. — Prolapsus of the Bowel
THROUGH THE PaTEXT OMPHALOMESENTERIC Duct. (After Helweg.)
A boy, four months old, had a definite projection at the umbilicus. This was covered over with mucosa and was sharply differentiated from the abdominal skin. A sound could be passed for a certain distance into the abdomen. The tumor was tied off at its base with a silk ligature. It became necrotic in four days.
As a result of violent coughing an S-shaped piece of intestine with a dark-red mucosa escaped through the umbilical opening. It was attached to the umbilicus by a short pedicle. At each end was a canal. After the tumor had been loosened at the umbilicus, it was found that two pieces of small bowel had passed out of the umbilical ring and terminated in each horn of the prolapsus. In other words, the bowel had turned inside out through the patent omphalomesenteric duct. The child died a few hours after operation.
Holmes, T.: Surgical Treatment of the Diseases of Infancy and Childhood, London, 1868,
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 233
Prolapsus of the Small Bowel Through a Patent Omphalomesenteric Duct.* — A boy, twelve days old, was supposed to have a persistence of Meckel's diverticulum. The midwife had tied off the cord well away from the body. When Hue saw the child, there was a sausage-like projection, about the size of an adult's thumb, and about 10 cm. long, lying on the abdomen. It was evidently covered with mucosa, and bore some resemblance to a prolapsed rectum in a child. It was deep red in color, livid, and had two orifices on its surface. The first was situated near the middle of the tumor, and from it gas and partly digested intestinal contents escaped. The second was situated at the end of the tumor, and from this neither gas nor feces came.
For the first three days stools were passed by the rectum. After that nothing escaped by the normal route. An enema of water and milk returned without escaping through either of the abdominal openings.
At autopsy it looked as if there had been a prolapse of Meckel's diverticulum. There was a persistence of the left omphalomesenteric artery. Deve, in the discussion of Hue's case, reported a case in which this also had persisted.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct.- — ■ Hiittenbrennerf saw a child who, as a result of an attack of whooping-cough in the fifth month, had a prolapse of nine inches of bowel from the umbilicus. .The prolapsed portion lay as a transverse tumor on the abdomen, and on each side had an opening. The condition was diagnosed as an invagination of the bowel through a patent omphalomesenteric duct. After removal of the prolapsus death followed as result of pneumonia.
A Patent Omphalomesenteric Duct with Prolapse of the Intestine Through i t . t — A male child was seen on the eighth day. Occupying the umbilicus was a fungoid growth supposed to have been caused by the nurse pulling on the cord and cutting it off too short. The fungus was removed by means of caustics. When it came away, feces escaped. The child was greatly emaciated; it developed a bronchitis, and a piece of bowel four inches long protruded through the umbilicus. During a fit of coughing feces were seen escaping from its open extremity. At the same time feces passed by the bowel. The wound was closed by cicatrization in about a year, but the child died a little later on, probably of tuberculosis.
Autopsy. — The diverticulum, which was five inches long, was found 18 inches above the cecum, and extended from the convexity of the ileum to the umbilicus, to which it was firmly attached. The umbilicus itself appeared to be fairly normal. There was in its center an area of granulation the size of a pea.
A Patent Omphalomesenteric Duct with Prolapse of the Bowel Through it.§ — ■ The patient was a boy who had at the umbilicus a reddish tumor the size of a strawberry. This was thought to be telangiectatic, and was accordingly tied off and removed. Kolbing saw the child when nineteen weeks old. Projecting through the umbilicus was a piece of red and distended intestine. The child was operated on at once, but died in thirteen hours. The
- Hue, Francois: Prolapsus ombilical diverticulaire. La Normandie med., 1906, xxi, 162.
t Huttenbrenner, A.: Allgem. Wien. med. Zeitung, 1878, Nr. 23, 225, 235.
t King, T. W.: Guy's Hospital Reports, 1843, 2. ser., i, 467.
§ Kolbing, A. : Beschreibung einer auf dem Nabel eines neugebornen Kindes befindlichen rothlichen Geschwulst, besonders wegen ihrer Folgen merkwiirdig. Neue Zeitschr. f. Geburtsk., 1843, xiv, 443.
234 THE UMBILICUS AND ITS DISEASES.
small intestine had grown to the lower end of the umbilical opening, and through the opening the intestine had inverted.
[Tillmanns said the ease was one of prolapsus in the usual sense, namely, through inversion of the bowel.]
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct.* — A personal communication from Karewski. The patient was a three-months-old boy who was in good health. On the fourteenth day there was "inflammation" of the umbilicus, and a spontaneous opening appeared from which a thin yellow fluid escaped. Dermatitis developed, and on the surface of the prominence of the umbilicus a pea-sized opening was seen. This was lined with a very red mucosa, and from it there escaped a feces-like discharge. Operation was refused. In consequence of ulceration the opening soon became the size of a 50-pfennig piece, and the child grew very weak. In three weeks the opening had increased to the size of a plum. The child cried a good deal and had stoppage of the bowels for several days. Strong pressure was applied to the umbilicus. Finally a prolapsus took place at the umbilicus, and a small piece of bowel, 5 cm. long, came down through the open omphalomesenteric duct. An abdominal incision was made, and the prolapsus was easily reduced. The open omphalomesenteric duct was situated just above the ileocecal valve. It was tied off and removed. The child, however, died twenty-four hours later.
At the present time in such a case an immediate laparotomy would be indicated; the diverticulum should be tied off, the umbilicus" removed, and probably a temporary enterostomy made.
Prolapsus of the Bowel Through an Open Omphalomesenteric Duct. — Ophuls | gives the autopsy report on a three-weeksold boy. The clinical diagnosis was peritonitis following a laparotomy. This operation had been performed on account of prolapsus of the bowel through an open Meckel's diverticulum, 10 to 15 cm. of the bowel having prolapsed. In this case the bowel had been reduced and the diverticulum removed. In the vicinity of the umbilical fistula was a small tumor the size of a hazelnut. It was roundish and firm in consistence, and covered over with mucosa. It was entirely independent of the bowel.
Autopsy showed that the intestinal suture had not held, and that fecal matter had escaped into the general abdominal cavity. The closure in the bowel was found to be 35 cm. above the ileocecal valve, and on the side opposite the mesentery.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct. | — A recently born child showed moisture at the umbilicus, which was found to be unusually prominent and firm. There was a groove in the middle where cicatrization had not occurred. Here there was still moisture, and yellow fluid and gas-bubbles escaped. Siebold thought the condition was due to lack of closure of the vitelline duct. At the end of the third week a small, black, gangrenous area was noted. When the child cried, the small bowel was forced out
- Lowenstein, L.: Der Darmprolaps bei Persistenz des Ductus omphalo-mesentericus mit
Mittheilung eines operativ geheilten Falles. Langenbeck's Arch. f. klin. Chir., 1894-95, xlix, 541.
t Ophuls, W.: Beitrage zur Kenntnis der Divert ikel-Bildungen am Darmkanal. Inaug. Diss., Gottingen, 189."., 36.
i Siebold, quoted by G. Schroder: Uber die Divertikel-Bildungen am Darm-Kanale. Inaug. Diss. (Erlangen), Augsburg, 1854.
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 235
from right to left from the gangrenous opening, forming two horns, like sausageskins filled with air; and when the child cried, both ends lengthened. A small opening was made at the umbilicus, and the intestine reduced. The child died in a few hours. Autopsy revealed a diverticulum three-quarters of an inch in length, which had opened at the umbilicus.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct.* — The patient was a well-developed boy. At birth it was noted that the umbilical cord was remarkably large at its base. It came away on the eleventh day. In the center of the cutaneous umbilical ring was a reddijsh tumor, conic in form, and resembling a fungus of the umbilicus. There were small ulcers on the surface of the tumor, and on the twenty-third day superficial hemorrhage occurred. The small intestine prolapsed through a fistula in the form of two horns, each 5 to 6 cm. in length, which were curved, forming a semicircle. They were covered over with mucous membrane. Attempts at reduction were made, without result. Two days later the child died.
The autopsy showed a true diverticulum of the small intestine adherent to the umbilical ring, and a prolapse of the bowel through it. There was no trace of inflammation of the peritoneum or of the intestine that had remained in the abdomen, but there was marked infiltration of the prolapsed portion of the bowel.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct. f — A boy was born on February 26, 1884, and admitted to the hospital on February 29th. The cord came away on the eighth day, and at the umbilical orifice was a small tumor which resembled a fungus. This was conic, red, and measured 1.5 cm. x 1 cm. At its base there was no vestige of an opening. By March 16th, twelve days after the cord had come away, the fungus had receded somewhat and was not over 5 mm. high, but there was a small ulcer in its center, from which a few drops of clear blood escaped. On the following day, while the bandage was being changed, the child cried, and there emerged from the summit of the tumor a mass resembling granulation. This was covered with mucosa and had a small central opening. On March 21st there was an intestinal prolapsus for a length of 10 cm. The mucosa was red and a yellow mucus escaped from the central opening. Gas and fecal matter also came away when the child cried. The general condition was not satisfactory, and it was impossible to reduce the prolapsus. Later the prolapsus receded in part, leaving a prominence measuring only 5 mm. The child died of gastro-intestinal catarrh on April 29th.
At autopsy there were signs of an acute enteritis with engorgement. The mesenteric glands were tumefied, reddish, and softened. The intestinal prolapsus had been reduced completely. The diverticulum was 60 cm. above the cecum. It was inserted into the umbilical ring. The mucosa reached the umbilical opening. There was atelectasis in the posterior part of both lungs.
Prolapse of the Bowel Through a Patent Omphalomesenteric Duct. J — The patient was a well-formed boy. After the dropping off of the umbilical cord a small, rather prominent, tumor, resembling a wild strawberry, was noted at the umbilicus. The physician raised it and tied it
- Theremin, E.: Sur les fistules entero-ombilicales diverticulaires. Rev. mens. d. mal. de
l'enfance, 1885, 558.
f Theremin: Loc. cit., Case 2. J Violbing: (Quoted by Bureau, op. cit.).
236 THE LTMBILICUS AND ITS DISEASES.
off at its base. When the child was nineteen weeks old there occurred a prolapsus of the intestine 1 % feet in length through the umbilicus. It came out as two cornua ; these were covered with mucosa. Death soon followed. At autopsy a diverticulum was found opening into the bowel.
Prolapse of Intestine Through a Patent Omphalomesenteric Duct.* — J. G., five months old, was admitted to the hospital on March 23, 1873. The umbilicus had been open since birth, and occasionally mucus had escaped, but no feces. During a severe coughing spell the day before his admission a bright-red, two-horned tumor had appeared at the umbilicus. The left horn was 4 cm. long, the right 11 cm. long, with several furrows on its concave side. At the end of each horn was an opening which admitted the tip of a finger. No feces escaped from these openings. The prolapsed tumor was constricted at the umbilicus.
The tumor was dark red, and undoubtedly covered with mucosa. The surface was covered with mucus and bled readily.
The abdomen was markedly distended; the child was very pale and breathed with difficulty. There was no vomiting.
The growth was cut off, a short stump and two lumina being left. The child died thirty hours later.
- Weinlechner: Vorfall des Dtinndarms durch den off en gebliebenen Ductus omphalomesaraicus. Jahr. f . Kinderheilk. u. physische Erziehung, N. F., 1874-75, viii, 55.
LITERATURE CONSULTED ON PROLAPSUS OF THE BOWEL THROUGH A PATENT
OMPHALOMESENTERIC DUCT. Amdt, C: Ein Fall von Dunndarmprolaps durch den off en gebliebenen Ductus omphalo entericus. Arch. f. Gyn., 1896, lii, 71. Barth, A.: Ueber die Inversion des offenen Meckel'schen Divertikels und ihre Complication
mit Darmprolaps. Deutsche Zeitschr. f . Chir., 1887, xxvi, 193. Basevi, Settimio: Jahrb. f. Kinderheilk. u. physische Erziehung, 1878, xii, 275. Blin: Diverticulum de l'intestin ileum chez un enfant de 6 mois; anus contre nature a l'ombilic,
issue d'une anse intestinale par l'orifice ombilical; etranglement; debridement; mort;
autopsie. Mem. de la Soc. de biol., Paris, 1853, 1. ser., iv, 131. Bureau, J. : Prolapsus ombilical du diverticule de Meckel. These de Paris, 1898, No. 257. Gesenius: Inversion des Diinndarmes durch ein am Nabel off en gebliebenes Divertikel. Jour. f.
Kinderkrankh., 1858, xxx, 56. Gevaert, G.: Inversion intestinale a travers l'ombilic. Chirurgie infantile. Charon et Gevaert,
deuxieme edition, Bruxelles, 1895, 251. Golding-Bird, C. H.: A Case of Intussusception through a Patent Meckel's Diverticulum. Clin.
Soc. Trans., London, 1896, xxix, 32. Helweg: Aabent Diverticulum ilei. Invagination, Prolaps, Inkarceration. Hosp. Tidende,
1884, ii, 705. Holmes, T. : Surgical Treatment of the Diseases of Infancy and Childhood, London, 1868, 182. Hue, P>ancois: Prolapsus ombilical diverticulaire. La Normandie med., 1903, xxi, 162. Huttenbrenner, A.: Allgem. Wiener med. Zeitung, 1878, xxiii, 225, 235. King, T. W.: Fseculent Discharge at the Umbilicus From Communication with the Diverticulum
Ilei. Guy's Hospital Reports, 1843, 2. ser., i, 467. Kolbing, A. : Beschreibung einer auf dem Nabel eines neugebornen Kindes befmdlichen rothlichen
( reschwulst, besonders wegen ihrer Folgen merkwurdig. Neue Zeitschr. f. Geburtsk., 1843,
xiv, 443. Lowenstein: Der Darmprolaps bei Persistenz des Ductus omphalo-mesentericus, mit Mittheilung
cine- open-it iv jrr-lieilten Falles. Langenbeck's Arch. f. klin. Chir., 1894-95, xlix, 541.
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 237
Ophuls, W.: Beitrage zur Kenntnis der Divertikelbildungen am Darmkanal. Inaug. Diss.,
Gottingen, 1895, S. 36. Siebold : (Quoted by G. Schroder, tJber die Divertikel-Bildungen am Darm-Kanale. Inaug. Diss.
(Erlangen), Augsburg, 1854.) Theremin: Sur les fistules entero-ombilicales diverticulaircs. Rev. mens. mal. de l'enfance,
1885, 558. Violbing: (Described in Bureau's article, Op. cit.) Weinlechner: Vorfall des Dtinndarms durch den off en gebliebenen Ductus omphalo-mesaraicus.
Jahrb. f . Kinderheilk. u. physische Erziehung, N. F., 1874-75, viii, 55.
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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