Book - Umbilicus (1916) 27
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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 XXVII. Umbilical Hernia
Hernia into the umbilical cord.
Congenital nipping off of an umbilical hernial protrusion.
Small umbilical hernia at birth.
Serous umbilical hernia; report of cases.
Serous umbilical hernia in children.
Escape of serous fluid from the umbilicus in a case of tuberculous peritonitis.
Serous umbilical hernia associated with an ovarian cyst.
A serous umbilical hernia associated with a large cystic myoma and marked abdominal ascites.
Umbilical hernia in the adult; radical cure in a patient weighing 464 pounds.
Cysts of the umbilicus.
Umbilical hernia has been so thoroughly considered in the texi>-books on surgery that I shall here confine myself to a very brief description of the various forms of hernia in this region.
1. Hernia into the umbilical cord.
2. Amniotic hernia.
3. Congenital nipping-off of a hernial protrusion.
4. A small umbilical hernia at birth.
5. Serous umbilical hernia.
6. Umbilical hernia in the adult.
7. Cysts of the umbilicus.
HERNIA INTO THE UMBILICAL CORD.
A reference to the chapter on Embryology (Fig. 8, p. 8; Fig. 10, p. 10; Fig. 11, p. 11, and Fig. 12, p. 12), will show that in the early months of fetal life the greater portion of the small intestine lies in the umbilical cord. This extra-abdominal cavity is called the exoccelomic cavity. The intestine gradually withdraws into the abdomen, and the cavity in the cord becomes obliterated.
In rare instances, however, this opening does not close. In such cases at birth there is a cystic swelling at the fetal end of the cord. The cyst-walls are very thin, consisting, for the most part, of the amnion and of peritoneum; consequently, the intestinal loops within the sac are readily visible.
I shall refer to only three cases of this character — one mentioned by Sheen, one by D'Arcy Power, and the third reported in detail by Reed.
Sheen* mentions the case of a patient seen by Hope at Queen Charlotte's Hospital. At birth there was a hernial protrusion into the cord. It formed a mass the size of a hen's egg. The neck of the sac was covered with skin, and the fundus with the covering of the cord. The umbilical vessels were spread out over the right
- Sheen, William: Some Surgical Aspects of Meckel's Diverticulum. Bristol MedicoChirurg. Jour., 1901, xix, 310.
THE UMBILICUS AND ITS DISEASES.
side of the sac. The sac contained large and small intestine. The small bowel was adherent to the sac, but was separated without difficulty. What appeared to be the vermiform appendix was so intimately fused with the tissues of the umbilical cord that it had to be ligated and cut off. The child recovered.
D'Arcy Power's* patient was a full-term boy. At the fetal end of the umbilical cord was a transparent sac containing several coils of small intestine (Fig. 196). Taxis was employed, but it was found impossible to push the bowel back into the abdomen. The sac was opened, and it was also necessary to cut the umbilical ring. About one foot of small intestine lay in the sac. After the bowel had been returned
Fig. 196. — A Case of Congenital Umbilical Hernia. (D'Arcy Power.) The labor was quite normal. Situated in the cord near the abdomen was a transparent sac containing several coils of small intestine. The cord was ligated and divided and an ineffectual attempt was made to replace the bowel through the umbilical opening. After the application of gentle taxis for ten minutes the umbilical ring was enlarged and a foot of small intestine was then with some difficulty returned into the peritoneal sac. The edges of the ring were subsequently brought together with silver wire. The child died of peritonitis three days later. The tumor appeared to be formed of a dilatation of the covering of the cord, which was fusiform in shape and had the main constituents of the abdominal cord running as a band along its lower border. The wall of the sac consisted of a thin, soft membrane which was so transparent that the coils of intestine could be seen through it. At the apex of the tumor the cord reappeared and had on its under surface a cyst containing viscid fluid.
into the abdomen the hernial ring was closed. The child died of peritonitis on the third day.
Powers said that Scarpa and Sir William Lawrence, in their classic treatises on rupture, have given a complete account of this variety of hernia.
One of the most remarkable cases of this character on record is that furnished by Edward N. Reed,f of Clifton, Ariz. The prompt and efficient manner in which Reed treated his case shows how much can occasionally be accomplished even when the outlook is most unfavorable.
- Power, D'Arcy: A Case of Congenital Umbilical Hernia. Trans. Path. Soc. London, 1888,
t Reed, Edward X.: Infant Disemboweled at Birth — Appendectomy Successful. Jour. Amer. Med. Assoc, July 19, 1913, 199.
UMBILICAL HERNIA. 461
"I was called to attend Senora Y. A., a Mexican woman, in confinement, March 14th. I found that the head of the infant was already free, and with the next pain, a moment later, the trunk was expelled. I was astonished at finding that the whole intestine, both small and large, was outside the abdominal cavity. Examination showed that the bowels had passed along inside the cord for about two inches, at which point the walls of the cord had ruptured, allowing the bowels to escape laterally.
"No preparations for the confinement had been made; the bed was filthily dirty, and the mass of intestines was thickly sprinkled with bits of straw, feathers, crumbs of food, and fecal matter from the mother.
"I had left the bedside of a woman just about to be delivered in order to respond to this call. I hurriedly ligated the cord, delivered the placenta, and wrapping the baby in the cleanest thing I could find, returned to the patient I had left.
"Finishing this case I called my colleague, Dr. T. B. Smith, and we went together to see the disemboweled infant and took it at once to the Arizona Copper Company's Hospital. It was placed on the operating table two hours after birth. By this time the bowels were matted together with fibrinous adhesions, which included many of the particles of debris mentioned above. They were cleansed gently with sponges and warm salt solution, but this cleansing was not very thorough, of course. The appendix, three-fourths of an inch long, seemed to be contused and swollen, and a catgut ligature was thrown around its base and it was then removed. The umbilical opening admitted the tips of two fingers. It was enlarged for half an inch upward and downward, and the cord-bearing edges were trimmed off. The intestines were then replaced, and a hurried closure was made with one layer of buried catgut and one of silkworm-gut.
"The child made an uneventful recovery, save for one small stitch-abscess, and is at this date well and growing normally."
In cases of this character the wisest plan is to do a radical operation at once. If no operation be performed, the cord must be ligated at a point distal to the hernial sac, but even if the intestine can be easily replaced, the thin-walled sac still persists, and, as its walls consist merely of amnion and peritoneum, they are liable to tear and there will then be great danger of peritonitis.
In 1881 Nicaise* referred to the amniotic umbilicus. He said that, according to Widerhofer, it is characterized by an absence of skin around the umbilicus, the defect being replaced by amnion which is reflected upon the abdomen from the cord. In such cases the surrounding abdominal wall is generally intact. The amniotic umbilicus does not usually interfere with the health of the child. In the case mentioned by Nicaise the amniotic disc was gradually replaced by scar tissue and the umbilicus completely closed.
R,unge,f in 1893, when discussing this subject, said that in rare instances there is a preponderance of amnion and a lack of skin at the umbilicus, and that this condition is spoken of as an amniotic umbilicus.
Where an amniotic umbilicus exists, the intra-abdominal pressure naturally tends to produce a hernial protrusion at the navel, particularly if the abdominal skin and underlying muscular walls are lacking over a wide area.
- Nicaise: Ombilic, Diet, encyclopedique des sciences medicales. Paris, 1881, 2. ser., xv, 140.
f Runge, M. : Die Wundinfectionskrankheiten der Neugeborenen. Die Krankheiten der ersten Lebenstage, Stuttgart, 1893, 2. Aufl., 56.
THE UMBILICUS AND ITS DISEASES.
Stewart,* in 1905, reported the case of a well-developed male child with a hernia of the cord the size of a ver}*- large apple. The cord dropped off at the usual time, leaving the sac exposed. The child thrived well. Stewart advised non-interference, but the parents were particularly anxious that something should be clone. Consequently a plastic operation was attempted. The sac contained a portion of the intestine and the whole of the liver so firmly adherent to the apex of the sac that its separation was impossible.
In 1903 Dr. S. E. Sanderson, f of Detroit, saw a new-born babe in whom the anterior abdominal walls had failed to develop. The entire abdominal contents were visible through a thin, transparent covering. The covering, being distended, allowed the abdominal organs to press forward, forming a sort of "total hernia,"
Fig. 197. — An Amniotic Hernia. (Photograph of Dr. H. Wellington Yates' case.) The photograph is of a new-born eight-month child with a large hernial protrusion occupying the greater part of the anterior abdominal wall. The walls of the hernia were composed of a very thin membrane, which was almost transparent and which appeared to consist of amnion and peritoneum. The skin of the abdominal wall extended up the sides of the sac for a very short distance. The sac contained the greater part of the bowel.
while the partly developed abdominal wall, composed of skin, muscle, and peritoneum, was retracted.
When Sanderson first saw the child it was one day old, was strong, in good condition, and seemed to be unaffected by the physical defect. It nursed and cried, as do other new-born babes. The thin abdominal covering had, however, begun to dry, and the intra-abdominal pressure had already produced a marked protrusion. Dr. Sanderson felt that the opportune time for repairing the defect was past, but as a last resort he advised operation. This was performed at the Grace Hospital. Sanderson, after resecting half of the liver, was able to bring the muscles and skin together. The child stood the operation well, but died twenty-four hours later.
As pointed out by Sanderson, the time to operate is immediately after birth,
- Stewart, G. C. : Hernia of the Umbilical Cord. Brit. Med. Jour., 1905, i, 247.
f Personal communication.
UMBILICAL HERNIA. 463
before there is any drying out of the thin membranous covering of the abdominal wall, and before the hernial protrusion has been increased in size by the accumulation of fluid in the stomach. As mentioned above, Sanderson was not called to see this case until twenty-four hours after birth.
In January, 1913, I gave an address in Detroit, on Diseases of the Umbilicus before the Wayne County Medical Society, and shortly afterward received the following letter from Dr. H. Wellington Yates, of that city:
"Detroit, February 1, 1913. "My dear Doctor. A short time ago I reported a case of congenital hernia of the cord in the new-born at the Wayne County Medical Society. I referred in my paper to three other cases which I had previously observed, together with references to those which had been reported in the literature up to that time. After the meeting your brother Ernest asked me if I would not send you a brief review of the cases reported, together with my reprint of 1907. I therefore take pleasure in inclosing these data, together with a copy of the picture of the case in question. I feel fortunate in having had four cases of this type come under my observation, and shall be glad if you can use the picture or case to any advantage.
"H. Wellington Yates."
The picture referred to by Dr. Yates is reproduced in Fig. 197. The child was born on January 11, 1913. It was an eight-month child, weighed six pounds, and was 183^2 inches long. Occupying the greater part of the abdominal wall was a hernial protrusion. This was 14 cm. broad and 17 cm. long. The child was otherwise well formed. Yates says that he was, unfortunately, unable to get an autopsy. The walls of the hernial protrusion were almost transparent, and apparently consisted of merely amnion and peritoneum. At the base the skin was continued for a short distance upon the sac. From what Yates could gather, the larger part of the intestine was in the sac.
It is obvious that in all such cases the only chance of saving the child is by operating immediately after birth.
CONGENITAL NIPPING-OFF OF AN UMBILICAL HERNIAL PROTRUSION.
In our study of the embryology of the umbilical region we have seen that in the early months a large part of the small bowel lies out in the umbilical cord. Later the intestine recedes into the abdomen. The cavity in the cord becomes obliterated and the umbilical ring closes. If for any reason the bowel becomes adherent to the cavity in the cord, it may be impossible for the adherent portion to pass back into the abdomen. If such a condition exists and the umbilical ring closes, we shall have one or more loops of small bowel nipped off and lying on the abdominal wall. Fortunately, such a condition is very rare. That it may occur, however, is clearly shown by instances reported by Kern and Ahlfeld.
Kern* reports an observation made by Meckel. Meckel, in examining a four months' embryo seven inches long, found malformations of the lower extremities and of the heart, and, in addition, noted that the intestine was divided into two halves, which did not communicate with each other. The upper or stomach half consisted of the normal stomach and of 11 inches of intestine. The intestine was
- Kern, Theo.: Leber die Divertikel des Darmkanals. Inaug. Diss., Tubingen, 1874.
THE UMBILICUS AXD ITS DISEASES.
for the most part of normal caliber, but for a space of one inch was dilated to four times the normal diameter. It then gradually became smaller and passed out through the umbilicus. It extended outward on the abdomen one inch, and then contracted down to a very fine thread. This passed over into an equally fine thread, which was continuous with the upper end of the lower portion of the intestinal canal. This is a good example of the nipping-off of the intestine outside the abdomen in early fetal life. In this case the umbilical ring was still open.
Ahlfeld.* in 1872. was asked by a midwife to examine a child with a rather unusual tumor. The child was six hours old, had passed no meconium, and cried constantly. It was well nourished and apparently healthy. At the navel was an
irregular tumor the size of an apple , v \ s (Fig. 198). This tumor was attached
^^y to the umbilicus by a very thin
- jfk. pedicle.
It was clearly evident that the tumor consisted of a nipped-off intestinal convolution. The individual parts of this were firmly adherent to one another as a result of adhesions. The tumor was hard in consistence, and was attached to the umbilicus by a definite pedicle.
The anus was well formed, and a flexible catheter could be passed into the rectum for a considerable distance. The rectum, however, contained no meconium.
The tumor was removed by Professor Crede, and the pedicle was found to be solid. Under the existing circumstances it was deemed advisable to make an artificial anus above the umbilicus, but the child died.
At autopsy it was found that the stomach was in the normal position. The duodenum and jejunum were markedly dilated, while the portion of the intestine between the enterostomy opening and the umbilicus was wide and flat. At a point 1 cm. above the umbilicus the intestine ended blindly, and from there to the umbilical ring there was nothing but a delicate strand of mesentery.
The ascending colon passed toward the pedicle of the tumor and ended blindly at the umbilical ring. The remainder of the bowel to the anus was small and filled with mucus.
The condition was due to the fact that a portion of the intestine lying on the abdomen had been cut off by closure of the umbilical ring.
- Ahlfeld: Zur Aetiologie der Darmdefecte und der Atresia ani. Arch. f. Gyn., 1873, v, 230.
Fig. 19S. — Several Loops of Bowel which Lay Outside the Umbilicus and were Xipped Off Dubixg Fetal Life. The Child Lived a Short Time After Birth. (After Ahlfeld.)
XI:, Umbilical elevation: Vs, umbilical cord; Dnd, small bowel; Died, large bowel; Pv, vermiform appendix. It will be noted that the pedicle of this tumor is very narrow at the umbilicus. It then expands somewhat and again becomes exceedingly narrow. The intestine forming this mass was totally cut off from the portion in the abdominal cavity.
UMBILICAL HERNIA. 465
Fortunately this complication is a great rarity. Should such a condition be noted at birth, immediate operation is indicated. After the umbilical growth has been cut off, the abdomen should be opened and the upper and lower portions of the bowel united by a lateral or end-to-end anastomosis.
SMALL UMBILICAL HERNIA AT BIRTH.
Hernise of this character are relatively common. On referring to Fig. 30 (p. 27) we see the umbilical weak spot. This is usually to the right of the umbilical vein, and above the umbilical arteries. In this connection it will be well for the reader to study the normal appearance of the umbilical ring as viewed from the peritoneal side (p. 39). A careful study of Plate VI will give a clear idea of the various appearances of umbilical herniae.
In the young infant the hernia is usually not over 1 to 2 cm. in diameter, and when an appropriate pad is applied, as a rule, gives rise to little trouble. The hernia tends to diminish gradually in size and may soon disappear. In those cases in which it persists, operation may be deemed advisable. In such cases a small longitudinal incision may be made, the edges of the ring dissected away, and the surfaces carefully approximated. It is often difficult to bring the peritoneum together as a separate layer, on account of its extreme delicacy in the infant.
One of the most ingenious and apparently the safest method of curing umbilical hernia in children is that practised by Nota, of Turin. His method has been clearly described by Brun.
Brun* expatiated on the ease, harmlessness, and effectual outcome of the method which Nota, of Turin, has applied since 1890 to 244 children from two months to nine years old. The earlier the operation, the smaller the hernia and the better the outcome. An elastic cord 30 to 40 cm. long is passed around the base of the hernia with a long curved needle worked through horizontally under the skin. The hernia is then reduced and held in place with the finger, while the elastic cord is drawn tight until the opening is entirely obliterated. The ends of the cord are then held with a clamp and tied with silk close to the skin and cut off, the short ends only being left protruding. The cord is drawn taut by an assistant, while the reduced hernia is controlled by the operator. In the course of a few days the rubber cord gradually cuts through the soft tissue in its grasp, the tissues growing together in its wake and thus solidly closing the opening. After twelve or fifteen days the entire rubber cord comes out through the hole in the skin from which the ends protrude, and a thick, solid cicatrix is left around and on the top of the old hernial opening. The dressings are not disturbed for ten days ; then a new dry dressing is applied, and it is wise to have the child wear a simple cloth binder around the abdomen for two or three months afterward. The elastic cord is sterilized by soaking for an hour in 70 per cent, alcohol containing 1.5 per cent glacial acetic acid. No complications of any kind were ever observed and the abdominal wall gradually becomes smooth and supple. Recurrence was observed in only one case — that of a young infant with a hernia 5 cm. in diameter. The hernia recurred during an attack of coughing, but was radically cured six months later by a repetition of the procedure. General anesthesia is not required for infants; for older children Nota uses a few whiffs of
- Brun: Treatment of Umbilical Hernia. Jour. Amer. Med. Assoc, 1912, October 26,
1578. Abstract from Arch, de medecine des enfants, Paris, Sept., xv, No. 9, 641. 31
466 THE UMBILICUS AND ITS DISEASES.
ethyl chloric!. The child comes to at once after the little operation, which never takes over six minutes, and can be taken home if kept quiet.
SEROUS UMBILICAL HERNIA.
In some instances in which the abdomen contains a large quantity of ascitic fluid, the umbilicus unfolds, as it were, and becomes distended, so as to suggest an umbilical hernia. Indeed, the condition has been termed a serous umbilical hernia. While this unfolding of the umbilicus is not very common, still it is by no means rare. The reason that so little has been written on the subject is evidently due to the fact that the accumulation of ascitic fluid in the umbilical sac has been looked upon as a perfectly natural accompaniment of the abdominal distention associated with a large amount of ascitic fluid.
The chief articles on the subject are those of Catteau (1876), Gauderon (1876), Nicaise (1881), Ledderhose (1890), Gallant (1906). and Perrin (1910). Nicaise referred to cases reported by Brehm. Van Home, Xuck, and Morgagni, and Ledderhose. to one recorded by Pineo-Hyannis.
Catteau examined the umbilicus in 19 cases of ascites, with the following results:
Slight projection of the umbilicus in 11 cases
Unfolding of the umbilicus in 3 cases
True umbilical hernia in 5 cases
Perrin. discussing this subject in 1910, said that in 32 cases of abdominal ascites that he collected, the umbilicus was more or less distended in 9 cases. He also said that Bertrand, in 28 cases of abdominal ascites, had noted umbilical distention in 6 cases. It is thus clearly evident that a serous umbilical hernia is no great rarity.
Clinical Course. — The majority of the patients concerning whom we have records were women between thirty and sixty-five years of age, but the umbilical dilatation may also occur in men. The ascites was usually attributable to chronic nephritis, cirrhosis of the liver, cardiac dilatation, or to a combination of these. When the ascites was first noticed, no change in the umbilicus was detected, but with the gradual abdominal distention alterations in the navel developed.
The Umbilical Tumor. — With increased abdominal tension the umbilicus gradually unfolds and a small hemispheric prominence is noted. This
Plate VI. Umbilical Herxia.
All but the last | No. 11) of the cases of umbilical hernia here depicted were accidental discoveries made during the study of normal umbilici on patients in the hospital wards. The results of this study are pictured on Plates I-IY.
In the fetus and new-born a small hernial protrusion at the upper margin of the umbilicus, or occasionally on the upper right or left, may be regarded as entirely normal. In the erect posture and on straining or coughing this small congenital hernia always becomes more pronounced, and an invisible hernia may thus become demonstrable. There is marked diastasis of the recti muscles in Xos. 1, 2, 3, 6.
The most prominent part of the hernia may contain the umbilical cicatrix (Xos. 1, 3, 6); the usual location is below the hernia. In the course of a few years this scar gradually becomes effaced (No. 3), and may entirely disappear (No. 5). Pregnancy also has a tendency to smooth out the folds of the scar (Xo. 4). Immediately afterbirth the skin over the navel puckers up (No. 9) and remains permanently so in a woman who has had many children (Xo. 7). The herniae in both Xos. 7 and 9 were capable of much distention, but were drawn while devoid of contents. No. 11 represent- a large multilocular hernia filled with adherent masses of omentum. This also was drawn when the patient's abdominal walls were relaxed. For the further appearances in this case see Fig. 203, p. 475, and Fig. 204, p. 476. Xo-. B and 10 are small hernia in the male adult. Xote the faint parumbilical vein coursing over the hernial sac in No. 8. In Xo. 10 the hernia was covered by perfectly white skin. The patient was a very dark-skinned negro, who had leukoplakia over the thighs, genitalia, etc. Thus in this case, there was a white umbilicus in a coal-black negro.
Female, age 58, IWIbe, 7 para Female , age 35 , ^6^+lbs. 5para
468 THE UMBILICUS AND ITS DISEASES.
may be very small, or reach 2 or 3 cm. in diameter. The overhang skin looks normal, and often the sac is seen to contain clear fluid. Sometimes, however, this can be detected only by transmitted light.
As the intra-abdominal pressure continues, the umbilical tumor may become as large as a goose's egg or an orange and may be either hemispheric or lobulated. When the hernia reaches such a size, the overlying skin is usually greatly stretched, and the fluid contents of the sac are easily distinguishable. The fluid from the sac can usually be forced back into the abdomen with or without gurgling, after which the finger can usually make out the sharp, hard margins of the umbilical ring. When the pressure is released, the fluid at once flows back into the sac, producing, as pointed out by Raciborski (Xicaise), a peculiar thrill.
Occasionally, when the sac is small, it may also contain a loop of small intestine, but where the abdominal distention is marked, it contains nothing but the fluid. This is evidently due to the fact that when the abdominal distention is marked, the mesentery of the small bowel is not long enough to allow the intestine to reach the abdominal wall.
As a rule, the serous umbilical hernia is only an incident in the course of the nephritis, cirrhosis, or cardiac disease. Occasionally, however, the local condition may attract some attention. Catteau mentioned a case of Morgagni's in which an umbilical tumor the size of a goose's egg broke, each day discharging limpid fluid. It finally healed. According to Nicaise, rupture of the umbilicus distended by ascitic fluid is very rare, as he knew of only two observations, those of Brehm and Van Home. Ledderhose mentions a case recorded by Pineo-Hyannis, in which the ascitic fluid escaped from the umbilicus and recovery took place.
Perrin reported a case of a man, aged fifty-one, suffering from hepatic cirrhosis. The umbilical sac was as big as an orange. It ruptured on the right side, but cicatrized and the patient was afterward tapped 15 times, an average of 24 pints of ascitic fluid being drawn off.
As a rule, the subsequent history of the patient will depend entirely upon the pathologic lesion responsible for the ascites. In a case reported by Perrin, a woman aged fifty-two had a serous umbilical hernia. This ruptured, the sac remaining open and shrunken. Erysipelas developed around the umbilicus and proved fatal.
Perrin has studied the umbilicus in normal and ascitic subjects and finds that at least three causative factors must be taken into account. In the first place, the umbilical ring varies greatly in diameter. In the second place, the ring is much more readily distended in some cases than in others, as its fibrous and connective tissue may be abundant and firmly welded together or loose in texture; and, finally, the obturator membrane varies greatly in strength.
Cases of Serous Umbilical Hernia.
From the following cases the reader may gather a clear idea of the clinical picture. The small number of cases here recorded is, however, no index of the frequency of serous umbilical hernia.
Prominences at the Umbilicus Associated with Interstitial Nephritis, Cirrhosis of the Liver, and Ascites.* — An alcoholic woman, aged thirty-two, who had interstitial nephritis
- Catteau: De l'ombilic ct de ses modifications dans les cas de distension de l'abdomen.
Thfefde Paris. 1*70, obs. 11, 12, 13.
and cirrhosis of the liver, had also had ascites for four weeks. The umbilicus was hemispheric, transparent, and 3 to 4 cm. in diameter. The finger could be easily introduced into the umbilical ring.
A patient, thirty-one years of age, who was suffering from Bright's disease, had an irregular umbilical tumor, 6 by 4 by 4.5 cm. It was lobulated, and the overlying skin was transparent.
A woman, aged forty-nine, had had marked abdominal enlargement for two months, and for six weeks had had at the umbilicus a tumor 3 cm. in diameter.
An Umbilical Protrusion Due to Abdominal Ascites.- — Gauderon* reports a case coming under Guyot's observation. The patient was a vigorous man, aged thirty-five, who entered Guyot's clinic with definite symptoms of Bright's disease, characterized by albuminuria, edema of the legs and of the abdominal walls, with moderate ascites. The ascites increased. The umbilicus was distended, and on March 12, 1876, an umbilical intestinal hernia developed. The hernia was irreducible, and gurgling could be made out. This man had never had an umbilical hernia before and had never used a bandage.
By April 3d of the same year the intestine had disappeared from the hernial sac and the site was occupied by serous peritoneal fluid. During this period the ascites had increased. The patient left the hospital at his own request on April 20th.
Serous Umbilical Hernia in Children.
Very few cases have been recorded, simply because ascites is much rarer in children than in adults. Were ascites just as frequent in children, we would have a much larger percentage of serous umbilical hernise in the child, as in early life the umbilicus gives way very readily. I shall here give a typical example of an umbilical hernia in an infant :
Baby H. Seen in consultation with Dr. Vogler at the Church Home and Infirmary, Baltimore, November 14, 1910. The child is eight months of age and has marked abdominal distention. Two weeks ago an umbilical hernia developed. The hernial sac is about 2 cm. in diameter and projects at least 1.5 cm. from the abdominal wall (Fig. 199). The skin over the umbilicus shows marked tension and is shiny; and one can detect clear fluid in the hernial sac. On percussion there is a distinct wave of fluctuation throughout the entire abdomen, and there is also much enlargement of the liver. Two or three days ago inguinal hernise developed on both sides. After much consideration it was felt wiser not to let the fluid out for fear that the child might develop a general peritonitis. He was taken home, but notwithstanding the most careful nursing he grew worse. He developed pneumonia about two months after leaving the hospital and died.
- Gauderon: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers rombilic. These de Paris, 1876, No. 148, 51.
Fig. 199.— A Serous Umbilical Hernia.
This represents the abdominal contour in the umbilical region of a child eight months old. The child's liver was markedly enlarged and the abdomen full of ascitic fluid. The umbilicus was unfolded and formed the projection here depicted. The overlying skin was very thin, and the fluid in the umbilical sac could be clearly seen.
470 THE UMBILICUS AND ITS DISEASES.
Escape of Serous Fluid from the Umbilicus in a Case of Tuberculous Peritonitis. Ledderhose* reports an observation by Henoch on an eight-year-old boy. On two occasions, on account of marked ascites, several liters of fluid had been removed by puncture and from time to time clear serum escaped from the distended umbilicus. This flow was followed by a diminution in the abdominal distention. Three months later, as a result of tuberculous meningitis, the child died. At autopsy tuberculosis of the peritoneum was found. In the abdominal cavity at the time of autopsy there were only about 100 c.c. of clear, light yellow fluid.
Serous Umbilical Hernia Associated with an Ovarian Cyst.
We have records of two such cases, those reported by Catteau and Gauderon. If there be ascites associated with an ovarian tumor, the development of serous umbilical hernia is easily explained. It is also easily understandable that if, through injury, rupture of the ovarian cyst occurs, the free ovarian fluid may pass into an umbilical hernia.
An Ovarian Cyst Associated with Umbilical Swelling. — Catteau, in Case 16, refers to a woman forty-five years of age, who had had an ovarian cyst for ten years. After falling on her back she vomited, and a tumor was noted at the umbilicus. Two months later there was an escape of fluid through an umbilical opening.
A Serous Umbilical Hernia Associated with an Ovarian Cyst.j — This case was communicated to Gauderon by his friend Dussaussay: Catherine S., aged sixty-five, entered the service of Dr. Millard, April 21, 1876. On admission she was found to have an enormous abdominal tumor, which had first been noticed six years previously and diagnosed as an ovarian cyst. It was complicated by the presence of ascitic fluid. When the patient entered the hospital there was a hemispheric tumor at the umbilicus. It was fluctuant and reducible without gurgling. After reduction the finger met with a hard umbilical ring. The tumor was supposed to be a serous hernia complicating ascites. The patient said that this small tumor had existed for more than a year. Several days later she developed peritonitis and died on May 2, 1876.
Autopsy revealed a multilocular ovarian cyst on the left side. There were traces of peritonitis. At the umbilicus there was a true serous hernia. The umbilicus was distended in the form of a hernia the size of a large walnut, and the hernial sac was lined with peritoneum. The umbilical ring itself was 1 cm. in diameter. The peritoneum of the sac was whitish and opalescent.
A Serous Umbilical Hernia Associated with a Large Cystic Myoma and Marked
While preparing this chapter the following case came under my care at the Johns Hopkins Hospital:
Gyn. No. 18101, Gen. No. 81548. E. G., colored, aged thirty-four, was admitted fco Ward January 16, 1912, complaining of abdominal distention and shortness of breath. She has always enjoyed good health previous to the present illness. During the last winter she has had several colds, which were accompanied by persistent cough and some expectoration. Since September, 1911, the patient has had periods of suppression of urine, which have lasted for twenty-four hours, and for
- Ledderhose: Deutsche Chirurgie, 1890, Lief. 45 b. t Gauderon: Op. cit., obs. 15.
UMBILICAL HERNIA. 471
the last four months there has been marked constipation. EleveD months ago the patient noticed that her abdomen was increasing in size. It has steadily grown larger, and she suffers a good deal from dyspnea. The limbs have become so swollen lately that whenever the patient has had to get into bed she has been obliged to have some one lift her legs for her. She has had very little abdominal pain, her main complaint being shortness of breath and abdominal swelling.
Present Condition. — The patient is a sparely nourished, rather emaciated negress. She has some trouble with dyspnea and reclines in bed on several pillows. The abdomen is markedly distended and there is an umbilical hernia. The abdomen is full and somewhat rounded. The distention extends from the xiphoid to the symphj'sis. There is a definite bowing of the xiphoid cartilage. It is pressed almost at right angles to the sternum. No masses are to be made out in the abdomen on deep palpation. There is considerable edema throughout the lower half of the abdomen and marked pitting on pressure. A definite fluctuation wave is made out. With the patient in the dorsal position, the dulness extends to either flank.
Operation. — Abdominal hysteromyomectomy, January 17, 1912.
The umbilicus was dilated, forming a hernia about 2 cm. in diameter. The walls here were very thin, and the sac, which was evidently filled with fluid, projected as a little dome about 2 cm. from the surface of the abdomen. I picked up the hernial sac on either side with forceps and opened it. A rubber hose was firmly pressed over the opening, and we removed over 17 liters of ascitic fluid from the general abdominal cavity. The incision was then increased in size, and I saw what appeared to be an ovarian cyst, with a small opening in it. I hooked my finger into this and raised it up still more. On getting it out I was surprised to find that, instead of an ovarian cyst, we had a cystic myoma, which projected from the posterior surface of a myomatous uterus. A supravaginal hysterectomy was done, and the abdomen closed without drainage. Convalescence was uneventful.
Path Xo. 16947. The multinodular myomatous uterus is approximately 12 cm. long, 10 cm. broad, 10 cm. in its anteroposterior diameter. The uterus contains numerous subperitoneal and interstitial nodules. Projecting from the fundus is a cystic nodule, approximately 14 cm. in diameter. At its upper end is a small hole from which serous fluid oozes. The tumor on section is found to be partly cystic, partly solid. There are numerous loculi which open into one another, and there are bands of tissue running from side to side in the main cyst. The right tube is the seat of a hydrosalpinx, and the entire mass is enveloped in adhesions. On the left side the tube is 9 cm. long and has been converted into a hydrosalpinx.
UMBILICAL HERNIA IN THE ADULT.
For a general consideration of this subject the reader is referred to the textbooks on surgery. I shall mention only the salient facts and refer to certain points that have particularly impressed me.
Umbilical hernia in the adult seems to be much more prevalent in the female than in the male, and not infrequently is noted after the abdominal distention consequent to pregnancy. It is more common in stout women than in thin persons. This is probable partly due to the fact that, when individuals take on adipose tissue externally, there is a coincident increase in the amount of fat in the omentum and mesentery, and therefore an increased tension on the abdominal wall.
THE UMBILICUS AND ITS DISEASES.
With the increase of adipose tissue there is an increased tendency toward a pendulous condition of the abdomen. If the umbilical hernia is small and can be readily reduced, the patient often experiences little or no discomfort. In those cases in which the hernia reaches a diameter of 3 to 4 cm., when the omentum is adherent
Fig. 200. — Freeing the Umbilical Hernial Sac From the Abdomen. (Head of Patient Below, Stmphysis
Above.) In this case an elliptic abdominal incision has been made around the hernia from above downward, and the adipose tissue has been reflected back on either side until the neck of the sac and the surrounding abdominal fascia are clearly exposed. In those cases in which there is much redundancy and it is deemed advisable to remove a large area of adipose tissue, the skin incisions should be from side to side. When the neck of the sac is well exposed, the fascia is cut through just above the sac, — above, because there are few if any adhesions at this point, — and a finger is introduced as indicated. With the finger as a guide the sac is cut free all the way around. The hernial mass is now isolated, and can be lifted well away from the abdominal wall and then walled off with gauze. The sac is now slit open from neck to base. If it contains intestinal loops, these are liberated and returned into the abdomen. Where the omentum is very loosely attached, it is also liberated and returned to the abdominal cavity, but when it is densely adherent, the extra-abdominal portion is tied off and removed with the sac. For the closure of the hernial opening see Figs. 201 and 202.
and the abdomen is pendulous, the patient experiences a dragging sensation if on her feet much. This is evidently due to tension on the transverse colon.
When a small umbilical hernia exists, the fat lobules occasionally present in the ring may increase in volume, thereby stretching the ring.
When the omentum has been incarcerated for a considerable time, there may be edema of the surrounding abdominal wall and a tendency for the more prominent parts of the hernia to become excoriated.
Fig. 201. — Clostjke of the Hernial Opening at the Umbilicus. A row of mattress sutures consisting of kangaroo tendon, chromicized catgut, or silk, as the operator may prefer, are so placed that the lower flap a is drawn well up under the upper flap 6. Before tying these the second row of mattress sutures is passed through the lower flap a. They are inserted now because, with the abdomen opened, one can take a much deeper bite, the finger serving as a guide to the depth of their insertion. When they are placed after the first row has been tied, the operator rarely grasps enough tissue, as he is afraid of piercing the underlying intestine. After the first row of mattress sutures has been tied, the ends of the second row of sutures are passed through the edge of the upper flap and tied. Needles have been placed on the ends of each of these sutures to facilitate the understanding of the procedure. In actual practice each pair of suture ends is temporarily clamped with forceps and rethreaded after the first row has been tied. (For the appearance of the ring when closed see Fig. 202.)
It is in the small hernia? that a knuckle of gut is liable to become incarcerated, and the patient then speedily develops the characteristic symptoms of a partial or complete intestinal obstruction.
Treatment. — Given a thin patient, the operation is usually easy. Unfortunately, however, the majority of these patients are stout, many of them quite
THE UMBILICUS AND ITS DISEASES.
obese, and show a marked tendency toward emphysema. Such patients are prone to develop postoperative lung complications, and this danger should be thoroughly considered before any operative interference is undertaken. I invariably follow the postoperative course of such a case for several days with some concern. The preparatory treatment of these cases has recently been admirably outlined by Alexius McGlannan (Proc. Southern Surg, and Gyn. Assoc, 1914, xxvii, 311).
The radical operation for umbilical hernia may be a most difficult procedure or a relatively simple operation, depending in large measure on the manner in which it is performed. So far as my personal experience goes, it is wise to make an elliptic incision from above downward or from side to side. A wide area is usually outlined and freed down to the fascia. The hernia and the flap of fat are dissected free until the neck of the sac stands out clearly on all sides. A small incision is then made
Fig. 202. — Closure of the Hernial Opening at the Umbilicus. For the first steps in the closure see Fig. 201. The first row of sutures has been tied, and the second row is nearly
through the fascia of the abdominal wall, at a point just above the sac — above, because the omentum is here usually free from adhesions. The opening in the abdomen should be just large enough to admit the finger. After the finger has been introduced, it acts as a guide, and the operator cuts down on it, severing the sac all the way round just at its point of attachment to the abdominal wall (Fig. 200).
When the neck of the sac has been cut loose, the hernia can be lifted out and laid on a large piece of gauze. After seeing that no intestinal loops are incarcerated in the hernia, the operator now slits up the wall of the sac to see if the omentum can be saved. Sometimes this is possible; in other cases, however, the omentum is so densely adherent to the sac that it must be removed with the sac.
Unless one has carefully dissected a series of large umbilical hernise, he has little idea of the many alcoves and channels running off from the main cavity (Fig. 204). After the omentum has been replaced or tied off, as the case may be, the peri
toneum is closed and the fascia overlapped from above downward, as advocated by Dr. Win. J. Mayo, Dr. Charles P. Xoble, and others. The fascia from the lower part of the abdominal ring is drawn up in under the fascia of the upper wall (Fig. 201). Two rows of mattress sutures in the fascia usually suffice to give a permanent cure (Fig. 202). The fat and skin are then approximated. It would be im
Fig. 203. — Ax Umbilical Herxia Associated with Marked Prolapsus of the Abdominal Wall.
The umbilical hernia was about 10 cm. in diameter. The elliptic transverse incision is indicated by the black line. The
lower figure indicates the shape and size of the piece of adipose tissue removed.
possible to lay too much stress on the importance of freeing the neck of the sac from the abdominal wall before attempting to unravel the sac-contents, and upon the ease with which this can be accomplished by using the finger in the abdomen as a guide in its liberation. I have used this method for years, and found it particularly useful in the following case:
THE UMBILICUS AND ITS DISEASES.
Mrs. C. J., aged thirty-five, admitted to the Church Home and Infirmary on February 11, 1914. This patient has had five children, the youngest being
Fig. 204. — An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds. This is a sketchy outline of the condition found. With the patient standing, the dependent portion of the abdomen reached the knees. As the omentum was adherent to the hernial sac, the transverse colon was markedly drawn downward. The dotted line indicates the line of dissection, the fat of the abdominal wall being removed down to the fascia. The hernial sac was divided into numerous secondary cavities. This is particularly well seen in the upper sketch, which was drawn from the hernial sac after removal.
eight months old. At the time of her marriage she weighed 225 pounds. Her weight today is 464 pounds. She complains of an umbilical hernia which is about 10 cm. in diameter. When on her feet, the abdomen hangs down to her knees.
The dragging sensation caused thereby is so great that she is forced to keep off her feet as much as possible. I was unwilling to operate, and explained the danger to her husband. The patient, who is still a relatively young woman, said that she was becoming a semi-invalid and insisted that she be relieved.
Operation. — February 12, 1914. On account of the marked redundancy of the abdominal wall, we decided to relieve her of a large quantity of fat, together with the hernia, as advocated by Dr. Howard A. Kelly. Accordingly, a large transverse elliptic area was outlined (Fig. 203). This area, when measured on removal, was 36 inches from side to side and 19 inches from above downward. The adipose tissue of the huge flap was dissected from the fascia of the abdominal wall all around as far
Fig. 205. — The Abdominal Scar After the Removal of a Vert Large Area of Fat. The abdominal wound gave a transverse measure of 36 inches. After the wound had healed, the scar had contracted down to 27 inches. Note the size of the patient relative to that of the bed. This was of the three-quarter size, the ordinary hospital bed being too small for the patient.
as the neck of the hernia. Then, with a finger in the abdomen as a guide, the neck of the sac was cut all around at its margin with the abdominal wall. The dotted line in Fig. 204 indicates the line of the dissection. The omentum in the sac was so intimately blended with the walls of the sac that this portion of the omentum was cut off and removed with the sac and redundant tissue. Max Brodel, in the upper sketch in Fig. 204, has clearly shown the neck of the sac and the numerous chambers passing off from it. The hernial opening was closed by the Mayo method — by sliding the fascia of the lower margin of the opening up under that of the upper margin. We used kangaroo tendon for the mattress sutures, and after the first row had been placed and tied, the edges of the upper flap were fastened down with
478 THE UMBILICUS AND ITS DISEASES.
a second row of mattress sutures. The abdominal wound was now approximated with interrupted silver-wire and silkworm-gut sutures. Each suture included the skin, fat, and a little of the fascia. Accurate skin approximation was obtained by using continuous black silk. At each end of the incision a protective drain was introduced.
The patient made a speedy recovery, and the abdominal wound healed perfectly. When the stitches were removed, the abdominal incision had contracted down until it measured only 27 inches from side to side (Fig. 205). Eight months later the patient was in excellent health.
Hernije Through Weak Spots in the Abdominal Wall. Where the hernia develops from a weak spot near the umbilicus it closely resembles an umbilical hernia, and clinically may be considered as such. This subject is discussed in detail on p. 55.
Fig. 206. — An Umbilical Ctst. (After Gallant.) A Scotch terrier developed a small umbilical hernia when about four months old. It enlarged so that the dog had to drag itself about on the floor. The cyst became larger and somewhat inflamed. The skin grew so thin that the fluid could be seen in the center. The ring had evidently contracted down on the omentum, and the peritoneal fluid had accumulated.
CYSTS OF THE UMBILICUS.
When an umbilical hernia exists, as a matter of course the peritoneum is carried ahead of the hernial mass and hence lines the hernial sac. If by any chance the hernial sac becomes completely separated from the abdominal cavity, peritoneal fluid may accumulate in this sac, producing a cystic tumor. Gallant and Walz report cases clearly demonstrating such a phenomenon. Gallant's* subject was a Scotch terrier that developed a small umbilical tumor when four months old. The hernia enlarged, and the puppy had to drag himself about the floor on his abdomen. The cystic mass increased in size and became somewhat inflamed. The skin covering it grew so thin that the fluid in the sac could be readily seen. At operation the condition depicted in Fig. 206 was found. Firmly plugging the hernial ring was a small piece of omentum, and the peritoneal lining had doubtless secreted the fluid found in the sac.
Walz,f on January 6, 1902, saw a gunmaker, aged fifty-one, lying in bed com
- Gallant: Disorders of the Umbilicus with Special Reference to the New-born and the
Infant; III Umbilical Infections. Internat. Clinics, 1907, 17. series, i, 1.51.
t Walz, Karl: Ein Beitrag zur Kenntnis der Nabelcysten. Munch, med. Wochenschr., 1902, xlix, 959.
UMBILICAL HERNIA. 479
plaining of pain in the umbilical region and of diarrhea. For several years the patient had noticed a tumor the size of a walnut at the umbilicus. This could be readily pressed back, but coughing caused it to reappear. For twenty-four hours the patient had had increasing pain at the umbilicus, and the tumor had rapidly increased in size and could not be reduced. Since that time there had been diarrhea, but no vomiting. His temperature was 37.6° C; pulse 90 and regular. In the umbilical region was a half-ball-shaped tumor, the size of a hen's egg, directly to the left of the umbilicus. It overlapped and covered the umbilicus. The overlying skin was movable and somewhat reddened.
Walz thought that the nodule was due to incarcerated omentum. At operation it was found to contain clear serous fluid supposed to be peritoneal fluid. After the fluid had escaped, the cavity was found to be empty. The walls were 0.5 to 1 mm. thick, and the sac ended in a pedicle the thickness of a lead-pencil, which passed into the umbilical ring. There was no opening into the abdomen. The sac was tied off and removed, and the patient made a good recovery.
Microscopic examination of the sac shows that it was composed of fibrous tissue with an inner wall of granulation tissue ; there were a few polymorphonuclear leukocytes, and no evidence of epithelium. Walz thought it possible that a hernial sac had been nipped off from the abdomen as a result of an inflammatory process, and that the fluid had accumulated. This seems to be the correct interpretation'.
These two cases clearly demonstrate how small umbilical cysts may be the endresult of old hernise.
Caruso* reports an instance of an umbilical cyst the size of a chestnut, in a woman forty-two years of age. On histologic examination it was found to be lined partly with cuboid, partly with low cylindric epithelium. He called it a cystic adenoma. Without seeing the specimen I should hesitate to classify it, but we know that the cells covering the peritoneal surface, when protected, frequently become cuboid.
Ledderhose,f in his masterly article on surgical diseases of the umbilicus, refers to the scanty mention of umbilical cysts. He then describes Lotzbeck's case, in which a multilocular tumor the size of a fist was removed by Brun from the umbilicus in a child two and one-half years old. It was noticed immediately after the birth, and at that time was the size of a walnut. It contained partly clear, amberyellow, somewhat alkaline fluid, partly a thick, honey-brown, gelatinous substance. The tumor lay between the skin and the rectus. The connective-tissue wall of the cyst contained small, thread-like, cartilaginous deposits, and the cyst was lined with simple squamous epithelium. The cyst fluid contained fat, cholesterin, and numerous cells. The possibility that this was a dermoid cyst must not be overlooked.
For umbilical cysts of urachal origin see pages 526 and 539.
Co5'me,± in 1909, reported a case that hardly belongs to the solid umbilical tumors, and yet, on the other hand, cannot be considered as a simple umbilical cyst.
- Caruso, F.: Contributo alio studio anatomo-patologico dei tumori cistici dell' ombelico.
Atti della Soc. Italiana di Ost. e Gin., 1901, viii, 293.
fLedderhose: Chirurgische Erkrankungen des Xabels. Deutsche Chirurgie, 1890, Lief. 45 b.
i Coj'-ne: Tumeur congenitale de l'ombilic developpee dans un vestige de la vesicule allantoidienne. Comptes rend, nebdom. des seances et Mem. de la Soc. de biol., Paris, 1909, lxvii, 383.
480 THE UMBILICUS AND ITS DISEASES.
Coyne's tumor was from a woman who had noticed it for sixteen months. She had always had some abnormality at the umbilicus. The mass was the size of an adult's head and was pedunculated. It was 20 cm. in diameter. On section it was found to contain arteries and veins in a reticulated tissue. There was one large cavity with three or four secondary cavities opening into it. These contained vegetations.
The cavities were lined with cylindric epithelium, and the vegetation was covered with cylindric epithelium. In the pedicle was found the fibrous tissue characteristic of the urachus. In the center were vestiges of the allantois. These portions of the allantois had undergone colloid cystic transformation and had been the point of departure for this cystic tumor.
Whether Coyne was right in his assumption I am not in a position to judge.
LITERATURE CONSULTED ON UMBILICAL HERNIA. Ahlfeld: Zur Aetiologie der Darmdefecte und der Atresia ani. Arch. f. Gyn., 1873, v, 230. Brun: Treatment of Umbilical Hernia. Jour. Amer. Med. Assoc, October 26, 1912, 1578. Abstract from Arch, de medecine des enfants, Paris, Sept., xv, No. 9, 641. Caruso, F. : Contribute alio studio anatomo-patologico dei tumori cistici dell' ombelico. Atti della
Soc. Italiana di Ost. e Gin., 1901, viii, 293. Catteau, J. F.: De l'ombilic et de ses modifications dans les cas de distension de l'abdomen.
These de Paris, 1876, obs. 11, 12, 13. Coyne: Tumeur congenitale de 1'ombilic developpee dans un vestige de la vesicule allanto'idienne.
Comptes rend, hebdom. des seances et Mem. de la Soc. de biol., Paris, 1909, lxvii, 383. Gallant, A. E. : Disorders of the Umbilicus with Special Reference to the New-born and the Infant ;
II; Umbilical Fistulas, Sinuses, and Cysts. International Clinics, 1906, 16. series, iii, 218.
See also International Clinics, 1907, 17. series, i, 151. Gauderon: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et
par evacuation du pus a travers l'ombilic These de Paris, 1876, No. 148. Kern, Theo.: Ueber die Divertikel des Darmkanals. Inaug. Diss., Tubingen, 1874. Ledderhose: Deutsche Chirurgie, 1890, Lief. 45 b.
Nicaise: Ombilic. Diet, encyclopedique des sci. med., Paris, 1881, 2. ser., xv, 140. Perrin, Maurice: Brit. Med. Jour., April 9, 1910. Epitome of Current Med. Lit., 58. Power, D'Arcy: A Case of Congenital Umbilical Hernia. Trans. Path. Soc, London, 1888,
xxxix, 108. Reed, Edward N.: Infant Disemboweled at Birth — Appendectomy Successful. Jour. Amer.
Med. Assoc, July 19, 1913, 199. Runge, M.: Die Wundinfectionskrankheiten der Neugeborenen. Die Krankheiten der ersten
Lebenstage, Stuttgart, 1893, 2. Aufl., 56. Sanderson, S. E.: Personal communication. Sheen, William: Some Surgical Aspects of Meckel's Diverticulum. Bristol Medico-Chirurg.
Jour., 1901, xix, 310. Stewart, G. C: Hernia of the Umbilical Cord. Brit. Med. Jour., 1905, i, 247. Wak, Karl: Ein Beitrag zur Kenntnis der Nabelcysten. Mtinch. med. Wochenschr., 1902,
xlix, 959. Yates, H. Wellington: Personal communication.
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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