TWO CASES OF CONGENITAL UMBILICAL HERNIA INTO 
THE CORD; OPERATION; RECOVERY. 
BY 
J. COLLINS WARREN, M.D., 
BOSTON, MASS. 
Reprinted from the 
Transactions of the American Surgical Association, i8gj. TWO CASES OF CONGENITAL UMBILICAL HERNIA 
INTO THE CORD; OPERATION; RECOVERY. 
By J. COLLINS WARREN, M.D., 
BOSTON. 
The two following cases are reported not only on account 
of their great rarity, but also to illustrate how conditions which 
in former times would have been considered almost hopeless, 
can now be dealt with successfully. 
Case I. Hernia of the Liver.—The parents of the father, as well 
as the father himself, are living and in good health. The mother is 
well but not robust. Her mother is living, but father died of con- 
sumption. She was married five years ago. Her first child was born 
three years ago, but died at the age of four months, of cholera infantum. 
It had no deformity and was in previous good health. 
The second child was born November 14, 1892. Labor began at 
6 p.m. of the 13th, and was completed at 10 a.m., and was normal in 
every respect. Dr. G. W. Nickerson, of Stoneham, Mass., who was 
her physician, states that he was surprised to see, after birth of head 
and shoulders, a tense, bladder-like tumor come popping out, after 
which followed the lower extremities. He states : “ I was puzzled at first 
to make out what it was, but seeing that it was covered by an expan- 
sion of the umbilical cord, concluded it must be a hernia.” The child 
was sent that afternoon to the hospital and was operated upon by me 
the next morning when it was about twenty-four hours old. On 
inspection the child was otherwise well formed, but thin and with a 
somewhat wrinkled face. It did not look strong. At the umbilicus 
was seen the cord, which was greatly distended at its point of insertion 
into the abdomen, forming a tumor about 6*4 cm. in diameter. The 
coverings of the cord were inserted into a raised rim of skin and were 2 
WARREN, 
opaque, so that the contents of the hernia could not be determined. 
(Fig- i.) 
There was also a moderately-sized right inguinal hernia. 
The child was etherized, and a hasty attempt having been made to 
render the field of operation aseptic, the sac was opened and was found 
to contain the liver, which seemed to be situated wholly external to 
the abdominal cavity. It was with some difficulty that the myxoma- 
tous tissue of the cord was separated from the surface of the liver, as 
it appeared to be adherent in several places. The umbilical vein and 
the two hypogastric arteries having been tied and cut, the cord was 
removed. The umbilical ring was slightly enlarged by an incision, 
and with some manipulation the liver was finally pushed through the 
opening into the abdominal cavity. A small amount of ascitic fluid 
escaped when the sac was first opened. The separation of adhesions 
from the liver caused a slight hemorrhage, which was checked by pres- 
sure. The wound was brought together by four or five strong silk 
stitches. The infant suffered somewhat from shock. There was, how- 
ever, no sign of peritonitis after the operation, and it took its nourish- 
ment well during convalescence. The food consisted of a mixture of 
cream and water. 
The stitches ulcerated somewhat, and were removed during the first 
week, in consequence of which the edges of the wound separated at 
one point and the liver could be seen. The edges were, however, 
approximated by crepe lisse and collodion, and the wound had healed 
at the end of two weeks, when the baby was taken home to be nursed 
by its mother.' 
The child has done well since, and at the time the second 
photograph was taken it was about four months old. (Fig. 2.) 
There is evidently an umbilical hernia, which is supported by 
an umbilical pad. The child is a sufferer from eczema, but 
otherwise enjoys excellent health, and has developed rapidly. 
Case II. Hernia of the Intestines.—The parents of this child are 
both healthy, and there is no family history of congenital deformity. 
The mother was a primipara, but had had one miscarriage. The labor 
was normal, lasting about seven hours. I was called immediately to 
see the case by Dr. W. L. Richardson. On inspection the child ap- 
peared to be well developed in other respects and weighed about eight 
pounds. The cord was enormously distended for about five inches Fig. i 
Case I CONGENITAL UMBILICAL HERNIA INTO THE CORD. 
from the navel and formed a large pear-shaped swelling. The tissue was 
perfectly transparent, and it was at once seen that the contents con- 
sisted of the greater portion of the intestinal canal. Near the apex of 
the hernial enlargement of the cord several loops of intestines had 
apparently pushed their way through the coverings of the hernia and 
were directly exposed to the air. 
An operation was performed for the reduction of the hernia when 
the baby was three hours old. The cord had, in the meantime, been 
protected by a towel wet in a weak sublimate solution. The myxoma- 
tous tissue was dissected off from the intestines with considerable 
difficulty, as it was everywhere adherent, and at one or two points the 
outer coat of the intestine was torn, so that there was considerable 
oozing during these manipulations. The intestines from the neigh- 
borhood of the duodenum to the descending colon were finally re- 
placed within the abdomen. A hasty examination showed the mesen- 
tery to be much elongated. Fortunately the coils of intestines were 
not distended. To my surprise the abdomen seemed capable of con- 
taining them without undue distention. The skin of the abdominal 
wall was reflected on to the neck of the hernia for some little distance 
by a tube-like prolongation. The upper margin of the ring was in- 
cised for some distance, as the original opening hardly admitted the 
forefinger. Eventually a portion of the redundant skin was cut away. 
The abdominal walls were brought together by six silk sutures, and an 
aseptic dressing was applied. During the next few days the child 
fared badly. No nourishment could be taken, and there was vomiting 
of a greenish-colored material. The temperature rose steadily until 
the evening of the fourth day, when it reached 102.4 degrees. Some 
meconium was found in the liquor and about one drachm was passed 
after birth. 
On the second day one-fortieth grain of calomel was given every 
hour for five hours, when a small movement occurred accompanied by 
a flow of urine, and on the third day one-fortieth grain of calomel was 
given hourly for four hours, when the child passed meconium a second 
time. The child cried constantly during that night, and in the early 
evening had an attack of coughing during which he seemed to strangle. 
He did not sleep more than a few minutes at a time. At 5 a.m., a 
hemorrhage took place from the wound, which stained freely the 
inner dressings. Later in the morning there were two good move- 
ments. Five drops of paregoric were given every two hours during 
the day until thirty drops had been given. Five drops of brandy 4 
WARREN, 
were also given every two hours. A small amount of cream and water 
had been given up to this time, but the whole amount hardly exceeded 
one ounce. The child looked pale and pinched, but it slept well the 
following night. The next morning vomiting had ceased it had 
passed gas several times, and the hemorrhages did not recur. On the 
fifth day the child took the breast for the first time. During the next 
two weeks it suffered greatly from colic and indigestion, but gained 
steadily in weight, and now (four weeks) weighs eleven pounds. The 
stitches were not removed until the fourteenth day to avoid a hernia. 
There is, however, a slight impulse, at one spot, over an area about 
the size of a pea. The baby wears a gauze pad and a firmly pinned 
band of flannel. 
This affection is termed by Steiner “ Hernia funiculi um- 
bilicalis.” 
Chadwick1 explains the existence of this form of hernia as 
due partly to deficient development of the abdominal plates. 
He says: “ If, however, the volume of the abdominal organs be 
too great to be easily embraced by the under-sized abdominal 
walls at the period when the latter should normally close, the 
intra-abdominal pressure prevents the retreat within the abdomi- 
nal walls of a certain portion of those intestinal convolutions 
which have, until that time, lain normally in the umbilical cord.” 
In the omphalo-mesenteric duct which connects the alimentary 
canal with the umbilical vesicle we find a cause for the extra- 
abdominal position of some of the coils of intestine. If the 
umbilical vesicle persists until a later period than usual, that 
portion of the intestinal tube to which it is attached is anchored 
outside the umbilical ring. 
Chadwick describes several museum specimens in which not 
only the intestines and the liver, but the heart and stomach, 
formed a part of the hernial contents. 
Howard Marsh says:2 “It is a familiar anatomical fact that 
from about the sixth to the twelfth week of intra-uterine life the 
caecum and neighboring portion of the ileum are contained in 
the part of the umbilical cord which is next the body of the 
1 Gynaecological Transactions, vol. i. 
2 St. Barth. Hosp. Rep., 1874, No. 10, p. 205. Fig. 2. 
Case FI CONGENITAL UMBILICAL HERNIA INTO THE CORD. 
embryo, and that they should subsequently retire into the cavity 
of the. abdomen. In some cases, however, this recession fails 
to take place, and the intestine remains, even up to the time of 
birth, still lodged in the commencement of the cord, which is 
dilated in the form of a membranous sac.” 
I find in literature a number of examples of this malformation 
in children who were born and lived for a short period. 
Tyler1 reports the case of a full-grown child with a protrusion 
of the entire intestinal tube. His proposal to enlarge the orifice 
of the opening was refused by the parents. The child lived 
thirty hours, the hernia apparently becoming gangrenous (?). 
The mother stated that she was thrown from a horse about four 
months before, striking with great violence on the abdomen. 
Lecorche-Columbe2 reports the case of a female child in which 
the hernial contents consisted of the left lobe of the liver and 
the fundus of the gall-bladder. They could be distinctly seen 
through the semi-transparent tissue of the cord. Attempts at 
compression with bandages and pad were made for a week, 
during which time the child did well. Taxis was then made, as 
the membrane was becoming decomposed, and brought on peri- 
tonitis, from which the child died on the twelfth day. 
Meredith3 reports the case of a male in which the tumor 
involved about three inches of the cord. Compresses were ap- 
plied, but the child died on the ninth day. The tumor when 
removed was about the size of a hen’s egg and contained meco- 
nium. There was a narrow opening communicating with the 
bowel. 
Thompson4 alludes to a case in which the expansion of the 
umbilical cord contained the whole of the small intestines and 
the ascending colon. The child lived four days. 
Colla5 operated upon a case in which the contents of the 
hernia were a portion of the liver and the gall-bladder. The 
1 American Medical Record, 1821. 
2 Gazette M6dicale de Paris, 1836, p. 191. 
3 British Med. Journal, Nov. 17,1877. 
4 Ibid., Dec. 1, 1877. 
5 Centralblatt fiir Gynakologie, No. 21, 1890. WARREN, 
operation was performed fifteen hours after birth, and the child, 
which was well developed, died seven hours later. In his article 
Colla refers to a similar case of Olshausen in which the hernia 
appeared to be undergoing a spontaneous reduction. The child 
lived five weeks. Several cases are reported that have recovered 
without treatment, and a few have been operated upon success- 
fully. 
Howard Marsh1 reports six cases of this deformity; in two 
of these cases strangulation had taken place. Three of the 
children died, and three recovered. 
Case II. is related by Cooper Foster. A boy, eighteen days old, 
born of syphilitic parents, was brought to him at Guy’s Hos- 
pital. The hernia was about the size of the patient’s head. The 
coverings are described as “ a green slough.” The umbilical 
ring was over two inches in diameter. “ The contents of the 
swelling were, as far as possible, returned: a bandage was 
placed around the abdomen and good nourishment given to both 
mother and child. To my surprise, the slough separated, the 
swelling became smaller, healthy granulations arose from the 
surface of the sore, the child improved in health, and at the age 
of six weeks the whole had cicatrized.” 
Case III. is reported by Visick, who tells us that he was called 
to see the newborn infant of a poor Spanish woman at Malaga, 
who believed that the nurse in dividing the cord had opened the 
cavity of the abdomen. He found the child enveloped in a 
firmly applied bandage from the shoulder to the hips, but he 
could see coils of intestines protruding beyond both its upper 
and lower borders. On unrolling the child a large sac was dis- 
covered at the umbilicus, which had burst, or perhaps been 
opened when the cord was divided, and from which almost all 
the small intestines and the ascending colon had escaped. The 
intestines were bleeding from several points and covered with 
“fluff” from the bandage. Considerable difficulty was experi- 
enced in returning the prolapsed intestine, but this was accom- 
plished within an hour and the child made a good recovery. 
1 Loc. cit. CONGENITAL UMBILICAL HERNIA INTO THE CORD. 
Case V., described by Pochkammer, was a case of hernia of 
the liver and gall-bladder. As the tumor was said to be the size 
of a hen’s egg only, it is probable that only a portion of the liver 
protruded. The coverings were dissected off from the liver, 
which was reduced. At the end of a year after the operation 
the umbilical ring remained dilated to the size of a crown piece, 
but the viscera were easily kept in situ by a simple bandage. 
Masurel1 describes the contents of the hernia of a child that 
lived ninety-five hours. The tumor contained the omentum and 
the intestine from the duodenum to the sigmoid flexure ; also 
the kidney, which had no ureter. He also states that the liver, 
spleen, bladder, and kidneys were normal. Perhaps that organ 
found in the hernial sac may have been a supernumerary kidney. 
Goyraud2 reports the case of enormous congenital umbilical 
eventration which was untreated, the child living 2j4 months. 
The coverings gradually melted away and were replaced by 
granulations ; the wound at the time of death had healed to the 
size of a two-franc piece. The child apparently died of peri- 
tonitis. 
Ronaldson3 successfully reduced such a hernia in a female 
child. A tube of skin projected downward and forward from 
the region of the navel. At the end of this tube sprang the 
umbilical cord, which was much distended and contained a por- 
tion of the liver and numerous coils of intestine which were 
distinctly visible “through the transparent peritoneal sac and 
amniotic covering.” The edges of the tube were refreshed and 
stitched together. The child recovered with an ordinary umbili- 
cal hernia. 
In Lawson Tait’s translation of Steiner there are a few cases 
that were allowed to heal by granulation, and recovered. 
Quite a number of cases are reported by Thudichum in an 
article written in 1854.4 
1 Bulletin M6d. duNord, 1863, vol. iv. 
2 Annales de la Chirurgie Francaise et etrangere, 1844, vol. x. 
3 Trans. Edinburgh Obstet. Society, vol. viii., 1883. 
4 Illustrirte med. Zeit., Muenchen, vol. ii.