Rare Forms of Umbilical 
Hernia in the Fetus 
BY 
JAMES R. CHADWICK, M. D. 
OF BOSTON 
REPRINT FROM VOLUME I 
(GBnecolosfcal 
1876 RARE FORMS OF UMBILICAL HERNIA IN 
THE FETUS. 
BY JAMES R. CHADWICK, M. D., 
Boston, Mass. 
Umbilical hernia in the new-born child is of sufficiently 
common occurrence to be familiar to all practitioners. The 
hernial sac is rarely larger than an acorn, and ordinarily 
contains but few intestinal convolutions, which readily re- 
treat into the abdominal cavity when the sac is squeezed be- 
tween the fingers. The neck of the sac, by which it com- 
municates with the abdomen, is often large enough to admit 
a finger, and therefore presents no obstacle to the reposition 
of the extruding intestinal coils. When the protrusion of 
the intestines through the umbilical ring of a newly-born 
child is prevented for a length of time by the pressure of a 
pad, supported by a bandage, the opening in the abdominal 
walls gradually contracts, until its closure is complete. 
This reparative process clearly indicates one of the agen- 
cies whereby umbilical hernia is produced during the growth 
of the fetus. Deficient development of the " abdominal 
plates " of embryonic life is generally accepted as the chief 
factor, but it must be borne in mind that the diminished ca- 
pacity of the abdominal cavity, which would result from the 
complete closure of imperfectly developed plates, might still 
suffice to contain the abdominal organs, in case they were 
equally undeveloped. If, however, the volume of the abdom- 
inal 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 re- 
treat within the abdominal walls of a certain portion of those 
intestinal convolutions, which have, until that time, lain nor- 2 
JAMES R. CHADWICK. 
mally in the umbilical cord. Under these conditions the ab- 
dominal plates coalesce, except at the point where intestinal 
coils interpose between their opposite borders. If artificial 
pressure be subsequently applied to the extruding mass of 
intestines, it may be crowded back into the abdomen, owing 
to the distensibility of its walls, and to the fact that its con- 
tained organs are, after birth, being repeatedly emptied and 
hence diminished in bulk. Under these circumstances the 
abdominal walls are free to unite, which they speedily do. 
From the specimens of umbilical hernia in the Warren 
Museum of the Harvard Medical College, I might adduce 
several instances of this form, but they are sufficiently well 
known to require no illustrations. Specimens four and five 
are probably of this nature, but as they present other com- 
plications, they may best be considered in another place. 
There is, however, another agency by which umbilical 
hernia may be brought about, without the assumption of any 
deficient growth in the abdominal plates. For a proper un- 
derstanding of this point, I must revert briefly to the devel- 
opment of the intestines. 
The alimentary canal is formed by the curving forwards 
of the internal layer of the blastodermic membrane, so as 
to constrict the vitelline sac, and ultimately to divide it into 
two cavities ; one of these is the intestinal canal, which ap- 
pears as a straight tube, closed at the ends ; the other is the 
umbilical vesicle. The cavities intercommunicate at the 
outset by a large opening, which, by subsequent changes, 
becomes a canal - the omphalo-mesenteric duct. The blood 
vessels, ramifying in the vitelline sac, become consolidated 
into two principal arteries and two veins, which convey all 
the nourishment to the embryo at this period, when the pla- 
cental circulatory system has not been formed. These are 
termed the omphalo-mesenteric vessels. The arteries are 
the main branches of the embryonic vertebral arteries, which 
later fuse to form the abdominal aorta. They give off many 
branches to the intestines, and then spread out on the 
umbilical vesicle. The veins return from the vesicle, and 
after receiving branches from the intestines, unite to form RARE FORMS OF UMBILICAL HERNIA IN FETUS. 
3 
a single trunk, which enters the lower end of the heart. As 
the placental system is developed, those vessels of the other 
system which ramify on the vesicle (omphalic) are super- 
seded by the placental, and gradually diminish in size until 
they disappear. Those vessels which are distributed to the 
intestines (mesenteric) continue to develop, being then sup- 
plied with blood from the placental circulation. 
In the omphalo-mesenteric duct, which connects the ali- 
mentary canal with the umbilical vesicle, and in the vessels 
that traverse its walls, we at once discover a possible cause 
for the extra-abdominal position of some of the coils into 
which the intestine is thrown, by its subsequent very rapid 
growth in length. We have only to conceive that the um- 
bilical vesicle and its duct, with their vessels, fail to atrophy 
in the process of embryonic growth, and persist, to a later 
period than usual, as a cord anchoring that portion of the 
intestinal tube, with which they are in connection, outside 
of the umbilical ring. Here, as above, the umbilical hernia 
is due simply to the retention of the intestines outside of 
the umbilical ring, the difference being confined only to the 
agency whereby the deformity is produced. In the one 
case, the retreat of the coils into the abdomen is resisted 
by the exaggerated intra-abdominal pressure; in the other, 
by the outward traction of the still attached and persistent 
omphalo-mesenteric duct. 
It is rare that the connection of the duct with the intes- 
tine can be demonstrated, as specimens seldom come into 
our hands early enough in the process of development. 
Kraemer,1 however, describes a case in which, on dissection, 
he found the liver occupying the greater part of the hernial 
sac. The umbilical vein was already obliterated ; the ura- 
chus with both umbilical arteries could be traced, as an ob- 
literated cord, to a point near the insertion of the round lig- 
ament into the abdominal walls. Between this cord and the 
ligament the hernial sac was connected with a coil of the 
1 Heilung eines sehr s. g. angebornen Nabel- oder Nabelschnur- 
Bruches. Zeitschrift filr rationelle Medicin N. F. Bd. III., p. 218. 
1853 4 
JAMES R. CHADWICK. 
ileum, sixteen inches above the cecal valve, by a ligamentous 
appendage. When the intestine was opened, a small canal 
was seen entering the appendage to the depth of two lines. 
This was clearly the remains of the omphalo-mesenteric 
duct. The traction exerted by it was such as to produce an 
acute flexion of the intestine at the point of insertion, but 
no occlusion. The presence of the liver in the hernial sac 
will be considered later. 
The omphalo-mesenteric duct is usually patulous until 
about the end of the fourth week of fetal life. It then rap- 
idly shrivels to a thin cord, and disappears by the end of the 
sixth week, when the intestine retreats into the abdominal 
cavity, and the umbilical ring closes. The remains of the 
duct in the umbilical cord may be seen as a slender pedicle 
as late as the end of the third month, and vestiges of it - 
and even of the vesicle - have recently been discovered in 
many placentae and cords, after delivery at full term.1 
Specimen one (Plate I.) is an anencephalous fetus, with a 
hernial sac over an inch long, connected with the abdominal 
cavity by a pedicle nearly as large as a goose-quill, and meas- 
uring three quarters of an inch in length. The sac contains 
many convolutions immediately continuous with the intra- 
abdominal portions of the alimentary canal. No trace of the 
omphalo-mesenteric duct can be found on the intestine, but 
it undoubtedly persisted until the abdominal walls had closed, 
so as to prevent the retraction of the imprisoned coils. In- 
stances of such herniae may be found in medical literature. 
They may be distinguished from those forms that are due to 
deficient growth of the abdominal 'plates, by the fact that 
the hernial sac lies at a distance from the umbilicus, being 
connected with it by a neck. Opposition to the entrance 
into the abdomen of the extruding coils of intestines at the 
sixth week of embryonic life, would manifestly have no 
power to remove the intestines to a distance from the abdo- 
men, as in the class of cases now under consideration. 
Specimen tivo (Plate II.) is a fetus with an umbilical hernia, 
1 Schultze. Das Nabelbldschen, ein constantes Gebilde in derNachge- 
\urt des ausgetragenen Kindes. Leipzig, 1861. RARE FORMS OF UMBILICAL HERNIA IN FETUS. 
5 
which is quite unique with respect to the length and attenu- 
ation of the canal which connects its sac with the abdominal 
cavity. The distance of the sac from the umbilical ring is an 
inch and three quarters. The two portions of the intestines 
that pass into, and out of, the ring, can be inflated to a point 
nearly half way to the sac, where they are evidently occluded 
by a post-mortem contraction on the part of the cord. I 
have no doubt that during life the intestinal canal was patu- 
lous throughout its whole course. 
This fetus presents many deficiencies of development, but 
none of interest in this connection, except the absence of the 
anus, and the termination of the alimentary canal as a blind 
pouch soon after its return to the abdomen. 
Ahlfeld-1 has recently called attention to the frequent co- 
incidence of congenital umbilical hernia with atresia ani, 
and pointed out the probable dependence of the latter mal- 
formation upon this displacement of the intestines. For a 
proper understanding of the subject, it is necessary to refer 
again to the earliest embryonic form of the intestinal canal 
as a straight tube closed at both ends. The allantois soon 
forms as an offshoot of the intestine at its lower end. The 
cavity of the allantois is, subsequently divided into two 
halves, the anterior of which becomes the urogenital canal, 
while the posterior half - continuous with the intestinal 
canal - forms the anterior wall of the rectum. At about 
the ninth week of fetal life the rectum opens into the anal 
groove. Several weeks before this occurs, it will be remem- 
bered, the abdominal walls should normally have closed. If, 
however, a portion of the intestines be contained in a her- 
nial sac external to the abdomen, owing either to persistence 
of the omphalo-mesenteric duct, or to non-union of the ab- 
dominal walls at the median line, the end of the rectum 
would, in all likelihood, be drawn away from the perineum, 
and thus fail to be in a position to connect with the anal 
groove, and to establish its excretory opening. As a re- 
sult, therefore, of umbilical hernia, we may, and often do 
have an imperforate anus, and the rectum terminating in a 
1 Archiv fiir Gynakologie, Bde. V. 2, p 230, and X. 2, p. 394. 6 
JAMES R. CHADWICK. 
blind pouch within the abdominal cavity. Of course this 
phenomenon would not take place unless the traction upon 
the rectum by the extruding intestines were sufficient to re- 
move its end from contiguity with the perineum. 
My second specimen may be regarded as a fair illustration 
of the views enunciated by Dr. Ahlfeld. So many coils of 
intestines are displaced to so great a distance from the 
abdomen, that the rectum terminates in a blind pouch soon 
after reentering the abdominal cavity, no connection having 
taken place with the anal groove. In the first specimen, 
however, the hernial pouch is comparatively short, and con- 
tains comparatively few intestinal convolutions. Hence, the 
traction upon the rectum at the beginning of the third 
month may be assumed to have been but slight, and insuffi- 
cient to drag it away from its natural position. We there- 
fore find, as we should expect, that the alimentary canal 
connects with the anus. In the third specimen, the whole 
alimentary canal, except the esophagus, is contained in the 
extra-abdominal sac, and terminates necessarily in a blind 
pouch. There is no trace of an anus, unless the small spot 
indicated in the drawing (Plate IV.) just beneath the umbili- 
cus - which is the opening of a minute canal that runs a 
short distance into the pseudo-cord, without, however, con- 
necting with its duct - can be regarded as an attempt at an 
anus. I am more disposed to consider this canal as a part of 
the undeveloped urogenital system. 
Specimens fout and five, likewise, exhibit umbilical herniae, 
containing, besides the liver and spleen, the stomach, and 
many convolutions of the intestines, yet in each the rectum 
enters the abdominal cavity, and terminates in a natural 
anus. In these two cases the traction upon the rectum, 
if it had been due to persistence of the duct, would seem to 
have been sufficient to have drawn its end away from the 
perineum, and thus to have prevented the formation of the 
anus. Ahlfeld meets this objection to the general applica- 
bility of his explanation, by supposing that the traction upon 
the rectum is not applied until the fusion of the terminal 
pouch and the anus has been effected. This view can RARE FORMS OF UMBILICAL HERNIA IN FETUS. 
7 
hardly be accepted, because the traction must exist, if at all, 
prior to the closure of the abdominal cleft at about the sixth 
week, whereas the junction of the rectum and anus does not 
take place until the ninth week. In other words, if there be 
be no dragging upon the intestines by a persistent omphalo- 
mesenteric duct before the sixth week, it cannot take place 
after the ninth week, because the abdominal walls will then 
have closed. 
These two cases may, however, be much more readily ex- 
plained, by supposing them to be due to deficient or retarded 
development of the abdominal walls. In that contingency, 
the hernial sacs would probably communicate with the ab- 
dominal cavities by rather large openings, which probably 
would not confine such coils, as had entered the herniae, 
until long after the rectum and anus had coalesced. Sub- 
sequent contraction of the abdominal walls at the median 
cleft might constrict the neck of the hernia until it should 
attain the small circumference found in the specimens. 
This suggestion receives some confirmation from the fact, 
that in the fifth specimen, the abdominal wall, with its in- 
tegument, is so tense as to have drawn the left leg and arm 
together, presenting a deformity that simulates the one so 
often produced by the cicatrices of extensive burns. 
Specimens three, four, and five (specimen six will be dis- 
cussed separately), differ from the previous ones in the pres- 
ence of several abdominal organs, notably of the liver, in the 
hernial pouch, besides the greater portion of the alimentary 
canal. This ectopia of the liver is by no means of rare oc- 
currence. In twenty-nine cases, in which Kraemer1 found 
the contents of the sac given, the liver was within its cavity 
twenty-two times. 
At first sight the prolapse of other organs than the intes- 
t.nes would seem to demand still further abnormities of 
growth for their production. A closer study of the devel- 
opment of the vascular system in the fetus will, however, 
demonstrate that the displacement of the liver, at all events, 
may be dependent upon the same causes as we have already 
discussed. 
1 Loc. cit., p. 234. 8 
JAMES R. CHADWICK. 
It has been stated above that the two omphalo-mesenteric 
veins form a single trunk before entering the lower end of 
the heart. Around this trunk is formed the liver as an off- 
shoot of the intestines. The umbilical veins, coming from 
the placenta, empty into the omphalo-mesenteric veins at 
the point where the latter unite in a common trunk. The 
right omphalo-mesenteric vein and the right umbilical vein 
soon shrivel up and disappear. The left omphalo-mesenteric 
vein diminishes in size as the nourishment of the fetus is 
gradually transferred from the vitellus to the placenta, while 
for the same reason the left umbilical vein increases in calibre. 
The common trunk of the omphalo-mesenteric system, into 
which all four veins, at one time, empty, likewise gains in 
size and appears as the direct continuation of the only re- 
maining umbilical vein. It is subsequently known as the 
ductus arteriosus Arantii. The development of the vence 
hepaticce advehentes from the umbilical vein proceeds in such 
a manner as to make the remaining omphalo-mesenteric vein 
empty into one of these branches, instead of into the main 
trunk as before. 
In 1850, Neugebauer1 published a theory, whereby he 
made the displacement of the liver into the hernial sac de- 
pend upon the junction of the omphalo-mesenteric and um- 
bilical veins lower in the abdomen than is customary, or 
even in the sheath of the umbilical cord. This abnormal 
fusion of the two veins he thought would be rendered pos- 
sible by a position of the duodenum unusually near to the 
navel. He admitted that the displacement of the liver might 
be further favored by the fact, that the organ is originally 
developed from this very portion of the intestines, and is 
permanently connected with it by the gall duct. The mal- 
position of the duodenum he attributed to an abnormal 
course of the intestinal canal, whereby " the right portion of 
the large intestine is displaced to the left side of the abdo- 
men, and the small intestine is, therefore, constrained to re- 
1 Ueber das Auftreten der Leber im Nabel als Fehler der Ersten 
Pildung. Caspar's Wochenschrift fiir die gesammte Heilkunde, 1850, 
38, p. 607, and 39, p. 616. RARE FORMS OF UMBILICAL HERNIA IN FETUS. 
9 
main exclusively in the right side." Owing to this derange- 
ment of the parts, the duodenum was supposed not to receive 
the habitual support from the transverse colon, and conse- 
quently prolapsed toward the umbilicus. 
This theory is an ingenious hypothesis, but has few, if any, 
facts in its support. On the other hand, the persistence of the 
omphalo-mesenteric duct and its vessels is quite generally 
accepted by embryologists as the determining cause of many 
cases of protrusion of the intestines into the umbilical cord. 
This being assumed to be correct, it is at once apparent that 
the same agency which displaces the intestines will also dis- 
place the liver, because one of the largest branches of the 
omphalo-mesenteric veins passes directly to the liver and 
might, in case it were unduly persistent, exercise consider- 
able traction upon the liver, in the same way as the duct 
itself and the other branch would upon the intestine. In 
Kraemer's case, the round ligament of the liver was shorter 
than usual. As this cord is the obliterated umbilical vein 
of the fetus, it is evident that the liver must have been dis- 
placed prior to the fusion of the umbilical with the omphalo- 
mesenteric vein, whose functions it usurped, or it would have 
appeared of normal length, and been coiled up by the de- 
scent of the liver. Undoubtedly, the development of the 
liver from the duodenum, and its permanent connection with 
it by means of the gall duct, are likewise potent, if not the 
chief, factors. According to this view, the same abnormity 
of growth is the chief cause of displacement of both the liver 
and the intestines. 
In the third specimen there is no spleen or pancreas, but 
the right kidney, and both genital bodies also, lie in the 
hernial sac. The left kidney is the only organ remaining in 
the abdominal cavity. The displacement of these other 
organs is not unnatural, when we consider that they are all 
connected with the liver and intestines by the peritoneum, 
and are, undoubtedly, dragged by means of it from their 
proper sites. The left kidney is the farthest removed from 
the liver and would naturally be the last dislodged. The 
force of the traction, in this specimen, is further illustrated 10 
JAMES R. CHADWICK. 
by the prolongation of the two pleural cavities just through 
the neck of the hernia, and of the pericardium as far as the 
umbilicus. The diaphragm is not distinguishable as such, 
but probably contributed to the formation of these pouches. 
One further peculiarity of the third specimen requires no- 
tice : the curvature of the spine to the right in the dorsal 
region. I can only regard this as an accidental complica- 
tion, due chiefly to the spina bifida, although the dislodg- 
ment of the liver may have exerted a traction that aided in 
determining the direction of the curvature. Foerster refers 
to the frequent coincidence with umbilical hernia, of ante- 
rior curvature of the veitebral column, so that the body ap- 
pears to be bent at its middle. This deformity is attributed 
to the absence of the support that is commonly given to the 
column by the abdomen and its contents, and to the traction 
applied to the middle of the column by the prolapsed or- 
gans. The last of my specimens is a remarkable instance 
of the extent to which this curvature may be carried, if the 
traction upon the middle of the column be greatly increased 
by an adventitious growth. 
Finally, specimen six (Plate V.) presents a new complica- 
tion of umbilical hernia, in the presence of a cyst as large as 
a medium-sized orange, which, growing from the vertebral 
column, has pushed the peritoneum, and all the abdominal 
organs, through the cleft in the abdominal walls. The source 
of this cyst cannot be definitely decided; it was bound 
firmly to the bodies of the lumbar vertebrae by many short, 
very strong fibrous bands, and was otherwise free over its 
whole surface. There was not the least indication of an 
opening in the spinal column, or of a pouch in the sac, 
which might suggest a former communication with the 
spinal canal. The entire absence of the right kidney sug- 
gests that this cyst may be an abnormal development of 
that organ, yet in that case we should have no reason to ex- 
pect that it would be so closely connected with the vertebral 
column, and it is difficult to imagine that it could insinuate 
itself, in the process of development, beneath the inferior 
vena cava, so as to have that vessel crossing the cyst at its 
largest circumference. RARE FORMS OF UMBILICAL HERNIA IN FETUS. 
11 
In this specimen the abdominal walls were cleft from the 
ensiform cartilage to the pubes, the seeming deficiency of 
their development being very great. The defect may, in a 
measure, be one of appearance only, and attributable to the 
extreme curvature of the spine. It moreover requires no 
stretch of imagination to understand that the abdominal 
plates, even if normally developed, would be unable to en- 
compass a cyst, relatively as great as that here existing, be- 
sides the other organs, which commonly alone suffice to fill 
the cavity. This is, of course, on the assumption that the 
cystic formation dates from the earliest embryonic stage of 
development, as is probable. 
The spinal column, after dissection, was found to bend 
backwards to the extent of a right angle in the lumbar re- 
gion. There was extensive posterior spina bifida in the 
same region. The coccyx and sacrum were so displaced 
in their relations to the pelvis, by the traction of the cyst, 
that they projected above the pelvic brim, the point of the 
coccyx lying one half inch above the pubes. 
One common trait is noticeable in all but one of these 
specimens, - spina bifida. This I am inclined to regard as 
merely a coincident manifestation of deficient development, 
although in such a case as the sixth it is readily conceivable 
that the compression applied to the arches of the vertebrae 
by the extreme anterior curvature might easily become a 
cause of deficient growth, or even of the absorption of the 
compressed parts of the vertebrae. 
Foerster1 asserts that umbilical hernia is much more 
common in the female than in the male fetus, which state- 
ment brings to mind the saying of Aristotle: that the oper- 
ations of Nature tend to perfection in all things, even in the 
formation of human beings; but if a male cannot be pro- 
duced owing to the resistance of matter, then a female is 
the result. 
The other deformities presented by this series of fetus 
will not be discussed now, as the only object of this paper 
is to sketch in outline the varied causes of umbilical herniae, 
1 Die Missbildungen des Menschen. Jena, 1861. 12 
JAMEo R CHADWICK. 
and to illustrate (i) their frequent dependence upon an ab- 
normal persistence of the omphalo-mesenteric duct; (2) the 
possible causal relation between such hernias and imperfo- 
rate anus ; and (3) the dependence of hepatic displacement 
in great measure upon the same cause as intestinal. 
DESCRIPTION OF THE SPECIMENS. 
All the specimens, except the sixth, had been preserved in 
alcohol for many months before the dissections and illustrations 
were made. The sixth was obtained in the fresh state. The 
preparations all belong to the Warren Anatomical Museum of 
the Harvard Medical College, and were placed at my disposition 
for study by the courtesy of the curator, Professor J. B. S. Jack- 
son, to whose catalogue I am indebted for many of the data re- 
corded. 
The plates have been made slightly diagrammatic by Dr. H. P. 
Quincy, for the purpose of rendering them more intelligible. 
They represent the specimens of natural size, except the sixth, 
which is reduced to one third of the natural size. 
The descriptions will not enter into detail upon points that are 
foreign to the subject of this paper. 
First Specimen. (Plate I.) No history. Anencephalous 
fetus five inches long. Spina bifida of all the dorsal vertebrae, 
but no cyst. Very sharp antero-posterior curvature of the spine 
in the dorsal region. The head is twisted to the left and closely 
united to the thorax by integument. The thoracic cavity is much 
flattened, and is smaller on the left side than on the right, owing 
to a slight twist in the vertebral column. The lungs are fused 
into a single one, overlying the spine and extending further into 
the right side of the thorax than into the left. The heart is of 
very diminutive size, being smaller than in the second specimen, 
but of the same shape. 
The diaphragm is normal. There is no liver, pancreas, or 
spleen. In the abdominal cavity are two large kidneys and supra- 
renal capsules. The stomach is normal. Half an inch from the 
pylorus the small intestine passes through the umbilical ring into 
a canal three quarters of an inch long, which communicates with 
an oblong hernial sac, an inch long. Within this sac is contained 
the greater part of the small and large intestines; the colon, PLATE L 
SPECIMEN I. 
Fetus with Hernial Sac containing Intestines only. PLATE II. 
SPECIMEN II. 
Fetus with Hernial Sac, containing only Intestines, 
I 3-4 inches from the Umbilicus. 
H. Heart 
L. Lungs. 
K K. Suprarenal capsules and kidneys. 
S. Stomach. » 
G G. Genital bodies. 
M. Mesentery covering the terminal rectal pouch. 
C. Colon. 
F. Hernial sac. 
P. Placenta. 
Z. Point at which the intestines are constricted. RARE FORMS OF UMBILICAL HERNIA IN FETUS. 
13 
however, reenters the abdominal cavity, and descends at once 
into the pelvis, terminating in a very large rectum and anus, de- 
void of any constriction at the outlet indicating the presence of 
sphincters. Along the left side of the sac, continuous with it, 
lay the umbilical cord and vessels. 
Second Specimen. (Plate II.) Presented to the Museum by 
Dr. H. Tuck. A blighted, very imperfectly developed fetus, one 
of triplets born prematurely; the other two fetus belonged to 
about the sixth month of pregnancy, and were well formed exter- 
nally, excepting one hand and varus of one foot. 
The head and trunk together measure one and three fourths 
inches in length. The head is anencephalous, and the spine bifid 
throughout. The right upper extremity is wanting ; the left upper 
arm, five eighths of an inch' long, is attached to the side; the 
lower arm and hand are very imperfectly formed. The left lower 
extremity is wanting. The right thigh is one inch long ; the leg 
two thirds of an inch long, very slender, and ends in a point, 
without a foot. The thorax is flattened on the right side so as to 
obliterate the cavity almost entirely. The lungs are fused, the 
right appearing as a lobe, protruding from the side of the left 
lung, which consists of but one lobe. The heart is shaped like a 
mitten. On the right side the diaphragm is wanting; on the left 
it is normal. 
The liver, pancreas, and spleen are wanting. The stomach is 
normal; the intestines, after a few convolutions, pass through a 
very small umbilicus and thin cord to a sac with thin, transparent 
walls, one and three fourths inch distant from the abdomen. 
This sac contains the greater part of the small and large intes- 
tines ; the latter returns through the umbilical cord to the ab- 
dominal cavity, where it ends in a blind pouch. The two intesti- 
nal tracts in the cords can be inflated as far as the point Z, 
where they appear to be constricted by post-mortem twists and 
dessication of the cord. There is no anus or genital opening. 
The two kidneys and supra-renal capsules, and two small genital 
bodies are likewise contained in the abdominal cavity. 
Third Specimen. (Plates III. and IV.) Presented to the 
Museum by Dr. J. R. Chadwick. - History: Mrs. B. was de- 
livered on March 14, 1875, at what was thought to be about the 
end of the sixth month of gestation, by operative procedure, in 
consequence of hemorrhage and a foul discharge from the vagina, 
which had persisted for six weeks and reduced the patient to a T4 
JAMES R. CHADWICK. 
perilous condition. The size (length four and three fourths 
inches) and condition of the fetus showed that it must have been 
dead for many weeks. No cause for the death was discovered at 
the time, but a recent dissection of the fetus has disclosed an 
absence of the laminae and spinous processes of the tenth, 
eleventh, and twelfth dorsal vertebrae. There was no cyst con- 
necting with the spinal canal, or curvature of the column. The 
importance of examining the spinal column for such deficiencies 
of growth, with a view to elucidating the cause of a miscarriage, 
is made apparent by this case. 
On June 23, 1876, Mrs. B. again miscarried spontaneously at 
about the fourth month of pregnancy. The specimen was imme- 
diately preserved in alcohol and not examined until three months 
later. 
Specimen. - The placenta measured two by one and three 
fourths inches, and varied from one quarter to one half an inch in 
thickness. It was connected by the chorion with what, at first 
sight, was supposed to be a placenta succenturiata, about an inch 
in diameter and a quarter of an inch in thickness; both surfaces 
of the latter were, however, seen to be covered with smooth mem- 
branes continuous with the fetal membranes. In these could be 
seen two vessels passing from the right border of the disk-shaped 
body to the placenta, in the substance of which they were lost. 
The centre of the supposititious second placenta was connected 
with the abdomen by an umbilical cord not over an eighth of an 
inch in length. 
The fetus was four inches long with the feet extended. The 
thorax contained both lungs and the heart in normal position ; 
the thymus gland was apparently wanting. Prolongations of the 
two pleural cavities extended through the pseudo-cord and ter- 
minated blindly, while a diverticle of the pericardium ended in the 
same way just within the umbilicus. There was no appearance 
of a diaphragm. 
The abdominal cavity was extremely small and only contained 
the left kidney. 
The disk-shaped body between the fetus and placenta proved 
to be a sac, the cavity of which communicated with the abdomi- 
nal cavity by means of the pseudo-cord. 
The hernial sac contained the liver, the right kidney, two geni- 
tal bodies, the stomach, and the small intestines ending in a blind 
pouch. There appeared to be no large intestine, spleen, or pan- PLATE III. 
SPECIMEN III. 
Fetus having a Hernial Sac connected with the Placenta bv the Mem- 
branes, through which run two Umbilical Vessels. Vide Plate IV. PLATE IV. 
SPECIMEN III. 
H Heart. 
L. Left lung, the right having been removed. 
B. Bronchi 
Y. Yellow body within the pericardium. 
V. Spine curved to the right. 
E. Esophagus. 
K K. Kidneys. 
D. Diverticle of the pericardium. 
G G. Genital bodies. 
N. Liver. 
S. Stomach. i5 
RARE FORMS OF UMBILICAL HERNIA IN FETUS. 
creas. The mesentery was inserted into the investing membranes 
of the sac at the line of junction of the anterior and posterior 
walls throughout the right half of the circumference. The esoph- 
agus passed from the stomach through the pseudo-cord, the ab- 
dominal and thoracic cavities to the mouth. 
Just below the umbilicus was the opening of a small canal 
which ran for half an inch through the walls of the pseudo-cord 
and hernial sac, without opening into their cavities; it was prob- 
ably the urogenital excretory duct. 
The vertebral column of the fetus showed a well-marked lateral 
curvature to the right, in the lower dorsal region, and posterior 
spina bifida, throughout the lumbar and sacral regions. 
Fourth Specimen. Presented to the Museum by Dr. J. F. 
Perry. - Anencephalous male fetus of about the fourth month, 
with the spine bifid throughout, and curved irregularly backwards 
and a little to the right. The head is rotated to left, and bound 
closely down upon the shoulder by integument; the tension of 
the latter having been so great as to have drawn the lower jaw 
widely distant from the upper. The right upper extremity is de- 
ficient. The left scapula is displaced forwards, and the left arm 
so distorted that the elbow seems directed towards the front; the 
hand is very strongly bent upon the fore-arm. Both feet are 
much bent upon the legs. 
The distance from the top of the sternum to the pubes is not 
over one and a half inches, owing to the curvature of the spine. 
The anterior abdomino-thoracic walls, especially their integu- 
ment, are very tense. On the left side the scapula and thigh are 
connected with each other, at a distance of three eighths of an 
inch apart, by tense integument. 
From an opening about one quarter of an inch in diameter are 
hanging, partly by the mesentery, the two lungs, the heart, liver, 
spleen, stomach, and greater part of the intestines; the colon, 
however, reenters the abdominal cavity, and on reaching the pel- 
vis becomes greatly distended, but finally ends in a natural anus. 
The thoracic cavity contains only the thymus gland. 
The abdominal cavity contains two large kidneys, two testicles, 
a bladder, and rectum. The right supra-renal capsule is elongated, 
and drawn partially out of the abdomen by the traction of the 
extra-abdominal organs. There is no trace of a sac investing the 
prolapsed organs. 
Fifth Specimen. Presented to the Museum by Dr. J. S. 16 
JAMES R. CHADWICK. 
Jones. - Fetus at about the fifth month. " The placenta ad- 
heres to the top of the head. The cranial cavity, which is large, 
was mostly filled by serum, though there was also an undevel- 
oped brain. The vault of the cranium is entirely wanting, the 
base being well developed." The spinal column is curved to the 
right in the dorsal region, but is otherwise normal, as are the 
limbs, except " the left thumb, which is an oval mass of flesh, 
attached by a thread-like process," and varus of both feet. 
The abdomino-thoracic walls seem normal, except that an 
opening one half inch in diameter exists at the umbilicus. The 
thorax contains both lungs, the heart, and the thymus gland. 
The diaphragm is entire. 
Through the umbilical ring passes the esophagus, the mesen- 
tery, and the colon. Outside the abdomen are the liver, invested 
over a great part of its surface by a thin membrane, which is in- 
timately connected with the upper border of the umbilical ring, 
and forms the chief apparent support of the liver. The stomach 
is closely bound to the liver by folds of peritoneum, and by ad- 
ventitious thin membranes, which likewise bind some few coils of 
the intestines to the liver. The spleen depends from the stom- 
ach. Nearly all the intestines lie without the abdomen; the 
colon, as soon as it reenters the abdominal cavity, descends at 
once to the anus, with which it is continuous. The bladder, kid- 
neys, supra-renal capsules, and testicles, occupy the abdomino- 
pelvic cavity. 
The umbilical cord is independent of the hernial mass, the 
vein not entering the abdominal cavity, but passing directly to 
the cleft of the liver; it is patulous. 
Sixth Specimen. (Plate V.) Presented to the Museum by Dr. 
M. B. Leonard, with the following history: The father and 
mother were healthy, and aged thirty and twenty-five years re- 
spectively. The mother had had no fright or anxiety during her 
first pregnancy, had felt vigorous fetal movements until labor was 
terminated, fifteen minutes before the arrival of Dr. L. The 
child was found in the bed, the cord having been lacerated ; the 
placenta, lying partly in vagina and partly in the uterus, was 
readily removed. There was no hemorrhage from the uterus, or 
from the cord, which latter was torn across close to the placenta. 
From the report of the nurse, and the state of the bed, the 
amount of liquor amnii was assumed to have been small. The 
head and one foot had presented. No deformity of the pelvis, PLATE V. 
SPECIMEN VI. 
Fetus with Abdominal Cleft, through which protrude the Heart, Left Lung, 
all the Abdominal and Pelvic Organs, besides a large Cyst. 
H. Heart. O. Right ovary. 
N. Liver. Q. Pouch from the bladder. 
A. Cyst. W. Kxstrophied bladder. 
I. Ileo-cecal valve. X. Vena cava inferior. 
J. Labia majora. C. Colon. 
. Umbilical vein. C W. Junction of colon and bladder. 
R. Undeveloped uterus.(?) RARE FORMS OF UMBILICAL HERNIA IN FETUS. 
i7 
or uterine tumor, are discoverable; there is no history of de- 
formities on either the father's or mother's side. 
Specimen. - The head seemed to have been subjected to pres- 
sure upon the left side, so as to be of ovoid shape, the two apices 
being at the right frontal bone and the left half of the occipital. 
The left ear was so flattened as to be very thin throughout, and 
almost devoid of the usual markings as well as of cartilage. The 
nose was likewise bent to the right side, and flattened upon the 
face. The head was so rotated that the right lower jaw rested 
upon the right shoulder, and the right cheek upon the left thigh 
and leg. The arms were crossed upon the chest. The legs were 
bent backwards so that the right buttock was apposed to the 
right shoulder blade, the leg resting in the hollow of the neck, 
and the foot upon the left shoulder. The left leg lay alongside 
the right. This position of the legs was rendered possible by the 
extreme curvature of the spine backwards and somewhat to the 
right. 
The sternum and thoracic integument were normal. An in- 
cision through the sternum in the median line revealed a large 
thymus gland extending from the upper to the lower margin of 
the sternum. The right pleural cavity was of fair size, and con- 
tained the right lung. On the left side the ribs were so flattened 
upon the spine as to leave little or no thoracic cavity. 
The abdominal walls were widely cleft from the sternum to the 
pubes. The left lung protruded through the abdominal fissure 
just below the ribs on the left side, resting upon the heart, which, 
inclosed within its pericardium, likewise protruded, and formed 
the upper portion of the hernial tumor. 
Next to the heart was the liver, flattened and spread out over a 
large eyst. Its fissure was on the lower surface toward the right 
side, and received a large, still pervious, umbilical vein, which ran 
in the thin membranous walls of the hernial sac at their junc- 
tion with the abdominal integument on the right side, and ter- 
minated in a torn end near the bladder. When the liver was 
turned up, the gall-bladder became visible, connected with the 
duodenum by the gall-duct and by folds of the peritoneum. The 
stomach lay in the median line over the lobus Spigelii of the liver. 
The course of the duodenum was at first toward the right, but it 
very soon took a sharp turn to the left, the angle apparently 
being due to the traction of the bile-duct and its investing layers 
of peritoneum. Hanging from the stomach by a double fold 
of peritoneum was the spleen. 18 
JAMES R. CHADWICK. 
Beneath the liver and intestines was a cystic tumor as large as 
a medium-sized orange. From the under side of the liver and 
from the mesentery the peritoneum was deflected over the sur- 
face of the cyst so as completely to invest it. Resting upon the 
cyst, on either side, about an inch from the margin of the ab- 
dominal cleft, were two oval bodies, as large as white beans, sup- 
posed to be the ovaries. The small intestines hung freely from the 
mesentery. The cecum, cleft longitudinally throughout most of 
its length, ended in a blind pouch, the cavity of which was divided 
into two equal halves by a longitudinal septum. The fissure in 
the colon extended to the bladder, which was directly continuous 
with the intestine and exstrophied throughout. In its posterior 
walls was a depression, three fourths of an inch deep, which was 
lined with what resembled integument. Near the base of the 
bladder, on the right side, was a prominence formed of firm tis- 
sues, which Dr. Fitz found under the microscope to be composed 
chiefly of muscular fibres; this was possibly one horn of an 
otherwise undeveloped uterus. On the left side of the cyst rested 
one solid body and a group of small cysts, taken respectively for 
a supra-renal capsule, and a kidney which had undergone cystic 
degeneration. No. right kidney could be found. The tumor was 
constricted at its middle by a large vein, beneath the peritoneum, 
which proved to be the inferior vena cava. The large cyst was 
attached by firm fibrous bands to the bodies of the lumbar verte- 
brae, being otherwise free. The labia majora depended as two 
long folds of integument. There was no anus or genito-urinary 
opening. 
On dissection by Dr. Jackson, a small cyst was found hidden 
in the gluteal muscles and communicating with the spinal canal 
by an opening in the upper sacral vertebrae. 
The vertebral column, when straightened, measures five and 
one fourth inches from the atlas to the tip of the coccyx. The 
cervical and dorsal vertebrae are rotated to the right so that the 
atlas is at right angles with the lumbar vertebrae. The spine 
is not curved above the lumbar vertebrae; in this region, however, 
it is bent so greatly backwards and to the right as to form a right 
angle. The sacrum and coccyx do not form the posterior wall of 
the pelvic cavity, but project across the pelvic brim, terminating 
one half inch above the pubes. The pelvis presents no other 
deformity except that the two pubic bones are one half inch 
apart, and are joined together by a firm fibrous band. The ribs RARE FORMS OF UMBILICAL HERNIA IN FETUS. 
19 
of the left side are bent forward upon themselves 'at their angles 
so as completely to obliterate the left thoracic cavity. Those on 
the right side are somewhat modified to meet the altered rela- 
tions. 
The large abdominal cyst was lined with a smooth membrane, 
and filled with a clear serum in which nothing characteristic was 
detected by Dr. Fitz. A round solid cord, as thick as ordinary 
twine, passed from one wall of the cyst across the cavity to the 
other, without being in any relation to the fetal vessels.