A CASE OF 
mGWHl UMBILICAL HERNIA; 
ABDOMINAL SECTION SIX HOURS AFTER DELIVERY; 
RECOVERY. 
BY 
WILLIS GOSS MACDONALD, M.D., 
Late Resident Surgeon, Albany Hospital; Assistant in Abdominal Surgery, Albany 
Medical College, 
Albany, N. Y. 
[Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, January, 1890.] 
NEW YORK : 
WILLIAM WOOD & CO., PUBLISHERS, 
56 & 58 Lafayette Place. 
1890. A CASE OF 
CONGENITAL UMBILICAL HERNIA; 
ABDOMINAL SECTION SIX HOURS AFTER DELIVERY; 
RECOVERY. 
BY 
WILLIS GOSS MACDONALD, M.D., 
Late Resident Surgeon, Albany Hospital; Assistant in Abdominal Surgery, Albany 
Medical College, 
Albany, N. Y. 
[Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, January, 1890.] 
NEW YORK : 
WILLIAM WOOD & CO., PUBLISHERS, 
56 & 58 Lafayette Place. 
1890. A CASE OF 
CONGENITAL UMBILICAL HERNIA; 
ABDOMINAL SECTION SIX HOURS AFTER DELIVERY; 
RECOVERY. 
Clinically, cases of congenital umbilical hernia (hernia fu- 
niculi umbilicalis) may be divided into two classes, viz.: those 
in which the hernia is reducible and may be retained by me- 
chanical appliances, and those in which reduction and retention, 
either or both, are impossible. The first class is, as a rule, not 
attended by any serious difficulties in its management. The 
second class, fortunately rare, requires prompt interference to 
avert disastrous consequences. The great advances made in 
abdominal surgery have given surgeons greater confidence ; 
and the radical operation for the cure of congenital umbilical 
hernia, by abdominal section, even in the new-born, has become 
a rational surgical procedure. I am not aware that the subject 
has been treated formally either in text-books or journals ;1 
and I have concluded to report a personal case, together with 
remarks, table of cases, and bibliography. 
On July 27th, 1889,1.saw at Schenectady, H. Y., with Drs. 
Marselius and Faust, a new-born female infant with the follow- 
ing history: Had been delivered six hours before. At the 
1 The small figures refer to the bibliography on page 9. 4 
MACDONALD : A CASE OF 
time of delivery an unusual condition of the cord was noticed, 
which, upon closer examination before its division, revealed 
the presence of a large umbilical hernia. A temporary ligature 
was thrown about the cord nearly eight inches from the abdo- 
men. After delivery, Dr. Faust made an earnest attempt to 
return the hernia into the abdomen, but failed. The child 
presented a normal appearance in all respects, except that at the 
umbilicus there was a hernial protrusion the size of an orange. 
The walls of the sac were thin and translucent, and beneath 
could be seen the already congested intestine. Gentle taxis 
succeeded in reducing a portion of the hernia, but it could 
only be retained by the finger in the ring. At this time I was 
not familiar with the application of abdominal section in the 
treatment of similar cases. However, the indications seemed 
so clear that a radical operation was determined upon. 
The infant was wrapped in a warm flannel blanket and 
placed on a table before a good light. Chloroform was given, 
and after complete anesthesia the sac was opened after the 
manner to be described later. The contents consisted of por- 
tions of the ileum, the ascending colon, and the cecum. The 
vermiform appendix, the size of a bean, was distinctly seen. 
The small intestine was immediately returned to the abdomen, 
but it was necessary to resect the peritoneal layer, the wall of 
sac about the cecum and colon, on account of firm adhesions. 
No hemorrhage followed. The ring, not more than an inch in 
diameter, was deeply transfixed by an encircling suture-a pro- 
cedure I should not again adopt-and the wound dressed with 
bismuth and borated cotton, with a flannel binder over all. 
The child made an uninterrupted recovery. 
Etiology.-The umbilical cord is formed after the first few 
weeks of gestation, from the urachus or pedicle of the allantois 
which communicates with the bladder from the vitello-intestinal 
duct, or the pedicle of the umbilical vesicle which communi- 
cates with the intestinal canal, and from a reflexion of the am- 
nion, the latter forming a sheath for all.2 Soon after the cord 
is formed the vitello-intestinal duct is normally absorbed, and 
the canal outside of the urachus and vessels is rapidly effaced 
from the chorion toward the umbilicus. At this period portions 
of the abdominal viscera lie in the canal of the cord, and recede 
into the abdomen only as the canal is effaced. When the 
vitello-intestinal duct remains patulous, it enters largely as a 
cause of umbilical hernia.3 These cases often terminate 
spontaneously in fecal fistula. Another case of umbilical 
hernia lies in the imperfect effacement of the canal of the 5 
CONGENITAL UMBILICAL HERNIA. 
cord. The ring may be normal, smaller, or replaced by a con- 
siderable cleft of the abdominal walls. The hernia varies in 
size from a small egg to that of the fist. Other malformations- 
spina bifida, imperforate anus, talipes, phimosis, and adhesions of 
the labia-are common complications of congenital hernia. Dr. 
Jacobi4 reported a case in the New York Pathological Society 
wherein a large umbilical hernia occurred with spina bifida and 
imperforate anus. Adhesions of the wall of the sac to the 
viscera are very common. 
The prognosis of irreducible umbilical hernia in the new- 
born has been very unfortunate when the cases have been left 
to themselves.6 The onset of peritonitis has been very rapid, 
and separation of the cord by gangrene takes place early, leav- 
ing the intestines free upon the abdomen.6 The exposed con- 
dition of the intestines, owing to the character of the sac, pro- 
duces a condition of shock from which the little ones die 
early. If they are able to withstand or escape the shock 
and peritonitis, the cases terminate by fecal fistula at the seat 
of the hernia, to be followed by death from inanition.7 So far 
as I have been able to learn, a radical operation, immediately 
after delivery, for relief of umbilical hernia, has been per- 
formed nineteen times with seventeen recoveries. 
No operation needs a special defence when employed in cases 
where the results without operation have been so unfortunate ; 
however, there are certain indications for a radical operation 
for umbilical hernia which must be present before the surgeon 
is warranted in proceeding to so serious an operation as an ab- 
dominal section in the new-born. 
I. The character of the sac must be such that delay will lead 
to its sloughing. 
II. The hernia must be irreducible, and 
III. If reducible, must be incapable of retention by suitable 
mechanical appliances. 
When shall we operate ? Delay of only a few hours often 
is accompanied by commencing gangrene of the cord and be- 
ginning peritonitis. Barton operated after thirty-three hours, 
when the cord was already very offensive and the intestines 
were covered with lymph. Hence the operation should be 
done at the earliest moment after delivery, and with unusual 
precautions to prevent shock and sepsis. 6 
MACDONALD : A CASE OF 
Cases of Abdominal Section foi 
i Umbilical Hernia in the New-born. 
No. 
Operator. 
Indications for the Operation. 
Technique of Operation, etc. 
| Result. 
| Reference. 
Remarks. 
1 
Dr. A. 0. Lindfors, 
1881. 
Large hernia; could not be retained 
by compress and bandage. 
Chloroform, thymol as an antisep- 
tic, resection of sac, and suture. 
R. 
8 
Child few hours old at time 
of operation. 
2 
Dr. Krukenberg, 1882. 
Large hernia, irreducible. 
Salicylic acid, antisepsis, resection, 
and suture. 
R. 
8 
Age not stated. 
3 
Dr. Souden, 1883. 
Large hernia, irreducible. 
Sac treated by encircling suture. 
R. 
9 
Age not stated. 
4 
Dr. Felsenreich, 
1883. 
Hernia size of an apple; cleft in ab- 
dominal wall 8.4 cm. long; large 
and small intestine in sac. 
Sac extirpated and sutured ; iodo- 
form dressing. 
R. 
10 
Child two days old at ope- 
ration. 
5 
Dr. Goodlee, 
1883. 
Hernia containing cecum, etc.; 
treated by compress until four- 
teenth day. 
Peritonitis existed at time of opera- 
tion, cecum adherent; sac extir 
pated, and suture. 
D. 
11 
Died three days after ope- 
ration . 
6 
Mr. Treves, 
1884. 
Hernia size of hen's egg; child in 
very bad condition. 
Operation 60 hours after delivery; 
necessary to puncture intestine 
on account of distention. Opera- 
tion same as in case 5. 
R. 
12 
Died twenty-three days later 
from convulsions. 
7 
Dr. Caldwell. 
Hernia size of an orange; cleft in 
abdomen 6 cm. long. 
Wound closed by harelip pins, 
followed by fecal fistulse. 
R. 
13 
Fistulas closed after time. 
Child thirty-six hours old 
at operation. 
8 
Dr. Reuter. 
Cleft 4.5 cm. long; large and ad- 
herent hernia. Peritonitis al- 
ready. 
Adhesions loosened, and intestines 
returned; sac extirpated; suture. 
R. 
14 
No shock from operation. 
9 
Dr. Piperno. 
Hernia size of child's head ; cleft 
size of a dollar. 
Operation done in cold room of 
farm house, with unskilled as- 
sistants, etc. 
D. 
15 
Died the second day from 
shock. 
10 
Dr. Dunlap. 
Great hernia of large intestine. 
Sac removed and opening sutured. 
R. 
16 
Child one hour old when 
operated upon. CONGENITAL UMBILICAL HERNIA. 
7 
1J 
Drs. Dohrn and Ecker- 
lein. 
Hernia size of lien's egg; child 
had six fingers on each hand. 
Amnion resected and Wharton's 
gelatin removed, after which pe- 
ritoneum was folded in and cov- 
ered by skin. 
R. 
17 
Wound healed by granula- 
tion very slowly. 
12 
Phenomenonoff and 
Stoly pinsky. 
Hernia size of goose egg. 
Chloroform and sterilized water. 
Inner wall of sac resected and 
returned to abdomen on account 
of adhesions to intestine. 
R. 
18 
Child one hour old at time 
of operation. 
13 
Olshausen, 
1887. 
Large hernia ; cleft in abdomen 4.5 
cm. broad. 
Same operation as in case 11. 
R. 
19 
Wound healed slowly by 
granulation. 
14 
Thos. Bryant. 
Large adherent hernia with trans- 
lucent walls. 
Same operation as in cases 11-13. 
R. 
20 
Child well two years after 
operation. 
15 
Mr. Harries. 
Hernia size of hen's egg, ad- 
herent. 
Wound closed by encircling su- 
ture. 
R. 
21 
Child but few hours old at 
time of operation. 
16 
Dr. J. M. Barton. 
Hernia size adult fist, opening two 
inches in diameter. 
Wound closed by harelip pins, sac 
excised. 
R. 
22 
Operation thirty-three hours 
after delivery, commenc- 
ing peritonitis. 
17 
Dr. C. Theims. 
Large adherent hernia. 
Not known, but an abdominal sec- 
tion. 
R. 
2:1 
18 
Dr. Ronaldson. 
Large adherent hernia. 
Treated same as cases 11, 13, 14. 
R. 
24 
19 
Dr. W. G. Macdonald. 
Hernia size of an orange, contained 
both large and small intestines, 
adherent to sac wall. 
Wall of sac resected, and part re- 
turned to abdomen; sac re- 
moved. 
R. 
Child is very vigorous two 
months later. 
In all 19 cases, with 17 recoveries and 2 deaths. I have been able to collect from various sources 12 caSes treated by the expectant 
method-i.e., with compress and bandage-with 3 recoveries and 9 deaths. 8 
MACDONALD: A CASE OK 
As nearly every operator has employed a different method 
of operating, it might not be amiss to detail the technique of 
the operation which seems most rational. The infant should 
be wrapped in warm flannel, with artificial heat to the extremi- 
ties, placed in a good light, and completely anesthetized, using 
chloroform. Anesthesia is necessary to control the spasm of 
the abdominal muscles. The abdomen and cord must be made 
thoroughly aseptic bv the use of a two-per-cent solution of creo- 
lin or a one to ten thousand solution of mercuric chloride. The 
sac should be divided away and to the left of the umbilical 
vessels, between two artery forceps. First the external layer 
(the amnion) throughout its whole extent, after which the 
gelatin of Wharton, must be carefully cleared away. Then 
the inner coat (peritoneum) should be freely incised between 
artery forceps, being careful to avoid adherent intestine, and 
the hernia examined. All portions not adherent should be im- 
mediately returned to the abdomen, and the ring closed by a 
sponge wrung out in sterilized warm water. Portions of the 
adherent intestines should be relieved by resecting, if necessary, 
the inner wall of the sac-a procedure not likely to be followed 
by any considerable hemorrhage. Adherent omentum had 
better be ligated at once and removed. When hemorrhage is 
controlled, the intestines should be returned, and a small, flat 
sponge placed within the abdomen to keep the intestines from 
protruding and to prevent the entrance of fluids into the abdo- 
men. The management of the sac will largely depend upon 
the size of the cleft. The entire sac down to the integument 
should be excised and the wound closed by through-and-through 
sutures of silk. The sutures should be introduced well back 
from the borders of the wound, so as to bring into good appo- 
sition the normal relations of the fascia about the umbilicus. 
Before tightening the sutures, the flat sponge should be re- 
moved. The line of incision should be well dusted with pow- 
dered boracic acid or bismuth, and dressed with plain borated 
gauze and cotton, with a flannel binder over all. It seems to 
me that iodoform as a surgical dressing for children ought not 
to be employed. My friend, Dr. Vander Veer, suggested to 
me the propriety of removing the vermiform appendix, which 
was clearly in sight. In one other case that procedure was 
successfully adopted. CONGENITAL UMBILICAL HERNIA. 
9 
I present, on pages 6 and 7, a table of cases treated by 
abdominal section, and the following bibliography : 
1/ Save by Dr. A. O. Lindfors, who 
has written two valuable ar- 
ticles for the Centralblatt fiir 
Gynakologie, No. 30, 1884, 
and No. 28, 1889. 
2. Cazeaux and Tarnier, Obstetrics, 
last Am. ed., 1889. 
3. Spiegelberg's Midwifery. 
4. Am. Journ. Obstetrics, 1880, 
vol. xii. p. 34. 
5. Detroit Lancet, 1883-4, vol. vii. 
p. 541. 
6. Brit. Med. Journ., 1888, vol. i. 
p. 744. 
7. Hygeia, Stockholm, 1886, vol. 
xlviii. p. 647. 
8. Centralblatt fiir Gynakologie, 
No. 28, 1889. 
9. Hygeia, Stockholm, 1883, vol. 
xlv., No. 40. 
10. Wiener Med. Presse, 1883, vol. 
xxiv. p. 532. 
11. Goodlee, Med. Times and Ga- 
zette, 1883. 
12. Treves, London Lancet, 1884. 
BIBLIOGRAPHY. 
13. Journ. Am. Med. Ass'n, 1886, 
vol. vii. pp. 104-107. 
14. Centralblatt fur Gynakologie, 
1887, No. 10. 
15. Centralblatt fur Gynakologie, 
1888, No. 28. 
16. Journ. Am. Med. Ass'n, 1888 ; 
also Centralblatt ffir Gynako- 
logie, 1888, No. 43. 
17. Zeitschrift f. Geburtsh. u. Gy- 
nak., 1888, Bd. xv. p. 2. 
18. Centralblatt fQr Gynakologie, 
No. 2, 1889. 
19. Archiv fiir Gynakologie, Bd. 
xxix. 1887. 
20. Bryant's Surgery. 
21. The London Lancet, 1886, vol. 
ii. p. 773. 
22. Med. News, Philadelphia, 1889, 
vol. Iv. p. 137. 
23. Frauenarzt, Berlin, 1889, vol. 
iv. 277, 1 pl. 
24. Trans. Edinburgh Obstet. Soc. 
1882-3, vol. viii. p. 101.