RARE OR OBSCURE CASES 337

AN UNUSUAL CASE OF UMBILICAL HERNIA IN AN INFANT.

BY ELLIS C. BOWDEN,

B. D., age 1 month, was brought to the hospital on May 1, 1927, with what appeared at first sight to be a prolapse of large intestine lying on the skin of the anterior abdominal wall through a rupture of the umbilicus, after a fit of crying.

HIsToRY.-The history given was that, after the cord had fallen off, the midvvlfe had applied ‘blue stone’ daily to the navel as it would not heal. Half an hour before admission to hospital the mother had noticed the present condition.

ON EXAMINATIoN.-The child was apparently not in pain, had not vomited, and his general condition was very good. On closer examination

ASSISTAXT SURGEON TO THE ROYAL VICTORIA AND WEST HANTB HOSPITAL, BOURNEXOUTH.

ANT.,ABDOMlN.WALL

SMALL INTESTINE

FIG. 246.-Diagram to show: A, Ulceration at umbilicus into adherent small intestine ; 6, The first stage of prolapse of mesenteric border ; C, The prolapse complete, and forming a sac communicating with the general peritoneal cavity.

it was noticed that the mass was bicornuate in shape and attached by a single pedicle protruding about t in. beyond the skin level a t the umbilicus. Each cornu was about 24 in. long and 1 in. in diameter, lying at right angles to the pedicle and parallel to the surface of the anterior abdominal wall. Their direction was roughly in the long axis of the body and they were pointing in opposite directions. The pedicle was midway between the tips of the two cornua.

OPERATION.-After irrigating the hernia with saline, an incision was made just to the left of the pedicle and the peritoneal cavity opened. Coils of normal small intestine were seen entering the pedicle and filling the two cornua. These coils were reduced, and when the last coil had come through a fold of mesentery was seen passing up into the pedicle. The pedicle was

The surface was smooth and of dark plum colour.

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338 THE BRITISH JOURNAL OF SURGERY

gcntly freed from the surrounding abdominal wall, and when this mesentery was pulled the sac of the hernia everted, leaving a dilated segment of small intestine with an opening on its antimesenteric border large cnough to admit an ordinary pencil. This opening was closed transversely by two layers of Lembert sutures, and the abdomen closed.

The infant made an uninterrupted recovery except for a subcutaneous abscess at the site of the incision. Unfortunately he developed acute gastro- enteritis six weeks later and died.

Thc explanation of this condition is, I think, that the application of the copper sulphate had gradually destroyed the abdominal wall at thc site of the umbilicus. A coil of small intestine became adherent as a result of the local irritation, and eventually the caustic had destroyed one wall of the adherent intestine (Pig. 245, A). The mesenteric border then prolapsed through the opening (a), with its mucous membrane on the outer surface. Finally, it dilated as the coils of small intestine passed into this sac, and formcd the bicornuate mass ( c).

There was no question of a Meckel’s diverticulum, as there was no sugges- tion of a stump, and apparently the coil involved was too far from the czcum for this, nor had there been any previous discharge, fzcal or otherwise.