CONGENITAL ANOMALIES OF THE UMBILICAL REGION (See Plate 7) 1. Amniotic Narel.—Normally the skin of the abdominal wall ex tends for about 1 cm. over the umbilical cord, the base of which it cylin drically encircles. In very rare cases the skin is lacking over the lower part of the cord and the adjacent abdominal wall, so that the amnion not only extends over the lowest part of the cord but also spreads out over the skin defect as a- delicate, transparent membrane.
The navel ring, the fibrous tissue, abdominal muscles and peri toneum are, however, normally developed. The disc of amnion becomes dessieated' like the cord, turns dark in color and separates after a few days. The skin-defeet heals by granulation and sear-formation. The life and progress of the child are not influenced by this anomaly.
2. Cutis Narel.—(Skin navel, cutaneous umbilicus).—A not un common anomaly occurs when the abdominal skin is not drawn in like a funnel, after the separation of the cord, and thus the formation of the navel-folds is wanting. Then there appears in the umbilical region a projecting cylinder of skin, about 1-11 cm. in length, at the apex of which the umbilical wound is found. The wound heals and the skin cylinder persists. This anomaly has been explained by assuming that the abdominal skin extends for an abnormally great distance over the cord (Widerhofer). However, it is more probable that in a large number of instances, the cutis navel does not arise in this way, but rather because of the failure of the physiologic infolding of the free margin of the skin of the cord, which should follow the separation of the cord. Umbilical hernia occurs frequently in such children. With the growth of the child the superfluous skin of the umbilicus is drawn upon for the covering of the abdomen so that it gradually disappears completely.
3. Hernia of the Umbilical Cord.—(Congenital umbilical hernia; hernia funiculi umbiliealis).—In the sixth to tenth week of fatal life the umbilical cord contains one or more loops of intestine, which later in foetal life are drawn back into the abdominal cavity. The persis tence of intestinal coils and other abdominal organs outside of the body cavity constitutes a failure of development which should here be con sidered on account of its frequency and the good results achieved by proper surgical treatment.
Symptoms and umbilical region in the newborn is found occupied by a swelling which is half-globular, egg-shaped, or pear-shaped. Its size varies; tumors from the size of a nut to that of a child's head have been found. They have a bluish-white transparent covering which is continuous with that of the cord; the cord is not usually attached to the middle of the tumor but rather to its lower half. The covering of the mass is sharply defined from the abdominal skin which surrounds its base. If the covering is transparent One is able to recognize the intestinal coils or the other abdominal organs. The cov ering is, however, usually thickened in spots and sometimes in its en tirety. The delicate transparent covering is formed by the amnion and the parietal peritoneum. The thickened areas result from the spread ing of Wharton's jelly over the covering of the tumor and sometimes from fibrous thickening following an inflammatory process. On palpa tion, the tumor is of a soft consistency containing harder masses within. It is sometimes attached to the abdomen by a broad base and some times it has n pedick. If the child lives a few hours or days, the cover ing becomes opaque and inflammatory signs ensue at the border of the abdominal skin: soon the covering of the mass dries up at the same time as the cord and then it separates. In very rare eases (and especially where the rupture is small) the hernial contents may return into the abdominal cavity; the abdominal cavity is then closed by granulations and thus the hernia is cured; or else the exposed parts, after separation of the tumor covering, become, as a consequence of an active inflamma tion, covered with granulations which gradually undergo epidermiza tion and the healing of the hernia is thus brought about. These are, however, very rare occurrences. In the vast majority of instances peri tonitis occurs after the separation of the hernial sac or before, and death follows.