With very large hernia•, or in difficult deliveries, the sac sometimes ruptures during labor and the child is born with extruded viscera,. ln some cases gangrene of the intestines and the formation of a fa.eal fistula occur even within the first days; in such cases the accompanying peri tonitis results fatally.
Pathogenesis.—The occurrence of hernia of the cord is ,generally attributed (Oken, Ahlfeldt) to the failure of the intestinal coils, nor mally present in the cord in the second and third foetal months, to re turn to the abdominal cavity before its complete closure. The cause of this lies, according to Ahlfeldt, in the behavior of the ductus oniphalo entericus, the vitelline duet, which in the second feetal month extends from the yolk-sac through the cord to the intestinal tube. Normally this duct becomes thinner and thinner and finally atrophies completely. The intestinal coils leave the cord and fall back into the abdominal cav ity before the abdominal wall closes down to the opening necessary for the passage of the structures of the cord. However, the return is hin dered in those cases where the ductus omphalomesentericus either does not disappear at all or else where it does not disappear until the cavity is closed clown to the umbilical ring, the opening for the vessels of the cord and the uraehus. It is difficult to explain the origin of those her nice in which the liver, with or without the intestine, forms the hernial contents.
Ahlfeldt's explanation might suffice, in the cases where the liver and other organs, together with intestines lie in the amniotic covering; on account of the extrusion of the intestinal coils there is more room in the abdomen for the other organs; these are, therefore, less tightly held in place, become more movable and fall into the hernial sac. Possibly the prolapse of the liver has some connection with the excessive growth of this organ and especially of its left lobe (Tandler).
According to Aschoff one can not explain these hernke, nor herniT of the liver alone, nor any umbilical cord hernim, by a persistence of the ductus omphalomesentericus; but rather in a totally different way. Aschoff assumes that in these cases the liver is not developed laterally in the abdomen under the closed abdominal wall, as in the normal development; but rather in an abnormal location. The abnormal posi
tion of the umbilical veins in these cases argues for this theory. This explanation may be considered as satisfactory for the rare cases in which the liver alone is found in the hernial sac.
The prognosis of hernia funiculi umbilicalis was formerly an lutely unfavorable one. However, since the institution of the operative treatment, the prospect of the survival of the child is very promising, if the operation is performed as early as possible. According to the statistics of Kindt, out of 65 cases treated by operation, 50 were cured. The treatment of hernia of the cord must not be expectant. Before the introduction of asepsis, operation was shunned and the treatment consisted in covering the sac with gauze; with small hernife the tents were sometimes reduced and the hernial sae closed with plaster or by applying silver coins. At the present time we believe that every co-called conservative method should be discarded and as soon after birth as possible one of the operations recommended should be per formed. The so-called radical operation, first performed by Lindfors in is the simplest; the hernial sac is opened and cut away, the skin margins are freshened and after reposition of the hernial contents the abdominal wound is sutured. Amniotic adhesions must be loosened. Olshausen recommends an extraperitoneal method in which the amnion is separated from the peritoneum and the latter with the hernial con tents is replaced without opening the peritoneal cavity; the edges of the opening are then freshened and sewed together. In the cases in which reposition without opening the sac can be carried out, or where the contents are very small, C. lireus reccmmends the employment of percutaneous ligature. The organs are replaced. a clamp is placed around the sac. taking in the skin, and the sac is then opened and dissected away; below the clamp two or more sutures are passed through and through and knotted and the clamp removed.