THE MANAGEMENT OF EXOMPHALOS

431 been associated with a bave been hereditary.

predisposition

Burgess et al. (1951) reported the case of a 53/4-lb. full-term male infant. At birth the entire small bowel and colon were external

to rickets and may

REFERENCES

and appeared gangrenous and atretic. The child was transferred immediately from the labour ward to the operatingtheatre. A stomach-tube was passed immediately after the operation, and continuous suction was maintained for 3 days, and intermittent suction for 2 days further. Oxygen was administered on and off for a month because of cyanotic attacks. Penicillin and streptomycin were given for a week. Subcutaneous fluids were given twice daily on and off for 9 weeks. On the 3rd day of life 2-hourly tube-feeding was started. The tube was removed on the 6th day, but regurgitation continued. On the 22nd day abdominal distension was severe and gastric suction was recommenced, together with an intravenous drip. This seemed to turn the tables ; the infant improved and was discharged on the 75th day. At the age of 15 months there was no defect of the abdominal wall. Case-Record

A. A., Holt, L. E. jun., Frankston, J. E., Irby, V. (1944) Albanese, Johns Hopk. Hosp. 74, 251. Bull. W. A., Pitts, R. F. (1947) Amer. J. Physiol.

Ayer.151,J. 168. L., Schiess,

E., Rose, G.

A.

(1951) Quart. J. Med. 20, 205.

Dent, C. Fanconi, G. (1951) Acta pœdiat., Stockh. 40, 409. Harrison, H. E., Harrison, H. C. (1941) J. clin. Invest. 20, 47. Jonxis, J. H. P., Smith, P. A., Huisman, T. H. J. (1952) Lancet,

ii, 1015.(1951)

Stein, W. H. (1948) J. Moore, - -S., Ibid, 192, 663. Neuberger,

A.

biol. Chem. 176, 367.

(1949) Annu. Rev. Biochem. 18, 243.

Proc. Soc. exp. Biol., N.Y. 78, 705. Stein, W. H.D.(1951) D., Dillon, R. T., MacFadyen, D. A., Hamilton, P. van Slyke, biol. 141, 627. (1941) J. Frankl,Chem. W., Dunn, M. S., Parker, P., Hughes, B.,

Yeh, H. L.,

György, P. (1947) Amer.

J. med. Sci. 214, 507.

THE MANAGEMENT OF EXOMPHALOS R. W. SMITHELLS M.B. Lond., D.C.H. PÆDIATRIC REGISTRAR, BRADFORD

GROUP

OF

HOSPITALS,

YORKS

EXOMPHALOS, or omphalocele, is a abnormality which has been estimated

rare

congenital

to occur about once in every 5000 births. It results from failure of the normal closure of the umbilicus, with protrusion of the

abdominal viscera into the umbilical cord. The viscera are thus covered by the wall of the cord, derived from the amniotic

membrane, but this delicate

sac

ruptured during labour. The prognosis in any exomphalos depends primarily upon whether

may be case of or

not

We recently had in this hospital, within the space of 10 days, two premature infants with exomphalos, in both of whom the membrane was ruptured during labour. The first infant was operated on 11/2 hours after birth, but died 18 hours later from asphyxia due to inhalation of regurgitated stomach contents. The second, a female infant, was delivered normally at home 4 weeks before term. She was admitted to hospital 4 hours after birth. The deficiency in the abdominal wall was about 2 in. in diameter, and through it protruded several coils of small intestine and the caecum. There was no membranous covering. No other congenital abnormality was noted.

A stomach-tube was passed through the mouth, and the stomach was emptied. Crystalline penicillin 100,000 units and streptomycin 500 mg. were given by intramuscular injection. At operation, an hour after admission, it was found impossible to return the viscera through the defect, which was therefore enlarged upwards in the midline The bowels were returned to the abdominal cavity with difficulty, and the wound was closed in a single layer. The ansesthetic used was open ether. On return to the ward the infant was placed in oxygen with the head lowered. Gastric suction was applied, every half-hour at first and later hourly, for 48 hours after operation. The volume withdrawn was measured and recorded, and subcutaneous injections of 2-5% glucose in 0-5% physiological saline solution were given twice daily, equivalent in volume to the amount of fluid withdrawn in the preceding 12 hours. Penicillin and streptomycin therapy was continued for 5 days, and a daily injection of vitamin K was given for sac. 3 days. His own case was a 61/2-lb. full-term male infant delivered On the 3rd day there was no abdominal distension, and with forceps. Two feet of bowel, the caecum, and part of gastric aspiration repeatedly failed to obtain any fluid. The the stomach were outside the abdominal wall. The operation baby weighed 4 lb. 31/2 oz., and milk feeds were started by took place 2 hours after birth, and treatment with oxygen mouth. At first 1 drachm was given hourly, and as there and penicillin was started immediately afterwards. Oral was no regurgitation the size of the feeds was rapidly feeding was started 12 hours after birth but was followed increased. By the end of the first week the infant was by regurgitation, so fluids were given subcutaneously and taking 1 oz. three-hourly and was gaining weight. Normal by intravenous injection on alternate days. Gastric suction -motions were passed from the 3rd day of life. was instituted on the 3rd day of life but abdominal distension There were only three small anxieties during the postremained severe. The abdomen was reopened on the 9th operative period. There was a small amount of bleeding day of life in view of the possibility of some congenital from the wound for 48 hours after operation, presumably obstruction. Peritonitis with adhesions and multiple abscesses from the ductus venosus, but it was never severe and stopped was found; the abscesses were drained. After operation spontaneously. The sutures were left in as long as possible ; continuous intravenous fluids, penicillin, and vitamin K were the first were removed on the 7th, and the last on the 14th, given, gastric suction was continued for 5 days after this postoperative day. The wound appeared to have healed second operation, and oral fluids were then introduced. soundly. Lastly, the umbilical cord, which had been left in 3 days later the intravenous infusion was stopped. The situ, stubbornly refused to slough off until 27 days after birth. abdominal incision later became infected and broke down, The infant was discharged at the age of 5 weeks. but thereafter the infant made an uneventful recovery and At the age of 2 months she weighed 8 lb. and there was was discharged home on the 35th day. At the age of 7 months slight bulging of her abdominal wall, but she was otherwise there was no defect of the abdominal wall. normal. Scheme of Management The second case was a full-term

this membrane is intact, and to a lesser extent upon the size of the visceral protrusion. Where the viscera are completely covered, which is usual, the mortality in capable hands is well below 50%, but where this protective covering has been ruptured the mortality approaches 100%. A survey of the literature shows that only three cases of survival have been reported when the viscera were thus unprotected. Without doubt there must be other cases which have not been reported, but the mortality with a defect of this kind clearly very high. Adams (1948) claimed the first survival after operation on this type of exomphalos. He cited 22 cases of exomphalos reported by Gross and Blodgett (1940) ; 12 of the babies died, including all those born with a ruptured -

(Maguire 1949)

male infant born with the entire intestinal tract external and no sac. The operation took place within half an hour of birth. Parenteral fluids were given for 4 days, oral fluids being started after 48 hours. At the age of 5 months there was no defect of the abdominal wall.

The fundamental principle is to reduce the volume of the abdominal contents to a minimum, both to facilitate the surgeon’s task and to reduce as far as possible the risk of postoperative obstruction. The other major hazard to be prevented is infection, especially where

432 the viscera are not covered. falls into three phases :

The scheme

we

followed

(1)Preoperative (a) Operation is arranged

as soon as possible, but not less than half an hour after admission, which is necessary for proper preparation. (b) The protruding bowel contents are covered with warm sterile saline packs. No attempt is made at a detailed examination, nor is the bowel cleaned. ’ (c) The fluid intake and output are charted. The stomach is emptied, the tube being left down, and the volume withdrawn measured and recorded. (d) Treatment with full doses of antibiotics is started before operation and should include streptomycin or some other drug effective against organisms of the Bact. coli group. No drugs are given by mouth. Atropine gr. 1/200 is given half an hour before operation, and an initial dose of vitamin K may be given.

(2) Operation (a) The anaesthesia must be sufficiently deep to relax the abdominal muscles. This requires the services of a skilled anaesthetist. (b) The external viscera are returned to the abdominal cavity as gently as possible, the umbilical cord being tied and cut at its root. If the natural orifice is not large enough, it may be enlarged by an incision downwards in the midline. If tension is not too great, the skin edges of the orifice should be freshened before it is closed. (c) As the viscera are returned to the abdominal cavity, intestinal contents are liable to regurgitate to the stomach, and may be removed by aspiration through the stomach tube. A mucus catheter should be at hand in case regurgitation into the pharynx should occur.

abnormalities,

and

the time-

lag

between birth and

operation. So far as infection is concerned, the increasing battery of antibiotics at our disposal should render this less Where the and less significant as a cause of death. exomphalos is enormous, special operations, such as that described by Gross (1948), enable the skin defect to be closed with relatively little increase in intraIn less extreme cases, which abdominal pressure. constitute the majority, management on the lines here indicated will ensure that the pressure is reduced to a minimum for as long as necessary.

Summary

-

exomphalos without an is very high. Three previously published cases of recovery are summarised, and a new one is described. The management and prognosis are discussed. The mortality in intact membranous

cases

of

covering

It is a pleasure to thank Dr. R. L. Langley, in charge of the case, and Mr. W. D. Hart, who carried out the operative repair, for permission to publish this case and for their help in preparing this paper. REFERENCES

Adams, F. H. (1948) J. Pediat. 32, 304. Burgess, C. M., Palma, J., Myers, W. A. (1951) Pediatrics, N.Y. 7, 627. Gross, R. E. (1948) Surgery, 24, 277. Blodgett, J. B. (1940) Surg. Gynec. Obstet. 71, 520. Maguire, C. H. (1949) Arch. Surg. 59, 484. -

(3) Postoperative

THE CONTACT TEST

Treatment with antibiotics and vitamin K is continued as long as necessary. Antibiotics may be stopped after 5 days if there is no evidence of infection. (b) The stomach is aspirated every half-hour at first. When less than 2 ml. is withdrawn, it may be done hourly, and is continued for at least 48 hours. If there is no regurgitation or abdominal distension, it may then be stopped. The tube is withdrawn daily for cleaning. (c) Fluid intake, which is by subcutaneous or intravenous route for at least 48 hours, should be equal in volume to the infant’s normal requirements plus the volume of fluid withdrawn by suction. This can be used as a guide to begin with, and adjustment made according to the clinical condition. Oral fluids may be started after 48 hours if the stomach is empty and there is no distension, starting with 1 drachm hourly. The rate of increase in size of the feeds, and the nature of the feeds, will be determined by the size of the infant and its progress. Oral fluids may have to be supplemented by parenteral fluids at first. Repeated vomiting or regurgitation is an indication for recommencing gastric suction. (d) The wound is disturbed as little as possible, and the Small frequent feeds, sutures are left in as long as possible. and sedatives if necessary, will keep the infant contented. Crying will strain the wound. (e) Any rise of temperature at two consecutive 4-hourly readings is an indication for an immediate return to full doses of antibiotics. Any non-infective cause, such as dehydration, should be corrected.

(a)

Discussion

The principal hazards facing the infant with exomphalos are infection while the viscera are outside the abdomen, and excessive intra-abdominal pressure after they have been replaced. This pressure may lead to regurgitation and asphyxia, as in our first case, or to intestinal obstruction, as in one of the American cases cited. Further, these infants are often weakly and may have other congenital defects. The prognosis therefore depends on the presence or absence of an intact membranous covering, which forms a considerable barrier to infection ; on the size of the exomphalos, which determines to some extent the increase in intra-abdominal pressure after repair ; and on the general condition of the infant, with special reference to it, maturity, the presence of associated

A METHOD OF MEASURING SPERMICIDAL ACTION

H. A. DAVIDSON M.R.C.S. DIRECTOR,

FAMILY PLANNING ASSOCIATION LABORATORIES; OITICER, MALE FERTILITY CLINIC, ROYAL

MEDICAL

NORTHERN

HOSPITAL, LONDON

MOST contraceptive preparations used as an adjuvant to occlusive devices consist of a vehicle (ointment base, jelly, &c.) which carries a chemical lethal to spermatozoa. The efficiency of such preparations depends on three main factors : (1) the capacity of the vehicle to interpose a mechanical barrier between the cervix and the ejaculate ; (2) the nature and amount of the chemical used; and (3) its ready release from the vehicle to penetrate into the surrounding medium. I do not propose to discuss the " barrier effect " here. This is a matter for the physicist. However, it cannot be overemphasised that in assessing the quality of a preparation the physical characteristics of the vehicle are at least as important as the spermicidal effect.

Spermicidal Tests Extensive

research

has

been

undertaken

on

the

spermicidal properties of a large number of pure chemicals and their commercial formulations. Standards of spermicidal power form the basis of selection for such publications as the " Approved List " of the Family Planning Association in this country, and the " New and Nonofficial Remedies " of the American Medical Association (1950). Most of the spermicidal tests in common use are conducted by mixing semen with diluted or undiluted spermicide in known quantities and noting the time required to kill all the spermatozoa. Alternatively, the assessment is based upon the highest dilution of a preparation lethal to spermatozoa in a given time. To cite two

examples :

In the Brown-Gamble test (Brown and Gamble 1941), adopted by the American Medical Association, equal quantities of semen and of a 1/4 dilution of contraceptive are mixed,

(1)