Book - Umbilicus (1916) 15
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Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.
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Chapter XV. Umbilical Concretions Associated with Inflammatory Changes in the Abdominal Wall
Cases with umbilical concretions.
Umbilical concretions frequently diagnosed as dermoids.
Cases of umbilical horn.
Other foreign substances in the umbilical depression.
This subject has been very carefully considered by Blum, Nicaise, Villar, Foulerton, Ledderhose, and Pernice. Umbilical concretions seem to be much more frequent in men than in women, and usually occur during the period of life in which the patient is most actively engaged in work, namely, between the twentieth and sixtieth year. They are exceptional in children and not common in the aged.
As a rule, the patient is unaware of any trouble until abdominal pain is felt. This is usually referred to the umbilical region, and may be increased on muscular exertion, on defecation, or on pressure upon the abdomen. On visual examination sometimes nothing is detected. Later induration is noted in the umbilical region, the umbilical opening becomes very small, and the surrounding tissue feels hard. The overlying skin may or may not be reddened. At this stage the patient may have excruciating abdominal pain, followed by the escape of a foreign body, together with some blood and pus. A speedy disappearance of the symptoms usually follows.
In the majority of cases the umbilical depression is the center of the trouble, but occasionally the swelling and induration are situated a short distance from it. This was noted in Williams's case. The tumor, the size of an egg, was situated one inch above the umbilicus, whereas the discharge came from the umbilicus itself.
The umbilical opening, as a rule, is very small, and suggests the mouth of a fistula. Its margins are usually flat, but occasionally the opening is surrounded by a zone of granulation tissue, as noted in cases reported by Foulerton, Nicaise, Polaillon, Richelot, Roques, Shattock, and Tremontani.
On examination the umbilical cavity is invariably found distended and filled with pus and a concretion or cheesy material. The cavity itself may be several centimeters in diameter. In Nicaise's case the umbilical depression opened through a very narrow aperture into a second cavity, which contained the concretion.
In Taylor's case, when opened up, the umbilical cavity was found to contain an ounce of foul-smelling pus, and this cavity communicated with a second filled with a softened, cheesy material and some hair.
Walters, under the title "An Umbilical Pocket," reports a very instructive
248 THE UMBILICUS AND ITS DISEASES.
case. A man, aged thirty-four, had complained of mild periodic attacks of abdominal pain. The umbilical depression led to a second pocket, containing a yellowish mass, which the patient said had been there for years. The mass consisted of sebaceous material and felted hair. The pocket was two inches in diameter and three-quarters of an inch deep.
Probably one of the most interesting and instructive cases is that reported by Foulerton. Protruding from the umbilical site was a smooth, solid, round, reddish growth, the size of a cherry, from which there was a slight discharge. Surrounding this was a zone of induration. Cancer was suspected. Under local freezing the growth was cut off flush with the abdominal wall, opening up an abscess sac which contained pus and a concretion the size of a cherry-stone. The red nodule proved to be granulation tissue around the mouth of a small fistulous opening, and the abscess sac was nothing more than the occluded umbilical depression. Healing was complete in two weeks.
Although the induration in the abdominal wall is usually uniform, there may be marked local elevation. In one instance the swelling was as large as a hen's egg, and in the one described by Gueterbock it reached the dimensions of a child's head, a large collection of pus being present. The umbilical discharge may be small in amount or very free. Sometimes it is seropurulent, but usually most offensive, and of an odor suggesting decomposing smegma.
The umbilical concretions are variously recorded as being the size of a pea, bean, almond, sparrow's egg, or pigeon's egg. They have reached 1.5 to 2.5 cm. or more in diameter. They may be whitish yellow, brown, or pearly in color. Sometimes they appear to consist almost entirely of sebaceous material, and are exceedingly friable. Other concretions are much firmer, have a laminated structure, present a pearly appearance, and constitute what Coenen has termed cholesteatomata. The surface of these concretions may be perfectly smooth, or small hairs may be seen projecting from their surfaces. These hairs may be colorless or correspond in color to those of the patient. The cheesy material sometimes contains, in addition, other foreign material, such as wool or cotton fibers from the patient's clothing and particles of such matter as clay, coal, or stone, according to the occupation of the individual. On histologic examination the cheesy material is seen to consist of fatty desquamated epithelium, and in some cases keratin, fatty debris, and cholesterin crystals are also found.
The cause of these umbilical inflammations is easy to explain. Owing to lack of cleanliness or to an unusually deep umbilicus, particles of hair or wool accumulate deep m the umbilical depression. These form a small ball, which in turn, by its irritation, causes exfoliation of the squamous epithelium. This adheres to the mass and gradually increases its size. Finally, as a result of the constant irritation, there ensues a mild inflammation of the tissue surrounding the umbilicus, which gradually narrows the umbilical opening until it becomes but little larger in diameter than a fistulous tract. Pus accumulates and dilates the umbilical depression, and an abscess cavity containing a concretion results.
This condition rarely leads to serious consequences. In one of Volkmann's* cases, however, it would seem that the long-continued irritation of the concretion had induced a primary carcinoma of the umbilicus.
The history of these cases is characteristic, and there should be little difficulty
- Volkmann (Cited by Pernice) : Die Nabelgeschwtilste, Halle, 1892.
Fig. 147. — A Small Umbilical Concretion. From a woman, ninety-seven years of age, seen at the Church Home June 4, 1910. The umbilical opening was small; completely filling it was a small black mass, which on pressure was partly forced out. It consisted of cheesy material. The superficial portion had become black as a result of exposure to the light, air, and dust.
in establishing the diagnosis. In Foulerton's case, however, the condition was supposed to be one of carcinoma of the umbilicus.
Treatment. — This consists in widely dilating the fistulous tract with the full knowledge that in the depth a concretion or caseous material or both will be found. Thorough removal of the foreign substance is invariably followed by prompt recovery, but as long as portions remain there will be a discharge. Occasionally an umbilical concretion may be present without producing any inflammatory reaction. On June 4, 1910, I saw a patient ninety-seven years of age at the Church Home, Baltimore. The umbilicus was exceedingly small; projecting from it, and completely filling the opening, was a small black mass (Fig. 147) . The house officer suspected a malignant growth. On making pressure I forced the mass farther out. The deeper portions presented the characteristic cheesy character of a concretion. The superficial portion had become hard and black on account of exposure to the light, air, and dust.
While analyzing this group of cases the following case came under my care: Mr. S. W., aged thirty-two, was seen on March 31, 1913. This patient had been ill for two weeks; previous to this time he had been perfectly well. On examination I found the umbilicus pouting out like a snout. It projected out about 1 cm., and from its center there was a discharge of creamy pus. The opening from which this pus escaped was about 2 mm. in diameter. The abdominal wall on each side was indurated over an area of about 3 cm., and there was a distinct flush. Fig. 148 is a water-color sketch of the condition. On pressure the parts were found to be indurated and there was a good deal of discomfort. I felt sure that we were dealing with an accumulation of sebaceous material, and that this had caused an acute inflammation.
Bichlorid compresses were applied for forty-eight hours. The patient was then brought to the operating-room, and with a pair of Kelly forceps the opening at the umbilicus was stretched. We then used a sharp curet and brought away quantities of sebaceous material. The
Fig. 148. — Acute Inflammation op the Umbilicus due to an Accumulation of Sebaceous Material. The umbilical depression is raised and tense. Near its center pus is seen escaping from a small orifice. The surrounding abdominal wall is swollen, red, and indurated. The small opening was stretched considerably, and the cavity evacuated. A large quantity of cheesy material was cureted away. The cavity was packed with gauze. The inflammation speedily subsided, and in a few weeks the umbilicus presented the normal appearance.
250 THE UMBILICUS AND ITS DISEASES.
cavity was packed with iodoform gauze. From clay to day the wound was washed out with hydrogen dioxid. The patient was discharged on April 5, 1913. On April 21st the umbilicus presented the normal appearance, and there was not the slightest trace of inflammation or of discharge.
CASES WITH UMBILICAL CONCRETIONS.
In some cases I have given an exact translation of the original title, although on careful examination of the description of the case it is evident that the patient was suffering from an umbilical concretion and not from a dermoid cyst, as diagnosed by the individual author.
Tuberculosis o f t h e Umbilicusf?].* — Ten days before the patient had had cramp-like pains in the abdomen, followed in three days by a discharge from the umbilicus, accompanied by tenderness and soreness in that region. His sisters had died of tuberculosis. There was a purulent discharge from the umbilicus and slight swelling to the right and below it, apparently in the deeper portion of the abdominal wall.
At operation the umbilical opening was enlarged, and over an ounce of "typical tuberculous " granulation tissue removed. The cavity, the size of a walnut, internal to the abdominal wall was exposed and packed with iodoform gauze.
Smears of this showed numerous "tubercle bacilli" in some specimens, none in others. Bouffleur questioned whether he was dealing with a primary tuberculosis of the blind urachus or- Meckel's diverticulum or with a primary umbilical tuberculosis.
[The history of the case and the findings at operation would rather suggest an accumulation of sebaceous material at the umbilicus than any tuberculous process. The acid-fast organisms found were possibly smegma bacilli.- — T. S. C]
Umbilical Concretions. f — In two cases of phlegmonous inflammation of the umbilical region with fistula, Bufalini found at the bottom of the abscess stony concretions which consisted of fatty and gritty particles, of carbonic acid chalk, exfoliated epithelium, and threads from clothing.
Cholesteatomata of the Umbilicus. — Coeneni said that in the last two years two cases of "pearl tumor" of the umbilicus had been seen in Kiittner's clinic. The first had already been reported in Brun's Beitrage, Bd. lviii, Hft. 3.
Case 1. — The patient, forty-nine years old, had a purulent discharge and a general phlegmonous condition in the region of the umbilicus. Slight jaundice developed and the umbilicus became very prominent. An incision was made, and an abscess cavity the size of a hen's egg was found at the umbilicus. This contained a tumor the size of a pigeon's egg (Fig. 149). It was made up of concentric layers of glistening mother-of-pearl tissue. These layers were arranged just as the various layers of an onion, and consisted of hornified epithelium. The process was complicated by suppuration.
Case 2. — A man of strong build, aged twenty-five, a few days before admission
- Bouffleur: Clinical Review, Chicago, 1898, ix, 329.
t Bufalini, G.: Jahresbericht der gesammt. Med., 1887, ii, 497.
i Coenen, H.: Ueber das Cholesteatom des Nabels. Beitrage zur klin. Chir., 1908, lviii, 718; Munch, med. Wochenschr., 1909, lvi, II, 1583.
Fig. 149. — Cholesteatoma from the Umbilicus in Case 1. (After Coenen.) From the description, this is apparently the natural size. It was described as being the size of a pigeon's egg.
to the hospital had noticed at the umbilicus a swelling from which purulent fluid escaped. At the umbilicus was a smooth, pea-sized elevation, reddish in color, soft in consistence. When slight pressure was made on the umbilical funnel, there escaped a body the size of an acorn (Fig. 150). It had a mother-of-pearl, glistening appearance, was composed of horny layers, and at once brought to mind the previous case of cholesteatoma of the umbilicus. With the patient anesthetized, the posterior surface of the umbilical ring was found adherent to the gastrocolic ligament. These adhesions, together with the ligamentum teres and the obliterated urachus, were cut through. The umbilicus, which contained a small tumor the size of a hazel-nut, was removed. The abdomen was closed, and healing took place without difficulty. Histologically, the tissue lying in the umbilical funnel consisted of markedly proliferating fibrous tissue with abundant small-round-cell infiltration and cells around the bloodvessels. Covering the surface of the fibrous tissue was a very thick layer of epithelium. This had exfoliated quantities of horny epithelium, so that in the space between this projection and the wall of the umbilical ring there was a large amount of horny epithelium. The connective tissue itself showed marked subepithelial cell proliferation, just as is seen in the vicinity of carcinomatous prolongations. Nevertheless, no carcinomatous infiltration by the epithelium could be definitely made out.
Sections from the cholesteatoma stained with Gram were intensely blue. The cells shewed keratin bodies. In the umbilical funnel there was a knob-like fibroma (Figs. 151 and 152). There was marked proliferation of its epithelial covering, and there had been a continual throwing off of layers of epithelium into the umbilical depression. This desquamated epithelium was held in the umbilicus, the fibroma acting as a cork to the umbilical opening. In layer after layer the exfoliated epithelial cells had accumulated into a large plaque, forming the cholesteatomatous mass. Probably this process had existed for years, but was only noted by the patient when an abundant purulent discharge took place.
According to Coenen, the primary cause in this second case of cholesteatoma of the umbilicus was without doubt the presence of the fibrous tumor in the umbilical depression. The continuous irritation of the products of the cholesteatoma in the umbilical ring could now easily lead to an eczematous inflammation of the skin of the umbilicus, to abscess formation, and to phlegmon.
Cholesteatoma of the Umbilicus. — Coenen * described a case from Kuttner's clinic. A woman, sixty-two years old, had a pendulous abdomen and lax abdominal walls. When the various folds were drawn away from one another, there was seen in the umbilicus the characteristic pearly, glistening epithelial exfoliation noted in a cholesteatoma. The growth could be lifted out with a spoon and appeared as small balls the size of a pea or of a bean. If the material had remained longer, it would have developed into a cholestea
- Coenen, H.: Loc. cit.
Fig. 1.50. — Cholesteatoma FROM Case 2. (After Coenen.)
It was the size of an acorn.
THE UMBILICUS AND ITS DISEASES.
toma. In this case there was a desquamative omphalitis with an accumulation of cholesteatomatous masses in the umbilical ring. Coenen calls attention to the analogy between cholesteatoma of the umbilicus and cholesteatoma of the ear.
Fig. 151. — The Coxxective-tissue Projection" Really Represexts a Small Fibroma in the Floor of the
Umbilicus. (After Coenen.)
It consists of fibrous tissue showing marked small-round-cell infiltration. The covering consists of many layers of
squamous epithelium, superficial portions of which are horny.
Fig. 152. — Exlargemext of Fig. 151. (After Coenen.) The excessive thickening of the squamous epithelium in the umbilical depression is shown. The center of the epithelial areas shows hornification. The underlying tissue shows small-round-cell infiltration, particularly well seen around the capillaries.
Fistulous Abscess of the Umbilicus.* — A digger, forty-six years of age, had always been healthy except for a pleurisy at four years of age. He said that fifteen days before coming under observation he had had pain in the
- Derville, L. : Abces fistuleux do I'ombilic. Jour. d. sci. med. de Lille, 1894, ii, 320.
UMBILICAL CONCRETIONS. 253
umbilical region, and at the same time a serous discharge from the umbilicus. The pain increased greatly, and after the application of poultices a grayish piece of stone the size of a pea came away. A probe was passed to a depth of 2 cm.
A Sebaceous Umbilical Tumor.* — At autopsy on a stout woman, seventy-five years of age, a small, elongate tumor at the umbilicus, with a little opening, was found. A probe introduced into this opening was arrested by a yellow, very hard body. An incision showed that the cavity was continuous with the skin. The body in this cavity was ovoid in form, the size of an almond, whitish yellow, and sticky. It had the odor of infected smegma.
On microscopic examination it was found to consist of cholesterin and an accumulation of exfoliated epithelium.
Growths from the Umbilicus. f — A dockyard laborer, aged forty-nine, had protruding from the site of the umbilicus a smooth, solid, round growth the size of a cherry. This had a covering resembling mucous membrane, and from it there was slight discharge. Its base was somewhat constricted, but there was no definite pedicle, and no sulcus could be detected between the growth and the surrounding skin. Around the growth was a zone of uniform induration extending for an inch and a quarter in every direction, involving the skin and subcutaneous tissue. The skin over the indurated region was of the natural appearance, adherent to the subcutaneous tissue, and extremely tender. The patient thought that his umbilicus had always been smaller than usual, but had noticed nothing else until three weeks previously, when a very painful lump had suddenly appeared there. The lump was considerably smaller when he first saw it than on admission. The pain had been extreme and continuous. The surgeon who sent him to Foulerton had diagnosed cancer, and, as a matter of fact, the growth had every appearance of epithelioma. The pain had been, however, too acute in its commencement and in its intensity. The growth was removed at the level of the skin under the ether spray, and a cavity was exposed. This contained some thin, purulent fluid, and a hard mass of inspissated sebaceous material the size of a cherry-stone. The cavity admitted the tip of the finger; it was laid open, scraped out, and a poultice was applied.' Four days later the induration was gone and the wound healed up in two weeks. Foulerton draws attention to his article in the Lancet of July 7, 1888, in which he described four intractable umbilical sinuses due to concretions. No microscopic examination was made in this case.
Dermoid Cysts of t heUmbilicus [?].j — -A man, thirty-five years of age, entered the hospital for umbilical suppuration. About five months before a small tumor had been noted at the umbilicus. This had reached the size of a walnut and was slightly painful. It had been incised a month before admission, and a caseous mass and a tuft of hair had escaped. Gonard found the umbilicus indurated and red; the orifice was very small, and from it drops of pus escaped. A probe was passed 2 cm. into the depth, and the sac dissected out. Gonard thought it was a dermoid cyst on account of the hair and the inner lining.
[Probably the case was one of inflammation due to the presence of a foreign body.— T. S. C]
- Fere, C. : Tumeur sebacee ombilical. Bull. Soc. anat. de Paris, 1875, 1, 622.
t Foulerton, A. G. R.: Illustrated Med. News, 1889, iv, 161.
t Gonard, G. : Des kystes dermoides. These de Alontpellier, 1906, No. 31.
254 THE UMBILICUS AND ITS DISEASES.
A Dermoid Tumor of the Umbilicus [?]. * — -A girl of sixteen had noticed a swelling in the abdomen fourteen days before coming under observation. During the last eight days this had rapidly increased in size. On admission it was the size of a child's head, round, and at several points markedly nodular. It was situated in the mid-line, was easily grasped, was firm, not very elastic, somewhat movable, and slightly painful on pressure. Three days later fever developed, and after two days more redness and fluctuation were noted. On the following day there was an abundant quantity of thin pus coming from an irregular hole in the tumor. Sebaceous masses and portions of a thin membrane were then removed. The tumor, after its contents had escaped, became markedly smaller and gradually disappeared. Microscopic examination showed free nuclei, granules, cholesterin crystals, and fat.
[If it had been a dermoid, why had it appeared so suddenly and why did it disappear completely, although all the wall was certainly not removed? Was it not more probably an abscess? — T. S. C]
An Umbilical Concretion the Size of a Pigeon's Egg. — Hahnf says concretions of the umbilicus occurring as a result of lack of cleanliness are not rare. His patient, a joiner, forty-three years old, fourteen days before he came under observation had noticed a painful swelling at the umbilicus. The skin was unchanged. For four days before Hahn saw him pus had been escaping from the umbilicus. On examination a swelling on the right side of the umbilical depression was found, and a tumor the size of a walnut, circumscribed, smooth, firm, and painful on manipulation. There was an escape of thick, greenish, foul pus in small quantities. The sound passed 2 cm. downward and to the right. After a few days there was edema of the skin and a slight elevation of temperature.
A transverse incision was made to the right. Pus with whitish, friable particles escaped. In the depth was a roundish, whitish, glistening tumor, the size of a pigeon's egg, which was easily removed. It was 3 cm. long and 2 cm. broad. It was yellowish white, rather firm, and friable. It had an outer covering 3 to 4 mm. thick, with a blackish central portion. On histologic examination it was found to be composed of horny epithelium, fat, sebaceous masses, dirt, and particles of coal. The dark center had the same constituents and also contained wool fibers. Hahn draws attention to the fact that such concretions are often confused with suppurating dermoids.
An Umbilical Concretion. — - According to Ledderhose,t Gilbert described a concretion which was composed of lamellae. It showed amorphous and crystalline fat, leukocytes, and fragments of chalk.
An Umbilical Concretion. § — Duplay's patient was a stout, elderly woman. At autopsy, at the umbilical level there could be felt a small, elongate tumor directed obliquely downward and then backward. This occupied a fatty pocket. The upper portion of the umbilical wall was intact. When the
- 1 Gueterbock, P.: Ueber einen Fall von Dermoidgeschwulst cles Nabels. Deut. Zeitschr. f. Chir., 1891, xxxii, 319; Deutsche med. Wochenschr., 1891, xvii, 1079.
t Halm, Otto: Ein Nabelkonkrement von Taubeneigrosse. Beitrage z. klin. Chir., 1900, xxvi, 80.
i Ledderho.se, G.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b.
§ Nicaise: Ombilic. Dictiormaire encyclopedique des sci. med., Paris, 2. ser., xv, 1881, 140.
UMBILICAL CONCRETIONS. 255
margins of the cutaneous depression were separated, at the bottom could be seen a small opening a little over 1 mm. in diameter. A probe introduced impinged upon a foreign body which was yellowish in color. An incision was made, and at the umbilical cicatrix was found a sac-like formation containing a hard, homogeneous body the size of an almond and consisting of sebaceous material.
An Umbilical Concretion. — Nicaise * r eports the following case, seen by Notta, in which an accumulation of sebaceous material had given rise to an inflammation of the umbilicus. A shoemaker, aged fifty-six, had previously had excellent health. Two years before he had noticed at the umbilicus a hardness without any change in color of the skin and without any discharge. This hardness had increased in volume very slowly, and only later had become painful. At last he could not bear the clothes to come in contact with the part, and his work naturally augmented the pain. He was not able to hold the shoe against his umbilicus, as is the custom with shoemakers, but was obliged to work with it applied to another part of the abdomen. About June 10, 1878, the pain had become more severe, the skin had reddened, ulceration had occurred in the center of the umbilicus, and a small amount of pus had escaped until a fragment of a sebaceous calculus, the size of a filbert, had come away spontaneously, and the pain had ceased. His physician later had extracted several fragments. When called in consultation, Notta found the umbilicus tumefied and the skin red and indurated for a distance of from 12 to 15 cm. around it. In the center was an area of ulceration 15 mm. in diameter, at the bottom of which, bathed in pus, was a whitish mass. After enlarging the opening Notta extracted the whitish mass, the size of a walnut, which consisted of hard sebaceous material. Linseed poultices were applied for twenty-four hours, and later lint steeped in aromatic wine. The umbilicus healed rapidly. The cause of this affection, according to Notta, was very simple. Sebaceous material had accumulated in the deep folds of the umbilicus, and little by little had condensed to form a mass having the appearance of a calculus. This had produced an inflammation which had caused the elimination.
Inflammation in the Umbilical Depression. — Park'sf patient was thirty years old, and for two or three years had had a slight but constant discharge from a small opening at the umbilicus. At no time had this had a fecal or urinary odor. It was seropurulent in character, and excoriated the parts.
The cavity was slit open with a probe as a guide. It had the diameter of an almond, and had glistening walls; it contained no hair or epithelial products. Park thought it was a dermoid. The cavity was scraped out, packed, and partly closed. Healing took place.
[In this case there had evidently been a simple inflammatory condition. — T. S. C]
Umbilical Concretion. — Pernice J reports a case of Longuet's.§ A young woman had a swelling at the umbilicus for three weeks. At first there was no pain. Later it began to suppurate. Three days after the patient's entrance
- Nicaise: Op. cit.
f Park, Roswell: Clinical Lecture on Congenital Fistulae and Sinuses at the Umbilicus. Med. Fortnightly, 1896, ix, 9.
t Pernice, L. : Die Nabelgeschwulste, Halle, 1892. § Longuet: Bull. Soc. anat. de Paris, 1875.
256 THE UMBILICUS AND ITS DISEASES.
to the hospital, as a result of the introduction of a sound, a foreign body was expelled. It was the size of an almond, hard, made up of epithelial masses and fatty crystals.
Umbilical Concretions.* — A man, forty years of age, after muscular exercise had felt something give way in the region of the umbilicus, and after that had had pain there. The umbilicus was red, swollen, and projected 3 cm. from the abdomen. From it there escaped a foul-smelling discharge. On pressure two bodies the size of beans were forced out. They consisted entirely of matted hair.
Suppurating Dermoid Cyst of the Umbilical Region [ ? ] . f — A woman, thirty years of age, presented a tumor in the umbilical region. When one year old, she had had a blow on the umbilicus. For several days, during the six weeks before she was admitted, her abdomen had continually come in contact with the wash-tub. For about three days she had had pain in the umbilical region. A few days later she had noticed a discharge from the umbilicus and a swelling for a distance of 2 cm. around the umbilical region. Squeezing caused a moderate amount of pus to escape from the umbilicus. On admission there was an elevated area of proud flesh the size of a pigeon's egg. The umbilicus was red and thickened; fluctuation was evident. An incision evacuated pus and grumous material. A probe passed 4 cm. downward. The cavity was irrigated. About two weeks later a sebaceous-like mass, the size of a walnut, escaped.
[The condition suggests a foreign body or a concretion rather than a dermoid. — T. S. C]
Subumbilical Tuberculous Abscesses [?].| — ■ Case 1 . A man, thirty-five years old, had complained of swelling in the umbilical region for about a month. He had vomiting, and pain at the umbilicus. Following this there had developed a painful swelling, but when his physician, thinking it was a hernia, had attempted to reduce the mass by taxis, pus had escaped from the umbilicus. Since then there had been a fistulous opening and a phlegmonous induration of the region. The patient's general condition was good. The tumefaction was exactly in the median line and symmetric. A probe could be introduced only with difficulty, except when curved. A sound passed 7 or 8 cm. below the umbilicus, both to the right and left.
The tumor opened toward the right side, and one day a large mass of caseous material came away. The opening closed, and the patient left the hospital. Six months later there was pain in the abdomen, but nothing was noted at the umbilicus.
Ten years before the patient had had inflammation of the left lung and a pleuropneumonia on the right side five years later, but never a hemorrhage. Auscultation was negative.
[The history of the case and the character of the discharge strongly indicate an accumulation of sebaceous material in the umbilicus. Had tuberculosis existed, one would hardly have expected the cavity to have closed so satisfactorily. — T. S. C]
Case 2. — Richelot reports a personal communication from Verneuil. A Sister of Charity, who had had scrofula as a child and also an old coxalgia, received a contusion beneath the umbilicus when using a good deal of force in closing a drawer.
- Pernice, L.: Op. cit. Labalbary: Gaz. des hop., 1862, 443.
t Polaillon: Kyste dermoi'de suppure de la region ombilicale. Gaz. med. de Paris, 1886, lvii, 43.5.
% Richelot, L. G.: Abces tuberculeux sous-ombilical. L'union med., 1883, xxxv, 61.
UMBILICAL CONCRETIONS. 257
Several weeks later a fluctuating tumor was noted at the umbilicus. It was incised, and a large quantity of milk-like fluid escaped. A fistula developed several months later; she began to cough, and finally died of tuberculosis.
An Umbilical Concretion.* — The patient, fifty years old, had been previously in good health. The umbilicus formed a deep cul-de-sac surrounded by a red and tumefied zone. It was painful on pressure. The pain was increased on movement or on defecation. Applications were made, and later there was a discharge of seromucous fluid and a small body came away. The symptoms rapidly subsided. This nodule was spheric, the size of a hazelnut, and hard. On section it showed black and white areas. The black particles occupied the center; the whitish areas were soluble in ether.
[There were evidently foreign bodies associated with an accumulation of epithelium.— T. S. C]
An Umbilical Concretion, f — A soldier, thirty-two years of age, complained of pain at the umbilicus for fifteen days. The pain was extreme and there was a certain amount of heat in the depth of the tissue. Surrounding the umbilicus was a tumefied and red area. When a probe was introduced, a sensation of a hard body in the depth could be made out and an abundant amount of sebaceous material escaped. At the end of five days a probe could be introduced 7 cm. On the twentieth day there were violent contractions, accompanied by severe pain, and a foreign body escaped with half a glass of pus and blood.
This body was the size of a sparrow's egg, pearly in color, and had a sebaceous odor. Its center was hard and consisted of a piece of clay containing several particles of grit and several hairs of the same color as those of the patient. He was a stone-cutter, and particles had evidently dropped into the umbilical cavity.
Two Specimens of Umbilical Calculi.! — -Case 1 . — A man, twenty-three years of age, had noticed a discharge from the umbilicus for eight weeks. The surrounding abdominal wall was indurated and tender. Later a calculus was extracted. The sinus and a granuloma which had formed around its margins rapidly disappeared. The concretion was 1.5 cm. long, oval in form, and consisted of closely packed squamous epithelial cells with a certain number of hairs.
Case 2 . — A man, thirty years old, had had a discharge from the umbilicus for five years, associated with a granuloma. Around the sinus was granular tissue which formed a tumor the size of a cherry. The sinus was opened and found to be burrowing in various directions. An oval concretion, 2.5 cm. long, was found. Over certain areas this was smooth and had a silvery exterior. From the surface projected the ends of fine hairs, and a section presented traces of laminations. In the center was a small piece of flocculent material — cotton fiber. The concretion consisted of closely packed, flattened, and wrinkled epithelial cells.
Dermoid Cyst in the Abdominal Wall of a Man [ ? ] . § — A man, twenty-two years of age, four weeks before coming under observation had noticed a small mass in the median line of the abdomen directly below the umbilicus. It had gradually increased in size until it was as large as an egg, hard and tender.
- Rouget: Gaz. des hop., 1862, 259.
t Roques: Kyste occasionne par la presence d'un fragment de terre dans l'ombilic. Gaz. des hop., 1862, 314.
t Shattock, S. G.: Trans. Path. Soc. London, 1900, li, 282. § Taylor, Wm. J.: Annals of Surgery, 1896, xxiii, 296. 18
258 THE UMBILICUS AND ITS DISEASES.
He had had some purulent discharge from the umbilicus before entering the hospital. This had increased in quantity.
An incision was made over the swelling, and about an ounce of foul-smelling pus was evacuated. The probe passed from the umbilicus into the abscess cavity. At the bottom of the cavity, and communicating with it, was a depression containing soft, cheesy material and a small amount of hair. Taylor considered the nodule as a small dermoid that had become infected. It was limited strictly to the abdominal wall. The abscess cavity and cyst were cureted freely; the umbilicus was dissected away. The cavity was filled with iodoform gauze. Prompt recovery ensued.
[In all probability this was an abscess due to retained material. Had a dermoid existed, it would have been almost impossible to curet and completely remove the cyst-wall.— T. S. C]
Dermoid Cyst of the Umbilicus [?].*■ — -A man, twenty-nine years of age, had a tumor the size of a walnut at the umbilical cicatrix. This was bright red in color, moist, and translucent. On the surface it was firm in consistence; it did not pulsate, was irreducible, and had a short pedicle. The pedicle was smaller than the top of the umbilicus, and there was a discharge of seropurulent fluid, yellowish in color and of an offensive odor. The tumor was dissected out, but returned rapidly. Histologic examination showed a membrane of fibrous tissue; the contents were cholesterin crystals, numerous epithelial cells, and colorless hairs. Tremontani thought the tumor was a dermoid.
[It strongly suggests an accumulation at the umbilicus. — T. S. C]
Umbilical Pocket. f — A man, thirty-four years old, complained of periodic attacks of mild stomachache with a slight discharge from the umbilicus. The umbilical depression led to a skin pocket containing a yellowish mass which the patient said had been there for years. The mass was readily detached by careful probing, and proved to consist of felted hairs and sebaceous material. The pocket was about two inches in diameter and three-quarters of an inch deep, with an opening half an inch in diameter. No hernia was present. The man was of cleanly habits, accustomed to take much exercise, and habitually wore a home-made belt of flannel, from which the hairs were derived.
An Umbilical Concretion. J — One inch above the umbilicus there was a tumor the size of a small egg. Pus escaped from the umbilicus. A flaxseed poultice was applied. Suddenly a small amount of blood and a concretion escaped. The wound healed up at once. The mass weighed only four grains, and appeared to be felted together like a concretion of ear-wax.
The two cases which follow are also in all probability instances of abscess due to an accumulation of foreign material at the umbilicus.
An Umbilical Sinus. § ■ — ■ The woman was twenty-five years of age, married, and very stout. Two years before she had noticed some discharge from the umbilicus. Eighteen months before admission there were signs of abscess,
- Tremontani, E.: Sopra un caso di granuloma ombellicale da cisti dermoide in un adulto.
II Morgagni ; Giornale Indirizzato Al Progresso Delia Medicina, 1903, xlv, Parte 1; Archivio, 387. t Walters, F. R.: Brit, Med. Jour., 1893, i, 173. 1 Williams, F. H.: Amer. Med. Jour., St. Louis, 1907, xxxv, 295. § Chislett, H. R. : Umbilical Sinus. The Clinique, Chicago, 1905, xxvi, 167.
UMBILICAL CONCRETIONS. 259
with pain, swelling, and redness. An incision was made. The sinus was an inch deep; the pocket extended to the peritoneum and contained thick pus. The abscess was evacuated, and the granulation tissue cureted away. Iodin was applied and the cavity packed wit h iodoform. She made a good recovery.
A Sub umbilical Tumor. — Fischer* said he operated on a woman who had a fistula to the right of and below the umbilicus, near the linea alba. This fistula was deeply seated and led to a fixed tumor the size of an apple, which extended from the umbilicus 8 cm. downward and was 5 cm. in breadth. On pressure there escaped pus and cheesy, tenacious masses and hair. The patient had noticed the tumor for only five weeks, and then, on account of the inflammation and swelling that had developed. It had ruptured fourteen days before admission. As the tumor was nowhere adherent to the peritoneum, it was removed without difficulty.
CASES OF UMBILICAL HORN.
This condition is evidently very rare, as I could find records of only two cases, those of Hennig and Xagel. Unfortunately, the data relating to these are not very clear.
In Hennig's case the horn was about 2 cm. long, 1 cm. in diameter, and slightly bent, while in Nagel's case it was 1 cm. long. The consistence is not mentioned in either case. Both dropped off spontaneously.
It is difficult to understand how a horny growth can appear in this situation. In 1910 I saw a woman over ninety years of age with a small, dark mass protruding from a very small umbilical depression. This mass was black and hard in consistence. When pressure was made around the umbilicus the mass protruded fully 1 cm. from the level of the abdomen. Further pressure caused still more protrusion, and the mass dropped out. It was an umbilical concretion. On account of the exposure to the air the superficial portion had become very hard and was black, whereas the part lying more deeply in the umbilicus was whitish yellow and cheesy (see Fig. 147, p. 249) . It will be noted that the superficial portion of Xagel's specimen was also black. It is just possible that in both of these cases the horns were in reality hardened umbilical concretions and not true umbilical horns.
A Case of Horn of the Umbilicus. — Pernicef says that Hennig saw a healthy American who from her childhood had had a horn at the umbilicus. It was about 2 cm. long, 1 cm. thick, cone-shaped, and slightly bent. In the eighth month of her first pregnancy the horn dropped off, partly as result of the unfolding of the umbilicus, "partly as a result of diminished nourishment."
A Small Horn at the Umbilicus. — In a letter to Dr. Kelly Prof. F. W. Nagel mentions the case of Frau H., who was born in Berlin, December, 1878. On the eighth of June, 1907, she was delivered for the first time by Nagel. About the middle of the pregnancy a little prominence, the thickness of a match, was noticed at the umbilicus. This was more and more -visible toward the end of pregnancy. It formed a horn 1 cm. long. At the beginning it was gray; later on it dried up and became black. After labor the horn drew in and disap
- Fischer, H. : Die Eiterungen im subunibilicalen Raume. Volkmann's Samml. klin. Vortrage, Neue Folge, Nr. 89 (Chir. No. 24), Leipzig, 1890-94, 519.
f Pernice, L.: Die Nabelgeschwiilste, Halle, 1892.
260 THE UMBILICUS AND ITS DISEASES.
peared. Nagel examined the patient on December 10, 1910, and by separating the umbilical folds was able to see the points of the now yellowish-white horn.
MAGGOTS IN THE UMBILICUS.
In a letter dated December 9, 1910, Dr. John S. Fulton gave me an account of a rather unusual umbilical condition. Several years previously a baker had come to his clinic at the University of Maryland complaining of some umbilical trouble. Fulton watched the man undress, and at once recognized his occupation by three rings of dough — "waist deep, midarm deep, and elbow deep." On examining the umbilicus he found it inhabited by six maggots. Their removal was followed by complete relief of the patient.
The only other case I know of in which a similar condition was noted was furnished by E. L. M.* in 1899. He was called to see an infant eight days old. The cord had come off on the fifth day. On examination the umbilicus was found filled with maggots. A few drops of chloroform were dropped into the umbilicus, and 24 dead maggots were washed out with sterilized water. Boric acid was then dusted in and there was no further trouble.
Escape of a Piece of Wild-oat Straw From an Umbilicus, t — The patient was one month old. The mother had noticed much moisture at the umbilicus ever since the cord had come away. At the umbilicus was a reddish, pedunculated tumor the size of a pea. This was cut away with scissors and cauterized. It recurred, but on being again treated in a similar manner, did not reappear. Some time later an abscess developed at the umbilicus. It was opened, some pus and a piece of wild-oat straw escaping. The fact that there was continual moisture at the umbilicus after the cord came away strongly suggested a remnant of either the omphalomesenteric duct or the urachus.
- E. L. M. : Maggots in the Umbilicus. Med. Council, Philadelphia, 1899, iv, 364.
f Fabrege: Note sur les excroissances polypeuses de la fosse ombilicale chez les enfants nouveau-nes. Rev. med. chir., 1848, iv, 353.
LITERATURE CONSULTED ON UMBILICAL CONCRETIONS ASSOCIATED WITH
INFLAMMATORY CHANGES IN THE ABDOMINAL WALL.
Blum, A.: Tumeurs de l'ombilic chez l'adulte. Arch. gen. de med., Paris, 1876, 6 e ser., xxxviii,
151. Bouffleur: Tuberculosis of the Umbilicus. Clin. Review, Chicago, 1898, ix, 329. Bufalini, G.: Jahresber. der gesammt. Med., 1887, ii, 497.
Coenen, H. : Ueber das Cholesteatom des Nabels. Beitrage z. klin. Chir., 1908, lviii, 71S. Cbislett, H. R. : The Clinique, Chicago, 1905, xxvi, 167.
Derville, L. : Abces fistuleux de l'ombilic. Jour, des sci. med. de Lille, 1894, ii, 320. Fere, G.: Tumeur sebacee ombilicale. Bull. Soc. anat. de Paris, 1875, 1, 622. Fischer, H.: Volkmann's Sammlung klin. Vortrage, Neue Folge, Nr. 89 (Chirurg., Xo. 24),
Leipzig, 1890-94, 519. Foulerton, A.'G. R. : Form of Umbilical Sinus Occurring in Adults. The Lancet, 1888, ii, 16. Foulerton, A. G. R. : Growths From the Umbilicus. Illustrated Medical News, 1889, iv, 261. Gonard, G.: Des kystes dermo'ides. These de Montpellier, 1906, No. 31. Gueterbock, P. : Ueber einen Fall von Dermoidgeschwulst des Nabels. Deutsche Zeitschr. f.
Chir., 1891, xxxii, 319.
UMBILICAL CONCRETIONS. 261
Hahn, Otto: Ein Nabelkonkrement von Taubeneigros.se. Beitrage z. klin. Chir., Tubingen,
1900, xxvi, 80. Ledderhose, G. : Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Nicaise: Ombilic. Dictionnaire encyclopedique des sci. m6cl., Paris, 1881, 2. ser., xv, 140. Park, Roswell: Clinical Lecture on Congenital Fistulso and Sinuses at the Umbilicus. Med.
Fortnightly, 1896, ix, 9. Pernice, L. : Die Nabclgcschwulstc, Halle, 1892.
Polaillon: Kyste dcrmoide suppure de la region ombilicale. Gaz. med. de Paris, 1886, lvii, 435. Richelot, L. G. : Abces tuberculeux sous-ombilical. L'union m6d., 1883, xxxv, 61. Rouget: Gaz. des hop., 1862, 259. Rouqes: Kyste occasionne par la presence d'un fragment de terre dans l'ombilic. Gaz. des hop.,
1862, 314. Shattock, S. G. : Two Specimens of Umbilical Calculi. Trans. Path. Soc. London, 1900, li, 282. Taylor, Wm. J. : Dermoid Cyst in the Abdominal Wall of a Man. Annals of Surgery, 1896, xxiii,
296. Tremontani, E.: Spora un caso di granuloma ombellicale da cisti dermoide in un adulto. II Mor gagni; Giornale Indirizzato al Progresso della Medicina, Parte 1, Archiv, 1903, 45, 387. Villar, F.: Tumeurs de l'ombilic. These de Paris, 1886, No. 19. Walters, F. R. : Umbilical Pocket. Brit. Med. Jour., 1893, i, 173. Williams, F. H.: An Umbilical Concretion. Amer. Med. Jour., St. Louis, 1907, xxxv, 295.
Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.
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