Book - Umbilicus (1916) 18
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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 XVIII. Diphtheria of the Umbilicus; Syphilis of the Umbilicus; Tuberculosis of the Umbilicus; Atrophic Tuberculid commencing at the Umbilicus
Diphtheria of the umbilicus.
Report of cases. Syphilis of the umbilicus, at or shortly after birth.
Report of cases. Syphilis of the umbilicus in the adult.
Report of cases. Tuberculosis of the umbilicus. Atrophic tuberculid starting at the umbilicus.
In this chapter are grouped several diseases which are very uncommon and which do not belong to the subjects considered in any other chapter.
DIPHTHERIA OF THE UMBILICUS.
We have records of only two cases in which the umbilicus was the seat of a primary diphtheritic deposit. The first case was described by Pitts in 1897, the second by Gertler in 1898. As one might naturally expect, the umbilicus became involved shortly after birth and before the umbilical stump had had time to cicatrize.
Pitts's patient was first seen on the fourteenth day after birth. The child's brother had just died of diphtheria, and its mother was ill with the same disease. Diphtheria bacilli were cultivated from the umbilical lesion. The child died, and at autopsy the diphtheritic deposit was found to be limited to the umbilicus, the respiratory tract being free from membrane.
Gertler's patient first came under observation when he was four weeks old. On the eighth day the cord, which had not come away, was cut off with a pair of scissors and the child was circumcised. When Gertler saw the patient, the umbilicus and the penis presented the characteristic diphtheritic deposits. Both lesions yielded the specific bacillus and promptly healed after the use of antitoxin.
Diphtheria of the Umbilicus.* — A child, fourteen days old, was admitted for an inflammation of the umbilicus. The cord had separated on the eighth day, and the resulting wound had continued to discharge extremely offensive pus. When seen on February 20th, there was a brawny, red, indurated area around the umbilicus, about the size of a five-shilling piece. From this area the epidermis had peeled off. The umbilicus itself was the seat of a dirty-looking, wash-leather slough, and was discharging offensive pus from an opening into which a probe could be passed for about an inch. The child's general condition was otherwise good. It had, however, an occasional inspiratory crow, and with it some slight cyanosis. The next day it was learned that the brother of the child had been
- Pitts, B.: The Lancet, London, 1897, i, 953.
278 THE UMBILICUS AND ITS DISEASES.
removed to a hospital suffering with diphtheria during the previous week, and had died on the morning the child was first examined. The mother had been taken to a hospital also suffering from diphtheria.
A culture from the umbilicus examined on February 22d showed diphtheria bacilli. The child had some vomiting, became weaker, and died on the same day. After death nothing abnormal could be found in the larynx or pharynx, nor had the condition at the umbilicus extended to any of the deeper structures.
Diphtheria of the Umbilicus.* — The umbilical cord had not come away normally, but had been cut off on the eighth day with a pair of scissors and the child had been circumcised. The physician could not tell whether the trouble had started first in the umbilicus or on the penis. The illness had lasted three weeks.
The child, four weeks old, was moderately well developed. In the umbilical region was an infiltration of the skin and underlying tissue, and surrounding it was a sharp line of demarcation which extended downward to the symphysis. Immediately around the umbilicus was a small, grayish-yellow deposit, and when pressure was made over the skin below the umbilicus, purulent fluid escaped.
The penis was swollen, and on the right side of the glans was a flat ulcer, likewise covered with a grayish-yellow, diphtheroid deposit. The inguinal glands on both sides were hard, and the subaxillary glands on the right side were enlarged. The pulse was 96; the temperature, 37.8° C. Cover-slips at once suggested diphtheria, and twenty-four-hour cultures gave a pure Loffler bacillus. The diagnosis of diphtheria of both the penis and the umbilicus was certain. On October 27th the serum was given, and on the following day the temperature was 38.2° C. and the local condition was better. The area of redness, which had extended to the symphysis, had narrowed down to 2.5 cm. around the umbilicus, and the infiltration of the skin was less.
On October 29th the skin infiltration in the umbilical region had disappeared. The skin was drawn up into folds, and a grayish-yellow membrane came away after the use of a 3 per cent, boric acid solution, leaving a superficial ulcer which did not bleed.
By October 30th the swelling in the umbilical region had become slightly smaller, and there was no membrane over the area of ulceration. The ulcer of the penis had dried up entirely.
On October 31st the umbilicus presented the normal appearance, and the ulcer of the penis had healed completely.
SYPHILIS OF THE UMBILICUS.
The literature on this subject is very meager, but lues of the umbilicus has been mentioned by Blum (1876), Villar (1886), Runge (1893), Bertherand and Merklen (1900), Hutinel (1903), Bondi (1903), Hartz (1905), and Chiarabba (1906).
Cases of syphilis of the navel are divided into two groups :
1. Syphilis of the umbilicus at or shortly after birth.
2. Syphilis of the umbilicus in the adult.
- Gertler, N. : Beitrag zu den Krankheiten des Nabels der Neugeborenen. Klin, therapeut.
Wochenschr., Wien, 1898, v, 1234.
SYPHILIS OF THE UMBILICUS. 279
Syphilis of the Umbilicus At or Shortly After Birth.
Bertherand and Merklen in 1900 drew attention to the fact that in a certain number of children presenting symptoms more or less characteristic of congenital syphilis, such as a purulent coryza, a tendency for the finger-nails to drop off, fissure in ano, etc., ulcerations of the umbilicus existed. They were inclined to think that the umbilical ulceration was part of the syphilitic process. In order that the reader may gain a clear idea of their findings and draw his own conclusions, they will be cited here somewhat fully.
Bertherand and Merklen observed, in the service of Hutinel, a variety of umbilical ulcers and thought these had not been previously mentioned. They state that Professor Hutinel a long time before had said that these infections suggested syphilis. The ulceration was situated at the umbilicus, and appeared shortly after birth. All the patients examined by Bertherand and Merklen were less than one month old. The exact date of the appearance of the ulcer could not be determined, as all the patients were brought to the hospital with the lesion already present. The youngest child was nine days old. An ulceration of this character may reach the size of a five-franc piece. The base of the ulcer is grayish, sometimes yellow, and there is a secretion of mucopus. The ulcer is red, irregular, has raised margins, and one of the cases showed appearances of gangrene. The ulceration may be accompanied by redness of the skin with desquamation, but without any evidence of inflammatory reaction. The authors further say that, of the four children observed, three died of hereditary syphilis, and that the ulceration still persisted at the time of their death. The fourth child survived and the ulceration cicatrized.
Case 1 . — ■ L. A., nine days old. The child had a purulent coryza which suggested syphilis. There was an ulceration at the umbilicus which had completely obliterated the umbilical depression and extended beyond it. The base of the ulcer was grayish, and covered with a little pus. Around the umbilicus was a little reddening, but only a slight reaction. The child was cachectic, lost weight, and died ten days after entering the hospital. At autopsy nothing of moment was detected in the lungs or in the digestive tract. The brain was normal, but the liver was large and congested, and the spleen was increased in size. The testicles were hard and sclerotic, but on section did not show anything of any moment. A longitudinal section of the femur showed that the bone-marrow was altered, especially in the upper and lower part. The spongy tissue of the bone was yellowish, and showed less color than normal.
[In this case it is possible that syphilis existed, but the history is in no way conclusive. One might very readily think of an ulcer at the umbilicus due to simple infection, possibly associated with syphilis. — T. S. C]
Case 2. — D. E. This child was admitted to the hospital when eleven clays old. He had a purulent coryza, a marked fissure at the anus, and erythema of the buttocks. No change was noted in the testicles, and there was no inflammation of the nails. At the umbilicus was an ulcer suggesting gangrene. It was deep, had irregular margins, and discharged a little mucopus. A few daj^s later it had increased in size, become deeper, and was larger than a five-franc piece. The child was cachectic, developed bronchopneumonia, and soon died.
At autopsy evidences of bronchopneumonia were found in both lungs. The liver was red and slightly enlarged, but showed little on section. A longitudinal
280 THE UMBILICUS AND ITS DISEASES.
section of the left humerus gave a marked discoloration of the bone-marrow at both extremities.
[In this case the coryza and the fissure at the anal margins point to syphilis, but the area of ulceration at the umbilicus and the erythema of the buttocks might equally well have been due to gangrene or simple ulceration of the umbilicus. The case is not clear. — T. S. C.J
Case 3 . — N. S., thirteen days old, was suffering from a purulent coryza. The diagnosis of hereditary syphilis was thought probable from the existence of an umbilical ulcer which was as large as a five-franc piece. The surface of this ulcer was covered with a greenish, clear pus. The margins were a little elevated and desquamated, and they were also red, but showed no induration. There was but little loss of tissue. The child developed an intestinal infection. The general condition became alarming, and the umbilical ulcer increased in size. Nearly a month after the child's admission to the hospital an inflammation of the extremities of the nails of the fingers was noted, and there was a tendency for the nails to become detached. The coryza continued without any new manifestations of syphilis except the inflammation of the nails. The child died a week later of bronchopneumonia.
At autopsy, in addition to the bronchopneumonia, on histologic examination, a periportal sclerosis and an obliterative endarteritis were found. At certain points the obliteration was complete. The small hepatic veins were thickened. The hepatic cells were a little opaque. The left kidney was pale. The right kidney was pale, and there was a tendency to fusion of the cells. At the upper extremity of the kidney was a white, pearly gumma, much paler than the rest of the renal tissue. The convoluted tubules and the loops of Henle were the seat of a degeneration, and the glomeruli were congested. The arteries of the glomeruli showed a slight degree of endarteritis, and some of the arterioles contained thrombi. A section of the superior extremity of the humerus demonstrated that the spongy tissue of the bone was yellowish and less colored than normal.
[In this case the purulent coryza was suggestive of syphilis, but the ulceration might very readily have been due to an ordinary infection. Inflammation of the extremities of the fingers also points toward syphilis. The report says that there was a gumma in the right kidney, but the description of the gumma is not at all conclusive. This is another case in which we cannot say absolutely that the umbilical condition was syphilitic. — T. S. C]
Case 4 . — C. C, one month old. At the umbilicus was an ulceration the base of which was grayish in color and covered with mucopus. The ulceration was surrounded by a reddish, desquamated zone, which was about the size of a twofranc piece. Two weeks later the child commenced to improve and the ulcer tended to diminish. Shortly afterward the child showed the characteristic purulent coryza, which tended to confirm the idea of hereditary syphilis. The ulcer gradually healed under simple local treatment. The coryza, however, persisted with the same intensity, and the child was sent to the country.
Bertherand and Merklen, in describing these cases, say that the histories showed that they were dealing with hereditary syphilis, causing a variety of ulcers of the umbilicus. The appearance of the lesion, the absence of general reaction, and the coexistence of further signs of syphilis, as coryza, fissure in ano, and inflammation of the nails, and examination of the testicles would permit one, according to their view, to decide in favor of the specific nature of the umbilical ulcer.
SYPHILIS OF THE UMBILICUS. 281
Hutinel, in 1903, wrote a very interesting article on the same subject. He said that during the thirteen years in which he had been a physician to the Hopital des Enfants-Assistes he had observed this peculiar umbilical lesion about a dozen times. From its appearance and mode of development and its anatomic characteristics he attributed the umbilical trouble to hereditary syphilis. His description of the local condition is very similar to that given by Bertherand and Merklen. Appended to his paper are several interesting cases.
Case 1 . — Rena M., born January 28, 1902, and admitted to the hospital on February 18th. This child had a purulent coryza, a lorgnette nose, and erythema of the buttocks. The diagnosis of hereditary syphilis seemed certain. Redness and swelling were present, and a phlegmonous appearance, forming a circle around the umbilicus and extending 4 cm. in all directions. This area of tumefaction was not hot nor painful on pressure, and had not the definite margin characteristic of erysipelas; there was no fever. In the center of the area was a small ulcer from which there was a slight discharge. At the end of two days the reddish circle had retracted somewhat, but the ulceration had increased in size and deepened. The surrounding tissue was hard, red, and raised, but there was no fever. The coryza persisted, and the characteristic papules were noted on the buttocks. On the following days the redness around the umbilicus gradually took on a livid tint, and in the center was a crater-like depression, yellowish black and bloody, and several red plaques appeared on the abdomen. On March 3d the umbilical ulcer formed a pit with precipitous margins, and at the bottom the surface was covered with a grayish exudate. The margins were indurated and violet-colored. The area of ulceration was about 1.5 cm. in diameter, and the pit measured 1 to 1.2 cm. in depth. Hutinel says that on March 7th the ulcerated area presented the picture of a gumma. This had increased in size and its base was yellowish in color. Its margins were precipitous, but the peripheral infiltration had diminished and had gradually lost its phlegmonous aspect. On March 10th the area of ulceration still retained its principal characteristics; the base, however, was enlarged, and the cutaneous orifice had diminished in size.
On March 14th the temperature, which had been absolutely normal, reached 38.2° C, the respirations became accelerated, and the child was very restless. A bronchopneumonia was evident. Death occurred on the following day. At autopsy the peritoneum at the umbilicus was found to be normal. In the angle formed by the urachus and the umbilical arteries there was a yellowish nodule. In a transverse section of the abdominal wall this was found to be 1.4 to 1.5 cm. in thickness at the site of the umbilical ulcer. The abdominal muscles on the right, in the vicinity of the ulcer, were pale and scarcely recognizable, and the subperitoneal connective tissue was thickened and presented a hyaline appearance. The peritoneum did not contain any liquid, and there were no omental or intestinal adhesions. Bronchopneumonia was the cause of death.
From a transverse section through the center of the umbilical cicatrix it was found that the floor of the ulcer consisted of a granular substance which resisted the action of the staining fluid. In the interval between elastic fibers could be recognized remains of leukocytes, and beneath this zone, where the necrosis had been less complete, there was an infiltration of round cells, and sometimes a few leukocytes which stained poorly. In the middle of the area the arterioles appeared thickened, and in some places had been completely obliterated; there existed an
282 THE UMBILICUS AND ITS DISEASES.
endarteritis and sometimes a peri-arteritis. In some places the infiltration had invaded the adipose tissue.
[The general picture in this case strongly suggests a mild umbilical infection. The histologic picture also is suggestive of the same thing. While one cannot say positively that syphilis did not exist, the evidence in favor of it is not particularly strong.- — T. S. C]
Case 5 . — On p. 90 Hutinel reports the case of a small girl, S. P., eight weeks old. She was born on March 9, 1903, and admitted to the hospital on May 5, 1903. An examination of this child was made by Budin. The labor had been normal; but the father of the child had manifested symptoms of syphilis and appeared to have tuberculosis. The child at birth weighed 3600 grams. On March 11th, after the expulsion of meconium, the child's weight dropped to 3400 gm., but by March 15th it had risen to 3650 gm. On March 20th, when the mother left the clinic, the child had not gained a gram in weight, and it was noted that the umbilicus was diseased. It was red and raised, and a superficial ulcer was noted above and to the right. The child had coryza. Sublimate baths were prescribed, and the umbilical ulcer was painted with iodin, and afterwards with silver nitrate; in addition, the child was given mercurial frictions. She remained in the clinic until April 30th, when the area of ulceration appeared to be healing. It did not heal, however, and on May 5th, when the child was brought for examination, the ulcer was found to be large and deep. The mother said that from the beginning the umbilicus was swollen and red over an area the size of a five-franc piece, and that it had become eaten out and had suppurated, after which the redness had disappeared. The swelling had been replaced by a depression, and there had remained at the umbilicus a triangular ulcer. The margins of the ulcer were sharply denned, the skin was red around the orifice, and a pinkish, serous fluid escaped. The child was very pale and had a yellowish, waxy tint that led one to suspect syphilis. The head was large, the nose lorgnette-shaped. There were no fissures of the lips and no inflammation of the nails. There was an erysipelas of the legs and arms and some papules on the buttocks. The epiphyses were a little enlarged, but there was no bone malformation. There was some thickening of the cranial bones. The liver was slightly enlarged, and the spleen was somewhat increased in size. On May 9th the umbilical ulcer, which had resisted treatment for six weeks, contracted and tended to disappear. Hutinel says that the fact that syphilis existed in this case is undeniable^ and that the mother, on May 22d, presented in the throat a very characteristic papulo-erosive syphilitic eruption.
Some of the cases reported by Bertherand and Merklen and by Hutinel were in all probability instances of congenital syphilis, but whether the umbilical lesions were directly caused by the spirochete or not is another question. Runge, in speaking of wound infections of the new-born, said that when the syphilitic manifestations make their appearance at birth, usually in premature children, these children are born dead, die almost immediately, or live only a few hours, rarely a day. He further says that, in addition to the usual syphilitic changes in these cases, there are numerous hemorrhages under the skin and in the internal organs.
Bondi says the diagnosis of hereditary syphilis in the new-born is very difficult. He covers the literature well, gives a large number of cases, and also presents some excellent pictures. His conclusion is excellent: "There were present the exudate with an inflammatory appearance, the edematous infiltration of the vessel
SYPHILIS OF THE UMBILICUS. 283
walls, with migration of polymorphonuclear leukocytes, and in one case a pouringout of fibrin and in two cases abscess-like formations in the vessel-walls, and sometimes necroses. In one case there was a deposit of chalk." He says that the changes are due to an arteritis and phlebitis; that the picture presented is not specific or characteristic, but the changes described have been those observed only in syphilis, and that, in the absence of proof to the contrary, we can with a moderate degree of certainty describe these as the pathologic findings in syphilis.
The umbilical pictures presented by the cases here recorded are so similar to those due to the umbilical infection formerly so frequent shortly after birth that, anatomically, they show little or no difference ; and even the histologic pictures of these supposedly syphilitic lesions of the umbilicus are by no means conclusive. If syphilis existed in these cases, the lowered vitality of the child would naturally render it more susceptible to any umbilical infection. While our knowledge of this subject is meager, careful examinations of umbilical ulcers for the Spirochseta pallida will, in the future, speedily determine whether these ulcerations are syphilitic or not.
Syphilis of the Umbilicus in the Adult.
Blum, in his article on Tumors of the Umbilicus in the Adult, published in 1876, when speaking of syphilis, mentions the case of a man, aged thirty-six, who had a fetid discharge from the umbilicus for two years. The umbilicus was prominent and formed a tumor. Its margins were swollen and possibly slightly ulcerated. Dupuytren considered the probability of a fecal fistula, but Breschet, who had seen several analogous cases, prescribed a specific treatment, and the patient was cured. From the clinical picture this case might equally well have been one of umbilical concretion, particularly if any local treatment was given.
Bille, in 1912, collected eight cases of primary syphilis of the umbilicus, and in 1914 referred to three others. In the latter article he shows the picture of a lesion in a young girl coming under the care of Lassar. At the umbilicus was an elongated, oval ulcer the size of a five-pfennig piece. The ulcer was deep, and its surface brownish red and glistening. Its margins were sharply defined and infiltrated. Surrounding the ulcer was a pale red, inflammatory zone.
The following case, observed by Fiaschi, was so carefully studied that I shall report it in detail :
Syphilitic Chancre of the Umbilicus. — In 1911 I received the following from Dr. P. Fiaschi, of Sydney, Australia:
"178 Phillip St., Sydney, Australia, March 14, 1911. . . . "As you are busy with your paper on the umbilicus, I thought you might like the following: Some three weeks ago I found a young man with a chancre of the inner aspect of the right lower quadrant of the prepuce and a chancre of the umbilicus (Fig. 160). He gave a history of an incubation of fourteen and seventeen clays. . . .
"I may say that my father concurred in the diagnosis of genital and extragenital primitive infection of the young man. The ultramicroscopic examination gave me one of the finest specimens of spirochetes I have managed to get from any lesion in any case I have examined so far. Inasmuch as you are interested in this work, you might look up the classic monograph of our distinguished master, M. Le Professeur Founder. You will find the report on page 284 and subsequent pages. Fournier, in a personal observation of 110 extragenital chancroids, in a total of 10,000 chancres that he has observed in private practice, found only 16 of the abdomen. They are evidently not common.
284 THE UMBILICUS AND ITS DISEASES.
"The result of the injection of salvarsan was very striking. Both lesions had cicatrized in five days, so that even after vigorously using an ophthalmic curet I could not get any spirochetes."
On May 25, 1911, Dr. Fiaschi writes:
"The young man took it into his head, after seeing his lesions healed, to leave this city and go to a country town, telling me that he knew he was cured, judging by the reports that he had read in magazines and newspapers. He did this notwithstanding my remonstration not to fool himself, but to place himself under the usual methodic mercurial treatment. I wanted to present him to a clinical meeting of our local medical society, and I wrote him to come to Sydney, and he did so the day before the meeting. On presenting himself I found that both lesions had
Fig. 160. — Syphilis of the Umbilicus. (Fiaschi.) The umbilical depression is filled with dome-like elevations of various sizes, and trickling from the umbilical orifice is a watery discharge. Spirochetes were obtained from the umbilicus and also from a chancre of the prepuce. Both lesions yielded promptly to salvarsan. The patient did not keep up the necessary treatment, and returned two months later with a mucous patch on the upper lip.
remained healed, but that he had a mucous patch on the upper lip, the size of a nickel, from which I obtained numerous spirochetes under the ultramicroscope, of the giant form, such as are frequently found in mucous patches. I had this mucous patch photographed, and am pleased to write you that I am now mailing you, under registered cover, four photographs, two of the chancre and one showing the result five days after intramuscular injection of salvarsan, and the fourth showing the relapse with mucous patch. The young man told me that he had noticed this two weeks before seeing me."
LITERATURE CONSULTED ON SYPHILIS OF THE UMBILICUS. Bertherand et Merklen: Sur une varietc d'ulceration ombilicale de nature syphilitique. Bull.
de la Soc. de ped. de Paris, 1900, ii, 248. Blum, A.: Tumeurs de l'ombilic chez l'adultc. Arch. gen. de med., Paris, 1876, vi. ser.. xxviii,
TUBERCULOSIS OF THE UMBILICUS. 285
Bondi, Josef: Die syphilitischen Veranderungen der Nabelschnur. Arch. f. Gyn., 1903, lxix,
223. Chiarabba, U. : Contributo alia Conoscenza della sifilide ombelicale (Flebite proliferativa gommosa
della vena ombelicale). Annali di ostetricia e ginecologia, 1906, Anno 28, i, 190. Fiaschi, P. : Personal communication. Fournier, A.: Les chancres extra-genitaux, Paris, 1897, 326.
Hartz, A.: Abnabelung und Nabelerkrankung. Monatsschr. f. Geb. u. Gyn., 1905, xxii, 77. Hutinel, V.: L'ulcere syphilitique de l'ombilic chez les nouveau-nes. La Syphilis, Paris, 1903,
i, 81. Pernice, Ludwig: Die Nabelgeschwiilste, Halle, 1892. Rille: Ueber den syphilitischen Primaraffekt am Nabel. Festschr. f. E. Lesser, Arch. f. Derm.,
1912, cxiii, 865. — Ein weiterer Beitrag zur Kenntnis des syphilitschen Primaraffektes am
Nabel. Dermatol. Wochenschr., 1914, lix, 1271. Runge: Die Wundinfectionskrankheiten der Neugeborenen. Die Krankheiten der ersten Lebens tage, 2. Aufl., 1893, 194.
tuberculosis of the umbilicus.
Bouffleur,* in 1898, reported a supposed case of tuberculosis of the umbilicus. The patient had been complaining only for ten days. He first had cramp-like pains in the abdomen, followed three days later by a discharge from the umbilicus with tenderness and soreness in the umbilical region. The discomfort was so marked that he had to stop work.
Several sisters had died of tuberculosis, but the patient, apart from repeated chancroidal infections and an occasional attack of colicky pain followed by diarrhea, after drinking beer, had been perfectly well.
On examination a purulent discharge was noted at the umbilicus, and to the right and below the umbilicus was a slight swelling, apparently situated in the deeper part of the abdominal wall. The purulent tract was enlarged, and with a curet over an ounce of typical tuberculous granular tissue was removed. A cavity the size of a walnut, internal to the abdominal wall, was exposed. It was packed with iodoform gauze. Some of the smears yielded large numbers of tubercle bacilli; others contained none.
Bouffleur asks whether this was a case of tuberculosis of a blind urachus or of Meckel's diverticulum.
[The clinical picture is strongly suggestive of a soft umbilical concretion. — T. S. C]
In 1911, in the course of a conversation with Dr. A. L. Stavely, of Washington, he referred to an interesting case which had come under his observation. On March 26, 1904, he sent the specimen to Dr. J. R. Mohler, of the Bureau of Animal Industry, who, in reply to an inquiry from me, reported as follows :
"Slides were prepared which showed numerous tubercle bacilli with the Ziehl-Nielsen stain. Two guinea-pigs were inoculated with the material, and both developed tuberculosis.
"No sections of the umbilicus were made, but we still have slides prepared from the pus in the fistulous tract, which show the presence of tubercle bacilli, somewhat faded as a result of nine years' preservation. "
Tuberculosis of the umbilicus is, to say the least, exceedingly rare. One might expect occasionally to find it in those rare cases in which a tuberculous bowe becomes adherent to and opens through the umbilicus.
- Bouffleur, Albert I.: Tuberculosis of the Umbilicus. Clin. Rev., Chicago, 1898, ix, 329.
THE UMBILICUS AND ITS DISEASES.
A CASE OF ATROPHIC TUBERCULIDE
The patient was a boy, aged twelve, who had been under Bunch's care for five years at the Queen's Hospital for Children, and before that under Dr. Adamson's care at the same hospital. The latter had shown him before the Dermatological Society of London on May 9, 1906. The eruption had begun, when the child was aged four, as a single red patch at the navel, on which small red nodules had developed later. The nodules were slightly raised, somewhat papular in character, and distinctly infiltrated. They had a tendency to necrose, and always left a superficial, shallow scar about x /% inch to l /i inch in diameter.
In 1906 there were about 30 such scars around the umbilicus, and scattered
Fig. 161. — Atrophic Tuberculid Starting at the Umbilicus. (After J. L. Bunch.)
Scattered over the lower abdomen and right thigh and over the region of the right shoulder are elevations, oval or
round in form. They were first noted at the umbilicus.
among these were about a dozen raised red papules, ranging in size from a milletseed to a split-pea. During the succeeding years similar necrotic papules had made their appearance in the inguinal region, on the thighs, on the upper part of the buttocks, in front of and behind both axillae, and on the shoulders and back (Fig. 161). Attention was called to the fact that the nodules and scars were always preceded by a circumscribed, irregular, dry, scaly, red dermatitis, such as had been described in 1906 for the inner side of the thigh and arm, where there were now the characteristic scars. Similar appearances had preceded the atrophic tuberculid elsewhere, and there was now a very well-marked patch of such a dermatitis on the right shoulder, which probably denoted the appearance of the nodular eruption within the next year or two.
- Bunch, J. L.: Proc. Roy. Soc. Med. (Dermatological Section), November, 1911, v, 21.
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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