Book - Umbilicus (1916) 19
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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 XIX. Umbilicus Abnormalities 2
The Escape Of Retroperitoneal And Abdominal Fluid From The Umbilicus; The Opening Of An Appendix Abscess At The Umbilicus; Abscess Of The Liver Opening At The Umbilicus; Peritonitis With The Escape Of Pus From The Umbilicus; The Piecemeal Removal Of A Suppurating Ovarian Cyst Through The Umbilicus
The escape of retroperitoneal fluid from the umbilicus.
A periprostatic abscess opening at the umbilicus.
A thoracic abscess opening at the umbilicus; report of cases.
A broad-ligament abscess opening at the umbilicus.
Cases of broad-ligament abscess opening at or near the umbilicus. An abscess of the umbilical vein in an adult. The opening of an appendix abscess at the umbilicus. Abscess of the liver opening at the umbilicus. Peritonitis with the escape of pus at the umbilicus, clinical picture; causes of the peritonitis;
differential diagnosis; report of cases. The piecemeal removal of a suppurating ovarian cyst through the umbilicus. Localized jaundice of the umbilicus with the presence of free bile in the abdominal cavity.
THE ESCAPE OF RETROPERITONEAL FLUID FROM THE UMBILICUS.
An effusion of fluid into the retroperitoneal tissue will tend to loosen up the peritoneum from the underlying adipose or muscular tissue by a process of dissection, the process gradually extending for quite a distance. For example, in February, 1912, I saw with Drs. Smouse, Fay, and Priestley, in Des Moines, Iowa, a patient giving the history of the sudden development of a more or less globular tumor to the left of and above the umbilicus. The man passed into a state of collapse and was thought to be dying. A few days later his condition was much improved, and an exploratory abdominal operation was deemed advisable. On opening the abdomen I could palpate a mass, about 10 cm. in diameter, in the region of the pancreas. The peritoneum of the right abdominal wall was bluish in color, and the mesocecum much thickened. I at once closed the abdomen and made a gridiron incision in the right iliac fossa, pushing the peritoneum toward the median line. The discoloration of the peritoneum was due to the action of old blood which had dissected this membrane from the underlying structures. As I passed my fingers upward toward the right renal pocket I found that between the peritoneum and the lateral abdominal wall there was a space, fully 2 cm. broad, which was filled with clotted blood. Surrounding the right kidney there was also a very large blood-clot. A drain was laid in the pelvis and in the right renal pocket, care being taken not to dislodge the clots. The man did well for over a week and then died suddenly.
At autopsy an aneurysm of the abdominal aorta was found (Fig. 162). This had perforated posteriorly and on the left side, producing the tumor that had suddenly appeared on the left of the median line. This blood had gradually passed over the vertebral column and gradually dissected free the peritoneum on the right
THE UMBILICUS AND ITS DISEASES.
side of the abdomen, a fact which accounted for the disappearance of the tumor on the left. The sudden death had been due to rupture of the aneurysm into the duodenum. Careful examination at autopsy showed that the peritoneum on the right lateral abdominal wall, as a result of the hemorrhage, had been dissected from the underlying structures as far as the right internal inguinal ring.
If blood under pressure can find its way extraperitoneally from one part of the abdominal wall to another, there is no reason why pus under pressure should not do the same thing. In a psoas abscess we have a good example of the extraperitoneal burrowing of pus.
Fig. 162. — Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket. H. S. W., February 16, 1912. In I, we see an aneurysmal dilatation of the aorta. In II, the aneurysmal sac has given way, with the escape of blood retroperitoneally. This caused the tumor that was noted clinically. The pressure of the escaping blood gradually dissected the peritoneum free, and the blood, following the line of the arrows, gradually passed over into the right renal pocket, as noted in III. At operation I found the peritoneum over the lateral wall of the lower abdomen bluish black. This was due to the presence of old blood lying between the peritoneum and the muscles of the lateral abdominal walls. At autopsy it was found that the blood had dissected its way extraperitoneally as far as the right internal inguinal ring.
A Periprostatic Abscess Opening at the Umbilicus. Nicaise refers to the case of a patient under the care of Castaneda. A periprostatic abscess gradually extended and opened at the umbilicus. In Fig. 163 is indicated the manner in which a periprostatic abscess may reach the navel.
Thoracic Abscess Opening at the Umbllicus. Both Blum and Nicaise refer to a case reported by Curran in the Lancet in 1872. A young boy in the beginning had symptoms of a right-sided pneumonia. Resolution failed to take place, and cachexia soon developed. The boy looked as if he had tuberculosis. At the end of six months an elevation, which was exceedingly
THE ESCAPE OF FLUID FROM THE UMBILICUS.
painful, developed just above the xiphoid and extended to the umbilicus. It soon opened, and an enormous quantity of pus escaped, the purulent discharge from the umbilicus continuing for fourteen days. The pulmonary symptoms disappeared, and the boy was able to go back to his occupation permanently cured. The abscess in this case had evidently been walled off by the cellular tissue between the attachment of the diaphragm and the sternum. Whether an abscess of the lung had
Fig. 163. — The Manner in which a Periprostatic Abscess may Occasionally Escape at the Umbilicus.
The periprostatic abscess may gradually dissect free the peritoneum of the lateral and anterior abdominal wall and reach the umbilicus. This has occurred in a few instances, but it is unusual, the abscess, as a rule, tending to empty itself into the bowel, bladder, or externally.
Fig. 164. — Escape of Pleural Fluid from the Umbilicus. This is a schematic representation of the manner in which a purulent accumulation in the pleural cavity may break through the diaphragm, gradually dissect free the peritoneum over a limited area, and finally escape at the umbilicus. In some cases, after the pus has broken through the diaphragm, a fistulous tract has been found extending intraperitoneally down over the liver to the umbilicus.
existed or whether there had originally been an accumulation of pus in the pleural cavity could not be determined.
Fig. 164 depicts in a schematic way the manner in which an empyema, after perforating the diaphragm, may travel downward and forward until it reaches the umbilicus.
A Broad-Ligament Abscess Opening at the Umbilicus.
According to Nicaise, Fereol was the first to describe a case of this kind; Bernutz and Guerin had also reported cases of phlegmon of the broad ligament opening at the umbilicus. 20
THE UMBILICUS AND ITS DISEASES.
Probably the most interesting articles on the subject are those of Yaussy, published in 1875, and of Gauderon, published in 1876.
We are all familiar -with the induration that is occasionally found in one or both
in broad tig.
Fig. 105. — The Opening of a Broad Ligament Abscess at the Umbilicus. (Schematic.) Broad ligament abscesses are most frequently observed after postpuerperal infections. Occasionally they form definite hard or boggy masses that can be readily palpated in one or both iliac fossa?. In rare instances the infection extends beyond the confines of the broad ligament. The pus dissects the peritoneum of the lateral and anterior abdominal wall free over a limited area, and finally escapes through the umbilicus, following the course roughly outlined by the arrows.
broad ligaments, and which, as a rule, has resulted from an infection following labor. Although such an inflammation is usually limited to the uterus, it may gradually separate the folds of the broad ligament and appear as a more or less indurated nodule in the right or left iliac fossa, and occasionally in both. If the tendency
THE ESCAPE OF FLUID FROM THE UMBILICUS. 291
toward suppuration continues, a further lifting up of the peritoneum may occur, and in this manner the pus may travel up to the umbilicus (Fig. 165) .
In nearly all the reported cases the patients have given a history more or less typical of a mild puerperal sepsis. After a period varying from a few days to several months' induration was noted at or near the umbilicus. This was in some instances accompanied by marked induration of the abdomen between the umbilicus and pubes. The center of the umbilical induration gradually softened. In some cases it opened spontaneously; in others it was opened before rupture had time to occur. The amount of pus escaping varied greatly, depending in large measure on the size of the broad-ligament abscess. The umbilical opening usually remained patent until the abscess-sac ceased to drain. In Vaussy's Case 1, however, it would temporarily close, only to discharge again. In the cases reported by Fereol and by Sottas, and in Vaussy's Case 6, the abscess also opened into the vagina. None of the patients died as a direct result of the abscess.
Treatment.- — • Sometimes it is possible to make counter-drainage, as in Sottas' case, in which a rubber tube was carried from the umbilicus to the vagina. If the abscess is large, it may be possible to enter the broad ligament from the vagina, but much care must be exercised to avoid injuring the ureter or uterine artery. When vaginal drainage does not seem feasible, the ordinary gridiron incision, as for an appendix operation, should be made; the peritoneum should be gradually pushed toward the median line until the broad ligament is reached and the abscess evacuated.
Cases of Broad-Ligament Abscess Opening at or Near the Umbilicus.
The following cases were encountered in looking up the literature on diseases of the umbilicus. There have doubtless been other cases recorded in the general obstetric and gynecologic literature. The number here cited is, however, sufficient to give a clear idea of the direction which abscesses in the broad ligament may occasionally take.
Fistula at the Umbilicus Following Suppuration in the Left Broad Ligament. — ■ Nicaise said the first observation of this kind was mentioned by Fereol.* Inflammation of the left broad ligament followed the labor. There then developed a local peritonitis, which later became general. At the same time the left side of the abdomen became tumefied and there was dulness on percussion. Toward the fifteenth day a small tumor appeared above and to the left of the umbilicus. It was hard, fluctuating, and opened spontaneously. Floods of pus escaped, soaking several draw-sheets during the night. Several days after another perforation took place, this time into the vagina. The umbilical fistula cicatrized in the course of six weeks.
Phlegmon of the Left Broad Ligament and of the Right Broad Ligament; Subperitoneal Escape of Pus by the Rectum; Escape of Pus Below the Umbilicus; H e a 1 i n g . f — Marie Noel, twenty-two years of age, was the mother of two children, one born in March, the other in December, 1875. After the labor she
- Fereol (Quoted by Nicaise): Ombilic. Dictionnaire encyclopedique des sci. med., Paris,
1881, 2. ser., xv, 140.
f Gauderon, E.: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers rombilic. These de Paris, 1876, 148.
292 THE UMBILICUS AND ITS DISEASES.
came under the care of Siredey. On December 20th a phlegmon of the left broad ligament was noted, and on February 5th there was a similar condition in the right broad ligament. About February 20th a thickening was made out in the anterior abdominal region, commencing three fingerbreadths beneath the anterior superior spine on the right, and reaching almost to the umbilicus. Pus had been discharged by rectum on February 12th. The abdominal tumor persisted and progressed toward the median line, apparently following the direction of the urachus toward the umbilicus. Pressure caused severe pain below the umbilicus. On February 11th fluctuation had been noticed below the umbilicus, and an opening had been made at this point which allowed the escape of a large quantity of creamy, thick pus. The umbilicus was never distended in the manner indicating the presence of a hernia.
Suppuration of the Tube and Ovary, with Opening at the Umbilicus. * — A woman, twenty-four years of age, was admitted to Viannay's clinic in August, 1910, on account of an abscess which had opened at the umbilicus. She had had a child twenty-three months before, but no miscarriages. Forceps were used at the labor. No fever followed. When she commenced to get up, pain was noted in the right iliac fossa. Some time later the abdomen was opened by Dr. Blanc for a salpingo-oophoritis. Recovery followed, but when the menses returned, pain was noted in the iliac fossa. There was a periodic purulent discharge from the uterus and pain in the lower abdomen. Little by little she developed a purulent accumulation around the umbilicus. This opened spontaneously and discharged an abundance of purulent material.
When admitted to the hospital, a small abscess the size of a walnut was noted in the lower part of the umbilical cicatrix. This had a punctiform orifice. The disproportion between the small size of the abscess and the great abundance of the umbilical discharge was very striking. On vaginal examination an induration was found in the right lateral cul-de-sac.
Operation. — The umbilical opening was increased in size and an abscess found in the subcutaneous tissue. The fistulous tract passed down the median line behind the muscle and the aponeurosis. The median incision was continued to within two fingerbreadths of the symphysis. A finger was introduced into the fistulous tract, and counter-palpation made through the vagina. Finally the abdominal finger opened up an abscess, which was drained from above. The vagina was not opened. The patient made a good recovery.
[This would appear to have been a broad-ligament abscess. — T. S. C]
Umbilical Fistula Following Puerperal Sepsis. — Nicaisef cites the case of one of Pujol's patients. The peritonitis developed in a woman shortly after confinement. A little later there was pain at the umbilicus and a small tumor formed, with a soft swelling around it. It was opened with a lancet and pus escaped. A sound introduced into the tract did not pass to the peritoneum. On the fourth day, in the depth, another tumor could be felt passing from the primary abscess. It opened spontaneously through the same opening, and a large quantity of pus escaped. The fistula closed in about six months.
- Maurin: Salpingo-ovarite suppuree, ouverte a l'ombilic. La Loire medicale, 1910, annee
t Nicaise (Pujol): Op. cit.
THE ESCAPE OF FLUID FROM THE UMBILICUS. 293
Subperitoneal Phlegmon of the Anterior Abdominal Wall Spontaneously Opening at the Umbilicus; Purulent Pleurisy, Followed by Recovery.* — Case 1. — This patient was twenty-one years of age and was admitted in May, 1875. Fourteen days previously she had had a normal labor, and four days later a chill, and the lochia had ceased. The abdomen increased in size, but there was no vomiting or nausea. On March 17th the umbilicus became red, projected somewhat, and showed a whitish point in its center. During the night of the eighteenth this ulcerated and there was a discharge of greenish liquid containing grumous material. During the evening the opening increased in size. By March 21st the discharge at the umbilicus had diminished. On April 3d it was very slight, but on the ninth the umbilicus opened again spontaneously and two liters of grumous, greenish pus escaped. The patient continued to have an appetite. There was some fever at night. By November 12th the patient had improved very much and was convalescing. During the first few months recovery was retarded by a purulent pleurisy. It was supposed that this patient had had a purulent peritonitis, and for that reason she was admitted to the hospital. Vaussy, however, was not certain that the condition was not due to inflammation of the perimetrium, with extension to the umbilicus.
[The latter explanation would seem to be the more rational one. — T. S. C]
Inflammation of the Left Broad Ligament Following Labor; Local Peritonitis, Mammary Abscess, Inflammation of the Femoral Vein, Spontaneous Perforation of the Abdominal Wall in the Neighborhood of the Umbilicus, also Opening into the Vagina. Cicatrization of the Umbilical and Vaginal Fistulae. Death Due to Tuberculosis of the Lungs. f — P. R., aged twenty-four, a healthy woman, was delivered on October 26, 1859. The labor was difficult. On October 31st the lochia ceased; the patient had a chill for half an hour. The abdomen became painful in the left inguinal region. The pulse was small, thready, frequent, and there was much thirst. The next day the lochia reappeared in small quantities. The abdomen was tympanitic, painful in the lower left side, where a tumefaction could be felt in the broad ligament. On November 2d the chills were constant and prolonged. The abdomen was swollen and painful. Pressure was intolerable. There was nausea without vomiting, and the face was pale and drawn. The pulse was small and frequent, and the skin hot and dry. On November 20th a phlebitis appeared in the left limb. On November 28th a small tumor was felt in the neighborhood of the umbilicus. It was immediately below and a little to the left, and was the size of a pigeon's egg. It was hard, although fluctuant. On November 30th an abscess presented in its center, a small plaque about the size of a 20-centime piece, from which a serous, transparent fluid was discharged. On December 1st a considerable quantity of greenish, serous pus escaped, which had a rather fetid odor. The abdomen diminished in size, and the tumor in part disappeared. On December 5th there was diarrhea, and the patient had a left intermammary abscess. She also suffered pain in the left lower abdomen.
- Vaussy, F. : Des phlegmons sous-p£ritoneaux de la paroi abdominale anterieure. These
de Paris, 1875, No. 445.
t Vaussy, F.: Op. cit., Case 6.
294 THE UMBILICUS AND ITS DISEASES.
The night preceding she had been inundated with pus that had escaped from the vagina. On the seventh the diarrhea continued; the discharge from the vagina diminished, but was abundant from the umbilicus. The chills appeared every day about 2 or 3 o'clock. There were definite signs of pulmonary tuberculosis. In the early part of January some improvement was noted. The fistula closed completely, the appetite returned, and the patient seemed to be on the point of recovery. Toward the end of January both lungs were found to be involved, and the patient died on February 24, 1860. At autopsy it was found that the intestinal loops were bound to one another by an old false membrane. Both lungs were infiltrated with tubercles.
In this case a woman, several days after labor, had a phlegmon of the broad ligament, which was extraperitoneal. It invaded the iliac fossa and the anterior abdominal wall, and there formed in this region, extraperitoneally, a large, purulent collection which reached to the umbilicus. The peritoneum was in contact with the abscess and became inflamed, whence there resulted a circumscribed adhesive peritonitis. Four weeks after labor the tumor opened at the umbilicus, and several days later a new opening took place spontaneously into the vagina. This latter opening was at the dependent portion of the abscess. The patient commenced to improve, but pulmonary tuberculosis suddenly developed. The autopsy demonstrated an old peritonitis, but no trace of any recent pus.
Suppurative Pelvic Peritonitis Opening Spontaneously at the Umbilicus.- — ■ Vaussy* reports a case observed by Sottas, an intern in the service of Marrotte, and published in L'Union medicale, June 2, 1864. R. A., aged twenty-three, was delivered of a child in the eighth month. After labor the patient had fever but no pain and no abdominal distention. There was nothing to indicate peritonitis. She left the hospital on April 22d, and three days later returned with all the symptoms of pelvic peritonitis. At that time an abscess is said to have opened into the vagina. In the course of two months she was again admitted to the hospital. She complained of pain in the left iliac fossa, and said that she had a tumor. In the month of September the swelling disappeared and the patient left the hospital in good health. She entered the hospital again on December 14, 1863. In the hypogastric region was an ovoid tumor, fairly firm, and painful on pressure. In the iliac fossa was an irregular solid tumor. The illness was attributed to a relighting up of the old pelvic inflammation. On January 2d fluctuation was noted in the hypogastric region, but this was so superficial that it was thought to be subcutaneous. The hypogastric region was prominent, and occupying it was a round tumor. At the umbilicus it was possible to feel the superior portion of the tumor, which was round and fluctuating. On examination the cervix was found to be back against the sacrum. Between the uterus and the symphysis was a round, soft tumor. Examination was painful, and the skin of the abdomen was red and suggested a phlegmon. On the night of January 5th a small nodule which had formed just below the umbilicus opened; there was a free escape of pus, and the hypogastric region became flatter. Later Bernutz and Gosselin saw the patient ; a probe introduced at the umbilicus passed down toward the vagina. On the tenth Gosselin dilated the umbilical orifice, punctured the vagina, and brought the probe through. A rubber tube was then passed from the umbilicus through into the vagina. On the nineteenth the urine escaped from the
- Vaussy, F.: Op. cit., Case 7.
THE ESCAPE OF FLUID FROM THE UMBILICUS. 295
umbilicus, and colored matter injected into the bladder escaped from the vagina and also from the umbilicus.*
The discharge of urine gradually ceased from the umbilicus, and on February 1st the patient voided without a catheter. The suppuration from the umbilicus and from the vagina had ceased. On February 6th the patient had chills and fever and the pain in the abdomen reappeared. On February 13th the umbilical fistula opened again, and a seropurulent discharge came away. On February 20th it was noted that the discharge had ceased for several days and the patient was in good condition. In the left iliac fossa could be felt an indurated tumor, but the patient remained well.
[In this case there was probably a broad-ligament abscess. Peritonitis cannot be absolutely excluded.]
An Abscess of the Umbilical Vein in an Adult.
This case hardly belongs in this chapter, but can be better considered here than elsewhere. As a rule, the umbilical vein has long since disappeared, but from Dr. Barlow's description it seems quite probable that the abscess here described developed in a partially patent umbilical vein.
An Abscess of the Umbilical Vein in an Adult, f ' — • The patient was a male, white, aged forty. At the age of fifteen he began to have sporadic attacks of pain, cramp-like in character, very severe, and coming on nearly always at night, after retiring. These attacks, as a rule, were of short duration. Two or three days after the pain was over the patient was apparently perfectly well again until the next attack.
On the evening of January 14, 1915, the patient was taken with severe pain involving the whole right abdomen. The pain was so severe that it caused him to draw his knees up and to cry out. He had no chills and was not jaundiced; temperature, 101° F.; nausea and vomiting once. Dr. E. C. McGehee, the family physician, examined him thoroughly and made a diagnosis of acute infection of the gall-bladder. One-quarter of a grain of morphin failed to relieve the pain, and it was necessary to allow him to inhale chloroform before any relief could be obtained. Dr. Barlow saw him in consultation next morning. At that time the temperature was 100° F.; the entire abdomen was distended; the acute pain was subsiding; the area of tenderness was localizing between the umbilicus and the liver, and the patient was sensitive under the right costal arch. Immediate operation was advised, but the patient did not consent until a week later.
Operation. — The usual gall-bladder incision was made, but as he was opening the peritoneum Dr. Barlow entered an abscess which he thought was the gallbladder. Exploration with the finger disclosed the fact that it was not the gallbladder but a well-walled-off abscess containing about one and one-half ounces of pus. This abscess in shape resembled a bottle-gourd, the larger portion being toward the umbilicus, the smaller or handle-like end extending into the fissure of the liver. This abscess was firmly fixed to the abdominal wall, to the upper border of the liver above the gall-bladder, and to the hepatic flexure of the colon.
After this sac had been dissected free from these attachments it was still found
- We would now administer phenolphthalein, which would give the reddish discharge from the
vagina and also from the umbilicus.
j Dr. E. E. Barlow, Dermott, Ark. Personal communication.
296 THE UMBILICUS AND ITS DISEASES.
anchored to the fissure of the liver by the handle-like portion of the sac, which proved to be the umbilical vein. This was patulous within an inch of its bifurcation. It was ligated above the patulous portion and removed.
The stomach,, duodenum, pancreas, gall-bladder and its ducts were examined and found to be normal. The portion of the hepatic flexure of the colon that was adherent to the sac was somewhat lacerated, and in the presence of infection Dr. Barlow did not feel justified in attempting to repair it. There was no evidence of ulceration at this point, the damage being due, as Dr. Barlow says, to an extensive dissection. A large coffer-dam drain was laid down between the liver and intestine. This was removed on the fifth day. Two days later a fecal fistula appeared but closed after five or six days. The patient made an uneventful recovery, and at the time of the report was apparently well.
LITERATURE CONSULTED ON THE ESCAPE OF RETROPERITONEAL FLUID
FROM THE UMBILICUS.
Fereol: Nicaise: Ombilic. Dictionnaire encyclopedique des sci. med., Paris, 1881, 2. ser., xv, 140.
Gauderon, E.: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers l'ombilic. These de Paris, 1876, No. 148.
Maurin: Salpingo-ovarite suppuree, ouverte a l'ombilic. La Loire medicale, 1910, annee 29, 495.
Nicaise: Op. cit.
Vaussy, F. : Des phlegmons sous-peritoneaux de la paroi abdominale anterieure. These de Paris, 1875, No. 445.
THE OPENING OF AN APPENDLX ABSCESS AT THE UMBILICUS.
An appendix abscess, in the vast majority of cases, naturally is intra-abdominal, and hence there is little opportunity of its passing upward in the abdominal wall unless the abscess has destroyed the peritoneum of the anterior abdominal wall over the abscess area, or unless, as happens very rarely, the appendix from the beginning has been retroperitoneal. In an experience extending over twenty years I have never seen the umbilicus involved in an appendix case. In the literature I have, however, found several cases which seem to indicate an extension to the umbilicus.
Vaussy* reports a very interesting case: A girl, sixteen years of age, was admitted on October 27, 1875. Seven months previously she had suddenly vomited, had had diarrhea, but no abdominal pain. Three months later the pain had become severe in the hypogastric region and the patient had noticed a tumor occupying the right iliac fossa. This was painful on pressure. She had had no chills, no nausea or vomiting. In the course of two months this tumor had increased in size, and the pain had become more severe, lancinating in character, and insufferable. The patient had lost her appetite and had fever, and her general condition was much altered. The tumor had become fluctuant. Two incisions were made, and about 500 c.c. of pus escaped. Several days later a small red plaque appeared below the umbilicus, and there was a tumor the size of a cherry. This opened spontaneously with the passage of a certain amount of pus. There was also a discharge of pus from the umbilicus. Toward the end of September the opening cicatrized. When seen on October 27th the patient was again pale, and there was a purulent
- Vaussy: Op. cit., Obs. 3, p. 27.
THE ESCAPE OF FLUID FROM THE UMBILICUS. 297
discharge from the umbilical region and also from the site of the incision. By November 11th the patient was in excellent condition and looked as if she were getting well. [While one cannot say that this was primarily a case of appendicitis, the picture strongly indicates it. — T. S. C]
Gauderon, in his thesis in 1876, refers to the same case.
Bryant and Hine, in 1878, reported a case in which the escape of pus was in all probability appendiceal in origin, as indicated by the perforated cecum detected at autopsy. A boy, aged thirteen, had pain in the lower abdomen and also soreness at the umbilicus, together with a fecal fistula at that point. He had been delicate since an attack of scarlet fever when three years old. His legs were scalded when he was eleven years old, and since then he had lost weight. His bowels had always been loose. Three weeks before admission he had sudden pain in the abdomen, and a week later his umbilicus began to swell, became purple, and in a few days burst, discharging a quantity of matter with a distinctly fecal odor. The boy died.
At autopsy the cecum was found to have ulcerated through, and the ulceration had extended along the abdominal wall to the umbilicus. The symptoms in this case strongly suggested appendicitis or an inflamed Meckel diverticulum.
Kelly and Hurdon report an interesting case coming under the care of R. L. Payne, of Norfolk, Va. The patient, a colored woman twenty years old, after repeated attacks of appendicitis, developed a tumor at the umbilicus. When an incision was made in the mid-line, just beneath the umbilicus, half a pint of fetid pus escaped and the appendix floated out. The patient recovered, but a fistula persisted.
We have here considered only those appendix cases in which an abscess was present, and in which no general peritonitis existed. For a description of the umbilicus in cases of peritonitis see p. 299.
LITERATURE CONSULTED ON THE OPENING OF AN APPENDIX ABSCESS AT THE
Bryant and Hine: Fecal Umbilical Fistula. Med. Times and Gaz., 1878, i, 460.
Gauderon, E.: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers l'ombilic. These de Paris, 1876, 148.
Kelly and Hurdon: The Vermiform Appendix and its Diseases. Phila., W. B. Saunders Co., 1905, 202.
Vaussy, F. : Des phlegmons sous-peritoneaux de la paroi abdominale anterieure. These de Paris, 1875, No. 445.
ABSCESS OF THE LIVER OPENING AT THE UMBILICUS.
Berard, in 1840, wrote on abscess of the liver opening at the umbilicus.
Leguelinel de Lignerolles, in 1869, said that hepatic fistulae opening at the umbilicus might be due to a calculous tumor, to hydatids, or originate from an abscess of the liver. He then reported in detail several cases in which biliary calculi and echinococci escaped at the umbilicus, but has little to say regarding hepatic abscesses opening at the umbilicus.
Nicaise, when summing up the subject, says that abscess of the liver does not, as a rule, tend to open externally, and that, judging from the statistics of Rendu, the majority of these abscesses do not open spontaneously. When rupture takes place, the pus tends to pass toward the thoracic more frequently than into the
298 THE UMBILICUS AND ITS DISEASES.
abdominal cavity. In those rare cases in which the abscess tends to escape externally the point of exit is liable to be in the region of the right hypochondrium, beneath the costal margin, where the abscess becomes walled off and then ruptures. Nicaise says that he knew of but one case, that of Ronis, in which a liver abscess opened directly at the umbilicus. Judging from a casual glance over the literature one would infer that an escape of the contents of a liver abscess from the umbilicus was not rare, but when we come to analyze the cases, it will be found that in nearly every instance the umbilical fistula was due to an infected gall-bladder which had become adherent to and opened at the umbilicus, as evidenced by the escape of gallstones with the pus.
The opening of a liver abscess at the umbilicus is a very rare occurrence.
LITERATURE CONSULTED ON ABSCESS OF THE LIVER OPENING AT THE UMBILICUS.
Berard, P. H.: Fistules de l'ombilic. Diet, de med., Paris, 1840, xxii, 64. Nicaise: Op. cit.
Leguelinel de Lignerolles, H.: Quelques recherches sur la region de l'ombilic et les fistules hepatiques ombilicales. These de Paris, 1869, No. 6.
PERITONITIS WITH THE ESCAPE OF PUS AT THE UMBILICUS.
From time to time isolated cases of peritonitis with escape of the pus from the umbilicus have been recorded. Among the earlier writers on the subject were Bricheteau in 1839, Cazaban in 1845, Aldis in 1848, and Baizeau in 1875. The most exhaustive treatise that we possess is the excellent thesis of Gauderon, published in 1876, and even to-day this monograph contains the most illuminating discussion of the subject. Nicaise, in 1881, gave a very complete review of the literature, and Cameron, in the Proceedings of the Royal Society of London, February, 1912, adds some very interesting data.
As pointed out by Gauderon, this disease occurs almost exclusively in girls. Boys, however, are occasionally attacked. Of the cases described here more or less in detail, and where the sex was mentioned, 12 occurred in girls and 1 in a boy.
Age. — ■ The youngest child was a year old, the oldest, seventeen. In 15 cases in which we have data as to the age, 14 of the patients were under twelve years of age.
Symptoms. — The child is usually attacked suddenly with severe abdominal pain. When seen, the legs are drawn up, the face has an anxious expression, the pulse is rapid and small, the temperature elevated ; the tongue is often red, and the skin hot. As the disease progresses there may be much vomiting associated with diarrhea. In fact, in Baizeau's case the gastro-intestinal symptoms were so accentuated that cholera was suspected. The exact condition is often very obscure. In Cameron's Case 6 appendicitis was first suspected, and later the child was supposed to be suffering from pneumonia. In Cameron's Case 7 the symptoms strongly suggested typhoid fever.
As the disease progresses the child may become delirious, as noted in Aldis' and Baizeau's cases, and emaciation become marked. After a period varying from a few days to several weeks fluid is detected in the abdomen, and a little later the umbilicus becomes prominent. Thus, in Triboulet's case, referred to by Gauderon, for
THE ESCAPE OF FLUID FROM THE UMBILICUS. 299
example, on the eighth clay a small, elevated tumor formed at the umbilicus. This was diagnosed as an umbilical hernia, and an attempt made to reduce it. In Cameron's Case 6, on the other hand, it was ten weeks before any umbilical swelling was noted. There is usually an unfolding, as it were, of the umbilicus, and a tumor is formed. The umbilical skin may be normal or somewhat thinned out. The tumor contains free fluid, and when this has been forced back into the abdomen, the hernial ring can at times be easily felt. This forcing back of the fluid into the abdomen is sometimes accompanied by a considerable amount of gurgling. As a rule, there is little or no evidence of inflammation at the umbilicus. In Cazaban's case, however, there was a phlegmonous inflammation at the umbilicus, and in Triboult's case the umbilicus was indurated.
Gauderon says that pus may escape from the umbilicus as early as the twelfth day, but that, as a rule, it comes away between the twentieth and thirtieth days. In some cases the umbilical prominence became red and opened in its center; in other cases, after the application of poultices, there was a sudden discharge of pus, much to the surprise of the physician or attendant. If there has been much abdominal tension, the pus will naturally escape in jets until the pressure has been relieved. It varies greatly in appearance. In some cases it was spoken of as a purulent fluid; in others, as that of a serous peritonitis, while in several cases it was thick and green in color. In some cases it was odorless; in others, foul-smelling. The amount of pus also varied greatly. In some cases it was estimated that several liters escaped.
Sometimes the fistula would remain open for weeks and then close. In other cases it would seal over -and open up again, only to repeat this procedure several times.
In some cases it was found necessary to irrigate the abdominal cavity frequently before the purulent secretion could be checked. The earliest permanent closure was in eight days — in Cazaban's case. In one case the fistula remained open seven and one-half months. Gauderon said that, on an average, the fistula closed in a month.
In a few cases the umbilical swelling was incised before it had time to rupture, thus facilitating the escape of the pus.
Complications. — -In Triboulet's case a friction-rub developed at the base of the right lung. In West's case there was a purulent pleurisy with effusion, and in Baizeau's case a pleuropneumonia developed.
Recovery. — As pointed out by Gauderon, nearly all the children in whose cases the peritonitis opened at the umbilicus recovered. Those dying succumbed to lesions in no way dependent on the peritonitis.
Causes of the Peritonitis. These cases have usually been spoken of as instances of idiopathic peritonitis, and as most of the reported cases occurred before bacteriologic examinations were made, we have no way of determining absolutely their mode of origin. According to Ledderhose, Henoch's patient had been trampled on by a large dog and the peritonitis had soon followed. Cameron's Case VI, reported in 1912, was due to the pneumococcus, and in his Case VII there was probably a similar origin. From a careful study of these cases one gathers the impression that the pneumococcus may be responsible for the majority of the cases of so-called idiopathic peritonitis.
300 THE UMBILICUS AND ITS DISEASES.
Differential Diagnosis. These cases of peritonitis are occasionally simulated by deep-seated inflammations between the umbilicus and pubes. These are usually due to an infection of remnants of the urachus. If the inflammation occurs in young children, for the first few days it may be impossible to differentiate between it and a general peritonitis, the symptoms being identical (p. 567), but after an interval of four to five days the abdominal swelling diminishes, the abdomen becomes flat, and a localized tumor is felt between the umbilicus and pubes, whereas in a peritonitis the intraabdominal fluid is still evident.
Cases of General Peritonitis Opening at the Umbilicus.
These cases are of interest from a historic standpoint, showing, as they do, how nature may liberate a purulent peritoneal accumulation. In the future we shall expect to see still fewer of these cases, since, with the operative facilities that we now possess, abdominal drainage will be adopted early in the disease.
Purulent Peritonitis with Spontaneous Evacuation Through the Umbilicus; Healing.* — A girl, aged seven years and four months, was visited by Dr. Aldis on June 5, 1846. She lay on her right side; the face was emaciated and drawn, and the expression was anxious. The extremities were atrophied. The urine was scanty, the abdomen was distended, and there was a projection at the umbilicus ; fluctuation was manifest. About eleven weeks before, the child had been seized with chills and fever, vomiting, and pain in the abdomen; on the following day she was delirious. An examination of the abdomen failed to reveal any induration. On June 7th an opening occurred spontaneously in the tumor, and over 2000 c.c. of purulent material escaped from the abdomen. The child complained of pain in the hips. The urine was abundant and pale. On the following days pus continued to escape. On June 12th the abdomen was perfectly flat, and the child was visited for the last time. On September 30th she was in good condition. The abdominal girth was only 20 inches in the region of the umbilicus, and the opening was closed by a solid cicatrix.
Probably a Peritonitis, with Escape of Pus From the Umbilicus. — Bricheteauf reported a case in which a large abscess of the abdomen, simulating an acute peritonitis, opened at the umbilicus. A girl, aged seventeen, of lymphatic constitution, on May 17, 1839, complained of abdominal pain. The abdomen was sensitive, and she could not bear to be touched with the hand. The skin was hot, the pulse somewhat accelerated. There was very frequent vomiting. The expression was anxious, but the general abdominal contour was not altered. Prolonged baths were given, but eight or ten days later the abdominal pain returned and was associated with tension. The patient could not sit up. Vomiting reappeared and there was diarrhea. Thirst was marked, and there was much heat of the skin and an increase of fever. The abdomen was distended and tympanitic on the left side, and the patient lay continuously on her right side. On June 12th Bricheteau noted that the skin of the umbilicus
- Aldis: Gaz. med. de Paris, 1848, 733. Cited by Gauderon: De la pcritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers l'ombilic. These de Paris, 1876, No. 148; obs. 25.
t Bricheteau: Des abces dans le tissu cellulaire sous-peritoneal. Arch. gen. de med., 1839, vi, 435.
THE ESCAPE OF FLUID FROM THE UMBILICUS. 301
was thin and raised, and two days later, on removal of a poultice, a jet of pus was seen escaping from the umbilicus and an enormous quantity came away. It was thick in consistence, without odor, and resembled the serous pus of peritonitis. The suppuration continued for several days, after which the opening closed. It opened again and finally closed permanently. The patient for a long period had digestive troubles with vomiting, and was not permanently cured until after a sojourn of three months in the country.
Purulent Peritonitis; Spontaneous Rupture at the Umbilicus; Abscess of the Parotid; Pleurisy; Recovery.* — ■ The patient was a boy, twelve years of age, in good health and of a strong constitution. Suddenly he complained of pain in the abdomen and fever developed. The abdomen became distended, ballooned out, and was very sensitive. The slightest pressure could not be made except near the hypogastrium. The facial expression was altered. The radial pulse was 110. The skin was burning. There was excessive thirst and incessant vomiting. The diagnosis did not offer any difficulties, but the cause of the peritonitis was not easy to determine. He showed no signs of external violence, and nothing indicating intestinal perforation. Twenty leeches were applied to the abdomen and were then replaced by fomentations. The abdomen had diminished in size by the next day, except in the region of the umbilicus, where the swelling had increased. The general condition remained the same; the fever and vomiting continued. Applications of leeches were again made. On the fifteenth day there was some improvement. The abdomen remained distended, but was less sensitive on pressure. The pulse was 100; the vomiting had ceased. There had been no movement of the bowels for two days. On the eighteenth day there was a marked change. After dinner an intense pain developed in the right hypochondriac region, reaching to the shoulder. The child cried, and the suffering was extreme. The vomiting returned, and the pulse reached 115. A right pleuropneumonia developed. The point of greatest intensity was at the right nipple. This new affection progressed. On March 15th pain was noted in the right parotid region and a large parotid abscess was opened. About March 20th the abdominal pain reappeared without appreciable cause. It was easily possible to make out an abundant quantity of fluid in the peritoneum. The umbilicus was pushed out by the fluid, and formed a small external tumor. On April 2d this broke, and several liters of greenish pus with thick, grumous material escaped. The discharge lasted for several days and improvement was noted. A drainagetube was introduced, and an injection of lukewarm water made. The suppuration diminished. At the same time, in the right nipple region, a fluctuating tumor was punctured. On April 10th about six quarts of pus escaped from the umbilicus. Toward the end of May the thoracic fistula closed. About June 21st there was severe pain in the region of the right shoulder, reaching to the lung, and accompanied by intense fever. In the course of several days a fluctuating tumor was detected, and on puncture an abundance of pus escaped. A drainage-tube was introduced and an injection of iodin was employed. The chest fistula closed on October 1st; that of the abdomen, on December 20th. The abdomen was soft and pliable. The respirations were normal.
- Baizeau: Arch. gen. de med., 1875, 163. Quoted by Gauderon, A. E.: De la peritonite
idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers l'ombilic. These de Paris, 1876, No. 148, observation xx.
302 THE UMBILICUS AND ITS DISEASES.
Purulent Peritonitis; Spontaneous Opening at the Umbilicus.*- — The subject of this observation was a young girl of ten who had a good constitution and had previously been well. For a month preceding her illness she had spent her time quietly with her parents. On May 31, 1872, she had constant pain in the abdomen, accompanied by nausea and vomiting. The eyes were sunken and the face was drawn. There were several liquid stools, and the patient had cramps in the legs. The case suggested cholera. On the following day, at 9 a. m., the vomiting, which had been frequent during the night, stopped. The patient commenced to complain of pain in the head. This became more and more violent, and was accompanied by delirium. Ice was applied to the head. The cerebral trouble for some time completely overshadowed the lesion in the abdomen. The delirium disappeared in the course of four or five days, but the fever continued. There was great thirst, and the tongue was covered with sordes. The abdomen was also painful and distended, and a certain amount of fluid could be detected in the peritoneal cavity. On the following day the pain was referred principally to the right hypochondriac region, and some complication in the liver was thought of. The child complained continually of suffocation and palpitation of the heart. The abdomen increased in size, and was in marked contrast to the extremities, which were greatly emaciated. This condition persisted for a month without any amelioration. The digestive troubles were more and more pronounced; very frequently there was vomiting of bile and a diarrhea. For some unknown reason a plaster was applied to the abdomen, and when it was drawn back in one of the early days in July, it was noted that the umbilicus was distended by the abdominal fluid. It was red and very thin in its center. On the following clay it opened spontaneously, and about 4 liters of purulent, greenish fluid escaped. The discharge continued that night and for several days in great abundance. The child felt relieved and slept; the appetite returned, and there was a marked change for the better. This, however, did not last; the fever returned, the nights were bad, and the digestion again became disordered. Baizeau was called in consultation on July 14th. He found the infant very much emaciated and feeble, and with a continuous fever. The abdomen was markedly distended, and there was an escape of grayish, thick pus, with a strong odor, and containing greenish streaks indicating its hepatic origin. This greenish material, which escaped in large quantities, yielded biliverdin. The abdomen was painful, and at times the child complained of severe pain. The pus was secreted by the peritoneum and escaped incompletely. The umbilical opening was too narrow for the introduction of a drainage-tube. The orifice was dilated with rubber, and on the third day a drain was introduced. Injections were made morning and evening with tepid water, and the fluid appeared to pass into all parts of the abdomen. The fever ceased, and a verj^ favorable change in the general condition was noted. The activity of the stomach returned, and the child, who had been fretful and depressed, became lively. The abdomen was more supple and less painful. Suppuration stopped, and the drainage-tube was taken out on August 28th. Three days later the umbilicus was completely closed. The child had not completely recovered her usual buoyancy, but the general condition was markedly improved. The abdomen was supple and looked normal. The abnormal sensibility had entirely disappeared, and the digestive functions were regular. About September loth she left Algiers for Paris, where she continued to improve.
- Baizeau: Quoted by Gauderon, op. cit., obs. 22.
THE ESCAPE OF FLUID FROM THE UMBILICUS. 303
Purulent Peritonitis; Escape of Pus at the Umbilicus; Persistence of the Umbilical Hernia; Healing.* — The patient was a child of five years who had been healthy. On January 4th the child presented symptoms of catarrhal fever. On January 6th signs of peritonitis had developed. Under treatment the fever diminished, but the abdomen was painful and much distended. Percussion showed that the distention was not due to the presence of air in the intestine, but to an effusion of fluid in the peritoneal cavity. The child refused absolutely to take medicine. On January 22d the umbilicus was prominent, semitransparent, and red. By the following day the tumor had increased in size to that of a hen's egg, and the skin had become thinner. The presence of fluid could be distinctly made out. On January 25th the tumor ruptured and fluid escaped in a stream the size of a goose-quill. The fluid was semipurulent ; about enough to fill a "bottle and a half" came away. On the following day the discharge was moderate in amount and the abdomen was sensitive. The febrile symptoms did not disappear. About February 12th the condition of the patient commenced to improve, but the umbilical fistula still persisted. Dr. Beonhardy attended the patient until September 15th. At that time the fistula had closed, but the child still continued to wear a bandage on account of the umbilical hernia. The destruction of the cellular tissue closing the umbilicus had favored the production of a hernia.
Pneumococcal Peritonitis Present at Umbilicus. f — Case VI. — A girl, aged five years, was admitted on April 5, 1911. Six weeks before, she had had an acute illness. At first appendicitis had been diagnosed, and later pneumonia. After a week the abdominal pain had disappeared, but the child had remained without appetite. Before admission the presence of free fluid in the abdominal cavity had been recognized. A diagnosis of tuberculous peritonitis was made, and the child was kept out-of-doors. The opsonic index to tuberculosis was 1.2. On April 30th a swelling appeared at the umbilicus and became so prominent that it was decided to operate. As soon as the peritoneum was opened pus poured out, three pints being collected. A pure growth of pneumococcus was obtained. Recovery followed, and the child was discharged well on July 8th.
Probable Pneumococcal Peritonitis Opening at the Umbilicus. ± — Case VII. — -A girl, aged eight, was admitted July 9, 1903, under Dr. Taylor's care. On April 20th she had suddenly complained of abdominal pain, and an acute illness of many weeks' duration had followed. It was supposed to be typhoid fever. In the fourth week she was still ill. On July 7 Dr. Taylor saw the child and admitted her to the hospital. The abdomen was swollen and contained fluid. On the day before her admission a fistula formed at the umbilicus. Mr. Lane operated, and one and one-half pints of greenish-yellow pus escaped. The child recovered and was discharged September 3, 1903. When heard from in March, 1905, she was well.
Abdominal Abscess Simulating Ascites; Spontaneous Opening at the Umbilicus. Recovery. § — A girl, five
- Beonhardy: Brit, and For. Med. Rev., xiv, 549. (Cited by Gauderon, op. cit.)
f Cameron, Hector Charles: The Relative Value of Immediate and Delayed Laparotomy in Pneumococcal Peritonitis. Proc. Roy. Soc. Med., February, 1912, v, Xo. 4, 123.
± Cameron, H. C: Op. cit.
§ Cazaban: Abces abdominale simulant une ascite; ouverture spontanee par le nombril; guerison. Jour, de chirurgie, 1845, iii, 252.
304 THE UMBILICUS AND ITS DISEASES.
years old, of weak constitution, was suddenly seized with pain in the abdomen. The bowels did not move, but blood and mucus escaped by the rectum. The pulse was rapid and small, the tongue red, the skin hot, and there was pain on pressure, chiefly in the hypogastric region. On her way to the hospital there were several inclinations to stool, but only tenesmus resulted. This condition kept up for eight or ten days. The symptoms of dysentery disappeared, but the abdomen was painful and the fever persisted. The child appeared to suffer less and seemed to be improving, but the abdomen remained sore. Local applications were used, but during September the child grew thinner, and the abdomen continued to distend. In October the abdomen was much larger and was oval in form.
It was decided to puncture, but this procedure was delayed five or six days. Meanwhile a phlegmonous erysipelas developed at the umbilicus. The cicatrix became prominent, and finally, in one day, more than four liters of whitish-yellow, creamy but odorless pus escaped from the umbilicus. The abdomen still remained painful after the fluid came away. Eight days later the umbilical opening had closed completely, the fever was gone, and the child was convalescing; in one month she was perfectly well.
Peritonitis with Escape of Pus from the Umbilicus.* — This case was observed in the service of Triboulet. Maria M., aged six and one-half years, entered the hospital on April 29, 1874. Without apparent cause she had become seriously ill on April 18th. At the beginning there had been pain in the abdomen and excessive vomiting, which had lasted for twenty-four hours. For several days there had been some ten diarrheal stools daily, but without a trace of blood or pus. The diarrhea had not disappeared entirely when the child entered the hospital. She had high fever, and lay immobile in her bed. Applications were made to the abdomen. On April 26th a small, elevated tumor was noted at the umbilicus, and when he saw her, on April 28th, the physician made a diagnosis of umbilical hernia. On admission to the hospital an attempt was made to reduce the supposed hernia. There were also signs of some thoracic affection. She was transferred to Triboulet's service. The facial expression was that of peritonitis — the eyes were sunken, the facial lines drawn; the respirations were 32 to the minute. Percussion of the lungs was negative, but a friction-rub could be heard at the base of the right lung and in front. The pulse was 140, the skin moderately hot. On April 30th signs of peritonitis still persisted. The tongue was red, and its epithelium was dropping off. There was an escape in a jet of about 1500 c.c. of a yellowish, odorless pus from the umbilicus. After the flow ceased, the umbilical cicatrix could be made out; it was distended and indurated, and at the top was a small orifice from which the pus had escaped. The child had some diarrhea after this, but no vomiting, nausea, or hiccups. By the same evening the facial expression had become better, and by the next morning the child wanted something to eat. There was no vomiting, and not the slightest trace of pus by bowel. A moderate amount of discharge still issued from the umbilicus. On May 3d a certain quantity of pus escaped. By the following day the diarrhea had ceased completely, and on June 1 the child was taken to a convalescent home. She was completely cured, and the umbilical fistula had closed. At no point in the abdominal wall was there any trace of induration.
- Gauderon: Op. cit.
THE ESCAPE OF FLUID FROM THE UMBILICUS. 305
General Peritonitis Cured by Incision of the Protruding Umbilicus. — Under date of June 3, 1910, Dr. W. D. Haggard, of Nashville, Tenn., wrote me concerning the history of a patient suffering from general peritonitis. The fluid had been evacuated through an incision into the protruding umbilicus. The patient was a girl twelve years old. She had had a violent attack of appendicitis with great initial prostration. At the end of three weeks she had improved considerably, but the temperature would reach 100° F. m the afternoon, and the abdomen, which had originally been hard and distended, was now soft and fluctuating, and showed a protruding, red, and thinned-out umbilicus. This was incised under ethyl chloricl inhalation, and fully three quarts of purulent fluid were evacuated. The umbilicus had to be reopened on account of an accumulation of a small quantity of fluid. Dr. Haggard told me that the patient was well two months later, but that an interval removal of the appendix had been advised.
Peritonitis with the Escape of Pus From the Umbilicus. — Ledderhose* says that Henoch described in his text-book the case of a girl, ten years old, who, after having been trampled upon by a large dog, had acute peritonitis which terminated by a breaking through at the umbilicus. Ledderhose adds that in grown people acute peritonitis has no tendency to break through at the umbilicus.
Purulent Peritonitis Following Scarlatina in an Infant Thirteen Months Old.f — This was the case reported by Dr. West. J A small, well-nourished girl had scarlet fever when eight months old. The eruption was not marked, but after its disappearance the child did not recover her health, continued to be restless, and had fever. Sometimes she would vomit, and the eyelids at times were swollen. Fifteen days after the appearance of the eruption she had two violent attacks of convulsions. She remained sick until she was ten and a half months old, when her mother noticed puffiness of the eyelids and swelling of the legs and of the abdomen. When the child came under West's observation there were still edema of the legs and distinct fluctuation in the abdomen. The urine was scanty and showed some pathologic changes. Three weeks later her general condition was considerably improved. The urinary secretion was more abundant, and the abdominal circumference was 4 cm. less than before. She had an attack of convulsions without any apparent cause. For a week seropurulent material escaped at the umbilicus and continued to do so, the amount varying from 150 to 200 c.c. This event was followed by improvement in the patient's condition, but after eleven days the fever and dyspnea increased and there was a dulness on percussion over the right lung and absence of the respiratory murmur in front. The discharge ceased for a week, at the time that the thoracic symptoms were most intense. Afterward there was again some discharge which was small in amount. The child at this time was very feeble and much emaciated. She was given stimulants, but forty-eight hours later died without any signs of convulsions, just five and a half months after the scarlet fever and two months after coming under observation. At autopsy a purulent pleurisy
- Ledderhose, G. : Deutsche Chirurgie, 1890, Lief. 45 b, 122.
t Gauderon (West): Op. cit., obs. 23.
X West, Charles: Lectures on the Diseases of Infancy and Childhood. Fifth Am. Ed., Phila., 1874, 107.
306 THE UMBILICUS AND ITS DISEASES.
was found on the right side and an effusion of about 180 c.c. of pus in the right pleural cavity. About 1250 c.c. of a similar liquid was found in the abdomen.
Umbilical Abscess Following General Peritonitis. — Gauderon* gives the abstract of a case published by Vetu in the Jour, de msd., chir., pharmacie et de med. veterinaire de la Cote d'Or, 1846. The patient was a small girl of four years who was convalescing from acute peritonitis. A tumor the size of an almond was noted in the umbilical region on May 14th. This was soft and elastic, and there was no change in color in the skin. It was depressible, and when it had disappeared, in the depression the finger could make out clearly the hernial ring, but when the pressure was released, the tumor reproduced itself. When the child cried or moved about, it became prominent. Vetu diagnosed the condition without hesitation as an umbilical hernia. On May 18th the tumor was larger, being the size of an elongated walnut. Vetu did not notice anything extraordinary in the aspect of the abdomen. Applications were made to the abdomen, and on May 22d, four days later, the physician was not a little surprised to find the child literally bathed in creamy pus. On removal of the dressing, it was found that the tumor had disappeared and that pus was escaping from the umbilicus, the total amount being estimated as 1500 to 2000 c.c. After the pus had stopped running, an opening which admitted the extremity of the finger was noted at the umbilicus. There was not a trace of hernia. In the course of ten days the ring was completely closed and the child recovered.
LITERATURE CONSULTED ON PERITONITIS WITH THE ESCAPE OF PUS AT THE
UMBILICUS. Aldis: Gaz. med. de Paris, 1848, 733. Baizeau: Arch. gen. demed., 1875, 163.
Bricheteau: Des abces dans le tissu cellulaire sous-peritoneal. Arch. gen. de med., 1839, vi, 435. Cameron, H. C. : The Relative Value of Immediate and Delayed Laparotomy in Pneumococcal
Peritonitis. Proc. Roy. Soc. London, February, 1912, v, No. 4, 123. Castel, J.: Considerations sur la pathogenie des fistules ombilicales. These de Paris, 1884, No.
56. Cazaban: Abces abdominal simulant une ascite; ouverture spontanee par le nombril; guerison.
Jour, de chir., 1845, hi, 252. Gauderon, A. E. : De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a. travers l'ombilic. These de Paris, 1876, 148. Haggard, W. D.: General Peritonitis Cured by Incision of the Protruding Umbilicus (personal
communication). Ledderhose, G.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Nicaise: Ombilic. Dictionnaire encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv,
140. Vaussy, F.: Des phlegmons sous-peritoneaux de la paroi abdominale anterieure. These de Paris,
1875, No. 445.
THE PIECEMEAL REMOVAL OF A SUPPURATING OVARIAN CYST THROUGH
From the following history it is clearly evident that the patient had an ovarian cyst. The suppuration was, no doubt, in a measure due to infection following the last abdominal puncture, and it is remarkable that the patient recovered. The woman came under observation over thirty years ago at a period when one hesi
- Gauderon: Op. cit., obs. 17.
THE ESCAPE OF FLUID FROM THE UMBILICUS. 307
tated a long time before opening the abdomen. Now, of course, the cyst would be promptly removed.
Inflammation of an Ovarian Cyst, Abscess Formation, Opening at the Umbilicus. Recovery.* — Madame F., aged forty-seven, was the mother of several children. When examined on September 10, 1878, she had signs and symptoms of an ovarian cyst of three years' duration. Between September 10, 1878, and November 20, 1879, the abdomen was punctured 11 times and 170 liters of a clear, serous fluid were removed. Shortly afterward there were signs of acute inflammation in the abdomen, distention, high fever, a small pulse, vomiting, and the characteristic facial expression. It was thought that she would die. Four days later the patient was still alive, and redness was noted at the umbilicus over an area 3 by 4 cm. In six days there were signs of fluctuation, and three days later between two and three liters of pus came away from the umbilicus. Trepan pulled out and cut off with the scissors a large amount of necrotic tissue. About eighteen months after his first visit he found the patient perfectly well and she remained so.
LOCALIZED JAUNDICE OF THE UMBILICUS IN THE PRESENCE OF FREE BILE IN
THE ABDOMINAL CAVITY.
In April, 1915, Dr. Joseph Ransohoff drew my attention to a most unusual condition, namely, localized jaundice at the umbilicus when bile exists free in the abdomen.
In the Transactions of the Southern Surgical and Gynecological Association for 1905 Dr. Ransohoff reported the case of W. B., merchant, fifty-three years old, who had had typhoid fever six years before coming under observation. In April he had what was supposed to be a mild attack of indigestion, and in August was seized with severe colicky pain in the umbilical region. The pain disappeared in five days. Ransohoff saw him in October. The patient had had a sudden chill during the night ; he had had pain in the right hypochondrium, and on the next day had complained of abdominal distention and excruciating pain in the right lower abdomen.
On admission to the hospital it was noted that the patient was a large-framed man, with every indication of intestinal obstruction from peritonitis. He had an anxious facial expression; the pulse was 130; the temperature, 100° F. Examination of the abdomen revealed extreme tympany, with the liver dulness very much pushed up and reduced in area.
On inspection of the abdomen marked jaundice at the umbilicus was noted. The navel was of a distinct, saffron-yellow color, in strong contrast with the skin over the rest of the abdomen. There was no evidence of jaundice elsewhere. Tenderness was extremely marked over McBurney's point. It seemed probable that a peritonitis was present in the appendicular region. At operation the subperitoneal fat was found to be yellow, and when the abdomen was opened, a quart or more of bile mixed with serum was found. The common duct was ruptured behind the gastrohepatic ligament, the opening being large enough to admit the tip of a finger. After removal of the abdominal fluid and draining of the common duct the man made a good recovery.
- Trepan: Kyste del'ovaire; inflammation des parois et issue des membranes par l'ouverture
ombilicale; guerison. Gaz. med. de Picardie, Amiens, 1883-84, ii, 16S.
Dr. Ransohoff, after reviewing the case, says: "I wish here to call attention to a sign which was adverted to in the case of ruptured duct before the incision was made, and one to which I believe attention has never before been directed. It is the localized jaundice of the umbilicus. Although a single case is not usually sufficient to warrant the assumption that something new has been observed, this feature was so marked that I cannot refrain from believing that further observation will give to this localized jaundice some value as a sign of free bile in the peritoneal cavity. In the case presented this feature gained in interest as the staining of the subperitoneal fat with bile was observed in the incision through the abdominal wall. The jaundice is doubtless purely the result of imbibition. It makes itself manifest, first, in the integument of the navel, because this part is thinner than the rest of the abdominal wall. It is possible, of course, that, by reason of the anatomic relations of the round ligament of the liver to the transverse fissure, there is a retrograde flow of bile through the lymphatics toward the navel."
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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