Book - Umbilicus (1916) 2
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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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- 1 Chapter II. The Anatomy of the Umbilical Region
- 1.1 The Appearance of the Umbilicus
- 1.2 Personal Clinical Studies of the Various Forms of the Umbilicus
- 1.3 Histologic Appearance of the Umbilicus
- 1.4 =Plate IV
- 1.5 Diverticula
- 1.6 Clinical Examples of Defects of the Abdominal Wall
- 1.7 The Relation of the Outside of the Umbilicus to the Peritoneal Side
- 1.8 The Umbilicus in Animals
- 1.9 The Lymphatics of the Umbilical Region
- 1.10 The Sensory Nerve-Supply of the Umbilicus
- 1.11 The Umbilicus During Pregnancy
Chapter II. The Anatomy of the Umbilical Region
The appearance of the umbilicus from without.
Personal clinical studies of the various forms of the umbilicus.
The umbilicus as viewed from its peritoneal side.
Varieties of the fibrous ring.
Disposition of the vessels.
Varieties of umbilical fascia.
Elevation of the peritoneum in the form of a mesentery.
Peritoneal fringes containing fat.
Clinical examples of defects of the abdominal wall.
Relation of the outside of the umbilicus to the peritoneal side.
The umbilicus in animals.
The lymphatics of the umbilical region.
The sensory nerve-supply of the umbilicus.
The skin umbilicus.
The amniotic umbilicus.
Absence of the umbilicus.
The umbilicus during pregnancy.
Kuster, in 1874, in his paper, "New Growths of the Umbilicus in the Adult and Their Operative Treatment," briefly refers to the anatomy of the umbilical region.
He enumerates the layers of the abdominal wall in the region of the umbilicus as follows :
- The skin.
- The superficial fascia and more or less fat.
- The superficial sheath of the abdominal muscle.
- The rectus abdominalis.
- The deep layer of the sheath.
- The subperitoneal connective tissue.
- The peritoneum.
In the mid-line of the abdomen layers 3-5 are replaced by a thick cord of connective tissue, forming the linea alba, which, at the umbilicus, may reach 1 cm. in breadth.
The umbilical scar contains four fetal structures: (1) the umbilical vein, which passes to the liver along the suspensory ligament; (2) and (3), the umbilical arteries, passing downward and outward to the bladder; (4) the urachus, which passes to the bladder.
The Appearance of the Umbilicus
Catteau in his thesis, in 1876, on the Umbilicus and its modifications in cases of abdominal distention, refers in some detail to the appearance of this region.
According to this author, the typical umbilicus presents a circular cushion or base, which forms the elevated outer margin of an area showing a hollow, from the bottom of which arises an elevation which Catteau calls the mamelon. Situated in or near this elevation is the umbilical scar. Between the mamelon and the umbilical cushion is a definite furrow. Fig. 34 shows roughly the component parts of Catteau's typical umbilicus.
Probably the most thorough study of the subject was made by Bert andViannay, who, in over one hundred cases, made molds of the umbilicus. The following is taken from some of the more important portions of their article : The umbilicus is a depression in the skin, at the bottom of which is concealed the cicatrix left by the throwing off of the cord. This cicatrix is drawn inward by the retraction of the umbilical vessels and of the special tissue which surrounds them (Wharton's jelly). Bert and Viannay set out to study more especially the morphology of the outside of the umbilicus, inasmuch as investigations bearing upon this special point up to that time had been lacking. They claimed that their method was superior to that employed by Catteau, who had relied on sketches made at the bedside of the patient, which lack both the exactness and the fidelity of molds. Their work was based on the comparative study of 112 models made in different hospitals, from individuals whose ages varied from two and one-half to seventy-seven years. More than half of the patients were males. They were taken as they came, without being selected, except that none presenting a pathologic umbilicus, distended by an intraperitoneal effusion or by a hernial sac, was included.
The examination of the molds at once impressed these observers with the fact that the form of the umbilicus presents a great variability, rendering a definite classification somewhat difficult. Nevertheless, a certain number of types can be distinguished. In one the umbilicus has its longest diameter directed transversely — t he transverse umbilicus. In another, on the contrary, vertical umbilicus. Furthermore, in a third type — t he round umbilicus — the vertical and transverse diameters are more or less equal.
Fig. 34. Normal Umbilicus According to Catteau.
A represents the scheme of the normal umbilicus as described by Catteau. This socalled typical umbilicus consists of a cushion and a central depression, in the bottom of which are two structures — -a mamelon which is more or less prominent, and the umbilical cicatrix. The mamelon must be regarded as the remains of the solid lower part of the fetal cord which contained the umbilical arteries and urachus (allantoic stalk;. The cicatrix, on the other hand, seems to be due to the puckering of the skin over the region where the exocoslomic funnel has left the embryo. The mamelon is said to lie, as a rule, to the left of the umbilical cicatrix, as indicated here. We have, however, observed the reverse. (See Plate II, No. 22.) The projection of the mamelon from the umbilical depression naturally gives rise to a surrounding furrow.
B illustrates the only example of this type that we have encountered in about 200 cases, and consequently our findings do not substantiate the claims of Catteau.
the prominence is vertical — t h e
Between these three main types can be found a large variety of intermediary forms. Sometimes, even after careful examination, one would hesitate to determine to which class a given umbilicus belongs.
Bert and Viannay's figures are as follows. Instances of —
- Transverse umbilicus 71 cases
- Round umbilicus 29 cases
- Vertical umbilicus 12 cases
They examined systematically the umbilical cicatrix in all patients coming under their care. They regard the umbilicus as a cutaneous depression, — a sort of retracted cone, — in which one is able to distinguish the base, open in front and continuous with the skin of the abdomen. The bottom, or the summit, according to the point of view, is adherent, and is formed by the umbilical cicatrix and the surrounding parts.
They also drew attention to the fact that Catteau had spoken of four constituent elements — a cutaneous cushion or collar, which corresponded to their base; an elevation or mamelon, which corresponded to their bottom and which carried the cicatrix; and, finally, a furrow or groove. They pointed out that the four elements are present in an occasional umbilicus, which they would then speak of as t h e complete umbilicus, but that this complete umbilicus is met with in less than half of the cases. For example, in 112 molds Bert and Viannay found the umbilicus 34 times devoid of a central mamelon, and 21 times without a surrounding cushion, but as the cushion and the mamelon, or teat-like elevation, are divided by the furrow, when one of the two elements or when both are absent, the depression is also absent. The absence of one or more of these constituents of the umbilicus creates multiple combinations, which are capable of producing a certain number of types — a type of umbilicus without cushion or mamelon, a type with cushion and without mamelon, a type without cushion but with mamelon, and so on.
The base, cushion, or umbilical hollow is open in front and continuous with the skin of the abdomen in something like 18.75 per cent of the cases. When the surrounding skin inclines gradually toward the umbilical depression by a gentle slope, no prominence can be distinguished. In such cases we are dealing with an umbilicus without cushion. More frequently the base of the umbilical depression is surrounded by a circular elevation, a veritable cutaneous cushion. In about 6 per cent of the cases this cushion is complete and forms a uniform elevation, completely surrounding the cutaneous orifice of the umbilical depression. Ordinarily it is incomplete and occupies only a portion of the circumference of the umbilicus; for example, half of the circumference, the superior or inferior, or one of its lateral walls. This cushion then takes the form of a halfmoon, a crescent, etc., and gives rise to numerous varieties in the appearance of the umbilicus.
The bottom of the umbilical depression, despite Catteau's description, is not always occupied by an eminence carrying the cicatrix.
(a) A smooth depression. In 34 cases Bert and Viannay found the bottom absolutely smooth, without any trace of elevation or mamelon. In these cases the umbilical depression was also regular and infundibular in form. They observed two varieties : In the first the umbilical orifice may be large, widely open, presenting at its extreme bottom the cicatrix, smooth or depressed, and having a stellar or linear aspect; in the second the opening is narrow, and one has to separate the folds in order to see the cicatrix which occupies the bottom of the depression.
(b) The mamelon or elevation. In about two-thirds of the cases the bottom of the umbilical depression is occupied by an eminence or mamelon. The form of the eminence shows an infinite variation: sometimes — and this is the rule — it is single, sometimes double, occasionally triple. When the mamelon is double, the two elevations may be juxtaposed, so that a vertical or median depression separates them. When superimposed, the superior elevation is separated from the inferior by a small transverse depression. Usually, however, when the mamelon exists, it is single.
(c) The umbilical cicatrix occupies the bottom of the umbilical depression when the latter is smooth. In the umbilicus with a mamelon in the depression it occupies sometimes the central point; at other times it is on one side of the mamelon. The cicatrix may be punctiform and hardly visible; at other times it is linear and branches in different directions. It may be vertical or more frequently transverse. Sometimes it has a stellar arrangement with a variable number of branches.
(d) The walls of the umbilical depression may present as many variations as the other elements constituting the umbilicus. These variations are chiefly dependent on the depth of the umbilical depression, which itself depends upon the degree of development of the subcutaneous adipose tissue. Hence we find an explanation of the fact that a deep umbilicus is more frequent in women and in stout people. On the other hand, young infants, old men, and cachectic patients have an umbilicus less deep, or even on a level with the skin. In the deep umbilicus the walls are sometimes absolutely smooth. Sometimes the depression is occupied by a cutaneous elevation uniting the cushion and mamelon, a condition analogous to that found in the case of the muscular pillars which hold up the walls of the ventricle of the heart.
The umbilical cavity varies in size and in form. It can readily be understood that the degree of depth of the umbilical depression, the presence or absence of the central mamelon, and the larger or smaller opening at the base of the skin, will modify entirely the form and dimensions of the cavity of the umbilicus. From this point of view the examination of their plaster molds is very instructive. They show that the axis of the umbilical opening is rarely perpendicular to its base. Instead of passing directly into the depth, it deviates sometimes upward, sometimes downward, sometimes laterally. Moreover, the solid cone of the plaster mold, representing the cavity of the umbilical depression, is always more or less incurved. Sometimes it is turned out in a fantastic fashion. In their series of molds, in addition to the transverse, the round, and the vertical umbilicus, with or without cushion, with or without mamelon, they encountered several odd forms — for example, the funnel-shaped umbilicus, those suggesting the mouth of a furnace, the snout of a fish, and others.
Personal Clinical Studies of the Various Forms of the Umbilicus
Together with Mr. Brodel I visited the various wards of the Johns Hopkins Hospital and examined the umbilicus of nearly all the patients, males and females, young and old, white and black, including quite a number of pregnant patients.
Thus in the large group of pictures presented we have a rather comprehensive idea of the various forms the umbilicus may assume under normal conditions. With the examination of many thousands of people doubtless other forms will be detected, but the pictures here presented serve to show the forms usually met with.
The 60 drawings of normal umbilici arranged on Plates I - IV were made in the wards with the patients in bed. This insured uniformity of posture, and eliminated accidental skin-folds, such as always appear when the body is in flexion or in hyperextension. These plates show that it is difficult to speak of a definite and uniform topography of this region. The variations are exceedingly numerous, and include a large number of the most bizarre forms. The following are attempts to roughly classify the cases into groups :
Group I. — Cushion incomplete; presents a crescent or horseshoe fold below the umbilicus (Figs. 1-7). This condition suggests a taut urachus and lateral umbilical ligaments pulling the navel downward.
Group II. — Cushion incomplete, but found above the umbilicus. This is the reverse of what is present in Group I (Figs. 8-12). This condition suggests the presence of a taut and short round ligament of the liver coexisting with relaxation of the abdominal wall. The most pronounced cases of this type seem to be found in women who have had many children.
Group III. — Funnel-shaped umbilicus (Figs. 13-19). The cushion has been padded with adipose tissue. At the bottom of the funnel the umbilical scar is found. The mamelon is absent. A deep funnel has a narrow apex (Fig. 14). A shallow funnel, on the other hand, possesses a broad bottom (Fig. 16). The cicatrix may be large (Fig. 16) or small (Fig. 19), central (Fig. 19) or peripheral (Fig. 18).
Group IV. — The horizontal oval umbilicus. A cushion completely surrounds a well-marked mamelon and an umbilical cicatrix (Figs. 20-24). This is the group which most nearly coincides with Catteau's scheme of the normal navel.
Group V . — The horizontal, slit-like umbilicus, short or long, occurs in both sexes. It should be remembered that almost every type of navel can be made to appear as a horizontal slit by bending the body sharply forward. In the three cases, Figs. 25-27, the appearances are not due to this factor, but represent the abdomen at rest with the individual in the recumbent posture.
Group VI. — The triangular, slit-like umbilicus resembling the letter T (Figs. 28, 29, 31), or horizontal, like an H viewed from the side (Fig. 30).
Group VII. — The perpendicular, slit-like umbilicus (Figs. 32-35). This form suggests a closer approach of the two recti muscles, with a consequent increased efficiency against intra-abdominal pressure.
Group VIII. — The perpendicular oval umbilicus (Figs. 36-41). Cushion and mamelon and scar are arranged as in Group IV (Figs. 20-24), with the usual range of variations.
Group IX. — The prominent, button-like umbilicus (Figs. 42-60). The button may be round (Fig. 42), oval (Fig. 45), or spiral (Figs. 54 and 55), usually with a central horizontal, scar-like furrow. A crescent-shaped pit may be found under the button (Figs. 49, 50, and 59). The button may have a cushion as a collar (Fig. 42) or be without one (Figs. 44 and 48). In pregnancy the button form may be simulated by a small hernial protrusion (Fig. 60). (See also Plate VI, p. 467.)
A few general facts worthy of note are as follows :
(1) The navel in the colored race is usually larger than that in the white race. This may be due to the fact that the negro's skin is thicker than that of the white, or possibly to the lack of proper medical attention during labor, resulting in a larger scar. Compare—
Fig. 6 with Fig. 7
" 19 " " 16
" 54 " " 55
" 58 " " 56
(2) The umbilicus in the infant is much larger in proportion to the body weight than is that of the adult. Compare —
(3) There is no definite relation between the size of the adult and the size of the umbilicus. A small person may have a large umbilicus, and vice versa.
(4) In the adult the depressed umbilicus is far more frequent than the elevated or button-shaped type.
(5) The button is the infantile form.
(6) A large umbilicus of the horizontal type is associated with a wide linea alba, also with diastasis of the recti abdominis muscles. Diastasis of the recti is especially pronounced in infants and children. It is also found at the end of pregnancy (Fig. 60), when it may lead to the formation of a small hernia. (See also Plate VI, p. 467.)
(7) The linea nigra in a multipara may be in the mid-line (Figs. 24, 31, and 40), or bilaterally displaced at the umbilicus, as in Figs. 21 and 60.
(8) The umbilicus of^ a multipara is, as a rule, more wrinkled, and the periumbilical skin more relaxed in character than in a nullipara (Figs. 9, 29, 30, 37, and 40).
(9) Except for the growth of hair around the navel in the adult male, there are no sexual differences between it and the navel in a nullipara. (In these drawings, in order to insure clearness of form, the hair has been omitted.)
(10) Obesity has a tendency to produce the funnel-shaped umbilicus (Figs. 12, 14, and 19).
Histologic Appearance of the Umbilicus
As pointed out by Hertz and others, the umbilical pit is at first covered over with squamous epithelium, but is devoid of papillae. Later the epithelium is identical with that of the outer skin. The scar, however, is usually lacking in sebaceous or sweat-glands. According to Hertz, Pernice was able to detect in three infants remnants of the omphalomesenteric duct in the scar, it being recognized as a canal lined with cylindric epithelium.
THE UMBILICUS AS VIEWED FROM ITS PERITONEAL SIDE.
The most important articles bearing on this subject are those of Gauderon (1876) and of Levadoux (1907).
As was pointed out in the chapter on the Embryology of the Umbilical Region, the umbilical arteries, the urachus, one or both umbilical veins, and the omphalomesenteric duct with its vessels, pass through the umbilical opening in early fetal life. About five or six months before birth all traces of the omphalomesenteric duct and its vessels usually disappear. The right umbilical vein is gone, and the urachus can generally be recognized as a solid cord. Thus in the normal umbilicus at birth we have to do with the remains of the umbilical arteries, the remnant of the urachus, the occluded umbilical vein, the peritoneum covering the umbilical region, and lastly with the umbilical ring, and in a certain number of cases the umbilical fascia.
Female, age 33 , 120 lbs. Opara.
Female, age 38. 116 lbs. I para
Female, agfc58, 22.8lbs. 5 para
1 Male,a5e30. 1^8 lbs
Female, age 58 . 120 Ibs.'Tpara Female, age36, 105 lbs. Opara
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Female, age 50, 110 lbs. Opara Male, age 39 . 130 lbs.
Female, age22, l'30 Ibs.Opara Female , agel9 , 1^5 lbs. I para
Male, age 58. I3& lbs.
Female, age 23, HZ lbs. Opara .22
Male, age 19. 120 lbs
Male, age 4-2, 125 lbs.
Female, age ¥2 , '39 lbs. 3 para
Male, age 63, 186 lbs
Female , age.38. IZ5 lbs. 3 para Female, age 45, 100 Ibs.Opara ,
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idle , age 79. 35 lbs. Opara Female , age Vf, 135 lbs. 3 para
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Female, age 19. 149 lbs. 7 para Female . age 66, 125 lbs. 2 para Female, age 18 , 130 lbs. I para
Female, age 14 150 lbs. 3 para Female , age 32. , HO lbs. 6 para Female, age 28 , 99 lbs . 2 pare
Female, age 18, 110 lbs para aq
Male, 6 months 9 lbs
Male, age 39 150 lbs
Female, age 3&, 128 lbs. 4 para Female, 1 '/l month b 5 lbs.
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Mate , 6 years , 43 lbs.
Female, age47, 101 lbs, Opara &&&
Female . age 6 , 45 Lbs.
8 Female, 13 days & lbs.
Male, age 3h , 30 lbs. 58
Male, age 36, 120 lbs.
49 _ Male, age 44. 130 lbs Female, age 51 f 100 lbs, II paro
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Female, age 20, 116 lbs, I para Female, age 21 . H5 lbs. pregnant
Fig. 35. A Type of Umbilical Region in the Adult, Viewed FROM Within. (Half nat. size.) Within the umbilical ring is seen a small, shallow pit with strong resistant walla and base. There is no mesentery of the obliterated hypogastric arteries or of the urachus, excepting perhaps in their pelvic portion. They are, nevertheless, clearly seen throughout their entire extent. The 'triangular falciform ligament is very short, and the round ligament of the liver becomes lost in the abdominal wall at least S cm. above the umbilicus. (Personal observation.)
Fig. 36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within. (Half nat. size.)
The umbilical ring is covered with radiating bundles of fascia through which the position of the ring can still be seen. The urachus and obliterated hypogastric vessels are not clearly defined in their upper portion, but appear to be lost in a broad, flat bandAs the two arrows show, there is a shallow recess be. hind this band on each side. The round ligament of the liver shows the same arrangement as in the preceding figure. (Personal observation.)
In the consideration of this subject I shall dwell chiefly upon the results obtained by Gauderon and by Levadoux, and briefly mention the findings of Max Brodel during his studies on the embryology of the umbilical region.
In Figs. 35, 36, and 37 are shown the most common appearances of the inner surface of the anterior abdominal wall, not only at the umbilicus, but also above and below this point.
Gauderon described his findings in 10 infants. He was struck with the variations in the relationship of the peritoneum of the umbilicus to the umbilical cicatrix. Sometimes he found the peritoneum presenting
Fig. 37. — The Umbilical Regiox of ax Adult, Viewed from Within-. (About half nat. size.) The umbilical ring is bridged over with fascial bands running for the greater part in a transverse direction. There are small globular masses of subperitoneal fat distributed around the vessels and the ring. Between these are seen two small shallow pits. The fibrous tissue at their bottoms is
particularly strong. Below are seen the two obliterated hypogastric (umbilical) arteries. Between them is the urachus, passing from the umbilicus to the bladder. A portion of the mesentery-like attachment to the ventral body-wall has been removed so as to show better the size of the structures, their relation to one another, and to the thin, band-like mesenteriolum. Above, the round ligament of the liver (obliterated umbilical vein) is seen suspended from the free border of the triangular falciform ligament. This ligament does not reach to the umbilicus; the round ligament continues just under the peritoneum, where it may be palpated as a broad band. From the free border of the round ligament are seen hanging a few pedunculated masses of fat. (Personal observation.)
a smooth surface at the umbilicus; in other cases there was a slight depression. In a few cases — 4 times out of 10 — the peritoneum was adherent to the umbilicus; in the remaining cases it was free. Sometimes it could be easily separated.
Before the separation of the peritoneum of the umbilicus it was easy to determine the existence or absence of the umbilical fascia, which forms the posterior part of the, umbilical canal described by Richet. In some of the cases the peritoneum was not reinforced at the umbilicus by any trace of the lamellae composed of fibers of the transversalis fascia. Gauderon says he was able to determine this fact in an infant two years of age. In 7 of his cases he encountered no other trace of the umbilical fascia except portions of lamellae of the transversalis, which reinforce the peritoneum for about 4 or 5 cm. around the umbilicus. These lamellae are not adherent to the posterior aponeurosis of the rectus muscle on the right, and as a consequence in these cases one cannot say that there exists a partial umbilical canal, as described by Richet. In only 2 of his 10 dissections did Gauderon find a complete umbilical canal, as described by Richet. One of these subjects was a child three years old, the other, four years old. In one of these cases the peritoneum had separated completely and one could see clearly remnants of the umbilical vein, of the umbilical artery, and of the urachus. These were inserted to the right of the inferior half circumference of the umbilical ring. In consequence, to the left and above the ring was a small depression in which there was found a small lump of fat. According to Gauderon, it is in this depression that the peritoneum tends to lie.
Gauderon sums up his investigations as follows: In the majority of infants the umbilical fascia shows defects. It was lacking 8 times in 10 cases. When it exists, it is not so placed as to reinforce the peritoneum at the umbilicus and to protect against distention or rupture. The umbilicus is one of the weakest parts of the abdomen.
The most important article on this subject is that written by Levadoux and published in 1907. This work was carried on under the direction of Charpy. In addition to comparative study, he examined 50 human cadavers. His investigations embrace the study of the umbilical ring in mammals, a consideration of the classic umbilicus, personal observations on the varieties in the form of the umbilicus, the form of the outer umbilicus, together with the anatomic formation of the ring, and the appearance of the inner surface of the umbilicus.
I have made a brief translation of the salient features of Levadoux's valuable paper, and all the references are exactly as the author has given them.
From his Chapter II, I have taken the following classic description of the umbilicus: The umbilicus of the adult is the orifice in the linea alba which corresponds to the point of attachment of the umbilical cord of the fetus. It is closed externally by the cicatricial skin, which is adherent to its contour. Its inner surface is free, and separated from the abdominal cavity by the parietal peritoneum which covers its surface. Sometimes — about once in five cases — an umbilical fascia of variable thickness covers the ring and makes a reinforcement of the peritoneum. This opening with its borders measures 1 cm. or more in diameter. It may very well be likened to the mouth of a furnace, with its upper margin arched and its lower margin rectangular. The central orifice is about 2 to 4 mm. in diameter and free. It is closed solely by a ball of fat. The margins of the orifice are formed by the oblique fascia of the aponeurosis of the linea alba, to which are added behind the fibers of the arch, so that there is formed a homogeneous mass. The upper border of the ring is free; the inferior border receives the insertion of the urachus, the umbilical arteries, and the umbilical vein (Fig. 38) in four separate cords.
The vein is attached sometimes to the right or to the center, and may be divided into filaments. The fusion of these various cords with the base of the ring results in a fibrous nodule which is thick and very adherent to the skin. The parietal peritoneum covers the inner surface of the ring; it is only lightly adherent, and in stout subjects is usually separated by adipose lobules. Sometimes it passes directly over the orifice and at other times is depressed. At this point only the skin and peritoneum close the abdominal cavity.
The umbilical fascia, when it exists, extends upward for a variable distance. It is formed by the fibers of the transversalis fascia attached to the peritoneum. This may extend to the margin of the rectus muscle, or join with the posterior layer of the aponeurosis. According to Stratz, a well-formed umbilical canal is situated high and should be small. Hyrtl compares the umbilical orifice in man to that in animals.
In Chapter III Levadoux takes up the varieties and forms of the umbilicus. He considers:
- Varieties of the fibrous ring.
- Variations in the disposition of the vascular cords.
- Variations of the umbilical fascia and their interpretation.
- Varieties of peritoneum with special reference to — (a) the formation of the mesoperitoneum; (b) fatty fringes; (c) diverticula; (d) atrophy.
Varieties of the Fibrous Ring
This ring represents the remains of the passage of the ccelomic funnel through the linea alba. Its outer surface can be studied after removal of the skin; by raising the peritoneum one brings into view the posterior surface. Viewed from its outer and subcutaneous surface, this ring is circular in form and closely adherent to the skin which covers it. Viewed from its posterior or subperitoneal surface also, it not infrequently appears circular, — in 22 out of 50 cases, — but sometimes it is elliptic, the axis running transversely. One type referred to by Blandin has the form of a semicircle or resembles the mouth of a furnace (Fig. 38). Since his description appeared, this has been considered as the normal type. Richet, who has more recently considered this question, described this orifice as quadrilateral, with rounded angles. In the case of individuals who have an umbilicus that is nearly circular, this configuration is explained by the disposition and the mode of insertion of the umbilical arteries and the urachus.
Where it has been impossible to recognize the ring, the orifice has been found completely closed, sometimes by fusion of the lateral walls, sometimes by some peculiar arrangement of the vessels. The margins of this fibrous ring have a variable thickness. In a little less than two-thirds of his cases Levadoux could observe no difference between the thickness of the margins of the ring and that of the linea alba. In several fat cadavers the fibrous ring was less thick than other portions of the linea alba, and in 17 of his subjects it was manifestly thicker. This reinforcement was produced by a fibrous cushion on the posterior surface of the ring. Levadoux disagreed with Richet that at this point in all cases superimposed fibers were present, but he found that, when the posterior pad existed, he could disassociate a certain number of these fibers and determine that they were not continuous with the sheaths of the muscles, but terminated on a level with the cushion. In all probability Levadoux had to do here with supplementary fibers. The central orifice of the ring measures from almost nothing to 6 mm. in diameter.
Fig. 38. — Classic Type of Umbilicus. (After Levadoux.) V, umbilical vein. The umbilical arteries (Ao, Ao) and the urachus (O) are attached to the lower margin of the ring. Om represents the ring, which is semicircular. / is the intervascular depression.
Disposition of the Vessels
This is discussed at length by Levadoux (p. 33). What impressed him most in this study was the great diversity of types. The majority of cases corresponded to the description given by Robin (Mem. de la Soc. de Biologie, 1860, 107). Levadoux designates two main groups:
Group 1 . — The inferior cords unite into one before reaching the lower and lateral margins of the fibrous umbilical ring. The vein remains independent of this cord, and is inserted as two or three branches in the superior or lateral walls of the ring.
Fig. 39. — Disposition of the Vasculab Cords (Usual Type). (After Levadoux.) Noted 18 times in 50 cases. The peritoneum has been removed. The umbilical vein (TO is bifurcated and terminates on either side of the ring. The urachus (0) and the arteries (Ao, Ao) unite in C. F , a depression. B, a bridge. +, the umbilical ring.
Fig. 40. — Vascular Cords op the Anastomosing Type, noted 7 Times in 50 Cases. (After Levadoux.)
The peritoneum has been removed. B, branches of the umbilical vein. M, an anastomosis between the umbilical vein and the right umbilical artery; C, a common cord formed by both umbilical arteries and the urachus.
Group 2 . — The inferior cords and the superior cord send anastomoses* reciprocally.
Levadoux gives a careful detailed description of the majority of types encountered and a classification according to the frequency with which they are found.
Variety 1 (Fig. 39) was noted 18 times in 50 cases. The three vessels, the urachus and the umbilical arteries, unite at the same point, 4 cm. below the umbilicus; the resulting cord is flattened in its anteroposterior diameter, and inserted by its upper extremity upon the inferior half of the circumference of the umbilical ring. Before its termination the urachus is reduced to a simple cylindric filament, whereas the remnants of the umbilical arteries still retain a good caliber. The vein, at a point about 6 cm. above the umbilicus, divides into two cords of equal size. These lie on the lateral wall of the ring, and their insertions merge with the more lateral fibers in the inferior cord. The peritoneum covering these vessels is applied in such a way that no mesentery for them exists.
Where Levadoux uses the term anastomosis the reader should consider it as meaning a fibrous connection of the solid vessel-walls.
Variety 2 (Fig. 40) was noted 7 times in 50 cases. Here at one point the union of the three inferior cords has not taken place. The urachus has become adherent to the right umbilical artery, about 8 cm. below the umbilicus. The left artery joins the cord at a point 2 cm. farther up. The resulting ligament is inserted into the inferior and lateral borders of the ring. The vein terminates in two short branches: one is inserted into the upper border of the ring, the other joins the right margin of the ring, where it merges with the fibers from the inferior cord. A long branch from the umbilical vein passes downward and anastomoses with the trunk of the right umbilical artery. The umbilical vein then divides and gives off three branches which terminate in the linea alba above the umbilicus.
Fig. 41. — Vascular Cord Type, noted 5 Times in 50 Cases. (After Levadoux.) V, the umbilical vein, which passes downward and divides into two branches, one inserted into the upper border of the ring, the other passing downward into the abdominal wall. Ao and O are the umbilical arteries and the urachus which unite to form the cord (C) that is inserted into the left lateral wall of the ring.
Fig. 42. — Vascular Cords, noted 5 Times in 50 Cases, Completely Filling the Umbilical Ring. (After Levadoux.) The peritoneum has been raised. The umbilical ring (+) is closed by the anastomosis of the cords on its posterior surface.
Fig. 43. — Vascular Cords, noted 3 Times in 50 Cases. (After Levadoux.)
The peritoneum has been removed. The umbilical vein divides into three branches; the umbilical arteries and the urachus are hypertrophied and permeable. They terminate in delicate filaments which have united to form a common cord (C).
Variety 3 (Fig. 41) was noted 5 times in 50 cases. The three inferior cords unite as in Fig. 40. The common cord is short, and is inserted at a point to the left of the middle of the ring and in its left lateral part. The vein presents two long branches of bifurcation: one is inserted into the superior border of the ring; the other passes to the abdominal wall and receives anastomoses from the left umbilical artery.
Variety 4 (Fig. 42) was noted 5 times in 50 cases. Here the inferior vessels form a cord in the same way. The umbilical orifice posteriorly is completely closed. The inferior vessels and the superior vessels fuse together at this point, forming a continuous cord from the inferior surface of the liver to the summit of the bladder, and unite with the lateral structures at the umbilicus.
Variety 5 (Fig. 43) was noted 3 times in 50 cases. The three cords are Irypertrophied and permeable up to a certain point; they end abruptly as a delicate cylinder at a point 2 or 3 cm. below the umbilicus, and are inserted into the inferior circumference of the ring. The vein divides into three portions, one of which is inserted into the upper border of the ring, its two lateral branches passing downward on either side and joining the inferior cord.
Variety 6 was noted 3 times in 50 cases. The urachus and the umbilical arteries show marked branchings, and pass upward as a network. The umbilical vein divides into three branches. The middle one becomes attached to the upper portion of the umbilical ring. The lateral cords are continuous with the inferior filaments.
Variety 7 was noted in 2 out of 50 cases. The urachus divides into numerous filaments, which disappear in the linea alba, 5 cm. below the umbilicus. The two arteries form a cord of small caliber, which terminates in the linea alba at a point 5 Cm. below the ring. The umbilical vein bifurcates. One of its branches is inserted into the right lateral margin of the umbilicus; the other anastomoses with the umbilical arteries.
Variety 8 (Fig. 44) was noted in 2 out of 50 cases. This type is very curious, and is found in those subjects in whom the cutaneous cicatrix does not correspond with the fibrous ring, but is situated below it. The two cords unite before penetrating into the fibrous ring. The united trunk which results, after passing through this ring, becomes subcutaneous and is inserted all around the cushion of the umbilicus. The fibers forming the inferior cord describe a crook in order to reach their termination at the umbilicus. The vein has two branches which terminate in the skin, after having passed through two orifices in the linea alba.
Fig. 44. — Vasculab Cords, noted in 2 out of 50 Cases. (After Levadoux.)
The umbilical openings do not correspond. The peritoneum has been removed. The inferior cord (C) and the vein ( V) pass through the orifice and descend in front of the linea alba to become fixed in the umbilical cushion (B), which is shown through the window cut out in the abdominal wall.
As a rule, the history of the filaments resulting from obliteration of the umbilical vessels is as follows: The urachus and the umbilical arteries unite in a common cord at a variable distance from the umbilicus. This flattened cord is inserted into the inferior and lateral margins of the ring. The umbilical vein divides into a variable number of filaments, which are inserted most frequently into the lateral margins of the ring — sometimes into the superior margin. A variable number of the ramifications of the vein and of the inferior cord terminate in the abdominal wall before reaching the umbilicus.
On page 46 Levadoux discusses the peri-umbilical veins. These have been described by Sappey, and more recently by Jores. Meriel has also published a note on this subject (Soc. anat. de Paris, 1902). This system of veins, which results from a union of the vesico-umbilical veins and the portal system, is very interesting. It is formed by two veins, the right and left periumbilical veins, and plays an important pathologic role in cases of cirrhosis of the liver. Jores considers the right peri-umbilical vein as the intra-abdominal portion of the right umbilical vein. Levadoux noted the presence of these peri-umbilical veins, but did not include them in his studies.
Varieties of Umbilical Fascia.- — Levadoux (p. 46) describes the different varieties of umbilical fascia, and mentions the description of it by Vidal de Cassis (Des hernies ombilicales et epigastriques, These de Paris, 1848). Later this aponeurotic sheath was described by Richet (Anatomie med.-chir. 1856-1857), by Gauderon (These de Paris, 1876), and Sachs (Die Fascia Umbilicalis. Arch. f. path. Anat., 1877). Richet called it the "umbilical fascia." From a study upon a well-formed and well-developed cadaver he found that the peritoneum, which envelops the umbilical vein, for the last 3 or 4 cm. above the umbilical ring is reinforced by a whitish layer of fibers directed transversely, and with the edge at right angles to the direction of the vein. These fibers may be continuous with the muscle, or they merge below with the posterior layer and the corresponding aponeurosis. Below, the fascia does not pass to the umbilical cicatrix. Sometimes, however, one finds it prolonged and terminating imperceptibly in the fibrous cord of the arteries. Above, it sometimes ends sharply at a point 3 or 4 cm. from the ring. At other times it is impossible to assign the precise limits of its termination. This umbilical fascia, though definite in certain subjects, is limited in others.
Richet considers the space situated between the posterior surface of the linea alba and the umbilical fascia as a canal, and calls it the " umbilical groove." This canal contains in the &dult the fibro-cellular cord, vestiges of the umbilical vein, surrounded by a cellular tissue, the meshes of which in some individuals are filled with an abundance of yellowish fat. Richet tries to establish a parallel between the umbilical canal and the inguinal canal. Gauderon examined 10 children, from two to fifteen years of age, and found the fascia well formed in only two cases. In seven cases it was reduced to lamellae which were not adherent to the corresponding sheath.
In speaking of variations in the condition of the umbilical fascia Sachs distinguished three groups:
- The fascia does not exist or ends far above the upper border of the ring.
- The fascia in its inferior border is sharply defined; it covers the upper border of the ring or is flush with it.
- The fascia covers the entire ring.
So far as the relative frequency is concerned, Sachs, from 207 autopsies made on infants between one and eleven months of age, arrived at the following conclusions :
Fascia absent in 64 cases
Fascia present in 143
Fascia covering the ring in 48 "
Fascia above the ring or flush with it in 25
Levadoux now gives his own observations.
Fascia absent in 8 cases
Fascia situated high and represented by a bridge 1 cm. broad in 9
Fascia developed 1 or more cm. in width, but not reaching the superior border of the ring in 11
Fascia reaching the upper border of the ring in 7
Fascia covering part of the ring in 3
Fascia covering all the ring in 5
Fascia descending below the ring in 7
According to Levadoux, the absence of the fascia is, therefore, much less frequent than is indicated by Sachs' figures. In the former's 50 observations it was lacking in only 8 cases (16 per cent), whereas Sachs gives 31 per cent, a percentage that is nearly double.
Levadoux would explain this difference in the findings by the difference in the ages of the bodies examined. Sachs made his observations on infants. Levadoux', on the contrary, were made upon adults. Levadoux goes on to say that in certain cases the fascia may form in the course of the growth of the individual, since we know that the fibrous tissue does not reach its full development until after puberty.
The fascia is represented by a simple bridge which may be easily overlooked. In such a case it is situated 4 or 5 cm. above the umbilicus. The fibers which form it may reach a breadth varying from several millimeters to one centimeter, and are always merged laterally with the corresponding sheaths. They may be disassociated or intimately blended together. In 11 out of 50 cases this umbilical fascia was formed of the fibers of the transversalis fascia, reaching as high as 5 or 6 cm. Its upper border was some distance from the ring (Fig. 45). The umbilical vein, therefore, passes along a canal formed by the linea alba and this fibrous sheath, which varies in thickness. It is easy to see that there exists no groove at the point of entrance or disappearance of this ligament. The peritoneum is intimately attached to it. In 7 cases only was fascia found reaching to the superior border of the ring (Fig. 46) and forming the type of Richet.
Fig. 45. — Umbilical Fascia. Peritoneum in Place. (After Levadoux.)
X, umbilical ring; F, the umbilical fascia; R, the fringe of adipose tissue; O, the inferior cord; V, the umbilical vein.
Fig. 46. — Umbilical Fascia and Umbilical Mesentery. (After Levadoux.)
The peritoneum is in place. It is reinforced by the umbilical fascia (F). V is the umbilical vein ; X, the umbilicus. The umbilical arteries are contained in a mesoperitoneum.
Fig. 47. — Reduplication of the Linea Alba. Peritoneum Removed. (After Levadoux.)
The umbilical vein (V) enters by an orifice (T) into a canal of the linea alba. The posterior wall is formed by the thickened fascia (F) . Om, the umbilicus; o, the urachus; A, A', the arteries.
In 3 cases the fascia descended a little below the middle of the ring, leaving the inferior part of this orifice covered with peritoneum only. Finally, in 5 cases the fascia covered the ring completely, ending at its inferior border, and 7 times it descended 3 to 4 cm. below its lower border.
The umbilical fascia varies, not only as regards its situation and extent, but also in its thickness. In certain types (30 out of 42) the fibers of the transversalis fascia, of which it is constituted, were intimately united; in the other cases they formed a reticulum, like a more or less coarse meshwork. In two observations the fascia presented, toward the middle of its extent, a rectangular orifice 3 cm. long. Here a zone of peritoneal atrophy was noted (Fig. 48).
The relations of the umbilical vein to the umbilical fascia are nearly constant. The vein passes in front of the fascia, which is applied to the posterior surface of the linea alba. Levadoux says that in its course it is usually surrounded by adipose tissue; nevertheless, we have one observation, communicated by Charpy, which does not conform to this rule. In this case the linea alba, 10 cm. above the umbili
Fig. 48. — Atrophy of the Umbilical Fascia, Posterior View. (After Levadoux.) The peritoneum is in place. The fascia (F, F) presents two atrophic patches, the one lozengeshaped, the other at the level of the umbilicus (X). V, the umbili
Fig. 49. — Formation of a Mesentery. Peritoneum in Place. (After Levadoux.) The mesentery (Af) of the umbilical vein (V) and the mesentery of the inferior vascular cord (M ') form a longitudinal partition. G, fringes of adipose tissue. X, the umbilicus.
Fig. 50. — Mesentery of the Urachus and of the umbilical Arteries. (After Levadoux.) The peritoneum is in place. It is reinforced by the fascia (F), behind which is the vein (V). +, the umbilicus. Below the umbilicuses the long mesentery (M) containing the urachus and the umbilical artercus, presented an abnormal thickening of 3 mm. (Fig. 47). The umbilical vein disappeared into a canal at a point 25 mm. above the ring. The anterior part was membranous and showed little resistance, whereas the posterior part was dense and exceptionally thick. This evidently represented not a portion of the umbilical fascia, but a sort of transposition of the linea alba behind the vein. When this fascia exists, its superior and inferior margins are nearly always very sharp and have an arched arrangement.
After having removed the peritoneum, one finds in a zone limited by the crest of the fascia a small cushion of cellular tissue. Beneath the inferior margin of this fascia this cushion is blended with the transversalis fascia. Toward the lateral borders, therefore, says Richet, the transversalis fibers merge with the posterior portion of the sheath. Levadoux, in dealing with pieces of fascia placed in formalin (0.5 per cent, for fifteen days), found it possible to separate the umbilical fascia from its sheath. He says that he carried out the plane of cleavage of the aponeurosis to the transversalis muscle. At its level he could see that the disassociated layer was a continuation of the posterior sheath of the aponeurosis developing from the transversalis muscle.
In 36 out of 50 cases the peritoneum was applied intimately to the umbilical region, forming a definite covering. In such cases the fibrous ring is not visible from the peritoneal surface. No depression marks the umbilical cicatrix.
Elevation of the Peritoneum in the Form of a Mesentery
Normally the umbilical vein travels in the free margin of a mesentery, a continuation of the falciform ligament of the liver, which is attached to the anterior abdominal wall. The mesentery is very short, and terminates in the inferior part of the liver, that is to say, about 7 or 8 cm. above the umbilicus. In 3 out of 50 cases this mesentery extended much farther down, reaching to within 3 cm. of the superior margin of the ring, while in 4 other cases it reached the upper border of the ring.
Fig. 51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place. (After Levadoux.)
The umbilicus (A) is closed by a pad of adipose tissue. V, the umbilical vein; O, the urachus.
Fig. 52. Adipose Fringes in a Stout Subject. Peritoneum in Place. (After Levadoux.) Om is the umbilicus, at the bottom of a mass of adipose fringes. V is the vein. shows the inferior umbilical vessels.
In these 4 cases, besides the mesentery of the umbilical vein, there existed an elevation of the peritoneum over the inferior cords. These united in a single cord at the summit of the bladder. They approached one another at the median line, and raised the peritoneum en masse as far as their insertion at the umbilicus (Fig. 49) . Between the umbilical insertion of these two mesenteries, at the level of the posterior surface of the ring, there existed two folds of peritoneum containing fat. The inferior mesentery may also exist alone, as occurred in two cases (Fig. 50). In another case this mesentery was represented by two peritoneal elevations each corresponding to an umbilical artery (Fig. 46).
Peritoneal Fringes Containing Fat
The peritoneum may be folded, fringed, and raised in folds to a' greater or less degree by masses of adipose tissue which infiltrate the subserous tissue. When the fat attains a certain development, these fringes, as a whole, become arranged somewhat in the shape of a collaret in which the umbilical ring occupies the center (Fig. 51). Their existence is not very rare in the human being. They are similar to the epiploic fringes of the large intestine, and to those of the pleura or of the pericardium, as described by Cruveilhier and more recently by Poirier. Occasionally, the fatty umbilical fringe presents an appearance similar to that seen in Fig. 52. This condition is also present in the dog.
This disposition of the adipose tissue in the umbilical region is often somewhat disconcerting to the surgeon, for when working in this area he is at times uncertain whether or not he is really in the peritoneal cavity. A knowledge of this arrangement of the fat will prevent any confusion on his part.
Levadoux (p. 61) takes up the discussion of diverticula. The peritoneum presented at the level of the ring (14 times in 50 of his cases) a more or less pronounced diverticular depression. In 8 out of 50 cases there were peri-umbilical fossettes
Fig. 53. — Peritoneal Diverticula. Peritoneum in Place. (After Levadoux.) Three diverticula (a, b, c) occupied by lobules of adipose tissue, which have been removed. X is the umbilicus; V is the umbilical vein with its three branches; O, the urachus.
Fig. 54. — Peri-umbilical Fossettes. Peritoneum in Place. (After Levadoux.) X is the umbilical ring, above which are two peritoneal fossettes occupied by adipose tissue, and above these again the fascia (F).
in the peritoneum. The umbilical diverticulum corresponds to a fibrous ring more or less open behind. The peri-umbilical fossettes are found at the breaking of the linea alba. They are of two kinds, and may exist together or separately in the same subject. The more common form is that resembling a crescent. Sometimes it occupies the lateral portion of the ring, sometimes the inferior margin; in other cases again, the other half of the ring is occupied by a mass of adipose tissue. This crescent may be replaced (6 times in 14 cases) by an ellipse which is largest in its transverse axis, whereas in 2 out of 14 cases it was represented as a round cupola. As regards their relation to the umbilicus, the peri-umbilical fossettes may themselves be divided into two groups— the subumbilical and those situated above the umbilicus. The former were noted by Levadoux only twice in 50 cases. Diverticula above the umbilicus were met with a little more frequently — 6 times in 50 cases. They are usually multiple, and correspond to a defect in the umbilical fascia. Their arrangement and anatomic constitution are characterized by the presence of small adipose fringes which cover them (Figs. 53 and 54). The linea alba at their level is lacking, and preperitoneal lobules are found. In this group of peri-umbilical fossettes we have included only those situated less than 3 cm. from the ring.
Clinical Examples of Defects of the Abdominal Wall
The subject of defects in the abdominal wall presents many points of interest. Two cases of this character have come under my observation.
In July, 1910, I saw, in consultation with Dr. A. H. A. Mayer, a boy, aged seventeen, who had a small hernial protrusion 4 cm. above and to the left of the umbilicus. This hernial protrusion projected 1 cm. through the fascia and was lobulated, forming a mass 3 cm. in diameter. The patient was of spare build. On cutting down on the hernial sac I found a small defect in the abdominal wall, through which protruded a small portion of the omentum. The omentum was readily returned, and the opening easily obliterated with a few sutures.
In the Journal of the American Medical Association (October 14, 1911, lvii, 1251) I reported a most unusual case of an ovarian tumor which had passed through a hernial opening to the outer side of the right rectus and at a point a considerable distance from the umbilicus. Although this case is slightly foreign to diseases of the umbilical region, it is of sufficient interest to warrant description here :
An Extra-abdominal Multilocular Ovarian Cyst. — On October 31, 1910, I saw, with Dr. Frank R. Smith, a woman who had a kidneyshaped tumor slightly below and to the right of the umbilicus. The patient had noticed a small lump in this situation several years before, which, for a long while, had remained quiescent, but during the last year had gradually increased in size. At operation it was found to be a partly solid, partly cystic tumor of the ovary, lying external to the abdominal muscles, the tumor and its surrounding sac being covered over with a small amount of adipose tissue and the skin. The pedicle of the tumor passed through a hernial ring to the outer side of the right rectus and obliquely across the lower abdominal cavity to what corresponded to the normal insertion of the right utero-ovarian ligament.
I have been unable to find any reference to a similar case in the literature.
History. — Mrs. M. W., aged fifty-six, was a short, well-developed woman, and apart from a tumor mass in the lower abdomen was in excellent health. She had had 11 children. Her periods had ceased at fifty. She had felt some pain in the right ovarian region for fifteen years, and for about ten years she had noticed a little tumor situated in the right lateral abdominal wall slightly above a line drawn between the umbilicus and the anterior superior spine. This, from her description, seemed to have been about the size of an ovary. During the last ten months this small lump had increased in size until it formed a lobulated mass, elongate in form, about 10 by 8 cm. It seemed to be but a short distance beneath the skin, and could be lifted up to some extent in the hand, but its absolute relationship could not be determined on account of the presence of a considerable amount of adipose tissue.
Operation. — November 1, 1910. On making a pelvic examination under anesthesia, I found that the uterus was normal and that there was no thickening laterally. Not being sure of the exact condition, I made a median incision. The uterus was normal; the left tube and ovary presented the usual appearance. The right tube showed no change, but the right utero-ovarian ligament was markedly drawn out into a band about 1 cm. broad. This led to a hernial opening with smooth margins in the right lateral abdominal wall, below and to the right of the umbilicus, but at least 12 cm. from the inguinal region (Fig. 55). After obtaining good exposure I found that this flattened band of the utero-ovarian ligament passed directly into a hernial opening about 2.5 cm. in diameter, and into this opening a finger could readily be introduced. The intra-abdominal portion of the pedicle was clamped off and sutured. An incision was then made over the prominent part of the abdominal tumor, which proved to be extra-abdominal. The more prominent part of this tumor lay directly beneath the skin, in the adipose tissue, and was very easily freed by blunt dissection to the point where the hernial ring entered the abdomen. I then cut the peritoneum around the hernial ring and delivered the tumor, with its peritoneal covering intact. The space occupied by the tumor having been obliterated, and the inner incision having been sutured, the outer wound was now closed. The ovarian tumor was multilocular.
There had evidently been a hernial protrusion through the right lateral abdominal wall, into which the ovary had dropped and in which it had remained for several years. During the last year it had increased in size and given rise to a multilocular ovarian cyst. Naturally, with the increase in size, the escape of the ovary from the sac had become impossible.
Fig. 55. — Ovarian Pedicle Passing from Uterus Out Through a Hernial Ring in the Abdominal Wall. A schematic representation of the pelvic structures as found at operation. The uterus and left appendages were normal. The right tube was unaltered, but passing from the uterus, where the right ovary should have been, was a band 1 cm. broad. This ran upward and outward and passed out through an abdominal ring to the outer side of the right rectus. At the ring a finger could be passed completely around this pedicle. It was nowhere adherent to the ring. The exact location of the ring is well shown. On looking through it a small portion of the glistening tumor could be readily seen. The dotted line indicates the relative size of the tumor.
Fig. 56. — Extra-abdominal Multilocular Fibrocystoma of the Ovary. The dotted lines indicate the pelvic structures and the right ovarian pedicle passing upward and outward until it emerges from the hernial ring, a short distance below and to the outer side of the umbilicus. After the abdominal relations had been determined, an incision was made directly over the tumor, and it and its peritoneal covering were removed intact. A thin layer of fascia and the peritoneum formed the sac. The tumor was roughly kidney-shaped and lobulated; it consisted partly of a solid tissue, partly of cysts. Deep clefts subdivided the tumor into several portions. The tumor in the main was free from adhesions, but in a few places there were points of union between it and the peritoneal covering. The drawing in the right upper corner shows the tumor on section. The fibrous tissue is abundant, but at this level the cysts predominate. The clefts are seen to have extended through the tumor. It was possible to lift the various segments out without disturbing the remaining ones. Fig. 57 gives the real form of the tumor when liberated from pressure.
Macroscopic Examination of Hardened Specimen (Path. No. 15,723). — The hernial opening was about 2.5 cm. in diameter. Its margins consisted of peritoneum, outside of which was a zone of adipose tissue. The tumor itself was kidnej^-shaped (Fig. 56), 12 cm. long, 7 cm. broad, and 6 cm. in thickness. It was covered everywhere with peritoneum, which could be readily separated from it. Here and there, attached to the outer surface of the peritoneum, were tags of adipose tissue. The tumor itself was in large measure solid, resembling a fibroma. It presented a lobulated appearance (Fig. 57). Here and there between nodules it showed cystic spaces, oblong, irregular, or round, varying from 2 mm. to 2 cm. in diameter. The majority of these were transparent and contained clear fluid. Some of them were slightly blood-tinged. So much could be made out through a window which was cut in the peritoneum. On peeping in through the hernial ring one could see cysts varying from 2.5 cm. to 3 cm. in diameter, and apparently filled with clear fluid. After the drawing had been made, the tumor was cut in two. The appearance on section is well shown in the drawing in the right upper corner of Fig. 56.
Histologic Examination.— The solid portion of the tumor consisted in large part of fibrous tissue containing triangular or spindle-shaped nuclei. In some places the nuclei were abundant, in others scanty in number. The tissue showed a considerable degree of hyaline degeneration. At one or two points characteristic ovarian stroma was still in evidence. No Graafian follicles could be found, but after an examination of numerous sections a typical corpus fibrosum was noted. In some sections a few bundles of non-striped muscle were visible. The stroma had a meager blood-supply, except in a few areas, where there were groups of rather large veins.
Scattered sparingly through the stroma were small circular or irregular glands, occurring singly or in groups of two or three. They were found to be fined with cylindric epithelium, and were similar to those so frequently noted in the hilum of the ovary. Some of the very small cystic spaces, noted macroscopically, were lined with cylindric ciliated epithelium and had an underlying stroma that stained rather deeply and that consisted of cells with oval vesicular nuclei. This stroma stood out in sharp contrast to the surrounding fibrous tissue. Such cysts frequently contained a little fairly fresh blood. They reminded one very much of the cystic spaces so frequently noted in an adenomyoma, but I believe that they represented only the earlier stages of the larger cysts.
The large cysts were lined with one layer of epithelial cells, which were cylindric, cuboid, or almost flat. Projecting into some of the cysts were papillary folds. These occasionally occurred as delicate, irregular, finger-like projections, but in the main as blunt, single, or branching outgrowths. All of them were covered over with one layer of epithelium. The stroma of the papillary masses had in many places undergone almost complete hyaline degeneration, and in a few liquefaction of this hyaline material had taken place. Even in some of the larger cysts a moderate amount of fresh blood was present. The stroma cells beneath the cyst epithelium had in some places become swollen and spheric, and were filled with yellow or brown pigment, indicating the absorption of blood at some previous time.
Fig. 57. — An Extra-abdominal Multilocttlar Flbrocystoma
A schematic representation of the shape which the tumor tended to assume, when relieved from its surrounding pressure. It in reality consisted of four lobes similar in character and joined together by broad or narrow pedicles.
On the surface of the tumor were a moderate number of vascular adhesions, and on the under and protected side of these the peritoneal cells had become cuboid, as is common on the under side of tubal or ovarian adhesions.
From the above description it will be seen that the dense matrix of the tumor consisted essentially of fibrous tissue, and that scattered throughout this were multiple cysts, in large measure similar in character, some of which had small papillary masses projecting into them. Had the tumor developed in the abdominal cavity, I believe that in all probability it would have been a multilocular cystoma, but as it lay between the abdominal muscles and skin, a rapid cystic growth was much more difficult, and the fibrous tissue was thus allowed to keep pace with the cystic formation.
There was no sign of malignancy.
Dr. Bloodgood tells me that he observed a case of hernia of the abdominal wall at the semilunar line, that was between the rectus muscle and those forming the lateral abdominal wall. The sac contained non-adherent loops of small bowel. The condition was readily cured. In our case the opening was also at, or near, the semilunar line, but instead of small bowel, the ovary had for some reason occupied the space and later had gone on to tumor development. It is just possible that this weakness in the wall had become particularly accentuated during a pregnancy, and that the ovary, during its ascent with the pregnant uterus, had dropped into the cavity. The possibility of an embryonic displacement of the ovary cannot, of course, be excluded.
The Relation of the Outside of the Umbilicus to the Peritoneal Side
Out of 13 complete umbilici, in 8 Levadoux noted a posterior umbilical fossette; in the other 5 cases the orifice was well closed by the umbilical fascia, which descended to its inferior border. When the fascia was raised, the fibrous ring was readily seen to be more or less open behind. In the 9 umbilici showing the teatlike elevation, without cushion, in 3 there was a corresponding peritoneal fossette; four others had only fascia covering the posterior opening of the fibrous ring; in the 2 others the fascia and fossette were absent. The opening was well closed by cordlike branches of the vessels. The type of the incomplete umbilicus, with cushion and without teat-like elevation, is much more common (in 23 out of 50 cases) . Frequently it shows a well-closed fibrous orifice. In 3 cases only did Levadoux note the peritoneal fossette; in 4 cases the umbilical fascia descended behind the ring. Out of 15 cases, in 9 the orifice was closed by a simple reapproachment of the margins, in 6 by a soldering of the margins and anastomosis of the fibrous cord of the inferior umbilical with the superior umbilical vessels. As a result of these studies Levadoux draws the following conclusions:
- The teat-like elevation of the umbilicus corresponds nearly always with the fibrous ring, which is open.
- When the cutaneous umbilicus is complete, in the majority of cases (8 out of 13) an umbilical peritoneal fossette is present.
- The umbilicus without the teat-like elevation usually corresponds to a fibrous ring that is closed (24 out of 27 times). The same holds good in obese subjects.
- The existence or the non-existence of the umbilical fascia at the level of the fibrous ring bears no relation to the cutaneous form of the umbilicus.
Having gone fully into the findings of Levadoux, I shall merely mention the results obtained by Brodel in his studies of the embryology of the umbilical region.
Fig. 16 gives the intraperitoneal view of the umbilicus in a human embryo 6.5 cm. long.
Fig. 17 gives the intraperitoneal view of the umbilicus in a human embryo 7.5 cm. long.
Fig. 18 gives the intraperitoneal view of the umbilicus in a human embryo 9 cm. long.
Fig. 19 gives the intraperitoneal view of the umbilicus in a human embryo 10 cm. long.
Fig. 20 gives the intraperitoneal view of the umbilicus in a human embryo 12 cm. long.
Fig. 21 gives the intraperitoneal view of the umbilicus in a human embryo 12 cm. long.
Fig. 22 gives the intraperitoneal view of the umbilicus in a human embryo 12 cm. long.
Fig. 24 gives the intraperitoneal view of the umbilicus in a human embryo 15 cm. long.
Fig. 28 gives th£ intraperitoneal view of the umbilicus in a human embryo about five months old.
Fig. 29 gives the intraperitoneal view of the umbilicus in a human embryo six to seven months old.
These pictures show the relations of the umbilical arteries to the urachus, and their mode of termination at or near the umbilical ring. They also give the relations of the umbilical vein. They show the appearance of the umbilical ring as viewed from the abdomen, and depict the mesenteries frequently found supporting the umbilical vessels and the urachus.
Figs. 35, 36, and 37 give accurate types of the adult umbilicus as seen at operation or at autopsy.
The Umbilicus in Animals
In a comparative study of the umbilicus Levadoux examined two species of hoofed animals, the horse and the donkey. He examined ten horses and two donkeys. In these animals the umbilicus is represented by an ellipsoid depression, arranged in a cranio-caudal direction. Posteriorly it is bounded by a smooth surface and a rudimentary vestige of a cutaneous cicatrix. In front of this the hairs have a disposition to diverge, on account of a sagittal line which forms a grand axis of the depression and produces what may be termed a "tuft." This disposition of the hair is entirely contrary to that observed in man, where the hairs of the umbilical region converge toward the umbilicus.
Levadoux (p. 18) says that in mammals there exists a cutaneous depression, circular in form, and completely covered with hair, located in the median abdominal line at the same height as in the solipeds.
For rodents Levadoux confined his observations to the mouse, water-rat, guinea-pig, and rabbit. In the mouse and in the rat nothing can be seen from the outer surface to indicate the point of implantation of the umbilical cord. In the guinea-pig, on the other hand, toward the middle of the median abdominal line, is seen a circular surface divested of hair, somewhat prominent, and about 3 mm. in diameter. It is surrounded by a circular furrow, and suggests the elevation in the human umbilicus. Thus, the cutaneous abdominal cicatrix is absent in the mouse and rat. The hairs have no special disposition. The rabbit does not present the cutaneous umbilical cicatrix, but the linea alba is clearly visible throughout the entire length of the recti muscles.
The carnivora are then dealt with (p. 23). The cat and the dog were studied. So far as regards the umbilical region, the cat has nothing to distinguish it from the rabbit. The anatomy of the umbilical region of the dog is more interesting, because it resembles more closely that found in the human being. The cutaneous surface of the umbilicus presents teat-like projections, smooth or covered with silky hair-follicles which project to a greater or less extent. Surrounding this teat-like projection is a furrow, and sometimes around the furrow is a remnant of a cushion. This arrangement was noted in 7 out of 10 cases. In the other cases the teat-like projections were lacking, and Levadoux found nothing more than a depression. All the abdominal hair converged toward the umbilicus.
The inner surface of the umbilicus of the horse and donkey shows a lozenge-shaped hollow which corresponds to the cutaneous depression. This is surrounded in all directions by a fibrous cord which is half cylindric and firmly attached. The two cords which are formed of longitudinal fibers unite at the two extremities of the lozenge and terminate in the linea alba, 4 or 5 cm. from their point of union. On transverse section at the site of this depression the fibrous thickenings are seen to be formed from the subjacent fibers, which become merged with those of the linea alba. The fibers in the linea alba have a radiating direction as regards this lozenge, and the deeper ones are inserted in its margins. At its anterior extremity, at the point of reunion of the two pillars, it is represented by a cylindric cord which is the remains of the umbilical vein. This cord, which is intimately connected with the abdominal wall by the peritoneum, terminates in the inferior surface of the fiver. In the solipeds there does not exist a vestige of the urachus or of the umbilical arteries. The peritoneum which covers the bottom of this depression is separated by the transversalis fascia.
On page 18 he briefly describes the inner appearance of the umbilicus in ruminants — the cow and the sheep. On page 20 he takes up the consideration of the rodents and describes the inner appearance of the umbilicus in the mouse, waterrat, guinea-pig, and rabbit.
The Lymphatics of the Umbilical Region
Relatively little has been written on the lymphatics of this region, either by the clinician or the anatomist. The former studied the manner in which abdominal carcinomata reach the umbilicus, and the mode of dissemination of primary umbilical growths, whereas the anatomist has reached his conclusions by injecting the lymphatics of the umbilical region. Although our knowledge of the subject is as yet by no means complete, the findings are of much interest.
In Figs. 58 and 59 Max Brodel has given us composite pictures of what is known of the umbilical lymphatics.
Neveu, in 1890, speaking of secondary malignant tumors of the umbilicus, says that the superficial lymphatics below the umbilicus pass to the inguinal glands, while the superficial lymphatics above the umbilicus pass to the axillary glands. The deeper umbilical lymphatics situated just external to the peritoneum are very abundant, especially in the median line. The deep lymphatics below the umbilical region pass to the iliac glands; those above the umbilicus go to the retrosternal glands. Neveu then briefly quotes Sappey's findings.
Quenu and Longuet, in their exhaustive monograph on secondary cancer of the umbilicus (1896), say that the lymphatics constitute an excellent avenue along which abdominal carcinomata may reach the umbilicus. They describe the manner in which the lymphatics of the pyloric end of the stomach and those of the duodenum communicate with those of the under surface of the liver. From this point there is a free lymphatic communication with the umbilicus along the suspensory ligament.
Speaking of the mode of extension of pelvic carcinomata to the umbilicus, these authors say that certain lymphatics of the uterus pass along the round ligament to the inguinal glands, and at times to the iliac glands; that there is a free lymphatic communication between the umbilicus and the inguinal and iliac glands, and consequently there is a direct connection between the pelvic lymphatics and the umbilicus.
Le Coniac, in 1898, when considering carcinoma of the umbilicus, secondary to carcinoma of the uterus or ovaries, says that a direct lymphatic path can be traced from the pelvis to the umbilicus. He quotes the studies of Poirier, who also found that some of the uterine lymphatics pass to the inguinal region, while others enter the iliac glands. From either the inguinal or iliac glands the cancer may extend to the umbilicus, in the later part of the journey probably passing against the lymph current. In the chapter on Cancer of the Umbilicus the following occurs : "The careful study of many umbilical lesions in the past has demonstrated that when the liver is involved in a malignant growth, which has extended to or encroached upon the suspensory ligament, the growth tends to pass by way of the lymphatics out along the suspensory ligament to the umbilicus. When a malignant pelvic growth extends to the umbilicus, it usually follows the lymphatics found in the course of the remnants of the obliterated umbilical arteries and urachus upward to the umbilical depression. If the umbilicus is the seat of a malignant growth, the inguinal or axillary glands may be secondarily involved according as the growth occupies the upper or lower part of the umbilicus."
Of special interest are the reports of primary and secondary carcinomata (pp.402, 412), in which is given a clear description of the various avenues along which the carcinoma may extend.
An Anatomic Study of the Umbilical Lymphatics. Cuneo and Marcille, in 1901, injected the umbilical lymphatics in 10 new-born children, and divided them into three groups, of which they gave the followingdescription :
- Cutaneous lymphatics.
- Lymphatics of the fibrous umbilical thickening.
- Lymphatics of the aponeurosis surrounding the umbilical ring.
Fig. .58. — Superficial Lymphatics of the Umbilical Region - . This is a composite drawing based on the studies of Cuneo and Marcille. The bulk of the lymph-channels pass in the subcutaneous fat and are seen to drain in four directions, the upper set passing to the axillary lymph-glands, while the lower empty into the external inguinal group. On the left side of the picture a small portion of the subcutaneous fat has been removed, showing branches of the deeper lymphatics resting on the muscular aponeurosis.
Fig. 59. — The Deep Umbilical Lymphatics as seen from the Peritoneal Side. This is a composite drawing, based on the studies of Cuneo and Marcille and Poirier. Like the superficial lymphatics, the deep likewise drain chiefly upward and downward. Those from the upper umbilical region pass on either side of the falciform ligament of the liver, pierce the diaphragm, and enter the anterior mediastinal glands. In their course small intercalated lymph-glands are occasionally found. An additional small lymph-channel is found along the course of the round ligament of the liver. It is along this channel that cancers of the stomach and gall-bladder find their way to the umbilicus. The lymphatics from the lateral portions of the umbilicus first pass outward and then, curving downward, reach the inguinal glands. The lymphatics from the lower portion of the umbilicus pass directly downward to the internal inguinal glands.
In the new-born the cutaneous lymphatics originate from the umbilical scrotum." They form a thin network which is difficult to inject. This network is continuous with that of the surrounding skin. From the umbilicus, four or five trunks pass in each direction immediately beneath the skin. They go downward and outward toward the fold in the groin, and terminate in two groups of glands — the superficial external and the superficial internal inguinal glands. It is unusual to see these lymph-trunks descending and passing over to the median line.
At the level of the umbilicus these authors were never able to inject a lymphtrunk that passed to the axillary glands.
The lymphatics of the fibrous cord were still more difficult to inject. From the fibrous cicatrix two or three lymph-trunks pass in each direction and disappear immediately in the sheath of the corresponding muscle.
The lymphatics of the aponeurosis of the umbilical ring are divided into two groups — the anterior and the posterior. The anterior lymphatics originate in the anterior or cutaneous surface of the corresponding sheath as a delicate network which encircles the umbilical ring. The resultant lymph-trunks are divisible into two groups. In the first and more important they run parallel to the sheath of the aponeurosis, disappear in it, and unite with those arising from the fibrous nodule. In the other the lymph-trunks pass outward parallel to the two obliques, and may be confused with those from the posterior aponeurosis.
The posterior lymphatics originate from a network attached to the posterior or peritoneal surface of the sheath. The collectors of this network may be divided into two groups. In the first the lymphatics pass upward and unite with the corresponding lymphatics, which, as we have seen, originate from the anterior part of the sheath of the muscle. These trunks follow their course in the sheath and terminate in the external iliac gland, resting on the anterior part of the iliac artery. The other trunks emanating from the posterior aponeurotic network pass downward in company with the vessels from the fibrous thickening, and usually accompany the epigastric artery, descending and terminating in the two external iliac glands immediately behind the crural arch. In the course of these lymphtrunks one may encounter from two to four glands, sometimes of small volume, which invariably accompany the epigastric artery. These are the epigastric glands of Gerota.
Cuneo and Marcille, in three out of ten cases, observed a small gland situated in the subperitoneal cellular tissue, 2 to 4 cm. below the umbilicus. This gland is always a little to one side of the median line. It was mentioned by Gerota in his work.
In one case they found two subperitoneal glands close to the umbilicus. They found that the lymphatics of the umbilicus anastomose with those of the liver and of the bladder by means of the lymphatic network which surrounds the umbilical vein and the network following the umbilical arteries and the urachus.
The Sensory Nerve-Supply of the Umbilicus
Spiller reviewed the literature on this subject in the Philadelphia Medical Journal, February 8, 1902, and reported a case that he had had under observation.
Spiller and Weisenburg (1904) discussed the subject still further. Boettiger had been uncertain whether the umbilicus lies in the distribution of the ninth or of the tenth thoracic segment. Walton had put it in the distribution of the eleventh thoracic segment; Dejerine in the distribution of the tenth thoracic segment. Head had attributed to the tenth thoracic sensory segment the supply of the subumbilical region, and had described the upper border of the segment as passing directly through the umbilicus. Spiller and Weisenburg say: "From this review it will be seen that there is much to be said in favor of the situation of the umbilicus within the tenth thoracic sensory segment, but this is an opinion we are unable to accept." In a preceding paper Spiller had reported a ease indicating that the umbilicus lies between the ninth and tenth thoracic sensory segments, and in a later paper a second case that was observed until death. From the data thus obtained Spiller and Weisenburg think that the umbilicus probably lies within the zone of the ninth thoracic segment. They say that the importance of this determination must be apparent on account of the prominence of the umbilicus as a surgical landmark.
THE SKIN UMBILICUS.
Runge, in his chapter on '"Wound Infections of the New-Born" (p. 61.. says that at the fetal end of the cord the amnion passes directly to the skin of the child. This point of transition occurs, as a rule, from 0.5 to 1 cm. out on the cord, and ends in a ring-shaped swelling. If the skin passes farther out on the cord, it is spoken of as a skin or flesh umbilicus. It is the antithesis of an amniotic umbilicus.
THE AMNIOTIC UMBILICUS.
Nicaise, in 1881, referred to this very rare condition. He said that, according to Widerhofer, it is characterized by an absence of skin around the umbilicus, the defect being replaced by amnion which is reflected upon the abdomen from the cord. In such cases the surrounding abdominal wall is usually intact. The amniotic umbilicus is small, and does not interfere with the health of the child. In the ease mentioned by Nicaise the amniotic disc was gradually replaced by scar tissue and the umbilicus completely closed.
Runge, in 1893, when discussing this subject, said that in rare cases there is a preponderance of amnion and a lack of skin at the umbilicus. The amnion spreads out as a flat funnel around the umbilicus, and the condition is spoken of as an amnion umbilicus.
A careful study of Fig. 2, p. 2, Fig. 3. p. 3, Fig. 197, p. 462, will render clear the mode of development of the amnion.
ABSENCE OF THE UMBILICUS.
As pointed out by Xicaise, the umbilicus may be confounded with the upper portion of an exstrophy. In such a case it is more distinct behind than in front of the abdominal wall. Sometimes it is situated immediately above the exstrophy; more rarely it is 3 or 4 cm. distant from it. The umbilical vein may be longer than normal. The umbilical arteries are slender and shorter. The urachus is wanting when the umbilicus corresponds to the upper portion of the exstrophy. In such cases there is no real absence of the umbilicus, but an unusual disposition of it, due to the exstrophy, which in turn is caused by the failure of the allantois and of the abdominal walls to close.
Evans, in 1895, referred to a young white man who virtually had no umbilicus — there was scarcely any depression, the parts being quite flush with the abdominal wall. As noted on page 62, there is no trace of the umbilicus in certain animals, and if the surgical treatment of the cord, as carried out by Dickinson, Flagg, and Buckmaster, were generally adopted, it would not be long before many adults would have but the faintest suggestion of an umbilicus.
The Umbilicus During Pregnancy
According to Xicaise, modifications of the umbilicus during pregnancy have been studied chiefly by Dubois, Cazeaux, and Stoltz. Catteau has also described them. Xicaise says that alterations in the umbilicus differ in the primipara and in the multipara. After the first and second months of the first pregnancy the umbilicus is drawn in a little; the patient has a sensation of a painful pulling at this point, and the umbilical region has an increased sensibility. At the third or fourth month the umbilicus is normal, but the umbilical area is slightly raised. In small patients the changes are more rapid and more marked. At term the umbilicus itself is generally raised a little above the surrounding parts, and its dimensions are increased. (Plate IV, 60, and Plate VI, 4.) Sometimes the umbilical ring is dilated and permits the introduction of the tip of the ringer. The umbilical cicatrix is more easily depressed, and the umbilical furrow is less marked. Hernia of the intestine or of the omentum rarely follows a first pregnancy.
During the following pregnancies the modification of the umbilicus is more marked and more rapid, and the umbilicus is readily distended. At the ninth month the umbilicus itself has unfolded, and is even with the abdominal wall. Xicaise says that the umbilicus at this time is distinguished only by the white coloration above and by the fine character of the skin of the scar.
The umbilical areola, according to Xicaise, is rare. He quotes Montgomery, who says that a brownish zone at times completely surrounds the umbilicus, and forms an areola analogous to that of the breasts.
Evans, when discussing the subject in 1895, said that an umbilical areola is an unimportant secondary sign of pregnancy, for by the time that the condition has advanced sufficiently to cause bulging at the umbilicus, the diagnosis is usually clear.
Literature Consulted On Anatomy Of The Umbilical Region.
Bert, A., et Yiannay, Charles: Etude sur la morphologic de l'ombilic. Compt. rend, de l'assoc.
des anatomistes, 104, vi, 116. Catteau, J. F.: De l'ombilic et de ses modifications dans les cas de distension de l'abdomen.
These de Paris, 1876, No. 210. Cullen, Thomas S. : An Extra-abdominal Multilocular Ovarian Cyst. Jour. Amer. Med. Assoc,
October 14, 1911, lvii, 1251. Cuneo et Marcille: Lymphatiques de l'ombilic. Bull, de la Soc. anat. de Paris, 1901, annee 76,
Evans, T. R.: Umbilical Freaks; Rationale of Umbilical Depression in Early Pregnancy. Gaillard's Med. Jour., 1S95, lxi, 28.
Gauderon, A. E.: De la peritonite idiopathique aiguedes enfants; de sa terminaison par suppuration et par evacuation du pus a travers l'ombilic. These de Paris, 1876, No. 148.
Hertz, W. H.: Ueber einen Fall von Adenocarcinom des Nabels bei einer 58-jahr. Frau. Inaug. Diss., "Wurzburg, 1905.
Kiister: Die Neubildungen am Nabel Erwaehsener und ihre operative Behandlung. Langenbeck's Arch. f. klin. Chir., 1874, xvi, 234.
Le Coniac, H. C. J.: Cancer secondaire de l'ombilic; consecutif aux tumeurs malignes de l'appareil utero-ovarien. These de Bordeaux, 1898, No. 19.
Levadoux, Michel-Joseph: Varietes de l'ombilic et de ses annexes. Fac. de Med. et de Pharm. de Toulouse, 1907, No. 711.
Neveu: Contribution a l'etude des tumeurs malignes secondaires de l'ombilic, 4°, These de Paris, 1890, No. 50.
Nicaise: Ombihc. Dictionnaire encyclopedique des sciences medicales, Paris, 2. ser., xv, 1881, 140.
Quenu et Longuet: Du cancer secondaire de l'ombilic. Rev. de chir., 1896, xvi, 97.
Runge: Die Wundinfectionskrankheiten der Neugeborenen. Die Krankheiten der ersten Lebenstage. Stuttgart, 1893, 56.
Spiller, William G., and Weisenburg, T. H.: A Further Study of the Sensory Segmental Zone of the Umbilicus. Review of Neurology and Psychiatry, Edinb., October, 1904, ii, 680.
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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