Book - Umbilicus (1916) 20
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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 XX. Fecal Fistula at the Umbilicus
Fecal fistulse at the umbilicus due to wide-spread ulceration of the large and small intestine.
Fecal fistula? at the umbilicus due to gangarene.
Fecal fistulse at the umbilicus due to external injury.
Umbilical fecal fistula? due to burns.
Tuberculous peritonitis followed by a fecal fistula at the umbilicus; report of cases.
Umbilical fistula (not fecal) due to tuberculosis of the vas deferens.
Umbilical fistulse may be due to a patent omphalomesenteric duct, to inflammatory changes commencing in the intestine and extending to the umbilicus, to carcinoma of an abdominal organ, usually of the stomach, reaching to and breaking through the umbilicus, to inflammatory conditions of the umbilicus extending to and involving the intestine, and to external injuries. All except the last two groups have been dealt with elsewhere. In the present chapter I shall refer briefly to certain cases of obscure abdominal lesions followed by fecal fistula at the umbilicus, and then describe those cases in which the fecal fistula was due to external injury of the umbilicus.
Le Cat, in 1775, reported a case of fecal fistula at the umbilicus. This case has also been recorded by Schrotter. The patient was a ten-year-old girl who had fecal masses escaping from the umbilicus. For a year before she came under observation the bowels had been sluggish. She had a poor appetite, associated with abdominal distention, and soon died. At autopsy the peritoneum was found to be as thick as a finger. The intestines were attached to the anterior abdominal wall. Below the umbilicus at one point there was an intestinal perforation, the opening communicating with the umbilicus. Between intestinal adhesions there was a considerable quantity of pus and fecal masses, and live lumbricoid worms were seen in the bowel. The mesenteric glands were enlarged, indurated, and suppurating. The intestines were ulcerated.
[At that date, of course, no histologic examination was made. The enlarged suppurating glands would naturally suggest tuberculosis. — T. S. C]
Winiwarter, in 1877, recorded a case of fecal fistula at the umbilicus. A boy, eight months old, had suffered from boils on several occasions. Fourteen days before admission to the hospital two of these had been opened. On September 20, 1875, the child looked badly; there was an infiltration, 9 cm. in diameter, in the umbilical region. This area, which was hard and covered with reddish, hot skin, formed a conic tumor with the umbilicus in the center. Poultices were applied, and after three days the swelling opened. On September 25th the opening was the size of a linseed, and from it yellowish, grumous, intestinal contents escaped. After this nothing passed by the rectum, for a time all the fecal contents being evacuated through the umbilicus. The child died on October 25th. At autopsy a localized
310 THE UMBILICUS AND ITS DISEASES.
peritonitis was noted at the umbilicus. Beneath the umbilicus was a hole, the walls of which were composed of intestinal loops. The fecal opening was in the colon.
As a possible cause, Winiwarter considered phlegmon of the abdominal wall. This, he said, might have tended to a localized peritonitis causing adhesions of intestinal loops. He says that an abscess in the abdominal wall may have broken into the abdomen prior to opening externally; the large bowel might thus have opened into the abscess cavity. Another explanation suggested by him was that there might have been a primary enteritis, and then a peritonitis with abscess formation near the anterior abdominal wall. No mention is made of tuberculosis, and the fact that the opening was in the colon would suggest that the original cause might possibly have been appendicitis.
Trelat, in 1883, and Nicolas in the same year, also report cases of fecal fistulse. Trelat 's patient was a girl, seventeen years of age. When the child was three years old, her mother noticed a swelling with redness and an opening at the umbilicus. As the wound would open and close from time to time, the child wore a bandage. When the umbilicus first opened the discharge had a fecal odor. The fistula was evidently of intestinal origin. There was no history of any operation. Nicolas' patient was also seventeen years of age, and it looks very much as if Trelat and Nicolas have recorded the same case. In none of these cases was it possible to determine the primary cause of the umbilical fistula.
FECAL FISTULiE AT THE UMBILICUS DUE TO WIDE-SPREAD ULCERATION OF THE
LARGE AND SMALL INTESTINE.
Knecht, in 1875, published the history of a strongly built man, twenty-nine years old. In 1873 he had had catarrh of the stomach which had become chronic, and, as a consequence, he had become anemic and had lost strength. After an acute attack of typhlitis there was some improvement, but after ten days the symptoms became severe again and there was a mild degree of peritonitis. After about three months immediately beneath the umbilicus there appeared a circumscribed, painful area of infiltration the size of a two-thaler piece. In addition there were several isolated areas of hardness in the right inguinal region and also above the umbilicus. Some time later an abscess in the mid-line opened and there escaped a large quantity of pus which had a fecal odor. After eight days a new abscess developed in the umbilical region. This opened spontaneously into the original abscess cavity. After about six weeks all the abscesses had united, forming one cavity. The overlying skin sloughed off, and the abdominal fascia lay free over an area the size of the palm of the hand. In the region of the umbilicus were numerous openings. The patient died a short while afterward. At autopsy there was a marked degree of emaciation and edema of the feet, together with much distention of the abdomen. In the mid-line was an ulcerated area, 17 cm. broad and 15 cm. long. This had raised and eaten-out margins, and in the center were the remains of the umbilicus. In the floor of the ulcer were openings with gangrenous walls which had led to an irregular cavity through destruction of the recti. Pressure upon it caused the escape of foul-smelling bubbles of gas. When the abdominal cavity was opened, about 10 liters of serum escaped. The abdominal contents were much displaced. The anterior surface of the cecum, the first fourth of the transverse colon, as well as a portion of the jejunum, had grown fast to the abdominal
FECAL FISTULA AT THE UMBILICUS. 311
wall on the inner side of the ulcer, and were also adherent to the posterior abdominal wall. The intestinal loops had grown fast to one another, as well as to the abdominal wall. Just above the ileocecal valve the mucosa of the ileum contained several ulcers which showed partial healing. In one of the intestinal loops adherent to the anterior abdominal wall was an opening through which a sound could be introduced from the outside. In the upper portion of the transverse colon were ulcers which communicated by a perforation with the anterior abdominal wall. There was a similar ulcer in the floor of the cecum, which communicated with a hole, lying behind the abdominal wall, and filled with pus and necrotic tissue. This cavity reached upward to the margin of the kidney and extended along the large vessels. The iliacus muscle on the right side had disappeared. In the apex of the left lung were several scars, but no fresh tubercles.
From the above history it is impossible to determine the exact starting-point of the disease. The evidence is, however, strongly suggestive of appendicitis or tuberculosis as the exciting factor.
The following case, reported by Martin, resembles in some particulars the one described by Knecht:
Abscess of the Umbilicus; Gangrene and Intestinal Perforation; General Peritonitis. Death. — This case was originally reported by Dr. M. E. Martin.* L. L., aged seven, entered the hospital on December 27, 1871, and died February 28th of the following year. The child, according to her mother, had coughed for about a year, and for the last three months a swelling had been noted at the umbilicus. From time to time the child had complained of pain, and on her entrance to the hospital a tumor was detected which occupied the region of the umbilicus. -This tumor was soft and fluctuating and there was redness of the skin. During January the child showed a considerable change for the worse, and on palpation an accumulation was detected deep in the abdomen and to the right of the umbilicus. On percussion dulness was noted over this area. During the process of inflammation the child complained of pain in the region of the umbilicus and in the right flank. On February 13th there was considerable distention; pain was severe on abdominal pressure, and the child vomited greenish material. The temperature rose to 39° C., the pulse to 140. The vomiting and peritonitis persisted, accompanied by diarrhea and greenish stools, for three days. On January 16th a seropurulent discharge with a definite fecal odor was noted from an orifice immediately beneath the umbilicus. On the seventeenth and eighteenth there was abundant discharge, and on the nineteenth pus, similar in character to that coming from the umbilicus, escaped from the rectum. On January 21st semisolid fecal matter commenced to escape from the umbilicus, and the fistulous opening and the tissue around the fistulous opening began to slough. On January 24th the area of sloughing had increased; the tongue was covered with sordes, and the extremities were cold.
On the following day the slough came away, and on January 27th all fecal matter was being passed by the umbilicus. The child became thinner and very weak, and died on February 28th.
Autopsy. — The lungs and heart were normal. At the umbilicus the area of sloughing was the size of a five-franc piece. The abdominal organs were bound to
- Martin, M. E.: Abces de l'ombilic; gangrene et perforations intestinales ; peritonite
generalisee; mort. Bull, de la Soc. anat. de Paris, 1872, xlvii, 148.
312 TKE UMBILICUS AND ITS DISEASES.
one another by a false membrane, and the peritoneum was intimately adherent to the abdominal wall in the right flank. There was an intestinal perforation 60 cm. from the pylorus. A portion of the ascending colon was slightly adherent to the umbilical opening, and six other perforations were noted in various portions of the intestine.
FECAL FISTULA AT THE UMBILICUS DUE TO GANGRENE.
Prior to aseptic days gangrene of the umbilicus was not infrequently observed in infants a few days old (page 73j. At the present time it is seldom seen, and in the adult is a rarity. Ledderhose, in 1890, considered this subject somewhat fully. Gangrene of the umbilicus has followed the continuous use of the ice-bag, and has been associated with infectious diseases of the umbilicus. Ledderhose referred to a case reported by Fischer. An ice-bag was applied to the abdomen of an anemic patient. Twenty-four hours later the skin showed a slight bluish color, and fortyeight hours later, after further applications of ice-bags, the tissues were deep blue and there was a sensation of burning. In the course of three weeks 150 c.cm. of gangrenous skin came off. Skin-grafts were employed over the raw area, and the patient recovered. Undoubtedly the anemia favored the development of gangrene.
Ledderhose mentions two cases of puerperal infection under Thiede's care. Ice-bags were kept on the abdomen for fifteen days in one case and for twenty days in the other. Gangrene of the abdominal wall developed in each instance. Thiede did not think that the ice-bag was responsible for the gangrene, but that the causative factor was rather to be sought in the squeezing and probable injury of the abdominal wall which was produced every time the uterus was emptied or washed out.
Ledderhose further says that gangrene of the umbilicus may develop during the course of infectious diseases of the navel or after exhausting diseases involving the stomach or intestinal tract. Sometimes only the superficial abdominal walls are involved; in other cases the gangrene extends to the deeper layers of the abdominal wall and leads to a peritonitis and perforation into the intestine or bladder. The prognosis is, in general, unfavorable, but even in severe cases recovery may ensue.
FECAL FISTULA AT THE UMBILICUS DUE TO EXTERNAL INJURY.
Fecal fistula? as a result of external injury at the umbilicus are evidently very rare. Murchison, in 1858, recorded a very interesting case that he saw with Keith, of Aberdeen. The patient was a woman with a family history replete with nervous and mental defects. She feigned illness and tried to have her arm amputated. Later, when discovered, she made believe that she had a cardiac lesion. Finally, she produced an opening between the skin and the stomach. Through this gastric fistula some interesting experiments were made. Murchison collected the cases in which the stomach opened upon the abdomen and found that the break seldom, if ever, occurred at the umbilicus.
Grawitz and Nicolas both record examples of an umbilical fistula due to a cut. and Fronmuller tells of a fistula due to injury produced by a long finger-nail.
Grawitz showed a specimen coming from a Pole, who, in 1849. was wounded in the umbilical region with a scythe. A fecal fistula developed and persisted for the remaining thirty years of his life. The patient during his late years grew thin and
FECAL FISTULA AT THE UMBILICUS. 313
very weak, and finally died of marasmus. Several attempts were made to close the opening, but without success. (This was before 1878.) There was a defect in the abdominal wall as large as the palm of the hand. The opening was in the small bowel, about 1 meter from the stomach.
Nicolas refers to a patient who had been examined by Fromantin.* The patient was a soldier who had received a cut in the umbilical region. The opening was small, and Fromantin thought little of it, although it occasioned much pain. On the tenth day there was some discharge with a fecal odor. The opening was dilated, and a quantity of fecal matter escaped. The fistula gradually diminished in size and closed.
Fronmuller reported the case of a man, forty-eight years of age, who had long finger-nails and was of rather uncleanly habits. After an attempt to remove some foreign body from the umbilicus with his finger-nail, pain and swelling in the umbilical region came on gradually. When seen fourteen days later the patient had a yellowish discharge from the umbilical depression. The umbilicus was rather tense, red, and half-moon-shaped on its right side and painful on pressure. On the floor of the umbilicus was a large, red, fleshy mass, and fluid was seen coming from a very fine opening. A sound introduced passed two inches into the adherent bowel. When the patient lay on his right side, the amount of the discharging fluid increased. The patient had a feeling of tension in the umbilical region. Three days later silver nitrate was applied, followed by a second treatment after two days. Four days after the second treatment a pinkish-red tumor developed in the left side of the umbilicus. This was accompanied by much pain. It broke two days later and a yellowish-white, foul-smelling fluid escaped. A second fistulous opening now formed into which a sound could be carried three and one-half inches. From time to time other fistulse developed until six were counted.
When the patient was seen four and one-half months later, all these fistulse had healed, and the man was in good condition. Fronmuller reported this case on account of its unusual character and as an example of a fistula due to injury from without and not from within.
UMBILICAL FECAL FISTULA DUE TO BURNS.
In the course of a conversation with Dr. Jesse W. Hirst, of the Severance Hospital, Seoul, Korea, he told me that in Korea the most frequent umbilical lesion is a fecal fistula. This is due to the common mode of treatment in cases of abdominal pain or peritonitis.
The natives take a piece of cotton-wool and some dried fungus, roll the two into a small lump, and lay it on the painful area. A match is applied and the roll is allowed to burn. The result is a sore about three-quarters of an inch in diameter, and usually only skin deep. The desired result, namely, a running sore, is obtained. This application is made in some instances three or four times. If there is pain or swelling in the umbilical region, the application is made over the umbilicus and frequently the surface of an umbilical hernia is burned.
Dr. Hirst observed about 15 cases in which such applications had been made at the umbilicus, and in three a fecal fistula developed. The cause of the fistula is
- Fromantin: Mem. d. l'Acad. de chir., Paris, 1743, i, 602.
314 THE UMBILICUS AND ITS DISEASES.
evident. The burning is sufficient to set up a localized peritonitis, intestinal loops become adherent, and a fistula results.
LITERATURE CONSULTED ON FECAL FISTULA AT THE UMBILICUS.
(See also literature at end of this chapter.)
Fronmiiller, G.: Kothfistel im Nabel. Memorabilien, Heilbronn, 1866, xi, 273.
Gauderon: 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. Grawitz: Berlin, klin. Wochenschr., 1878, xv, 9. Knecht: Ausgebreitete Ulcerationen im Dick- und Diinndarm, mit Perforation der vorderen
Bauchwand. Arch. d. Heilkunde, 1875, xvi, 539. LeCat: Surun engorgement par congestion dans toute l'etendue du peritoine devenu suppura toire, complique d'adherence et d'ulceration des intestins avec issue des matieres fecales par
l'ombilic. Jour, de med., 1755, ii, 356. Also reported by Schrotter: Arch. f. Kinder heilk., 1902-03, xxxv, 398. Ledderhose: Deutsche Chirurgie, 1890, Lief. 45 b. Martin, M. E.: Abces de l'ombilic. Gangrene et perforations intestinales; peritonite genera lisee, mort. Bull, de la Soc. anat. de Paris, 1872, xlvii, 148. Murchison, C: Communication with the Stomach through the Abdominal Parietes Produced by
Ulceration from External Pressure. Med. Chir. Transactions, London, 1858, xli, 11. Nicolas, P. : Sur deux varietes de fistules ombilicales. These de Paris, 1883. Trelat: Fistules ombilicales. Jour. d. connaiss. med. pratiques et de pharm., 1883, 1, 364. Winiwarter, A. : Fistula stercoral, umbilic. Jahrb. f . Kinderheilk. und physische Erziehung, N. F.,
1877, xi, 193.
TUBERCULOUS PERITONITIS FOLLOWED BY A FECAL FISTULA AT THE
As pointed out by Feulard, the opening at the umbilicus of a tuberculous process in the peritoneum is not rare. Fischer observed three cases, in two of which there was a fistulous opening between the bowel and the umbilical depression. The subject has been carefully considered by Nicaise, Ledderhose, Tillmanns, Ziehl, Owen, and others.
When a tuberculous peritonitis exists in children, there seems to be a definite tendency for it to open at the umbilicus. Helmreich (quoted by Schrotter) claimed that of all known cases of abdominal fistula, three-fourths developed at the umbilicus. This seems to tally with the experience of other observers. Heinrich, in 1849, drew attention to several cases in which the opening was in the abdominal wall near the umbilicus.
Ziehl, in 30 cases of abdominal fistula following tuberculous peritonitis in children, found that in 18 cases the opening was at the umbilicus.
In order that we may get a clear idea of this class of cases I have assembled a group which depicts the salient features of the disease. No attempt has been made to collect all the cases recorded in the literature. We here have records of 19 cases. Sixteen of the patients were children. The youngest was one year old. Eleven were under ten years of age, and five between ten and sixteen years of age, these figures being in accordance with the claims of previous writers that fecal fistula at the umbilicus due to tuberculous peritonitis is most common in childhood; only 3 of the 19 patients were adults.
Symptoms. — The previous history in these cases, as a rule, is colorless, but in a
FECAL FISTULA AT THE UMBILICUS. 315
few instances is of value. Crooke's patient had previously complained of pain in the hip, and was of a scrofulous diathesis. Clairmont's gave a history of a previous pulmonary affection. One of Ziehl's patients had suffered from rickets, and another from tuberculosis of the lungs. Rachford's patient also gave a similar history.
The children usually first complain of abdominal distention, with or without pain. This increases, the appetite gradually diminishes, and emaciation follows. Constipation develops, and may or may not alternate with diarrhea. As the disease advances the temperature frequently rises. The pulse becomes rapid and small, the tongue is coated, and the breath fetid. Chills may accompany the fever, and, if the lungs be involved in the tuberculous process, severe coughing and night-sweats may be present, and pleurisy may be detected.
The abdominal enlargement continues to increase, and it may be possible to detect solid masses or an accumulation of abdominal fluid. Occasionally the diagnosis of tuberculous peritonitis may be rendered more definite by a rectal examination. In two of Schmitz's cases he was able, with his finger in the bowel, to detect small nodular masses in the pelvis.
After a varying length of time the umbilicus may become altered in appearance. The changes may occur in a few months, but, as in a case recorded by Nicaise, a year and a half may elapse before the slightest difference can be detected. The picture varies considerably. In Catteau's case a tumor, 3 cm. in diameter, and forming a semicircle, was noted. There was discoloration of the skin and the tumor was transparent. In Baginsky's case there was a half-moon-shaped thickening with the convexity directed downward. The skin was tense and edematous; reddening followed, and later a fistula developed, pus and fecal matter escaping. Ziehl's patient, who was nearly four years old, had a circumscribed edema at the umbilicus, and immediately around the depression were small, shot-like nodules in the skin. The umbilicus ruptured, and a large quantity of fluid escaped. The abdomen collapsed, and later a round worm was passed through the umbilical opening. In Vallin's case there was marked abdominal reddening for a distance of 5 to 6 cm. around the umbilicus. The tissue was edematous, and the umbilical folds were distended. This condition persisted for two months. The redness then disappeared, and a nodule the size of a walnut and containing gas and fluid appeared at the umbilicus. In Crooke's case there was a marked prominence at the umbilicus, followed by the escape of pus and feces. In Rintel's case the umbilical ring opened and pus escaped with great force. In Schmitz's eleven-year-old patient the umbilical walls were exceedingly thin, and gas and fluid could be seen through the skin. Bertherand's patient had a conic umbilicus and a prominence the size of an almond. The overlying skin was mottled. The tumor contained fluid with gas, and could be reduced.
From the foregoing it will be noted that the inflammatory changes at the umbilicus are of slow development, and that the abdominal fluid reaches the surface by two methods — either by gradual disintegration of the abdominal wall or by distention of the umbilical opening, which allows the fluid to escape into the hernial protrusion. In addition to the opening at the umbilicus a secondary one may develop in the vicinity.
The tuberculous process gradually advances, and, if the lungs have not already been involved, they are apt now to be implicated. The child grows weaker and weaker, and usually dies a few weeks after the umbilicus has opened.
316 THE UMBILICUS AND ITS DISEASES.
Autopsy Findings.- — At the umbilicus the fistula found varies from one to several millimeters in diameter. The surrounding skin may or may not show marked irritation, depending upon the situation of the opening into the bowel and on the irritating character of the discharge. In some cases the skin, fascia, muscle, and peritoneum are so intimately blended as a result of the inflammation that it is almost impossible to separate them.
When the abdomen is opened, a loop of small or large bowel is often found firmly fixed to the opening at the umbilicus, and it is from this that the feces escape. Sometimes two or more loops are adherent to the umbilicus. In those cases in which the umbilicus was distended and gas and feces could be distinctly made out, there was usually a cavity of considerable size lying immediately beneath the umbilicus. At one or more points the lumen of the small bowel or of the large bowel, or the lumina of both, communicated with the cavity. The walls of the cavity were composed of intestinal loops alone, or of intestinal loops, one or more of the abdominal organs, the omentum, and the abdominal wall. When the intestinal perforation occurs, the surrounding tissue naturally tends to wall it off at once if adhesions have not already formed. The cavity may be small, or occupy fully half the abdomen. Its inner surface resembles granulation tissue, and it contains pus and fecal matter. Definite tuberculous masses have in some cases been noted in the wall of the sac. The intestinal loops throughout the abdomen are usually adherent, and between them are tubercles, accumulations of serous or flocculent material, or pus, according to the stage of the disease and the presence or absence of a mixed infection.
In those cases in which sudden death has occurred, as in those of Bertherand and Vallin, the walls of the cavity have given way, allowing fecal matter to escape into the general abdominal cavity. With the patient in an already weakened condition, the shock has been sufficient to occasion sudden death.
An associated pulmonary tuberculosis is often noted at autopsy.
Differential Diagnosis. — In making the diagnosis it is necessary to exclude the possibility of an umbilical concretion, carcinoma, other forms of peritonitis opening at the umbilicus, and other umbilical fistulse. Umbilical concretions occur during the active working period of life; tuberculous fistulse preponderate in childhood. Carcinoma is also a disease of middle life or of old age, and is thus readily excluded. Any form of peritonitis followed by an escape of pus, and possibly feces, at the umbilicus may at first be confused with tuberculous peritonitis. The onset of a purulent peritonitis is, however, usually very acute; the disease runs a rapid course, and the child either speedily dies or rapidly recovers. Umbilical fistulse due to round worms escaping through the bowel and passing out through the umbilicus may for a time occasion some confusion, but with the escape of the worms the fistula may close, while in cases of tuberculous peritonitis the condition goes from bad to worse.
Treatment. — With the early recognition of tuberculous peritonitis and its appropriate treatment — laparotomy — cases of umbilical fistula will naturally diminish in number. As emphasized by Tillmanns, poultices are to be strenuously avoided. As has been said, the umbilicus may be reddened for months without the formation of a fistula, but once feces commence to escape by this channel, the fistula remains open until death.
FECAL FISTULA AT THE UMBILICUS. 317
CASES OF TUBERCULOUS PERITONITIS WITH A FECAL FISTULA DEVELOPING AT THE UMBILICUS.
Umbilical Fecal Fistula Due to Tuberculous Peritonitis.* — A boy, one year and three months old, was admitted to the hospital on December 23, 1879, for an otitis purulenta. He was fairly well nourished and showed no signs of rickets. The abdomen was hard and distended. At the umbilicus was a half-moon-shaped thickening, with the convexity directed downward; the overlying skin was tense and edematous. The condition remained the same until February 9, 1880. At this time examination of the thorax was negative. Around the umbilicus, especially in the lower portion, there were edema and reddening. There was definite fluctuation. The abdomen itself was hard and distended, but no palpable tumor could be detected. On February 12th an opening, the size of a bean, was detected at the umbilicus, and from this a considerable quantity of fecal material and purulent fluid escaped. When the child was raised up, these fecal masses escaped readily. He died on February 13th.
At autopsy the body was markedly emaciated and anemic. The lower lobe of the right lung was reddish gray. The costal pleurae and the diaphragm and pericardium were covered with grayish miliary tubercles. The diaphragm, liver, and spleen were completely adherent to the abdominal wall. The purulent cavity beneath the umbilicus was walled off by these and the omentum, and the cavity extended into the pelvis. The pelvis was filled with feces and purulent fluid, and the intestinal convolutions of the lower abdomen were covered with a greenish, necrotic deposit, and at several points were perforated. Through one perforation the little finger could be passed into the small bowel. At this point the vermiform appendix had ulcerated. On the left side of the transverse colon were numerous ulcers, some of which had extended only through the mucosa. At other points they had perforated the entire thickness of the bowel, opening into a cavity situated at the vertebral column. The mesenteric glands were markedly swollen and caseous. In the spleen were numerous nodules.
Intestinal and Peritoneal Tuberculosis with Perforation and the Formation of a Fecal Reservoir Opening at the Umbilicus. f — A soldier came under observation on September 21, 1851, on account of obstinate diarrhea. On February 16, 1852, he had severe abdominal pain and dysuria. On May 12th of the same year for the third time he presented the picture of marked disturbances of nutrition. His pulse was rapid and small, and there was marked emaciation. Diarrhea was present, and he had a dry cough and night-sweats. The abdomen was very painful and distended. From the pubes to a point above the umbilicus was a doughy, immovable tumor of nodular character. All indications pointed to a chronic mesenteric inflammation. On June 10, 1852, there developed beneath the umbilicus a conic prominence the size of a large almond. The skin over it was mottled. The tumor was reducible and filled with fluid and gas. A few days later the prominence was incised, and there escaped blood, pus, foul-smelling gas, and a little later fecal matter. Fecal
- Baginsky: Zur Demonstration eines Praparates. Verhandl. d. Berl. med. Gesellschaft,
Jahrg. 1879-80, xi, 90.
t Bertherand, A. : Observation d'entero-peritonite tuberculeuse avec perforations intestinales, formation d'un reservoir stercoral sous la paroi abdominale; fistule ombilicale. Gaz. med. de Strasbourg, Novembre, 1852, douzieme annee, 572.
318 THE UMBILICUS AND ITS DISEASES.
matter also passed through the rectum. During the night of June 18th the patient raised himself suddenly and died with a loud cry.
At autopsy it was found that there was a deep pus-cavity behind the umbilicus. This was filled with old pus and tuberculous masses. The anterior wall of the cavity appeared to be formed of the posterior surface of the transversalis muscle and remains of the peritoneum. The posterior wall was bounded by two thick layers of large omentum, which laterally was adherent to the peritoneum, thus fastening the intestinal loops together. The inner irregular cavity communicated behind and above with the transverse colon through two holes, 15 and 18 mm. in diameter. At the end of the ileum were three openings with sharp margins, probably resulting from freshly broken-down tubercles. From these had escaped the fresh fecal masses which were found in the abdomen, and thus the sudden death is explained. There was a direct connection between the umbilical opening and the pus-sac.
In this case there was also a pulmonary tuberculosis.
Tuberculous Peritonitis with Dilatation of the Umbilical Ring.* — A man, forty-one years of age, had a peritoneal tuberculosis. At the umbilicus was a transparent tumor, 3 cm. in diameter, forming three-quarters of a circle. There was no discoloration of the skin. The tumor was easily reducible, and the finger could be carried into the abdomen. [This was evidently a small umbilical hernia containing ascitic fluid. It is recorded here to show the early umbilical changes before a fecal fistula has developed. — T. S. C]
Fecal Fistula Probably Due to Tuberculous Peritonitis, f — A boy, fifteen years old, in 1897 had inflammation of the lungs and also of the abdomen. In June of the same year he complained of pain in the abdomen and noticed a swelling. Owing to increased pain and fever the patient went to bed in September. In October pus was found escaping from the umbilical region. After this the pain eased up, but a fistula persisted, and there was a varying degree of pain. In April, 1898, the pain became severe in the right side. In June, 1898, the boy appeared to be well developed and showed no definite changes in the chest, but the abdomen in the umbilical region was still distended. At the umbilicus the fistula still secreted a little, and occasionally a small amount of fecal matter escaped.
Operation. — Under ether below the fistula a resistant area, about the size of a five-mark piece, could be felt. Pressure on this caused a discharge of pus. The fistulous tract was dissected out, and during the manipulations a second loop of bowel was opened up, but was closed immediately. The opening in the bowel was about the size of a five-pfennig piece, and the walls of the bowel at this point were infiltrated. In addition, there were numerous loops of small bowel adherent to the anterior abdominal wall in the region of the umbilicus. The portion of the bowel forming the fistula was resected. Extraperitoneally and to the left of the umbilicus was a caseous focus, 4 cm. long and 2 cm. broad. This was drained. At operation the ends of the bowel were held in place by a Murphy button, which came away on the eleventh day.
[This case seems to be one of tuberculous peritonitis. — Ti S. C]
- Catteau, J. F. : De l'ombilic et de ses modifications dans les cas de distension de l'abdomen.
These de Paris, 1876, obs. 10.
fClairmont, Paul: Casuistischer Beitrag zur Radicaloperation der Kothfistel und des Anus praeternaturalis. Klinik, Prof. v. Eiselsberg, Konigsberg. Langenbeck's Arch. f. klin. Chir., 1901, lxiii, 691.
FECAL FISTULA AT THE UMBILICUS. 319
Tuberculous Peritonitis Followed by Perforation at the Umbilicus.* — An eleven-year-old boy with a definite scrofulous diathesis had suffered for eighteen months from vomiting and from pain in the hip. At the umbilicus there was also pain. The child lay with his thighs drawn up. Some time later marked diarrhea was noted and severe pain in the umbilical region. This, in the course of six weeks, became markedly prominent as a result of abscess formation. About three weeks later there was a spontaneous opening at the umbilicus, with the escape of purulent fecal masses. A month later a similar tumor developed, two and a half inches below the umbilicus. This broke at three points. From the upper opening fecal matter escaped, while the lower discharged serous material. The bowels were regular, and the appetite was good. In the course of six weeks the abdomen became flattened and the pulse small; the appetite was poor. There was marked pain at the umbilicus. Three months later the child died.
At autopsy the omentum was found adherent to the abdominal wall. The underlying intestines had grown fast to one another. Tubercles were found in the left iliac region, under the descending colon, and also beneath the peritoneum of the anterior stomach-wall. In the lower part of the ileum, about six inches from the cecum, were the remains of a large tubercle which had broken down. Here it was found that the intestine had become adherent to the umbilicus and communicated with the opening from the bowel. In the peritoneum itself were several minute tubercles. The spleen was enlarged, and the mesenteric lymph-glands were hard and gritty.
Tuberculous Fistula at the Umbilicus, f — This case came under Habershon's observation. The patient was a small girl, six years old, who had had chronic peritonitis for a year. Six months before her death a tumor appeared at the umbilicus. This opened, and a fistula resulted from which pus mixed with fecal matter escaped. At autopsy pulmonary and peritoneal tuberculosis was found. The intestines were adherent; several loops had perforated, and a fecal fistula had formed, with an exit at the umbilicus.
Probable Tuberculous Fistula at the Umbilicus.! — The patient was a small Italian child. There was a fecal discharge from the umbilicus, through several openings. The child died of tuberculous peritonitis.
Artificial Anus Established Spontaneously Through the Umbilicus.§ — A boy, nine years old, had been under treatment for six months on account of a peritoneal and pulmonary tuberculosis. In February, 1891, the umbilical region was found to be sensitive, red, and more prominent than the already distended abdomen. On February 13th the boy's father came and said that the abdomen had flattened out and that the stools were coming from the umbilicus. Light pressure was made on the abdomen, and gas and fecal matter escaped through an opening, and the boy felt as well as usual. Six hours later his temperature was 99° F., and fecal matter and gas continued to escape from the
- Crooke, E. G.: On a Case of Tubercular Peritonitis Followed by Perforation of the Abdominal Parietes. The Lancet, 1849, ii, 668.
f Nicaise: Ombilic. Dictionnaire encyclopedique des sc. med. ; Paris, 1881, 2.ser., xv, 140.
| Park, Roswell: Clinical Lecture on Congenital Fistula? and Sinuses at the Umbilicus. Med. Fortnightly, 1896, ix, 9.
§ Rachford: Arch, of Pediatrics, 1891, viii, 680.
320 THE UMBILICUS AND ITS DISEASES.
umbilicus. From the rectum no stools passed. By means of a bandage the feces could be entirely controlled. After the perforation at the umbilicus the boy felt better and developed an appetite, and his night-sweats disappeared. On March 10th he complained of sudden pain in the abdomen, collapsed, and died the next day.
Autopsy. — Only the abdomen could be examined. The intestines had been transformed into a large, hard tumor, as a result of tuberculous masses. In the transverse colon was a round perforation the size of a ten-cent piece, with thick margins. On the outer side of the intestine, around the opening, was a rough, red circle about an inch and a half in diameter, where the intestine had been adherent to the abdominal wall around the umbilicus. The umbilical opening passed into a cavity which was filled with fecal matter. From this, one opening was found entering the ileum and another the ascending loop of the transverse colon. Scattered throughout the peritoneum were tubercles. Some showed definite inflammation, others had gone on to suppuration.
The bowel had evidently torn partly loose from the abdominal wall, allowing the fecal matter to escape into the general cavity. This explains the faintness with the pain and collapse that followed.
A Case of Tuberculosis of the Intestine with Perforation of the Duodenum and Cecum into the Peritoneal Cavity. Fecal Fistula at the Umbilicus.* — A threeand-one-half -year-old girl complained of pain in the abdomen and of loss of appetite. Over the surface of the distended abdomen bluish, dilated veins were noted. There was free fluid in the abdomen. In the inguinal region on both sides the glands were enlarged. After two months pain and severe fever developed, and two days later the umbilical ring opened and there was an escape, with great force, of a purulent fluid having a foul odor and mixed with yellow fecal matter. Fecal matter continued to escape from this opening and also from the rectum until the child's death. Emaciation increased; the urinary secretion stopped almost completely. The child died a month after the umbilical opening appeared.
At autopsy the abdomen was markedly distended, especially in the vicinity of the umbilicus, where there was an opening the size of a pin-head. On pressure, clear, yellow, thin fecal material escaped drop by drop.
A fine sound could be passed directly downward to the vertebral column. On palpation very hard nodular masses could be felt around the umbilicus. When the abdomen was opened, the anterior wall above the umbilicus was found adherent to the omentum. On the opposite side the wall was united with the transverse colon by thick, firm adhesions. Here had formed the cavity that communicated with the umbilicus through the canal mentioned, and through an opening into the duodenum the size of a Groschen (five-cent piece) . Just below the opening of the bile-duct there was another perforation into the colon. The cavity produced was filled with fecal masses, and the small intestine was involved in the exudate. In the cecum was an ulcer which extended almost to the peritoneal surface, and directly at the ileocecal valve was another perforation. The vermiform appendix had also been destroyed. The upper part of the cecum and the lower part of the ileum were firmly glued to the wall of the cavity. There were numerous ulcers throughout the intestines. Both lungs were normal.
- Rintel: Ein Fall von Darmtuberculose mit Perforation des Duodenum und Caecum in's
Cavum peritonei. Berlin, klin. Wochenschr., 1867, iv, 332.
FECAL FISTULA AT THE UMBILICUS. 321
Tuberculous Fecal Fistula at the Umbilicus.* — A girl, fourteen years old, at first complained of severe abdominal pain in the hypogastric, hypochondriac, and umbilical regions. Several months later she returned to the hospital with a round opening at the umbilicus. Its margins were slightly excoriated, and fecal matter was escaping. Her constitution had been weakened, and general tuberculosis had existed for six months.
At autopsy pelvic peritonitis was found. The intestinal loops were adherent to each other, and between them were purulent foci. A loop of small bowel had opened at the umbilicus.
Cases of Fecal Fistula at the Umbilicus Due to Tuberculous Peritonitis. f — Case 1. — A girl, eleven years of age, had been ill for three or four months. She had had abdominal distention with diarrhea and was emaciated. On admission the abdomen was much distended. At the umbilicus there was sensitiveness on pressure. The umbilicus was covered over with very thin skin, and immediately beneath were gas and fluid. The patient's temperature was subnormal.
An incision was made opening up a fecal abscess, at the bottom of which was an intestinal fistula. The child died on the tenth day.
At autopsy the organs of the lower abdomen were found grown together and forming a tangled mass. Between them were numerous caseous foci. Opening into the posterior wall of the umbilical abscess were several small holes which communicated with the intestine. There was a total adhesive pericarditis.
Case 2 . — A boy, six years old, for two and one-half months had had fever, pain in the abdomen, and vomiting. For one month he had had obstinate constipation. The abdomen had increased in size, and emaciation had become marked. For one week there had been a reddening at the umbilicus. The mesogastrium and hypogastrium were filled with nodular tumors. On rectal examination minute hard nodules could be felt. The child had intermittent fever.
Operation. — Beneath the umbilicus was a large, foul-smelling accumulation of pus. The abdomen was studded with tubercles. The omentum was markedly adherent. When the bandages were changed, an abundant quantity of fecal matter came out of the cavity. The fever continued, and the patient died three weeks later.
Autopsy. — Folds of the peritoneum were adherent to one another at many points. Between them were isolated and confluent tuberculous nodules. Similar nodules were also found in the omentum. In the ascending colon was a perforation admitting the tip of the finger. About 20 cm. above this point was a small group of miliary tubercles in the mucosa. In the lower portion of the large bowel were several flat ulcers with thickened margins. The remaining portion of the intestinal tract was normal. In the pelvis, between intestinal loops, was an isolated abscess, and the liver and spleen were covered with adhesions. There was a pleurisy on the left side. The pleurae of both lungs were studded with tubercles. The bronchial glands were swollen.
Case 3 . — A girl, nine years old, from September, 1892, had had acute
- Rombeau: Anus contre nature, suite de peritonite. Bull, de la Soc. anat. de Paris, 1851,
f Schmitz, A.: Ueber Bauchfelltuberculose der Kinder. Jahrb. f. Kinderheilk., 1897, xliv, 316.
322 THE UMBILICUS AND ITS DISEASES.
abdominal pain, fever, and obstipation, and there had been a gradual increase in the size of the abdomen. In May, 1893, a swelling at the umbilicus associated with redness was noted. The mass was of the size and form of a fist. It broke, and feces escaped. In July the patient was markedly anemic and the abdomen was enlarged and painful. At the lower margin of the umbilicus was a fecal fistula, which was discharging the contents of the small bowel. The inguinal glands were swollen. By the rectum several flat nodules could be felt.
Operation. — The omentum was adherent to the small intestine and to the parietal peritoneum. Numerous hard nodules, some as large as a pea, were found. The umbilical fistula led to a fecal opening the size of a walnut. This communicated with a loop of small bowel by an opening, 3 cm. in diameter. The patient died five days later.
At autopsy general adhesions of the intestine with the parietal peritoneum, the omentum, and liver were found. There were also numerous peritoneal tubercles. In the capsules of the liver and spleen were tubercles. The uterus was increased in size; its cavity was dilated and filled with cheesy pus, and the mucosa was covered with a cheesy membrane. In the ileum was a perforated ulcer, 1.5 cm. in diameter. The fistula in the ileum had been closed tightly at operation. The mesenteric glands had undergone caseation. The mucosa of the intestine was swollen, but free from tuberculous ulcers.
Tuberculosis of the Umbilical Region.* — A boy, sixteen years of age, was said to have had a fall in the latter half of 1895. Before admission the abdomen had become much distended. Immediately before the operation it was noted that, for his age, he was larger than usual and very thin. The abdomen was markedly and uniformly distended; the umbilicus was pushed forward somewhat like a bladder. The skin was of the thinness of paper. Surrounding the umbilicus the tissue was red and painful on pressure, and over the entire abdomen there were dulness and a sensation of fluctuation.
On April 17, 1896, an incision was made extending from the ensiform cartilage through the umbilicus to three fingerbreadths above the symphysis. There escaped between 10 and 12 liters of very cloudy, odorless fluid, which contained numerous white, grayish flocculi and a membranous network. The greater amount of fluid was found in the anterior portion of the sac. On pressure and when the patient was turned on his side, however, an abundance of fluid escaped from the posterior portion. Schrotter thought he was dealing with tuberculosis, but no tubercle bacilli were found and no tissue that histologically gave that picture. [In this case no fistula existed. — T. S. C]
Umbilical Fecal Fistula Due to Tuberculous Peritonitis. — Schrotter f (p. 415) reports an observation by Jung.
The patient was a scrofulous, emaciated child, three years and nine months old. The abdomen was distended, especially around the umbilicus, where, after the application of poultices, an abscess formed. This broke, and feces, pus, and blood escaped. The child died, and at autopsy the intestines were found adherent to one another and to the peritoneum. The intestine at one point had perforated.
- Schrotter: Zur Kenntnis der Tuberculose der Nabelgegend. Arch. f. Kinderheilk., 190203, xxxv, 398.
f Schrotter: Op. fit., p. 415. Rhein. Generalberioht. Ref. Canstatt's Jahresbericht, 1842, ii.
FECAL FISTUL.E AT THE UMBILICUS. 323
Peritoneal Tuberculosis with Fecal Fistula at the Umbilicus.* — An eight-year-old girl had swelling of the abdomen. Her tongue was coated, the breath was fetid, and she had a severe cough. Her skin was of a dark brownish color. She had diarrhea, and there was edema in the lower part of the abdomen and in the legs. Indefinite fluctuation could be made out in the lower abdomen. Later on the lower abdomen presented a conic form, the umbilicus forming the point of the cone. It opened, and from it escaped brownish fecal material of a very foul odor. No feces passed through the rectum from that time. Three weeks later the patient died.
At autopsy the intestines were found adherent to one another and to the abdominal wall, except in the lower right side, where, between the anterior wall and the intestine, fecal masses were found. The whole of the peritoneum, both that covering the abdominal wall and that of the viscera, was riddled with tubercles^ some of which had become caseous. The mesenteric glands were enlarged and tuberculous.
In this case there was tuberculous disease of the mesenteric glands with a healthy intestinal mucosa.
Umbilical Inflammation Following Tubercular Peritonitis, f — A soldier, twenty-two years of age, who is said to have been previously healthy and strong, a month before admission noticed a swelling of the abdomen. His appetite diminished, he had obstipation alternating with diarrhea, but never vomited and had no cough. On December 8, 1867, there was abdominal distention. Palpation, however, was not painful. In the hypogastric region was a definite fluctuation. On December 20th he noticed a marked reddening around the umbilicus. The skin in the umbilical region, for a distance of 5 or 6 cm., was edematous, and the umbilical folds were distended. There was no pain, and the overlying skin was not sensitive. The reddening and edema remained unchanged for two months. At the end of January the exudate in the abdomen had disappeared, but the distention had increased and the patient was cachectic. He had fever, a dry, hot skin, and marked night-sweats. The umbilicus remained the same. Commencing February 16th a pleurisy was noticed, and the weakened condition of the patient increased. There was diarrhea. The skin at the umbilicus was not so red, but for fourteen days had taken on a yellowish color, and at the umbilicus there was a small, irreducible tumor the size of a walnut, which contained gas and fluid. On February 27, 1868, at 4 o'clock in the morning, the patient felt something tear. The umbilicus broke, and there was an abundant discharge of cloudy fluid with a feculent appearance. He died an hour later.
At autopsy marked emaciation was noted. The abdomen was sunken. The umbilical scar on the left side was irregular and torn, and there escaped on light pressure a yellow, diarrhea-like fluid. The anterior abdominal wall was difficult to loosen on account of extensive adhesions to the intestine and omentum. The muscle, aponeurosis, and skin were thickened, and had grown fast to one another, so that their separation was possible only by careful dissection with the knife. The liver, stomach, and transverse colon were firmly united to the abdominal wall.
- Scott, John: Perforation of the Intestine with External Opening. Edinburgh Med. and
Surg. Jour., 1835, xliii, 97.
| Tallin, E.: De l'inflammation periombilicale dans la tuberculisation du peritoine. Arch, gen. de rued., 1S69, xiii, 558.
324 THE UMBILICUS AND ITS DISEASES.
Several loops of small bowel, which were tied to one another by a pseudomembrane, had been invaded by softened tubercles. These were adherent to the abdominal wall at the point mentioned. Between the umbilicus posteriorly and the ulcerated intestinal wall was an irregular cavity, through which fecal masses had passed outward into the abdominal cavity. A transverse section through the abdominal cavity at this point allowed one to see the intimate relation between the parietal peritoneum, the aponeurosis of the trans versalis, and the recti muscles. In this case the omentum and mesentery were matted together with tubercles in all stages. The mesenteric glands were markedly enlarged and some had softened. The intestinal mucosa as a whole was normal, and. as far as could be seen, not ulcerated. One could readily see that the perforation of the intestine had been from without inward. The mucosa at this point was markedly pigmented and infiltrated with blood. It was through this cavity that the intestinal contents during life had passed out at the umbilicus.
Tuberculosis of the Umbilical Region.* — Case 1. — St. W., aged six, was small and gave evidence of having outgrown rachitis. When admitted to the hospital on April 30th the child showed marked emaciation. The abdomen was greatly distended and balloon-shaped. At the level of the umbilicus the girth was 60 cm. Above the symphysis there was dulness for a handbreadth. There was no free fluid and no fever. The appetite was good. On May 16th the patient complained of pain in the lower abdominal region, and redness was noted at the umbilicus. Three days later the reddening became marked and there was some fever. On May 23d the pulse became weak and the lower part of the abdomen was painful. On the twenty-seventh, in the median line at the umbilicus, there was noted a perforation from which fecal matter and yellow fluid escaped. The abdominal measurement had diminished. On June 3d the abdominal distention had again increased somewhat and there was only a slight discharge. On the seventeenth the patient felt hot, and an accurate examination could not be made on account of severe pain. The discharge from the umbilicus contained remnants of digested food and had an acid reaction. The patient suffered from diarrhea. He died on June 22d.
At autopsy, twenty-four hours later, there was a bluish discoloration of the abdominal wall and marked emaciation. At the umbilicus was a bluish-red point, and in the center of this a fistulous opening the size of a goose-quill. When pressure was exerted on the lower abdominal wall, yellow fecal masses escaped. A sound could be passed inward for 2 cm. The discoloration of the abdominal wall indicated a cavity which extended downward from the umbilicus and occupied the greater part of the lower abdomen. It was lined with reddish grsiy, partly granular walls, which contained numerous nodules. Through softened places in the sac-wall a sound could be passed into the intestinal lumen. In the posterior wall of the cavity was a membrane which covered the indefinite intestinal loops. The cavity contained fluid, solid fecal masses, caseous products, and round worms. The intestinal follicles were markedly swollen and here and there ulcerated. The mesenteric and retroperitoneal glands were enlarged, and at certain points ulcerated to the extent of perforation.
- Ziehl: Cited by Schrotter: Zur Kenntnis der Tuberculose der Nabelgegend. Arch. f.
Kinderheilk., 1902-03, xxxv, 398.) Ueber die Bildung von Darmfisteln in der vorderen Bauchwand infolge von Peritonitis tuberculosa. Heidelberger Dissertationschrift, 1881.
FECAL FISTULA AT THE UMBILICUS. 325
Case 2 . ■ — K. A., three years and nine months old. In January there was vomiting accompanied by swelling of the abdomen. The abdomen was markedly distended, the circumference at the umbilicus being 68 cm. There was tuberculosis of the lungs, slight edema of the lower extremities, and fluid in the lower abdomen. On March 31st the abdominal girth was 71 cm. and the inner abdominal wall appeared to be infiltrated. On April 6th the child had measles, accompanied by a mild cough without expectoration. Nine days later the skin beneath the umbilicus showed circumscribed edema. On May 8th, after the use of santonin, round worms were expelled through the rectum. On May 9th it was noted that the lower abdomen was the seat of what appeared to be a rather large tumor. It began a fingerbreadth below the free margin of the ribs on the left, and extended within two fingerbreadths of the symphysis. It was resistant and had a nodular surface. The child had attacks of fever and chills. The stools were normal. On September 13th around the umbilicus were noted small tumors, which felt like shot. In the hypogastrium was a definite tumor which impinged on the liver and which, on the left, was connected with the umbilical swelling. On October 19th the abdomen was painful, the umbilicus ruptured, and there was an escape of an abundance of purulent fluid with a fecal odor. On the following day the flow of fluid still continued, and the fistulous opening was the size of a linseed. The abdomen collapsed and was very sensitive; there was diarrhea, and the patient's appetite was very poorOn the twenty-sixth there was still a free discharge, and a round worm passed through the fistulous opening, the margins of which were reddened and inflamed. On the twenty-ninth there was vomiting of bitter masses. The skin was cool. The child died on October 30th.
At autopsy, thirty-two hours later, the abdominal walls were of a bluish-green color. At the umbilicus was a fistulous opening into which a sound could be introduced downward and to the right; on pressure there escaped yellow masses with a fecal odor and mixed with gas.
In the lower lobes of the lungs nodules were detected. The intestines were more or less firmly attached to the peritoneum of the anterior abdominal wall. In the umbilical region was a portion of intestine running transversely and intimately attached to the abdominal wall, so that its liberation was impossible. These loops communicated with the umbilical fistula. The stomach, liver, spleen, and large and small intestine had grown together and the individual loops w r ere firmly adherent to one another. Between them was a purulent exudate. In the intestinal serosa were numerous nodules, but in the mucosa itself no tubercles. Scattered throughout the small intestine were numerous ulcers.
UMBILICAL FISTULA DUE TO TUBERCULOSIS OF THE VAS DEFERENS.* While discussing the subject of umbilical diseases w^th Dr. Ramon Guiteras, of New York, he told me of a case of tuberculosis of the vas deferens which had opened at the umbilicus. I have not found the record of a similar case in the literature. Dr. Guiteras kindly sent me his notes on the case. Although no fecal fistula existed, it can be best considered in this chapter.
Umbilical Fistula Due to Tuberculosis of the Yas Deferens. f — J. G., an Italian laborer aged thirty, was first seen by Dr.
- Although this fistula was not fecal in character it can be best considered here.
t Guiteras, Ramon: Personal communication.
326 THE UMBILICUS AXD ITS DISEASES.
Guiteras in the Columbus Hospital. He was cachectic in appearance, although fairly well nourished. His breathing was more rapid than usual, owing to an old pleurisy on the left side. He entered the hospital on account of suppuration from the umbilicus. On examination a probe entered a sinus an inch long in the lower part of the umbilicus. There was a small, blind pouch of the same length on the right side of the scrotum, although there was no evidence of communication between the two. The case was a very obscure one. Dr. Guiteras expected to find either an abscess of the urachus or necrosis of the under surface of the pelvic bone.
After the patient was anesthetized, the probe, bent in a certain way, was passed downward and outward nearly to the anterior superior spine of the ilium. An incision was made through the abdominal wall over the point of the probe, which corresponded to the site of the appendix, and Dr. Guiteras expected to find a sinus leading to an old appendiceal abscess; but such was not the case. He introduced a probe through the incision and found that it extended down to the inguinal canal. He then continued the incision down to the canal, opened it, and found that the vas deferens was tuberculous. A portion of the diseased cord was excised, the upper part of the wound was closed, and the inguinal canal was packed and drained. Dr. Guiteras, in referring to the case, thought that he might have to do a more extensive operation on the vas deferens, but ten days afterward the patient had an attack of apoplexy and died in three days.
LITERATURE CONSULTED ON TUBERCULOUS PERITONITIS FOLLOWED BY FECAL
FISTULA AT THE UMBILICUS. Baginsky, A.: Zur Demonstration eines Praparates. Verhandl. der Berlin, med. Gesellschaft,
Jahrg. 1879-80, xi, 90. Bertherand, A.: Observation d'entero-peritonite tuberculeuse avec perforations intestinales,
formation d'un reservoir stercoral sous la paroi abdominale; fistule ombilicale. Gaz. med.
de Strasbourg, Xovembre, 1852, douzieme annee, 572. Catteau, J. F.: De l'ombilic et de ses modifications dans les cas de distension de l'abdomen.
These de Paris, 1876, Xo. 210. Clairmont, Paul: Casuistischer Beitrag zur Radicaloperation der Kothfistel und des Anus praeternaturalis. Klinik, Prof. v. Eiselsberg, Konigsberg. Langenbeck's Arch. f. klin. Chir.,
1901, lxiii, 691. Crooke, E. G. : On a Case of Tubercular Peritonitis Followed by Perforation of the Abdominal
Parietes. The Lancet, 1849, ii, 668. Feulard: Fistule ombilicale et cancer de l'estomae. Arch. gen. de med., 1887, 7e ser., xx, 158. Fischer, H. : Die Eiterungen im subumbilicalen Raume. Yolkmann's Samml. klin. Vortrage,
n. F., Xo. 89 (Chir. Xr. 24), Leipzig, 1890-94, 519. Heinrich: Leber beschrankte sogenannte aussere oder tuberculose Peritonitis bei Kindern, oder
liber Entziindung der Subkutanenschicht der Bauchwand und fiber die Bildung von Absces sen und Verhartungen daselbst. Jour. f. Kinderkrankh., 1849, xii, 6. Nicaise: Ombilic. Diet, eneyclopedique des sc. med., Paris, 1881, 2. ser., xv, 140. Ledderhose, L.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Owen, E.: Surgical Diseases of Children, third ed., London, 1897, 269. Park, Roswell: Clinical Lecture on Congenital Fistula? and Sinuses at the Umbilicus. Med.
Fortnightly. 1896, ix, 9. Rachford, B. K.: Artificial anus established spontaneously through the umbilicus. Arch, of
Pediatrics, viii, 680. Richelot, L. G: Abces tuherculeuxsousombilical. L'Unionmed., 1883, xxxv, 61. Rintel: Ein Fall von Darmtuberculose mit Perforation des Duodenum und Caecum in's Cavum
peritonei. Berlin, klin. Wochenschr., 1867, iv, 332. Rombeau: Anus contre nature, suite de peritonite. Bull, de la Soc. anat. de Paris, 1851, xxvi,
FECAL FISTULA AT THE UMBILICUS. 327
Scott, John: Perforation of the Intestine with External Opening. Edinburgh Med. and Surg.
Jour., 1835, xliii, 97. Schmitz, A. : Ueber Bauchfelltuberculose der Kinder. Jahrb. f . Kinderheilk., 1897, xliv, 316. Schrotter, E.: Zur Kenntnis der Tuberculose der Nabelgegend. Arch. f. Kinderheilk., 1902-03,
xxxv, 398. Tillmanns, H.: Ueber angeborenen Prolaps von Magenschleimhaut durchden Nabelring (Ectopia
ventriculi) und tiber sonstige Geschwlilste und Fisteln des Nabels. Deutsche Zeitschr. f.
Chir., 1882-83, xviii, 161. Ziehl: Cited by Schrotter. Vallin, E.: De rinflammation periombilicale dans la tuberculisation du peritoine. Arch. gen.
de med., 1869, xiii, 558.
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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