Book - Umbilicus (1916) 22
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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 XXII. The Escape of Various Foreign Substances from the Umbilicus
Gall-stones escaping at the umbilicus; report of cases.
Hydatids at the umbilicus.
The escape of liquor amnii or of fetal remains through the umbilicus.
Escape of foreign bodies through the umbilicus.
Gall-stones escaping at the Umbilicus
The escape of gall-stones from the umbilicus is very rare. One of the earlier reported cases was that of Buettner, published in 1744. I have been unable to obtain the original article, but it was referred to by Duplay in 1833. In Buettner's case 38 biliary calculi escaped from the umbilicus. Berard, in the French Dictionary of Medicine, published in 1840, says that there were several examples of a biliary fistula opening at the umbilicus, and sometimes associated with the escape of calculi. The most exhaustive and best treatise on the subject is that of Leguelinel de Lignerolles, published in Paris in 1869. Other names closely identified with the development of the subject are Nicaise, Murchison, Courvoisier, and Ledderhose. According to Nicaise, Murchison collected 86 cases in which the gall-bladder opened in the right hypochondrium on a level with the fundus of this viscus; in other cases, in regions more or less distant in the abdominal wall. In a certain number of the cases they opened at the umbilicus. Courvoisier, in his Pathology and Surgery of the Bile-ducts, published in 1890, gives the following table of 169 cases in which the gall-bladder opened through the abdominal wall :
In the right hypochondrium '. 49 times
At the edge of ribs on the right side 36
In the right mesogastrium 17
In the right iliac region 10
In the epigastrium 6
In the neighborhood of the umbilicus 26
Through the umbilicus 12
Below the umbilicus . 11
In the left inguinal region 1 time
Multiple openings 1 "
From this table it will be noted that in 26 of the 169 cases the opening occurred in the neighborhood of the umbilicus; in 12 instances at the umbilicus, in 11 cases below the umbilicus. Thus in 49 cases it occurred at or near the umbilicus.
I have not attempted to cover the literature on the subject, but have gathered together only sufficient material to give a fairly comprehensive composite picture of this class of cases. Of course, this complication will naturally occur during the decades when gall-stones are most frequently found. The youngest patient was twenty-three years of age. The great majority of the patients were over forty years of age.
338 THE UMBILICUS AND ITS DISEASES.
Of 12 cases of biliary fistula at the umbilicus of which we have definite records. 1 was in a man and 11 were in women. This large percentage in women is rather striking, and may be due in some measure to the weakened condition of the umbilicus as a result of the stretching caused by pregnancy. I am not in a position to prove this point, however, as data on pregnancy in these cases are not available.
These patients, as a rule, give the usual history of gall-stones. Sometimes the initial pain is in the gall-bladder region, but occasionally it is first noted in the left hypochondrium, and after a time shifts to the right side. In addition to the hepatic colic noted there are sometimes nausea, vomiting, and diarrhea. After a varying length of time changes may be noted at the umbilicus. In Bramann's case fully two years elapsed before the umbilicus was involved.
Umbilical Changes. — The umbilical region usually becomes indurated, and may remain so for several weeks or months. In other cases it rapidly shows signs of reddening, becomes painful, and may soon open spontaneously.
In Clement's case the reddening around the umbilicus was treated as an eczema for some time; finally a biliary fistula developed.
In Richet's case, reported by Leguelinel de Lignerolles, a small tumor presented at the umbilicus, and in three months had grown to the size of an adult's fist and opened spontaneously.
When the abscess breaks, there is an immediate discharge of pus, sometimes, but not always, fetid. In Leclerc's case it contained sandy particles. With the escape of pus small biliary calculi may be discharged. As a rule, however, several days elapse before any are noted. If they are small, their exit may occasion little inconvenience, but when they are of any appreciable size, their expulsion is accompanied by marked abdominal contractions and much pain. In some of the cases it was only on probing the fistulous tract that calculi were detected at the bottom. When the stone is large, it may become firmly wedged in the fistula, and can then be removed only by dilating the channel and grasping the stone with forceps. With the escape of a large stone bile may for the first time appear at the umbilicus. In other instances the discharge has never showed even occult bile.
The subsequent history of the fistula depends on the contents of the gall-bladder, If the gall-bladder contains small stones, these escape from time to time, the fistula frequently being temporarily sealed over in the meantime. Where only one large stone has been present, after its expulsion the sinus usually closes permanently. In short, when once the umbilical fistula has formed, it rarely closes permanently until the gall-bladder has been completely emptied of its stones. Stones may escape at intervals for years.
The majority of the patients regain their normal health. In the case of Madame X, reported by Leguelinel de Lignerolles, the patient became emaciated and died. At autopsy a contracted gall-bladder was found which contained a calculus, and a calculus was present in the hepatic duct. In Robert's case, cited by Nicaise, dilatation of the fistulous tract was followed by peritonitis and death. In Leroy des Barres' case the patient, six years later, died of cancer of the stomach and liver.
Murchison's description of the mode in which biliary fistulse penetrate the abdominal wall in various places is most instructive and is well worth a thorough study.
When the fistula develops at the umbilicus, it is either due to perforation of the gall-bladder with abscess formation and later perforation of the umbilicus by the
THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 339
abscess; or the enlarged and prolapsed gall-bladder may become adherent to the umbilicus and open.
In some cases the gall-bladder is excessively long. In a case I saw with DrFranklin B. Smith in Frederick, Md., the greatly enlarged viscus hung over the brim of the pelvis and almost touched the uterus. The gall-bladder was distended with stones. Such a gall-bladder could very readily have become adherent to the umbilicus. A reference to Bramann's case will show that in that case the gallbladder projected downward almost to the symphysis. It had become adherent and opened at the umbilicus.
Cases of Biliary Fistula at the Umbilicus with the Escape of Gall-Stones.
In America very little attention has been paid to biliary fistulse at the umbilicus, and the literature in the English language, apart from the excellent monograph of Murchison, is so meager that I append a number of cases sufficient to give an adequate view of the subject. Furthermore, although these cases have been rare in the past, they will be even rarer in the future because of the prompt operative measures now invariably adopted, when acute or chronic inflammations of the gallbladder exist.
Case 1 . — A Biliary Tumor Forming Two Small Abscesses at the Umbilicus, Followed by Fistula and Escape of Three Biliary Calculi. Healing.* — This case was reported from the clinic given on January 11th at La Pitie, by Professor Richet. The patient had complained of abdominal pain for seven or eight months previously. For three months she had noted a small tumor at the umbilicus, but had never suffered from hepatic colic and gave no history of jaundice. The pain had been accompanied by alternating diarrhea and constipation. On her admission to Richet's service in December the patient presented a tumor situated in the umbilical region. It was the size of an adult's fist. It diminished a little as a result of fomentations and poultices, but was very red and painful on pressure. It gradually lost the character of a phlegmon. After eight or ten days it began to increase in size. The skin became thinner and broke, and there was an escape of pus and fragments of albumin and fibrin. A fistulous opening formed a few days later. A probe introduced into the two openings disappeared for a depth of 7 cm. and impinged upon a hard body. The patient at this time was pale, somewhat jaundiced, and had lost a little in weight. Richet considered in the differential diagnosis acute phlegmon, abscess of the glands, cold abscess, cancer, a syphilitic tumor, fecal fistula, and a fetal cyst.
On February 10th the tumor was opened and a large quantity of pus was evacuated. The two orifices were opened by a long incision. At the bottom was a hard body which was free, mobile, and had facets. Richet endeavored to remove it with forceps, but did not succeed. A few clays later the body had approached more and more to the surface, and on February 17th a biliary calculus escaped. Richet probed again and detected a second calculus. This escaped. A few clays later a third calculus, similar to the two others, was removed. The umbilical opening closed completely, and the patient was discharged well in the early part of March.
- Leguelinel de Lignerolles: Quelques recherches sur la region de l'ombilic et les nstules
hepatiques ombilicales. These de Paris, 1869, No. 6, obs. 1.
340 THE UMBILICUS AND ITS DISEASES.
Fistulous Abscess of the Liver Communicating with the Gall-bladder; Dilatation and Cauterization of the Fistulous Tract; Escape of 14 Small Faceted Calculi and of Two Large Calculi Without Facets.* — In April Dr. Vacher was called to see a woman, twenty-three years of age, who had a good previous history. She said that following a cut she had had an abscess of the liver. This abscess had opened spontaneously and for two months there had been a purulent discharge from the umbilicus, with pain and fever. A fistula had resulted. Vacher found a fistulous opening about three fingerbreadths from the umbilicus. On pressure seropurulent fluid escaped from it. A sound penetrated transversely and to the right for a depth of 4 cm. Abscess of the liver was diagnosed. Crepitation was transmitted to the sound, indicating old calcareous concretions like those sometimes found in the bottom of a cyst. The consultant advised against dilatation of the fistula and gave an unfavorable prognosis. Vacher, however, dilated the fistulous tract with sponges, and then could detect with a sound distinct signs of a calculus. The calculus escaped spontaneously a few days later. It was blackish, faceted, and the size of a pea. Greenish bile also escaped with the calculus. Two and later four other calculi of the same size came away. A calculus of large dimensions presented and was removed with a polyp forceps. It was the size of a pigeon's egg, similar to the others, and consisted of cholesterin. Three or four days later a similar calculus was extracted in the same manner. From this moment the patient improved. The tract was kept dilated for fifteen days. The patient recovered rapidly, and six years after was in excellent health.
A Biliary Tumor Opening Spontaneously in the Umbilical Region, with Escape of a Calculus and Development of a Fistula. f — ■ In the first part of February, 1862, a man, aged forty-one, came saying that he had suffered with pain at the umbilicus for some time. At the umbilicus was a reddish tumor the size of a walnut, painful on pressure, and fluctuating. It was taken for an abscess. It opened spontaneously the next day, and a calculus with a small quantity of seropurulent liquid escaped. The cavity occupied by the calculus was lined with granulation tissue. On the sixth clay it presented a small opening from which a little serous pus escaped. In the course of eight days the opening was completely closed. It, however, reestablished itself, and pus escaped, but no other calculi. In May, 1868, this patient had ascites and cachexia and died in October from cancer of the liver and of the stomach.
A Cystic Tumor Opening in the Region of the Umbilicus; Escape of Biliary Calculi From the Fistula. J — This case was originally reported by Dr. John Cockle. § A woman, fifty-nine years old and well developed, had complained of very severe pain in the abdomen for nine days before her entrance to the hospital. She had had nausea and vomiting. The stools had been normal, and there had been no jaundice. At the level of the umbilical region there was a tumor which was red and inflamed, and there was also an opening. Eight days after entrance the patient discharged 14 small calculi.
- Leguelinel de Lignerolles: Op. cit., obs. 2. [Abstract from Traite d'affections calculeuses
du foie, Fauconneau-Dufresne, 482.]
t Leguelinel de Lignerolles: Op. cit., obs. 3. [Observation by Dr. Leroy des Barres, of Saint Denis. This case was related to the author by the son of Dr. Leroy.]
X Leguelinel de Lignerolles: Op. cit., obs. 4.
§ Cockle, John: Med. Times and Gaz., May 10, 1862, p. 476.
THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 341
Several days later three more calculi came away. The redness then disappeared, but the fistula remained. At a point 2 cm. to the right and below the umbilicus was a seromucous discharge. A probe detected the presence of a hard calculus, which appeared to be the size of a hen's egg. There was also an increase in size of the liver. After some time the swelling and redness reappeared and another calculus was removed. Three weeks later still another became fixed in the fistulous tract, about 2 cm. from the opening. As a result of the disastrous experience which Robert had had after the extraction of similar calculi under like circumstances, the surgeon did not attempt to remove this calculus, but from time to time small biliary concretions escaped.
Tumor of the Umbilical Region; Abscess with Fistulous Tract; Spontaneous Escape of Several Biliary Calculi; Grave Jaundice; Marked Emaciation. Death.* — Madame X, aged sixty-five, had suffered from chronic gastritis. In 1857 she complained of vague pain in the right hypochondrium and a tumor could be made out in the region of the umbilicus. The tumor was hard, without any nodulation, and was painful on pressure. It opened at the umbilicus, and a considerable quantity of whitish pus escaped. In March, 1858, a biliary calculus appeared, and in the course of six months a large number escaped spontaneously. The opening closed after the exit of each calculus, but reopened to allow another to pass out. The patient gradually became emaciated, and died with a marked jaundice. At autopsy a sound introduced at the umbilicus passed into a cul-de-sac 3 cm. in depth. The liver was increased in size, and infiltrated with biliary material. The gall-bladder was transformed into a small, very hard tumor, round, the size of a walnut. It contained a calculus resembling those which had escaped. The hepatic duct was obstructed by a calculus.
Escape of a Biliary Calculus by an Abscess to the Left of the Umbilicus. f — This case was reported by Alle.t A woman, forty-six years of age, had had good health until 1828, when she had had what was called "nervous fever" (typhoid ?). In 1830 she commenced to complain of pain in the left hypochondrium. A tumor was detected. The patient went to take the waters at Baden, but on her way there had very severe pain in the right hypochondrium, accompanied by headache and vomiting. In July, 1831, the skin in the region of the umbilicus became inflamed. After applications of poultices an abscess developed, which opened and a considerable quantity of pus escaped. On October 24th the patient experienced a very unusual sensation. She felt as if a foreign body had broken in the cavity of the abscess, and on the twenty-seventh noticed something hard presenting at the opening. A biliary calculus the size of a pigeon's egg escaped. The general condition of the patient was grave. She was becoming markedly emaciated, and had a continuous fever with exacerbations in the evenings and night-sweats. She was also constipated. The fistulous tract did not have the dimensions of a lentil. A probe introduced impinged upon a hard, immovable body. The opening was increased in size with a sponge. On November 25th a calculus presented. The surgeon attempted to remove it with forceps, but
- Leguelinel de Lignerolles: Op. cit., obs. 5. Abstract from L'Union med., 1859, 465.
t Leguelinel de Lignerolles: Op. cit., obs. 6.
t Alle (in Briinn) : Vier grosse Gallensteine, welche durch einen Abscess zunachst unter dem Nabel abgingen. Med. Jahrb. K. K. Oster. Staates, 1837, N. F. xii, 115.
342 THE UMBILICUS AND ITS DISEASES.
it broke into four large fragments and several smaller ones. These were extracted, and the patient's health improved. The pain was severe, but the fistulous tract closed. In May, 1835, the fourth calculus was removed. Fifteen days later the opening closed completely, and it required only one month for the patient to regain her general health. When the fragments of the extracted stone were assembled, it was found that, together, they formed one calculus.
Biliary Calculus Escaping From the Umbilical Region . * — A woman, sixty-seven years of age, had had pain in the epigastrium, in the right hypochondriac region, and in the umbilical region. At the umbilicus she developed a tumor which, by February, 1858, had reached enormous proportions. Her general condition, however, was satisfactory. At the beginning of April the tumor had a projection in its center. The skin at this point was thin and red. On the eighth day a large quantity of pus, sandy in character and fetid, escaped. Iodin and quinin were injected. Shortly afterward the patient went back to her work, but from time to time she had pain at the umbilicus and a seropurulent discharge; a fistula remained. Four years later the pain returned. In January, 1861, a blackish liquid with foul odor escaped from the fistula. At the same time at the orifice of the fistula was seen a black body, which escaped on Januarjr 23d, after violent abdominal contractions and much pain; it was hard, resistant, and the size of a pigeon's egg. A sound introduced into the opening disappeared for a distance of 5 cm. without impinging upon any solid body. The patient recovered. The body expelled without doubt was a biliary calculus which had made a channel toward the abdominal wall in the umbilical region. It was dark green in color, had the appearance and consistence of cholesterin, and burned in the flame of a candle.
A Biliary Tumor Descending Toward the Umbilicus; Escape of a Calculus; Fistula. Recovery. f — The wife of a pharmacist had been gradually weakened as a result of long suffering from hepatic colic. Reaching from the gall-bladder region toward the umbilicus was a tumor evidently containing a calculus which could be easily felt. This tumor ulcerated, bile escaped, and also a biliary calculus. The patient felt relieved and the opening closed. In the course of three months a new opening occurred in the region of the cicatrix and a second calculus escaped. It had evidently lain in the gall-bladder.
Biliary Fistula at the Umbilicus.! — The patient in Bramann's Case 2 was an unmarried woman, sixty-three years of age. She had had typhoid fever at thirteen. At forty-five years of age she had complained of a sudden abdominal pain, had had a high fever, much discomfort in the gall-bladder region, and some nausea. The abdomen was somewhat swollen. A tumor the size of a fist had been made out in the umbilical region above and to the right. It had grown slowly and tended to pass more and more downward toward the symphysis.
Two years later a large quantity of foul-smelling pus had escaped from the umbilicus. This discharge had continued, the amount varying at different times. The patient was in good condition.
On admission her abdomen was slightly distended. The skin covering the umbili
- Leguelinel de Lignerolles: Op. oit., obs. 7. Abstract from a case reported by Dr. Leclerc, Gaz. des hopitaux, 1863, p. 48.
t Leguelinel de Lignerolles: Op. cit., obs. 8. [This case was observed by Dr. Manec and reported by Fauconneau-Dufresne.]
t Bramann, F.: Zwei Falle von offenem L'rachus bei Erwachsenen. Arch. f. klin. Chir., Berlin, 1887, xxxvi, 996.
THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 343
cus was covered with crusts and exfoliated epithelium and small cysts. The umbilicus was retracted, and a small fistulous tract was discharging foul-smelling pus.
On palpation exactly in the middle line a long, egg-shaped tumor could be felt. At the umbilicus this was 5 cm. broad. It extended almost to the symphysis, and its lower end was from 7 to 8 cm. wide. The tumor lay distinctly behind the abdominal wall, and only in the neighborhood of the umbilicus was it intimately attached. In the lower part it was somewhat movable. On pressure it was found to be of dense consistence. A sound could be passed 12 cm. toward the symphysis, and the cavity widened out as it passed downward. Calculi were detected in the bottom of the cavity. The urine was always normal.
Operation. — An incision, 8 cm. long, was made from the umbilicus downward. Four faceted calculi the size of pigeon's eggs were removed from the sac. The cavity was cureted out. Healing occurred after three months, but it was necessary to curet several times. Microscopic examination of the calculi yielded cholesterin and bile-pigment, but no urinary salts.
Fatal Peritonitis Following a Biliary Fistula at the Umbilicus.* — A woman, thirty-five years of age, had had for eight months a purulent fistula at the umbilicus. With a catheter introduced into the fistula Robert was able to detect a calculus situated at the bottom of the traet. He dilated the tract, but the patient developed peritonitis and died.
Escape of Biliary Calculi From the Umbilicus. — Clementj showed at the Medical Society two biliary calculi. The woman had had previous attacks of abdominal pain. When seen by Clement, she had a reddening around the umbilicus. This was unsuccessfully treated as an eczema. A fistula developed, and two days later a calculus escaped. On the day previous to the meeting Clement had extracted the two very small calculi from the umbilicus.
A Biliary Fistula at the Umbilicus. — Poncett saw a patient with an umbilical fistula which from time to time discharged bile. The physician, under whose care the patient was, said that in the beginning an abscess had developed and a calculus had escaped. The resultant fistula resisted all treatment.
- Robert: Cited by Nicaise: Ombilic. Dictionnaire encyclopedique des sc. med., Paris,
1881, 2. ser., xv, 140.
t Clement: Lyon med., 1888, lvii, 53. i Poncet: Lyon med., 188S, lvii, 54.
LITERATURE CONSULTED ON GALL-STONES ESCAPING FROM THE UMBILICUS.
Berard, P. H. : Diet, de med., Paris, 1840, xxii, 66.
Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., Berlin, 1887, xxxvi, 996.
Clement: Lyon med., 1888, lvii, 53.
Courvoisier, L. G. : Casuistisch-statistische Beitrage zur Pathologie und Chirurgie der Gallenwege, Leipzig, 1890, 117.
Duplay: Arch. gen. de med., 1833, 2e serie, i, 373.
Ledderhose, G. : Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 bs
Leguelinel de Lignerolles: Quelques recherches sur la region de l'ombilic et les fistules hepatique. ombilicales. These de Paris, 1869, Xo. 6.
Alurchison, C. : Case of communication with the stomach through the abdominal parietes produced by ulceration from external pressure. Medico-chir. Trans., London, 1858, xli, p. 11.
Nicaise: Ombilic. Dictionnaire encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv, 140.
Poncet: Lyon medical, 1888, lvii, 54.
344 THE UMBILICUS AND ITS DISEASES.
HYDATIDS AT THE UMBILICUS.
The presence of hydatids at the umbilicus is exceptional. Examples have, however, been recorded by Guattani, Dupuytren, Thompson, Berard, and Roux.
The parent echinococcus cyst usually develops in the liver, and the growth gradually extends to the umbilical region. The tumors may become adherent to the umbilicus and open, fluid and daughter-cysts escaping. Dupuytren's case is particularly interesting, in that autopsy showed that the primary focus was in the lung. The fistulous tract had perforated the diaphragm; it lay between the liver and abdominal wall, and opened at the umbilicus.
Leguelinel de Lignerolles reported Guattani's case.* The patient was a man, forty-eight years of age, who had had, in the region of the liver, a tumor which was resistant, circumscribed, and tense. In the center an obscure fluctuation could be detected. Guattani was uncertain as to its character, and decided to temporize. Nine months later the tumor was prominent, the skin had become reddened, and through an opening at the umbilicus there escaped more than 300 hydatid cysts. A stilet introduced into the fistulous tract detected a large cavity which it was impossible to explore thoroughly. The fistulous tract remained open for a long time without any inconvenience to the patient. Healing took place six years afterward. [I was not able to study this case in the original. There seems to be some controversy, however, as Nicaise says the observation of Guattani cannot be considered as an example of hydatid fistula at the umbilicus. He claims that the tumor was in reality in the epigastric and not in the umbilical region, and that it ruptured, with the escape of more than 300 hydatids.]
Dupuytren reported his case in 1833. A woman entered the Hotel-Dieu in 1811 with an inflammatory tumor of the umbilicus. As fluctuation was evident, and as it was manifest that the skin would give way, Dupuytren opened it and a large quantity of pus escaped, and with it several hydatid cysts. The woman died. At autopsy a communication was found between the umbilical opening and a cavity in the lung. The fistulous tract had perforated the diaphragm and lay between the liver and the abdominal wall. The cavity in the lung contained a large number of hydatid cysts. It was evident that the lung was the primary seat of the hydatids.
Leguelinel de Lignerolles cites Thompson's case. The original appeared in the Medical Gazette, 1844, and was recorded in the Memoirs of the Medical Society, London. The patient at intervals for a period of thirty years had discharged hydatid cysts from the umbilicus. She died at the age of fifty-three. The swelling was first noted after an abdominal injury. Following an abdominal incision she discharged numerous cysts, accompanied by a peculiar liquid which was sometimes purulent. The cysts continued to escape through an opening which developed at the umbilicus, and the patient experienced a great deal of abdominal pain. She had frequent attacks of diarrhea and occasionally fell into a state of great weakness. At autopsy, at the umbilicus were found two tumors communicating with the opening. The one contained friable material mixed with "quicklime," the other had very fetid contents. The fistula passed to the upper portion of the liver, with which it had evidently communicated. Eight or nine isolated hydatid cysts were found on the surface of the liver, and there was also an abscess which contained pus and remnants of hydatids. The gall-bladder was very much dis
- Guattani: De ext. Aneurys., Roma, 1772, 109.
THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 345
tended and contained similar cysts. In addition there were numerous hydatids between the folds of the mesentery.
Berard, in 1840, reported the case of a woman who entered his service at St. Anthony's Hospital. For eighteen months she had had an umbilical fistula. On pressure over the right hypochondrium the purulent discharge from the umbilicus increased, and with the pus escaped several empty hydatid sacs.
Nicaise refers to Roux's case, which had been reported by Cruveilhier. A woman had at the umbilicus a tumor which had been taken for a hernia and a bandage had been applied. Roux noted that the skin covering the tumor had spontaneously opened; that there was a convex surface, whitish and prominent, at the opening of the skin. He thought of a hernial sac. He made several incisions to relieve the supposed strangulation, and was surprised to find that he was dealing with hydatid cysts.
Fischer, in his article on Suppurations in the Subumbilical Space, drew attention to an isolated echinococcus cyst of the abdominal wall. This was not situated at the umbilicus, but immediately in its vicinity, and was in no way connected with the abdominal cavity. It is of such interest that I report it in detail. He says (p. 537) that he operated on a man thirty-two years of age in whom a painless, smooth, fluctuating, immovable tumor, the size of a fist, had developed beneath and to the right of the umbilicus near the mid-line. Its increase in size had been very gradual, as it took six years for development. The patient during this time had often had vomiting, but was otherwise healthy. For three weeks the tumor had been painful and increasing in size. The skin had become reddened and edematous. The tumor had the size, form, and position of the subumbilical space. Fischer made an incision in the outer wall of the rectus along the subumbilical space, and found a densely adherent echinococcus sac, which could not be extirpated on account of its firm adherence to the peritoneum. He split it, scraped it out, and packed. The patient recovered and apparently remained well.
LITERATURE CONSULTED ON HYDATIDS AT THE UMBILICUS. Berard, P. H. : Diet, de med., Paris, 1840, xxii, 66. Davaine, C. : Traite des entozoaires, Paris, 1860, 416. Dupuytren: Tumeurs hydatiques. Clin, chir., 1833, iii, 378. Fischer: Die Eiterungen im subumbilicalen Raume. Volkmann's Samml. klin. Vortrage, n.F.,
No. 89 (Chirurg. No. 24), Leipzig, 1890-94, 519. Ledderhose, G.: Chirurg. Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Leguelinel de Lignerolles: Quelques recherches sur la region de l'ombilic et les fistules hepatiques
ombilicales. These de Paris, 1869, No. 6. Nicaise: Ombilic. Dictionnaire encyclopedique des sc. med., Paris, 1881, 2. ser., xv, 140.
THE ESCAPE OF LIQUOR AMNII OR OF FETAL REMAINS THROUGH THE UMBILICUS. A tubal pregnancy of small size niay in time almost totally disappear. If it be of moderate dimensions and not operated upon, it may remain in situ, nothing but the distorted skeleton being left. I saw a most interesting example of this condition about fifteen years ago. Dr. J. Whitridge Williams received the specimen from New York, and on making a careful examination found that the tube near the uterus contained a recent small pregnancy, while in the outer end of the same tube was the skeleton of a previous tubal pregnancy. The bones of this fetus had been
346 THE UMBILICUS AND ITS DISEASES.
compressed into a rounded mass several centimeters in diameter. On May 4, 1907, at the Johns Hopkins Hospital, I operated on a colored woman (Gyn. No. 13806) who had a definite mass in the ileocecal region. Her previous history was not clear and did not give us a clue as to the exact condition. On making an incision over the mass I found a packet of bones. (See Fig. 249, p. 584.) These were gradually dislodged. The end of one femur, which was fully 5 cm. long, had projected into the bladder, and the portion of the bone that had come in contact with the urine had a phosphatic covering several millimeters thick. The lumen of the large bowel in the vicinity of this collection of bones was perforated at two points, the ends projecting into the intestinal lumen. The opening in the bladder and the apertures in the bowel were closed and the sac drained. The patient made a prompt recovery.
In the case reported by Pfeffinger and Fritze, and referred to by Kussmaul, after the fetal bones had remained quiescent in a rudimentary uterine horn for over thirty years, suppuration had developed and the patient died. The accuracy of this case was fully attested, as the patient was a life prisoner and had escaped capital punishment years before only because at the time of the trial she claimed that she was pregnant. This case Dr. George L. Wilkins and I referred to several years ago.
The passage of fetal bones by the rectum has in the past been no great rarity. Where the pregnancy has been abdominal, the fetus in many instances goes on to term and becomes encapsulated, as was well seen in a full-term pregnancy that I removed several years ago and where the child had lain in the abdomen for four years. Sometimes the child may become calcified, as was clearly evident in the case reported by Dr. John G. Clark.
In the foregoing I have briefly outlined some of the end-results of an extrauterine pregnancy. While going over the literature I found two cases in which there had been a tendency for the fetus to break through at or near the umbilicus, and to this I will add one coming under my own care.
Josenhans, in 1841, reported the case of a woman, sixty years of age, who was married at twenty and in short succession had two children. At thirty she complained of severe abdominal pain, with a rupture near the umbilicus. At first there was an escape of pus and then fecal matter, and on several occasions pieces of bone and hair. The fistula remained open and there was a prolapsus of the bowel through the opening. The patient died at sixty-four. There had evidently been an abdominal pregnancy, with escape of parts of the fetus through the abdominal wall. Had the bone and hair been due to a dermoid, a suppurating sinus would always have remained.
In 1874 Duboue reported the case of a woman, aged twenty-six, who entered the maternity hospital after being in labor for twenty-four hours. The pain diminished, and the patient complained of nausea and vomiting. On examination the enlargement suggested a seven and one-half months' pregnancy. The tumor was situated more to the right than to the left, and the nurse had previously made out the fetal heart. The patient improved and was sent home to await results. In February, at the time of the patient's admission, she was in fairly good health. A week after the labor pains had ceased, the patient lost her appetite, could not sleep, grew thinner, and had a peculiar brownish tint in her face. On February 7th she noted a considerable discharge of chocolate-colored material by the bowel.
THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 347
On March 12th she again entered the hospital. The uterus was dilated on March 27th, and to the surprise of the surgeon was found to be empty. On April 9th the sac opened at the umbilicus and the fetus was then extracted piecemeal. The general peritoneal cavity was not opened, but the cavity containing the fetus was washed out. Two days later fecal matter came out of the sac. The patient gradually improved, and was discharged on June 6th. The fistula, which persisted until September of the same year, was scarcely perceptible, but there was an occasional escape of gas.
In 1901 I saw the following case at the Cambridge (Md.) Hospital:* On February 28, 1901, Dr. Goldsborough was called in by Dr. I. N. Tannar, of Vienna, Maryland, to see what the doctor supposed to be a case of obscure pregnancy. The patient had had one child nine years before. In April, 1900, she had missed her period and since then had presented the usual signs of pregnancy — nausea, enlarged breasts, increase in size of the abdominal girth. In August, while lifting some boxes, something had suddenly given way in her left side. This had occasioned severe pain and she had remained in bed until November 1st. About the middle of September there had been a bloody uterine discharge, and accompanying it considerable pain and nausea. Subsequently, she had had several similar discharges, which may have been menstrual periods. During the month of November she had been able to be out of bed, but had had to return in December. Throughout the entire illness she had had a good appetite and had been fairly well nourished. When seen, her temperature was 101.5° F.; her pulse, 140. Immediate removal to the Cambridge Hospital was advised, and on the following day she was driven 23 miles.
On examination under anesthesia the abdomen was seen to be very prominent. There was, however, no bulging in the flanks. The umbilicus had been converted into a tumor fully 5 cm. long by 3 cm. broad (Fig. 166). The skin over it appeared to be much thinned out, and at one point had given way. From this abraded area an exceedingly offensive, chocolate-colored fluid was escaping. Around the umbilicus the tissue was markedly indurated and pitted on pressure. On vaginal examination the cervix was found intact, but it was impossible to outline the uterus. Nothing could be detected laterally. An incision was made just below the sternum, and continued down almost to the pubes. The abdominal cavity proper was not exposed; that is to say, none of the abdominal contents came into view. Filling the cavity was a large quantity of chocolate-colored fluid, a fetus between six and seven months, and a large placenta. The placenta was attached low down in the pelvis, was exceedingly friable, but came away without producing any hemorrhage. The walls of the sac were about 4 mm. in thickness and excessively friable. They reminded me very much of granulation tissue. It was impossible to determine where the pregnancy had taken place, as the pelvic organs were entirely walled off. It is probable, however, that the uterus had ruptured and that the fetus with its membranes intact had escaped into the abdominal cavity. The fetal membranes had then become attached to the abdominal wall and to the surrounding structures. After removal of the fetus and the placenta, this large sac, which extended almost from the sternum to the pubes and laterally filled the entire anterior portion of the abdomen, was thoroughly washed out with salt solution and loosely packed
- Goldsborough, Brice W., and Cullen, Thomas S.: A Rare Form of Extra-uterine Pregnancy. Amer. Medicine, April 6, 1901, p. 32.
THE UMBILICUS AND ITS DISEASES.
with iodoform gauze. The upper half of the incision was closed, the lower half I left open to insure thorough drainage. At the time of operation the patient's pulse was 140. The operation occasioned no shock.
After the operation the temperature ranged from normal to 101.5° F. for the first four days, but after that time became normal. The pulse was weak and irregular for six days, but gradually regained its normal tone. The pack was removed on the seventh day, with the escape of a moderate amount of discharge. A light gauze drain was then inserted. On March 13th the abdomen was perfectly flat
Fig. 166. — Abdominal Pregnancy with Spontaneous Escape of Liquor Amnti from the Umbilicus.
The drawing, of course, is somewhat diagrammatic. It represents a longitudinal section of the body. The fetus and the fetal membranes are lying immediately beneath the abdominal wall, and are attached anteriorly to the peritoneum almost from the sternum to the pubes. At the umbilicus the fetal sac bulges into the hernial opening, and at the most prominent point this hernial sac has given way, allowing the fluid to escape externally. The fetus is well preserved, appears to be about six months old, and shows slight maceration on the face, arms, and legs. The site of the placenta is roughly outlined by the dotted lines. The cervix is normal, but on account of the marked distortion, the presence of the abdominal tumor, and the edema it was impossible to outline the uterus or appendages; hence their relation is left hazy. The bladder and rectum are in their normal positions. As will be seen from the drawing, a median incision in the abdominal wall would open directly into the sac and in no way involve the general peritoneal cavity.
and all evidence of edema had disappeared. On removal of the drain there was a slight discharge. On bimanual examination it was now possible to outline the uterus to some extent. The organ was about the size of a two months' pregnancy, and situated directly behind the pubes. It was slightly movable.
Pathological Report (Gyn. Path. No. 4744). — The specimen consists of a fetus with its accompanying placenta. The fetus, when folded upon itself, is 17 cm. in length. The distance from the occiput to the heel is 29 cm. The child is well formed, shows no external abnormality, and is a female. There is a moderate quantity of hair, but the skin has to a great extent macerated, and the pigmented
THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 349
layer is readily peeled off. The umbilical cord appears to be about 8 cm. in length. It shows nothing of interest. The placenta is approximately 16 by 10 by 5 cm. It is very friable. In some places it presents the usual appearance; in others, especially in the depth, the tissue is somewhat homogeneous, hemorrhagic, and seems to be breaking down.
Histologic examination of sections from various parts of the placenta shows that it consists almost entirely of necrotic tissue and canalized fibrin. The contours of the villi are everywhere visible, but the nuclei of the epithelial cells, as well as those of the stroma of the villi, have entirely disappeared. The central portions of numerous villi are partially filled with calcareous plaques. At one point are a moderate number of disintegrated polymorphonuclear leukocytes. Otherwise the entire tissue is devoid of nuclei.
This complete necrosis of the placenta accounts for the ease with which it was peeled off and also for the absence of hemorrhage during its removal.
The discharge of bone and hair from the umbilicus, although it affords strong presumptive evidence of pregnancy, is not necessarily conclusive, as shown by Sanderson's case. Dr. S. E. Sanderson, in writing me from Detroit under date of March 31, 1913, says: "In September, 1897, I was called to see a German woman of the poorer class, aged about twenty-seven, married, with no children. She was suffering from a large abdominal tumor, and at the same time there was a bulging at the umbilicus covered with reddened skin and very compressible. This swelling evidently contained fluid.
"Several days after seeing this patient I was hurriedly called to her house. On arriving I found that rupture had taken place through the umbilicus. Several pints of a pea-soup-like fluid and two or three teeth had been discharged, while from the opening there extended a long strand of hair. The abdomen was greatly diminished in size, and the patient felt more comfortable. I advised her removal to the hospital for proper care, but she refused, and I lost track of her. About a year later I was told that she had gone to the hospital for operation and had had a large tumor removed."
As Sanderson says, this was without doubt a dermoid cyst. We all know that dermoid cysts show a peculiar tendency to become adherent, and that they are prone to suppurate. This cyst had suppurated, grown fast to the umbilicus, and part of its contents had escaped through the umbilical opening.
LITERATURE CONSULTED ON ESCAPE OF LIQUOR AMNII OR FETAL REMAINS
THROUGH THE UMBILICUS.
Clark, J. G. : A Rare Case of Lithopedion. Johns Hopkins Hosp. Bull., November, 1897, viii, 221. Cullen and Wilkins: Pregnancy in a Rudimentary Horn, Rupture, Death, Probably Migration
of Ovum and Spermatozoa. Johns Hopkins Hosp. Reports, 1897, vi, 126. Cullen, T. S.: A Series of Interesting Gynecologic and Obstetric Cases. Jour. Amer. Med.
Assoc, May 4, 1907, 1491. Duboue: Observation de grossesse extra-uterine, gastrotomie, guerison. Fistule intestinale au
niveau de 1'ombilic. Arch, de tocologie, des maladies des femmes et des enfants nouveau nes, 1874, i, 577. Goldsborough and Cullen: A Rare Form of Extra-uterine Pregnancy. Amer. Medicine, April 6,
1901, 32. Josenhans: Merkwurdiger Fall von kiinstlichem After. Med. Correspondenzbl., Wurtemberg,
1841, xi, 60.
350 THE UMBILICUS AND ITS DISEASES.
ESCAPE OF FOREIGN BODIES THROUGH THE UMBILICUS.
Blum, in his article on Tumors of the Umbilicus in the Adult, published in 1876, cites three cases — those observed by Ambroise Pare, Diemerbroeek, and Greenhill.
Ambroise Pare's patient, a woman, had swallowed a brass needle. Two years . later it passed out at the umbilicus through a small opening.
Diemerbroeck's patient, a child, had swallowed a shoemaker's awl. Later a small, painful, non-suppurating tumor presented at the umbilicus. This contained the foreign body.
GreenhilTs case was reported in the Philosophical Transactions of the Royal Society of London in 1700, vol. hi, p. 93. A woman, who had swallowed a certain number of plum-stones, finally developed a tumor in the umbilical region. This suppurated, and the stones escaped from the umbilicus. The woman died twenty days later.
"Weiss briefly referred to a case seen by Cladus. The patient was a man. Plum-stones and worms escaped from his umbilicus.
Petrequin's case, in which a uterine sound introduced through the vagina was lost and finally presented at the umbilicus, is of such interest that I shall report it in detail.
Uterine Sound Introduced Into the Uterine Cavity and Removed Through the Umbilicus.* — Madame X, mother of several children, claimed that when she was between six and eight weeks pregnant a midwife had introduced a sound to bring on a miscarriage. The sound was passed far up and could not be reached again. Miscarriage followed, but no sound came away. Six days later, after the most careful examination, no evidence of the sound could be found. Examinations on several days in succession were of no avail. Four months later the patient was in good health, but came to the hospital on account of a small enlargement at the umbilicus. It looked like a beginning umbilical hernia.
On bimanual examination with the patient standing, the upper end of the sound could be felt at the umbilicus. The uterus was dilated, and several attempts made to remove the sound from below, but without avail. An incision was finally made at the umbilicus, and by manipulation the sound was removed from above. The patient was perfectly well in seven days. In this case the sound had perforated obliquely the anterior portion of the cervix, and its lower end had slipped between the bladder and the cervix, while the upper end gradually had reached the umbilicus. Petrequin and Foltz claim this as the only case of the kind on record.
These are the only cases of foreign bodies escaping from the umbilicus which we have found in the literature.
- Petrequin et Foltz: Extraction par l'ombilic d'une sonde de femme introduite par les
voies genitales. Lyon rued., 1869, iii, 509.
LITERATURE CONSULTED ON THE ESCAPE OF FOREIGN BODIES THROUGH THE
Blum, A.: Tumeurs del'ombilic chez l'adulte. Arch. gen. de mod., Paris, 1876, 6. ser., xxviii, 151.
Petrequin et Foltz: Extraction par l'ombilic d'une sonde de femme introduite par les voies genitales. Lyon med., 1869, iii, 509.
Weiss, E.: Leber diverticulare Nabelhernien und die aus ihnen hervorgehenden Xabelfisteln. Inaug. Di— ., 'lie-sen, 1868.
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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