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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.

Umbilicus (1916): 1 Umbilical Region Embryology | 2 Umbilical Region Anatomy | 3 Umbilical New-born Infections | 4 Umbilical Hemorrhage | 5 Umbilicus Granuloma | 6 Omphalomesenteric Duct Remnants | 7 Umbilicus Abnormalities | 8 Meckel's Diverticulum | 9 Intestinal Cysts | 10 Patent Omphalomesenteric Duct 1 | 11 Patent Omphalomesenteric Duct 2 | 12 Bowel Prolapsus at Patent Omphalomesenteric Duct | 13 Abdominal Wall Cysts by Omphalomesenteric Duct Remnants | 14 Omphalomesenteric Vessels Persistence | 15 Umbilical Inflammatory Changes | 16 Subumbilical Space Abscess | 17 Umbilicus Paget's Disease | 18 Umbilicus Infections | 19 Umbilicus Abnormalities 2 | 20 Umbilicus Fecal Fistula | 21 Umbilicus Round Worms | 22 Umbilicus Foreign Substance Escape | 23 Umbilical Tumors | 24 Umbilicus Adenomyoma | 25 Umbilicus Carcinoma | 26 Umbilicus Sarcoma | 27 Umbilical Hernia | 28 The Urachus | 29 Congenital Patent Urachus | 30 Urachus Remnants | 31 Urachal Remnants Producing Tumors | 32 Large Urachal Cysts | 33 Anterior Abdominal Wall Abscesses | 34 Urachal Cavities | 35 Umbilicus Acquired Urinary Fistula | 36 Urachal Concretions and Urinary Calculi | 37 Urachus Malignant Changes | 38 Urachus Bleeding into the Bladder | 39 Patent Urachus Tuberculosis | Figures
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Chapter XXIII. Umbilical Tumors

Hypertrophy of the umbilicus.

Angiomata of the umbilicus; report of cases.

Umbilical lymphocele.

Myxomata.

Fibromata; report of cases.

Papillomata; report of cases.

Lipomata.

Dermoids or atheromatous cysts; report of cases.

Umbilical tumors consisting chiefly of sweat-glands.

An abdominal tumor attached to the inner surface of the umbilicus by a pedicle two inches in

diameter.

Papilloma of the umbilicus secondary to papilloma of the ovary.


Benign :


UMBILICAL TUMORS.


Hypertrophy.

Angiomata.

Lymphocele.

Benign comiective-tissue growths.

Myxomata.

Fibromata.

Papillomata. *

Lipomata. Dermoid cysts. Sweat-gland tumors.

Abdominal myoma springing from the umbilicus. Papilloma secondary to growth in ovary, f Aclenomyomata.

Malignant :

Carcinoma of the umbilicus.

A t> • / 1. Squamous-cell carcinoma.

A. unmary. ^^ 2 Adenocarcinoma.

f 1. From the stomach. 2. From the gall-bladder.

, 3. From the intestine.

B. Secondary. j 4 From the ovary _

5. From the uterus.

6. From other abdominal organs. Sarcoma.

1. Telangiectatic myxosarcoma.

2. Spindle-cell sarcoma.

3. Round-cell sarcoma.

4. Melanotic sarcoma.

  • In the ordinary umbilical papilloma the growth is caused by a proliferation of the stroma —

the squamous epithelium covering the papillae occupies merely a passive role. It is for this reason that we have grouped these small tumors with the benign connective-tissue growths.

t These may or may not be malignant.

351


352 THE UMBILICUS AND ITS DISEASES.

GENERAL REMARKS.

Many authors who have published cases showing abnormalities of the umbilicus have endeavored to classify satisfactorily umbilical diseases. Probably one of the best articles on the subject is the exhaustive treatise by Nicaise, published in Paris in 1881. In 1883 Codet de Boisse gave a satisfactory resume of the subject, and the following year Reginald H. Fitz, of Boston, published a most instructive article in which he included lesions of the umbilicus owing their origin to persistence of the omphalomesenteric duct.

Villar, in 1886, wrote a thesis on umbilical tumors, going into the subject very carefully, and making a satisfactory classification of the various umbilical tumors. In 1890 Ledderhose discussed umbilical diseases very fully and satisfactorily, and in 1892 Pernice published his well-known monograph on Umbilical Tumors. Finally, in 1906, Guiselin, in his Bordeaux thesis entitled Cancer of the Umbilicus, outlined a very practical classification of umbilical tumors. After reviewing the literature on the subject, I have found the above classification the most satisfactory:


LITERATURE CONSULTED ON UMBILICAL TUMORS IN GENERAL.

Codet de Boisse: Tumeurs de l'ombilic chez l'adulte. These de Paris, 1883, No. 311.

Fitz, Reginald: Persistent Omphalomesenteric Remains, Their Importance in the Causation of

Intestinal Duplication, Cyst Formation, and Obstruction. Amer. Jour. Med. Sci., 1884,

lxxxviii, 30. Guiselin, E. J. M. J. : Du Cancer de l'ombilic. These de Bordeaux, 1906, No. 47. Ledderhose, G. : Deutsche Chirurgie, 1890, Lief. 45 b.

Nicaise: Ombilic. Dictionnaire encyclopedique des sc. med., Paris, 1881, xv, 140, deuxieme ser. Pernice, Ludwig: Die Nabelgeschwiilste, Halle, 1892. Villar, Francis: Tumeurs de 1'ombilic. These de Paris, 1886. No. 19.


HYPERTROPHY OF THE UMBILICUS. Villar* speaks of hypertrophy of the umbilicus in a patient sixty years of age. Inasmuch as from the description it is clear that there was a definite umbilical suppuration and the histologic examination showed an inflammatory condition, we should certainly hesitate to class the case as one of true hypertrophy of the umbilicus. I have encountered no other literature on the subject.


ANGIOMATA OF THE UMBILICUS.

Definite literature on the subject is very rare.

Virchow, in 1862, mentions two varieties of umbilical fungi. The one is usually rich in blood-vessels, bleeds readily, and is found after the cord comes away. It consists of granulation tissue, and after the use of astringents soon disappears. He is evidently referring to the simple granulation tissue not infrequently noted after the cord comes away.

The second variety represents a congenital tumor, and in the majority of cases is a remnant of the omphalomesenteric duct. Virchow then refers to cases reported by Maunoir and Lawton.

  • Villar: Op. cit., p. 76.


UMBILICAL TUMORS. 353

Xicaise refers to the subject and mentions three cases from the literature.

Ledderhose briefly refers to angiomata of the umbilicus, and says that cases have been recorded by Maunoir, Chassaignac, Lawton, Boyer, and Colombe.

Kidd and Patteson, in 1889, in an article on Capillary Angioma of the Umbilicus, reported a case in a child six weeks old. From the description, however, it would seem probable that the tumor consisted of granulation tissue and was not an angioma in the accepted sense of the word, although it must be admitted that granulation tissue in itself at times has such a rich capillary blood-supply that it might with propriety be called an angioma.

Pernice, in his exhaustive monograph on Tumors of the Umbilicus, briefly considers the cases recorded in the literature. He also refers to a case recorded by Boyer. A nine-3 r ear-old girl from her birth had had an umbilical tumor largely made up of varicose veins. This tumor was pedunculated, like a polyp, grew slowly, was bluish in color, and felt soft. After being repeatedly tied off, it completely disappeared.

Robson, in 1872, reported a somewhat complicated tumor of the umbilicus occurring at birth. The soft and elastic portion of the tumor was of a dirty, livid color and probably represented an area of hemorrhage and not a genuine angioma. The essential points in the case are as follows :

The mother of the child was delivered before Robson arrived, but he noticed an abnormal condition at the umbilicus, three distinct tumors resting on the abdomen, and connected with the umbilicus close to the integument of the navel. The one containing the cord was about the length and circumference of a one-ounce quinin jar, with a continuation of a small, shriveled cord projecting from its extremity. The under part of this tumor consisted of firm, compact tissue; the upper was soft and elastic, without any pulsation, and of a dirty, livid color. Immediately beneath and growing from the first, at its junction with the abdomen, was a second tumor consisting of a transparent, globular mass the size of a large orange, and a third, the size of a pullet's egg, containing a thick, albuminous substance like jelly. The growths were extirpated.

The tumor consisted mainly of the cord in a spiral form, each coil adhering to the other and thoroughly agglutinated by the albuminous substance. There was extravasation of blood, with here and there organized matter.

In the cases reported by Chassaignac, Lawton, and Colombe, a definite angioma of the umbilicus existed. The first two were noted in infants, but Colombe's case occurred in an adult.

As seen from the detailed report, when Chassaignac's patient was twelve days old, a minute nodule was noted at the umbilicus. At six months the tumor was as large as a hen's egg and was non-pedunculated; the overlying skin had a bluish tinge, and beneath the surface a varicose network of veins could be seen. Where the veins were very near the surface, the bluish tinge of the skin was naturally more accentuated. A large vein appearing to the left of the xiphoid passed downward to the umbilicus and was continuous with the tumor.

Lawton's observation was made on a new-born child, and in addition to the tumor there was an umbilical hernia. The tumor was the size of a jargonelle pear, and darkish in color. It was of the consistence of placental tissue. On microscopic examination, it was found to be composed chiefly of the ramifications of large blood-vessels held together by areolar tissue. 2-i


35-1 THE UMBILICUS AND ITS DISEASES.

Colombe's patient, when twenty-six years old, noticed a small tumor the size of a grain of wheat at the umbilicus. It gradually increased in size, was purple and soft. When seen ten years later, it was the size of the end phalanx of the little finger. Two years before coming under observation she had had a hemorrhage from the tumor lasting two days. The bleeding was controlled by styptics. Three days before admission the hemorrhage recurred and the bleeding was so excessive that the patient showed marked constitutional symptoms.

The cases of Chassaignac, Lawton, and Colombe are so interesting that I report them in detail:

An Erectile Venous Tumor Developing in the Region of the Umbilicus in a Child Six Months Old.* — The child was six months old. To the left of the umbilicus was attached a tumor the size of a small hen's-egg. This was regular, non-pedunculated, raising the left half of the umbilical margin and the skin, and giving the overlying skin a bluish tinge. The surface of the tumor was evidently made up of a network of varicose veins (subcutaneous), and had three or four small spots where the bluish tint was more marked. Another bluish spot, with the diameter of a 50-centime piece, had occupied the summit of the tumor. This was crescentic, with the hollow of the crescent directed upward and toward the median line. A large vein appearing to the left of the xiphoid passed downward to the umbilicus and evidently was continuous with the tumor.

Pressure on the tumor produced pallor, but, when the finger was raised again, the color returned with increasing intensity.

The mother noticed, twelve or thirteen days after birth, a small spot the size of a pin-head at the umbilicus. A bandage was applied, but the spot increased in size and became thickened. It was removed satisfactorily. The tumor consisted of two parts — adipose tissue and blood-vessels surrounded by cellular tissue. The vessels were very abundant, and in several places showed varicose dilatations. This tumor was an angioma.

A Case of Vascular (Erectile) Tumor in the Sheath of the Cord in a New-born. — Mr. Lawtonf was called to the delivery of a fine male child, and when he proceeded to tie the cord, he found a tumor the size and shape of a medium jargonelle pear with its neck communicating with the cavity of the abdomen through the umbilical opening and strongly adherent to the cord, the covering being common to both. Mr. Lawton divided the cord above the tumor in the usual way. On examination the growth felt tough, rather fleshy, and somewhat like a placenta might feel before degeneration commences — it did not feel at all like intestine, although when the child cried, both it and the investing membrane, together with the tegumentary portion of the umbilicus, enlarged very much — the tumor from being engorged with blood and the membrane from protrusion of intestine. Pressure reduced the one and somewhat decreased the size of the other.

After reduction of the hernia, pressure was applied by means of a pad and banda^-, and it was resolved to wait and see what might be the termination of the case if left to nature, as it was thought that the tumor might dry up and slough with the cord. After a day or two affairs presented nearly the same appearance as

  • Chassaignac, M. E.: Traite de l'ecrasement lineaire, Paris, 1856, 535.

t Lawton: London Obstet. Trans., 1866, vii, 210.


UMBILICAL TUMORS. 355

at first, and Mr. Lawton determined to explore a little. He did so by carefully dissecting (over the fundus of the tumor) the outer covering, when a clear, yellow serum escaped. He then made a small opening into the second covering, and blood of a dark color flowed pretty freely. A pad and bandage were immediately applied, and the case was allowed to take its course for two days more. On entering the room on the third day the smell of the decomposing membranes was strong, and the integument around the umbilicus much inflamed. The umbilical opening was large enough to receive four fingers, and was more or less oval.

At the lower end protruded a knuckle of gut; at the upper end, a non-pulsating, pyriform tumor, and at the right-hand side, the cord, between the knuckle of gut and tumor. The membranes were gangrenous and the fundus of the tumor was bare. It presented a dark color; to the touch it felt firm, unless strongly compressed, when it somewhat diminished in size and was a little flaccid. The crying of the child gave now no impetus to the tumor.

Lawton resolved to return the protruded intestine, and, after applying a ligature around the neck of the tumor, to excise it. After chloroform had been given, a finger and thumb were applied to the neck of the growth and fully compressed it. The operator made a slight incision in the fundus of the tumor, and on careful relaxation of the pressure, the blood was inclined to flow very freely. A ligature was then applied around the neck of the growth, but the membranes, being gangrenous, it cut through them, and, the abdominal muscles becoming rigid at the same time, from eight to ten inches of gut protruded. The tumor was excised above the ligature, the cord tied as low down as possible, and after careful and patient manipulation the protruded intestine was returned. The opening was closed as far as possible by passing through four common needles in place of harelip pins; a pad and bandage were applied in the usual way. The child's bowels were not moved for three days after the operation, when they acted freely. The little patient had no bad symptoms, and at the time of the report was quite well.

Microscopic examination by Dr. J. Braxton Hicks showed that the whole mass was penetrated by large blood-vessels, of the ramifications of which it was principally composed, coupled with areolar tissue, in the network of which were nucleated cells of round or oval form, generally in groups of four or five. There was in some parts, however, an excess of the connective-tissue elements so as to form solid portions. The tumor was an angioma.

A Vascular Tumor of the Umbilicus.* — The patient was a woman, thirty-six years of age, in good health. She had had a child at nineteen. Ten years before she had noticed a small tumor the size of a grain of wheat at the umbilicus. It had gradually increased in size. It was purple, rather soft, painless, but made her uncomfortable. About the week before she was seen, it was the size of the end of the phalanx of the little finger. Two years before there had been a hemorrhage from the tumor, the bleeding coming in jets of the diameter of a pin. The hemorrhage lasted two days, was not continuous, and was controlled by perchorid of iron. Three days before admission she had a second hemorrhage and perchloric! of iron was used, the flow ceasing just as the astringent was employed. The volume of bleeding could be compared to that from the femoral artery; the bleeding, however, was intermittent. The patient was in a sea of blood. She was

  • Colombe: Tumeur vasculaire de l'ombilic, hemorrhagic, guerison. Gaz. med. de Paris,

1887, lviii, 245.


356 THE UMBILICUS AND ITS DISEASES.

pale and apparently in a serious condition. Forceps were applied, and the area ligated en masse, but with difficulty, as the bleeding came from the bottom of the umbilicus. Seven days later the bleeding again recurred. A ligature was applied, and the bleeding stopped and never returned. The tumor disappeared.


LITERATURE CONSULTED ON ANGIOMATA OF THE UMBILICUS.

Chassaignac, M. E.: Traite de l'ecrasement lineaire, Paris, 1856, 535.

Colombe: Tumeur vasculaire de l'ombilic, hemorrhagie, guerison. Gaz. med. de Paris, 1887,

lviii, 245. Kidd and Patteson: Capillary Angioma of the Umbilicus. Illustrated Med. News, 1889, iv,

148. Lawton: Case of Vascular (Erectile) Tumor in the Sheath of the Cord in a New-born. London

Obstet. Trans., 1866, vii, 210. Ledderhose, G.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Nicaise: Ombilic. Dictionnaire encyclopedique des sc. medicales, Paris, 1881, 2. ser., xv,

140. Pernice, L.: Die Nabelgeschwulste, Halle, 1892.

Robson, R.: Disease of the Funis Umbilicalis. Medical Examiner, Chicago, 1872, xiii, 33. Virchow: Die krankhaften Geschwulste, 1862-63, hi, erste Halfte, 467.


UMBILICAL LYMPHOCELE.

Koeberle,* in 1878, speaking of ovarian cysts, said that sometimes the lymphatic vessels beneath the umbilicus take on an excessive development and the umbilicus becomes the site of a tumor consisting exclusively of the sac-like dilatations of the lymphatic vessels.

Codet de Boisset quotes a letter from Koeberle to Blum in which Koeberle stated that in his Cases 49 and 50 he had removed growths of this character when operating for ovarian tumors. One of these umbilical tumors was 8 cm. in diameter. He further drew attention to the fact that similar tumors had never been described. They are evidently very rare, as I have not found mention of any in the literature. In a very large series of patients from whom ovarian tumors have been removed at the Johns Hopkins Hospital we have never seen umbilical growths of this character.


BENIGN CONNECTIVE-TISSUE GROWTHS OF THE UMBILICUS.

Under this head are included myxomata, fibromata, papillomata, and lipomata. As a rule, papillomata are classified with epithelial growths. In umbilical papillomata, however, the connective-tissue growth is the essential feature, the epithelium playing a passive role. I have accordingly included them under connective-tissue growths.

Myxomata of the Umbilicus.

These tumors are exceptionally rare. According to Ledderhose, J Weber collected three cases — those of Fischer-Coin, Busch, and his own. In Busch's case the tumor was the size of a goose's egg. Its surface was ulcerated.

  • Koeberle: Nouveau dictionnaire de med. et de chir. prat., 1878, xxv, 522.

t Quoted by Pernice: Die Nabelgeschwiilste, Halle, 1892, 21. % Ledderhose, G.: Deutsche Chirurgie, 1890, Lief. 45 b.


UMBILICAL TUMORS. 357

Mori* described a sessile umbilical tumor the size of a cherry, which had ulcerated at its most prominent part. Histologically, it consisted of fibrous and myxomatous tissue. He gives a very good picture of the microscopic appearance •-.

In Pernice'sf monograph will be found the best description of this class of umbilical tumors. He says that myxoma of the umbilicus was first described by Weber, and was supposed to originate from portions of Wharton's jelly. The rendition is very rare, only nine cases being found in the literature. On section the tumors look like white pork, are pale, edematous, and gelatinous. Some are soft. others hard, according to the amount of connective tissue. They vary in size from that of a hazelnut to that of a goose's egg. In four cases the tumors were pedunculated and the pedicle came directly from the umbilical scar. In two cases the tumors lay on the top of an umbilical hernia. Pernice points out that only the cases since Weber's time have been examined microscopically. The blood-vessels are abundant. The vessel- walls are thick and lie in a connective-tissue framework consisting chiefly of spindle-cells and sometimes of round-cells. There is an intercellular substance. In other words, the ground-substance is like that encountered in embryonic tissue. Most of these tumors are covered over with normal skin, and only rarely is the surface ulcerated. The prognosis is good.

Pernice then goes on to record cases reported by Weber, Maunoir, Chassaignac. Lawton, Villar, Virchow, and Leydhecker. In only a few of the cases are the microscopic reports of any value.

Fibromata of the Umbilicus.

Growths of this character are likewise rare. Although the majority occur in middle life and in males, they are sometimes found in infants. The size of the tumors reported varied greatly. One was as large as a bird's egg, another the size of a walnut, another as large as an apple. The largest was said to be the size of an infant's head at term. They are usually oval or round and more or less pedunculated, the pedicle springing from the umbilical depression. Sometimes, however, the umbilicus may be recognized as an irregular slit in the center of the tumor.

The growth is usually covered with normal or slightly atrophic skin. On account of the exposed site of the tumor, its more prominent surface may be excoriated, presenting blackened points; or the injured areas may be covered with crusts.

On section, the growth usually presents a grayish-white or whitish-yellow surface, with a definite fibrous arrangement. In a few instances one or more small cysts containing serous fluid were found, or a small quantity of fat was detected in the tumor.

Histologic examination shows that the skin covering the growth is normal or atrophic, or that there is some thickening of the squamous layers. In the last type the papilla? are much elongated. The stroma of the tumor consists, as a rule, of typical fibrous tissue containing a varying number of spindle-shaped nuclei. Some of the growths, particularly where there has been an irritation of the surface, show marked small-round-cell infiltration in the vicinity of the point or points of such irritation. Here, as in other parts of the body, the diagnosis between a very cellular fibroma and a spindle-cell sarcoma is fraught with much difficulty or is impossible.

  • Mori, A. : Contribute) alio studio dei tumori ombelicali. Gazzetta degli ospedali, Milano,

1902, xxiii, 632.

f Pernice: Die Nabelgeschwulste, Halle, 1892.


358 THE UMBILICUS AND ITS DISEASES.

On account of the rarity of this condition, I append those cases in which the diagnosis of fibroma of the umbilicus was certain, or at least highly probable.

Cases of Fibroma of the Umbilicus.

Fibroma of the Umbilicus. — Legrand* reported from Sappey's service the case of a man fifty-one years of age. When the patient was thirty-nine years old a tumor the size of a hazelnut had been observed at the umbilicus. This was soft and covered with skin of a natural color. For five months before the patient came under observation it had been increasing rapidly, becoming more than twothirds larger. Later, small excoriations were noticed on the surface. These were covered with crusts.

On admission to the hospital an ovoid tumor, about seven or eight inches in its vertical diameter, was found in the umbilical region. It was somewhat pedunculated, and with the patient- lying down reached to within 1 cm. of the xiphoid. The pedicle was inserted in the umbilical scar. The tumor itself was hard, smooth, round, and in its right third bossed and ulceiated. In other portions it was covered with brownish-yellow crusts alternating with a purple discoloration of the skin. At some points fluctuation was noted, but there was no hemorrhage from the surface. The patient's general condition was good. The tumor was removed and recovery followed. The tumor on section was whitish in color, homogeneous, and very hard. It contained a small, cyst-like cavity with serous fluid contents. Robin, who made the histologic examination, said that it was a fibroplastic tumor and not a cancer.

A Fibro nucleated Tumor at the Umbilicus. f — The patient was thirty years of age, and the tumor had been noticed for three months. On admission to the hospital in April, 1857, the tumor was the size of an orange and situated beside the umbilicus. It had evidently developed in the umbilical wall, and was firm and fibrous in character. The general health was good. On histologic examination the tumor was found to be composed of fibrous tissue. Bryant draws attention to the fact that such tumors are evidently rare.

Fibrolipoma of the Umbilicus. J — Hugh G., aged thirty, seven years before had noticed a small lump about the size of a walnut at the site of the navel. It increased gradually for two years, when a surgeon, probably a quack, "put it back," but it soon returned. Until six months before Barton saw him the tumor had increased only gradually, but since then had doubled in size. It was so large that it prevented the patient from walking. It was oval, and extended across the abdomen from the umbilicus to the left anterior superior spine. It was slightly constricted at its base, measured 23 inches in circumference, and was fixed to the skin only at the umbilicus. On removal it was found attached to the underlying tissue at only one point. The abdomen was not opened. No histologic examination is mentioned.

Fibromata of the Umbilicus. — ■ Damalix§ treats the subject in general, and says that Sappey and Limange report cases in which the pedicle came from the umbilicus.

  • Legrand: Tumeur volumineuse de la region ombilicale de nature fibroplastique, prise pour

une tumeur encephalo'ide. Gaz. des hop., 1850, 29.

t Bryant, T.: Guy's Hospital Reports, 1863, ix, 245.

% Barton: Reported by Bennett: Dublin Jour. Med. Sci., 1882, lxxiv, 239.

§ Damalix: Etude sur les fibromes de la paroi abdominale anterieure. These de Paris, 1886, No. 148.


UMBILICAL TUMORS. 359

A F i b r o m a of the Umbilicus. *-^A woman, twenty- two years of age, entered the Hotel-Dieu on May 20, 1888. In February, 1887, one month after her child had been weaned, an umbilical tumor was first noticed. This was the size of a hazelnut, and could be rolled between the fingers. For a time it grew slowly, but after six months rapidly.

At the umbilical site was a tumor the size of the head of a child at term. Its summit was divided by the distended umbilical cicatrix. The tumor was hard, with several points of softening. It was irregular and bossed. The skin covering was normal, without any marked dilatation of the veins. It slid readily over the tumor.

The growth was easily dissected out, but was found intimately adherent to the peritoneum. Recovery followed.

The tumor was hemispheric, irregular, about 10 cm. in diameter; it had a whitish surface, and presented an irregular, bossed appearance in the depth, where there were several depressions dividing it into lobules. On section it was whitish and smooth ; in the deeper portion, yellowish in color. Here it had a definite fibrous arrangement.

Histologically, the tumor was composed exclusively of fibrous tissue, wavy threads for the most part running parallel to one another, but with no characteristic arrangement. The cells were abundant and in general well developed. They were fusiform in shape. The tumor seemed to have originated from the aponeurosis. It was a fibroma.

Fibrous Tumors in the Umbilicus. — Pernicef says this form of tumor cannot be sharply differentiated histologically from those of inflammatory origin. It may originate from three different parts of the umbilicus: (1) From the dense connective tissue of the umbilical scar; (2) from that of the skin which, as we have seen, is really scar tissue covered with epithelium ; (3) in young individuals from myxomatous connective-tissue remains of the cord.

Fibroma of the Umbilicus [?].| — This case occurred in Volkmann's private practice. E. H., aged forty-two, had at the umbilicus a hard, slightly lobulated, broad-based tumor the size of an apple. This was thought to be a fibroma. On histologic examination, however, it proved to be a spindle-cell sarcoma. The spindle-cells were relatively small and had large nuclei. The abdomen was not opened. The woman was well at the end of ten years. [A sarcoma occurring in the abdominal wall is so intimately associated with the surrounding tissue that one would hardly expect a permanent recovery, such as occurred in this case. This fact would rather indicate a cellular fibroma. — T. S. C]

A Fibroma of the Umbilicus[?].§ — A man, forty-nine years of age, entered Polaillon's service at the Hotel-Dieu March 25, 1895. Eighteen months before he had noticed at the umbilicus small tubercles, which had caused pain and inconvenience.

Attached to the lower border of the umbilicus was a pedunculated tumor, cylindric in form, 5 cm. long and 12 or 13 mm. in diameter. Its free end showed a small crust covering a healed area of ulceration. The skin covering it was deli

  • Pic, Adrien: Lyon med., 1888, lix, 546.

t Pernice, L.: Die Nabelgeschwi'ilste, Halle, 1892. t Pernioe, L. : Op. cit., obs. 69.

§ Sourdille, Gilbert : Sarcome pedicule de la peau de l'ombilie. Bull, de la Soc. anat. de Paris, 1895, lxx, 302.


360 THE UMBILICUS AND ITS DISEASES.

cate and reddish in color. On taking the tumor between the fingers it gave the sensation of the finger of a glove filled with nuts. The skin surrounding the tumor contained seven or eight pinkish tubercles about the size of green peas. The skin alone was involved, as the tumor was movable on the underlying aponeurosis. No enlarged glands were detected, and the general health was good. The diseased area was removed. Histologic examination of the main tumor and of the small nodules showed sarcoma fusocellulare covered with skin. The superficial half of the skin seemed to have been the starting-point of the tumor, which tended to pass out and become pedunculated.

[The growth may equally well have been a fibroma associated with secondary small nodules. The microscopic examination is not conclusive. — T. S. C]

Probably a Fibroma of the Umbilicus.* — J. W., ten months old, was brought to the clinic February 27, 1896. He had remains of the omphalomesenteric duct at the umbilicus, as recognized by a reddish tumor covered with intestinal mucosa. In addition there was a smooth, cap-like area partly covering this reddish tumor, which was composed chiefly of fibrous tissue (Fig. 124, p. 209). [Evidently a true fibroma. — T. S. C]

A Small Fibroma Associated with an Umbilical Concretion. — Coenenf reports cholesteatomata of the umbilicus, and in his Fig. 2 shows a definite but small fibroma occupying the umbilical cicatrix. It is covered over with many layers of squamous epithelium. The central portion consists of fibrous tissue, and scattered throughout it are many small round-cells, indicatingrecent inflammation. The inflammatory reaction was evidently started up by the umbilical concretion (Fig. 151, p. 252).

Papillomata of the Umbilicus.

Probably the first case of this character recorded was that of Fabricius von Hilden, published in 1526. From that time on isolated cases of papilloma of the umbilicus have been recorded, but, as in the majority of these no microscopic examination was made and as the gross picture was not sufficiently convincing, we have omitted most of these, confining our attention chiefly to those cases in which a careful histologic description has been given. Most of the tumors have been noted between the twenty-fifth and fiftieth years. In Broussolle's case, however, in a child only two months old, a typical papilloma, 5 mm. in diameter, occupied the umbilical depression. Ordinarily one would consider this small nodule in such a young individual as a mass of granulation tissue left after the cord had come away, or as a remnant of the omphalomesenteric duct. Broussolle, however, distinctly says that its surface was covered with squamous epithelium analogous to that of the skin.

From the limited number of cases it is difficult to draw any definite conclusion, but papillomata seem to be equally frequent in both sexes.

As a rule, they are of slow growth and vary from 5 mm. in diameter to the size of a walnut. They are usually pedunculated, but in the case reported by Peraire the papillary growth had spread out for a considerable distance into the surroundingabdominal wall.

  • Sauer, F.: Ein Fall von Prolaps eines offenen Meckel'schen Divertikels am Nabel.

Deutsche Zeitschr. f. Chir., 1896-97, xliv, 316.

t Coenen, H.: Das Nabelcholcsteatom. Miinch. med. Wochenschr., 1909, 56. Jahrg., 1583.


UMBILICAL TUMORS. 361

Where the growth is small, it frequently looks red and reminds one of a raspberry, and on examination with a magnifying-glass it is found to be composed of blunt papillary masses. As the growth increases in size the portion near the pedicle may have a violet tint, while the superficial portion is pinkish in color.

In Segond's case, reported by Villar, the growth consisted of rounded projections varying greatly in size. The largest nodule was bean-shaped and contained a small cyst; another was the size of a pea, and lying between them were smaller ones. As a rule, when the tumor reaches its full size it resembles a large wart. Its surface is covered with myriads of papillae, and these are flattened laterally, owing to the close juxtaposition. On section the papillary or tree-like arrangement is clearly evident, and the stroma of the nodule and of its pedicle is seen to consist of fibrous tissue.

Histologic examination shows that the surface of the papillae is covered with squamous epithelium, in which epithelial pearls can occasionally be demonstrated. Where there has been much irritation, the epithelium may be thickened and the skin papillae greatly lengthened. The stroma of the papillary growth consists of fibrous tissue. Just beneath the epithelium this may show marked infiltration and greatly dilated blood capillaries. The general appearance, both macroscopically and microscopically, is similar to that of skin papillomata in any part of the body.

Cases of Papilloma of the Umbilicus.

Papillomata of the Umbilicus[?]. — Kiister* cites a case seen by Fabricius von Hilden and recorded in 1526. A man, twenty-five years of age, well nourished, had a fungating excrescence at the umbilicus which had developed in about six months. The tumor was the size of a walnut, bright red in color, and emitted an odor like that of foul cheese. At first it was painless; later there were severe pain and two hemorrhages. Fabricius considered the growth a carcinoma. On exposing the tumor he found that it consisted of three portions, each with a delicate pedicle. He ligated the pedicles and the patient was well five months later.

[This does not seem to have been carcinoma, but suggests rather a papilloma with inflammation of the umbilicus due to accumulation of foul material. Of course, at that time no histologic examination was made. — T. S. C]

In Kuster's Case 8 a man, thirty-six years of age, had had a specific ulcer on the glans penis eight months before. Six weeks prior to observation he noticed that the umbilicus was moist. In the left umbilical fold was a small tumor which grew rapidly. Astringents proved of no value. On examination, in the left side of the umbilical cavity was a pedunculated tumor the size of a phalanx of the little finger; it was movable, and discharged a foul-smelling fluid. It was covered with small red bodies (papillae) and looked like a raspberry. When the umbilicus was split open small papillary outgrowths were found springing from it. [On histologic examination the mass was found to be a simple papilloma covered over with several layers of epithelium. In some places there were epithelial pearls.]

Papilloma of the Umbilicus. — Tillmanns,f after saying that Kiister had described a papilloma of the umbilicus, mentions a case seen by Wilms.

Papilloma of the Umbilicus. ± — In a woman, fifty-four years of

  • Kiister: Die Neubildungen am Nabel Erwachsener und ihre operative Behandlung.

Langenbeck's Arch. f. klin. Chir., 1874, xvi, 234.

f Tillmanns: Deutsche Zeitschr. f. Chir., 1882-83, xviii, 161. % Demarquay: Bull, de la Soc. de chir., 1870-71, 2. ser., xi, 209.


362 THE UMBILICUS AND ITS DISEASES.

age, a tumor developed from a congenital umbilical nevus. This tumor became excoriated, and there was a discharge of bloody fluid. It reached the volume of an egg, and two enlarged glands were noted in the inguinal region. The tumor and the glands were removed. Demarquay says the inguinal glands were not malignant, but that the enlargement was due to irritation from the growth. On histologic examination the growth proved to be a papilloma.

Papilloma of the Umbilicus.* — The patient, a concierge, forty-three years of age, a year before he entered the hospital had noticed an irritation of the umbilicus. In the umbilical depression there were small elevations the size of pinheads. They had gradually increased in size, until six months later the tumor had emerged above the level of the umbilical depression and there were excoriations. At operation the growth was the size of a franc piece, round, with a narrow base. Microscopic examination showed that it was a fibropapilloma of the umbilical cicatrix.

Papilloma of the Umbilicus. — Broussollef reported a case of a child, two months old, who suffered from suppuration at the umbilicus. There was a minute umbilical tumor, reddish in color, 5 mm. in diameter. Microscopic examination showed that it was a true papilloma composed of connective tissue only slightly organized. Its surface was covered with squamous epithelium analogous to that of the skin.

Papilloma of the Umbilicus. | — This case was communicated to Villar by E. Launois. M. H., aged forty-six, was operated upon by Dr. Segond for a very large fibroma of the uterus. At the umbilicus also she had a lobulated tumor, which occupied all the cavity of the umbilical depression. This tumor had first been noticed six years previously. It had increased slowly in volume, its development occurring chiefly in the appearance of small lobules. The mass was very tender on pressure and on palpation. On examination it was found to consist of a series of small elevations juxtaposed to one another. Above and below were two rounded masses. The upper one was the size of a pea, the lower one presented the form and volume of a bean. Between the two were other lobules. The surface of the two voluminous portions was covered with skin which had retained its characteristic appearance, but was wrinkled. The small granulations had a blackishviolet appearance. At first sight the growth suggested a melanotic tumor. The umbilical nodules were included in the abdominal incision when the uterine tumor was removed.

At the base of the tumor were a number of vascular orifices distended with blood. The mass, which was the size of a pea, consisted of a small cyst containing yellowish liquid.

Histologic Examination. — The tumor was divided into three fragments. The fir-t contained the cyst which has been described. The walls were composed of dense connective tissue. At several points in the cyst were remnants of epithelium. The second fragment comprised all the small elevations between the two larger ones. They were composed of a series of papillae. Each papilla was formed of dense connective tissue containing a few nuclei. The skin covering the surface presented

  • Nicaise, M. : Fibro-papillome de la cicatrice ombilicale. Revue de chir., Paris, 1883, iii, 29.

t Broussolle, E.: Des vegetations de I'ombilic. Revue mens, des mal. de l'enfance, 1886, iv. 314. '

% Villar: Tumeura de I'ombilic. These de Paris, 1886, obs. 38, p. 71.


UMBILICAL TUMORS. 363

the usual characteristics. The Malpighian layer was thicker than usual, and many cells contained yellowish-brown pigment. In each of the papillae were numerous capillary vessels anastomosing with one another. The third fragment consisted of the inferior elevation, and was much larger than the first; it was formed of dense connective tissue, and the skin covering was somewhat thinner. The entire growth was evidently a papilloma.

Papilloma of the Umbilicus. — Ledderhose* says that Rizzoli had a patient, fifty-one years old, with an ulcerating papilloma at the umbilicus which was removed with zinc paste.

Fibropapilloma of the Umbilicus. f — M. K., a fireman, aged thirty-five, three months before admission and shortly after a blow in the umbilical region, had noticed a small tumor at the umbilicus. This had steadily increased in size, and latterly caused much inconvenience and at times a dull, throbbing pain. The umbilical cavity was completely obliterated by a prominent, firm growth the margin of which was continuous with the skin of the abdominal wall. This growth was circular, with a diameter of 1% inches. Its surface presented a warty appearance, and was covered with elongated papillary growths varying in size and flattened laterally by mutual compression. The surface of the tumor was pinkish in color, intact, and free from discharge of any kind.

This prominent and warty growth was seated on and continuous with a very hard, thick growth extending all around and into the umbilicus, and forming a subjacent swelling about three inches in diameter. The whole mass was freely movable in all directions. When the growth was removed, the abdomen was examined and found perfectly normal.

On section the tumor was of a dull white color, and its substance, which was of almost cartilaginous hardness, was directly continuous without well-defined margins. It had extended into the surrounding fat and other tissue. . The peritoneum was adherent to the tumor and drawn up into it. The entire tumor presented to the naked eye an appearance very similar to that of a recent specimen of cancer of the mamma.

On histologic examination it was found to consist of fibrous tissue fully developed. The growth was a so-called fibropapilloma.

[Smith's description is a particularly good one. — T. S. C]

Papillary Fibromata of the Umbilicus. — In the literature Pernice| found only seven definite cases of papilloma of the umbilicus, and he added one from the Halle clinic. [These cases did not impress us very definitely as being instances of simple papilloma.] Pernice says that the outer surface of the papilloma, as well as the stroma, is similar to that found in other parts of the body. Where an ulcerated papilloma of the umbilicus exists, a lymphatic swelling of the inguinal glands may follow, but this does not necessarily indicate that carcinoma exists. Where a papilloma is not pedunculated, the diagnosis may be difficult prior to operation. The clinical course of papilloma is benign throughout. He then goes on to report the cases of Kuster, Weber, Billroth, Blum, Villar, and mentions some reported by Duges. In very few of these is it absolutely clear that a careful histologic examination was made. In a second case of Kuster 's the microscopic

  • Ledderhose: Deutsche Chirurgie, 1890, Lief. 45 b.

t Smith, J. : The Lancet, 1890, i, 1013.

% Pernice, L. : Die Nabelgeschwtilste, Halle, 1892.


364 THE UMBILICUS AND ITS DISEASES.

examination showed that the growth was a simple papilloma. Pernice also reports some rather indefinite cases from the clinic at Halle.

Pernice says that when his article was already in the printer's hands he had an opportunity of seeing a rare case of papilloma of the umbilicus observed in a patient coming under the care of Dr. Harttung, of Frankfort. This patient was a woman, fifty-two years old, very corpulent, and previously healthy. Four years before, the umbilicus, which was markedly funnel-shaped, had commenced to be moist. The patient was not cleanly. After some time there was a reddening in the depth with much irritation and itching, which caused the patient to rub the umbilicus. Later on a wart-like appearance was noted. The secretion was much more abundant, and the patient complained of pain.

On examination the umbilicus was found to be much drawn in, very much reddened, and there were excoriated places on the skin about the size of a mark. In the center of this eczematous area was the umbilicus. It was covered with a large number of papillary-like growths, each being about the size of half a grain of wheat. These papillomata resembled in their color and arrangement pointed condylomata. When the abdominal walls were drawn apart, a large number of smaller papillomata were seen and there was a purulent secretion.

No induration could be made out at the base of the tumor, the axillary and inguinal glands were not swollen, and there were no symptoms referable to other organs.

The diagnosis of papilloma of the umbilicus was made, and the growth removed. The tumor was about 2 cm. in height and the skin of the part was raised. From the center of the tumor sprang about 20 or 30 wart-like growths of soft consistence. These were covered with smooth epidermis, and all their ends were somewhat pointed. These papillary masses filled the entire umbilical pocket, which was 2 to 3 cm. deep. Their epidermis was not ulcerated at any point.

The microscopic picture was very simple, and corresponded identically with the picture of the soft warts — in other words, the growth was a true papilloma. Along the edge was perfectly normal skin; toward the center the epidermis became thicker, and between the papillae of the skin the epithelial projections were irregular, sometimes longer and narrower, and at other times thick and plump. The papillary masses consisted of a connective-tissue groundwork with an epithelial covering. The epithelium was here more irregular, and sometimes sent prolongations downward. The masses were, however, simple throughout. On the surface the hornification was somewhat advanced. The connective tissue of the tumor and also of the surrounding skin showed abundant small-round-cell infiltration.

Papilloma of the Umbilicus.* — R. A., aged twenty-seven, had had a swelling at the umbilicus for four months, which discharged a serosanguineous fluid. On admission a tumor, the size of a walnut, was found situated in the center of the umbilicus. At its base it had a violet tint, and at its summit was grayishwhite. It was sessile, soft, and round, resembling a wart. It was very painful on palpation. It was thought to be a papillofibroma of the umbilicus, and was removed under local anesthesia.

The microscopic examination was made by Professor Cornil. The skin was very irregular and in the form of papillae. The papillae on the surface of the tumor were

  • Peraire, Maurice: Fibro-papillome de l'ombilic. Bull, de la Soc. anat. de Paris, 1902,

lxxvii, 346.


UMBILICAL TUMORS. 365

very long, very abundant, tree-like, and formed the depression penetrating the connective tissue. They were composed of dense connective tissue supporting the blood-vessels and were covered with epithelium. Between the epithelial cells were leukocytes. The tumor was a fibropapilloma showing inflammatory reaction, Peraire remarks that this variety of tumor is rare. Villar reported only four cases — those of Kiister, Blum, Nicaise, and Segond.

Papilloma of the Umbilicus.* — Mrs. B. C. C, aged forty-two, a patient of Dr. W. T. Watson, was admitted to the Church Home and Infirmary October 26, 1910. During the abdominal preparation prior to removing the appendix and shortening the round ligaments, we noticed a small papillary mass at the umbilicus. It was excised.

Gyn.-Path. No. 15692. The specimen is 5 mm. broad, 4 mm. long, slightly pedunculated. Its surface is divided into three lobules, which are perfectly smooth and remind one very much of a small fibroma (Fig. 167).

Histologic Examination. — The greater part of the specimen imbibes hematoxylin with avidity. The surface is covered with very atrophic squamous epithelium, the superficial portion of which is hornified. The deepest layer contains yellowish and brownish pigment in places, and reminds one of the skin of a colored person, although the patient is white. Beneath the epithelium is a narrow zone of connective tissue, poor in cell elements, and beneath this again fibrous tissue, literally packed with cells containing oval or round, uniformly staining nuclei. Dividing the fibrous tissue into alveoli are minute arterioles. The fig. 167.— Small papcentral portion of the specimen is made up of fibrous tissue 1LLOM A IN THE Um ~

BILICAL DEPRES poor in cell elements. The picture at first suggests sar- sion.

coma. The surface epithelium is, however, everywhere in- The small growth

, rr-M i • c ii n ui i vi was tabulated, the sur tact. 1 he nuclei of the stroma cells, although exceedingly face of each lobule be _

abundant, are uniform in size and there is no evidence of ing relatively smooth.

nuclear figures. In addition, the clinical history shows that

the patient had had this small nodule for years. It is a simple papilloma of the

umbilicus.

LlPOMATA OF THE UMBILICAL REGION.

In the umbilical depression there is little or no fat, consequently we should not expect to find any fatty tumors in this situation. Tillmanns,t however, points out that Wrany has drawn attention to the fact that, where there is a dilatation of the umbilical ring, some of the subperitoneal fat may escape through the hernial ring, producing an " adipose hernia " or a lipoma, which may be confused with an omental hernia.

A reference to Levadoux'sJ masterly article on the Anatomy of the Umbilicus clearly shows just how such a hernial protrusion may occur at or near the umbilicus.

  • Cullen, Thomas S.: Personal observation.

f Tillmanns: Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia ventriculi), und iiber sonstige Geschwiilste und Fisteln des Nabels. Deutsche Zeitschr. f. Chir., 1882-83, xvhi, 161.

\ Levadoux: Varietes de l'ombilic et de ses annexes. These de la Fac. de med. et de pharm. de Toulouse, 1907, No. 711.



366 THE UMBILICUS AND ITS DISEASES.

LITERATURE CONSULTED ON BENIGN CONNECTIVE-TISSUE GROWTHS OF THE

UMBILICUS.

Barton: Fibrolipoma of the Umbilicus. Dublin Jour. Med. Sc, 1882, lxxiv, 239.

Bennett: See Barton.

Bryant, T. : A Fibronucleated Tumor. Guy's Hospital Reports, 1863, ix, 245.

Broussolle, E. : Des vegetations de l'ombilic. Rev. mens, des mal. de l'enfance, 1886, iv, 314.

Coenen: Das Nabelcholesteatom. Munch, med. Wochenschr., 56. Jahrg., 1909, 1583.

Cullen :, Thomas S. : Papilloma of the Umbilicus.

Damalix: Etude sur les fibromes de la paroi abdominale anterieure. These de Paris, 1886, No.

48. Demarquay : Cancer de l'ombilic. Bull, de la Soc. de chir., 1870-71, 2. ser., xi, 209. Green, CD.: Trans. Path. Soc. of London, 1899, 1, 243. Kiister, E. : Die Neubildungen am Nabel Erwachsener und ihre operative Behandlung. Langen beck's Arch. f. klin. Chir., 1874, xvi, 234. Ledderhose, G.: Deutsche Chirurgie, 1890, Lief. 45 b. Legrand: Tumeur volumineuse de la region ombilicale de nature fibroplastique, prise pour une

tumeur encephaloi'de (fibrome de l'ombilic). Gaz. des hop., 1850, 29. Mori, A.: Contributo alio studio dei tumori ombelicali. Gazz. degli ospedali, Milano, 1902,

xxiii, 632. Nicaise: Fibro-papilloma de la cicatrice ombilicale. Rev. de chir., Paris, 1883, hi, 29. Peraire, Maurice: Fibro-papillome de l'ombihc. Bull, de la Soc. anat. de Paris, 1902, lxxvii, 346. Pernice, L. : Die Nabelgeschwulste, Halle, 1892. Pic, Adrien: Lyon med., 1888, lix, 546. Sauer, F.: Em Fall von Prolaps eines offenen Meckel'schen Divertikels am Nabel. Deutsche

Zeitschr. f. Chir., 1896-97, xliv, 316. Smith, J.: Fibroma of the Umbilicus. The Lancet, 1890, i, 1013. Sourdille, G. : Sarcome pedicule de la peau de l'ombilic. Bull, de la Soc. anat. de Paris, 1895, lxx,

302. Tillmanns: Deutsche Zeitschr. f. Chir., 1882-83, xviii, 161. Villar, F. : Tumeurs de l'ombilic. These de Paris, 1886, No. 19.


DERMOIDS OR ATHEROMATOUS CYSTS OF THE UMBILICUS.*

Judging from the number of cases reported one would infer that dermoids at the umbilicus are by no means rare. Nevertheless, on carefully following the clinical histories and checking up the pathologic findings, one finds that in nearly all the cases the supposed dermoid cyst was nothing more than an umbilical concretion, in the majority of the cases associated with suppuration, and that the diagnosis of dermoid cyst has erroneously been made owing to the presence of the sebaceous material and hairs in the discharge from the infected umbilicus. Villar, in 1886, pointed out this erroneous conception, and several others have also mentioned it.

After carefully analyzing the cases of supposed dermoids or atheromata of the umbilicus that are available in the literature, I have found among them only six that were true umbilical dermoid cysts. These were reported by Kiister, Lotzbeck, Morestin, Lannelongue and Fremont, Hue and Guelliot. These atheromatous tumors were all noted in young patients. In three they were found at birth, in one after the cord came away, and in the remaining two they had been present since childhood.

A dermoid cyst may spring from the umbilical cicatrix or from the side of^the umbilicus. It may reach the size of a walnut and tend to become pedunculated.

  • In this connection we used the words dermoid and atheromatous as synonymous terms.


UMBILICAL TUMORS. 367

It may be tense or occur as a flaccid sac. It contains sebaceous material, which, on histologic examination, yields epithelium, fat-droplets, and frequently cholesterin crystals. The cyst-walls examined histologically have shown an inner lining of squamous epithelium devoid of hairs or glands of any sort, and in none of the cases have hairs been detected in the cyst contents.

The skin covering these cysts is, as a rule, unaltered. In Morestin's case, however, as a result of the rubbing of the clothing, it had become reddened at one point and slight suppuration had occurred, followed by discharge of the characteristic cyst contents.

Detailed Report of Cases of Dermoid or Atheromatous Cysts of the Umbilicus.

Dermoid Cyst at the Umbilicus.* — Case 7. — In July, 1872, Kiister saw a woman, twenty-one years old, who had a tumor at the umbilicus. This had been noted since birth. It was round, soft, and attached to the umbilicus by a pedicle. It sprang from the left of the umbilical depression, and was easily shelled out. It had thin walls, and the sac was filled with atheromatous material, fat, epithelial cells, and cholesterin crystals. No microscopic examination was made of the nodule. It was probably, as Kiister thought, a dermoid.

A Pedunculated Sebaceous Cyst of the Umbilicus.! — A man, twenty-seven years of age, entered the service of Pean. At birth he had had at the umbilicus a tumor the size of a hazelnut. Within five or six weeks before he entered, as the result of pressure produced by a belt, it had increased to four times its original size; it had become red at its prominent part, slightly ulcerated, and a whitish, thick, granular, or clotted material had escaped from it. On examination the tumor was found to be the size and shape of a small fig, and was attached to the umbilical cicatrix. It was lax, a little wrinkled, and gave the sensation of a half-empty pouch. It was not painful on pressure.

The skin covering it was thin. The patient refused operation. A congenital sebaceous cyst was diagnosed.

Cyst of the Umbilicus, Possibly a Dermoid. — Ledderhose,| after saying that the literature on the subject, is scanty, refers to a case reported by Lotzbeck, in which Bruns removed a multilocular tumor the size of a fist from a child two and one-half years old. This had been noticed immediately after birth, and was then the size of a walnut. It contained fluid which was partly clear amber yellow, somewhat alkaline, and partly thick, honey-brown, and gelatinous. The tumor lay between the skin and the rectus. The connective-tissue wall of the cyst contained small, thread-like, cartilaginous deposits, and was lined with a simple squamous epithelium. The contents were fat, cholesterin, and numerous cells.

A Congenital Dermoid Cyst.§ — A child, nine years old, presented in the middle of the umbilicus a hemispheric protuberance the size of half

  • Kiister: Die Neubildungen am Nabel Erwachsener und ihre operative Behandlung.

Langenbeck's Arch. f. klin. Cbir., 1874, xvi, 234.

| Guelliot: Observation de kyste sebace pedicule de l'ombilic. Revue de chir., 1883, iii, 193.

i Ledderhose: Deutsche Chirurgie, 1890, Lief. 45 b.

§ Lannelongue et Fremont: De quelques varietes de tumeurs congenitales de 1'ombiUc et plus specialement des tumeurs adenoides diverticulaires. Arch. gen. de med., 1884, 7. ser., xiii, 36.


368 THE UMBILICUS AND ITS DISEASES.

a walnut. The skin had not changed color. The central portion of the tumor was soft and fluctuating. It was circumscribed, but in the deeper portion adherent. It was not enlarged by crying, was irreducible, and was found to be a cyst. It had been noted immediately after the cord came away, and had enlarged rapidly during the first five or six months of life. At operation it was found to contain sebaceous material.

A Dermoid Cyst at the Umbilicus. — Hue* noted a dermoid cyst of the umbilicus as large as a pigeon's egg. It had been taken for an umbilical hernia. The patient, a girl of nineteen, had carried it from childhood, and had only suffered from some slight inconvenience. The umbilical depression had been replaced by this round tumor. The skin covering it was normal, but the tumor was attached to the umbilical cicatrix by a flattened pedicle. It was soft, painless, and irreducible, but was easily removed. At the meeting of the Medical Society Hue showed photographs of the case. I wrote asking Dr. Hue if he could send me a photograph of the tumor. He replied saying that the photographs had been mislaid, but as soon as he found them he would gladly send me one, but thus far I have not received a second communication from him.

Deve found it to be a cyst covered over with normal skin, and containing a whitish, creamy material without any development of hair. The cyst-wall was scarcely 1 mm. thick, composed of fibrous tissue, and lined with squamous epithelium without hair or glands of any sort. Hue thought it had originated from a nipping-off of a fragment of skin in the umbilical cicatrix following the dropping-off of the cord.

A Dermoid Cyst of the Umbilicus, f — The patient was a male, nineteen years old. Since childhood he had had a small round tumor attached to the umbilicus. A few days before Morestin saw him it had become tender, more prominent, and pink or reddish in color. It had occasioned some suffering. On the night after admission a whitish material was seen escaping from a small opening at the point where the redness had developed.

On examination the nodule was found to be the size of a walnut, whitish red, and occupying the center of the umbilical region. It was attached by a pedicle to the center of the umbilicus. The surrounding skin was normal. The growth was removed under local anesthesia, but the peritoneal cavity was not opened. The cyst contained some greasy whitish material. There were no hairs. Mallet made slides and found an epithelial lining, but no hairs and no glands. He felt sure that the tumor was a dermoid cyst.

A Possible Dermoid of the Umbilicus. — In this case of Villar's it is impossible to determine accurately whether or not the cyst was in reality atheromatous in character. It did not seem to be in any way associated with an inflammation of the umbilicus.

Yillart reports a case of dermoid cyst occurring in the service of Professor Verneuil. M. 0., a Russian officer twenty-seven years old, was seen in consultation June, 1886, for a small tumor of the umbilicus situated exactly in the left of the umbilicus and passing off from the umbilical depression. The tumor

  • Hue, F.: Kyste dermoide de l'ombilic. La Xormandie medicale, 1909, xxiv, 28.

f Morestin, H.: Kyste dermo'ide de l'ombilic. Bull, de la Soc. anat. de Paris, 1909, annee 84, 742.

% Villar: Tumeurs de l'ombilic. These de Paris, 1886, 66.


UMBILICAL TUMORS. 369

was the size of a walnut and semifluctuant. On pressure it did not change in volume. It had been present for a little more than two years and had not increased in size until a short while before. On pressure it was painful. The diagnosis lay between a small umbilical hernia, a cyst, and a lipoma. The tumor was opened with a bistoury and there escaped a clear liquid; a cystic sac remained. The histologic examination was made by Clado. The tumor was as big as a large walnut, was whitish blue, and fibrous in character. The inner surface presented a granular appearance and had a caseous-like covering; the contents were liquid and seropurulent. Microscopic examination showed white blood-corpuscles in large numbers and also some red blood-corpuscles, numerous very attenuated hairs, and small cholesterin crystals. Cultures from the liquid yielded a diplococcus. Examination of the cyst-wall was difficult. In the wall there were neither glandular elements nor hair-follicles. [The origin of this cyst does not seem to be perfectly clear.]

LITERATURE CONSULTED ON DERMOID CYSTS OF THE UMBILICUS.

(See also the literature on Umbilical Concretions, p. 260.)

Bondi, J.: Zur Kasuistik der Nabelcysten. Monatsschr. f. Geb. u. Gyn., 1905, xxi, 729. (From

Schauta's clinic.) Guelliot: Observation de kyste sebace pedicule de l'ombilic. Revue de chir., 1883, iii, 193. Hue, F. : Kyste dermoiide de l'ombilic. La Normandie medicale, 1909, xxiv, 28. Ktister, E. : Die Neubildungen am Nabel Erwachsener und ihre operative Behandlung. Langen beck's Arch, f . klin. Chir., 1874, xvi, 234. Lannelongue et Fremont: De quelques varietes de tumeurs congenitales de l'ombilic et plus

specialement des tumeurs adenoiides diverticulaires. Arch. gen. de med., 1884, 7. ser., xiii, 36. Ledderhose, G.: Deutsche Chirurgie, 1890, Lief. 45 b.

Morestin, H.: Kyste dermoi'de de l'ombilic. Bull, de la Soc. anat. de Paris, 1909, annee 84, 742. Pernice, L. : Die Nabelgeschwulste, Halle, 1892. Villar, F. : Tumeurs de l'ombilic. These de Paris, 1886.

UMBILICAL TUMORS CONSISTING CHIEFLY OF SWEAT-GLANDS.

Three cases have been recorded in which the tumor was supposed to have originated in whole or in part from sweat-glands. These were reported by Wullstein, von Noorden, and Ehrlich.

In Wullstein's and also in von Noorden's case there is some doubt, and from the histories it seems to me that the growths probably originated from Miiller's duct or from uterine mucosa. This point the reader can decide for himself, as they are reported in full on p. 384 and p. 387.

In Ehrlich's case part of the growth consisted of sweat-glands, the remaining portion of uterine glands. The sweat-glands were gathered into definite colonies. Each colony was embedded in a stroma, which was sharply differentiated from the surrounding stroma, although essentially similar in character to it. The epithelium lining the glands was of the characteristic low cuboid variety. Some of the glands were dilated (Fig. 176, p. 383).

On page 398 I have referred to a small aggregation of sweat-glands occurring in an adenomyoma of the umbilicus that came under my personal observation.

Fig. 183, p. 398, from this case reminds one somewhat of the gland grouping found in fibromata of the breast. Although, as a rule, there are no sweat-glands in the umbilicus, nevertheless, the normal skin is so close to it that a tumor consist25


370 THE UMBILICUS AND ITS DISEASES.

ing of sweat-glands might so encroach upon the umbilicus that it could not be distinguished from one growing in the umbilical depression.

In the specimen recently sent me by Dr. Edward G. Jones of Atlanta I found sweat-glands and glands resembling those of the body of the uterus. Part of the small umbilical tumor, which was three-quarters of an inch in diameter, undoubtedly consisted of sweat-glands.


LITERATURE CONSULTED ON UMBILICAL TUMORS CONTAINING SWEAT-GLANDS. WuUstein, L.: Arbeit-en aus dem Path. Inst, in Gottingen, R. Virchow, zum 50. Doctor-Jubilaum,

1893, 245. Von Xoorden: Deutsche Zeitschr. f. Chir., 1901, lix, 215. Ehrlich: Arch. f. klin. Chir., 1909, lxxxix, 742.


AN ABDOMINAL TUMOR ATTACHED TO THE INNER SURFACE OF THE UMBILICUS BY A PEDICLE TWO INCHES IN DIAMETER.

From the description of this case one gathers the impression that the tumor was a myoma. It may have been a myoma that had engrafted itself upon the umbilicus. A few details in the description point to the possibility that the growth was an adenomyoma ("ferous matter"). We know that a small adenomyoma with glands identical with those of the uterine mucosa may be found at the umbilicus. In the cases recorded the growths have been on the outer or skin surface of the umbilicus, but there seems to be no adequate reason why they might not just as well project from the inner or peritoneal side of the umbilicus, producing, as in this case, an abdominal tumor with its pedicle attached to the umbilicus. In the umbilical adenomyomata reported, however, the tumors have always been of small size.

A Hydrops Ascites From a Tumor Depending from the Navel Internally.* — -A multipara, about forty-three years of age, was thought to be pregnant. After going a year she had labor-like pains for eighteen hours. Her periods returned and continued to be regular for eight or nine months. There was then one flooding, after which no further periods were noted. She complained of fulness in the abdomen. Six years later she was tapped, large quantities of fluid being removed from time to time.

The patient finally died. A large carnous excrescence was found depending from the umbilicus by a pedicle two inches in diameter. The tumor was adherent to several parts of the peritoneum, but these adhesions were easily separated with the hand. Xo vessels were seen except those in the pedicle of the tumor. The tumor appeared to be composed of cells communicating with each other. Some contained "ferous matter," others were full of a substance of the consistence of "marrow." From these cells tubes as large as goose-quills and full of the same material passed out into the umbilicus, being contained in a thick, muscular substance of which the neck of the tumor was principally composed. The entire tumor weighed eight pounds. Nothing widely deviating from the ordinary structures was noted in the abdominal viscera.

[At this time no careful histologic examinations were made. The muscular character of the tumor, coupled with the appearance of "ferous matter" and

  • Johnston, William: Medical Essays and Observations, Edinburgh, 1744, v, part ii, 640.


UMBILICAL TUMORS. 371

of spaces as broad as goose-quills filled with the same material, strongly suggests to us the possibility of an adenomyoma. Of course, this is merely surmise. The presence of ascites with a parasitic myoma is not of rare occurrence. — T. S. C]


PAPILLOMA OF THE UMBILICUS SECONDARY TO PAPILLOMA OF THE OVARY.

This is the only case of this character of which we have any record. As will be noted from the history, papilloma of the ovary and secondary abdominal nodules were found at operation in 1898. The patient was seen from time to time, and about six and a half years later a small, partially ulcerated, umbilical nodule was removed. On histologic examination the superficial portions of the nodule showed some inflammatory reaction. The remaining portions were composed of papillary masses covered over with cylindric epithelium and conforming exactly in appearance to the histologic picture of papilloma of the ovary, but differing totally from a primary papilloma of the umbilicus. The relatively benign character of the growth is evident, as the patient was in fair condition over six years after partial removal of the papillary masses from the abdomen.

Papilloma of the Umbilicus Second a r'y to Papilloma of the Right Ovary. — ■ Gyn. No. 6112. F. M., a woman, was admitted to the Johns Hopkins Hospital on May 18, 1898. An exploratory laparotomy was made, and a large sac was removed, together with papillary masses from the peritoneum.

Path. No. 2377. The growth proved to be papillary in origin and came from the right ovary.

Gyn. No. 6523. November 18, 1898: Two liters of ascitic fluid were removed.

November 13, 1899: The abdomen was opened for papillomata of the ovary involving the peritoneum, and also for post-operative ventral hernia.

Gyn. No. 8284. November 7, 1900: An exploratory operation was performed, and 14 liters of ascitic fluid were evacuated. There was a papilloma of the right ovary the size of a child's head and also papillary growths in the parietal peritoneum. In the pelvis was a subperitoneal cystic growth surrounding the rectum on both sides. It did not seem to be made up of papillary masses, but appeared to be due to an effusion of serous fluid beneath the peritoneum. The parietal peritoneum was roughened and reddened.

Gyn. No. 8575. March 13, 1901: Ascitic fluid was removed.

March 20, 1901 : The fistulous opening in the abdominal wall was excised.

March 19, 1905 : A small umbilical nodule was removed by Dr. Hunner.

Path. No. 8417. The superficial portion consists of granulation tissue. The surface is covered with hyaline material embedded in which are a large number of polymorphonuclear leukocytes; beneath this is canalized fibrin, also containing polymorphonuclear leukocytes, and in the depth are dilated capillaries surrounded by young connective-tissue cells. The central portions are well organized. The more protected parts consist of typical papillary masses, large and small. They are covered over with one layer of cylindric ciliated epithelium. The epithelium varies considerably; in some places it is exceedingly high, and in others cuboid. The nuclei may be oval and uniformly staining, or oval and vesicular. The tumor presents the typical picture of papilloma of the ovary, although found at the umbilicus. Some of the papillary masses are well organized. In places the stroma has been replaced by hyaline tissue. In short, we have at the umbilicus a papilloma identical with an ovarian papilloma. On account of irritation from the clothing, the superficial portion has become inflamed and is partly replaced by granulation tissue. It is remarkable that the woman has lived so long, particularly with such wide-spread papillary masses. Some of these patients, however, live for a great many years. In 1894 I* reported a case of double papillocystomata of both ovaries. Fifteen years later I heard from the same patient. She was well and had gained 49 pounds.

  • Cullen, Thomas S.: Johns Hopkins Hosp. Bull, November, 1894, No. 43, 103.



Umbilicus (1916): 1 Umbilical Region Embryology | 2 Umbilical Region Anatomy | 3 Umbilical New-born Infections | 4 Umbilical Hemorrhage | 5 Umbilicus Granuloma | 6 Omphalomesenteric Duct Remnants | 7 Umbilicus Abnormalities | 8 Meckel's Diverticulum | 9 Intestinal Cysts | 10 Patent Omphalomesenteric Duct 1 | 11 Patent Omphalomesenteric Duct 2 | 12 Bowel Prolapsus at Patent Omphalomesenteric Duct | 13 Abdominal Wall Cysts by Omphalomesenteric Duct Remnants | 14 Omphalomesenteric Vessels Persistence | 15 Umbilical Inflammatory Changes | 16 Subumbilical Space Abscess | 17 Umbilicus Paget's Disease | 18 Umbilicus Infections | 19 Umbilicus Abnormalities 2 | 20 Umbilicus Fecal Fistula | 21 Umbilicus Round Worms | 22 Umbilicus Foreign Substance Escape | 23 Umbilical Tumors | 24 Umbilicus Adenomyoma | 25 Umbilicus Carcinoma | 26 Umbilicus Sarcoma | 27 Umbilical Hernia | 28 The Urachus | 29 Congenital Patent Urachus | 30 Urachus Remnants | 31 Urachal Remnants Producing Tumors | 32 Large Urachal Cysts | 33 Anterior Abdominal Wall Abscesses | 34 Urachal Cavities | 35 Umbilicus Acquired Urinary Fistula | 36 Urachal Concretions and Urinary Calculi | 37 Urachus Malignant Changes | 38 Urachus Bleeding into the Bladder | 39 Patent Urachus Tuberculosis | Figures

Reference

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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