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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 XXV. Carcinoma of the Umbilicus

General consideration.

Classification.

Primary squamous-cell carcinoma of the umbilicus.

Primary adenocarcinoma of the umbilicus; report of cases.

Carcinoma of the umbilicus secondary to carcinoma of the stomach; symptoms; treatment; detailed report of cases.

Carcinoma of the umbilicus secondary to cancer of the gall-bladder; report of cases; personal observation.

Carcinoma of the umbilicus secondary to cancer of the intestine; report of cases.

Carcinoma of the umbilicus secondary to ovarian carcinoma; report of cases; personal observation.

Carcinoma of the umbilicus secondary to carcinoma of the uterus.

Cases of secondary carcinoma of the umbilicus in which the source of the primary growth was not determined.

A retroperitoneal carcinoma accompanied by cancer of the umbilicus.

In an article on Surgical Eiseases of the Umbilicus which I read before the Surgical Section of the American Medical Association in June, 1910, and which was published in the Journal of February 11, 1911, the subject of umbilical cancer was briefly referred to, and several cases that had come under my observation were reported. In the present article cancer of the umbilicus will be much more fully considered, and the cases hitherto recorded in the literature brought together. Associated intimately with the early development of the subject. of carcinoma of the umbilicus are the names of Parker,* Chuquet,f Villarj Feulard,§ Burkhart,|| Ledderhose,** Neveujt Morris,|J Pernice,§§ Quenu and Longuet,|||| Le Coniac,*** and Besson.tft Many other authors have enriched the literature by publishing individual cases.

Before discussing the malignant epithelial growths occurring at the umbilicus, it may be well to refresh our minds as to the histologic appearance of the normal

  • Parker, W. : Excision of Umbilicus for Malignant Disease. Arch. Clin. Surg., New York.

1876-77, i, 71.

t Chuquet : Du carcinome generalise du peritoine. These de Paris, 1879, No. 548. i Yillar, Francis: Tumeurs de 1'ombilic. These de Paris, 1886.

§Feulard: Fistule ombilicale et cancer de l'estomac. Arch. gen. de med., 1887, 7. ser., xx, 158.

|| Burkhart, 0.: Ueber den Nabelkrebs. Inaug. Diss., Berlin, 1889.

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

ffNeveu: Contribution a l'etude des tumeurs malignes secondaires de l'ombilic. Paris, L890.

%X Morris: .Malignant Disease of the Navel as a Secondary Complication. Verhandl. d. 10. Internat. Med. Cong., 1890, Berlin, 1891, iii, 7. Abth., 122. §§ Pernice, L.: Die Nabelgeschwiilste, Halle, 1892.

Qu£nu and Longuet : Du cancer secondaire de l'ombilic. Rev. de chir., 1896, xvi, 97. "* Le Coniac, H. C. J. : Cancer secondaire de l'ombilic, consecutif aux tumeurs malignes de l'appareil utero-ovarien. ThSse <\<- Bordeaux, 1898, No. 19. -_„ttt Besson, E.: Cancer de l'ombilic. These de Paris, 1901, No. 263.

400


CAKCINOMA OF THE UMBILICUS. 401

umbilicus and as to the umbilical lymphatics. The umbilical scar is covered over with a very thin squamous epithelium and is devoid of hair-follicles, sweat-glands, and sebaceous glands.

In a few cases remnants of the omphalomesenteric duct have been detected at the umbilicus. These may be recognized as small fistulous tracts or as cysts lying between the peritoneum and the rectus muscle, or just beneath and communicating with the skin. In a few instances remnants of the omphalomesenteric duct have been present as small tubular glands opening directly upon the surface of the umbilical depression. Such a case has been particularly well described by Fox and MacLeod* (p. 268).

From the above description it is evident that, while, as a rule, we have only a very attenuated squamous epithelium at the umbilicus, in some cases cylindric epithelium is present. Consequently we can have two varieties of primary carcinoma in this region.

The careful study of many umbilical lesions in the past has demonstrated that, when the liver is involved in a malignant growth which has extended to or encroached upon the suspensory ligament, the growth tends to pass by way of the lymphatics out along the suspensory ligament to the umbilicus. Where a malignant pelvic growth extends to the umbilicus, it usually follows the lymphaties found in the course of the remnants of the obliterated umbilical arteries and urachus upward to the umbilical depression. If the umbilicus is the seat of a malignant growth, either the inguinal or axillary glands may be secondarily involved, according as the growth occupies the upper or lower part of the umbilicus. The lymphatics of the umbilical region are considered at length in Chapter II.

From a study of the literature it is found advisable to divide carcinomata of the umbilicus into two main groups — those that are primary, and those that are secondary to some intra-abdominal tumor. Each of these groups may be subdiv ded as follows :

1. Squamous-cell carcinoma.

2. Adenocarcinoma.

1. From the stomach.

2. From the gall-bladder.

3. From the intestine.

4. From the ovaries.

5. From the uterus.

6. From other abdominal organs.


A. Primarv umbilical carcinoma.


B. Secondary umbilical carcinoma, i


Cancer of the umbilicus, whether primary or secondary, is exceptionally rare.f Thus, according to Parker (1876), Walshel states that Tanchou found that the mortuary register of Paris and two adjacent arrondissements yielded 9118 deaths from cancer between the years 1830-40 inclusive, and that in only two instances was the umbilicus the seat of the carcinoma. With the early recognition of abdominal lesions and their timely surgical treatment, carcinoma of the umbilicus will in all probability diminish instead of increase.

  • Fox and MacLeod: A Case of Paget's Disease of the Umbilicus. Brit. Jour. Dermatol., 1904,

xvi, 41.

1 1 have carefully read Sir William Osier's splendid series of lectures on the Diagnosis of Abdominal Tumors, published in vols, lix and lx of the New York Medical Journal, 1894. but failed to find any case in which the umbilicus was the seat of a secondary carcinoma.

i Walshe: Nature and Treatment of Cancer, London, 1S46, 92. 27


402 THE UMBILICUS AND ITS DISEASES.

PRIMARY SQUAMOUS-CELL CARCINOMA OF THE UMBILICUS.

Malignant squamous-cell growths occurring at the umbilicus are exceedingly rare. Hannay,* in 1843, reported a case of scirrhous cancer of the umbilicus. A microscopic examination was. however, not given, and it is impossible to determine whether or not the growth was primary.

Pernice'sf Case 77 from Yolkmann's clinic is more suggestive. The patient for a long while had had an umbilical stone. A carcinoma developed, and there was a purulent secretion. When Volkmann saw him, there was an ulcerated area the size of a thaler. On account of the cauliflower-like walls the growth was diagnosed as a cancroid (squamous-cell) carcinoma. The diagnosis was probably correct, although we have no data as to any histologic examination. It would seem that in this case the constant irritation of the foreign body had stimulated the development of a malignant growth.

Pernice, in his Case 79, reports another carcinoma, also from Yolkmann's clinic. The patient was a man, fifty-nine years of age, and of uncleanly habits. Xot long before admission he had noticed a large number of brownish-looking spots all over the body. These varied in size from a finger-nail to a lentil. When the crusts were removed, there was free bleeding. For six or eight years he had noticed moisture around, and an odor from, the umbilicus. He consulted a physician, who removed several small particles of secretion. The walls of the umbilicus formed a cuff of cancroid or epithelial cancer. When Volkmann saw the patient, it was the size of a thaler and secreted a great deal. There was marked infiltration of the abdominal wall. The abdomen was opened during the operation. The patient died of sepsis in thirty-six hours. No further details of this case are given. The growth was evidently a primary carcinoma of the umbilicus, and in all probability had developed from the squamous epithelium, as indicated by the mode of origin and the slow growth. These are the only cases I could find suggesting a primary squamous-cell carcinoma of the umbilicus.


PRIMARY ADENOCARCINOMA OF THE UMBILICUS. In the cases reported in the literature it is very difficult to determine accurately whether the umbilical tumors were primary or secondary. Where the patient gave no history of any abdominal lesion, and where careful abdominal inspection before and at operation brought to light no evidence pointing to the existence of any other primary abdominal growth, one may, with a relative degree of certainty, conclude that the tumor was primary at the umbilicus. Still it must be remembered— as was clearly demonstrated in Valette's case — that, although a careful visual and manual examination may fail to reveal any priman* cancer in the stomach, such a growth may nevertheless exist. In Valette's case, when the umbilical growth was removed, the stomach was brought up into the wound for examination, and was apparently free from disease. The patient died of peritonitis, and at autopsy a latent carcinoma of the stomach was found. The absence of an}* abdominal symptoms for a period of two or three years after a removal of an umbilical carcinoma is the most certain proof that the growth has originated in the umbilicus.

  • Hannay: Edin. Med. and Surg. Jour., 1843, lx, 313.

t Pernice, L. : Die Nabelgeschwiilste, Halle, 1892.


CARCINOMA OF THE UMBILICUS. 403

Pernice found in the literature 21 cases of what he considered primary carcinoma of the umbilicus. In this number he included both the squamous-cell and the glandular variety. I have discarded several of the cases included in his group, and have added several recorded since his valuable monograph was written in 1892 ; and still the actual number of cases remains uncertain. In the cases reported by Dejerine and Sollier, Bonvoisin, Forgue and Riche, Hue and Jacquin, Maylard, Parker, and Tillaux and Barraud, the growths seem, without a doubt, to have been primary. The growths reported by Ajello, Burkhart, Despres, Dannenberg, Demarquay, Giordano, Guiselin, Heurtaux, Ippolito, Jores, Lewis, Stori, and Wagner were also probably primary adenocarcinomata of the umbilicus, although the evidence in these cases is not quite so convincing. In Besson's case the picture \/ suggested to some extent the presence of an umbilical tumor containing uterine glands. Hertz's case need be only mentioned here. From the description the growth does not seem to have been a carcinoma, but resembled in some degree the type of umbilical tumors containing uterine glands.

Pernice's Case 78 bears a striking resemblance to that reported b\ r Fox and MacLeod. The man was seventy-two years of age, and the commencement of the umbilical growth dated back five or six years. It was the size of a two-mark piece, and was here and there covered with hard crusts. It looked very much like a rodent ulcer. On microscopic examination it was found to be a slowly growing, relatively benign carcinoma of the epithelium. Here and there a definite tendency toward gland formation was noted. It is quite possible that these glands were remnants of the omphalomesenteric duct, and that the proliferation of the squamous epithelium was similar to that noted in the case reported by Fox and MacLeod, and designated as Paget's disease of the umbilicus.

In Doderlein's case and in Pernice's Case 76, although the umbilical growths were considered as primary, they would seem to have been secondary to an abdominal lesion.

Primary adenocarcinoma of the umbilicus usually develops as a very small nodule in the umbilical depression, which may grow slowly or rapidly. In some cases it has not been larger than a small nut; in others it has reached the size of a walnut or a hen's egg. Such a tumor has been known to grow to the size of a fivefranc piece in the course of six months. It may be smooth or have a slightly papillary surface. With the increase in size there is a tendency for the surrounding tissue to become infiltrated. The central portions of the nodule tend to ulcerate, and these areas of ulceration may be covered over with crusts. The ulceration is naturally accompanied by serous secretion, and occasionally by some bleeding.

Histologically nearly all these growths have been put down as adenocarcinomata of the type usually developing from the small intestine. This is but natural, as they originate from remnants of the omphalomesenteric duct.

Age. — In the cases which I have collected and in which the age was given, the youngest patient was thirty-seven, the oldest, seventy-six.

Under 40 years 2 cases

Between 40 and 50 2 cases

" 50 and 60 7 cases

" 60 and 70 6 cases

" 70 and 80 5 cases


29


z cases


404 THE UMBILICUS AND ITS DISEASES.

Sex. — Of 20 patients of whom I have records on this point, 9 were men and 11 women. This tends to show that the disease is equally prevalent in both sexes.

Treatment. — This naturally consists in the wide removal of the umbilicus, care being taken not to spread the carcinoma cells into the surrounding healthy abdominal wall. The inner surface of the umbilicus should be carefully examined to see if adhesions exist, and then, after fresh abdominal dressings have been applied, a systematic inspection of the abdominal viscera should be made to exclude the possibility of carcinoma of the stomach, intestine, or pelvic organs. If no abdominal focus be found, and provided a wide removal of the growth has been possible, the prognosis is relatively good.

Detailed Report of Cases of Primary Adenocarcinoma of the Umbilicus.

In the majority of the cases the umbilical tumors were undoubtedly primary, but in several it is not certain that they were not secondary to some intra-abdominal growth.

A Primary Adenocarcinoma of the Umbilicus. [ ? ] — Ajello's* patient was a woman, sixty-four years old, from whom an umbilical growth was removed. He gives a picture of the outer surface and also of the smooth peritoneal surface of the tumor.

Histologic examination showed a definite regular glandular growth. Ajello then discusses the literature.

Primary Cancer of the Umbilicus. — Bessonf reports the case of a woman thirty-seven years of age. The patient's father had died of some pulmonary trouble, the mother of cancer. This woman, ten years before, on making an extra effort, had complained of intense pain at the umbilicus, and later noticed a small tumor developing in the umbilical cicatrix. It was the size of the last phalanx of the index-finger, and was hard in consistence. Elevation of the arms increased the sensitiveness at the umbilicus. The region was also somewhat painful at the menstrual period. The patient had been assured that the tumor was not reducible. It had increased in size quite slowly. According to the patient, during the last four months it had become painful and larger, and the skin had become violet in color. There had been some emaciation, associated with paleness. When the patient entered the hospital, the umbilical cicatrix formed a crescent with the concavity directed downward. Palpation showed that this elevation was produced by a solid tumor which was hard and about the size of a mandarin orange. The skin was not movable over the tumor, as it was adherent at the umbilical cicatrix. The tumor was removed, and the patient made a good recovery.

Histologic examination showed that it was composed of fibrous tissue and of a glandular growth similar to that developing from intestinal glands. When seen four years later, the patient was perfectly well. The growth was diagnosed as a cylindric-cell carcinoma. It had developed at the umbilical cicatrix, and was covered with skin. It consisted of fibrous tissue and glands lined with cylindric epithelium resembling that of the adult or embryonic Lieberkuhn's glands. The epithelial cells had infiltrated into the stroma, and there was a tendency to invade the surrounding tissue.

  • Ajello: Contribute alia genesi embrionale di un adeno-epitelioma cistico primitivo dell'

ombelico. From Tansini's Clinic. j La Riforma medica, 1899, anno 15, iii. 663. f Besson : Cancer de l'ombilic. These de Paris, 1901, No. 263, 66.


CARCINOMA OF THE UMBILICUS. 405

Primary Adenocarcinoma of the Umbilicus. — Bonvoisin,* after citing a case already described by Tillaux, reports a second also from Tillaux's service. The patient, a man sixty-four years of age, had the general appearance of a sick person. He had been ill for about two months. At the umbilicus was a brawny excrescence. There was no history of injury. When the nodule was first noticed it was the size of a small pea. In about fifteen days it commenced to ulcerate and the physician thought it was eczema. At the time of Tillaux's examination the umbilicus had disappeared and had been replaced by a shallow area of ulceration covered with a blackish crust surrounded by an area of inflammation several millimeters in diameter. The total zone of inflammation was the size of a five-franc piece and about 1 cm. broad. The mass was immobile vertically, but could be pushed from side to side. There was no enlargement of the axillary or inguinal glands.

The umbilicus was removed, but the patient died. Autopsy failed to reveal any peritonitis, and the peritoneal portion of the growth was free from adhesions. The stomach and intestines were normal. The growth was a primary adenocarcinoma of the umbilicus and had evidently originated from remains of a fetal structure. Ducellier made the microscopic examination in Prof. CorniFs laboratory.

Primary Carcinoma of the Umbilicus. — Dannenbergt reports the case of a day laborer, seventy-one years old, operated upon by Maas. For three months before admission he had complained of pain in the umbilicus, and now showed an umbilical tumor 3 cm. broad, 2.5 cm. long, and raised 5 mm. above the surface of the abdomen. There was a dark-red, funnel-shaped ulceration in the middle. The tumor was firm in consistence and the surrounding tissue was infiltrated. There was pain on contraction of the abdominal muscles, and swelling in the inguinal glands, more marked on the left than on the right side. The appetite was good. When the tumor was removed, the peritoneum was found perfectly free at the umbilicus. The patient made a good recovery.

Microscopically, solid nests were here and there visible, and at other points cavities lined with one layer of cylindric epithelium. The tumor was diagnosed as a scirrhous carcinoma, but from the description it would seem to have been an adenocarcinoma. [Although there are many points suggesting a primary growth in this case, in the absence of a most thorough abdominal examination it is impossible to say that it might not have been secondary. — T. S. C]

  • > Primary Adenocarcinoma of the Umbilicus. J — At an

autopsy on a man, fifty-four years of age, who had had tabes for eleven years, a tumor of the umbilicus was found, circular in form, about 7 or 8 cm. in diameter and 5 to 6 cm. thick. It lay in front of the aponeurosis, and had not encroached on the peritoneum. It was an adenocarcinoma. There was no evidence of metastases. This tumor was looked upon as a primary carcinoma of the umbilicus.

Carcinoma of the Umbilicus. — Demarquay's§ patient, fiftyfour years of age, had a tumor the size of an egg at the umbilicus. She had had a congenital nevus at the umbilicus, and this had started to increase in size two years

  • Bonvoisin, G. : Etude pathogenique et histologique sur une variete de l'epitheliome de

l'ombilic. These de Paris, 1891, No. 305.

f Dannenberg, O. : Zur Casuistik der Nabeltumoren insbesondere des Carcinoma umbilicale. Inaug. Diss., Wurzburg, 1886.

t Dejerine et Sollier: Bull. Soc. anat, de Par., 1888, 649.

§ Demarquay: Cancer de l'ombilic. Bull. Soc. de chir. de Par. (1870), 1871, 2. ser., xi, 209.


406 THE UMBILICUS AND ITS DISEASES.

before her admission. The tumor had become excoriated, was painful, and there was a small amount of hemorrhage. Demarquay hesitated to operate on account of two small tumors in the inguinal region. These, however, were looked upon as papillomata of the inguinal glands, not malignant, but caused by irritation from the umbilical growth. The general health of the patient became poor, and a fatal issue seemed probable.

/\ Carcinoma of the Umbilicus (Primary or Secondary?) .* — The patient, a man of seventy-four years, complained of pain when the clothes came in contact with the umbilicus. Situated in the umbilicus was a reddish nodule the size of a pea, which was slightly blood-tinged. The tumor increased rapidly and reached the size of a two-franc piece. It was removed, and examination proved it to be an adenocarcinoma. There were no signs of any other growth. ^ Primary Adenocarcinoma of the Umbilicus. — Doederlein'sf patient was a woman fifty-five years of age. Three months before admission she had first noticed a small, hard, painful tumor at the umbilicus. Four weeks before coming under observation the tumor had shown a small ulcer on its surface. The physician that saw her had diagnosed inflammation of the umbilicus, and ordered moist applications. The condition had become worse, and several other ulcers had developed around the umbilicus. When Doederlein saw her, the umbilicus was funnel-shaped and drawn in. The entire skin of the umbilicus was very thick, and the underlying parts were fixed. The surface was ulcerated, and there was a serous secretion. In the vicinity of the umbilicus were numerous dilated blood-vessels. Diffusely scattered, particularly toward the symphysis, were small hard nodules in the skin, the size of millet-seeds or linseeds. These on pressure were not painful. In both inguinal regions were hard packets of tumors the size of a goose's eggs. They were somewhat movable, and on pressure were not painful. Under anesthesia the umbilicus was widely removed. When the abdomen was opened, the peritoneum in the vicinity of the umbilicus was found to contain numerous small nodules. The umbilical tumor was removed, and the inguinal growths were dissected out. The patient died ten days later in collapse.

The portion of the abdominal wall removed was 20 by 12 by 4 cm., and the umbilical funnel was 2.5 cm. deep. The skin over the prominence of the umbilicus was somewhat stretched. On both sides of the umbilical depression were small superficial ulcers. These had irregular margins and somewhat reddened and dirty surfaces. In general the condition suggested that the depth of the umbilicus had consisted of small tumors which had pressed the skin forward and tended to break through. On palpation one could feel the nodules beneath the surface of the skin, and in the umbilical depression they merged with one another, forming a hard mass. A sharp outline between the skin and the tumor was macroscopically impossible.

On histologic examination the umbilical growth was found to be an adenocarcinoma; the enlargement in the inguinal glands was also due to carcinomatous involvement.

The liver contained about 20 irregular, small metastases on its surface. These varied from a millet-seed to a bean in size. There was also one on the anterior surface of the gall-bladder. The gall-bladder contained stones. In the visceral

  • Despres: Bull, et Mem. Soe. de chir. de Par., 1883, ix, 245.

t Doederlein, F.: Ein primares Adenokarzinom des Nabels. Inaug. Diss., Erlangen, 1907.


CARCINOMA OF THE UMBILICUS. 407

peritoneum were about 60 or 80 nodules. Doederlein came to the conclusion that the growth in the gall-bladder was a secondary one.

[From the evidence at hand it is impossible for us to determine whether the umbilical carcinoma was primary or secondary. — T. S. C]

<? v P r i m a r y Adenocarcinoma of the U mbilicus. — Forgue and Riche* report the case of a woman, aged fifty-six, who six months before coming under observation had noticed a reddish point at the umbilicus. At the time she was operated on it was the size of a five-franc piece and indurated, and for four months there had been a slight ulceration which emitted at times a bloody discharge. Xo abdominal tumor could be demonstrated at operation. The pelvis was empty; no enlarged glands could be detected. The tumor was removed 1 , and on microscopic examination proved to be a typical adenocarcinoma. The glands in some places resembled those of Lieberkiihn.

The patient was well twenty-two months after operation. This tumor would seem to have been a primary adenocarcinoma which had probably developed from remains of the omphalomesenteric duct.

\> Probable Primary Carcinoma of the Umbilicus. -| — ■ The patient, a porter aged thirty-eight, had a papillary-like growth at the umbilicus from which there was bloody discharge. The growth varied from 10 to 15 mm. in diameter. The pictures given by Giordano are excellent. He thought he was dealing with a primary carcinoma of the umbilicus. He gives a short review of the literature.

Primary Carcinoma of the Umbilicus. — Guiselint reports a case observed by Villar that had not yet been published. The woman was sixtyfour years of age, a music teacher. Her father had died at seventy of cancer of the tongue. For five months she had noticed a small, painless enlargement at the umbilicus. The tumor had increased gradually in size and had become reddish in color during the two months before she was seen by Guiselin. On examination the umbilicus was found to be violet in color, and a tumor, the size of a hazelnut, occupied the umbilical depression. It presented bosses, was hard, adherent, and reducible. When the abdomen was opened, no tumor could be made out in the intestinal tract, stomach, liver, or genital organs.

Histologic examination showed the growth to be epithelial in character and of a cylindric type. It appeared to be a primary adenocarcinoma of the umbilicus.

Adenocarcinoma of the Umbilicus. [?]§ — The woman, fiftyeight years of age, had a tumor the size of a small hazelnut at the umbilicus. This was very soft and reddish gray in color. Microscopic examination showed glandspaces surrounded with loose connective tissue. The epithelium in some places was one and in others several layers in thickness. There were also " Schichtungsperlen, " but a real hornification did not exist. In other places there was a definite malignant growth of the glands. Hertz says that, although the growth was malignant, it must have developed from the epithelium of the intestine or of the omphalo

  • Forgue et Riche: Alontpellier med., 1907, 2. s., xxiv, 145-169.

t Giordano, D. : Sopra un caso di cancro dell' ombelico. La Medicina Italiana, 1911, ix, 6. + Guiselin: Du cancer de l'ombilic. These de Bordeaux, 1906, No. 47.

§ Hertz: L'eber einen Fall von Adenocarcinom des Nabels bei einer 5S-Jahrigen Frau. Inaug. Diss., Wurzburg, 1905.


408 THE UMBILICUS AND ITS DISEASES.

mesenteric duct. [The growth strongly suggests an umbilical tumor containing uterine glands. — T. S. C]

Carcinoma of the Umbilicus.* — The patient was fifty-one years old. A small tumor had developed at the umbilicus a few months after she had received a blow. Microscopic examination showed that it was a cylindric-cell carcinoma.

Probable Primary Cancer of the Umbilicus.f — The patient, a soldier forty-five years of age, had a nodule at the umbilicus. This was opened and was thought to contain pus, although there was only a slight discharge. It became fungating, and grew as large as a fist. There was bladder involvement. Whether the growth was primary or not was uncertain.

Microscopic examination showed that it was a carcinoma, apparently of the adenocarcinomatous type. Autopsy revealed no growth in the intestine or stomach.

The fungating process was probably hastened as a result of the cutting; consequently I omit any description of the umbilicus.

Adenocarcinoma of the Umbilicus. — IppolitoJ gives a brief review of the literature and then reports the case of a woman fifty-one years of age. An umbilical growth was removed, which microscopically proved to be an adenocarcinoma of the intestinal type. Ippolito thought it was primary, but there is no note made of any careful abdominal examination. [Possibly it was a secondary growth.— T. S. C]

Probable Adenocarcinoma of the Umbilicus. § — The tumor was removed by Professor Witzel; it was the size of a walnut. The peritoneum was intact. The tumor on section was hard, firm, and appeared to be encapsulated in fibrous tissue. On microscopic examination it. proved to be an adenocarcinoma of the type resembling that usually found developing in the stomach. Examination of the patient did not give any evidence of cancer in the abdomen. This was probably a primary growth.

A Malignant Tumor in an Umbilical Hernial Sac. j | — The patient was sixty-seven years of age and had had an umbilical hernia for fifteen years. No truss had been used, but the hernia had been reduced without difficulty until a year before. Pain in the umbilicus increased rapidly and radiated to the stomach and the pelvic region. The patient lost flesh and strength and had frequent vomiting, with constipation and diarrhea.

On examination a hard, nodulated, bluish-red tumor was found at the umbilicus. Its surface was slightly ulcerated. The sac contained omentum, which was not diseased, and also subperitoneal tissue infiltrated as far as a finger could reach. The growth was removed, but the patient died of shock six hours later. Microscopic examination showed a malignant growth, which the author thought was a sarcoma connected with Lieberkiihn's glands, although he questioned whether or not it might represent remains of the omphalomesenteric duct. The case is not very clear, but the tumor was evidently malignant.

  • Heurtaux: Epitheliome de l'ombilic. Gaz. med. de Nantes, 18S6, iv, 46.

t Hue et Jacquin: Cancer colloid e de la l'ombilic et de paroi abdominale anterieure ayant envahi la vessie. L'Union med., 1868, 3. ser., vi, 418.

i Ippolito: t it caso d'epitelioma dell'ombelico. Gazz. Internaz. di med., 1901, iv, 302.

§ Jores: Cylinder-Epithelkrebs des Nabels. Vereins-Beilagc der Deutsch. med. Wochenschr., 1899, xxv, 22.

|| Lewi.-,: Med. Record, 1889, xxxvi, 394.


CARCINOMA OF THE UMBILICUS. 409

Cylindric-cell Carcinoma of the Umbilicus.* — The specimen was from a man sixty-five years of age. For two months before admission he had complained of pain in the lumbar region. He had not noticed the umbilical nodule until it was pointed out to him by the doctor. A small projection the size of a pea was readily seen and felt in the pit of the umbilicus. On deep palpation it appeared to be larger. It was removed through an elliptic incision. The peritoneal surface was puckered. On section, the tumor presented a solid appearance.

Microscopic examination showed a cylindric-cell carcinoma. Maylard suggested that it had developed from the omphalomesenteric duct. Macewen, in the discussion at the Glasgow Path, and Clin. Society, before which this case was reported, said he had seen two similar cases, but when brought to him both patients already had advanced peritoneal disease. Each of the umbilical growths was considered primary. In one case pain in the back was thought to be due to the involvement of the liver, as found at autopsy.

Primary Carcinoma of the Umbilicus. f — A woman seventy-six years of age, had a malignant growth at the umbilicus. The disease gradually progressed and she died. At autopsy the feasibility of an operation for the removal of the mass forcibly impressed itself on Parker. The growth was evidently primary.

Primary Carcinoma of the Umbilicus. % — Case 76. — Volkmann removed from a man, seventy-four years of age, a squamous-cell carcinoma the size of a hen's egg from the umbilicus. The omentum was already degenerated with carcinomatous nodules, and death followed five months later with abdominal carcinoma and ascites. The growth was not glandular.

Primary Carcinoma of the Umbilicus. § — ■ Case 78. — A forester, seventy-two years of age, came to Volkmann suffering from an ulceration at the umbilicus the size of a two-mark piece, which had first begun some five or six years previously. Here and there it was covered with hard crusts. The condition strongly suggested a rodent ulcer. On microscopic examination it proved to be a slowly growing, relatively benign, carcinoma. The slightly thickened walls of the ulcer were excised, the abscess was cureted out and freely cauterized, and a plaster laid over it. The wound healed speedily, and the man had no return of the growth, but died of pneumonia four or five years later. Examination of the tumor showed no evidence of a horny layer or of nests of cells resembling those of the rete Malpighii . Here and there was a definite tendency toward gland formation.

[It is quite possible that in this case there were remains of the omphalomesenteric duct at the umbilicus, as seen in Fox and MacLeod's case, which they diagnosed as Paget's disease of the umbilicus (see p. 268). — T. S. C]

Adenocarcinoma of the Umbilicus. || — The patient, sixtyeight years of age, for nearly a year had complained of discomfort just above the umbilicus, which was continuous and independent of digestion. At the umbilicus was an indurated area, the size of a pigeon's egg. When seen at operation, it was

  • Maylard: Trans. Glasgow Path, and Clin. Soc, 1886-91; 1892, iii, 294.

t Parker: Excision of Umbilicus for Malignant Diseases. Arch. Clin. Surg., Xew York, 1876-77, i, 71.

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

§ Pernice, L.: Op. cit.

|| Stori: Contribute alio studio dei tumori dell'ombelico. Lo Sperimentale, Arch, di biologia normale e patologia, 1900, liv, 25.


410 THE UMBILICUS AND ITS DISEASES.

ovoid in form, 6 cm. in its longest diameter, and 4 cm. broad. It seemed to be a primary tumor of the abdominal wall. It was removed, and the patient died of peritonitis. Microscopic examination showed that the growth was an adenocarcinoma.

[Whether this was primary or secondan- is uncertain. — T. S. C]

Carcinoma of the Umbilicus Developing in the Depth of an Umbilical Diverticulum.* — The patient, a woman forty years of age, entered the hospital for an umbilical tumor. In childhood she had had no serious diseases. Seven months previously, while bathing, she had noticed a small crust at the umbilicus. This she had removed, and had seen a small, darkred tumor the size of a lentil. There was no ulceration and no discharge. It had increased steadily in size and had been cauterized, but had reappeared as a small but rapidly growing tmnor. At the end of three weeks it had ulcerated, and there had been slight hemorrhages. On admission the entire umbilicus was found transformed into a tumor about the size of a ten-centime piece. It was .circular and bulging. It was dark red, ulcerated, and cup-shaped over an area the size of a fivecentime piece. The surrounding tissue was indurated. No axillary or inguinal gland enlargement was noted. The patient was in good condition and had no indigestion. An extensive removal was made. The omentum was not adherent, and no abdominal lesion was noted. Recovery followed.

Cornil made the following report: "The tumor consists of a cylindric-cell epithelioma. The epithelioma is analogous to that which develops primarily in the intestinal glands." [Of course, the length of time — about four months — was too short to warrant a final prognosis. — T. S. C]

Carcinoma of the Umbilicus, f — A woman, aged forty, who had had 12 children, two years previously had noticed two pea-sized bodies in the skin on the left side of the umbilicus, winch had grown gradually for eighteen months. Blisters had formed and broken, discharging a foul-smelling pus. On admission the tumor was 43^ inches in its longest diameter and 11 inches in circumference; it was lobulated and had a dirty, ulcerated surface, covered with a foul-smelling discharge. Xo other local manifestations were detected. The growth was removed in 1816 and the patient recovered. Naturally, at that time there was no microscopic examination. ^ [The duration is strongly indicative that this growth was primary, in view of the fact that, when the umbilical growth is secondary, the primary tumor usually causes death in the course of five or six months. — T. S. C]

A Supposed Sub malignant Adenocarcinoma of the Umbilicus. — From the history this growth seems to have been primary. Its situation and relation would suggest its origin from the urachus, but Koslowski says that the glands in it were of the intestinal type. It is probable that it had developed from extraperitoneal remnants of the omphalomesenteric duct. As it does not nsemble any case heretofore described, I have allotted it a separate place.

Koslowski'si patient was operated upon in October, 1902. Five weeks before, he had noticed, in the mid-line, between the symphysis and umbilicus, a small

  • Tillaux and Barraud: Epithelioma de l'ombilie, developpe aux depens d'un diverticule

intestinal; omphalectomie, guerison. Annales de Gyn., Paris, 1887, xxvii, 401.

f Wagner: Abtragung eines carcinomatosentarteten Nabels. Med. Jahrb. d. k. k. oster. 31 lates, Wien, 1839, n. F., xviii, .585-589.

i Koslowski: Ein Fall von wahrem Xabeladenom. Deutsche Zeitschr. f. Chir., 1903, lxix, 469.


CARCINOMA OF THE UMBILICUS. 411

painful tumor which grew to the size of a walnut. The abdominal pain radiated. On examination the man, although only fifty-five years old, was markedly emaciated and looked as if he were about seventy. He had had frequent diarrhea. He was bent over as if guarding the abdominal muscles. Between the umbilicus and the symphysis, near the mid-line, was a tumor reminding one of a patella. The overlying skin was free. The tumor was very painful and slightly movable. It felt dense and gradually merged into the surrounding tissue. Toward the umbilicus was a cord the size of a goose-quill. The growth was thought to be a malignant epithelial tumor of the urachus.

A median incision showed that the tumor had grown through the linea alba and the sheath of the rectus. A portion of the rectus muscle, of the transversalis fascia, and of the peritoneum were removed. After the abdomen had been opened and the tumor had been drawn up, fibrous cords were seen passing from the umbilicus. The upper one was the size of a goose-quill, firm and infiltrated; the lower contained a venous cord, was less firm, and passed into the vesico-umbilical ligament. The peritoneum covering the posterior surface of the tumor showed evidence of scarring and of ulceration. The patient made a good recovery.

The tumor in form, as mentioned above, resembled a patella. The peritoneum was firmly attached to it, and the surrounding muscle had been penetrated by it. On microscopic examination the growth was found to be made up of glands varying in size between that of a urinary tubule and that of a gland large enough to be seen with the naked eye. The diagnosis was fibro-adenocarcinoma submalignum. The glands resembled those of the intestinal type.


LITERATURE CONSULTED ON PRIMARY CARCINOMA OF THE UMBILICUS.

Ajello: Contributo alia genesi embrionale di un adeno-epiteliorna cistico primitivo deU'ombelico

(from Tansini's clinic). La Riforma medica, 1899, Anno 15, iii, 663. Besson, E. : Cancer de l'ombilic. These de Paris, 1901, No. 263. Bonvoisin, G. : Etude pathogenique et histologique sur une variete de l'epitheliome de 1'ombilic.

These de Paris, 1891, No. 305. Burkhart, O.: Ueber den Nabelkrebs. Inaug. Diss., Berlin, 1889. Chuquet: Du carcinome generalise du peritoine. These de Paris, 1879, No. 548. Dannenberg, O. : Zur Casuistik der Nabeltumoren insbesondere des Carcinoma uuibilicale. Inaug.

Diss., Wiirzburg, 1886. Dejerine et Sollier: Bull. Soc. anat. de Paris, 1888, 649.

Demarquay: Cancer de l'ombihc. Bull. Soc. de Chir. de Par. (1870), 1871, 2. s. xi, 209. Despres: Bull, et Mem. Soc. de chir. de Paris, 1883, ix, 245.

Doederlein, F. : Ein primares Adenokarzinom des Nabels. Inaug. Diss., Erlangen, 1907. Fox and MacLeod: A Case of Paget's Disease of the Umbilicus. Brit. Jour. Dermatol., 1904, xvi,

41. Forgue et Eiche: Montpellier med., 1907, 2. s., xxiv, 145-169.

Feulard: Fistule ombilicale et cancer de l'estomac. Arch. gen. de med , 18S7, 7. ser., xx, 158. Giordano, D.: Sopra un caso di cancro dell'ombilico. La Medicina Italiana, 1911, ix, 6. Guiselin, E. J. M. J. : Du cancer de l'ombihc. These de Bordeaux, 1906, No. 47. Hertz, W. H.: Uber einen Fall von Adenocarcinom des Nabels bei einer 58-Jahrigen Frau.

Inaug. Diss., Wiirzburg, 1905. Heurtaux: Epitheliome de l'ombilic. Gaz. med. de Nantes, 1886, iv, 46. Hue et Jacquin: Cancer colloide de l'ombihc et de la paroi abdominale anterieure ayant envahi

la vessie. L'Union medicale, 1868, 3. ser., vi, 418.


412 THE UMBILICUS AND ITS DISEASES.

Ippolito, G. : Un caso epitelioma dell'ombelico. Gaz. internaz. di med., 1901, iv, 302.

Jores: Cylinder-Epithelkrebs des Nabels. Vereins-Beilage der Deutsch. med. Wochenschr., 1899,

xxv, iv, 22. Koslowski: Ein Fall von wahrem Nabeladenom. Deutsche Zeitschr. f. Chir., 1903, lxix, 469. Ledderhose, G. : Deutsche Chirurgie, 1890, Lief. 45 b.

Lewis, D.: A Malignant Tumor in an Umbilical Hernial Sac. Medical Record, 1889, xxxvi, 394. Le Coniac, H. C. J.: Cancer secondaire de l'ombilic, consecutif aux tumeurs malignes de l'ap pareil utero-ovarien. These de Bordeaux, 1898, No. 19. Maylard: Cylinder-celled Epithelioma of the Umbilicus. Trans. Glasg. Path, and Clin. Soc,

1886-91; 1892, iii, 294. Morris, R.: Malignant Disease of the Navel as a Secondary Complication. Verhandl. d. 10.

Internat. Med. Cong., 1890, Berlin, 1891, iii. Abth., vii, 122-126. Neveu, v. : Contribution a l'etude des tumeurs malignes secondaires de l'ombilic. Paris, 1890. Osier, Sir William: Lectures on the Diagnosis of Abdominal Tumors. New York Med. Jour.,

1894, lix; lx. Parker, W. : Excision of Umbilicus for Malignant Disease. Arch. Clin. Surg., New York, 1876 77, i, 71. Pernice, L. : Die Nabelgeschwiilste, Halle, 1892.

Quenu et Longuet: Du Cancer secondaire de l'ombilic. Revue de Chir., 1896, xvi, 97. Sollier, Paul Henri: See Dejerine. Stori, T.: Contributo alio studio dei tumori dell'ombelico. Lo Sperimentale, Archivio di biologia

normale e patologia, 1900, liv, 25. Tillaux and Barraud: Epithelioma de l'ombilic, developpe aux depens d'un diverticule intestinal;

omphalectomie; guerison. Ann. de Gyn., Paris, 1887, xxvii, 401. Villar, F. : Tumeurs de l'ombilic. These de Paris, 1886. Wagner: Abtragung eines carcinomatosentarteten Nabels. Med. Jahrb. d. k. k. oster. Staates,

Wien, 1839, N. F., xviii, 585-589.


CARCINOMA OF THE UMBILICUS SECONDARY TO CARCINOMA OF THE STOMACH.

In 27 cases we have found fairly conclusive evidence that the umbilical growth was secondary to carcinoma of the stomach.

Age. — In 23 of these we have definite data as to the age of the patient. The youngest patient was twenty-six, the oldest seventy-two, years of age.

26 years old 1 case

Between 30 and 40 1 "

" 40 and 50 4 cases

" 50 and 60 , 10 "

" 60 and 70 5 "

" 70 and 80 2 "

From the above it will be seen that the age distribution corresponds to that in which carcinoma of the stomach is usually found.

Sex. — Of the 27 cases, data as to the sex are given in 23. Ten of the patients were men and 13 were women, indicating that men are nearly equally liable to this affection.

Trauma. — Occasionally, as in the cases reported by Attimont, Burkhart, and Wulckow, and in my own Case G., the patient attributed the umbilical lesion to an injury. Attimont's patient dated her symptoms from the time she had hurt her abdomen on the edge of a tub. Burkhart's patient noticed an umbilical nodule four months after her abdomen had been accidentally and forcibly compressed; Wulckow's patient, as he was going home on a dark night, struck his abdomen against a stony projection and complained from that time on. My patient, shortly


CARCINOMA OF THE UMBILICUS. 413

before the umbilical growth was noticed, had been struck in his umbilical region by a boot, which was probably not unusual for him, as he kept a shoe-store.

Gastric Symptoms. — In about two-thirds of the cases symptoms suggestive of deranged digestion were noted. In some there was loss of appetite, in others indigestion accompanied by more or less epigastric pain; some vomited food, and in one case at least the vomitus contained blood.

A deep-seated tumor in the pyloric region was detected in several cases, and the condition was so clear that the physician diagnosed cancer of the stomach. In a few cases a definite enlargement of the liver was found, and in several instances the abdomen contained ascitic fluid. Quite a number of the patients, however, gave no gastric symptoms whatsoever, but felt weak and looked cachectic. In at least one case (Valette's) there was not the slightest evidence at operation of any other abdominal lesion. It will be noted that the umbilical growth was the size of a 50centime piece, and that its central portion was ulcerated, and, moreover, that it was firmly fixed. During removal of the tumor the abdomen was inspected and small peritoneal metastases were found. The stomach, however, appeared to be normal. The patient died on the eighth day, and at autopsy a primary carcinoma was found in the stomach.

The umbilical nodule, when first noted, may not be larger than a grain of wheat. In the course of a few months it has increased in some cases to the size of a small nut, in others to that of a chestnut. Sometimes it is first noted in the umbilical depression; in other instances in the umbilical wall or in the tissues immediately adjacent to the umbilicus. At first these tumors may be sharply circumscribed, the overlying skin being free. But with the growth of the nodule the skin soon becomes adherent and the tumor may show a bluish-violet or brownish-red discoloration. The more prominent portions of the tumor tend to become ulcerated, and may discharge a serous or purulent fluid or be covered with crusts. In a few instances there have been several small hemorrhages from them. With the continued growth of the nodule the central portion may be deeply ulcerated, and surrounding the ulcer papillary or cauliflower-like masses may form and the nearby skin show considerable infiltration, frequently of an inflammatory character.

In Cannuet's case there was a small umbilical hernia. This contained incarcerated omentum, in which was found a carcinomatous nodule. In a case which I have recently seen (Plate V) the patient had had an umbilical hernia for thirty-two years. A few months before coming under my care the hernial mass had become hard, and on palpation definite firm nodules could be felt scattered throughout it. At operation I found an ovarian tumor, general peritoneal carcinosis, and a markedly thickened omentum. The portion of the omentum incarcerated in the umbilical hernia also contained carcinomatous nodules. The primary growth in this case was apparently in the ovary.

There is another group of cases presenting a totally different picture. The umbilicus may or may not be the seat of a nodule, but a slight tumefaction of the region is noted. The swelling increases in amount and abscess is suspected. In some cases the picture is that of an acute phlegmon. On the supposition that the condition was inflammatory, several of the tumors were opened. The incision in some yielded nothing but blood and serous fluid; in others small foci of pus were found. In a short time the supposed inflammatory area would undergo gradual dissolution or necrosis en masse, and a fungating base be left at the site of the


414 THE UMBILICUS AND ITS DISEASES.

umbilicus. A little later gas-bubbles would be noted, and ere long stomach-contents would commence to pass through the fistulous opening. The margins of the fistulous opening in some cases were surrounded by large papillary or fungoid growths. In these cases the carcinoma had not extended to the umbilicus by way of the suspensory ligament, but by direct continuity. The carcinoma of the stomach had become adherent to the abdominal wall at or near the umbilicus, and by direct extension had caused a gradual disintegration until the surface of the abdomen had been reached.

If the carcinoma is situated at or near the pylorus and becomes adherent to the abdominal wall, it is only natural that the attachment should be in the umbilical region. If the disease, however, be in another part of the stomach, the abdominal wall may be attacked at another point, as was well shown in the following case :

Mrs. B., seen in consultation with Dr. Edwin B. Fenby July 8, 1910. This patient had been seized that evening with sudden abdominal pain about an inch and a half above and to the left of the umbilicus. She had a temperature of 100° F. ; pulse, 116. "When I saw her, she was rather pale. Appendicitis was ruled out, but some malignant growth was suspected. She had a leukocytosis of 15,000. She was at once removed to the hospital' for observation. Ten days later we made an incision through the left rectus, and on cutting down to the fascia found some edema. On going into the peritoneal cavity we found that the stomach had become adherent to the anterior abdominal wall. After adhesions had been liberated, the parts were walled off as thoroughly as possible, and a tract 3 mm. in diameter was found passing from the stomach directly to the abdominal wall. In other words, there was a perforation of the stomach at this point. We gradually loosened the organs from the surrounding indurated tissue, which in some places was fully 2 cm. thick and as hard as gristle. The stomach was brought out and was found to be indurated in every direction. The growth was a carcinoma. The area of induration in the anterior wall was 7 by 5 cm., and just beneath the point of perforation there was a punched-out area in the carcinoma 2 cm. long. It was at the thinnest point of this that the perforation had taken place. We removed about half of the stomach. The patient made a very satisfactory recovery, and for a year there were no definite signs of a return of the growth. These, however, developed later and she died on November 12, 1911.

In those cases in which the disease reaches the umbilicus by way of the suspensory ligament the peritoneal surface of the umbilicus is usually smooth, because the lymphatics are extraperitoneal. On section an intact carcinomatous nodule of the umbilicus does not resemble cancer, but we find what looks like a diffuse fibrous thickening, and one can hardly realize that it is fairly riddled with glands. This fibrous appearance is well seen in Fig. 184, B (p. 424), and Fig. 190 (p. 443). Where ulceration exists, however, the true character of the growth is more manifest. On histologic examination the tumor is found to consist of fibrous tissue with myriads of carcinomatous glands scattered throughout it. The gland type is identical with that found in the original gastric tumor, and where ulceration has occurred, the usual picture of gland disintegration, together with polymorphonuclear leukocytes and small-round-cell infiltration, is noted on the surface.

Treatment. — -If a patient has given definite signs of carcinoma of the stomach, by the time an umbilical nodule has developed the malignant process has become so wide-spread that operative interference is of no avail. In those cases in


CARCINOMA OF THE UMBILICUS. 415

which the cancer has extended to the abdominal wall by continuity and has broken down, causing a gastro-umbilical fistula, operation is out of the question.

There are a certain number of cases, however, in which, even when a secondary abdominal nodule exists, gastric symptoms are lacking. Here the surgeon will naturally remove the umbilical growth in the hope that it may be a primary lesion. In all such cases, when the abdomen is opened, a careful survey of the stomach and abdominal contents should be made to determine if any visceral carcinoma exists.

Prognosis. — Where an umbilical carcinoma is secondary to carcinoma of the stomach, practically all the patients speedily succumb.

Cases of Carcinoma of the Umbilicus Secondary to Cancer of the Stomach.

In the majority of the cases here detailed the diagnosis is certain, as proved at operation or at autopsy. In a few of the cases such absolute proof was wanting, but the clinical picture strongly suggested the stomach as the source of the primary tumor.

Carcinoma of the Umbilicus Secondary to Carcinoma of the Stomach. — Attimont's* patient was a woman fifty-three years of age. She had enjoyed good health until three months before he saw her, and dated ■ her gastric symptoms from the time she hit her abdomen on the edge of a tub. On palpation no internal tumor could be found, but at the umbilicus were two small nodules the size of grains of wheat. At the end of two months the patient returned emaciated. The nodules at the umbilicus had increased in size, one being as large as a small walnut. It was hard, and the overlying skin was adherent. The umbilical mass was removed and proved to be an adenocarcinoma.

Autopsy at a later date showed carcinoma of the lesser curvature of the stomach, with secondary nodules on the surface of the liver and uterus and cancerous masses between the folds of the suspensory ligament.

Cancer of the Stomach; Gastro-abdominal Fistula. f — A woman, forty-nine years of age, complained of epigastric pain, difficult digestion, and frequent vomiting. Blood had never been noted in the vomited material or in the stools. On palpation an ill-defined tumor was found in the epigastric region which was painful on pressure. Cancer of the stomach was diagnosed. Some time after the patient entered the hospital she had fever at night. The tumor rapidly increased in size. The abdominal wall became a little red, was painful on pressure, and fluctuation was detected. On making an opening with the bistoury odorless pus escaped. A sound could be passed inward for 5 or 6 cm. The fever disappeared and the patient ate without vomiting or pain. A month later the skin around the incision was thinner, reddened, and an area of ulceration the size of a five-franc piece existed. In the depression were fungoid masses which gave off a fecal odor. Two weeks later all trace of the umbilicus had disappeared and there was an area of ulceration as large as the palm of the hand, and three fungoid masses, forming a tumor the size of a fist, presented. The discharge was so fetid that the patient was isolated. Gas and particles of stomach-contents escaped. The mushroom growths increased rapidly and broke down easily. Hemorrhages

  • Attimont, A.: Remarques sur le cancer de l'ombilic. Gaz. med. de Nantes, 1887-88, vi,

137; 149.

f Auger, M. G.: Cancer de l'estomac fistule gastro-abdominale. Bull. Soc. anat. de Paris, 1875, i, 708.


416 THE UMBILICUS AND ITS DISEASES.

resulted, which were controlled with difficulty. The patient became very cachectic, and died two weeks later.

At autopsy the abdomen contained clear yellow fluid. The intestines were small in caliber, but not adherent. The anterior part of the stomach was adherent to the ulcerated abdominal wall. The opening was near the pylorus; the area round it was hard and infiltrated. The subcutaneous abdominal tissue was necrotic. The right lobe of the liver contained cancerous masses. In this case the carcinoma of the stomach had become adherent to the umbilicus and the opening between the stomach and the umbilicus had resulted.

Carcinoma of the Stomach with Perforation of the Abdominal Wall.* — The patient was a weakly woman, fifty-two years of age, and the mother of 17 children. In the spring she had complained of pain in the abdomen, and in July had had to give up work. She was very anemic and wasted. In August she had had severe colicky pains in the region of the spleen; in September these had migrated to the umbilical region. At this time there could be felt a tumor the size of a fist deep in that region. The tumor descended until it lay behind the umbilicus, forming a mass about 5 inches in diameter, with the umbilicus in the center. It became softer, and a few days later a small area sloughed, and the stomach-contents escaped. The opening rapidly increased in size and the patient soon died. The growth was a carcinoma of the stomach which had opened near the umbilicus.

Carcinoma of the Umbilicus Probably Secondary to Carcinoma of the Stomach. f — A delicate, poorly nourished woman, fifty-nine years of age, entered Bergmann's clinic. Some time before, her abdomen had been accidentally compressed, and four months later she had noticed a painless but hard nodule at the umbilicus. The skin covering it was smooth. Three months later the tumor was the size of a hazel-nut. On examination the umbilicus was elevated. The tumor was the size of a two-mark piece and could be sharply outlined. The surface was very red and nodular, and suggested dense granulation tissue. It secreted pus. Operation was not advised, but was insisted upon by the patient. She left the hospital before any local return had occurred. The growth was a glandular carcinoma and probably secondary to carcinoma of the stomach.

Carcinoma of the Umbilicus Secondary to Carcinoma of the Stomach. t — A farmer, aged seventy-two, for six months had been complaining of gastric disturbances. Ten weeks before coming under observation he had noticed a moistness at the umbilicus and a discharge of a tarrylooking, brownish secretion. Later there had been ulceration, which had gradually increased. The patient was well nourished and strong. At the umbilicus was an irregular ulceration the size of a two-mark piece. It was hard and seemed unattached. At operation it was necessary to remove the ligament um teres to the liver. The patient died one month after. A carcinoma the size of a three-mark piece was found near the pylorus; it was adherent to the liver, and in the liver diffuse carcinomatous infiltration was present.

  • Balluff: Magenkrebs, Erweichung unci Aufbruch desselben durch die allgemeinen Bauchdecken, Magenfistel. Correspondenzbl. des Wiirtemberg. arztl. Vereins, Stuttgart, 1854, xxiv, 37.

t Burkhart: Ueber den Nabelkrebs. Inaug. Diss., Berlin, 1889. X Burkhart: Op. cit.


CARCINOMA OF THE UMBILICUS. 417

Carcinoma of the Liver with Carcinoma of the Omentum; Incarcerated Umbilical Hernia.' — ■ Cannuet* reported the case of a patient with carcinoma of the liver probably secondary to carcinoma of the stomach. There was an umbilical hernia containing incarcerated omentum, and in this incarcerated omentum was a cancerous nodule.

Carcinoma of the Umbilicus Secondary to Carcinoma of the Stomach, f — -A man, sixty-three years of age, had had pain in the abdomen, complained of indigestion, and later had noticed a tumefaction at the umbilicus. He had diarrhea and vomiting and a supposed abscess of the abdominal wall. This was opened and bloody fluid escaped. Later there was the characteristic fetid cancerous discharge from the umbilicus. At autopsy a carcinoma of the pylorus was found adherent to the umbilical tumor.

Carcinoma of the Umbilicus Secondary to Cancer of the Stomach. J — In a woman, twenty-six years of age, a fistula developed at the umbilicus. There was no vomiting, but emaciation. Just above the umbilical cicatrix was a reddening. The skin was distended, hot, and painful and serous or purulent fluid escaped from the opening. At autopsy cancer of the pyloric region was found. On the outer surface of the pylorus were cancerous vegetations. These had become adherent to the abdominal wall; suppuration had followed, and an opening had developed at the umbilicus.

Carcinoma of the Umbilicus Secondary to Cancer of the Stomach. — Fischer § operated on a woman fifty-two years of age who had a carcinomatous tumor of the umbilicus which had extended as far as the interior of the abdomen. On opening the abdomen he discovered that the anterior part of the stomach was perforated and transformed into a large carcinomatous ulcer, which penetrated directly into the transverse colon. The patient had never manifested any gastric symptoms. Fischer removed the entire anterior portion of the stomach and the diseased colon. The patient made a good recovery, but developed other stomach symptoms and died five months later.

Carcinoma of the Umbilicus, Secondary. 1 1 ■ — -A woman, fifty years of age, had had a warty, nodular growth at the umbilicus for two or three months and was not in good health. No abdominal lesions being noted, Hutchinson made an elliptic incision and removed the growth. It extended to but had not invaded the peritoneum. Two months later there was a nodular thickening of the liver, great irritability of the stomach, and the patient died four months after operation. Hutchinson thought that the umbilical growth was secondary to that in the liver. In two other of his cases, he says, a carcinoma of the umbilicus had developed secondarily to a growth in the liver.

[Of course, the majority of the cases of cancer of the liver are secondary to those of the stomach.— T. S. C]

Carcinoma of the Umbilicus Secondary to Cancer of the Stomach.** — A man, forty-four years of age, gave a history of vom

  • Cannuet: Bull. Soc. anat. de Paris, 1852, xxvii, 274.

f Codet de Boisse: Tumeurs de l'ombilic chez l'adulte. These de Paris, 1883, No. 311. X Feulard: Fistule ombilicale et cancer de l'estomac. Arch. gen. de med., 1887, 7. s., xx, 158. § Fischer (Breslau) : Resection de l'estomac. La Semaine med., Paris, 1888, viii, 134. || Hutchinson, Jonathan: Arch, of Surgery, 1893, iv, 153 (1 pi.).

    • Largeau, R.: Cancer de l'ombilic. Bull. Soc. anat. de Par., 1884, lix, 210-212.

28


418 THE UMBILICUS AND ITS DISEASES.

iting and loss in weight. At the umbilicus was a tumor 5 cm. in diameter. Its central portion was ulcerated and surrounded by a zone of induration. At death the growth was found extending to the peritoneal surface, but there was no adhesions. The patient had cancer of the stomach, which had extended to the liver. There were numerous other Secondary nodules.

Carcinoma of the Umbilicus Probably Secondary to Cancer of the Stomach or Liver. — Ledderhose,* after giving a survey of the literature, reports a case communicated to him by A. Cahn. L., fifty-eight years of age, complained of gradually increasing lack of appetite and of the development, a few months later, of edema of the lower extremities and varicose veins in the leg. Still later the scrotum and the abdominal wall became edematous and there was also ascites with complete loss of appetite and intestinal obstruction. At the umbilicus was a hard, semicircular nodule. By deep ballottement, enlargement of the hardened liver could be made out. A provisional diagnosis of carcinoma of the liver with peritonitis was made. No microscopic examination is given. In all probability the umbilical growth was secondary to a carcinoma of the stomach with implication of the liver. Ledderhose follows this by two other observations; in none of the cases, however, was any autopsy made.

Carcinoma of the Umbilicus Secondary to Carcinoma of the Stomach. f — A man, forty-five years of age, gave a history of vomiting for a year. He was well nourished and of good color, but had lost 24 pounds. At the upper and left side of the umbilicus was a small tumor the size of a bean; the overlying skin was free. In two weeks the tumor had become adherent to the skin and had increased in size. Two months later the abdomen was distended with ascitic fluid, and the patient died soon after the fluid had been removed.

Autopsy showed carcinoma of the lesser curvature of the stomach and compression of the portal vein; no involvement of the liver was found. No microscopic examination of the abdominal tumor is recorded.

Umbilical Fistula Due to Latent Cancer of the Stomach. — Monod's t patient was a woman sixty-six years of age. She was cachetic, but had had no vomiting. At the umbilicus was a fistulous opening of recent date. A diagnosis of latent cancer of the stomach was made. At autopsy in the region of the umbilicus Monod found a compact mass consisting of the stomach, liver, transverse colon, and duodenum. The lesser curvature of the stomach was adherent to the liver. The anterior surface of the stomach was involved in the cancer, which extended to the posterior surface; the fistulous opening reached the umbilicus. The transverse colon communicated by an oblique opening, measuring 5 x 6 cm., with a pocket formed by the stomach and the left lobe of the liver.

Cancer of the Umbilicus Secondary to Cancer of the Pylorus. § — -A woman, seventy years of age, came with a diagnosis of cancer of the pylorus. Six months from the beginning of her symptoms she had begun to have pain at the umbilicus and noticed a small lump there. This became very

  • Ledderhose : Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief.

45 b.

f Mirallie: Reported by Attimont.

t Monod: Fistule Ombilicale; cancer latent de l'estomac. Bull. Soc. anat. de Paris, 1877, lii, 38.

§ Morris, Robert : Lectures on Appendicitis and Notes on Other Subjects, 1895, 95.


CARCINOMA OF THE UMBILICUS. 419

hard, was about as large as a chestnut, bluish red in color, and had a smooth surface, which was somewhat ulcerated and discharged a little straw-colored serum. Morris removed the diseased umbilicus and found that it was not in contact with anything but normal structures. The patient died two months later with the ordinary symptoms of cancer of the pylorus. No autopsy, however, was permitted. The umbilical growth was an adenocarcinoma.

Cancer of the Pylorus; Secondary Growth at the Umbilicus. — Morris * cites an extract from a letter from Dr. Grinnell, of Burlington, Vermont. The patient was a man sixty-eight years of age who had symptoms of cancer of the pylorus. Eight months before death the umbilicus became hard and painful and there was a malodorous discharge from it. Five months before death enlargement of the liver was noted; the death was caused by cancer of the liver, as determined at autopsy.

Carcinoma of the Umbilicus Probably Secondary to Cancer of the Stomach, f — Case 109 was a personal communication received by Pernice from R. Volkmann. The man was tapped on account of the presence of ascitic fluid, which proved to be hemorrhagic in character. After the removal of the fluid a tumor could be palpated. The umbilicus, stomach, and liver region were involved, and at the umbilicus were adhesions to the skin. The patient died without operation and no autopsy was allowed.

Secondary Carcinoma of the Umbilicus. J — A woman, aged fifty-nine, entered the Frauenklinik in Breslau. About six or nine months before, she had noticed below the umbilicus a small, hard nodule, that gave rise to little trouble and did not interfere with her work. She suffered from lack of appetite, vomiting, and constipation. The nodule grew rapidly and commenced to give trouble. The umbilicus became reddened and inflamed. On admission she looked frail and cachectic. The swelling at the umbilicus had extended to the surrounding parts, and the tissue was very hot and painful. On examination there could be felt in the depth a tumor the size of an ostrich's egg. On both sides the tumor extended 5 cm. from the umbilicus and could be sharply outlined. About 3 cm. above the umbilicus were several other fluctuating nodules. An exploratory operation was made, and three small abscesses, containing purulent, smeary masses were removed. The abdomen was opened, and the tumor was found to involve the stomach. Resection of the stomach was done, and the patient died of shock. In this case there was a primary carcinoma of the stomach and a secondary growth at the umbilicus. It will be noted that the primary tumor in the beginning had given hardly any symptoms.

Secondary Carcinoma of the Umbilicus. § — This case was reported from the Universitatsklinik in Halle. A man, fifty-eight years of age, had been strong and healthy until he began to complain of pain in the abdomen and of a brownish vomitus. Later he had pain in the region of the umbilicus and then a nodule was detected. The patient on admission was very feeble, and the skin had a jaundiced tint. The umbilicus was somewhat distended by a nodule the size of a 10-pfennig piece. It was very hard and painful, brownish red, and on the surface slightly ulcerated. In this case there was probably a carcinoma of the stomach with secondary carcinoma at the umbilicus. Operation was refused.

  • Morris: Op. cit., 114. f Pernice: Die Nabelgeschwulste, Halle, 1892.

t Pernice: Op. cit., obs. 110. § Pernice: Op. cit., obs. 123.


420 THE UMBILICUS AND ITS DISEASES.

Carcinoma of the Umbilicus Secondary to Cancer of the Stomach.* — For about a year a woman, sixty-two years of age, had had symptoms of cancer of the stomach. For four months she had noticed a hardening at the umbilicus. This was prominent; the skin was reddened, the surface of the tumor uneven and very dense. It was sharply defined and showed no ulceration.

Carcinoma of the Umbilicus Secondary to Abdominal Carcinoma. f — A woman, forty years of age, suffered from a malignant disease in the abdomen and had been frequently tapped. At autopsy carcinoma of the liver, omentum, and peritoneal surfaces of the intestine was found, and the uterus and ovaries formed one mass. At the umbilicus was a circumscribed tumor the size of the last phalanx of the thumb, looking like an umbilical hernia. This was also a carcinoma, evidently secondary to the abdominal tumor, which had probably originated in the stomach.

Carcinoma of the Umbilicus Secondary to Cancer of the Stomach. — Tillmannsi said he saw a case of carcinoma of the stomach with a secondary growth at the umbilicus.

Secondary Carcinoma of the Umbilicus. § — -A farmer, aged fifty-two, for two months had noticed an enlargement at the umbilicus which had increased rapidly in size and become ulcerated. The patient was slightly emaciated. The inguinal glands were enlarged. Peritoneal carcinosis, which had probably originated from the stomach, was found at operation. No microscopic examination was made.

Cancer of the Umbilicus Secondary to Cancer of the Cardiac End of the Stomach. |j — The patient, fifty years of age, was admitted to the service of Damaschino. Cancer of the stomach could be definitely made out. Later on, just beneath the umbilicus, one could feel with the ends of the fingers a hard tumor occupying the lower portion of the epigastric region. This tumor had a regular surface and presented the characteristics of a secondary neoplasm. Still later, at the umbilical cicatrix, there appeared a small, violet-colored tumor. This was covered over with a delicate crust. Microscopic examination showed that the tumor of the stomach and omentum, the abdominal glands, and the growth in the umbilical cicatrix were of precisely the same type of cancer.

Carcinoma of the Umbilicus Secondary to Carcinoma of the Stomach.- — ■ The report of the case was communicated to Villar** by Broussolle. X. entered the service of Professor Le Fort in 1885. There had been no digestive disturbances. The patient had come to Paris to consult a

  • Schlesinger : Die Bedeutung cler Nabelmetastasen ftir die Diagnose abdomineller Neoplasmen. Wien. med. Wochenschr., 1911, No. 8, 519.

f Storer: Circumscribed Tumor of the Umbilicus Closely Simulating Umbilical Hernia, etc. Boston Med. and Surg. Join - ., 1864, lxx, 73.

X Tillmanns, H.: Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia ventriculij, und iiber sonstige Geschwulste und Fisteln des Nabels. Deutsche Zeitschr. f. Chir., 1882-83, xviii, 161.

§ Tisserand: A propos de deux cas de cancer secondaire de l'ombilic. La Loire med., St. Etienne, 1906, xxv, 131.

|| Villar: Tumeurs de l'ombilic. These de Paris, 1886, obs. 79.

    • Villar: Op. cit., obs. 85.


CARCINOMA OF THE UMBILICUS. 421

surgeon on account of a vegetative, ulcerating tumor situated in the umbilical region.

On admission to the hospital he was very feeble, and this feebleness was attributed to the fatigue of the journey. In the epigastric region and encroaching on the umbilicus was a vegetating tumor which was ulcerating and bled. At first sight it appeared to be a phlegmon, but on careful examination was found to present special characteristics. Some time afterward cancerous nodules appeared in the liver. At autopsy cancer of the pylorus was found and cancerous masses of the liver and plaques of carcinoma, which occupied the umbilicus and a certain portion of the anterior abdominal wall.

Carcinoma of the Umbilicus Secondary to Latent Carcinoma of the Stomach. — Valette* gives a list of the cases of primary and secondary carcinoma of the umbilicus, and then cites the history of a woman, sixty-one years old, who entered the hospital on August 16, 1896. In March of the same year she had noticed a small lump at the umbilicus. Later this had become painful, in some weeks had reached the size of a large nut, and ulcerated.

On admission the umbilical depression was found replaced by an elevation of the skin with an ulceration in the center and fungus-like margins. The growth was the size of a 50-centime piece (about 2 cm. in diameter). The ulceration had extended to the aponeurosis and the tumor was fixed. The inguinal glands were not enlarged. The question arose as to whether the growth was primary or secondary. The patient gave no history of stomach trouble and had had no vomiting, but the appetite was slightly diminished and she had lost weight in the last six months. At operation the peritoneal surface of the umbilicus was found smooth. There were small metastases in the peritoneum. The stomach was apparently normal. The patient died on the eighth day. At autopsy an adenocarcinoma of the stomach was found. The growths in the abdomen and at the umbilicus were similar to that in the stomach and were evidently secondary. This case demonstrates very clearly the fact that a malignant growth in the stomach may be unrecognizable during life, and be detected only at autopsy.

Carcinoma of the Umbilicus Secondary to Carcinoma of the Stomach. f — The patient was a man, thirty-three years of age, of strong build. When going home one dark night he struck his abdomen in the region of the stomach against a stony projection and was never well afterward. Early next year he consulted his physician for indigestion. In the fall of the same year he noticed that the umbilicus was inflamed, but there was no pain. When seen by Wulckow the umbilicus was slightly raised above the surrounding skin and was reddened. Along the margins were rough excrescences, and where the skin was gone the surface was moist. The entire mass was the size of a large plum. The skin around the umbilicus was reddened over an area the size of a two-thaler piece (about 6 cm. in diameter). The growth could be lifted up from the underlying abdominal contents. The patient died of hemorrhage of the stomach. At autopsy carcinoma was found in the stomach and at the umbilicus. The umbilical growth was in all probability secondary to that in the stomach.

  • Valette: Contribution a. 1' etude du cancer secondaire de l'ombilic. These de Paris, 1898,

No. 550.

f Wulckow: Beitrag zur Casuistik der Xabelneubildungen. Berlin, klin. Wochenschr., 1875, xii, 533.


422 THE UMBILICUS AND ITS DISEASES.


LITERATURE CONSULTED ON CARCINOMA OF THE UMBILICUS SECONDARY TO

CARCINOMA OF THE STOMACH.

Attimont, A. : Remarques sur le cancer de I'ombilic. Gaz. med. de Nantes, 1887-88, vi, 137; 149. Auger, M. G.: Cancer de l'estomac, fistule gastro-abdominale. Bull. Soc. anat. de Paris, 1875,

1, 70S. Balluff: Magenkrebs. Erweichung und Aufbruch desselben durch die allgemeinen Bauchdecken,

Magenfistel. Med. Correspondenzbl. des Wurtemberg. arztl. Vereins, Stuttgart, 1854,

xxiv, 37. Burkhart, O.: Ueber den Nabelkrebs. Inaug. Diss., Berlin, 1889. Cannuet: Bull. Soc. anat. de Paris, 1852, xxvii, 274.

Codet de Boisse: Tumeurs de I'ombilic chez l'adulte. These de Paris, 1883, No. 311. Feulard, H.: Fistule ombilicale et cancer de l'estomac. Arch. gen. de med., 1887, 7. ser., xx, 158. Fischer: Resection de l'estomac. La Semaine med., Paris, 1888, viii, 134.

Hutchinson, J. : Carcinoma of the Umbilicus, Secondary. Arch, of Surgery, 1893, iv, 153 (1 pi.). Largeau, R. : Cancer de I'ombilic. Bull. Soc. anat. de Paris, 1884, lix, 210-212. Ledderhose, G. : Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Mirallie: Reported by Attimont. Monod, E.: Fistule ombilicale; cancer latent de l'estomac. Bull. Soc. anat. de Paris, 1877, lii,

38.' Morris, Robert T. : Lectures on Appendicitis and Notes on Other Subjects, 1895, 95. Pernice, L. : Die Nabelgeschwulste, Halle, 1892. Schlesinger: Die Bedeutung der Nabelmetastasen fur die Diagnose abdomineller Neoplasmen.

Wien. med. Wochenschr., 1911, No. 8, 519. Storer, H. R. : Circumscribed Tumor of the Umbilicus Closely Simulating Umbilical Hernia,

etc. Boston Med. and Surg. Jour., 1864, lxx, 73. Tilhnanns, H: Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia

ventriculi), und iiber sonstige Geschwulste und Fisteln des Nabels. Deutsche Zeitschr. f.

Chir., 1882-83, xviii, 161. Tisserand, G. : A propos de deux cas de cancer secondaire de I'ombilic. La Loire med., St. Etienne,

1906, xxv, 131-136. Valette, A.: Contribution a 1' etude du cancer secondaire de I'ombilic. These de Paris, 1898, No.

550. Villar, F. : Tumeurs de I'ombilic. These de Paris, 1886. Wulckow: Beitrag zur Casuistik der Nabelneubildungen. Berlin, klin. Wochenschr., 1875, xii,

533.


CARCINOMA OF THE UMBIXICUS SECONDARY TO CANCER OF THE GALL-BLADDER.

Inasmuch as primary carcinoma of the gall-bladder is relatively rare, we should not expect to find many growths of the umbilicus secondary to it. Ledderhose, in 1890, reported a case that he had observed in Kussmaul's clinic. A woman, fifty-six years old, was brought to the hospital on account of jaundice. It was impossible to detect any growth in the liver either by palpation or percussion. At the umbilicus, however, was a bean-sized, hard tumor which suggested the diagnosis of carcinoma of the liver or of the gall-bladder. Subsequently it became possible to detect large and irregular masses with nodular margins in the liver. At autopsy a primary carcinoma of the gall-bladder was found which had given rise to the umbilical growth.

In 1901 Besson gave a splendid resume of the literature on secondary carcinoma of the umbilicus, and cited a case of carcinoma of the gall-bladder with a secondary growth at the umbilicus. The umbilical growth was the size of a small hazelnut.

The histologic pictures from this case are given in Figs. 225, 226, and 227 of ( oinil and Ranvier's Manuel d'histologie pathologique, published in the same year.


CARCINOMA OF THE UMBILICUS. 423

Tisserand, in 1906, reported a case of this character. A woman, fifty-four years old, the mother of four children, had had pain for five months in the umbilical region, but her general health had been good. On abdominal examination the cicatrix of the umbilicus seemed to be simply inflamed. It was very red, slightly painful, and indurated. An exploratory operation was performed. The patient died suddenly on the tenth day. There was a carcinoma of the gall-bladder with biliary stones. The glands along the suspensory ligament of the umbilicus showed a bead-like involvement. No trace of cancer could be found in any other organ. In this case there was a definite carcinomatous extension along the lymphatics.

Schlesinger, in 1911, reported a case of primary carcinoma of the gall-bladder with a secondary nodule at the umbilicus.

In this connection the following case of biliary fistula reported by Gross may be of interest:

Biliary Fistula at the Umbilicus.* — A man, aged fortyfour, two months before had noticed a small lump at the umbilicus; it was not painful, but caused a continuous pricking sensation. The lesion had progressively enlarged, and on admission the umbilical growth was the size of a large red button and the man had a continuous dull pain. For a month it had been severe enough to prevent him from sleeping. The patient had become emaciated, but had had no intestinal disturbances.

On admission he was thin, and grayish in color. On January 29th a tumor covered by intact red skin was removed. It was adherent to the peritoneum. Microscopic examination showed it to be a cancer. The patient developed pneumonia, but recovered from it. On February 18th, an irritating biliary discharge was noted, but no inflammatory reaction. He left the hospital on March 11th well of his pneumonia, but with a biliary fistula.

Gross thinks that the gall-bladder had become adherent to the umbilicus, and after operation a small abscess had developed and perforation of the gall-bladder had taken place.

[It is just possible that a primary carcinoma of the gall-bladder existed in this case.— T. S. C]

While reviewing the literature on diseases of the umbilicus I was asked to see the following case, and profiting by the knowledge gleaned from the literature, at once ventured a provisional diagnosis of either carcinoma of the stomach or of the gall-bladder with gall-stones and a secondary malignant growth at the umbilicus.

Adenocarcinoma 'of the Umbilicus Secondary to Carcinoma of the G a 1 1 - b 1 a d d e r . f — Mrs. B., aged fifty-eight, was seen in consultation with Dr. George L. Wilkins and admitted to the Church Home and Infirmary April 24, 1910.

The patient showed a slight bulging at the umbilicus on standing. This was painful when the clothes rubbed against it. It had been noticed first in December, 1909, that is, about four months before examination. For some months the patient had suffered at intervals with pain in the region of the gall-bladder and had been jaundiced. The pain had radiated to the back and to the right shoulder. At the time of examination there was some tenderness in the gall-bladder region. She

  • Gross, G.: Neoplasme de l'ombilic. Revue med. de Test., Nancy, 1898, xxx, 559.

f I reported this case in Jour. Amer. Med. Assoc, 1911, lvi, 391.


424


THE UMBILICUS AND ITS DISEASES.


A.


m


had suffered from the presence of gas and from constipation. No clay-colored stools had been noted. The heart, lungs, and kidneys were normal.

From the history and general condition a provisional diagnosis was made of

either cancer of the stomach or of the gall-bladder, associated with a secondary nodule at the umbilicus. On examination of the umbilicus there was just a slight rollingout, but nothing to suggest a nodule until one picked the umbilicus up between the fingers, when marked sensitiveness became apparent (Fig. 184).

Operation. — April 25, 1910. On making a right rectus incision I at once encountered little nodules in the lesser omentum. The gallbladder contained numerous stones and also a new-growth. The latter was firm and had extended to the lymph-glands around the portal vein. One of these was over 3 cm. in diameter. We were dealing with a carcinoma of the gallbladder, together with metastases in the lesser omentum and the umbilicus. On account of the marked involvement of the lymph-glands complete removal of the primary growth was impossible. As the patient had had a great deal of pain in the umbilicus, this was removed. The inner or peritoneal surface of the umbilicus was free from adhesions. The patient made a good temporary recovery and was discharged May 9, 1910. She subsequently developed large secondary nodules in the abdominal cavity, and died on September 16, 1910. Pathologic Examination (Path. No. 14968). — The specimen consists of the umbilicus and surrounding skin. It is 7 cm. in length, 5 cm. in breadth. The umbilicus is slightly prominent. It is commencing to unfold a little, as seen in Fig.



B.


^Y


Fig. 184. — Appearance op the Carcinomatous Umbilicus After Removal. (Natural size.) Path. No. 14968. A., The parts are slightly distorted from the action of the hardening fluid and the umbilicus comes out more prominently than it really did in the patient. There is, however, a slight unfolding of the umbilicus, and one part seems somewhat raised. The umbilicus itself, however, was perfectly intact. B., A transverse section through the umbilicus. The half to the left is more prominent and represents the elevation noted in the umbilical depression. The surface, however, is intact. There is an increase in the amount of connective tissue, but no evidence of any definite nodule. Histologic examination showed that this area was everywhere infiltrated with carcinomatous glands.


CARCINOMA OF THE UMBILICUS. 425

184. It was not quite so prominent, however, in the fresh state. The nodule could be readily felt on lifting the umbilicus up with the fingers. It appeared to be about 1 cm. or more in diameter. In the hardened specimen the tissue was contracted, bringing the tumor out more prominently. The skin was everywhere intact. The peritoneal surface was slightly puckered, but was free from adhesions. On section of the umbilicus the tissue looked fibrous and in its middle portion was what appeared to be a little area of hemorrhage about 2 mm. in diameter. At first sight one would not for a moment suspect the presence of carcinoma.

Histologic Examination. — The squamous epithelium is intact, and immediately beneath it in a few places are some sweat-glands. Approaching the peritoneum colonies of glands are found closely packed together with very little connective tissue between them. The gland epithelium is for the most part one layer in thickness. In some places it is cuboid, at other points cylindric, and there are very minute glands. The nuclei of the epithelial cells stain uniformly, but vary considerably in size. In some places the epithelial cells seem to have a tendency to be arranged in single rows. The growth is without doubt a carcinoma. The small metastatic nodules found in the lesser omentum in the neighborhood of the gallbladder present a precisely similar appearance. We are undoubtedly dealing with a primary carcinoma of the gall-bladder, involving the lymphatics around the portal vein. There have been metastases in the lesser omentum and also involvement of the umbilicus.

Treatment. — When the diagnosis is perfectly clear, operation is not indicated, as it is impossible completely to eradicate the disease. In my case the operation was undertaken solely on account of the severe pain caused by the umbilical nodule.


LITERATURE CONSULTED ON CARCINOMA OF THE UMBILICUS SECONDARY TO

CANCER OF THE GALL-BLADDER. Besson, E.: Cancer de l'ombilic. These de Paris, 1901, Xo. 263. Cornil et Ranvier: Manuel d'histologie pathologique, 3. ed., Paris, 1910, i, 493. Gross, G. : Xeoplasme de 1'ombilic. Revue med. de Test., Nancy, 1898, xxx, 559. Ledderhose, G. : Deutsche Chirurgie, 1890, Lief. 45 b. Schlesinger: Die Bedeutung der Nabelmetastasen fur die Diagnose abdomineller Xeoplasmen.

Wien. med. Wochenschr., 1911, Xr. 8, 519. Tisserand, G. : A propos de deux cas de cancer secondaire de 1'ombihc. La Lone med., St. Etienne,

1906, xxv, 131-136.


CARCINOMA OF THE UMBILICUS SECONDARY TO CANCER OF THE INTESTINE.

I have found five cases of this character in the literature, those of Lage, Chuquet, Villar, Pernice, and Barker. It is quite probably that Plagge's case also belongs to this group, although the tumor was described as a myxosarcoma. In Chuquet's case the carcinoma was situated in the rectum.

On reading the histories of these cases it will be seen that in the majority of the cases, in addition to the primary growth, there were wide-spread abdominal metastases facilitating extension of the carcinomatous process to the umbilicus.

Histologically, the umbilical growths conform exactly to the type of the original intestinal tumor.


420 THE UMBILICUS AND ITS DISEASES.

Cases of Carcinoma of the Umbilicus Secondary to Cancer of the Intestine.

Carcinoma of the Large Bowel "With Metastases at the Umbilicus.* — The patient died of carcinoma involving nearly all of the large bowel. There were metastases in the mesenteric glands. At the umbilicus was a brownish red. mottled growth. The umbilicus felt like a broad, hard, flat surface. The growth was probably a carcinoma secondary to that of the large bowel.

Carcinoma of the Rectum With Seco n d a r y Carcinoma at the Umbilicus, f — This case had been reported by Lebert (Bull. Soc. anat. de Paris). A woman, fifty-four years of age, six weeks before coming under observation had- commenced to have violent colic and pain at the umbilicus with digestive disturbances. On admission she looked cachectic and the abdomen was much distended. Beneath the umbilicus was felt a hard, cartilaginous plaque which at its prominent part raised the skin nearly 3 cm.

At autopsy small carcinomatous masses were found scattered over the peritoneum and there was a scirrhous carcinoma of the rectum. The umbilical growth had developed in the linea alba.

[Although the growth was probably secondary to that in the rectum, one cannot feel absolutely sure. — T. S. C]

Carcinoma of the Umbilicus Secondary to Carcinoma of the Transverse Colon.- — Villar % describes a case occurring in the sen-ice of Damaschino. The patient, fifty-three years of age, had a cancer of the transverse colon involving the omentum, cancerous nodules in the peritoneum, ulceration and cancer of the umbilicus, and seconda^ nodules in the liver.

During the progress of the disease a hard mass developed in the umbilical region, and in two months the umbilical depression was effaced by a violet mass which reached the dimensions of a two-franc piece. This was covered with a thick crust. When this was removed, the new-growth was found to be nodular, irregular, and reddish. On palpation one could feel in the umbilical region, over an area 10 cm. in diameter, a hard, slightly movable, mass. At autopsy it was found that the tumors of the omentum and of the peritoneum, as well as the umbilical mass, were of exactly the same structure as the intestinal growth.

Cancer of the Transverse Colon with Secondary Carcinoma of the Umbilicus.§ — Case 1. — "A man, aged thirtyseven, admitted to the University College Hospital February 3, 1910. In March, 1909. he noticed occasional pains around the navel irrespective of food. These lasted three or four months. In the July following he entered a country hospital, having noticed for about a fortnight a swelling in the abdominal wall at the umbilicus. This was opened with the knife on July 24th and was said to have given exit to pus and to have healed again in a week. In the September following the swelling increased ag:ain and burst, and has been discharging ever since. On admission on February 3d he was well nourished. Below and to the left of the navel was a discolored and irregular prominence about 2}/> inches in diameter, with a wound

  • Lage: Krebshafte Entartung eines grossen Theils des Dickdarms. Schmidt's Jahrbuch,

1847, Iv, 295.

fChuquet: Du carcinome generalise du peril oine. These de Paris, 1879, No. 548, obs. 18. i Villar, F. : Tumeurs de l'ombilic. These de Paris, 1886, obs. 78, 112. j Barker, A. E.: TheLancet, London, July 19, 1913.


CARCINOMA OF THE UMBILICUS. 427

discharging through the old scar. On palpation the induration was much larger than it looked. It extended downward for several inches in the left rectus muscle and was everywhere very hard. Except to the skin over the most prominent part, it showed no attachment anteriorly, but was incorporated with the rectus. The discharging sinus led downward and outward about V/2. inches. To be quite sure of its nature, which was believed to be cancerous, I made an incision into the swelling, and, finding it unmistakably so, prepared for removal. This was done on February 20th, between two long elliptic incisions from above downward, opening the abdomen and including most of the left rectus muscle. The tumor was then seen to be obviously a growth of the transverse colon fungating through the umbilicus. I then clamped the colon on each side and removed it with about IY2 inches on both sides of the growth — about seven or eight inches in all. The ends of the divided bowel were brought together in the usual way, and the wound was only partially closed, as there was little or no muscle to fill it. Some suppuration followed, as I expected, from the foul state of the breaking-down growth, and a fecal fistula formed for a little while, but soon closed and the wound granulated up. On May 6th I removed a nodule of growth, cutting the skin and inserting a delicate wire netting. Since then all has gone well, and I have recently seen the man — more than three years after the operation — quite free from any sign of recurrence. He plays golf and performs on a wind instrument; he has no hernia.

"The growth was a typical columnar carcinoma, and corresponded to an ulcer on the mucous surface of the free side of the transverse colon, as large as a crown piece, with everted edges. There were no tangible glands in the mesentery or any other signs of generalization."

Secondary Carcinoma of the Umbilicus.* — Case 129, reported from the Frauenklinik of Breslau. A woman, fifty-two years of age, complained of a sticking, burning pain, which was more marked on pressure. The abdomen was much distended. In the vicinity of the stomach and also in the region of the umbilicus nodules could be made out. The patient looked weak and cachectic. In the umbilical region there was marked resistance. This extended three fmgerbreadths to the right and over a handbreadth and a half to the left. On account of the ascites, nothing more could be made out. There was a small umbilical tumor. At an exploratory operation carcinomatous nodules were found on the intestine, and the omentum was everywhere covered with small carcinomatous nodules.

A Case of Myxosarcoma of the Umbilicus. [?]f — In childhood the man had difficulty in digestion, and later vomiting and diarrhea. In the summer of 1887 he had pain in the stomach for the first time and noticed a small tumor at the umbilicus. By November of the same year the tumor had reached the size of a hazel-nut, and four weeks later a nodule the size of a pea below and to the left, close to the linea alba, could be felt. The patient became emaciated and died on March 14, 1888. At autopsy the umbilicus showed a thickening, the size of a five-franc piece, raised 2 cm. above the abdominal level. Above and below, the thickening could be followed 5 cm. in each direction. The skin was movable over the area of thickening. When the abdomen was opened, a nodule 2 mm. in diameter was found in the umbilical region. In the ligament passing from the umbilicus

  • Pernice, L.: Die Nabelgeschwiilste, Halle, 1892.

t Plagge, H.: Em Fall von Myxosarcoma des Xabel. Inaug. Diss., Freiburg i. B., 1889.


428 THE UMBILICUS AND ITS DISEASES.

were small nodules. The omentum, diaphragm, and intestine were implicated. The stomach was normal. Microscopically, a diagnosis of myxosarcoma was made. [The clinical picture in no way indicated a primary growth. The condition resembles in some degree a case of a colloid carcinoma of the intestine with secondary growths at the umbilicus. — T. S. C.l


LITERATURE CONSULTED ON CARCINOMA OF THE UMBILICUS SECONDARY TO

CANCER OF THE INTESTINE. Barker, A. E.: Three Cases of Solid Tumors of the Umbilicus in Adults. The Lancet, London,

July 19, 1913. Chuquet, A. : Du carcinome generalise du peritoine. These de Paris, 1879, No. 548. Lage: Krebshafte Entartung eines grossen Theils des Dickdarms. Schmidt's Jahrbuch, 1847, lv,

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

Plagge, H. : Ein Fall von Myxosarcom des Nabel. Inaug. Diss., Freiburg i. B., 1889. Villar, F. : Tumeurs de l'ombilic. These de Paris, 1886, obs. 78.


CARCINOMA OF THE UMBILICUS SECONDARY TO OVARIAN CARCINOMA.

I have found several cases of this character in the literature, and two have been observed in the Gynecological Department of the Johns Hopkins Hospital. A very careful review of the subject was given by Le Coniac in his thesis published in 1898.

The youngest of the patients here recorded was thirty-two years of age; the oldest, sixty-eight. Five of the nine patients were between fifty and sixty years of age.

Most of the umbilical growths were small, and some of them were very hard. In Gueneau de Mussy's case the growth was pedunculated. A small umbilical hernia had existed, and a month before the patient came under observation it had become irreducible. It then became very hard, and was evidently infiltrated with cancer. In Burkhart's case, in addition to the umbilical nodule, there was also one attached to a rib. The umbilical nodule in one of Demons and Verdelet's cases was ulcerated. In one of our cases (Gyn. No. 6150) there was a round, ulcerated area with sharply cut edges and a granular base. As seen from Fig. 185 (p. 432) the floor of this ulcer consisted of carcinomatous tissue. In Aslanian's case the carcinoma had extended to the inguinal glands.

It is hardly necessary to analyze the histories of these cases, as the findings are common to those ordinarily noted where carcinoma of the ovaries, together with wide-spread peritoneal carcinosis, is present. It will be noted that in all but one of the cases there was a wide-spread peritoneal carcinosis, and consequently secondary involvement of the umbilicus was relatively easy.

The histologic picture of these umbilical nodules naturally corresponds to that present in primary ovarian tumors. In Fig. 185, which Mr. Hart kindly photographed for me, we see the edge of the carcinomatous nodule in case Gyn. No. 6150. The growth can be traced through the abdominal wall as far as the epithelial covering of the umbilicus. Over the area of ulceration the skin covering had disappeared entirely and the carcinomatous tissue formed the floor of the ulcer. Any operative treatment in these cases is of little or no value.


CARCINOMA OF THE UMBILICUS. 429

Cases of Carcinoma of the Umbilicus Secondary to Ovarian Carcinoma.

Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries. — Aslanian* covers the literature on peritoneal carcinosis very thoroughly. He cites the following case: A woman, aged thirty-five, had cancer of the ovaries with metastases to the abdominal peritoneum. Eleven months before she had given birth to a child. Fifteen days later she had commenced to suffer with abdominal pain and developed an induration at the umbilicus. The umbilical growth had finally ulcerated, and it was for this that the patient entered the hospital. During surgical intervention metastatic nodules were noted in the parietal peritoneum. The patient recovered from the operation, but did not improve. The appetite diminished more and more, and she became thin. She returned to the hospital on account of the abdominal pain and another growth in the umbilical region. At the site of the umbilicus the scar contained a soft tumor the size of a walnut. In both inguinal regions the glands were enlarged and formed two elongate tumors parallel with the inguinal folds. One could detect beneath the integument of the abdominal wall some small nodules the size of lentils or peas, and over these the skin was adherent. To the left of the tumor was. a hard cord, 3 to 4 cm. long, which terminated in the enlarged glands. Deeper down, nodules could be made out in the hypogastrium. At the level of the umbilicus on the right was a deep-seated induration. Palpation was not painful, and there was an accumulation of ascitic fluid.

All the time the patient was in the hospital she continued to complain of pain. The emaciation increased, and toward the end of her illness there was edema of the feet.

At autopsy the peritoneal cavity was found to contain 300 c.c. of reddish fluid. In the pelvis the normal relations were markedly altered. Both ovaries had been converted into hard tumors the size of apples. They were nodular and had uniform surfaces. The left ovary presented a small cyst. On section, the tumors were found to have a uniform, hard, grayish surface, with yellowish areas scattered here and there through them. The Fallopian tubes showed hypertrophy. Their extremities -were free, but the mucosa of the fimbriae contained cancerous nodules which were yellowish in color, very hard, and simulated eruptions of tubercles. The entire peritoneum was involved in the cancer. The neck of the cervix was hard and infiltrated in its entire thickness with numerous cancerous nodules, some as large as a pea. In addition to the wide-spread peritoneal involvement, the omentum was contracted into numerous folds and contained cancerous nodules. It was adherent to the abdominal wall at the umbilicus. At this point the cancerous nodules were very abundant. The small intestines did not show any secondary nodules, but there were some in the mesentery. The liver was voluminous and nodular, and occupied all the epigastrium. Glisson's capsule did not contain any nodules, but in the hepatic tissue there were 15 secondary growths varying from the volume of a pomegranate to that of a peach in size. On the inferior surface of the diaphragm on the right side were cancerous plaques. On the anterior abdominal wall were whitish cords. These were cancerous lymphatics, following the direction of the umbilical arteries, and terminating at the umbilical tumor

  • Aslanian, G.: Contribution a l'etude de la peritonite cancereuse. These de Paris, 1895,

No. 150, obs. 70.


430 THE UMBILICUS AND ITS DISEASES.

where the omentum was adherent to the abdominal wall. The nodules at this point varied from the size of a pin-head to that of a pea. Cancerous nodules were present in the thorax.

On histologic examination, the ovary, uterus, intestine, muscle, and peritoneum of the umbilical tumor all showed an alveolar carcinoma. Aslanian says that pregnancy played a large role in the provocation of the generalization of the cancer, not only on the serous surfaces, but also in the generative organs and in the anterior abdominal wall. His article is a very thorough one.

Carcinoma of the Umbilicus Secondary to Ovarian Carcinoma. — Burkhart* reports Kiister'sf case of a woman, fifty-seven years of age, who had had several labors. Two years before she had complained of a dull feeling in the lower abdomen, and six months before a small nodule had been detected at the umbilicus; two months before coming under observation nodules had been noted on the ribs near the sternum. At the time of the patient's death the tumor at the umbilicus was the size of a nut. The overlying skin was movable. The malignant growth had involved the uterus and ovaries. It had originally been an ovarian cyst and had become carcinomatous.

Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovary. J - — Case 1. — A woman, forty-five years of age, for a month had had an abdominal enlargement. She was thin, and the abdomen contained an accumulation of fluid. At the umbilicus was a small tumor. Deep palpation revealed a large tumor attached to the uterus. At operation the abdomen was found to contain pelvic tumors. There were papillomata involving the intestine and the omentum, and converting the ovaries and uterus into one mass. The fluid was removed, and the umbilical tumor taken away. The histologic picture noted in the umbilical tumor was identical with that frequently found in the ovary.

Cancer of the Ovaries with a Secondary Growth at the Umbilicus.§ — Case 2. — A woman, fifty-three years of age, for nine months had had abdominal pain. Shortly after falling on her abdomen she had noticed a small, non-painful enlargement. The abdomen increased in size and the patient became emaciated. On examination abundant free fluid was found. At the umbilicus was a small tumor which was not ulcerated and lay beneath the skin. Hard, fixed masses could be felt in the lower abdomen. Vaginal examination revealed a nodular, irregular tumor. The condition was diagnosed as carcinoma of the ovaries with secondary carcinoma of the umbilicus. At operation 12 liters of ascitic fluid were removed. Tumors were found filling Douglas' cul-de-sac. Attached to the parietal peritoneum were several secondary nodules, and the omentum formed a tumor mass. The umbilical growth was removed and the abdomen closed.

Probable Carcinoma of the Ovary with a Secondary Growth at the Umbilicus. || — A woman, sixty-eight years of age, a year before admission had had abundant uterine hemorrhages and since then had been ill. The abdomen was slightly distended. Her appetite had gone, she was

  • Burkhart, ().: Uebcr don Xabelkrebs. Inaug. Diss., Berlin, 1889.

f Krister: Beitrage z. Geb. u. Gyn., 1875, iv, 6.

% Demons et Verdelet: Cancer secondaire de l'ombilic. Congres pcriodique de gyn., d'obstet. et de paed., 1898, ii, 344.

§ Demons et Verdelet: Op. cit. || Demons et Verdelet: Op. cit.


CARCINOMA OF THE UMBILICUS. 431

con.stipai.ecl, and had been gradually wasting away. She had pain in the abdomen. Two months previously she had first noticed at the umbilicus a hard, irregular tumor, which soon ulcerated. Eight days before admission jaundice had become pronounced. On examination the abdomen was found distended, tympanitic, and at the umbilicus was a small, indurated tumor with diffuse margins. It was ulcerated. A diagnosis of cancer was made. In Douglas' pouch was a tumor. The outlines were not clear. The patient was too weak for operation. The condition was diagnosed as cancer of the ovaries with secondary growths at the umbilicus. [Of course, there is a chance for error in this case, as no operation was performed. — T. S. C]

Probable Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries.* — A woman, fifty-nine years of age, for three months had been supposed to have influenza. Two months before coming under observation she had become yellow and had had pain in the abdomen. On admission she was jaundiced, had lost weight, vomited bile, and gave a history of vomiting blood on one occasion. At the umbilicus was a knob-like hardness drawn inward, as if pulled by something from within. At autopsy carcinoma of both ovaries was found. There were small nodules in the peritoneum and pleurse. The gall-bladder was small and filled with stones. The common duct was compressed by cancerous nodules. The growth at the umbilicus was apparently secondary to that in the ovaries.

Carcinoma of the Umbilicus Secondary to Cancer in the Pelvis.- — Gueneau de Mussy's t patient, a woman fifty-nine years old, was suffering from an obscure abdominal lesion. At the umbilicus was a small, hard disc, the size of a large almond, attached by a pedicle in the umbilical ring. The patient said she had had a small hernia, easily reducible, but for the past month it had been hard and remained outside.

At autopsy, several months later, an abdominal carcinoma was found. The pelvis contained a mass the size of a new-born child's head, and other foci existed.

Probable Adenocarcinoma of the Umbilicus Secondary to Carcinoma of the Ovary. — Gyn. No. 2004; Path. Xo. 8. Mrs. C. W., aged thirty-two. Admitted to the Johns Hopkins Hospital May 25, 1893. Operation by Dr. Kelly. The abdomen contained about 8 ounces of ascitic fluid; the peritoneum was dark in color. The right ovary was the size of an orange, and was surrounded by a capsule 34 m ch in thickness. This was easily torn. Several small nodules were felt in different portions of the peritoneum; in the median line and around the umbilicus was a loosely encapsulated white lump the size of a shellbark nut. This was not removed, on account of the presence of secondary nodules. The liver was covered with whitish nodules, similar in character; these extended from the liver down to the umbilicus.

Path. No. 8. The specimen consists of the ovary, tube, and a portion of the broad ligament. The ovary is very much enlarged and contains three or four cysts. The surface is irregular in outline. There is a dense, hard capsule with several small cysts showing through the outer surface. At the inner end of the ovary is a cyst, 2 cm. in diameter, filled with clear, watery fluid. The cysts are confined to the superficial portion of the ovary. On section, the greater portion of the mass appears

  • Liveing: The Lancet, 1875, ii, 8.

t Gueneau de Mussy : Cancer du peritoine. Clin, med., Paris, 1875, ii, 28.


432


THE UMBILICUS AND ITS DISEASES.


to be made up of translucent, grayish tissue having an edematous appearance, and running through this in every direction is dense fibrous tissue. There are ecchymotic patches here and there throughout the specimen. The broad ligament is thickened and contains numerous hard masses varying from a pin-head to a lima bean in size. On histologic examination the matrix of the tumor is found to consist of very edematous fibrous tissue. Scattered sparsely or abundantly throughout the stroma are colonies of carcinomatous glands. The gland type in some areas is very well preserved. At other points the carcinoma seems to form solid masses.



£9


m




£*






Fig. 185. — Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries. Gyn. No. 6150; Path. No. 2407. The umbilicus has been converted into a round, ulcerated area, with sharp edges and a granular base. The picture is taken from the indurated tissue near the edge of the ulcer. To the left is squamous epithelium, which in places is much thickened, but in the upper part of the picture is normal in thickness. On the surface is some exfoliated and partly hornified epithelium. Immediately beneath the skin the stroma shows considerable small-round-cell infiltration. The right half of the field consists of nests of cancer-cells. The floor of the ulcer to a large extent is made up of cancerous tissue. In many portions of the growth the typical glandular character of the tumor was evident. It was an adenocarcinoma.


There is no trace of ovarian stroma remaining. The growth is a virulent adenocarcinoma of the ovarjr. It is exceptional with such an early tumor to find such wide-spread metastases. The nodule at the umbilicus, although not examined histologically, was undoubtedly similar in origin. Whether the umbilical growth was due to extension upward from below or from above is problematic, but with metastases in the liver and extending down along the suspensory ligament to the umbilicus it looks very much as if the growth were secondary to the liver nodules.

Adenocarcinoma of the Ovary; Metastases to the Peritoneum and to the Umbilicus. — Gyn. No. 6150. A. H.,


CARCINOMA OF THE UMBILICUS. 433

admitted to the Johns Hopkins Hospital June 6, 1898. The patient, fifty-five years of age, was married twenty-six years ago. She has had no children and no miscarriages. The present illness began over a year ago. She has gradually grown weaker, and has not been able to work for a long time. She complains of abdominal enlargement, of marked constipation, and of a growth at the umbilicus.

At operation the parietal peritoneum was studded with small, whitish elevations, and the abdominal cavity contained several cystic masses reaching to the umbilicus. They could not be removed. The umbilicus itself had been converted into a round, ulcerated area with sharp edges and a granular base. This was excised when the abdomen was opened. The patient was much relieved by the operation and the tenderness over the abdomen disappeared.

Path. No. 2407. The specimen consists of fluid from the peritoneal cavity, of a small section of a cyst wall, and of the umbilicus.

Section from the Umbilicus. — The skin surrounding the umbilicus is perfectly normal. As one approaches the area of ulceration it is raised somewhat and becomes thickened, and the papillae extend a certain distance downward. The tissue beneath the squamous epithelium is normal, but as one approaches the area of ulceration it shows small-round-cell infiltration around the capillaries. Near the edge of the ulcerated area one finds nests of epithelial cells which have retracted somewhat from the surrounding stroma (Fig. 185) . In certain areas one can make out a definite gland arrangement. The growth is an adenocarcinoma with a tendency to form solid nests. As one passes to the ulcer, the squamous epithelium disappears. The surface is covered with fibrin, polymorphonuclear leukocytes, and small roundcells. The nuclei of the cancer-cells vary considerably in size. Some cancer-cells are large, stain deeply, and contain irregular masses of chromatin. The entire floor of the ulcer is made up of granulation tissue and nests of cancer-cells. The line of junction between the surface epithelium and the cancer is very sharply defined. In the depth of the ulcer the tissue consists almost entirely of nests of cancer-cells. The process has undoubtedly extended up from the abdomen as a wedge and raised the squamous epithelium. Over the area of carcinoma the skin has given way and an ulcer has resulted. The umbilical growth is identical in character with the ovarian tumor from which it originated.

After the book was in type and shortly before going to press the following interesting case came under my care :

Adenocarcinoma in the Omentum Incarcerated in an Old Umbilical Hernia (Plate V). — The primary growth was apparently in the ovary, possibly in the uterus. Mrs. Annie E., aged seventy- two, referred to me by Dr. Albert Singewald, was admitted to the Church Home and Infirmary September 28, 1915. The patient had had two children and one miscarriage. The menopause had occurred at forty.

Present Illness. — About four years before she had noticed vaginal bleeding, which had persisted up to the time of admission. For the last two or three months she had had profuse bleeding, lasting from three to four days. Between these attacks there had been a continuous thin, pinkish discharge. For the last two months she had suffered a great deal with pain over the sacrum and in the lower abdomen, and during the same time there had been pain on voiding. She had lost 25 pounds within the last two months. 29


434 THE UMBILICUS AND ITS DISEASES.

The patient was a very large woman, weighing 235 pounds. She looked relatively well. On physical examination the abdomen was found much distended, but there was some laxness in both flanks. An umbilical hernia (Plate V) was noted, which presented a somewhat unusual appearance. It seemed somewhat lobulated, and the umbilicus itself was crescentic. The entire raised area measured about 5 cm. from above downward and about 4 cm. from side to side. It did not present the uniformity of outline so frequently noted in umbilical hernise. On palpation it felt hard, and one could detect definite nodular thickenings in the hernial mass. These were apparently four or five in number, and immediately suggested metastatic nodules.

On carefully questioning the patient we learned that she had had an umbilical hernia since she was forty; in other words, for thirty-two years. During the last three months she had noticed that the hernia, which hitherto had been quite soft, had become gradually hard and nodular.

On abdominal palpation a definite tumor mass could be felt to the left of the umbilicus. Its exact dimensions could not be determined on account of the abdominal distention. In either flank fluctuation could be elicited.

I kept the patient in the ward several days, while debating whether any operative procedure should be undertaken. She was so anxious for relief that I finally consented to make an exploratory incision.

Operation October 1, 1915. — An elliptic incision was made around the enlarged and nodular umbilicus, and in the abdominal muscles just above the umbilicus was found a definite nodule, about 1 x 1.5 cm. After the umbilical growth had been freed from the abdominal wall, a tongue of omentum was discovered that passed into the hernial sac. This portion of omentum was intimately blended with the umbilicus and was removed with the sac. The parietal peritoneum everywhere was studded with carcinomatous nodules varying from 1 to 6 mm. in diameter. To the left of the umbilicus was an ovarian tumor which appeared to be about 16 cm. in diameter. The omentum was markedly thickened, and the greater part of it lay rolled up above the umbilicus. Loops of small bowel were adherent to the anterior abdominal wall near the symphysis, and also at other points, and here and there,

plate v.

Cancer op the Umbilicus Apparently Secondary to a Tcmor of the Ovary.

Gyn.-Path. No. 21554. Mrs. A. E.

Fig. 1 gives the general relations as found at operation. At the umbilicus was the hard umbilical hernial mass containing cancerous nodules, and at operation a cancerous nodule was found in the mid-line just above the umbilicus.

To the left of the umbilicus was an ovarian tumor apparently cystic. The greater part of the omentum was rolled up and formed a tumor mass about midway between the xiphoid and the umbilicus. As there was a general peritoneal carcinosis and many adhesions, a more extended examination w r as not made.

Fig. 2 is an exact drawing of the umbilicus as it appeared before operation. The umbilical area is sharply raised from the surrounding abdominal walls, and the umbilical depression is represented by a crescentic slit. In this tumor four or five very hard nodules could be distinctly made out, at once suggesting malignancy.

Fig. 3 graphically depicts the condition noted when the abdomen was opened. Occupying the left side of the lower abdomen is an ovarian cyst. This below and posteriorly is adherent. The omentum above the umbilicus is greatly thickened as a result of involvement in the carcinomatous process.

The lower end of the omentum fills the umbilical hernial sac. This portion of the omentum is also much thickened and has become intimately blended with the hernial walls. The incarcerated omentum is riddled with cancer. In the lower part of the omentum, that lies in t lie hernia, is a small cyst.

F i g . 4 shows a longitudinal section of the umbilical tumor. Between a and a' we see small carcinomatous nodules in the- parietal peritoneum of the anterior abdominal wall. The omentum (6) projects into, completely fills, and is intimately blended with the hernial sac. In the upper part of the picture, where a catgut ligature is seen, the omental fat can still be fairly well recognized, but most of the omentum in the hernia looks very much like fibrous tissue. It was everywhere invaded by adenocarcinoma. The cyst (c) was lined with one or more layers of cancer cells, d indicates the lower limit of the hernial sac; e is the bottom of the crescentic umbilical slit seen in Fig. 2.


CARCINOMA OF THE UMBILICUS.


435


PLATE V. Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary.


  •  : . ; i & v : . - \ I a . ■' \ n °

i fete" 1 ™ \)


Carcinomatous nodule



■ '


Peritoneum


Ornenium


a... i


a'



436 THE UMBILICUS AND ITS DISEASES.

where such adhesions existed, the bowel was covered over with flakes of fibrin. Further examination being impossible, the abdomen was closed as soon as the umbilical growth had been removed.

The patient rallied remarkably well and left the hospital on October 23, feeling very much relieved.

Gyn.-Path. No. 21554. Sections involving the entire hernial mass show that the omentum which had extended into the hernia has become blended with the walls of the hernial sac, and that very little adipose tissue remains, the stroma consisting almost entirely of fibrous tissue, rich in spindle cells (Plate V, Fig. 4). Scattered through this are many glands occurring singly or in groups. In some places they are lined with one layer of epithelium, the cells being somwhat cuboidal or roundish and manifesting a tendency to drop off. In other places there are colonies of glands, some of the gland-spaces being partially or completely filled with epithelial cells. The nuclei of the epithelial cells vary markedly in size. Some of them contain large masses of deeply staining chromatin. The picture is that of an adenocarcinoma of a type usually noted in the ovary. The cyst-like space noted at one end of the umbilicus is lined with epithelium. In some places this is almost flat; in other places it is drawn up in papillary-like folds. In this case we have a definite adenocarcinoma of the umbilicus.

From the foregoing it is perfectly clear that the primary cancer was either in the ovary or in the uterus. The type of gland found in the carcinoma might well have been from either the body of the uterus or from the ovary. Uterine hemorrhage extending over a period of four years is somewhat unusual in so old a patient unless some serious uterine trouble exists. On the other hand, we all know that uterine hemorrhage is not infrequently associated with an ovarian tumor.

The presence of the ovarian tumor, with apparently thick walls, would strongly suggest the ovary as the primary seat of the trouble. Further, metastases from an ovarian carcinoma are not uncommon. Peritoneal metastases of such a character following a carcinoma of the body of the uterus I have never seen.

In all probability, then, this patient had a primary carcinoma of the left ovary; general peritoneal metastases had developed, and finally the omentum in the umbilical hernia had been invaded by carcinomatous nodules. Here they could be palpated with the utmost ease.

LITERATURE CONSULTED ON CARCINOMA OF THE UMBILICUS SECONDARY TO

OVARIAN CARCINOMA. Aslanian, G.: Contribution a P etude de la peritonite cancereuse. These de Paris, 1895, No. 150. Burkhart, 0.: Ueber den Nabelkrebs. Inaug. Diss., Berlin, 1889. Cullen, Thomas 8.: Gyn. Xo. 2004, from the records of the Johns Hopkins Hospital; Gyn. No.

0150, from the records of the Johns Hopkins Hospital. Cullen, Thomas S. : Cancer of the Uterus, 1900. Demons el Verdelet: Cancer secondaire de Pombilic. Congr. periodique de gyn., d'obstet. et

de paod., 1898, ii, 344. Gueneau de Mussy: Cancer du peritoine. Clin, med., 1875, ii, 28. Liveing: Cancer of Ovaries and Peritoneum and Umbilicus. The Lancet, 1875, ii, 8.

CARCINOMA OF THE UMBILICUS SECONDARY TO CARCINOMA OF THE UTERUS.

Extension of carcinoma of the uterus to the umbilicus is exceptionally rare. In

the examination of an unusually large number of cases of uterine cancer I have


CARCINOMA OF THE UMBILICUS. 437

never detected an umbilical involvement. Le Coniac,* in his thesis on cancer of the umbilicus secondary to primary uterine or ovarian growths, says that in one case there existed between the cancer of the uterus and the umbilical tumor a chain of nodules along the anterior abdominal wall.

Catteau,t in his thesis in 1876, described the case of a young woman who had carcinoma of the body of the uterus. There were two nodules in the abdomen and a tumor the size of a filbert at the umbilicus. The inguinal glands were enlarged. In this case the umbilical growth was in all probability secondary to that in the uterus. These are the only two cases that I can find in any way suggesting cancer of the umbilicus secondary to a primary growth in the uterus.

Quenu and Longuet,J however, in their paper mention two cases of cancer of the uterus with secondary nodules at the umbilicus.

CASES OF SECONDARY CARCINOMA OF THE UMBILICUS IN WHICH THE SOURCE OF THE PRIMARY GROWTH WAS NOT DETERMINED.

These cases closely resemble those of secondary carcinoma of the umbilicus already considered. A few, however, present particularly well some of the salient points and other features not illustrated by the preceding cases.

In Bantigny's case a small, ovoid, sessile nodule was present at the umbilicus. The inguinal, axillary, and subclavicular glands on both sides were implicated.

In Chuquet's Case 3, at the umbilicus was a cancerous plaque, 10 by 5 cm., which was continuous with the induration in the suspensory ligament.

My case (G) was unusual, in that the umbilical changes had become apparent exceptionally early, there being merely a delicate papillary growth in the umbilical depression. This growth on section clearly shows the fibrous appearance of these tumors (Fig. 188, p. 441). The specimens from three others of these cases came under my personal attention. In Dr. W. T. Willey's case the growth was bluish red and very prominent, as seen in Fig. 186, p. 439. It showed areas of ulceration. Operation was contraindicated, and we were unable to get an autopsy. In Irving Miller's case the umbilical growth reached the surface of the umbilicus. Haggard's case is particularly striking on account of the large dimensions of the umbilicus (Fig. 190, p. 443), its general contour being still preserved. This tumor on section also clearly showed the apparent fibrous character of these growths. The carcinomatous structure would not for a moment be suspected from such a picture.

Secondary Carcinoma of the Umbilicus. — Bantigny's patient, § a man fifty-three years of age, six months before coming under observation, had noticed a tumor the size of a pea in the center of the umbilical depression. His digestion had been poor for some time, and he had had radiating pains in the umbilical region. There had been loss of appetite and progressive emaciation for two months. At the time of operation the umbilical nodule was the size of a small walnut, ovoid in form, and with a broad pedicle. It was purple in color, ulcerated, but apparently movable. The inguinal glands on both sides were enlarged. The subclavicular and axillary glands were also involved.

  • Le Coniac, H. C. J. : Cancer secondaire de l'ombilic, consecutif aux tumeurs malignes de

l'appareil utero-ovarien. These de Bordeaux, 1898, No. 19.

f Catteau, J. F. : De l'ombilic et de ses modifications dans les cas de distension de l'abdomen. These de Paris, 1876.

X Quenu et Longuet: Du cancer secondaire de l'ombilic. Rev. de chir., 1896, xvi, 97.

§ Bantigny, A. : Un cas de cancer de l'ombilic. Jour, des sci. med. de Lille, 1898, 2. s., xxi, 91.


438 THE UMBILICUS AND ITS DISEASES.

At operation the omentum was found adherent, and at its extremity was a small tumor the size of a pea, hard, and manifestly cancerous. Bantigny held that the umbilical cancer was secondary to some visceral growth.

Carcinoma of the Umbilicus Secondary to Peritoneal Carcinosis. — Chuquet* bases his paper on general carcinosis of the peritoneum on 46 cases.

Case 3. — A woman, sixty years of age, two and one-half months before, had begun to complain of severe pain in the legs and in the inguinal region. At that time a painful, hard, and ulcerated enlargement at the umbilicus had been noticed. The ulceration was superficial and covered with a crust which dropped off at intervals. At the same time she had had a diarrhea lasting three weeks.

The abdomen was enlarged, and on examination an area of induration, 5 by 6 cm., could be felt at the umbilicus, and in the abdomen hard masses could be detected. Several glands were palpable in the inguinal region.

At autopsy several liters of ascitic fluid were found. The intestines were studded with small cancerous nodules. A large tumor was present in the omentum, which was adherent to the anterior surface of the stomach. At the umbilicus was an indurated plaque, 10 cm. long by 5 cm. broad, continuous with an induration in the suspensory ligament of the liver. The ulceration of the umbilicus was only superficial. Nodules were present in the pelvis and the liver. The mucosa of the stomach had not been invaded.

[Of course, in this case the primary site is still in doubt. — T. S. C]

A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth. —Mrs. J. J., aged eighty, seen in consultation with Dr. W. T. Willey, October 5, 1910. This patient has had indigestion for years, more marked during the last few months. She rises early for her breakfast and then goes to bed for several hours on account of the uncomfortable sensation in the abdomen. For about ten years she has had uterine hemorrhages at irregular intervals. Her chief complaint is of pain and enlargement at the umbilicus.

Examination. — The umbilicus is rolled out and its right side is occupied by a bluish-red nodule, 3.5 cm. in diameter (Fig. 186). This presents a glazed appearance. In some places it is covered over with skin, but at a few points are little areas of ulceration, which, however, do not bleed much. If one attempts to roll the tumor out of the umbilicus, some pus escapes from the crevices. Surrounding the umbilicus is a zone of induration about 1 cm. in diameter. The umbilical tumor seems to be fairly well fixed.

On pelvic examination the uterus is found to be about four times the natural size. The cervix is normal.

It looks very much as if the growth at the umbilicus is a carcinoma, and that it is secondary to some abdominal growth. It is just possible that it may come from a carcinoma of the body of the uterus, but it is more probable that it is secondary to some growth in the stomach.

After considering the matter fully I decided against operation on account of the patient's age, and because there existed some inoperable growth in the abdomen. The patient died a few months after my visit. No autopsy was permitted.

  • Chuquet, A. : Du carcinome generalise du peritoine. These de Paris, 1879, No. 548.


CARCINOMA OF THE UMBILICUS.


439


Carcinoma of the Umbilicus Secondary to an Abdominal Growt h . (Personal communication from Dr. Irving Miller.) — E. M. was operated on at the Church Home and Infirmary on August 31, 1909. She was a woman fifty-eight years of age, married, and had had one child. At the lower end of the umbilical depression was a painless growth the size of a lentil, grayish red in color. There was a considerable amount of moisture. No nodule could be detected in the abdomen, and the patient had no indigestion. During the removal of the growth nodules were found in the omentum and mesentery. These varied



w V


Fig. 186. — A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth. This photograph of Dr. Willey's patient was made by Dr. Cecil Vest. A growth occupies the site of the umbilicus; this is several centimeters broad, as indicated by comparing it with the fingers. The skin is still intact, but very thin, and over the dark areas is almost wanting.


from the size of a pea to that of a hazelnut. The peritoneum was free and there was no hernia.

Dr. Miller thought that the umbilical growth was secondary, but could not locate the original tumor. It did not emanate from the pelvis.

Path. No. 14122. The specimen measures 3 by 1 cm., and consists of tissue covered over with skin. Occupying the umbilical region is a firm nodule which, on section, has a whitish, fibrous appearance. The entire specimen resembles a large umbilicus.

On histologic examination the squamous epithelium in the vicinity of the umbilicus is perfectly normal and the underlying stroma unaltered. It ends abruptly,


440


THE UMBILICUS AND ITS DISEASES.


and coming up from below and reaching the surface is a cancerous growth (Fig. 187). This is glandular in character, and consists of long, finger-like folds or of papillary masses or groups of glands. The cells are very regular, but mitotic figures are very abundant. Only at one point over a very limited area is the skin lacking. Here the cancerous tissue reaches the surface. It is covered with a moderate amount of fibrin in which are a few leukocytes. Certain portions of the tumor show small areas of calcification. It is without doubt a secondary carcinoma of the umbilicus. The picture present resembles very closely that found in cancer of



Fig. 187. — Adenocarcinoma of the Umbilicus Secondary to an Intra-abdominal Growth. Gyn.-Path. No. 14122. (Specimen sent by Dr. Irving Miller, Baltimore.) The surface on the left is covered over with squamous epithelium, which shows little deviation from the normal. As we pass to the right the squamous epithelium gradually disappears, and on the extreme right the surface is composed of cancerous tissue. The right half of the picture shows a definite papillary or finger-like character of the growth. It is an adenocarcinoma. Along the advancing margins of the cancer the stroma shows much small-round-cell infiltration.


the body of the uterus. It is impossible for us, however, to determine absolutely the original source of the growth.

Secondary Carcinoma of the Umbilicus; Metastases in the Right Inguinal Glands. — Mr. G.,* forty-two years of age, was seen in consultation August 30, 1904. The patient was well nourished, and complained of a discharge from the umbilicus. Six weeks before he had been struck in the abdomen with a shoe and the umbilicus had commenced to discharge three weeks later. The umbilicus itself presented a granular appearance (Fig. 188) and the tissue surrounding it was indurated. The patient had had dyspepsia for years;

  • This case was reported by me in the Jour. Amer. Med. Assoc., 1911, lvi, 391.


CARCINOMA OF THE UMBILICUS.


441


also pain in the lower abdomen over the appendix. He was admitted to the Church Home. Under anesthesia the inguinal glands were carefully palpated. A definite enlargement was found in the right side. An incision 10 cm. in length was made and the inguinal glands were removed, together with the surrounding fat. I then made a long elliptic incision around the umbilicus and removed the umbilical tumor, giving the hardened area a wide berth. The growth at the umbilicus closely resembled a retracted nipple. The patient took the anesthetic badly, and consequently I could not make as thorough an abdominal exploration as I desired. With the finger carried in all directions I was unable to detect any thickening.



Fig. 188. — Adenocarcinoma of the Umbilicus. The umbilicus looks very much like an inverted carcinomatous nipple. The margins present a fine nodular appearance. The dotted line indicates the limits of the incision. On the right is shown a longitudinal section through the umbilicus. There is much thickening due to carcinomatous infiltration. The peritoneum beneath the umbilicus was free from adhesions. (Gyn.-Path. No. 7729.)


Histologic Examination. — Path. No. 7729. — The umbilical growth proved to be a typical adenocarcinoma. The squamous epithelium in many places was normal, but along the edge of the growth it was impossible to distinguish between the cells of the adenocarcinoma and those of the squamous epithelium. There was as yet little breaking down. The growth in the inguinal glands macroscopicalfy looked like cancer (Fig. 189). On histologic examination it presented exactly the same pattern as that noted at the umbilicus.

On January 25, 1905, the patient was in fairly good health; but was still constipated and had great difficulty in defecation. On February 24th a firm globular mass fully 10 cm. in diameter was found occupying the middle of the abdomen and


442


THE UMBILICUS AND ITS DISEASES.


the left inguinal glands were considerably enlarged. The umbilical growth was undoubtedly secondary to the intra-abdominal cancer. In May, 1905, 1 again saw the patient. His bowels had not moved for ten days, and he was so emaciated that one could hardly recognize him. Nodules were palpable everywhere in the abdomen. He died a few days later.

Cancer of the Umbilicus. — Haggard * reports the case of a man fifty-nine years of age. Three months before admission the patient had noticed a hard nodule the size of a hickory-nut just above the umbilicus. The hardness

gradually increased, and the umbilicus commenced to bulge. The tumor was slightly tender, and there was a sense of uneasiness; it was the size of a goose's egg, was stony hard, and the skin could not be moved over it. The mass was fixed. The patient commenced to lose flesh.

Haggard removed the umbilicus February 17, 1904, making an elliptic incision. The resultant opening gaped nearly as large as a saucer. The stomach, gall-bladder, and liver were examined for cancer, but none was found. The gall-bladder was very hard and thickened and contracted down on a stone; this was removed and the gall-bladder drained. The peritoneum could not be approximated. The omentum was turned up and sewed to the serous margins of the incision. With considerable difficulty the fascia and muscle were partly brought together with interrupted sutures of catgut. The edges of the wound were still about 13^ inches apart. The silver wire filigree of Willard-Bartlett was used. This was laid on corduroy sutures of catgut, the edges resting between the fat and the fascia, and the skin was closed. The wound healed without incident.

Secondary Adenocarcinoma of the Umbilicus. f — Path. No. 15029. — The specimen sent me by Dr. Haggard, of Nashville, Tenn., in April, 1910, consists of the umbilicus with a good deal of surrounding tissue. The entire specimen measures 10 cm. in length, 7 cm. in breadth. The umbilicus is 2.5 cm. across and is covered with skin. It presents a rather uneven, nodular

  • Haggard, W. D. : Cancer of the Umbilicus. Amer. Jour. Surg, and Gyn., St. Louis, 190304, xvii, 196.

t This case was reported by me in Jour. Amer. Med. Assoc, 1911, lvi, 391.



Fig. 189. — The Section Shows Carcinoma of the Right Inguinal Glands. Scattered throughout the adipose tissue are several solid areas. Those indicated by a are small lymph-glands. The lymph-gland at b is greatly enlarged, and everywhere infiltrated by carcinoma which is invading the surrounding tissue; c is also an area of carcinoma. Fig. 188 shows the umbilical cancer in the same case.


CARCINOMA OF THE UMBILICUS.


443


surface, and is much more prominent than usual, having welled up in the center (Fig. 190). There is no evidence of ulceration at any point. On section the distance between the umbilicus and the peritoneal surface is 2 cm. The tissues look fibrous, and in the vicinity of the umbilicus show infiltration, apparently with fibrous tissue. At one point is an area of what looks like localized fibrous thickening, 2.5 cm. in diameter. The adipose tissue has been almost entirely replaced at this point.


B.



,.:■ .' . <^*. }£<nHx^


Fig. 190. — Secondary Carcinoma of the Umbilicus. (Natural size.) Path. No. 15029. (Specimen sent by Dr. W. D. Haggard of Nashville, Tenn., April, 1910.) The umbilical fold is much widened, and the umbilicus is shallower than usual. It presents a somewhat uneven and nodular appearance, but is everywhere intact. On the right is shown a longitudinal section through the umbilicus. There is a deep cleft along the skin surface, and the umbilical fold is deeper than usual. The fat in the depth has been replaced to a large extent by fibrous tissue, which is everywhere infiltrated with carcinoma. The peritoneal surface, which is to the left, is perfectly smooth; there is no evidence of any adhesions.


Histologic Examination. — The squamous epithelium is intact, and there is pigmentation in the deeper layers, suggesting that the specimen has come from a colored patient. The tissue immediately beneath the skin in some places is normal; at other points it shows some small-round-cell infiltration. Scattered everywhere throughout the thickened fibrous tissue are glands. Some of them are small and round, others elongated or tubular; others are dilated. The glands are lined with cylindric or cuboid epithelium, which in most places is one layer in thickness. The


444 THE UMBILICUS AND ITS DISEASES.

nuclei of the epithelial cells are for the most part oval and stain uniformly. A few of the epithelial cells have very large and deeply staining nuclei. Where the glands are dilated, the epithelium tends to become cuboid. At other points the glands are very abundant, are undergoing disintegration, and are filled with mucus. In some places the epithelium is several layers in thickness. Here and there gland epithelium has proliferated to such an extent that new glands are being formed. The growth is undoubtedly a carcinoma of a glandular type and similar to one originating either in the stomach or intestine.

Encephaloid Cancer of the Umbilicus.* — The umbilicus of an old man was occupied by a tumor the size of a fist, and presenting a bluish aspect. It was apparently adherent to the peritoneum and to the skin at the umbilicus. It was soft, but could not be moved at all without displacing the abdominal wall. The patient had lancinating abdominal pains. Demarquay diagnosed cancer of the umbilicus, but did not operate. The patient died.

Cancer of the Umbilicus. — Demarquayf with Dr. Roger saw a patient, sixty years of age, who had a soft and somewhat fluctuating tumor at the umbilicus. It was the size of two hands. It had originated at the umbilicus. It was opened at several points and fungating masses grew from it. A diagnosis of encephaloid cancer was made. The patient died. No histologic examination is reported.

Cancer of the Omentum and Umbilicus Simulating H e r n i a . J — Mary T., aged sixty-six, the mother of four children, had been in good health until four years previously, when she had noticed a projection at the umbilicus. This was the size of a finger-tip, and was pressed on by her stays. The bowels had been regular until one month before, when diarrhea had commenced. This had ceased without any treatment, but had returned two weeks later, accompanied by pain in the abdomen, especially at the umbilicus. Vomiting had then started, and the patient had rapidly grown worse.

After admission she vomited frequently. The vomitus had an offensive but non-fecal odor. The patient had an anxious expression. She was stout and well nourished; the abdomen was distended, tympanitic, and tender. There was a nodular projection in the left half of the umbilicus, half an inch in diameter. The overlying skin was normal, but immediately beneath the umbilicus and in the abdominal cavity was an ill-defined, very hard, slightly movable tumor, apparently continuous with that of the umbilicus. The patient on the twelfth day developed a temperature of 104° F. and died.

Autopsy showed invasion of the peritoneum by cancer. The mass involving the omentum had extended into the umbilicus. [This case at first simulated a small, strangulated umbilical hernia. There is no note as to the original site of the cancer. — T. S. C]

— .Carcinoma of the U m b i 1 i c u s . § — A stout woman, forty-nine years of age, had had an umbilical hernia for a long time. Six months before she had received a slight injury of the umbilicus, and from that time the hernia had

  • Demarquay: Bull. Soc. de chir., 1870, 2. ser., xi, 209. Seance du 8 Juin.

f Demarquay: Op. cit.

% Forster, J. Cooper: Guy's Hospital Reports, 1874, 3. s., xix, 4.

§ Gallet, M. A. : Epithelioma de l'ombilic. Jour, de chir. et ann. Soc. beige de chir., Bruxelles, 1901, i, 565.


CARCINOMA OF THE UMBILICUS. 445

increased in size. On admission it was as large as an egg, hard, painful on pressure, and irreducible.

The umbilical growth was removed. The omentum was found adherent, and in it were enormous cancerous masses. Two large ovarian cysts were removed at the same time. At autopsy gall-stones were found. The intestinal tract was normal. Gallet thought the cancer was primary in the umbilicus. No microscopic examination, however, was given, as the case was reported at the society on the day of the operation.

[The umbilical growth was probably secondary. — T. S. C]

Carcinoma of the Umbilicus. — Kuster* reports a case personally communicated to him by Wilms. An old Israelite had a carcinoma of the umbilicus and died in consequence of digestive disturbances. The general history suggests that the umbilical growth was secondary.

Cancer of the Umbilicus. f — A young married woman, twentyseven years of age, had a tuberculous peritonitis with effusion. In the region of the umbilicus was an ulcerated and hemorrhagic area. McMurtry opened the abdomen, evacuated the contents and took the umbilicus out through an elliptic incision. He diagnosed the case as one of fibroid carcinoma.

[In the absence of mention of a microscopic examination a possible tuberculous character of the umbilical lesion cannot be absolutely excluded. — T. S. C]

Carcinoma of the Umbilicus. J — A man, fifty-four years of age, had carcinoma of the glands of the left groin for two years and intra-abdominal symptoms of malignant disease. For four weeks a small, very painful, fungating mass had been developing at the umbilicus. The umbilicus as a whole was not enlarged or hardened. From its center sprang a tuft of purplish-red granulation about as large as a small pea. Morris removed the umbilicus, and at the same time made an exploratory opening for examination of the abdomen. The omentum was the seat of a colloid carcinoma, but there were no adhesions of the omentum to furnish a route for infection to the umbilicus. The umbilical growth was an adenocarcinoma.

Cancer of the Umbilicus. — Nelaton§ speaks of a scirrhus of the umbilicus in a patient sixty years of age. It was spheric, regular, about 2.5 cm. in diameter. No microscopic examination was made.

Carcinoma of the Umbilicus Secondary to Abdominal Carcinoma. |[ — A woman, fifty-one years of age, had had an abdominal enlargement for fifteen months. In the right iliac fossa was a round enlargement increasing in size. Her digestion was poor, and she suffered from nausea and vomiting and lost weight. Blood and pus were present in the stools. One of the left inguinal glands was enlarged to the size of a hazelnut. The point of origin of the tumor was not certain. At the umbilicus was also a carcinomatous nodule the size of a walnut, hard and purple in color. In the vicinity there was another nodule.

  • Kuster, E. : Die Xeubildungen am Xabel Erwachsener unci ihre operative Behancllung.

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

t McMurtry, L. S.: Louisville Monthly Jour, of Med. and Surg., 1902-03, ix, 492.

t Morris, R.: Lectures on Appendicitis and Xotes on Other Subjects, 1S95, 96.

§ Nelaton: Squirrhe ombilical. Gaz. des hop., Paris, 1860, xxxiii, 294.

|| Xeveu, V.: Contribution a l'etude des tumeurs malignes secondares de l'ombilic, Paris, 1890, No. 50.


446 THE UMBILICUS AND ITS DISEASES.

The growth was an adenocarcinoma. Neveu then goes on to give a general resume of the subject.

Secondary Carcinoma of the Umbilicus. — Pernice* cites a case reported by Bergeat (Inaug. Dissert., Munich, 1883). A woman, sixty-one years old, for three years had had a tumor at the umbilicus which had ulcerated. The inguinal glands were swollen. At autopsy a tumor the size of a child's head was found, which projected into the abdomen. The gall-bladder was adherent and had opened into the tumor.

Excision of Umbilicus for Malignant Diseases. f — The patient, thirty-seven years of age, was thin and cachectic. At the umbilicus was a nodule the size of a hen's egg. It had been growing rapidly, was painful and ulcerated. Operation was advised, but the patient disappeared.

Secondary Carcinoma of the Umbilicus. J — A woman, fifty years of age, had been in perfect health until six months before, when she commenced to lose her appetite and have vomiting spells. In less than two months she had lost 15 kilos. A month before admission she had noticed a moderate-sized induration at the umbilicus. A few days later it had become dark red. She never had had any pain. The umbilicus was removed. No tumor was detected in the abdominal cavity. The specimen consisted of a violet-colored mass which had ulcerated, and there was induration of the surrounding tissue. On cutting through there was a gritty-like feel suggestive of carcinoma. The peritoneum covering the under surface was indurated, but smooth. There was no evidence of neoplasm in the abdomen. On histologic examination the growth proved to be a cylindriccell carcinoma. From the findings thus far the tumor might have been considered as primary. Three months later, however, the patient was suffering from hemorrhage from the bowels. The inguinal glands on both sides were enlarged, forming a definite mass. The patient became cachectic and soon died. The umbilical growth had evidently been secondary.

Quenu and Longuet gave the following data concerning cases with secondary carcinoma of the umbilicus

In 32 cases in which the sex is recorded, 23 of the patients were females — a proportion of 70 per cent. (To explain this Damaschino expressed the opinion that carcinoma of the umbilicus occurs secondarily to carcinoma of the uterus or the ovaries.) In 19 out of 36 cases in which accurate data were given, the primary growth was in the gastro-intestinal tract. Of these 19 cases, in 14 the growth was primary in the stomach, in 4 in the intestine, and in 1 in the stomach and intestine. In two cases the primary cancer was in the uterus, and in three cases the original tumor was found in the ovaries.

Secondary Carcinoma of the Umbilicus. — Verchere§ gives a short review of the literature and reports the case of a woman, fifty-five years of age, who for several days had had signs of intestinal obstruction. Her general health up to that time had been good. The abdomen was distended, and at the umbilicus was a tumor slightly smaller than half an apple. It was hard, red,

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

t Parker, Willard: Arch. Clin. Surg., New York, 1876-77, i, 71.

X Quenu et Longuet: Du cancer seconclaire de l'ombilic. Rev. de chir., 1896, xvi, 97. § Verchere: De hi valeur si'meiologique du cancer de l'ombilic. Rev. des mah cancereuses, 1895-96, i, 81.


CARCINOMA OF THE UMBILICUS. 447

and ulcerated, but on the surface was smooth and regular. It was surrounded by a deep funnel, the walls of which were composed of healthy skin. Verchere thought it was a secondary growth, and made a rectovaginal examination, inquired for gastric and intestinal symptoms, and examined the anterior surface of the liver. All these examinations gave negative results. At operation he found, on the peritoneum of the anterior abdominal wall, many small, whitish-yellow, cancerous nodules. The primary source of the abdominal growth which had given rise to these metastases and to the secondary carcinoma at the umbilicus could not be located.

Adenocarcin o m a of the Umbilicus.* — The patient was sixtyeight years old, and for nearly a year had had discomfort just above the umbilicus. This was almost continuous and was independent of digestion. At the umbilicus was an indurated area the size of a pigeon's egg. When the patient came under observation the induration was ovoid in form, 6 cm. in its longest diameter, and 4 cm. broad. It seemed to be a primary tumor of the abdominal wall. It was removed but the patient died of peritonitis.

On microscopic examination, according to Stori, the growth proved to be an adenocarcinoma.

A Retroperitoneal Carcinoma Associated with Cancer of the Umbilicus. — From the accompanying history it appears that the primary growth was retroperitoneal. From what epithelial structure it originated, it is, however, impossible to say.

MacMunn'st patient was a woman sixty-three years of age. She was cachectic and had a "mouse smell. " The lymphatics in the left groin were of stony hardness and considerably enlarged. At the umbilicus was a hemispheric tumor, purplish in color, the size of a plum. It was firm, and had on its surface two small ulcers. When lifted up, the tumor could readily be isolated from the deeper structures.

At autopsy the umbilical growth was found to be bluish or grayish white and hard; it projected through the abdominal wall, raised the peritoneum slightly, but was not adherent to the structures. A few small, whitish nodules were found between the umbilicus and the pubes. The omentum contained nodules, the largest 23^ by 3^2 inch. Secondary growths were also present in the mesentery. The umbilical growth was undoubtedly secondary to the retroperitoneal tumor.

  • Stori, Teodoro: Contribute) alio studio dei tumori dell' ombelico. Lo Sperimentale, Arch,

di biologia normale e patologia, 1900, liv, 25.

f MacMunn: Case of Retroperitoneal Cancer Accompanied by Cancer of the Navel. Dublin Jour, of Med. Sci., lxii, 1876, 1.

LITERATURE CONSULTED ON CASES OF SECONDARY CARCINOMA OF THE UMBILICUS IN WHICH THE SOURCE OF THE PRIMARY GROWTH WAS NOT

DETERMINED.

Bantigny, A. : Un cas de cancer de 1'ombilic. Jour, des sci. med. de Lille, 1898, 2. s., xxi, 91.

Chuquet: Du carcinome generalise du peritone. These de Paris, 1879, No. 548.

Cullen, Thomas S. : Dr. W. T. Willey's case: Secondary Carcinoma of the Umbilicus.

Cullen, Thomas S. : Dr. Irving Miller's case: Secondary Carcinoma of the Umbilicus.

Cullen, Thomas S.: Personal case.

Cullen, Thomas S.: Surgical Diseases of the Umbilicus. Jour. Amer. Med. Assoc, February 11,

1911, lvi, 391. Haggard, W. D.: Cancer of the Umbilicus. Amer. Jour. Surg, and Gyn., St. Louis, 1903-04,

xvii, 196.


44"v THE UMBILICUS AND ITS DISEASES.

Deniarquay : Cancer de l'ombilie. Bull. Soc. de chir., 1S70, 2. ser., xi, 209. (Seance du 8 Juin.) Forster, J. C: Cancer of the Omentum and Umbilicus Simulating Hernia. Guy's Hospital

Reports, 1S74, 3. s.. xix. 4. Gallet. M. A.: Epitheliorue de l'ombilie. Jour, de chir. et arm. Soc. beige de chir., Bruxelles,

1901, i, 565. Exist er, E.: Die Xeubildungen am Nabel Erwachsener und ihre operative Behandlung. Langen beck's Arch. f. klin. Chir., 1874, xvi, 234. McMurtry, L. S.: Cancer of the Umbilicus. Louisville Monthly Jour. Med. and Surg., 1902-03,

ix, 492. Morris, R.: Carcinoma of the Umbilicus. Lectures on Appendicitis and Notes on Other Subjects, 1S95, 96. Nelaton: Squirrhe ombihcal. Gaz. des hop., Paris, 1860, xxxiii, 294.

Neveu, V. : Contribution a l'etude des tumeurs mahgnes secondaires de l'ombilie. Paris, 1890. Pernice, L.: Die Nabelgeschwulste, HaUe, 1892. Parker, W. : Excision of Umbihcus for MaUgnant Diseases. Arch. Clin. Surg., New York, 1876 77. i. 71. Quenu et Longuet : Du cancer secondaire de l'ombilie. Rev. de chir., 1896, xvi, 97. Stori, T. : Contributo alio studio dei Tumori dell' ombelico. Lo Sperimentale, Arch, di biologia

normale e patologia, 1900, liv, 25. Verchere, F. : De la valeur semeiologique du cancer de l'ombilie. Rev. des maladies cancer euses, 1895-96, U, 81.



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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