Book - Umbilicus (1916) 26
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Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.
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Chapter XXVI. Sarcoma of the Umbilicus
Spindle-cell sarcoma of the umbilicus: report of cases.
Round-cell sarcoma of the umbilicus.
Melanotic sarcoma of the umbilicus.
The literature on this subject is in a very chaotic condition. From the recorded cases it is possible to make the following classification :
1. So-called telangiectatic myxosarcoma occurring at or near the time of birth. This in reality is not malignant.
2. Spindle-cell sarcoma.
3. Round-cell sarcoma.
4. Melanotic sarcoma.
At best my description of sarcoma of the umbilicus will be fragmentary and incomplete. I shall give abstracts of the more characteristic cases recorded, so that the reader may draw his own conclusions. After careful histologic studies of such cases in the future it is to be hoped that before many years the subject of sarcoma of the umbilicus will be placed on a clear and satisfactory basis.
Cases of this nature have been reported by Virchow, Kaufmann, and von Winckel. In 1864 Gerdes saw a child, a few hours old, with a horn-like projection from the umbilicus. It was four inches in length and about the thickness of the index-finger, and gradually tapered to the end. At first it was bright red in color, later dark. It was very smooth, had an abundant blood-supply, was rather firm, had no pulsation, and on compression did not diminish in size. The growth was composed of spindlecells separated from each other by a mucous intercellular substance. Virchow termed it a telangiectatic myxosarcoma.
In Kaufmann's case, reported in 1890 (Figs. 191 and 192), the tumor was likewise present at birth, and in the course of a few days was observed to grow gradually. It projected 6 cm. from the abdominal wall and was 16 cm. in circumference. It was partly covered with skin, partly with amnion. Its outer portion was dense; its central part cavernous. On histologic examination the former was found to consist of spindle-cells, the latter of myxosarcomatous tissue. The angiomatous appearance in the central portion was due to the great dilatation of the arteries.
Von Winckel in 1893 observed a red tumor at the umbilicus in a new-born child. This tumor (Fig. 194) was 4 cm. long, and at the umbilicus 2.8 cm. in diameter. It was bright red in color. Its surface was covered with what appeared to be a hyaline membrane. The growth was composed chiefly of spindle-shaped cells. There was an abundance of large blood-vessels, and, in addition, large lymphspaces. At certain points the endothelium of the lymph-spaces had proliferated. 30 449
THE UMBILICUS AND ITS DISEASES.
These endothelial cells were markedly enlarged and projected into the lumina of the lymphatics. The stroma-cells in the vicinity were very large (Fig. 195), but the majority of them contained no nuclei and looked more like cells undergoing degeneration. This case, apart from dilatation of the lymphatics, bore a striking resemblance to those reported by Virchow and Kaufmann. Abstracts of Kaufmann's and von Winckel's cases are appended.
v A Congenital Umbilical Tumor.* — On the second day after birth Lissner saw the child. The mother was forty-eight years of age, strong, and well nourished. The patient was the twelfth child. The labor had been easy, and the umbilical tumor had caused no hindrance. At first it was small, but by the end of twenty-four hours had grown markedly. When seen, it was the size of an apple, reddish in color. The skin of the abdomen extended up for some distance on the sides of the tumor. The remaining portion of the tumor was covered over with amnion, which was continued upon the umbilical cord. The
tumor was firm in consistence, and on pressure could not be rendered smaller. After six days it had grown a good deal and there had been bleeding from it, which had been
Fig. 191. — Telangiectatic Myxosarcoma of the Umbilicus. (After Kaufmann.) This is from the specimen after it had been hardened in alcohol. Below and to the left one sees where the tumor has been amputated from the umbilicus. To the right is the attachment of the cord. Here the tumor was partly covered with amnion.
Fig. 192. — Appearance op the Umbilicus After Removal of the Tumor shows in Fig. 191. (After Kaufmann.) a, The umbilical vein; b, cross-section
of the umbilical artery; c, cross-sections of
checked by the use of styptics. Under chloroform narcosis three needles were passed through the base of the tumor and a bichlorid silk thread was tied around it. The tumor was then cut away, and the wound dressed antiseptically. Six days later the remnant of the tumor was recognized as a thick, brown, hard, dry, mummified crust, which came away readily. Healing took place rapidly.
The tumor (Fig. 191) was firm in consistence, almost round, 16 cm. in circumference, and reached a height of 6 cm. At its base, where it passed to the umbilical ring, were seen cross-sections of the umbilical arteries and of the umbilical vein. The latter contained a red thrombus. In addition there were cross-sections of other blood-vessels (Fig. 192).
Xear the surface the tumor is everywhere dense and fibrous. In the middle portion it is of a myxomatous character, and in this myxomatous tissue are numerous blood-vessels, some of which present a cavernous appearance (Fig. 193).
- Kaufmann: Ueber eine Geschwulstbildung des Xabelstrangs. Virchows Arch., 1890,
SARCOMA OF THE UMBILICUS. 451
Beneath the surface epithelium the cells are partly round, but to a great extent spindle-shaped. These spindle-cells are narrow and often long, resembling musclefibers, but the nuclei are more delicate. From the picture Kaufmann concludes that it is a spindle-cell sarcoma. As one nears the center of the tumor the spindlecells become more sparse and we have a picture of myxomatous tissue. It is in the
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Fig. 193. — Myxosarcoma of the Umbilicus. (After Kaufmann.) This is a low-power picture of Fig. 191. At a, where we should have the epithelial covering, it has been rubbed off. Beneath this the tumor is dense and consists of spindle-cells. The central portion, d, is composed of mucoid-like tissue containing large arterial sinuses.
myxomatous portion of the tumor that the blood-vessels have increased in size and that a cavernous appearance is noted. Some of the blood-vessels show many branchings — some narrow, others wide. A few of the vessels are still filled with blood. The cavernous appearance is due to dilated arteries. Kaufmann designates the tumor as a myxosarcoma telangiectodes, and speaks of its resemblance to the case reported by Virchow.
THE UMBILICUS AXD ITS DISEASES.
A Congenital Solid Tumor of the Umbilical Portion of the Cord. — On December 16, 1893, von Winckel* saw a female child, 49 cm. long and weighing 2500 grams. At the margin of the umbilical cord, immedi
Fig. 194. — Telangiectatic Myxosarcoma Projecting From the Right Side of the Umbilicus. (After v. Winckel.) a, The cord; 6, the margin of the amnion over it; c, the telangiectatic myxosarcoma.
ately after labor, a tumor had been noted (Fig. 194). This was firm in consistence,
bright red in color, and had here and there a bluish, translucent surface. Near the
free end were two fine threads with small bodies the size of linseeds on their surfaces. The entire tumor was 4 cm. long, at its base, 2.8 cm. thick, and near the end, 1.6 cm. in diameter. The tumor was removed with the cautery, and the peritoneum opened for a breadth of from 2 to 5 mm., a small quantity of serous fluid escaping. The operation did not last over fifteen seconds. A compression band was applied, and the child made a satisfactory recovery. Fourteen daj^s later, however, she died suddenly of pneumonia. The outer surface of the tumor was covered with what appeared to be hyaline
membrane, which contained connective-tissue nuclei in large or small numbers.
Beneath the surface there was a net-like arrangement of threads consisting of
- von Winckel: Ueber angeborene solide GeschwiiLste des (perennirenden) Theiles der Nabelschnur. Sammlung klin. Yortrage, n. F. No. 140. (Gyn. Nr. 53.)
Fig. 195. — A Telangiectatic Myxosarcoma. (After v. Winckel.) The section is from the tumor seen in Fig. 194. It consists of very large, well-defined cells, r, r, Giant-cells. Here and there between the cells are a few leukocytes.
SARCOMA OF THE UMBILICUS. 453
connective-tissue nuclei and leukocytes. In the superficial layers of the tumor there was an abundance of large blood-vessels. In addition there were lymphvessels showing a definite endothelial lining;. These contained fibrin threads and leukocytes. The endothelium of the lymphatics appeared to be proliferating. The endothelial cells were markedly enlarged and projected into the lumen; here and there they contained mitotic figures. In the vicinity of these lymph-spaces, in the connective tissue, spindle-shaped cells were seen, between which there appeared to be some fluid. There were also large epithelioid cells in the stroma (Fig. 195). These stained with hematoxylin-eosin a diffuse violet. The majority contained no nuclei and resembled degenerated tissue-cells.
In the pedicle of the tumor a similar structure was noted. The large, deeply tinged cells, however, were lacking. The blood-vessels were abundant. Von Winckel said that, from the description of his case, there was no doubt that he was dealing with a telangiectatic myxosarcoma similar to those reported by Virchow and Kaufmann.
From a careful study of these cases it would appear that they bear a marked resemblance to those considered under angiomata of the umbilicus, and that, in all probability, they should be included in that class. They do not seem to be malignant.
SPINDLE-CELL SARCOMA OF THE UMBILICUS.
Only a few instances have been recorded, and, as pointed out by Nicaise, Perniee, and others, even in such cases careful histologic reports are usually lacking. Spindle-cell sarcoma of the umbilicus would appear to be the most common variety, and the growth has been designated as a spindle-cell sarcoma, a fibrosarcoma, a myxosarcoma, or a sarcoma fibrocellulare.
Firm connective-tissue growths of the umbilicus are relatively rare. They may occur in the young, middle-aged, or old. They usually are oval or round, and may slowly or rapidly reach the size of a fist or an orange. As a rule, they have an intact skin covering. This may be normal, have large veins coursing over its surface, or the skin may show a purple discoloration. Occasionally, as a result of irritation, the surface of the tumor may be slightly ulcerated. The tumor may be sessile or somewhat pedunculated.
Clinically, it is almost impossible to determine whether such a growth is a fibroma or a spindle-cell sarcoma unless metastases occur; and, even if a nodule develops in the abdominal wall, several months or a year or more after the tumor has been removed, there is still the possibility that this second nodule may be a fibroma.
On section, most of these tumors have a fibrous appearance, few of them presenting the homogeneous, pork-like surface so characteristic of sarcoma. If, on histologic examination, the cells contain large, irregular nuclei with deeply staining chromatin, or if nuclear figures are abundantly distributed throughout the tumor, the diagnosis of sarcoma is clear. If, on the other hand, only quiescent spindlecells are in evidence, it is absolutely impossible to make the diagnosis from the histologic findings, and the surgeon remains in the dark as to the exact character of the tumor, unless its malignancy is clearly shown by the later development of metastases.
Where the sarcoma of the umbilicus is secondary, the growth may tend to spread out into the abdominal wall and wall not be so prominent and well defined.
454 THE UMBILICUS AND ITS DISEASES.
Cases Reported as Instances of Spindle-cell Sarcoma of the Umbilicus.
Some of these tumors were clearly sarcomatous; others in all probability were fibromata. The reader can draw his own conclusions as to the proper diagnosis in each case. Those cases that were clearly instances of fibroma, although previously classified as sarcoma, are included under fibromata, while quite a number in which not even a probable diagnosis could be made have been entirely omitted.
Spindle-cell Sarcoma of the Umbilicus.* — This tumor was removed by Wehsarg from the umbilical region of a poorly nourished girl aged fourteen. The tumor had grown slowly until three or four years before, when it had suddenly become painful and rapidly grown to the size of a fist. At operation it was round and the size of an orange, smooth, smaller at its base, and slightly pendulous, the umbilicus being pushed down. The skin over the tumor was very thin, bluish red in color, and there were numerous dilated veins. The lower part of the tumor showed several excoriated ulcerated plaques covered with clots and pus. The tumor was removed. It lay on the superficial fascia of the abdominal wall. On section it was yellow, homogeneous, and resembled pork, with here and there darker places surrounded by vessels. Microscopically it proved to be a spindlecell growth.
Possible Sarcoma of the Umbilicus. — Villarf describes the case of a woman aged forty-six who entered the service of Professor Guyon, September 17, 1886. About December, 1885, she had noticed that her corsets produced pain in the umbilical region, and on examination had found a small, reddish tumor the size of the head of a pin in the umbilical depression. This tumor grew slowly. In May, 1886, the patient presented herself at the hospital for examination. In August, after she had been using iodin without any results, she again came to the hospital. Examination at this time showed that, at the umbilical depression, was a tumor the size of a small bird's egg, but different in form. It was conic, with its base continuous with the umbilical cicatrix. It was slightly pedunculated, firm in consistence, but elastic and reddish in color. At its top was a blackish point 2 mm. in diameter. There was no discharge from the tumor. Two or three days later the blackish point ruptured and there was an escape of dark blood. No glandular enlargement was detected. The tumor was removed. The tumor in question was a little less firm than a fibroma. On section a capsule was found surrounding the central mass. The tumor was whitish gray and had numerous dark spots no larger than the head of a pin scattered throughout it.
Histologic examination showed that the capsule was formed of connective tissue. The central portion of the tumor was composed of sarcomatous tissue, the cells being fusiform. In the center of the tumor there were cavities lined with pavement-cells. These cavities presented various forms. Some were round, others were oval and had anastomosed with one another. In the stroma between the spaces were a small number of blood-vessels. The skin covering the outer surface of the tumor was exceedingly thin, but presented the usual appearance. In the center there had been some extravasation of blood recognizable by deposits of pigment.
(This woman was forty-six years of age. Although the description is not per
- Leydhecker, F. : Zur Diagnose der sarcomatosen Geschwiilste, Giessen, 1856.
t Villar, Francis: Tumeurs de l'ombilic. These de Paris, 1886, obs. 68.
SARCOMA OF THE UMBILICUS. 455
fectly clear, it bears somewhat the ear-marks of the ease reported by Mintz — a case that proved to be an adenomyoma of the umbilicus (see Fig. 174, p. 381). It does not tally with our usual idea of sarcoma. — T. S. C]
A Case of Myxosarcoma of the Umbilicus. — Plagge* reports the case of a man, twenty-two years of age, who in childhood had 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 in the umbilicus. By November, 1887, the tumor was the size of a hazel-nut. Four weeks later there was a nodule the size of a pea below and to the left, close to the linea alba. The patient was much emaciated. He died on March 14, 1888. At autopsy, at the umbilicus a thickening the size of a five-mark piece was noted rising 2 cm. above the abdominal level. Above and below, this thickening could be followed 5 cm. in each direction; the skin was movable over it. On examination of the abdominal cavity in the region of the umbilicus was a nodule, 2 mm. in diameter. In the ligament passing from the umbilicus was a small nodule. The omentum, diaphragm, and intestines were involved. The stomach was normal.
Microscopic examination showed that the growth was a myxosarcoma.
[If this had been a primary malignant growth, why had it not broken clown? The clinical picture in no way indicates a primary growth. The histologic appearance suggests very much a colloid carcinoma of the intestine with a secondary growth at the umbilicus. — T. S. C]
Sarcoma at the Umbilicus, f — An East Indian male, aged twentyfour years, was admitted on June 2, 1889. Several weeks before, April 5th, he had exposed himself to the night air after returning from a party. The next morning he felt pain in and around the umbilicus. Two weeks later a small, hard swelling was detected in the navel, and in a few days an unpleasant sensation in this region caused vomiting. The swelling was considered inflammatory in origin, and local applications were made. On examination a subcutaneous growth the size of a hen's egg was found situated exactly at the umbilicus. The skin covering it was deep purple and firmly adherent. The growth was apparently deeply attached by a pedicle fixed to the right side of the umbilicus. A few hard bosses were noted over the surface of the tumor, and a nodule the size of a hazel-nut, detected on the right abdominal wall, was apparently connected with the tumor. This nodule was situated about three and a half inches from the umbilicus. The secondary growth had only recently been noted. Both tumors were tender to the touch.
The main growth and the secondary nodule were removed, but the abdomen was not opened. The patient did not improve, but became profoundly cachectic. About a month after operation a small, freely movable nodule was felt in the subcutaneous connective tissue, about an inch from the abdominal incision below the umbilicus. Soon after, another was noted in the left rectus, close to the cartilage of the ribs. This increased rapidly; there was great nausea and occasional vomiting, suggesting dissemination in the diaphragm. [Microscopic examination showed that the umbilical growth was a fibrosarcoma. The abdomen was not opened. The secondary growth proved the malignancy of the condition, and the vomiting and loss of weight strongly suggested a primary abdominal growth with secondarj^ manifestations at the umbilicus.]
- Plagge, Heinrich: Ein Fall von Myxosarconi des Nabels. Inaug. Diss.. Freiburg, 1889.
t O'Brien, Surgeon- Maj or: Indian Med. Gaz., 1889, xxiv, 215..
456 THE UMBILICUS AND ITS DISEASES.
A Supposed Sarcoma of the Umbilicus. — Neveu* reported an unpublished case of Monnier's. The patient was a woman fifty years old. She had a uterine growth which extended to the umbilicus. The curet showed sarcoma fusocellulare. Implicating the umbilicus was a mass the size of a hazelnut. No microscopic examination of the umbilical growth was made.
[It is often very difficult, when examining a submucous myoma, to determine whether it is really a spindle-cell sarcoma or a simple myoma. Without an examination of the umbilical nodule we should hesitate to accept this as representing a nodule secondary to the growth in the uterus. — T. S. C]
Sarcoma of the Umbilicus. — Pernicef reports the cases of Blum, Bryant, and Villar. None of the descriptions seem to me to be convincing enough to warrant the growths being included as sarcomata.
Pernice then reports from the Halle Clinic the case of R. Schroeder, aged nineteen. As a child she had a small tumor at the umbilicus. It was not painful and did not grow until the thirteenth year; it was then extirpated. Two years later a new tumor appeared, and, when she was admitted to the hospital, it was the size of a baby's head and was covered with intact umbilical skin. The tumor shone through the skin and was hard. The inguinal glands were not enlarged. The abdomen was widely opened during removal of the tumor, and the patient recovered. About three years later she was in good condition, but shortly afterward a return of the growth was noted. This tumor was the size of a small apple when the patient came back to the hospital. It was situated in the upper angle of the previous incision.
No histologic examination was given. This tumor had not yet been removed when Pernice reported the case.
[Pernice then goes on to report several other cases, none of which would appear to be an undoubted instance of sarcoma.
Although it is quite possible that the growth reported by Pernice was a sarcoma, we must remember that it may equally well have been a fibroma. Where one fibroma develops, others are prone to occur. — T. S. C]
Possibly a Sarcoma of the Umbilicus. — SourdilleJ reports the case of a man, forty-nine years of age, who entered Polaillon's service at the Hotel-Dieu March 25, 1895. Eighteen months before he had noticed at the umbilicus small tubercles. These caused him some pain and inconvenience. On admission, attached to the lower border of the umbilicus was found a pedunculated cylinclric tumor, 5 cm. long and 12 to 13 mm. in diameter. Its free end was covered with a small crust over a healed ulceration. The skin covering it was delicate, thin, reddish in color. When grasped between the fingers, the tumor gave the sensation of a finger of a glove filled with hazelnuts. The skin surrounding the tumor contained seven or eight pink tubercles, about the size of green-peas. The skin was movable on the underlying aponeurosis. No enlargement of the glands could be made out. The patient's general health was good. The diseased area was removed.
On histologic examination the main tumor and the small nodules gave a picture of sarcoma fusocellulare covered -with skin. The superficial half of the skin seemed
- Neveu: Contribution a l'etude des tumeurs malignes secondares de l'ombilic, Paris,
t Pernice, L. : Die Xabelgeschwulste, Halle, 1892.
+ Sourdille, Gilbert: Sarcome pedicule de la peau de l'ombilic. Bull, de la Soc. anat. de Paris, 189.5, lxx, 302.
SARCOMA OF THE UMBILICUS. 457
to be the starting-point of the tumors, which tended to pass out and become pedunculated.
[This growth may equally well have been a fibroma with very small nodules. The microscopic examination was not very extensive.]
Primary Sarcoma of the Umbilicus. — Gamier * reports for Blanc the case of an otherwise healthy man fifty years old. Six months previously he had noticed a small, hard, painless tumor in the right border of the umbilical depression. It was independent of the skin, and was the size of a hazelnut. The patient had some colic, but no constitutional trouble. He thought that the pain in the pyloric region was due to pressure of the growth on the pylorus. He had lost in weight in the last month.
On admission the tumor was the size of a mandarin orange, round, and was carrying the unfolded umbilicus on its surface. It was hard, painless, and firmly fixed by the contraction of the abdominal muscles. The overlying skin was purple.
At operation it was found that the tumor had developed in the deeper layers. The underlying peritoneum was perfectly smooth, and the tumor was easily removed. Blanc regarded it as a great rarity, this being the first instance observed. He based his assumption that the growth was primary on the absence of functional trouble and on the relative integrity of the patient's general condition.
[He does not mention the examination of the abdominal cavity at the time of operation, and furthermore does not account for the sense of discomfort experienced in the region of the stomach; nor do we know the final outcome. — T. S. C]
On microscopic examination the growth was found to be composed of myriads of small cells separated from one another by a delicate stroma. The cells in general were round or fusiform and had but little protoplasm. Histologically, the growth appeared to be malignant and was a sarcoma. It had developed from the fibrous tissue of the abdominal wall.
ROUND-CELL SARCOMA OF THE UMBILICUS.
The following case represents the only definite instance of round-cell sarcoma of the umbilicus with which I am familiar. The umbilical growth was a secondary one.
Pernicef reports a secondary sarcoma of the umbilicus (Case 71, from the Breslau Gyn. Clinic) . The patient was a woman thirty-two years of age. The umbilicus was lifted 3 cm. above the surface of the abdomen. It had the form of an egg-cup, was very hard, but covered with normal skin. There was marked ascites, which made palpation useless. At operation eight liters of hemorrhagic fluid were removed and the omentum protruded. Scattered over it were tumors the size of plums. The umbilical tumor was completely isolated and was removed. It was in no way connected with the omentum. The primary tumor could not be discovered. Microscopic examination showed that the tumors were large round-cell sarcomata.
MELANOTIC SARCOMA OF THE UMBILICUS. Pernice draws attention to two cases — -one observed by Volkmann, the other by Olshausen. Volkmann's case occurred in a young girl who had an umbilical tumor
- Garnier: Cancer [Sarcoma] primitif de l'ombilic. La Loire medicale, 1910, xxix, 503.
t Pernice, L. : Op. cit., obs. 71.
458 THE UMBILICUS AXD ITS DISEASES.
not larger than a cherry. Notwithstanding the wide removal of the growth, countless secondary tumors were soon noted and the girl died.
Olshausen's patient was a woman twenty-one years of age. She had at the umbilicus a melanotic sarcoma the size of an apple. It had been noted first a year and a half before she came for operation. The growth was removed, but twentyone months later the patient died, with brain symptoms strongly indicative of cerebral metastases.
Catoir* also reports a case of melanotic sarcoma of the umbilicus. The patient was a man sixty-five years old. He noticed a slight, faintly blood-tinged discharge from the umbilicus. At that time there could be seen a simple brownish spot, without any underlying induration. Four months later there was a thickening surrounding the umbilicus. Applications were employed, and an attempt was made to remove the growth with the thermocautery. Two months later the tumor was 3 cm. in diameter. It was raised and formed a semicircle with the umbilicus in the ceEter. The tumor was removed. Xo note is given as to the prognosis.
^Microscopic examination corresponded with the clinical diagnosis of melanotic sarcoma. Xo other primary source of the growth could be found.
[Despite the probability of the correctness of the diagnosis, in the absence of an abdominal exploration it is impossible to feel sure that the growth was primary. — T. S. C]
- Catoir, S.: Sarcome melanique de la region ombilicale chez un homme de 65 ans. Jour.
d. sci. med. de Lille, 1899, xxii, 36.
LITERATURE CONSULTED ON SARCOMA OF THE UMBILICUS. Aveling: Brit. Gyn. Jour., 1886-87, ii, 56; 187.
Berard, P. H.: Fistules urinaires. Diet, de med., Paris, 1840, xxii, 64. Blum, A.: Tumeurs de l'ombihc ehez l'adulte. Arch. gen. de med., Paris, 1876, 6. ser., xxviii,
151. Catoir, S.: Sarcome melanique de la region ombilicale chez un homme de 65 ans. Join, des sci.
med. de Lille, 1899, xxii, 36. Dannenberg, O.: Zur Casuistik der Xabeltumoren insbesondere des Carcinoma umbihcale.
Inaug. Diss., Wlirzburg, 1886. Demarquay: Cancer de l'ombihc. Bull, de la Soc. de chir.. 1870-71, 2. ser., xi, 209. Forgue et Riche: Montpellier med., 1907, xxiv, 145.
Gamier: Cancer [Sarcoma] primitif de l'ombihc. La Loire med., 1910, xxix, 503. Kaufmann, E.: Leber eine Geschwulstbildung des Xabelstrangs. Virchows Arch., 1890, exxi, 513. Leydhecker. F.: Zur Diagnose der sarcomatosen Geschwlilste, Giessen, 1S56. Xeveu, X.: Contribution a l'etude des tumeurs malignes seeondaires de l'ombihc, Paris, 1S90, No.
50. Nicaise: Fibro-papilloma de la cicatrice ombilicale. Rev. de chir., Paris, 1883, hi, 29. O'Brien, Surgeon-Major: Sarcoma at the Umbilicus. Indian Med. Gaz., 1889. xxiv, 215. Pernice, L. : Die XabelgeschwuLste, Halle, 1892.
Plagge, H.: Ein Fall von Myxosarcom des Nabels. Inaug. Diss., Freiburg, 1889. Quenu et Longuet: Du cancer secondaire de l'ombilic. Rev. de chir., 1896, xvi, 97. Sourdille, G.: Sarcome pedicule de la peau de l'ombihc. Bull, de la Soc. anat. de Paris, 1895,
Lxx, 302. Tillmanns. H.: Deutsche Zeitschr. f. Chir., 1882-83, xviii, 161. Yillar, Francis : Tumeurs de l'ombihc. These de Paris, 1886. Yirchow, R.: Virchows Arch., 1864, xxxi, 128. von Winckel, F.: Ueber angeborene solide Geschwiilste des (perennirenden) Theiles der Xabel schnur. Sammlung klin. Vortrage, n. F. Xo. 140. (Gyn. Nr. 53.)
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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