Book - Umbilicus (1916) 7
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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 VII. Congenital Polyps - Fistula or Cystic Dilatations at the Umbilicus
Chapter VII. Congenital Polyps; Fistula Or Cystic Dilatations At The Umbilicus; With A Mucosa More Or Less Similar To That Of The Pyloric Region Of The Stomach, And Secreting An Irritating Fluid Bearing A Marked Resemblance To Gastric Juice. Persistence Of The Outer Portion Of The Omphalomesenteric Duct.
So-called gastric mucosa at the umbilicus.
The fluid secreted by the polyp or fistula.
Action of the fluid on the skin surrounding the umbilicus.
Report of cases of congenital polj'p or fistula at the umbilicus and having a mucosa resembling that of the stomach. Persistence of the outer portion of the omphalomesenteric duct.
Report of cases in which the outer end of the omphalomesenteric duct remained patent.
Tillmanns, in 1882, made a most interesting observation .on a boy thirteen years old. On questioning the parents it was learned that the umbilical cord was unusually thick, and that it had dropped off on the fourth day, leaving a tumor the size of a cherry. This grew slowly. When Tillmanns saw it, it was the size of a walnut, bright red in color, and covered with mucosa (Fig. 87). It had no central opening. It was attached to the umbilical depression by a thin pedicle. After the boy had eaten, the tumor would sometimes swell perceptibly; it would become redder, and its mucosa thicker.
This umbilical tumor secreted a tenacious mucus, which was especially abundant when the tumor was irritated. At such times 2 to 3 c.c. of fluid could be collected in fifteen minutes. The discharge was so copious that it was necessary to wear dressings, and even then it would at times saturate the boy's clothes.
The fluid secreted was acid, but when old, it became alkaline. The fluid digested fibrin in an acid solution at 39° C. A chemical examination, made by Dreschel, showed that it corresponded more or less closely with gastric juice.
Microscopic examination of the tumor revealed the fact that the mucosa was similar to that of the stomach.
The digestive action of the fluid secreted by this tumor had caused a maceration of the abdominal skin surrounding the umbilicus. The pedicle of the tumor was severed, and the wound soon healed (Fig. 88). No connection with the abdominal cavity was found.
The literature on this subject is rather scanty, but several subsequent observers have reported mucosa at the umbilicus that bore more or less resemblance to stomach mucosa. Cases have been recorded by Roser (1887), Siegenbeek van Heukelom
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS. 145
(1888), von Rosthorn (1889), Reichard (1898), Weber (1898), Lexer (1899), Strada (1903), Minelli (1905), and Denuce (1908).
MACROSCOPIC APPEARANCE OF THE UMBILICAL REGION. In the majority of the cases the umbilical abnormality was observed just as soon as the cord had dropped off. The local picture varies considerably. It may be roughly classified as follows:
1. An umbilical polyp attached to the umbilical depression by a short pedicle.
2. An umbilical polyp with a cystic cavity opening on the surface of the polyp.
3. An umbilical fistula with or without a small projection.
The umbilical polyp in van Heukelom's case, and also in Reichard's case, was the size of a hazel-nut; and in Minelli's, Strada's, and Tillmanns' cases the tumor was considerably larger.
Roser's patient, a boy a year and a half old, had a bright-red swelling at the umbilicus, and opening on the surface of it was a cystic cavity 1 cm. in diameter.
In Denuce's, Lexer's, von Rosthorn's, and Weber's cases there was seen at the umbilicus a fistulous tract which extended directly inward for a distance of 1.5 to 2 cm.
In Lexer's case no nodule was found at the umbilicus, but in the other cases the cutaneous end of the fistula had raised margins, producing a small red thickening.
Where a polyp exists, it is bright red in color, covered with mucosa, and is attached to the umbilical depression by a definite pedicle. In those cases in which a fistula exists, and where it is wide enough to allow one to see its inner surface, it is found lined with mucosa.
THE MICROSCOPIC PICTURE.
The surface of the polyp is covered with mucosa, the glands of which resemble more or less closely those found at the pyloric end of the stomach. In certain cases, some of the glands look more or less atrophic. At times both Lieberkuhn's glands and also pyloric glands have been noted in the mucosa.
The central portion of these polyps consists of non-striped muscle, and occasionally a little adipose tissue is present.
The fistulse are lined with mucosa, which is for the most part similar to that of the pyloric region, but here also the mucosa at one point may contain Lieberkuhn's glands, and at another, pyloric glands. This was particularly well shown in von Rosthorn's case. The outer walls of the fistulous tract are composed of non-striped muscle.
THE FLUID SECRETED BY THE POLYP OR FISTULA.
The polyp or fistula, as the case may be, secretes a fluid which may be watery, clear, and stringy, or cloudy and tenacious. The amount varies greatly. In Denuce's case, 3 c.c. were secreted in thirty-six hours; in von Rosthorn's case, 5 c.c. were discharged in twenty-four hours, while in Tillmanns' case 2 to 3 c.c. were collected in fifteen minutes. In Weber's case the father estimated that half a wineglassful came away daily; so abundant was the flow that the child's clothes were soaked.
In Denuce's case, as soon as the child commenced to eat, the flow increased, and Tillmanns drew attention to the fact that irritation of the tumor in his case caused an abundant secretion. 11
146 THE UMBILICUS AND ITS DISEASES.
The fluid is usually acid. In Weber's case, however, it was alkaline. In Tillmanns' case the fresh fluid was acid, but after it had been kept for some time it became alkaline.
Lexer said that in his case the fluid chemically resembled gastric juice. The fluid in Tillmanns' case digested fibrin in an acid solution at 39° C, and Drechsel found that it corresponded to gastric juice.
Yon Jaksch made a careful chemical examination of the fluid in von Rosthorn's case, and found albuminous bodies, peptone, pepsin in small quantities, but no free hydrochloric acid. Denuce found free hydrochloric acid and peptone, but no pepsin. He describes the fluid as a "sort of gastric juice."
From these findings it is clear that the fluid secreted in these cases bears a strong resemblance to gastric juice.
Action of the Fluid on the Skin Surrounding the Umbilicus. — In von Rosthorn's case the abdominal wall around the umbilicus was slightly irritated.
In Tillmanns' case the skin in the vicinity of the polyp was macerated. In Denuce's case the skin surrounding the fistula was ulcerated for a certain distance. This ulcerated area was bright red in color, and the tissue surrounding it was tumefied. The total area of ulceration was about the size of a five-franc piece.
In Reichard's case, commencing just below the fistula and extending downward 6 cm. toward the pubes, was "a digestive ulcer" which had indurated margins. The ulceration was situated just where the fluid from the fistula trickled down the abdominal wall. The patient was a child five years old. He was able to walk around; hence the fluid flowed downward instead of irritating the parts all around the umbilicus.
Weber's patient was a boy three years old. Four months before coming under observation a canal-shaped wound developed. This commenced at the umbilicus and extended 4 cm. downward toward the symphysis. It was increasing in size and had callous walls. The umbilicus itself and the surrounding tissue over an area the size of the palm of the hand were markedly macerated. The umbilical region presented the typical picture of a digestive process.
The action of the fluid alone would make one strongly suspect the presence of gastric juice.
SYMPTOMATOLOGY. These polyps or fistulas are more common in males than in females. They are congenital, and accordingly are usually noted at, or shortly after, the time the cord comes away. They are recognized by the appearance of a small red polyp or fistula at the umbilicus. The secretion from the navel varies in amount, is usually acid in reaction, and tends to increase at meal-times or when the polyp is mechanically irritated. In at least half of the cases there is more or less digestion of the abdominal wall in the umbilical region. This digestive action clearly differentiates these from ordinary umbilical polyps, and suggests the presence of mucosa identical with or strongly resembling that of the stomach.
ORIGIN. Considerable speculation has been rife as to the origin of these so-called gastric polyps or fistulas. Naturally the easiest explanation would be that in embryonic life there has occurred a displacement of patches of gastric mucosa.
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS. 147
In Denuce's case the fistulous tract was removed without any opening into the peritoneum. The peritoneum was transparent, and it was possible to see a little to the left of the deep attachment of the fistula a cylindric cord, which passed from the umbilicus to a loop of bowel. This cord was evidently the remnant of the omphalomesenteric duct.
In Reichard's case the abdomen was opened and the tumor found to be cystic, bluish, and translucent. Sharply defined and passing from it was a very thin pedicle, which extended upward in the abdominal cavity. Further examination could not be made on account of the weak condition of the child.
Weber, in removing the umbilical fistulous tract in his case, opened the peritoneum. From the fistulous tract a thin cord passed upward and led to the under surface of the liver. He thought that this cord represented the remains of the umbilical vein.
We have no positive evidence in any of the cases that the umbilical growth was connected with the stomach. On the other hand, it is quite probable that in one of them it was connected with the small bowel by a fibrous cord.
Judging from the embryologic development of the umbilical region, one would naturally conclude that such growths are remnants of the omphalomesenteric duct. Furthermore, we learn, from the microscopic descriptions of the fistula?, that in some parts the glands resembled intestinal glands; in other places glands of the pyloric region. Again, in Lexer's case (Fig. 85) the fistulous tract was almost continuous with a patent Meckel's diverticulum. The fistula was fined with what resembled a gastric mucosa; the Meckel's diverticulum, with a mucosa similar to that of the small bowel.
As is well known, the entire digestive tract develops from the yolk-sac. It has been claimed that, prior to the passage of the various fluids, such as bile and pancreatic fluid, over the intestinal mucosa, it is identical with or bears a strong resemblance to that of the stomach. Be that as it may, it is certain that we have a small group of cases in which polyps or fistula? have developed at the navel, and that these are covered or fined with a mucosa that histologically closely resembles gastric mucosa; and that this mucosa secretes a juice that acts very much as gastric juice will do. Personally, I believe that these growths are remnants of the omphalomesenteric duct.
TREATMENT. Where a polyp exists, it is only necessary to tie the pedicle and cut off the growth. In those cases in which a fistula exists, the umbilicus should be encircled, the abdomen opened, and the growth removed. If it be connected with the bowel, the intestinal stump should be treated as an appendix stump. In those cases in which much maceration exists, local alkaline applications should be employed until the skin is healthy, after which removal of the growth can be readily carried out.
CASES OF CONGENITAL POLYPS OR FISTULiE AT THE UMBILICUS AND HAVING A MUCOSA RESEMBLING THAT OF THE STOMACH.
A Pseudopyloric Congenital Fistula at the Umbilicus. — ■ Denuce* speaks of a rare variety of fistula occurring at the umbilicus.
- Denuce: Fistules pseudo-pyloriques congenitales de l'ombilic. Revue d'orthopedie, 1908,
148 THE UMBILICUS AND ITS DISEASES.
A secretion is present, which gives an acid reaction, and on chemical examination is found to be practically identical with gastric juice. Moreover, the digestive action of this fluid manifests itself on the tissues surrounding the fistula. Histologic examination shows that the structure of the mucosa lining the fistulous tract is exactly similar to that of the stomach and the pyloric region.
Denuce saw a case of this character in the surgical clinic at Bordeaux, and the diagnosis was made before operation. The patient, a boy twenty-one months old, was admitted to the hospital on account of a congenital umbilical fistula. The umbilical cord in its outer aspect showed nothing abnormal at birth. When it came away, there was left what appeared to be a granulation at the umbilicus. This was cauterized. There was a discharge, which at first was slight, but later at times became very abundant. The fluid, as a rule, was colorless, but sometimes it had a hemorrhagic tint.
On admission the child's general condition was poor; the fistulous tract was painful. Methylene-blue was administered, but none was discharged from the fistula, showing that the latter was not urinary in character. Urination was normal. Digestion was normal and the bowels moved regularly. At the umbilicus was a small orifice from which there came a liquid discharge. The surrounding skin was ulcerated for some distance. This ulcerated area had a bright-red color, and the tissue around it was tumefied. At the summit of the ulceration was a fistulous orifice. The total area of ulceration at the umbilicus was about the size of a five-franc piece. A probe could be introduced into the fistula for about 1.5 cm. The fluid, when first examined, was clear, but when the child started - to eat, there was an immediate increase in the quantity of the discharge from the umbilicus. In about thirty-six hours 3 c.c. of liquid were secured. An analysis of this fluid gave the following:
Free hydrochloric acid +
Further examination of the " gastric juice" from the same patient showed an estimated total acidity of 2.4 gm. to the liter. The presence of free hydrochloric acid, peptone, and lab ferment was detected. The conclusions drawn were that this liquid might be considered as a sort of gastric juice.
The fistulous tract was removed without any opening into the peritoneum. The peritoneum was transparent, and it was possible to see a little to the left of the deep portion of the fistula the attachment of a cylindric cord, which, at its inner extremity, was inserted into one of the intestinal loops. It was easily recognized that this cord represented Meckel's diverticulum, which, at its distal extremity, was attached to the umbilicus. The umbilical fistula was ligated at its base and burned off with the thermocautery. The child made a good recovery.
Sections through the fistulous tract showed a mucous structure analogous to that of the stomach. Fig. 83 represents a transverse section of the fistulous tract. Owing to the presence of the villus-like projections the general appearance of this
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS.
tract reminds one somewhat of the Fallopian tube projections. The cavity contained granular remains, and round or oval cells. The fistula might be described as a sort of small cul-de-sac lined with a kind of gastric mucosa. Denuce speaks of this case as an instance of pseudopylorus, and says such cases are exceedingly rare. He then goes on to discuss the cases of Tillmanns and Roser, and considers the various hypotheses as to the origin of these fistulae. In young embryos, he points out, the intestinal tract is lined with epithelium which is the same throughout, and the differentiation between the epithelium of the stomach and that of the intestine is a later development.
Fig. 83. — Transverse Section- of a Pseudopyloric Congenita! Fistula at the Umbilicus. (After Denuce.) The mucosa resembled somewhat that of the intestine, somewhat that of the stomach. The finger-like and papillaryoutgrowths are, however, unusually long. For the appearances under the high power see Fig. 84.
Gastric Mucosa in a Persistent Omphalomesenteric Duct . — Lexer* says there is a small group of cases which, on account of their individual structure and the character of the mucous lining, are obscure. These cases have a mucosa that not only closely resembles that of the pyloric region but also secretes a fluid resembling gastric juice. He then refers to the cases of Tillmanns and Siegenbeek van Heukelom.
Lexer's patient was one year old. It had a congenital umbilical fistula, and the surrounding skin was eroded. The fluid which was collected for several hours was clear, stringy, contained no intestinal contents, was strongly acid, and chemically
- Lexer: Magenschleirrihaut im persist irenden Dottergang.
Chir., 1899, lix, 859.
Lanaenbeck's Arch. f. klin.
THE UMBILICUS AND ITS DISEASES.
resembled stomach juice. It rapidly digested albumen (fibrin). At operation the fistulous tract was found attached to the convexity of the small bowel (Fig. 85). It closed at a point 1.5 cm. behind the umbilicus. Meckel's diverticulum was lined with intestinal mucosa, but that of the umbilical portion of the fistula was totally different, consisting of what Lexer termed pseudopyloric mucous membrane. The cylindric epithelium lining the outer portion of the fistula was high, and the mucosa itself resembled that of the pylorus, but was drawn out into fingerlike projections.
According to Lexer, the picture as a whole demonstrated the persistence of the
omphalomesenteric duct, the outer portion of which differed entirely from that communicating with the bowel. This variation in type, he thought, is probably due to an early severance of the outer portion of the fistulous tract from the inner portion.
An Umbilical Polyp. — Minelli*
gives a low-power picture showing a tumor
l which suggested an adenoma of the umbili ( ,,':•" cus. He then gives a resume of the liter
Fig. S4. — High-power Picture of a Fistulous Tract at the Umbilicus, Showing Glands Resembling those of the Pylorus. (After DenucS.)
1, Excretory glands: 2, 2, 2, 2, acini; 3, 3, cells bordering acini; 4, 4, eosinophiles; 5, 5, mast cells; 6, island of lymphoid tissue.
Fig. 85. — An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach. (After Lexer.) This sketch is from Plate 16 accompanying Lexer's article. It shows the lack of continuity of the fistulous tract. The inner portion is from Meckel's diverticulum, and is lined with a mucosa like that of the small bowel. The outer portion of the tract was cut off entirely from the inner and was lined with mucosa resembling that of the pylorus.
ature. His was a congenital tumor, which later had increased to the size of a walnut. Histologically, it presented the picture of a gastric adenoma.
A Cystic Umbilical Tumor Secreting a Fluid that Tended to Digest the Abdominal Wall.f — In the case of a boy five years old, moisture had been noticed in the umbilical region since his birth. Four months before entering the hospital he developed a serpiginous ulcer, which extended from the umbilicus downward. On admission the child was pale. In the
- Minelli, S.: Adenoma Ombelicale a struttura gastrica. Gaz. med. Italiana, 1905, lvi, 101.
t Reichard: Centralbl. f. Chir., 1898, xxv, 587.
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS. 151
umbilical region was a tumor, the size of a hazel-nut, which showed a fine fistulous opening from which clear fluid escaped. The digestive ulcer extended down the abdominal wall for a distance of 6 cm. Its margins were indurated.
The abdomen was opened, and the tumor was found to be cystic, bluish, translucent, and sharply defined. Passing from it was a very thin pedicle which extended upward in the abdominal cavity. Further examination could not be made on account of the weak condition of the child. The entire umbilical area was removed, and the child recovered.
The cavity was lined with mucosa which microscopically seemed to be of the gastric type. Reichard says that this reminded him of Tillmanns' case, although neither inversion nor prolapsus of the tumor had occurred.
An Umbilical Fistula.* — The boy, a year and a half old, entered the hospital November 4, 1886. The umbilicus was swollen, and from it an acid, watery fluid escaped. The surrounding tissue was slightly macerated. The opening at the umbilicus was red and granular, and the walls were indurated and thickened. The cavity was 1 cm. in diameter.
Operation. — The thickened skin was cut out and the red, granulating mucosa removed with forceps and scissors. Roser thought that he had cut down to the subperitoneal connective tissue and did not enter the abdominal cavity. Several weeks later he noticed that some of the mucosa had been left behind, and a sound could be carried 3 mm. downward. The discharge was small in amount, but slightly acid in reaction. A small tampon saturated with a solution of zinc chlorid was placed in the cavity, and several weeks later all trace of the fistula had disappeared. The scar was hardly visible when the child left the hospital in December.
Microscopic examination by Professor Marchand showed that the mucosa was similar to that of the stomach. The tubular glands were closely packed, and beneath them was an abundant layer of smooth muscle.
Roser says that when one remembers that, in the early fetal life, the pylorus is in a different position to that which it occupies later, — that is to say, the stomach is perpendicular, and the pylorus is in the umbilical region, — one can surmise that a portion of the wall of the stomach may be detained at the umbilicus and when the stomach draws back, may be held there. In this way a diverticulum might form, and as a result a cyst would develop.
A Congenital Umbilical Fistula, f — A boy, seven years old, was admitted on account of an umbilical fistula. Its presence had been noted when the cord dropped off. On the fourth day a projection 4 cm. long and of about the thickness of a little finger was noted at the umbilicus. It was glassy in appearance and pale. In the course of a month a small opening developed in the center of it, from which came a continuous flow of clear, watery fluid. The projection gradually diminished until it disappeared, but the opening grew larger until its diameter reached that of a penholder. No feces, no fecal odor, and no urine were at any time detected at the umbilicus.
On admission the boy was strong and well nourished. At the umbilicus was a tumor the size of a hazel-nut. It was round, red, and glistening, 1 cm. in diameter,
- Roser, W.: Zur Lehre von der umbilikalen Magencvstenfistel. Centralbl. f. Chir., 1887,
t Von Rosthorn: Ein Beitrag zur Kenntniss der angeborenen Nabelfisteln. Wien. klin. Wochenschr., 1889, ii, 125.
152 THE UMBILICUS AND ITS DISEASES.
soft in consistence, and had a velvety covering. Through the central opening a probe could be passed directly inward for 2 cm. The abdominal wall around the opening was slightly irritated.
The secretion from the umbilical tumor amounted to about 5 c.c. in twentyfour hours. It was acid in reaction. Von Jaksch made the chemical examination. Organic : Albumin bodies, peptone and albumose, ferments and pepsin, in small quantity; sugar, urinary salts, bile-coloring matter, urobilin, absent. Inorganic : Reaction for free hydrochloric acid negative. Chlorids in large quantities. No phosphates or sulphates. Microscopic examination of the diverticulum, which extended to the peritoneum, showed typical Lieberkuhn's glands; near the middle portion were glands with clear cells resembling closely those of the pyloric region.
A Congenital Umbilical Fistula Lined with a Mucosa Possibly Resembling that of the Stomach.* — The child, two and one-half years old, had had trouble at the umbilicus since the cord came away. The umbilical region was never dry, and in the depression was a tumor the size of a
hazelnut, red in color, and with a granular, moist surface. It was attached to the umbilical depression by a short, thin pedicle. It looked like a typical granu•d loma of the umbilicus. The pedicle was cut, but so much oozing took place that the thermocautery was necessary to check the bleeding. On microscopic ex Fig. 86. — Appearance of the Um- _ " ° x
bilical depression in von animation a transverse section of the polyp showed rosthorn's case. ^at the surface was covered with glands. The cen o, the umbilical opening; b, the , ■> ,. • .l 1 c i • i ,• , • •
bottom of the depression; c, the peri- tral portion consisted of adenoid tissue contaimng toneum. many smooth muscle-fibers. The epithelium and
glands of the tumor resembled those of the intestine.
An Umbilical Polyp. — Stradaf gives a short survey of the literature, and then reports the case of a young woman of twenty who had a tumor at the umbilicus. This grew slowly to the size of a walnut, was round, red, and covered with mucosa. It was attached by a short pedicle and was irreducible. It was removed.
On microscopic examination it was found to be covered with cylindric epithelium. The majority of the glands, according to Strada, were of the pyloric type; others resembled Lieberkuhn's glands. In the center of the tumor was adipose tissue; surrounding it, non-striped muscle. Strada gives a splendid picture of this case, and then carefully reviews the cases in which the mucosa at the umbilicus resembled gastric mucosa.
Congenital Prolapsus of Stomach Mucosa Through the Umbilical R i n g . % — In July, 1881, August W., aged thirteen, was brought to Tillmanns. With the exception of an unusual condition at the umbilicus, the child was perfectly healthy, although somewhat anemic.
- Siegenbeek van Heukelom: Die Genese cler Ectopia ventriculi am Nabel. Virchows Arch.,
1888, cxi, §475.
Strada, Ferdinando: Adenoma Congenito Ombelicale a tipo gastrico. Lo Sperimentale Archivio di biologia normale e patologia, 1903, lvii, 637.
| Tillmanns, H.: Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia Ventriculi; und iiber sonstige Geschwtilste und Fisteln des Nabels. Deutsche Zeitschr. f. Chir., 1882-83, xviii, 161.
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS.
At the umbilicus was a bright-red tumor the size of a walnut (Fig. 87j. It was painless on manipulation, but caused the patient some feeling of discomfort. The surface of the tumor secreted a cloudy, tenacious, mucus-like acid juice, which was especially abundant when the tumor was irritated. At no point was there any evidence of an opening downward, and no canal could be made out. The entire tumor was covered with mucosa. It was attached to the umbilicus by a thin pedicle. It was not increased in size by coughing or by pressure on the abdominal wall. The skin in the vicinity of the tumor had been macerated by the secretion.
The secretion was relatively abundant. It was possible, in the course of fifteen minutes, to collect from 2 to 3 c.c. and, when the tumor was mechanically irritated with the ringer or a sound, the secretion increased. Tillmanns first thought that he was dealing with a Meckel's diverticulum with prolapse of the intestinal mucosa, or possibly that a urachal fistula existed. Thiersch also saw the boy and came to the same conclusion, but the acid reaction of the mucus, the experiments as to its power of digestion, and later the histologic examination of the tumor, made them conclude that they had to deal with stomach mucosa.
The secretion digested fibrin in an acid solution at 39° C. Pepsin was evidently present. The fresh secretion was strongly acid. That which had been secreted for some time and lay in the vicinity of the tumor in several instances gave an alkaline reaction. Professor Drechsel, of the Chemical Department, examined the secretion and found that it corresponded to that coming from the stomach.
The mother said that the cord dropped off about the sixth day, and that immediately a reddish tumor, about the size of a cherry, was seen at the umbilicus. The umbilical cord was unusually thick, and it was thought possible that the midwife had tied the cord too close to the umbilical ring. Several days after the cord had come away the tumor became more prominent. During the last few years it had grown very slowly, and in the four months previous to his admission there had been hardly any increase in size. After the boy had eaten, this tumor would sometimes swell perceptibly; it would become reddish, and the mucosa would increase in thickness. At this time it would also secrete abundantly. The discharge had been so copious that it was necessary for the patient to wear dressings. These would sometimes be saturated and his clothes would be wet. There was no evi
Fig. 8.. — Gastric Mucosa at the Umbilicus. (After Tillmanns.) Projecting from the umbilicus is a bright-red, velvety tumor mass. This was covered over "with mucosa, which on histologic examination resembled mucosa of the pyloric region. It had an abundant secretion.
THE UMBILICUS AXD ITS DISEASES.
dence of fecal matter or of stomach-contents at the umbilicus. The boy had never suffered from indigestion, and his defecation was normal.
On account of the discharge the boy was anxious to have the tumor removed. This was readily accomplished. The pedicle was cut across, and the few small vessels were controlled with the Paquelin cautery. Within a few days all trace had disappeared, and the patient, up to the time Tillmanns reported the case, had been perfectly well (Fig. 88).
Microscopic examination of the tumor by Professor Weigert showed that it consisted of stomach-wall, all the layers being present. In the center was serosa, then came subserosa, then a layer of muscle, and covering the outer surface, mucosa. The glands were very abundant, but were in part atrophic. Several portions on casual examination might very readily have been mistaken for intestinal mucosa; but others at once indicated their origin from the pylorus.
Tillmanns says that, from the chemical and anatomic examination, it was evident that a portion of the stomach-wall in the vicinity of the pjdorus had prolapsed
through the umbilical ring in such a way that the mucosa was on the outer surface, while the muscular coats formed the center. He said he was unable to find a similar case reported in the literature. To explain the origin of the condition he supposed that there had probably been an umbilical hernia, in which a portion of the stomach diverticulum had been included; that the thick, funnel-shaped umbilicus had probably been tied too close to the umbilical ring, and in all probability a portion of the stomach diverticulum had been tied off with the cord. He added that, at the time of labor, the diverticulum of the stomach was probably no longer in connection with the stomach proper. An Umbilical P o 1 y p Covered with Stomach Mucosa.* — A boy, three 3-ears old, was admitted January 5, 1897. The labor had been normal, but the cord did not come away on time. When it did drop off, a small, red tumor was found at the umbilicus. This was cauterized by the attending physician. From that time it secreted a fluid which was whitish and contained brown flocculi or white clots, and occasionally mucous threads. There was never any indication of the escape of intestinal or stomach-contents. According to the father, about half a wineglassful of fluid escaped daily. The clothes and dressing were always soaked.
The flow increased at midday, and at that time was often accompanied by colicky pain. In the morning, on the other hand, the child was comfortable.
Four months before his admission a canal-shaped wound developed from the umbilicus downward. This would not heal, but continued to increase in size. The boy's appetite was good; the bowels were regular.
- Weber, W. : Zur Kasuistik der Ectopia ventriculi. Beitrage z. klin. Chir., 1898, xxii, 371.
Fig. 88. — Appearance of the Umbilicus after Removal of the Stomach Mucosa seen in Fig. 87. - Tillmanns.; The umbilical depression is very uneven, but perfectly intact. There was no opening into the abdomen.
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS. 155
On admission the child was anemic. On separation of the umbilical folds a drop of clear, serous fluid escaped. Passing down the abdominal wall from this point was a canal-shaped, ulcerated area, about four cm. long, having callous walls. The wound itself and the surrounding epidermis over an area the size of the palm of the hand were markedly macerated. The umbilical region presented the typical picture of a digestive process.
Operation. — An incision including this area was made and the peritoneum opened. From the fistulous tract a thin cord passed upward and led to the under surface of the liver. The umbilical growth was sharply defined, bluish, and cystic. There was no connection with the intestine or with the stomach. The tumor was removed. In three weeks only two small areas of granulation remained.
The cystic tumor was lined with a thick mucosa, macroscopically resembling that of the stomach. The mucosa was alkaline in reaction. On microscopic examination it was found to be of the pyloric type. Beneath it was a submucosa, then layers of non-striped muscle. Weber says that, from this description and the microscopic picture, it is certain that we are dealing with normal stomach mucosa from the pyloric region. The microscopic examination was made in the Berlin Pathological Laboratory by Privatdocent Krause.
Weber thought that the cord passing to the under surface of the liver represented remains of the umbilical vein.
Although the secretion was alkaline, the free secretion at noontime, and the maceration, together with the anatomic appearance above noted, indicated that the growth had developed from the stomach. Weber gives a resume of the literature on the subject.
LITERATURE CONSULTED ON CONGENITAL POLYPS, FISTULiE, OR CYSTIC DILATATIONS AT THE UMBILICUS, SHOWING A MUCOSA MORE OR LESS SIMILAR TO THAT OF THE PYLORIC REGION OF THE STOMACH, AND SECRETING AN IRRITATING FLUID BEARING A MARKED RESEMBLANCE TO GASTRIC JUICE.
Denuce: Fistules pseudo-pyloriques congenitales de l'ombilic. Revue d'orthopedie, 1908, xix, 1. Lexer: Magenschleimhaut im persistirenden Dottergang. Langenbeck's Arch. f. klin. Chir.,
1S99, lix, 859. Minelli, S.: Adenoma Ombelicale a struttura gastrica. Gaz. med. Italiana, 1905, lvi, 101. Reichard: Centralbl. f. Chir., 1898, xxv, 587.
Roser: Zur Lehre von der umbilikalen Magencystenfistel. Centralbl. f. Chir., 1887, xiv, 260. Von Rosthorn: Ein Beitrag zur Kenntnis der angeborenen Nabelfisteln. Wien. klin. Wochenschr.,
1889, ii, 125. Siegenbeek van Heukelom: Die Genese der Ectopia ventriculi am Nabel. Virchows Arch., 1888,
cxi, 475. Strada, F.: Adenoma Congenito Ombelicale a tipo gastrico. Lo Sperimentale Archivio di bio logia normale e patologia, 1903, lvii, 637. Tillmanns, 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. Weber, W.: Zur Kasuistik der Ectopia ventriculi. Beitrage z. klin. Chir., 189S, xxii, 371.
PERSISTENCE OF THE OUTER PORTION OF THE OMPHALOMESENTERIC DUCT.
The picture presented is practically the same as where a simple umbilical
polyp exists. (See Fig. 89.) Situated at the umbilicus is a red nodule, varying
from a pea to a chestnut in size. Occasionally it may be longer, as in Wheaton's
THE UMBILICUS AND ITS DISEASES.
case. In Chandelux' case it was 6 cm. long. This length, of course, is exceptional.
Occupying the center of the prominent part of the nodule is a canal, into which a sound can be introduced (Figs. 89, 90, and 91), sometimes only for a short dis
Fig. 89. — Persistence of the Outer End of the Omphalomesenteric Duct. (Schematic.) The persistence of the outer end of the omphalomesenteric duct as a wide funnel is most unusual, but has occasionally been noted. The duct can be traced for about half its length, and then ends in a fibrous cord which extends to and is adherent to the convex surface of the bowel.
Fig. 90. — Atrophy of the Inner End of the Omphalomesenteric Duct. (Schematic.) At the umbilicus is a polyp-like outgrowth covered with intestinal mucosa in the center of which is a canal — the outer end of the omphalomesenteric duct. The intra-abdominal portion of the duct is represented by a fibrous cord which extends from the umbilical region to the convex surface of the bowel.
tance, usually for from 1.5 to 2.5 cm. From the fistula a glairy mucus or a clear fluid escapes. In one of Florentin's cases the fluid coagulated, resembling apple jelly. In this case, in addition to the fistula, there was a pus-pocket, the size of a small mandarin orange, lying to one side of the fistulous tract. These projections, and also the fistulous tract, are covered with mucosa of the small bowel.
The condition is usually noted at the time that the cord comes away, or shortly afterward.
When the abdomen is opened for the removal of the umbilical fistula, the abdominal end of the tract will usually be found to end in a fibrous cord, which is attached to the convex surface of the small bowel. When removing the fistula it is always wise to treat the stump at the bowel as a patent tube, as one never knows when a fistulous tract or a thick adhesion may contain a minute opening that connects with the lumen of the bowel.
-A Long Umbilical Poltp as a Remnant of the Omphalomesenteric Duct. (Schematic.) A short, round umbilical polyp is the most common remnant of the duct noted clinically. Such a long penile projection as here depicted is exceptional. In such a case as this there is a long reddish projection springing from the umbilical depression. It is covered with intestinal mucosa. In its center is a fistulous opening into which a probe can be carried for a variable distance. Traces of the intra-abdominal portion of the duct may or may not be present.
IN WHICH THE OUTER END OF THE OMPHALOMESENTERIC Duct Remained Patent.
Persistence of the Outer Portion of the Omphalomesenteric Duct.* — A child, two and one-half years old, had had at the umbilicus, since birth, a projection, about 6 cm. long, resembling a portion of umbilical cord. When the child was admitted to the hospital, the growth was still about cm. in length. Its extremity was free and somewhat enlarged. In its center was a slight depression which admitted a probe for a short distance. The
Chandelux, A.: Observation pour servir a l'histoire de l'exomphale. Arch, de physiol. norm, et pathologique, 1881, xiii, 2. ser., 93.
PATENT OUTER PORTION OF OMPHALOMESENTERIC DUCT. 157
growth bore some resemblance to a penis. The surface was not smooth, but had a granular aspect and was reddish in color. Here and there were pale areas suggesting islands of skin. Its surface was covered with an abundant viscid discharge. This was never yellow, nor could a fecal odor be detected. Urination was normal. The nodule could not be reduced by taxis. The patient's health was good. This nodule was successfully removed. On histologic examination its outer surface was found to be covered with intestinal mucosa, and its central portion was made up of non-striped muscle.
A Partially Patent Omphalomesenteric Duct. — Florentin* refers to a boy, five weeks old, who came to Professor Froelich's clinic. The cord had been ligated 3 cm. from the umbilicus. Eight days after birth, when the cord came away, a small umbilical tumor was noted which discharged a clear liquid. The nodule did not change in volume and was not painful. When the child came to the clinic, the umbilicus looked somewhat tumefied, and in its center was a small pedunculated tumor about the size of a pea. It was dark red, firm, irreducible, and showed but little tendency to bleed. In its center was a small depression from which mucus escaped in small amount. A probe could be introduced for 2 cm. The fistulous tract was removed.
It was found to be continuous with a cord, which was implanted in the intestine. This cord was cut off near the intestine with the thermocautery, covered over, and the abdomen was closed. The child made a good recovery. The outer surface of the tumor was covered with Lieberkuhn's glands, and the cord itself presented a lumen lined with cylindric epithelium. This tumor was a partially patent omphalomesenteric duct.
A Partially Patent Omphalomesenteric Duct. — Florentinf refers to an umbilical fungus in a child two months old in Froelich's clinic. Just as soon as the cord came away a small reddish mass, the size of a pea, was noted at the umbilicus. There was no history of intestinal trouble. The umbilical nodule did not increase in size. It was firm, hard, and did not resemble a simple granulation. It had a short pedicle. It was dark red in color, smooth, and only slightly painful. It was irreducible. At its summit was a fistulous tract from which a small amount of clear liquid without odor escaped. A probe could be introduced for 3 cm.
At operation it was found that the under portion of this fistulous tract was adherent to a cord, and that the base of it was attached to the intestine. This cord was burned off, and the base turned in as in an appendix operation.
Histologic examination showed that the outer or umbilical surface of the fistula was covered with glands, beneath which was muscle. The condition was due to a partially patent omphalomesenteric duct.
Umbilical Polyp with a Partially Patent Omphalomesenteric Duct. — Florentin J describes a fungous diverticulum with a fistula at the umbilicus and a pocket of pus, in a boy one year old. This patient was observed in Froelich's clinic. After the cord came away a tumor of considerable size was found at the umbilicus. It discharged a clear liquid similar to apple jelly. After the third month the fistula closed, but it reopened four months later,
- Florentin, P. : Fongus de l'ombilic chez le nouveau-ne' et chez l'enfant. These de Nancy,
1908-09, No. 22, p. 83.
t Florentin: Op. cit., 82. J Florentin: Op. cit., 80.
158 THE UMBILICUS AND ITS DISEASES.
at which time a little pus escaped from the orifice. The general health of the child was excellent.
At the umbilicus was a tumor the size of a large horse chestnut. It was solid in consistence and uniform in outline. Its surface was glistening, brilliant, and pink in color. At one point it was possible to introduce a probe for a short distance. On removal it was found that, at the bottom, the umbilical tissue was very firm and much thicker than usual. At a point 1.5 cm. beneath the cord-like thickening the operator opened into a pocket the size of a small mandarin orange, which contained bloody pus. The fistulous tract was about 3 cm. long. The tumor was removed, the pocket was cureted, and the wound healed thoroughly.
On histologic examination numerous tubular glands were found. Outside of these there were muscular tissue and connective tissue. The condition was undoubtedly due to remains of the omphalomesenteric duct.
An Omphalomesenteric Duct Open in its Outer Portion but Closed at the Intestinal End.* — The specimen was removed from a male infant ten weeks old. A small pink tumor had been noted at the umbilicus two weeks after the cord came away. It had steadily increased in size. It was the size of a filbert, one inch long and half an inch in diameter. It was attached to the umbilicus by a narrow pedicle. At the upper end of the tumor was a small orifice, situated in the middle of a depression. A probe passed into the abdomen for 2^ inches and then met an obstruction. The surface of the tumor was pink and velvety, and a mucoid fluid constantly flowed from it. It was removed by means of a ligature and the stump treated with silver nitrate.
Microscopic Examination.— The mucosa in the canal and also on the surface was found to resemble that of the intestine, escept that the villi and solitary glands were lacking. The growth represented a partially patent Meckel's diverticulum, open almost to the bowel.
- Wheaton, S. W. : Prolapse of Meckel's Diverticulum in an Infant, Forming an Umbilical
Tumour. Obst. Trans., London, 1892, xxxiv, 184.
LITERATURE CONSULTED ON PERSISTENCE OF THE OUTER PORTION OF THE
Chandelux, A. : Observation pour servir a l'histoire de l'exomphale. Arch, de physiol. norm, et
pathologique, 1881, xiii, 2. ser., 93. Florentin, P. : Fongus de l'ombilic chez le nouveau-ne et chez l'enf ant. These de Nancy, 190S-09,
Xo. 22, p. 83. Wheaton, S. W.: Prolapse of Meckel's Diverticulum in an Infant, Forming an Umbilical Tumour.
Obst. Trans., 1892, London, xxxiv, 184.
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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