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VII. Exstrophy of the Bladder 484-485  
VII. Exstrophy of the Bladder 484-485  
==Chapter XVII. Paget's Disease of the Umbilicus==
Fox and MacLeod's case.
Milligan's case.
The results with radium in a case of Paget's disease of the umbilicus.
Eczema of the umbilicus.
The first case of this character found in the literature is that recorded by Fox
and MacLeod and published in 1904. In 1911, W. A. Milligan reported a case.
As the condition is very rare, these cases will be cited here somewhat in detail.
A Case of Paget's Disease of the Umbilicus.* — The
patient under consideration appeared before the Dermatological Society of London
on November 13, 1901, and a microscopic section of a portion of the diseased tissue
was demonstrated. At the meeting of the society on March 12, 1902, further microscopic specimens were exhibited, confirming the diagnosis of Paget's disease. The
following detailed account is given by Fox and MacLeod :
" The patient, a seafaring man of sixty-five years, came under the care of Mr. W.
Turner, surgeon to the Dreadnought Hospital at Greenwich, and assistant surgeon
to the Westminster Hospital. The man possessed a good constitution, and there
was nothing of moment to note in his personal history, and no family historj- of
cancer. In the umbilical region was a rounded, eczematoid patch of about two
inches diameter [Fig. 155] which had gradually been forming for about eleven
years, but the applicant had not been much bothered by it, and exact details as to
the history of the patch were not forthcoming. The central part of the patch was
of a brilliant red color, exulcerated, and exuding serum, but silvered over in spots
with epithelium. This raw center passed peripherally into a well-marked, raised,
smooth, broad border, which terminated abruptly, and over which the cuticle
was intact. The whole of the patch felt considerably infiltrated.
"Mr. Turner was struck by the objective features of the patch, and by its
chronicity and steady eccentric progression. The man was under treatment for a
considerable time, and as the patch proved quite intractable to all treatment tried
short of destruction or removal, Mr. Turner very kindly brought the patient to the
Skin Department of the Westminster Hospital, with the suggestion that the case
was one of Paget's disease. Histologic examination after a biopsy confirmed the
diagnosis, and thereupon Mr. Turner removed the diseased skin, and was kind
enough to hand it to us for investigation and to allow us to record the case.
"Histologic Changes Present in the Case. — As the whole
of the diseased patch was excised, an abundance of material was obtained for purposes of histologic examination. A quadrant of the excised tissue was cut out, and
from this, longitudinal sections were made. As a reference to the above clinical
description will show, the patch was roughly circular and had a clearly defined
* Fox and MacLeod: Brit. Jour. Dermatol., 1904, xvi, 41.
268
paget's disease of the umbilicus. 269
raised border and an excoriated central portion. The sections of the quadrant thus
included the border and the healthy tissue outside it and a portion of the central
excoriated area. These sections were about an inch in length. The tissue was
fixed and hardened in alcohol, embedded, and cut in paraffin, and the sections were
stained with various dyes, such as borax-methylene-blue, polychrome-methyleneblue, safranin, and water-blue, to demonstrate the finer structure of the cells of
the epidermis, the pseudococcidia, and the cellular and fibrous elements of the
corium.
" 1. Changes in the Epidermis. — With the low power the epidermis of the outer
extremity of the section showed a slight proliferation in a downward direction by a
regular elongation and widening of the interpapillary processes and a rounding of
their extremities. This proliferation became very much more pronounced in the
middle third of the section, which corresponded to the raised edge. Here the
processes had become twice the length of those in the outer third, and were far more
irregular in their shape and width. Some were clubbed at the extremities, others
broad and rounded, and a few were conic and tapered. Here and there, owing to
the obliquity of the section of the ridge-net system, the familiar appearance of
irregular islands of the corium situated in the epidermis was produced. But in
spite of the irregularity in shape and size of these interpapillary processes, they all
ended at about the same level in the corium, and did not spread down irregularly
into it as in condyloma and epithelioma. In the outer two-thirds of the section the
epidermis had an imperfect stratum corneum, which showed a tendency to desquamate and was unusually thin. Here and there it extended down in small plugs
or formed concentric horny pearls where a depression existed on the surface. The
basal layer was present in this situation, and although it was not perfectly regular,
still it remained unbroken. The epidermis did not stain regularly, and the lower
ends of the processes especially stained faintly as if they were edematous. Irregular
spaces were present in the Malpighian layer, but the interepithelial lymphatics
were not uniformly distended with edematous fluid as they are in psoriasis and
eczema. Another peculiar feature of the epidermis noticeable with the low power
was the presence in it of a number of darkly stained, more or less rounded bodies,
some of which were several times larger than a prickle-cell. These were irregularly
distributed in the epidermis, some being situated superficially near the horny layer,
others deep down toward the basal layer, but the majority being in about the middle
of the epidermis. These were arranged singly or in clusters, and occasionally they
were grouped together in a concentric manner, forming variously shaped figures.
They were situated among the prickle-cells, and only a few of them could be detected
at the edges or lying free in the irregular spaces already referred to. These rounded
structures are the "cocciclia" of Darier and Wickham.
"Toward the middle of the section the ordinary epidermis stopped abruptly,
and was replaced by a single layer of columnar epithelium, which extended over
the surface and dipped down at intervals to form a lining for a number of glands
similar in appearance to Lieberkuhn's follicles of the small intestine. These follicles
extended down into the underlying fibrous stroma, and some of them reached to a
lower level than the longest interpapillary process. This showed that in this case
a portion of Meckel's diverticulum had been included in the umbilicus, an occurrence
which occasionally takes place. A reference to [Fig. 156] will serve to show the
general appearance of the section as seen under a low power. Only a portion (about
270
THE UMBILICUS AND ITS DISEASES.
three-fifths) of the section is there depicted, the outer fifth and inner fifth bein^
left out in the drawing.
Fig. 155. — Paget's Disease of the Umbilicus. (After Fox and MacLeod.)
The umbilicus as such is not recognizable, but its site presents a somewhat worm-eaten appearance. For the histologic
picture see Figs. 156 and 157.
Fig. 156. — Paget's Disease of the Umbilicus. Histologic Appearaxces ix Fig. 155. (After Fox and MacLeod.)
Drawing of the central three-fifths of one of the longitudinal sections referred to in the text. It shows the raised
border and the central mucous portion, a, a. Imperfect stratum corneum; b, proliferating epidermis; c, small cornified cell-nest; e, columnar epithelium lining the surface, the remains of Meckel's diverticulum; /, tubular glands lined
with columnar epithelium: g, dense infiltration, consisting chiefly of plasma-cells; h, dilated blood-vessel. [This has
been reduced so much in size that the finer details are lacking. — T. S. C]
" With the high power (Oc. iv, Obj. T V, Oil imm., Leitz) the explanation of the
peculiar changes in the epidermal cells already referred to was apparent. Even at
the outer margin of the section, but far more marked toward the center, the prickle
paget's disease of the umbilicus. 271
cells at the lower parts of the interpapillary processes were found to be swollen,
their protoplasm faintly stained, and their nuclei frequently situated in spaces
within the cells. The cells were evidently edematous, and though toward the
surface they stained more naturally, yet the edema was still present sufficiently
to interfere with the process of cornification, and there were scarcely any cells in
the position of the granular layer in which even a trace of keratohyalin could be
detected. The stratum lucidum was also absent, and the horny layer was unusually
thin and tended to desquamate. The cornification thus took place without the
formation of keratohyalin, as it does in the red portion of the lips [Fig. 157]. In
spite of the edema of the cells, however, a number of nuclei in the process of
a
Fig. 157. — Paget's Disease op the Umbilicus. (After Fox and MacLeod.)
Drawing of a portion of the epidermis with the raised border of the umbilical growth seen in Fig. 155. a. Pricklecells; b, edematous cell, partially cornified and globular, prickles lost, protoplasm homogeneous, granular center
through degeneration of the nucleus; cell much swollen; c, cell similarly affected with edema, and showing a hardened
ectoplasm with an edematous nucleus; d, multinuclear edematous cell; e, multinuclear edematous cells - one of the
nuclei has become surrounded with protoplasm, forming a round cell.
karyokinesis were observed, and the cells of the basal layer and those immediately
above it showed numerous mitotic figures.
" The inter epithelial edema was not pronounced in the middle and upper portion
of the epidermis, though here and there it was sufficient in degree to allow of leukocytes making their way between the cells toward the basal layer. Wide, irregular
spaces were present, in which were deformed prickle-cells, leukocytes, and debris.
A number of prickle-cells were found to have lost their fibrillary skeleton, the spongioplasm and its continuations into interepithelial fibrils had disappeared, and the
protoplasm had become homogeneous. In this way the cells had assumed a globular appearance. Many of these cells lying immediately beneath the stratum
corneum had become surrounded by a hardened, probably keratinized, covering.
"Several types of these degenerated cells were formed in this way, and these
were variously grouped, e. g.:
" (a) Round, swollen cells with a finely granular, almost homogeneous proto
272 THE UMBILICUS AND ITS DISEASES.
plasm, and a darkly stained nucleus lying in a space or surrounded by a halo of
fluid protoplasm, which stained faintly.
* ' These nuclei had chromatin bodies and a good intranuclear network.
" (b) Round or oval cells with a faintly stained nucleus, but a more defined and
darkly colored ectoplasm, which stained similarly to that of the cells of the stratum
corneum. These cells had a slight resemblance to coccidia.
" (c) Cells in which, in spite of the edema, an active nuclear division had taken
place, but in which the division of the protoplasm of the cell had not kept pace
with that of the nuclei, and so multinucleated cells containing several oval, faintly
stained nuclei had been produced.
" (d) Groups of cells in which the nuclei had become flattened and crescentic in
form, and a great variety of shapes had resulted. It is unnecessary to describe in
detail these different groups and figures. Occasionally a leukocyte had become
impacted in such a group and further complicated it.
"The single cells, or 'pseudococcidia, ' could be demonstrated by any of the
ordinary stains, such as methylene-blue, hematoxylin, and picric acid (Banti),
but the most satisfactory specimens of them were obtained by staining the protoplasm of the cell with water-blue and the nuclei with safranin.
"The columnar epithelial cells lining the surface of the central portion and the
follicles which dipped down from it were seen under the high power to be very
regular in shape, and to have oval nuclei situated near the base of the cell. These
cells appeared to be perfectly healthy, and showed no evidence of edema or other
degenerative process.
"2. Changes in the Corium. — The most noticeable feature in the corium when
examined under the low power was a dense sheet of cellular infiltration, which
occupied the papillary and subpapillary layers and the upper portion of the reticular
layer. This infiltration was densest in the middle third of the section, especially
where the raised border existed, and in this situation it was peculiarly diffuse and
ended abruptly below in an almost straight line. It was not quite so dense in the
papillae, and about the blood-capillaries the cells tended to be collected in foci. At
the outer end of the section it was less diffuse, and was arranged in foci around the
papillary and subpapillary blood-vessels, while in the center, beneath the columnar
epithelium, it was also less dense and more irregular, and spread farther down into
the underlying stroma.
" With the high power the infiltration was found to consist largely of plasma-cells,
with a few leukocytes and connective-tissue nuclei. These plasma-cells were
perfect in shape and showed no tendency to special grouping or to form giant-cells.
This cellular infiltration was thus more than a simple inflammatory infiltrate,
such as is met with in eczema, psoriasis, or any acute inflammatory condition of the
skin. It was more closely allied to that which occurs in certain of the 'infective
granulomata, ' such as syphilis and yaws, and suggested a chronic inflammatory
process. Unna described it as a singularly pure 'plasmoma, ' and Karg has likened
it to a bulwark against the cancerous invasion.
" The papillae were edematous and swollen, especially in the middle of the section.
The fibrous elements of the corium were affected only in the area of infiltration.
There the collagen stained faintly, especially in the edematous papillae, but showed
no basophilic degeneration. The elastin was also affected in that it stained badly,
was swollen, and formed an imperfect supporting skeleton.
paget's disease of the umbilicus. 273
''The blood-vessels of the papillary and subpapillary layers were much dilated,
and there were a few dilated capillaries in the corium beneath the infiltration."
(A brief resume of the literature of Paget's disease follows.)
''Remarks on the Histology of our Case and Conclusions. — There are several points of interest in connection with the microscopic
changes present in our case which, although they can hardly be said to settle this
controversy, still are worthy of consideration:
"1. Although the affected epidermis was that of the umbilicus and not the
areola of the nipple, still, the changes present in it, the peculiar degenerated pricklecells, the occurrence of the dense sheet of plasma-cells infiltrating the underlying
papillary layer of the corium, in short, the whole histologic architecture, was similar
in every detail to that which has been repeatedly described in the typical cases of
the disease. These initial peculiar cellular changes in the epidermis, allied somewhat to those which occur in Psorospermosis follicularis vegetans (Darier's disease),
could no longer be mistaken for those of chronic eczema or psoriasis, and it is
unnecessary to repeat any labored details with regard to the histologic diagnosis
from these affections. It would seem that the histologic changes in the epidermis
in Paget's disease are characteristic and pathognomonic, whether the affection
occurs in the nipple, the umbilicus, or the genitalia.
"2. In this case there was no evidence of definite malignant change in the epidermis. The degree of proliferation was limited, and the basal layer was intact.
It has been asserted that the peculiar change of the epidermis is malignant from the
first. This does not seem to us to be so any more than that ordinary warts, the
warty growth in xeroderma pigmentosum, or pigmented nevi (moles), are malignant
from the outset. They may all be described as precancerous lesions of the skin
which have a potentiality more or less certain of becoming malignant.
"3. The inclusion of a portion of Meckel's diverticulum in the center of the
umbilicus, in this the only case of Paget's disease which has been recorded in that
situation, may be a coincidence, but it is a suggestive one. Cases have been
recorded in which the cancer grew from the epithelial cells of mucous glands, and,
had malignancy supervened, it is possible that it might have taken its origin in the
cells lining the follicles in the cut-off portion of gut in the umbilicus. Still, in the
sections the columnar epithelium on the surface and lining these follicles seemed
perfectly healthy, although the neighboring epidermis was markedly affected."
[The causative factor in Fox and MacLeod's case is clearly evident. From Fig.
156 it will be seen that some of the tubular glands which were similar to those of the
small intestine opened directly on the surface, and naturally produced some secretion which would keep the parts moist and tend to irritate them. The nature of the
man's occupation favored lack of systematic bathing. During early and middle
life nature was able to resist any active cell changes, but when he reached the period
at which atypical cell changes are prone to occur, the first symptoms manifested
themselves. From the history it is seen that he was fifty-four when this process
was first noted, and that it had gradually increased until he came under observation eleven years later.
In the case reported by Milligan, and later by Pinch, the patent urachus was
evidently the exciting factor. It is particularly interesting that in both of the
recorded cases the cause was a congenital umbilical defect. — T. S. C]
19
274 THE UMBILICUS AND ITS DISEASES.
Pa get's Disease of the Umbilicus Cured by the Application of Radium.* — " Mrs. W., aged thirty-one, came complaining of a
smelly discharge from the navel, accompanied by an eruption around the navel.
The trouble had begun four years previously, with a smarting pain around the waist
and a redness toward the right side of the umbilicus.
"Ordinary remedies were tried, but with no success, the condition steadily getting worse. The patient was then subjected to x-ray treatment — four applications
of ten minutes each. This apparently cured it, but very shortly afterward it broke
out again. For twelve months or so ordinary remedies were resorted to, but with
no result. Again .r-ray treatment was tried, — six applications, — but this time it
got worse instead of better.
Fig. 158. — Paget's Disease op the Umbilicus. (After Milligan.)
The small opening in the umbilicus is clearly seen. Surrounding this is a granular, sharply circumscribed, raised area, involving the abdominal wall on all sides. The appearance of the umbilicus after the use of radium is seen in Fig. 159.
"Sir Malcolm Morris saw the patient in consultation about the middle of June
last, and he advised either total excision or radium treatment. Accordingly, small
doses of radium were applied around the edge of the eruption, which now had a
radius of about two inches from the umbilicus. The radium was applied in successive places around the edge, and each place had an exposure of four hours. This
certainly had a good effect, although it did not cure it. Finally, on August 21, 1911,
at the Radium Institute, the patient had a treatment of 70 mg. of pure radium for
one and one-half hours direct on the skin, there being no intervening screen. For
ten days nothing was felt by the patient, and then she had a burning sensation
around the waist, and the discharge got worse. This lasted for two weeks, and
then the skin healed, leaving only a small sore spot on the right side.
"The condition prior to the last application of radium is well shown in the
* Milligan, W. A.: Proc. Roy. Soc. Med. (Dermat. Section), November, 1911, v, No. 2, 30.
PAGET S DISEASE OF THE UMBILICUS.
275
photograph [Fig. 158], and consisted of a raised, indurated edge all around, with a
raw weeping surface extending into the umbilicus.
"The condition is now apparently cured [Fig. 159], although there is still some
discharge, and the question arises as to whether there may or may not be a patent
urachus. This has not been conclusively proved, although at times the discharge
has an ammoniacal smell. It is interesting to note the large close of radium used
by Mr. Pinch at the Radium Institute, a dose corresponding to 2,000,000 activities."
Mr. A. E. Ffayward Pinch, when referring to the same case, said that a slight
Fig. 159. — The Appearance in a Case of Paget's Disease of the Umbilicus after Treatment with Radium.
(After Milligan.)
The umbilicus is relatively smooth, but somewhat paler than the surrounding tissue. The line of demarcation of
the tumor is still clearly evident. The skin around the umbilicus looks normal, but to the (patient's) left there apparently is still a little thickening. For the appearance of the umbilicus before treatment see Fig. 15S.
recurrence took place early in September, 1912. The same treatment was adopted,
with an equally good result, and the patient since then had remained perfectly well.
Sir Malcolm Morris, chairman of the meeting, said that a case of Paget's disease of the umbilicus was shown years ago before the old society by Mr. Marmaduke
Sheild.
In 1912 I wrote Dr. Milligan asking if it would be possible for him to send me
photographs of his case, as the reproductions in the Proceedings of the Royal Society
were not very satisfactory. Dr. Milligan complied with my request and sent me
the photographs here reproduced.
276 THE UMBILICUS AND ITS DISEASES.
ECZEMA OF THE UMBILICUS.
This condition is by no means rare, although the literature on the subject is very
meager. In the new-born, during the process of cicatrization of the cord, there
may be slight irritation of the umbilicus without any evidence of infection. In an
adult with a very delicate skin there may be a slight irritation of the umbilicus and
some cracking of the skin, notwithstanding the utmost cleanliness and care. This
is prone to occur in stout individuals when the weather is excessively warm and the
patient perspires a great deal. The most common cause of an eczematous condition around the umbilicus is the existence of an umbilical concretion, which, on
account of the contracted condition of the umbilical opening, is frequently overlooked. Cantrell.* in 1897, and Morris, f in 1895, briefly discussed eczema of the
umbilicus. Umbilical concretions are discussed in detail on p. 247.
Recently I saw a mild case of eczema of the umbilicus in consultation with Dr.
Frank Sladen in the Johns Hopkins Hospital. The patient was eighteen years old.
From time to time there had been an irritating discharge from the umbilicus. On
examination I found an eczematous condition in this situation. There was a little
depression at the side of the umbilical depression. There was no evidence of a
concretion.
* Cantrell, J. A.: Eczema Umbilici and its Treatment. Therap. Gaz., 1897, xxi, 82.
" Morris. R. : Lectures on Appendicitis and Notes on other Subjects, 1895, 93.




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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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Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus

By

Thomas Stephen Cullen

Associate Professor of Gynecology in the Johns Hopkins University

Assistant Visiting Gynecologist to the Johns Hopkins Hospital

Illustrated By

Max Brodel


W. B. Saunders Company, Philadelphia And London, 1916


This book is affectionately dedicated to my Mother Mary Cullen

Daughter of the late Rev. Thomas and Mary Greene

Born on July 12, 1841, at Polminick, near

Penzance, Cornwall, England

Preface

During the summer of 1904 I saw a case of cancer of the umbilicus with Dr. Jacob L. Winner. Up to that time I had thought that hernia was practically the only lesion to be noted in this locality. The patient did well for a time, but later large intra-abdominal tumors could be felt and finally he died. Xo autopsy was obtained. Histologic examination of the umbilical growth showed that it was an adenocarcinoma.


I was at a loss to explain the presence of glands in this position, and a cursory examination of the text-books failed to elucidate the matter. I could not rid myself of the desire to find out definitely just how an adenocarcinoma could exist in the umbilicus, and several years later, when other and more pressing problems had been completed, I carefully searched the literature for cases of cancer of the umbilicus and was amazed to find the records of many instances.

In the majority of the cases the umbilical growth was secondary to a cancer of the stomach, gall-bladder, intestine, or ovary. Cases of primary adenocarcinoma and of squamous-cell carcinoma of the umbilicus occur, but they are very rare.

During this study I encountered a wealth of material dealing with the omphalomesenteric duct. We have long been familiar with Meckel's diverticulum, but two facts, that the omphalomesenteric duct may be patent throughout its entire extent at birth, and that remnants of the outer end of the duct may give rise to the small umbilical polyps sometimes noted after the cord drops off, have not been commonly appreciated.

The literature is rich in records of devastating infections that prevailed before the era of asepsis. These occurred generally in hospitals, and most often when an epidemic of puerperal sepsis was rampant among the mothers. The descriptions of some of them are intensely graphic, and from the detailed reports of the individual cases one can obtain a wonderful picture of the terminal infections occurring in these infants.

I found a somewhat extensive literature on dermoids of the umbilicus, but on analyzing the cases was obliged to conclude that the majority of these growths represented nothing more than inflammations due to irritation exerted by an umbilical concretion. It was the presence of caseous material and the admixture of wool from the patient's clothing that had led to the erroneous diagnosis.

I found records of cases of Paget's disease, diphtheria, and syphilis of the umbilicus. There is also an extensive literature on the escape of intra- and extraabdominal fluid, usually pus, through the umbilicus, and many cases of umbilical fistula are recorded.

Many umbilical tumors have been reported, some benign, others malignant. I was especially interested in one group of cases. These tumors were small; they always occurred in women; they tended to swell at the menstrual period, and some urachus have been collected, the cases classified, and the appropriate methods of treatment outlined. I trust that this work may help the general practitioner, the pediatrician, and the surgeon to treat more satisfactorily lesions of this heretofore relatively unknown region, unknown, although up to the daj r of birth it is on the main highway between the mother and the child.

Thomas S. Cullen.

The Johns Hopkins Hospital, May, 1916.


Contents

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
  1. Embryology of the Umbilical Region
  2. Anatomy of the Umbilical Region
  3. Umbilical Infections in the New-born
  4. Umbilical Hemorrhage
  5. Granulation Tissue or Granuloma of the Umbilicus
  6. Remnants of the Omphalomesenteric Duct
  7. Congenital Polyps; Fistul.e 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
  8. Meckel's Diverticulum
  9. Intestinal Cysts
  10. A Patent Omphalomesenteric Duct
  11. The Patent Omphalomesenteric Duct (continued)
  12. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct
  13. Cysts in the Abdominal Wall Due to Remnants of the Omphalomesenteric Duct
  14. Persistence of the Omphalomesenteric Vessels
  15. Umbilical Concretions Associated with Inflammatory Changes in the Abdominal Wall
  16. Abscess in the Subumbilical Space
  17. Paget's Disease of the Umbilicus
  18. Diphtheria of the Umbilicus . Syphilis of the Umbilicus; Tuberculosis of the Umbilicus; Atrophic Tuberculid commencing at the Umbilicus
  19. The Escape of Retroperitoneal and Abdominal Fluid from the Umbilicus; the Opening of an Appendix Abscess at the Umbilicus. Abscess of the Liver Opening at the Umbilicus; Peritonitis with the Escape of Pus from the Umbilicus; the Piecemeal Removal of a Suppurating Ovarian Cyst through the Umbilicus
  20. Fecal Fistula at the Umbilicus
  21. The Escape of Round Worms from the Umbilicus
  22. The Escape of Various Foreign Substances from the Umbilicus
  23. Umbilical Tumors
  24. Adenomyoma of the Umbilicus
  25. Carcinoma of the Umbilicus
  26. Sarcoma of the Umbilicus
  27. Umbilical Hernia
  28. The Urachus
  29. Congenital Patent Urachus
  30. Remnants of the Urachus
  31. Urachal Remnants Producing Tumors between the Umbilicus and Symphysis
  32. Large Urachal Cysts
  33. Abscesses in the Anterior Abdominal Wall between the Umbilicus and Symphysis Due to Infection of Urachal Remains or of Urachal Cysts
  34. Urachal Cavities between the Symphysis and Umbilicus Communicating with the Bladder or Umbilicus or with Both
  35. Acquired Urinary Fistula at the Umbilicus
  36. Urachal Concretions and Urinary Calculi Associated with Urachal Remains
  37. Malignant Changes in the Urachus
  38. Bleeding from the Urachus into the Bladder
  39. Tuberculosis of the Patent Urachus

List of Illustrations

1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus and allantois 2

2. A More Advanced Stage in the Formation of the Umbilical Region 2

3. A Composite Picture Showing the Formation of the Umbilicus in an Embryo 3

4. A Diagrammatic Representation of a Human Embryo, about 3.5 mm. Long, Show ing the Effect of the Expanding Amnion upon the Yolk-sac and Body-stalk ... 4

5. Sagittal View of a Human Embryo 5 mm. in Length 5

6. Anterior View and Transverse Section of a Human Embryo 7 mm. Long, Showing

the Umbilical Region 6

7. Sagittal Section of the Umbilical Region in an Embryo 7 mm. in Length 7

8. Sagittal View of the Umbilical Region of a Human Embryo 10 mm. in Length 8

9. Graphic Reconstruction of the Umbilical Cord of a Human Embryo 12.5 mm. in

Length 9

10. Anterior View of the Umbilical Cord of a Human Embryo 18 mm. in Length 10

11. Sagittal Section of the Umbilical Region in a Human Embryo 23 mm. in Length .. 11

12. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 3 cm.

Long 12

13. Sagittal Section of the Umbilical Region in a Human Embryo 4.5 cm. in Length .. 13

14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm.

in Length as Viewed from within the Abdomen 14

15. Sagittal View of a Graphic Reconstruction of the Umbilical Region of a Human

Embryo 5.2 cm. in Length 15

16. Intra-abdominal View of the Umbilical Region of a Human Embryo 6.5 cm. in

Length 17

17. Intra-abdominal View of the Umbilical Region in a Human Embryo 7.5 cm. Long . . 18

18. Intra-abdominal View of the Umbilical Region in a Human Embryo 9 cm. in

Length 18

19. Intra-abdominal View of the Umbilical Region in a Human Embryo 10 cm. in

Length 19

20. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. Long . . 19

21. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in

Length 20

22. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in

Length 21

23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm.

in Length 22

24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long 23

25. A Composite Representation of Abnormal Umbilical Structures, Based on the

Work of Keibel, Lowy, and Others 24

26. A Composite Representation of Abnormal Umbilical Structures, Based on the

Work of Keibel, Lowy, and Others 24

27. A Composite Representation of Abnormal Umbilical Structures, Based on the

Work of Keibel, Lowy, and Others 24

28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left . . 25

29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven

Months 25

30. Three Diagrams of the Umbilical Ring and Its Significance in the Development

of Ventral Hernia 27

XV


XVI LIST OF ILLUSTRATIONS

Fig. Page

31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the

Embryo 5.5 cm. Long 28

32. The Umbilical Region, the Cord, and the Placenta at Term 29

33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term .... 32

34. Normal Umbilicus according to Catteau 35

35. A Type of Umbilical Region in the Adult, Viewed from Within 44

36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within .... 44

37. The Umbilical Region of an Adult, Viewed from Within 45

38. Classic Type of Umbilicus 47

39. Disposition of the Vascular Cords (Usual Type) 48

40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases 48

41. Vascular Cord Type, Noted 5 Times in 50 Cases 49

42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical

Ring 49

43. Vascular Cords, Noted 3 Times in 50 Cases 49

44. Vascular Cords, Noted in 2 out of 50 Cases 50

45. Umbilical Fascia. Peritoneum in Place 52

46. Umbilical Fascia and Umbilical Mesentery 52

47. Reduplication of the Linea Alba. Peritoneum Removed 52

48. Atrophy of the Umbilical Fascia, Posterior View 53

49. Formation of a Mesentery. Peritoneum in Place 53

50. Mesentery of the Urachus and of the Umbilical Arteries 53

51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place 54

52. Adipose Fringes in a Stout Subject. Peritoneum in Place 54

53. Peritoneal Diverticula. Peritoneum in Place 55

54. Peri-umbilical Fossettes. Peritoneum in Place 55

55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Ab dominal Wall 57

56. Extra-abdominal Multilocular Fibrocystoma of the Ovary 5S

57. An Extra- abdominal Multilocular Fibrocystoma 59

58. Superficial Lymphatics of the Umbilical Region 64

59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side 65

60. The Umbilical Vessels about the Time of Birth 72

61. The Umbilical Vessels in the Adult 72

62. 63. Method of Treating the Umbilical Stump at Birth 98

64. Nature's Method of Checking Bleeding from the Umbilical Arteries 107

65. An Umbilical Granulation 117

66. The Gradual Atrophy of the Omphalomesenteric Duct 121

67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord . . 121

68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord 121

69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia : . . 123

70. A Polypoid Outgrowth from the Umbilicus 129

71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70 129

72. A Diverticular Tumor at the Umbilicus 132

73. A Glandular Tumor from the Umbilicus 132

74. A Glandular Growth at the Umbilicus 133

75. Section in the Long Axis of a Small Umbilical Growth 134

76. Adenoma of the Umbilicus 135

77. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord. 138

78. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord . . . 138

79. An Umbilical Polyp 139

80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression 139

81. An Umbilical Polyp 140

82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression .... 141

83. Transverse Section op a Pseudopyloric Congenital Fistula at the Umbilicus . . . . 149


LIST OF ILLUSTRATIONS XV11

Fia. Fage

84. High-power Picture op a Fistulous Tract at the Umbilicus, Showing Glands Re sembling those of the Pylorus 150

85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach 150

86. Appearance of the Umbilical Depression in von Rosthorn's Case 152

87. Gastric Mucosa at the Umbilicus 153

88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in

Fig. 87 154

89. Persistence of the Outer End of the Omphalomesenteric Duct 156

90. Atrophy of the Inner End of the Omphalomesenteric Duct 156

91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct 156

92. Meckel's Diverticulum 159

93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus. . 160

94. An Abnormally Large Meckel's Diverticulum 161

95. A Meckel's Diverticulum with a Lobulated Extremity 161

96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface 162

97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment . . 163

98. An Accessory Pancreas in the Tip of Meckel's Diverticulum 163

99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel 164

100. A Diverticulum Tying Off a Loop of Small Bowel 165

101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum. . . . 166

102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a

Hole in the Mesentery of a Meckel's Diverticulum .170

103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel 171

104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary 175

105. An Intestinal Cyst 176

106. An Intestinal Cyst Attached to the Umbilicus by a Pedicle but not Connected

with the Bowel 176

107. Volvulus of Meckel's Diverticulum 177

108. An Intestinal Cyst Developing from Meckel's Diverticulum 178

109. Intestinal Cysts in the Abdominal Cavity 182

1 10. An Intramesenteric Cyst 183

111. A Patent Omphalomesenteric Duct 190

112. A Patent Omphalomesenteric Duct with a Polypoid Formation at the Umbilicus . 190

113. A Very Short Omphalomesenteric Duct 190

114. A Patent Omphalomesenteric Duct with a Polyp- like Formation at the Umbil icus 190

1 15. A Patent Omphalomesenteric Duct 192

116. A Patent Omphalomesenteric Duct 193

1 17. A Patent Omphalomesenteric Duct 197

118. A Patent Omphalomesenteric Duct 197

119. A Patent Omphalomesenteric Duct 202

120. A Patent Omphalomesenteric Duct 205

121. A Patent Omphalomesenteric Duct 206

122. Part of a Patent Omphalomesenteric Duct 206

123. Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Om phalomesenteric Duct 207

124. An Umbilical Polyp and a Fibrous Nodule at the Umbilicus. There was Origin ally a Patent Omphalomesenteric Duct 209

125. Longitudinal Section through the Entire Center of a Partially Closed Om phalomesenteric Duct 209

126. A Patent Omphalomesenteric Duct 211

127. A Patent Omphalomesenteric Duct Opening at the Base of the Umbilical Cord . . 216

128. A Patent Omphalomesenteric Duct 216

129. A Patent Omphalomesenteric Duct as Seen from the Abdominal Cavity 216

130. Inversion of the Bowel through a Patent Omphalomesenteric Duct Opening on the Side of the Umbilical Cord 219

131. A Patent Omphalomesenteric Duct of Large Diameter 224

132. Commencing Prolapsus of Small Bowel through a Patent Omphalomesenteric Duct 224

133. Partial Prolapsus of the Small Bowel through the Omphalomesenteric Duct . . . 224

134. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct .... 224

135. Complete Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 225

136. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct, and an Umbilical Hernia between the Loops of Prolapsed Bowel 225

137. Prolapse of the Small Bowel through an Open Omphalomesenteric Duct 227

138. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct 228

139. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Sec ondary Complications 229

140. Prolapsus and Inversion of the Intestine through a Patent Omphalomesenteric Duct 230

141. Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 232

142. A Small Cyst of the Umbilicus Due to a Remnant of the Omphalomesenteric Duct 238

143. Small Cyst of the Abdominal Wall Due to a Remnant of the Omphalomesenteric Duct 238

144. A Small Intestinal Cyst Lying between the Peritoneum and the Recti 240

145. An Omphalomesenteric Duct Originating from the Concave Side of the Bowel and Attached to the Umbilicus by a Fibrous Cord 243

146. A Remnant of an Omphalomesenteric Duct Causing Fatal Intestinal Obstruction 245

147. A Small Umbilical Concretion 249

148. Acute Inflammation of the Umbilicus Due to an Accumulation of Sebaceous Material 249

149. Cholesteatoma from the Umbilicus in Case 1 251

150. Cholesteatoma from Case 2 251

151. A Connective-tissue Projection Really Representing a Small Fibroma in the Floor of the Umbilicus 252

152. Enlargement of Fig. 151 252

153. Subumbilical Phlegmon 262

154. The Subumbilical Space 264

155. Paget's Disease of the Umbilicus 270

156. Paget's Disease of the U/mbilicus 270

157. Paget's Disease of the Umbilicus 271

158. Paget's Disease of the Umbilicus 274

159. The Appearance in a Case of Paget's Disease of the Umbilicus After Treatment with Radium 275

160. Syphilis of the Umbilicus 284

161. Atrophic Tuberculid Starting at the Umbilicus 286

162. Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket 288

163. The Manner in Which a Periprostatic Abscess may Occasionally Rupture at the Umbilicus 289

164. Escape of Pleural Fluid from the Umbilicus 289

165. The Opening of a Broad Ligament Abscess at the Umbilicus 290

166. Abdominal Pregnancy with Spontaneous Escape of Liquor Amnii from the Umbilicus 348

167. Small Papilloma in the Umbilical Depression 365

168. A Shall Umbilical Tumor Containing Glands and Stroma Identical with Those of the Uterine Mucosa 376

169. Glands from a Small U\iisiLirALTuMOR 377

170. Typical Uterine Mucosa in a Small Umbilical Tumor. An Enlargement of Area B in Fig. 168 378

171. Glands in a Small Umbilical Tumor 379

172. Dilated Glands in a Small Umbilical Tumor 380

173. Dichotomous Branching of Glands in a Small Umbilical Tumor 381

174. Uterine Glands in an Umbilical Tumor 381

175. Gland Hypertrophy in a Small Umbilical Tumor 382

176. A Tumor of the Umbilicus Composed Partly of Hypertrophic Sweat-glands 383

177. Uterine Mucosa in an Umbilical Tumor 384

178. A Small Umbilical Tumor Containing Numerous Glands 388

179. Glands in a Small Umbilical Tumor 389

180. An Adenomyoma in the Abdominal Wall Near the Anterior Iliac Spine 394

181. A Small Umbilical Tumor Containing Glands Similar to Those of the Body of the Uterus 396

182. Adenomyoma of the Umbilicus 397

183. A Group of Sweat-glands in an Umbilical Tumor 398

184. Appearance of the Carcinomatous Umbilicus After Removal 424

185. Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries 432

186. A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth 439

187. Adenocarcinoma of the Umbilicus Secondary to an Intra-abdominal Growth .... 440

188. Adenocarcinoma of the Umbilicus 441

189. A Section Showing Carcinoma of the Right Inguinal Glands 442

190. Secondary Carcinoma of the Umbilicus 443

191. Telangiectatic Myxosarcoma of the Umbilicus 450

192. Appearance of the Umbilicus After Removal of the Tumor Shown in Fig. 191. . 450

193. Myxosarcoma of the Umbilicus 451

194. Telangiectatic Myxosarcoma Projecting from the Right Side of the Umbilicus . . 452

195. A Telangiectatic Myxosarcoma 452

196. A Case of Congenital Umbilical Hernia 460

197. An Amniotic Hernia 462

198. Several Loops of Bowel Which Lay Outside the Umbilicus and were Nipped Off During Fetal Life. The Child Lived a Short Time After Birth 464

199. A Serous Umbilical Hernia 469

200. Freeing the Umbilical Hernial Sac from the Abdomen 472

201. Closure of the Hernial Opening at the Umbilicus 473

202. Closure of the Hernial Opening at the Umbilicus 474

203. An Umbilical Hernia Associated with Marked Prolapsus of the Abdominal Wall 475

204. An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds 476

205. The Abdominal Scar After the Removal of a Very Large Area of Fat 477

206. An Umbilical Cyst 478

207. Exstrophy of the Bladder Opening at or Near the Umbilicus 482

208. Exstrophy of the Bladder. A side View of the Case Depicted in Fig. 207, Showing the Relative Distance from the Symphysis to the Opening in the Abdominal Wall : 483

209. Exstrophy of the Bladder 483

210. Escape of Urine from the Umbilicus When the Inner Urethral Orifice Is Blocked by a Membrane 488

211. A Patent Urachus with a Mushroom-like Projection at the Umbilicus 489

212. A Patent Urachus with a Penile Projection at the Umbilicus 489

213. The Appearance of the Umbilicus in a Case in Which both a Patent Omphalomesenteric Duct and a Patent Urachus Existed 493

214. Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same Child 493

215. A Picture of the Child Three Weeks After Removal of a Patent Omphalomesenteric Duct and a Patulous Urachus 494

216. A Patent Urachus 497

217. A Urachus Open from Bladder to Umbilicus 498

218. An Open Urachus 499

219. Escape of Urine from the Umbilicus Due to a Patent Urachus 502

220. A Patent Urachus with a Penile Projection at the Umbilicus 505

221. A Ring-shaped Vesical Calculus with a Fine Hair in Its Axis 507

222. A Partially Patent Urachus 515

223. A Patent Urachus 517

224. A Portion of a Urachus Seven Times Enlarged, with Numerous Large and Small Dilatations 518

225. Portion of a Urachus Ten Times Enlarged 518

226. Cysts of the Urachus Arranged Like a String of Pearls .- 520

227. Spindle-Shaped Dilatations of the Urachus 520

228. A Small Cyst of the Urachus 532

229. A Patent Urachus 534

230. A Multilocular Cyst of the Urachus 535

231. Section of a Patent Urachus .' 536

232. Transverse Section of a Patent Urachus 537

233. A Small Cyst of the Urachus 538

234. A Diffuse Neuroma of the Bladder 542

235. Cut Surface of the Bladder Showing a Diffuse Neuroma of Its Walls 543

236. A Diffuse Neuroma Forming a Mantle Around the Cavity of the Bladder 544

237. Diagram Showing the Arrested Development of the Genital Tract and the Relation of the Malformed Parts to the Cyst of the Urachus 551

238. Section of the Segment of Urachus Which Passed between the Bladder and the Cyst- wall, as Seen under a Low Power 552

239. The Abdominal Contour in a Case of Very Large Urachal Cyst 558

240. A Urachal Cyst Turned Inside Out and Showing Papillary Masses, Particularly in the Lower Part of the Picture 559

241. Infected Urachal Remains 568

242. An Infected Urachus Opening between the Umbilicus and Bladder 570

243. Urachal Cyst 576

244. A Dilated Urachus Communicating with the Bladder 579

245. Large Accumulation of Urine in a Partially Patent Urachus 579

246. An Infected Urachus Opening at the Umbilicus 580

247. A Patent Urachus Dilated in Its Middle Portion 580

248. Accumulation of a Large Quantity of Urine in a Urachal Pouch 581

249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac 584

250. A Phosphatic Deposit on the End of a Long Bone 585

251. A Dilated Urachus Communicating with the Bladder 598

252. Urachal Cyst 599

253. Urachal Cyst 603

254. Urachal Cyst 603

255. A Patent Urachus Containing a Vesical Calculus 625

256. Carcinoma of the Patent Urachus 632

257. A Multilocular and Malignant Cyst of the Urachus 637

258. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus 638

259. Giant-cells in the Wall of an Adenocarcinoma of the Urachus 639

260. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus. . .640-641

261. Adenocarcinoma of the Urachus 642

262. A Papillary-like Area i.\ an Adkxocarcinomatous Cystofthe Urachus 643

263. Metastasis from Adenocarcinoma of the Urachus 644

264. An Umbilical Cyst 645

265. \\ aj.i of an Umbilical Cyst 645

266. Giant-cells in the Wall of an Umbilical Cyst 646

267. Tuberculosis of the Urachus 652

268. An Area Suggesting a Tubercle 653

269. A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus 654


List of Plates

I. Drawings of Normal Umbilici 40

II. Drawings of Normal Umbilici 41

III. Drawings of Normal Umbilici 42

IV. Drawings of Normal Umbilici 43

V. Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary. .434-435

VI. Umbilical Hernia 466-467

VII. Exstrophy of the Bladder 484-485


Chapter XVIII.

CHAPTER XVIII. DIPHTHERIA OF THE UMBILICUS; SYPHILIS OF THE UMBILICUS; TUBERCULOSIS OF THE UMBILICUS; ATROPHIC TUBERCULID COMMENCING AT THE UMBILICUS.

Diphtheria of the umbilicus.

General consideration.

Report of cases. Syphilis of the umbilicus, at or shortly after birth.

Report of cases. Syphilis of the umbilicus in the adult.

Report of cases. Tuberculosis of the umbilicus. Atrophic tuberculid starting at the umbilicus.

In this chapter are grouped several diseases which are very uncommon and which do not belong to the subjects considered in any other chapter.


DIPHTHERIA OF THE UMBILICUS.

We have records of only two cases in which the umbilicus was the seat of a primary diphtheritic deposit. The first case was described by Pitts in 1897, the second by Gertler in 1898. As one might naturally expect, the umbilicus became involved shortly after birth and before the umbilical stump had had time to cicatrize.

Pitts's patient was first seen on the fourteenth day after birth. The child's brother had just died of diphtheria, and its mother was ill with the same disease. Diphtheria bacilli were cultivated from the umbilical lesion. The child died, and at autopsy the diphtheritic deposit was found to be limited to the umbilicus, the respiratory tract being free from membrane.

Gertler's patient first came under observation when he was four weeks old. On the eighth day the cord, which had not come away, was cut off with a pair of scissors and the child was circumcised. When Gertler saw the patient, the umbilicus and the penis presented the characteristic diphtheritic deposits. Both lesions yielded the specific bacillus and promptly healed after the use of antitoxin.

Diphtheria of the Umbilicus.* — A child, fourteen days old, was admitted for an inflammation of the umbilicus. The cord had separated on the eighth day, and the resulting wound had continued to discharge extremely offensive pus. When seen on February 20th, there was a brawny, red, indurated area around the umbilicus, about the size of a five-shilling piece. From this area the epidermis had peeled off. The umbilicus itself was the seat of a dirty-looking, wash-leather slough, and was discharging offensive pus from an opening into which a probe could be passed for about an inch. The child's general condition was otherwise good. It had, however, an occasional inspiratory crow, and with it some slight cyanosis. The next day it was learned that the brother of the child had been

  • Pitts, B.: The Lancet, London, 1897, i, 953.

277


278 THE UMBILICUS AND ITS DISEASES.

removed to a hospital suffering with diphtheria during the previous week, and had died on the morning the child was first examined. The mother had been taken to a hospital also suffering from diphtheria.

A culture from the umbilicus examined on February 22d showed diphtheria bacilli. The child had some vomiting, became weaker, and died on the same day. After death nothing abnormal could be found in the larynx or pharynx, nor had the condition at the umbilicus extended to any of the deeper structures.

Diphtheria of the Umbilicus.* — The umbilical cord had not come away normally, but had been cut off on the eighth day with a pair of scissors and the child had been circumcised. The physician could not tell whether the trouble had started first in the umbilicus or on the penis. The illness had lasted three weeks.

The child, four weeks old, was moderately well developed. In the umbilical region was an infiltration of the skin and underlying tissue, and surrounding it was a sharp line of demarcation which extended downward to the symphysis. Immediately around the umbilicus was a small, grayish-yellow deposit, and when pressure was made over the skin below the umbilicus, purulent fluid escaped.

The penis was swollen, and on the right side of the glans was a flat ulcer, likewise covered with a grayish-yellow, diphtheroid deposit. The inguinal glands on both sides were hard, and the subaxillary glands on the right side were enlarged. The pulse was 96; the temperature, 37.8° C. Cover-slips at once suggested diphtheria, and twenty-four-hour cultures gave a pure Loffler bacillus. The diagnosis of diphtheria of both the penis and the umbilicus was certain. On October 27th the serum was given, and on the following day the temperature was 38.2° C. and the local condition was better. The area of redness, which had extended to the symphysis, had narrowed down to 2.5 cm. around the umbilicus, and the infiltration of the skin was less.

On October 29th the skin infiltration in the umbilical region had disappeared. The skin was drawn up into folds, and a grayish-yellow membrane came away after the use of a 3 per cent, boric acid solution, leaving a superficial ulcer which did not bleed.

By October 30th the swelling in the umbilical region had become slightly smaller, and there was no membrane over the area of ulceration. The ulcer of the penis had dried up entirely.

On October 31st the umbilicus presented the normal appearance, and the ulcer of the penis had healed completely.


SYPHILIS OF THE UMBILICUS.

The literature on this subject is very meager, but lues of the umbilicus has been mentioned by Blum (1876), Villar (1886), Runge (1893), Bertherand and Merklen (1900), Hutinel (1903), Bondi (1903), Hartz (1905), and Chiarabba (1906).

Cases of syphilis of the navel are divided into two groups :

1. Syphilis of the umbilicus at or shortly after birth.

2. Syphilis of the umbilicus in the adult.

  • Gertler, N. : Beitrag zu den Krankheiten des Nabels der Neugeborenen. Klin, therapeut.

Wochenschr., Wien, 1898, v, 1234.


SYPHILIS OF THE UMBILICUS. 279


Syphilis of the Umbilicus At or Shortly After Birth.

Bertherand and Merklen in 1900 drew attention to the fact that in a certain number of children presenting symptoms more or less characteristic of congenital syphilis, such as a purulent coryza, a tendency for the finger-nails to drop off, fissure in ano, etc., ulcerations of the umbilicus existed. They were inclined to think that the umbilical ulceration was part of the syphilitic process. In order that the reader may gain a clear idea of their findings and draw his own conclusions, they will be cited here somewhat fully.

Bertherand and Merklen observed, in the service of Hutinel, a variety of umbilical ulcers and thought these had not been previously mentioned. They state that Professor Hutinel a long time before had said that these infections suggested syphilis. The ulceration was situated at the umbilicus, and appeared shortly after birth. All the patients examined by Bertherand and Merklen were less than one month old. The exact date of the appearance of the ulcer could not be determined, as all the patients were brought to the hospital with the lesion already present. The youngest child was nine days old. An ulceration of this character may reach the size of a five-franc piece. The base of the ulcer is grayish, sometimes yellow, and there is a secretion of mucopus. The ulcer is red, irregular, has raised margins, and one of the cases showed appearances of gangrene. The ulceration may be accompanied by redness of the skin with desquamation, but without any evidence of inflammatory reaction. The authors further say that, of the four children observed, three died of hereditary syphilis, and that the ulceration still persisted at the time of their death. The fourth child survived and the ulceration cicatrized.

Case 1 . — ■ L. A., nine days old. The child had a purulent coryza which suggested syphilis. There was an ulceration at the umbilicus which had completely obliterated the umbilical depression and extended beyond it. The base of the ulcer was grayish, and covered with a little pus. Around the umbilicus was a little reddening, but only a slight reaction. The child was cachectic, lost weight, and died ten days after entering the hospital. At autopsy nothing of moment was detected in the lungs or in the digestive tract. The brain was normal, but the liver was large and congested, and the spleen was increased in size. The testicles were hard and sclerotic, but on section did not show anything of any moment. A longitudinal section of the femur showed that the bone-marrow was altered, especially in the upper and lower part. The spongy tissue of the bone was yellowish, and showed less color than normal.

[In this case it is possible that syphilis existed, but the history is in no way conclusive. One might very readily think of an ulcer at the umbilicus due to simple infection, possibly associated with syphilis. — T. S. C]

Case 2. — D. E. This child was admitted to the hospital when eleven clays old. He had a purulent coryza, a marked fissure at the anus, and erythema of the buttocks. No change was noted in the testicles, and there was no inflammation of the nails. At the umbilicus was an ulcer suggesting gangrene. It was deep, had irregular margins, and discharged a little mucopus. A few daj^s later it had increased in size, become deeper, and was larger than a five-franc piece. The child was cachectic, developed bronchopneumonia, and soon died.

At autopsy evidences of bronchopneumonia were found in both lungs. The liver was red and slightly enlarged, but showed little on section. A longitudinal


280 THE UMBILICUS AND ITS DISEASES.

section of the left humerus gave a marked discoloration of the bone-marrow at both extremities.

[In this case the coryza and the fissure at the anal margins point to syphilis, but the area of ulceration at the umbilicus and the erythema of the buttocks might equally well have been due to gangrene or simple ulceration of the umbilicus. The case is not clear. — T. S. C.J

Case 3 . — N. S., thirteen days old, was suffering from a purulent coryza. The diagnosis of hereditary syphilis was thought probable from the existence of an umbilical ulcer which was as large as a five-franc piece. The surface of this ulcer was covered with a greenish, clear pus. The margins were a little elevated and desquamated, and they were also red, but showed no induration. There was but little loss of tissue. The child developed an intestinal infection. The general condition became alarming, and the umbilical ulcer increased in size. Nearly a month after the child's admission to the hospital an inflammation of the extremities of the nails of the fingers was noted, and there was a tendency for the nails to become detached. The coryza continued without any new manifestations of syphilis except the inflammation of the nails. The child died a week later of bronchopneumonia.

At autopsy, in addition to the bronchopneumonia, on histologic examination, a periportal sclerosis and an obliterative endarteritis were found. At certain points the obliteration was complete. The small hepatic veins were thickened. The hepatic cells were a little opaque. The left kidney was pale. The right kidney was pale, and there was a tendency to fusion of the cells. At the upper extremity of the kidney was a white, pearly gumma, much paler than the rest of the renal tissue. The convoluted tubules and the loops of Henle were the seat of a degeneration, and the glomeruli were congested. The arteries of the glomeruli showed a slight degree of endarteritis, and some of the arterioles contained thrombi. A section of the superior extremity of the humerus demonstrated that the spongy tissue of the bone was yellowish and less colored than normal.

[In this case the purulent coryza was suggestive of syphilis, but the ulceration might very readily have been due to an ordinary infection. Inflammation of the extremities of the fingers also points toward syphilis. The report says that there was a gumma in the right kidney, but the description of the gumma is not at all conclusive. This is another case in which we cannot say absolutely that the umbilical condition was syphilitic. — T. S. C]

Case 4 . — C. C, one month old. At the umbilicus was an ulceration the base of which was grayish in color and covered with mucopus. The ulceration was surrounded by a reddish, desquamated zone, which was about the size of a twofranc piece. Two weeks later the child commenced to improve and the ulcer tended to diminish. Shortly afterward the child showed the characteristic purulent coryza, which tended to confirm the idea of hereditary syphilis. The ulcer gradually healed under simple local treatment. The coryza, however, persisted with the same intensity, and the child was sent to the country.

Bertherand and Merklen, in describing these cases, say that the histories showed that they were dealing with hereditary syphilis, causing a variety of ulcers of the umbilicus. The appearance of the lesion, the absence of general reaction, and the coexistence of further signs of syphilis, as coryza, fissure in ano, and inflammation of the nails, and examination of the testicles would permit one, according to their view, to decide in favor of the specific nature of the umbilical ulcer.


SYPHILIS OF THE UMBILICUS. 281

Hutinel, in 1903, wrote a very interesting article on the same subject. He said that during the thirteen years in which he had been a physician to the Hopital des Enfants-Assistes he had observed this peculiar umbilical lesion about a dozen times. From its appearance and mode of development and its anatomic characteristics he attributed the umbilical trouble to hereditary syphilis. His description of the local condition is very similar to that given by Bertherand and Merklen. Appended to his paper are several interesting cases.

Case 1 . — Rena M., born January 28, 1902, and admitted to the hospital on February 18th. This child had a purulent coryza, a lorgnette nose, and erythema of the buttocks. The diagnosis of hereditary syphilis seemed certain. Redness and swelling were present, and a phlegmonous appearance, forming a circle around the umbilicus and extending 4 cm. in all directions. This area of tumefaction was not hot nor painful on pressure, and had not the definite margin characteristic of erysipelas; there was no fever. In the center of the area was a small ulcer from which there was a slight discharge. At the end of two days the reddish circle had retracted somewhat, but the ulceration had increased in size and deepened. The surrounding tissue was hard, red, and raised, but there was no fever. The coryza persisted, and the characteristic papules were noted on the buttocks. On the following days the redness around the umbilicus gradually took on a livid tint, and in the center was a crater-like depression, yellowish black and bloody, and several red plaques appeared on the abdomen. On March 3d the umbilical ulcer formed a pit with precipitous margins, and at the bottom the surface was covered with a grayish exudate. The margins were indurated and violet-colored. The area of ulceration was about 1.5 cm. in diameter, and the pit measured 1 to 1.2 cm. in depth. Hutinel says that on March 7th the ulcerated area presented the picture of a gumma. This had increased in size and its base was yellowish in color. Its margins were precipitous, but the peripheral infiltration had diminished and had gradually lost its phlegmonous aspect. On March 10th the area of ulceration still retained its principal characteristics; the base, however, was enlarged, and the cutaneous orifice had diminished in size.

On March 14th the temperature, which had been absolutely normal, reached 38.2° C, the respirations became accelerated, and the child was very restless. A bronchopneumonia was evident. Death occurred on the following day. At autopsy the peritoneum at the umbilicus was found to be normal. In the angle formed by the urachus and the umbilical arteries there was a yellowish nodule. In a transverse section of the abdominal wall this was found to be 1.4 to 1.5 cm. in thickness at the site of the umbilical ulcer. The abdominal muscles on the right, in the vicinity of the ulcer, were pale and scarcely recognizable, and the subperitoneal connective tissue was thickened and presented a hyaline appearance. The peritoneum did not contain any liquid, and there were no omental or intestinal adhesions. Bronchopneumonia was the cause of death.

From a transverse section through the center of the umbilical cicatrix it was found that the floor of the ulcer consisted of a granular substance which resisted the action of the staining fluid. In the interval between elastic fibers could be recognized remains of leukocytes, and beneath this zone, where the necrosis had been less complete, there was an infiltration of round cells, and sometimes a few leukocytes which stained poorly. In the middle of the area the arterioles appeared thickened, and in some places had been completely obliterated; there existed an


282 THE UMBILICUS AND ITS DISEASES.

endarteritis and sometimes a peri-arteritis. In some places the infiltration had invaded the adipose tissue.

[The general picture in this case strongly suggests a mild umbilical infection. The histologic picture also is suggestive of the same thing. While one cannot say positively that syphilis did not exist, the evidence in favor of it is not particularly strong.- — T. S. C]

Case 5 . — On p. 90 Hutinel reports the case of a small girl, S. P., eight weeks old. She was born on March 9, 1903, and admitted to the hospital on May 5, 1903. An examination of this child was made by Budin. The labor had been normal; but the father of the child had manifested symptoms of syphilis and appeared to have tuberculosis. The child at birth weighed 3600 grams. On March 11th, after the expulsion of meconium, the child's weight dropped to 3400 gm., but by March 15th it had risen to 3650 gm. On March 20th, when the mother left the clinic, the child had not gained a gram in weight, and it was noted that the umbilicus was diseased. It was red and raised, and a superficial ulcer was noted above and to the right. The child had coryza. Sublimate baths were prescribed, and the umbilical ulcer was painted with iodin, and afterwards with silver nitrate; in addition, the child was given mercurial frictions. She remained in the clinic until April 30th, when the area of ulceration appeared to be healing. It did not heal, however, and on May 5th, when the child was brought for examination, the ulcer was found to be large and deep. The mother said that from the beginning the umbilicus was swollen and red over an area the size of a five-franc piece, and that it had become eaten out and had suppurated, after which the redness had disappeared. The swelling had been replaced by a depression, and there had remained at the umbilicus a triangular ulcer. The margins of the ulcer were sharply denned, the skin was red around the orifice, and a pinkish, serous fluid escaped. The child was very pale and had a yellowish, waxy tint that led one to suspect syphilis. The head was large, the nose lorgnette-shaped. There were no fissures of the lips and no inflammation of the nails. There was an erysipelas of the legs and arms and some papules on the buttocks. The epiphyses were a little enlarged, but there was no bone malformation. There was some thickening of the cranial bones. The liver was slightly enlarged, and the spleen was somewhat increased in size. On May 9th the umbilical ulcer, which had resisted treatment for six weeks, contracted and tended to disappear. Hutinel says that the fact that syphilis existed in this case is undeniable^ and that the mother, on May 22d, presented in the throat a very characteristic papulo-erosive syphilitic eruption.

Some of the cases reported by Bertherand and Merklen and by Hutinel were in all probability instances of congenital syphilis, but whether the umbilical lesions were directly caused by the spirochete or not is another question. Runge, in speaking of wound infections of the new-born, said that when the syphilitic manifestations make their appearance at birth, usually in premature children, these children are born dead, die almost immediately, or live only a few hours, rarely a day. He further says that, in addition to the usual syphilitic changes in these cases, there are numerous hemorrhages under the skin and in the internal organs.

Bondi says the diagnosis of hereditary syphilis in the new-born is very difficult. He covers the literature well, gives a large number of cases, and also presents some excellent pictures. His conclusion is excellent: "There were present the exudate with an inflammatory appearance, the edematous infiltration of the vessel


SYPHILIS OF THE UMBILICUS. 283

walls, with migration of polymorphonuclear leukocytes, and in one case a pouringout of fibrin and in two cases abscess-like formations in the vessel-walls, and sometimes necroses. In one case there was a deposit of chalk." He says that the changes are due to an arteritis and phlebitis; that the picture presented is not specific or characteristic, but the changes described have been those observed only in syphilis, and that, in the absence of proof to the contrary, we can with a moderate degree of certainty describe these as the pathologic findings in syphilis.

The umbilical pictures presented by the cases here recorded are so similar to those due to the umbilical infection formerly so frequent shortly after birth that, anatomically, they show little or no difference ; and even the histologic pictures of these supposedly syphilitic lesions of the umbilicus are by no means conclusive. If syphilis existed in these cases, the lowered vitality of the child would naturally render it more susceptible to any umbilical infection. While our knowledge of this subject is meager, careful examinations of umbilical ulcers for the Spirochseta pallida will, in the future, speedily determine whether these ulcerations are syphilitic or not.

Syphilis of the Umbilicus in the Adult.

Blum, in his article on Tumors of the Umbilicus in the Adult, published in 1876, when speaking of syphilis, mentions the case of a man, aged thirty-six, who had a fetid discharge from the umbilicus for two years. The umbilicus was prominent and formed a tumor. Its margins were swollen and possibly slightly ulcerated. Dupuytren considered the probability of a fecal fistula, but Breschet, who had seen several analogous cases, prescribed a specific treatment, and the patient was cured. From the clinical picture this case might equally well have been one of umbilical concretion, particularly if any local treatment was given.

Bille, in 1912, collected eight cases of primary syphilis of the umbilicus, and in 1914 referred to three others. In the latter article he shows the picture of a lesion in a young girl coming under the care of Lassar. At the umbilicus was an elongated, oval ulcer the size of a five-pfennig piece. The ulcer was deep, and its surface brownish red and glistening. Its margins were sharply defined and infiltrated. Surrounding the ulcer was a pale red, inflammatory zone.

The following case, observed by Fiaschi, was so carefully studied that I shall report it in detail :

Syphilitic Chancre of the Umbilicus. — In 1911 I received the following from Dr. P. Fiaschi, of Sydney, Australia:

"178 Phillip St., Sydney, Australia, March 14, 1911. . . . "As you are busy with your paper on the umbilicus, I thought you might like the following: Some three weeks ago I found a young man with a chancre of the inner aspect of the right lower quadrant of the prepuce and a chancre of the umbilicus (Fig. 160). He gave a history of an incubation of fourteen and seventeen clays. . . .

"I may say that my father concurred in the diagnosis of genital and extragenital primitive infection of the young man. The ultramicroscopic examination gave me one of the finest specimens of spirochetes I have managed to get from any lesion in any case I have examined so far. Inasmuch as you are interested in this work, you might look up the classic monograph of our distinguished master, M. Le Professeur Founder. You will find the report on page 284 and subsequent pages. Fournier, in a personal observation of 110 extragenital chancroids, in a total of 10,000 chancres that he has observed in private practice, found only 16 of the abdomen. They are evidently not common.


284 THE UMBILICUS AND ITS DISEASES.

"The result of the injection of salvarsan was very striking. Both lesions had cicatrized in five days, so that even after vigorously using an ophthalmic curet I could not get any spirochetes."

On May 25, 1911, Dr. Fiaschi writes:

"The young man took it into his head, after seeing his lesions healed, to leave this city and go to a country town, telling me that he knew he was cured, judging by the reports that he had read in magazines and newspapers. He did this notwithstanding my remonstration not to fool himself, but to place himself under the usual methodic mercurial treatment. I wanted to present him to a clinical meeting of our local medical society, and I wrote him to come to Sydney, and he did so the day before the meeting. On presenting himself I found that both lesions had



Fig. 160. — Syphilis of the Umbilicus. (Fiaschi.) The umbilical depression is filled with dome-like elevations of various sizes, and trickling from the umbilical orifice is a watery discharge. Spirochetes were obtained from the umbilicus and also from a chancre of the prepuce. Both lesions yielded promptly to salvarsan. The patient did not keep up the necessary treatment, and returned two months later with a mucous patch on the upper lip.

remained healed, but that he had a mucous patch on the upper lip, the size of a nickel, from which I obtained numerous spirochetes under the ultramicroscope, of the giant form, such as are frequently found in mucous patches. I had this mucous patch photographed, and am pleased to write you that I am now mailing you, under registered cover, four photographs, two of the chancre and one showing the result five days after intramuscular injection of salvarsan, and the fourth showing the relapse with mucous patch. The young man told me that he had noticed this two weeks before seeing me."

LITERATURE CONSULTED ON SYPHILIS OF THE UMBILICUS. Bertherand et Merklen: Sur une varietc d'ulceration ombilicale de nature syphilitique. Bull.

de la Soc. de ped. de Paris, 1900, ii, 248. Blum, A.: Tumeurs de l'ombilic chez l'adultc. Arch. gen. de med., Paris, 1876, vi. ser.. xxviii,

151.


TUBERCULOSIS OF THE UMBILICUS. 285

Bondi, Josef: Die syphilitischen Veranderungen der Nabelschnur. Arch. f. Gyn., 1903, lxix,

223. Chiarabba, U. : Contributo alia Conoscenza della sifilide ombelicale (Flebite proliferativa gommosa

della vena ombelicale). Annali di ostetricia e ginecologia, 1906, Anno 28, i, 190. Fiaschi, P. : Personal communication. Fournier, A.: Les chancres extra-genitaux, Paris, 1897, 326.

Hartz, A.: Abnabelung und Nabelerkrankung. Monatsschr. f. Geb. u. Gyn., 1905, xxii, 77. Hutinel, V.: L'ulcere syphilitique de l'ombilic chez les nouveau-nes. La Syphilis, Paris, 1903,

i, 81. Pernice, Ludwig: Die Nabelgeschwiilste, Halle, 1892. Rille: Ueber den syphilitischen Primaraffekt am Nabel. Festschr. f. E. Lesser, Arch. f. Derm.,

1912, cxiii, 865. — Ein weiterer Beitrag zur Kenntnis des syphilitschen Primaraffektes am

Nabel. Dermatol. Wochenschr., 1914, lix, 1271. Runge: Die Wundinfectionskrankheiten der Neugeborenen. Die Krankheiten der ersten Lebens tage, 2. Aufl., 1893, 194.

tuberculosis of the umbilicus.

Bouffleur,* in 1898, reported a supposed case of tuberculosis of the umbilicus. The patient had been complaining only for ten days. He first had cramp-like pains in the abdomen, followed three days later by a discharge from the umbilicus with tenderness and soreness in the umbilical region. The discomfort was so marked that he had to stop work.

Several sisters had died of tuberculosis, but the patient, apart from repeated chancroidal infections and an occasional attack of colicky pain followed by diarrhea, after drinking beer, had been perfectly well.

On examination a purulent discharge was noted at the umbilicus, and to the right and below the umbilicus was a slight swelling, apparently situated in the deeper part of the abdominal wall. The purulent tract was enlarged, and with a curet over an ounce of typical tuberculous granular tissue was removed. A cavity the size of a walnut, internal to the abdominal wall, was exposed. It was packed with iodoform gauze. Some of the smears yielded large numbers of tubercle bacilli; others contained none.

Bouffleur asks whether this was a case of tuberculosis of a blind urachus or of Meckel's diverticulum.

[The clinical picture is strongly suggestive of a soft umbilical concretion. — T. S. C]

In 1911, in the course of a conversation with Dr. A. L. Stavely, of Washington, he referred to an interesting case which had come under his observation. On March 26, 1904, he sent the specimen to Dr. J. R. Mohler, of the Bureau of Animal Industry, who, in reply to an inquiry from me, reported as follows :

"Slides were prepared which showed numerous tubercle bacilli with the Ziehl-Nielsen stain. Two guinea-pigs were inoculated with the material, and both developed tuberculosis.

"No sections of the umbilicus were made, but we still have slides prepared from the pus in the fistulous tract, which show the presence of tubercle bacilli, somewhat faded as a result of nine years' preservation. "

Tuberculosis of the umbilicus is, to say the least, exceedingly rare. One might expect occasionally to find it in those rare cases in which a tuberculous bowe becomes adherent to and opens through the umbilicus.

  • Bouffleur, Albert I.: Tuberculosis of the Umbilicus. Clin. Rev., Chicago, 1898, ix, 329.


286


THE UMBILICUS AND ITS DISEASES.


A CASE OF ATROPHIC TUBERCULIDE

The patient was a boy, aged twelve, who had been under Bunch's care for five years at the Queen's Hospital for Children, and before that under Dr. Adamson's care at the same hospital. The latter had shown him before the Dermatological Society of London on May 9, 1906. The eruption had begun, when the child was aged four, as a single red patch at the navel, on which small red nodules had developed later. The nodules were slightly raised, somewhat papular in character, and distinctly infiltrated. They had a tendency to necrose, and always left a superficial, shallow scar about x /% inch to l /i inch in diameter.

In 1906 there were about 30 such scars around the umbilicus, and scattered



Fig. 161. — Atrophic Tuberculid Starting at the Umbilicus. (After J. L. Bunch.)

Scattered over the lower abdomen and right thigh and over the region of the right shoulder are elevations, oval or

round in form. They were first noted at the umbilicus.


among these were about a dozen raised red papules, ranging in size from a milletseed to a split-pea. During the succeeding years similar necrotic papules had made their appearance in the inguinal region, on the thighs, on the upper part of the buttocks, in front of and behind both axillae, and on the shoulders and back (Fig. 161). Attention was called to the fact that the nodules and scars were always preceded by a circumscribed, irregular, dry, scaly, red dermatitis, such as had been described in 1906 for the inner side of the thigh and arm, where there were now the characteristic scars. Similar appearances had preceded the atrophic tuberculid elsewhere, and there was now a very well-marked patch of such a dermatitis on the right shoulder, which probably denoted the appearance of the nodular eruption within the next year or two.

  • Bunch, J. L.: Proc. Roy. Soc. Med. (Dermatological Section), November, 1911, v, 21.


Chapter XIX.

THE ESCAPE OF RETROPERITONEAL AND ABDOMINAL FLUID FROM THE UMBILICUS; THE OPENING OF AN APPENDIX ABSCESS AT THE UMBILICUS; ABSCESS OF THE LIVER OPENING AT THE UMBILICUS; PERITONITIS WITH THE ESCAPE OF PUS FROM THE UMBILICUS; THE PIECEMEAL REMOVAL OF A SUPPURATING OVARIAN CYST THROUGH THE UMBILICUS.

The escape of retroperitoneal fluid from the umbilicus.

A periprostatic abscess opening at the umbilicus.

A thoracic abscess opening at the umbilicus; report of cases.

A broad-ligament abscess opening at the umbilicus.

Cases of broad-ligament abscess opening at or near the umbilicus. An abscess of the umbilical vein in an adult. The opening of an appendix abscess at the umbilicus. Abscess of the liver opening at the umbilicus. Peritonitis with the escape of pus at the umbilicus, clinical picture; causes of the peritonitis;

differential diagnosis; report of cases. The piecemeal removal of a suppurating ovarian cyst through the umbilicus. Localized jaundice of the umbilicus with the presence of free bile in the abdominal cavity.

THE ESCAPE OF RETROPERITONEAL FLUID FROM THE UMBILICUS.

An effusion of fluid into the retroperitoneal tissue will tend to loosen up the peritoneum from the underlying adipose or muscular tissue by a process of dissection, the process gradually extending for quite a distance. For example, in February, 1912, I saw with Drs. Smouse, Fay, and Priestley, in Des Moines, Iowa, a patient giving the history of the sudden development of a more or less globular tumor to the left of and above the umbilicus. The man passed into a state of collapse and was thought to be dying. A few days later his condition was much improved, and an exploratory abdominal operation was deemed advisable. On opening the abdomen I could palpate a mass, about 10 cm. in diameter, in the region of the pancreas. The peritoneum of the right abdominal wall was bluish in color, and the mesocecum much thickened. I at once closed the abdomen and made a gridiron incision in the right iliac fossa, pushing the peritoneum toward the median line. The discoloration of the peritoneum was due to the action of old blood which had dissected this membrane from the underlying structures. As I passed my fingers upward toward the right renal pocket I found that between the peritoneum and the lateral abdominal wall there was a space, fully 2 cm. broad, which was filled with clotted blood. Surrounding the right kidney there was also a very large blood-clot. A drain was laid in the pelvis and in the right renal pocket, care being taken not to dislodge the clots. The man did well for over a week and then died suddenly.

At autopsy an aneurysm of the abdominal aorta was found (Fig. 162). This had perforated posteriorly and on the left side, producing the tumor that had suddenly appeared on the left of the median line. This blood had gradually passed over the vertebral column and gradually dissected free the peritoneum on the right

287


288


THE UMBILICUS AND ITS DISEASES.


side of the abdomen, a fact which accounted for the disappearance of the tumor on the left. The sudden death had been due to rupture of the aneurysm into the duodenum. Careful examination at autopsy showed that the peritoneum on the right lateral abdominal wall, as a result of the hemorrhage, had been dissected from the underlying structures as far as the right internal inguinal ring.

If blood under pressure can find its way extraperitoneally from one part of the abdominal wall to another, there is no reason why pus under pressure should not do the same thing. In a psoas abscess we have a good example of the extraperitoneal burrowing of pus.



Aortic aneurysm

Fig. 162. — Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket. H. S. W., February 16, 1912. In I, we see an aneurysmal dilatation of the aorta. In II, the aneurysmal sac has given way, with the escape of blood retroperitoneally. This caused the tumor that was noted clinically. The pressure of the escaping blood gradually dissected the peritoneum free, and the blood, following the line of the arrows, gradually passed over into the right renal pocket, as noted in III. At operation I found the peritoneum over the lateral wall of the lower abdomen bluish black. This was due to the presence of old blood lying between the peritoneum and the muscles of the lateral abdominal walls. At autopsy it was found that the blood had dissected its way extraperitoneally as far as the right internal inguinal ring.

A Periprostatic Abscess Opening at the Umbilicus. Nicaise refers to the case of a patient under the care of Castaneda. A periprostatic abscess gradually extended and opened at the umbilicus. In Fig. 163 is indicated the manner in which a periprostatic abscess may reach the navel.


Thoracic Abscess Opening at the Umbllicus. Both Blum and Nicaise refer to a case reported by Curran in the Lancet in 1872. A young boy in the beginning had symptoms of a right-sided pneumonia. Resolution failed to take place, and cachexia soon developed. The boy looked as if he had tuberculosis. At the end of six months an elevation, which was exceedingly


THE ESCAPE OF FLUID FROM THE UMBILICUS.


289


painful, developed just above the xiphoid and extended to the umbilicus. It soon opened, and an enormous quantity of pus escaped, the purulent discharge from the umbilicus continuing for fourteen days. The pulmonary symptoms disappeared, and the boy was able to go back to his occupation permanently cured. The abscess in this case had evidently been walled off by the cellular tissue between the attachment of the diaphragm and the sternum. Whether an abscess of the lung had



Fig. 163. — The Manner in which a Periprostatic Abscess may Occasionally Escape at the Umbilicus.

The periprostatic abscess may gradually dissect free the peritoneum of the lateral and anterior abdominal wall and reach the umbilicus. This has occurred in a few instances, but it is unusual, the abscess, as a rule, tending to empty itself into the bowel, bladder, or externally.


Fig. 164. — Escape of Pleural Fluid from the Umbilicus. This is a schematic representation of the manner in which a purulent accumulation in the pleural cavity may break through the diaphragm, gradually dissect free the peritoneum over a limited area, and finally escape at the umbilicus. In some cases, after the pus has broken through the diaphragm, a fistulous tract has been found extending intraperitoneally down over the liver to the umbilicus.


existed or whether there had originally been an accumulation of pus in the pleural cavity could not be determined.

Fig. 164 depicts in a schematic way the manner in which an empyema, after perforating the diaphragm, may travel downward and forward until it reaches the umbilicus.

A Broad-Ligament Abscess Opening at the Umbilicus.

According to Nicaise, Fereol was the first to describe a case of this kind; Bernutz and Guerin had also reported cases of phlegmon of the broad ligament opening at the umbilicus. 20


290


THE UMBILICUS AND ITS DISEASES.


Probably the most interesting articles on the subject are those of Yaussy, published in 1875, and of Gauderon, published in 1876.

We are all familiar -with the induration that is occasionally found in one or both



Abscess

in broad tig.


Fig. 105. — The Opening of a Broad Ligament Abscess at the Umbilicus. (Schematic.) Broad ligament abscesses are most frequently observed after postpuerperal infections. Occasionally they form definite hard or boggy masses that can be readily palpated in one or both iliac fossa?. In rare instances the infection extends beyond the confines of the broad ligament. The pus dissects the peritoneum of the lateral and anterior abdominal wall free over a limited area, and finally escapes through the umbilicus, following the course roughly outlined by the arrows.


broad ligaments, and which, as a rule, has resulted from an infection following labor. Although such an inflammation is usually limited to the uterus, it may gradually separate the folds of the broad ligament and appear as a more or less indurated nodule in the right or left iliac fossa, and occasionally in both. If the tendency


THE ESCAPE OF FLUID FROM THE UMBILICUS. 291

toward suppuration continues, a further lifting up of the peritoneum may occur, and in this manner the pus may travel up to the umbilicus (Fig. 165) .

In nearly all the reported cases the patients have given a history more or less typical of a mild puerperal sepsis. After a period varying from a few days to several months' induration was noted at or near the umbilicus. This was in some instances accompanied by marked induration of the abdomen between the umbilicus and pubes. The center of the umbilical induration gradually softened. In some cases it opened spontaneously; in others it was opened before rupture had time to occur. The amount of pus escaping varied greatly, depending in large measure on the size of the broad-ligament abscess. The umbilical opening usually remained patent until the abscess-sac ceased to drain. In Vaussy's Case 1, however, it would temporarily close, only to discharge again. In the cases reported by Fereol and by Sottas, and in Vaussy's Case 6, the abscess also opened into the vagina. None of the patients died as a direct result of the abscess.

Treatment.- — • Sometimes it is possible to make counter-drainage, as in Sottas' case, in which a rubber tube was carried from the umbilicus to the vagina. If the abscess is large, it may be possible to enter the broad ligament from the vagina, but much care must be exercised to avoid injuring the ureter or uterine artery. When vaginal drainage does not seem feasible, the ordinary gridiron incision, as for an appendix operation, should be made; the peritoneum should be gradually pushed toward the median line until the broad ligament is reached and the abscess evacuated.

Cases of Broad-Ligament Abscess Opening at or Near the Umbilicus.

The following cases were encountered in looking up the literature on diseases of the umbilicus. There have doubtless been other cases recorded in the general obstetric and gynecologic literature. The number here cited is, however, sufficient to give a clear idea of the direction which abscesses in the broad ligament may occasionally take.

Fistula at the Umbilicus Following Suppuration in the Left Broad Ligament. — ■ Nicaise said the first observation of this kind was mentioned by Fereol.* Inflammation of the left broad ligament followed the labor. There then developed a local peritonitis, which later became general. At the same time the left side of the abdomen became tumefied and there was dulness on percussion. Toward the fifteenth day a small tumor appeared above and to the left of the umbilicus. It was hard, fluctuating, and opened spontaneously. Floods of pus escaped, soaking several draw-sheets during the night. Several days after another perforation took place, this time into the vagina. The umbilical fistula cicatrized in the course of six weeks.

Phlegmon of the Left Broad Ligament and of the Right Broad Ligament; Subperitoneal Escape of Pus by the Rectum; Escape of Pus Below the Umbilicus; H e a 1 i n g . f — Marie Noel, twenty-two years of age, was the mother of two children, one born in March, the other in December, 1875. After the labor she

  • Fereol (Quoted by Nicaise): Ombilic. Dictionnaire encyclopedique des sci. med., Paris,

1881, 2. ser., xv, 140.

f Gauderon, E.: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers rombilic. These de Paris, 1876, 148.


292 THE UMBILICUS AND ITS DISEASES.

came under the care of Siredey. On December 20th a phlegmon of the left broad ligament was noted, and on February 5th there was a similar condition in the right broad ligament. About February 20th a thickening was made out in the anterior abdominal region, commencing three fingerbreadths beneath the anterior superior spine on the right, and reaching almost to the umbilicus. Pus had been discharged by rectum on February 12th. The abdominal tumor persisted and progressed toward the median line, apparently following the direction of the urachus toward the umbilicus. Pressure caused severe pain below the umbilicus. On February 11th fluctuation had been noticed below the umbilicus, and an opening had been made at this point which allowed the escape of a large quantity of creamy, thick pus. The umbilicus was never distended in the manner indicating the presence of a hernia.

Suppuration of the Tube and Ovary, with Opening at the Umbilicus. * — A woman, twenty-four years of age, was admitted to Viannay's clinic in August, 1910, on account of an abscess which had opened at the umbilicus. She had had a child twenty-three months before, but no miscarriages. Forceps were used at the labor. No fever followed. When she commenced to get up, pain was noted in the right iliac fossa. Some time later the abdomen was opened by Dr. Blanc for a salpingo-oophoritis. Recovery followed, but when the menses returned, pain was noted in the iliac fossa. There was a periodic purulent discharge from the uterus and pain in the lower abdomen. Little by little she developed a purulent accumulation around the umbilicus. This opened spontaneously and discharged an abundance of purulent material.

When admitted to the hospital, a small abscess the size of a walnut was noted in the lower part of the umbilical cicatrix. This had a punctiform orifice. The disproportion between the small size of the abscess and the great abundance of the umbilical discharge was very striking. On vaginal examination an induration was found in the right lateral cul-de-sac.

Operation. — The umbilical opening was increased in size and an abscess found in the subcutaneous tissue. The fistulous tract passed down the median line behind the muscle and the aponeurosis. The median incision was continued to within two fingerbreadths of the symphysis. A finger was introduced into the fistulous tract, and counter-palpation made through the vagina. Finally the abdominal finger opened up an abscess, which was drained from above. The vagina was not opened. The patient made a good recovery.

[This would appear to have been a broad-ligament abscess. — T. S. C]

Umbilical Fistula Following Puerperal Sepsis. — Nicaisef cites the case of one of Pujol's patients. The peritonitis developed in a woman shortly after confinement. A little later there was pain at the umbilicus and a small tumor formed, with a soft swelling around it. It was opened with a lancet and pus escaped. A sound introduced into the tract did not pass to the peritoneum. On the fourth day, in the depth, another tumor could be felt passing from the primary abscess. It opened spontaneously through the same opening, and a large quantity of pus escaped. The fistula closed in about six months.

  • Maurin: Salpingo-ovarite suppuree, ouverte a l'ombilic. La Loire medicale, 1910, annee

29, 495.

t Nicaise (Pujol): Op. cit.


THE ESCAPE OF FLUID FROM THE UMBILICUS. 293

Subperitoneal Phlegmon of the Anterior Abdominal Wall Spontaneously Opening at the Umbilicus; Purulent Pleurisy, Followed by Recovery.* — Case 1. — This patient was twenty-one years of age and was admitted in May, 1875. Fourteen days previously she had had a normal labor, and four days later a chill, and the lochia had ceased. The abdomen increased in size, but there was no vomiting or nausea. On March 17th the umbilicus became red, projected somewhat, and showed a whitish point in its center. During the night of the eighteenth this ulcerated and there was a discharge of greenish liquid containing grumous material. During the evening the opening increased in size. By March 21st the discharge at the umbilicus had diminished. On April 3d it was very slight, but on the ninth the umbilicus opened again spontaneously and two liters of grumous, greenish pus escaped. The patient continued to have an appetite. There was some fever at night. By November 12th the patient had improved very much and was convalescing. During the first few months recovery was retarded by a purulent pleurisy. It was supposed that this patient had had a purulent peritonitis, and for that reason she was admitted to the hospital. Vaussy, however, was not certain that the condition was not due to inflammation of the perimetrium, with extension to the umbilicus.

[The latter explanation would seem to be the more rational one. — T. S. C]

Inflammation of the Left Broad Ligament Following Labor; Local Peritonitis, Mammary Abscess, Inflammation of the Femoral Vein, Spontaneous Perforation of the Abdominal Wall in the Neighborhood of the Umbilicus, also Opening into the Vagina. Cicatrization of the Umbilical and Vaginal Fistulae. Death Due to Tuberculosis of the Lungs. f — P. R., aged twenty-four, a healthy woman, was delivered on October 26, 1859. The labor was difficult. On October 31st the lochia ceased; the patient had a chill for half an hour. The abdomen became painful in the left inguinal region. The pulse was small, thready, frequent, and there was much thirst. The next day the lochia reappeared in small quantities. The abdomen was tympanitic, painful in the lower left side, where a tumefaction could be felt in the broad ligament. On November 2d the chills were constant and prolonged. The abdomen was swollen and painful. Pressure was intolerable. There was nausea without vomiting, and the face was pale and drawn. The pulse was small and frequent, and the skin hot and dry. On November 20th a phlebitis appeared in the left limb. On November 28th a small tumor was felt in the neighborhood of the umbilicus. It was immediately below and a little to the left, and was the size of a pigeon's egg. It was hard, although fluctuant. On November 30th an abscess presented in its center, a small plaque about the size of a 20-centime piece, from which a serous, transparent fluid was discharged. On December 1st a considerable quantity of greenish, serous pus escaped, which had a rather fetid odor. The abdomen diminished in size, and the tumor in part disappeared. On December 5th there was diarrhea, and the patient had a left intermammary abscess. She also suffered pain in the left lower abdomen.

  • Vaussy, F. : Des phlegmons sous-p£ritoneaux de la paroi abdominale anterieure. These

de Paris, 1875, No. 445.

t Vaussy, F.: Op. cit., Case 6.


294 THE UMBILICUS AND ITS DISEASES.

The night preceding she had been inundated with pus that had escaped from the vagina. On the seventh the diarrhea continued; the discharge from the vagina diminished, but was abundant from the umbilicus. The chills appeared every day about 2 or 3 o'clock. There were definite signs of pulmonary tuberculosis. In the early part of January some improvement was noted. The fistula closed completely, the appetite returned, and the patient seemed to be on the point of recovery. Toward the end of January both lungs were found to be involved, and the patient died on February 24, 1860. At autopsy it was found that the intestinal loops were bound to one another by an old false membrane. Both lungs were infiltrated with tubercles.

In this case a woman, several days after labor, had a phlegmon of the broad ligament, which was extraperitoneal. It invaded the iliac fossa and the anterior abdominal wall, and there formed in this region, extraperitoneally, a large, purulent collection which reached to the umbilicus. The peritoneum was in contact with the abscess and became inflamed, whence there resulted a circumscribed adhesive peritonitis. Four weeks after labor the tumor opened at the umbilicus, and several days later a new opening took place spontaneously into the vagina. This latter opening was at the dependent portion of the abscess. The patient commenced to improve, but pulmonary tuberculosis suddenly developed. The autopsy demonstrated an old peritonitis, but no trace of any recent pus.

Suppurative Pelvic Peritonitis Opening Spontaneously at the Umbilicus.- — ■ Vaussy* reports a case observed by Sottas, an intern in the service of Marrotte, and published in L'Union medicale, June 2, 1864. R. A., aged twenty-three, was delivered of a child in the eighth month. After labor the patient had fever but no pain and no abdominal distention. There was nothing to indicate peritonitis. She left the hospital on April 22d, and three days later returned with all the symptoms of pelvic peritonitis. At that time an abscess is said to have opened into the vagina. In the course of two months she was again admitted to the hospital. She complained of pain in the left iliac fossa, and said that she had a tumor. In the month of September the swelling disappeared and the patient left the hospital in good health. She entered the hospital again on December 14, 1863. In the hypogastric region was an ovoid tumor, fairly firm, and painful on pressure. In the iliac fossa was an irregular solid tumor. The illness was attributed to a relighting up of the old pelvic inflammation. On January 2d fluctuation was noted in the hypogastric region, but this was so superficial that it was thought to be subcutaneous. The hypogastric region was prominent, and occupying it was a round tumor. At the umbilicus it was possible to feel the superior portion of the tumor, which was round and fluctuating. On examination the cervix was found to be back against the sacrum. Between the uterus and the symphysis was a round, soft tumor. Examination was painful, and the skin of the abdomen was red and suggested a phlegmon. On the night of January 5th a small nodule which had formed just below the umbilicus opened; there was a free escape of pus, and the hypogastric region became flatter. Later Bernutz and Gosselin saw the patient ; a probe introduced at the umbilicus passed down toward the vagina. On the tenth Gosselin dilated the umbilical orifice, punctured the vagina, and brought the probe through. A rubber tube was then passed from the umbilicus through into the vagina. On the nineteenth the urine escaped from the

  • Vaussy, F.: Op. cit., Case 7.


THE ESCAPE OF FLUID FROM THE UMBILICUS. 295

umbilicus, and colored matter injected into the bladder escaped from the vagina and also from the umbilicus.*

The discharge of urine gradually ceased from the umbilicus, and on February 1st the patient voided without a catheter. The suppuration from the umbilicus and from the vagina had ceased. On February 6th the patient had chills and fever and the pain in the abdomen reappeared. On February 13th the umbilical fistula opened again, and a seropurulent discharge came away. On February 20th it was noted that the discharge had ceased for several days and the patient was in good condition. In the left iliac fossa could be felt an indurated tumor, but the patient remained well.

[In this case there was probably a broad-ligament abscess. Peritonitis cannot be absolutely excluded.]

An Abscess of the Umbilical Vein in an Adult.

This case hardly belongs in this chapter, but can be better considered here than elsewhere. As a rule, the umbilical vein has long since disappeared, but from Dr. Barlow's description it seems quite probable that the abscess here described developed in a partially patent umbilical vein.

An Abscess of the Umbilical Vein in an Adult, f ' — • The patient was a male, white, aged forty. At the age of fifteen he began to have sporadic attacks of pain, cramp-like in character, very severe, and coming on nearly always at night, after retiring. These attacks, as a rule, were of short duration. Two or three days after the pain was over the patient was apparently perfectly well again until the next attack.

On the evening of January 14, 1915, the patient was taken with severe pain involving the whole right abdomen. The pain was so severe that it caused him to draw his knees up and to cry out. He had no chills and was not jaundiced; temperature, 101° F.; nausea and vomiting once. Dr. E. C. McGehee, the family physician, examined him thoroughly and made a diagnosis of acute infection of the gall-bladder. One-quarter of a grain of morphin failed to relieve the pain, and it was necessary to allow him to inhale chloroform before any relief could be obtained. Dr. Barlow saw him in consultation next morning. At that time the temperature was 100° F.; the entire abdomen was distended; the acute pain was subsiding; the area of tenderness was localizing between the umbilicus and the liver, and the patient was sensitive under the right costal arch. Immediate operation was advised, but the patient did not consent until a week later.

Operation. — The usual gall-bladder incision was made, but as he was opening the peritoneum Dr. Barlow entered an abscess which he thought was the gallbladder. Exploration with the finger disclosed the fact that it was not the gallbladder but a well-walled-off abscess containing about one and one-half ounces of pus. This abscess in shape resembled a bottle-gourd, the larger portion being toward the umbilicus, the smaller or handle-like end extending into the fissure of the liver. This abscess was firmly fixed to the abdominal wall, to the upper border of the liver above the gall-bladder, and to the hepatic flexure of the colon.

After this sac had been dissected free from these attachments it was still found

  • We would now administer phenolphthalein, which would give the reddish discharge from the

vagina and also from the umbilicus.

j Dr. E. E. Barlow, Dermott, Ark. Personal communication.


296 THE UMBILICUS AND ITS DISEASES.

anchored to the fissure of the liver by the handle-like portion of the sac, which proved to be the umbilical vein. This was patulous within an inch of its bifurcation. It was ligated above the patulous portion and removed.

The stomach,, duodenum, pancreas, gall-bladder and its ducts were examined and found to be normal. The portion of the hepatic flexure of the colon that was adherent to the sac was somewhat lacerated, and in the presence of infection Dr. Barlow did not feel justified in attempting to repair it. There was no evidence of ulceration at this point, the damage being due, as Dr. Barlow says, to an extensive dissection. A large coffer-dam drain was laid down between the liver and intestine. This was removed on the fifth day. Two days later a fecal fistula appeared but closed after five or six days. The patient made an uneventful recovery, and at the time of the report was apparently well.

LITERATURE CONSULTED ON THE ESCAPE OF RETROPERITONEAL FLUID

FROM THE UMBILICUS.

Fereol: Nicaise: Ombilic. Dictionnaire encyclopedique des sci. med., Paris, 1881, 2. ser., xv, 140.

Gauderon, E.: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers l'ombilic. These de Paris, 1876, No. 148.

Maurin: Salpingo-ovarite suppuree, ouverte a l'ombilic. La Loire medicale, 1910, annee 29, 495.

Nicaise: Op. cit.

Vaussy, F. : Des phlegmons sous-peritoneaux de la paroi abdominale anterieure. These de Paris, 1875, No. 445.

THE OPENING OF AN APPENDLX ABSCESS AT THE UMBILICUS.

An appendix abscess, in the vast majority of cases, naturally is intra-abdominal, and hence there is little opportunity of its passing upward in the abdominal wall unless the abscess has destroyed the peritoneum of the anterior abdominal wall over the abscess area, or unless, as happens very rarely, the appendix from the beginning has been retroperitoneal. In an experience extending over twenty years I have never seen the umbilicus involved in an appendix case. In the literature I have, however, found several cases which seem to indicate an extension to the umbilicus.

Vaussy* reports a very interesting case: A girl, sixteen years of age, was admitted on October 27, 1875. Seven months previously she had suddenly vomited, had had diarrhea, but no abdominal pain. Three months later the pain had become severe in the hypogastric region and the patient had noticed a tumor occupying the right iliac fossa. This was painful on pressure. She had had no chills, no nausea or vomiting. In the course of two months this tumor had increased in size, and the pain had become more severe, lancinating in character, and insufferable. The patient had lost her appetite and had fever, and her general condition was much altered. The tumor had become fluctuant. Two incisions were made, and about 500 c.c. of pus escaped. Several days later a small red plaque appeared below the umbilicus, and there was a tumor the size of a cherry. This opened spontaneously with the passage of a certain amount of pus. There was also a discharge of pus from the umbilicus. Toward the end of September the opening cicatrized. When seen on October 27th the patient was again pale, and there was a purulent

  • Vaussy: Op. cit., Obs. 3, p. 27.


THE ESCAPE OF FLUID FROM THE UMBILICUS. 297

discharge from the umbilical region and also from the site of the incision. By November 11th the patient was in excellent condition and looked as if she were getting well. [While one cannot say that this was primarily a case of appendicitis, the picture strongly indicates it. — T. S. C]

Gauderon, in his thesis in 1876, refers to the same case.

Bryant and Hine, in 1878, reported a case in which the escape of pus was in all probability appendiceal in origin, as indicated by the perforated cecum detected at autopsy. A boy, aged thirteen, had pain in the lower abdomen and also soreness at the umbilicus, together with a fecal fistula at that point. He had been delicate since an attack of scarlet fever when three years old. His legs were scalded when he was eleven years old, and since then he had lost weight. His bowels had always been loose. Three weeks before admission he had sudden pain in the abdomen, and a week later his umbilicus began to swell, became purple, and in a few days burst, discharging a quantity of matter with a distinctly fecal odor. The boy died.

At autopsy the cecum was found to have ulcerated through, and the ulceration had extended along the abdominal wall to the umbilicus. The symptoms in this case strongly suggested appendicitis or an inflamed Meckel diverticulum.

Kelly and Hurdon report an interesting case coming under the care of R. L. Payne, of Norfolk, Va. The patient, a colored woman twenty years old, after repeated attacks of appendicitis, developed a tumor at the umbilicus. When an incision was made in the mid-line, just beneath the umbilicus, half a pint of fetid pus escaped and the appendix floated out. The patient recovered, but a fistula persisted.

We have here considered only those appendix cases in which an abscess was present, and in which no general peritonitis existed. For a description of the umbilicus in cases of peritonitis see p. 299.


LITERATURE CONSULTED ON THE OPENING OF AN APPENDIX ABSCESS AT THE

UMBILICUS.

Bryant and Hine: Fecal Umbilical Fistula. Med. Times and Gaz., 1878, i, 460.

Gauderon, E.: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers l'ombilic. These de Paris, 1876, 148.

Kelly and Hurdon: The Vermiform Appendix and its Diseases. Phila., W. B. Saunders Co., 1905, 202.

Vaussy, F. : Des phlegmons sous-peritoneaux de la paroi abdominale anterieure. These de Paris, 1875, No. 445.


ABSCESS OF THE LIVER OPENING AT THE UMBILICUS.

Berard, in 1840, wrote on abscess of the liver opening at the umbilicus.

Leguelinel de Lignerolles, in 1869, said that hepatic fistulae opening at the umbilicus might be due to a calculous tumor, to hydatids, or originate from an abscess of the liver. He then reported in detail several cases in which biliary calculi and echinococci escaped at the umbilicus, but has little to say regarding hepatic abscesses opening at the umbilicus.

Nicaise, when summing up the subject, says that abscess of the liver does not, as a rule, tend to open externally, and that, judging from the statistics of Rendu, the majority of these abscesses do not open spontaneously. When rupture takes place, the pus tends to pass toward the thoracic more frequently than into the


298 THE UMBILICUS AND ITS DISEASES.

abdominal cavity. In those rare cases in which the abscess tends to escape externally the point of exit is liable to be in the region of the right hypochondrium, beneath the costal margin, where the abscess becomes walled off and then ruptures. Nicaise says that he knew of but one case, that of Ronis, in which a liver abscess opened directly at the umbilicus. Judging from a casual glance over the literature one would infer that an escape of the contents of a liver abscess from the umbilicus was not rare, but when we come to analyze the cases, it will be found that in nearly every instance the umbilical fistula was due to an infected gall-bladder which had become adherent to and opened at the umbilicus, as evidenced by the escape of gallstones with the pus.

The opening of a liver abscess at the umbilicus is a very rare occurrence.


LITERATURE CONSULTED ON ABSCESS OF THE LIVER OPENING AT THE UMBILICUS.

Berard, P. H.: Fistules de l'ombilic. Diet, de med., Paris, 1840, xxii, 64. Nicaise: Op. cit.

Leguelinel de Lignerolles, H.: Quelques recherches sur la region de l'ombilic et les fistules hepatiques ombilicales. These de Paris, 1869, No. 6.


PERITONITIS WITH THE ESCAPE OF PUS AT THE UMBILICUS.

From time to time isolated cases of peritonitis with escape of the pus from the umbilicus have been recorded. Among the earlier writers on the subject were Bricheteau in 1839, Cazaban in 1845, Aldis in 1848, and Baizeau in 1875. The most exhaustive treatise that we possess is the excellent thesis of Gauderon, published in 1876, and even to-day this monograph contains the most illuminating discussion of the subject. Nicaise, in 1881, gave a very complete review of the literature, and Cameron, in the Proceedings of the Royal Society of London, February, 1912, adds some very interesting data.

Clinical Picture.

As pointed out by Gauderon, this disease occurs almost exclusively in girls. Boys, however, are occasionally attacked. Of the cases described here more or less in detail, and where the sex was mentioned, 12 occurred in girls and 1 in a boy.

Age. — ■ The youngest child was a year old, the oldest, seventeen. In 15 cases in which we have data as to the age, 14 of the patients were under twelve years of age.

Symptoms. — The child is usually attacked suddenly with severe abdominal pain. When seen, the legs are drawn up, the face has an anxious expression, the pulse is rapid and small, the temperature elevated ; the tongue is often red, and the skin hot. As the disease progresses there may be much vomiting associated with diarrhea. In fact, in Baizeau's case the gastro-intestinal symptoms were so accentuated that cholera was suspected. The exact condition is often very obscure. In Cameron's Case 6 appendicitis was first suspected, and later the child was supposed to be suffering from pneumonia. In Cameron's Case 7 the symptoms strongly suggested typhoid fever.

As the disease progresses the child may become delirious, as noted in Aldis' and Baizeau's cases, and emaciation become marked. After a period varying from a few days to several weeks fluid is detected in the abdomen, and a little later the umbilicus becomes prominent. Thus, in Triboulet's case, referred to by Gauderon, for


THE ESCAPE OF FLUID FROM THE UMBILICUS. 299

example, on the eighth clay a small, elevated tumor formed at the umbilicus. This was diagnosed as an umbilical hernia, and an attempt made to reduce it. In Cameron's Case 6, on the other hand, it was ten weeks before any umbilical swelling was noted. There is usually an unfolding, as it were, of the umbilicus, and a tumor is formed. The umbilical skin may be normal or somewhat thinned out. The tumor contains free fluid, and when this has been forced back into the abdomen, the hernial ring can at times be easily felt. This forcing back of the fluid into the abdomen is sometimes accompanied by a considerable amount of gurgling. As a rule, there is little or no evidence of inflammation at the umbilicus. In Cazaban's case, however, there was a phlegmonous inflammation at the umbilicus, and in Triboult's case the umbilicus was indurated.

Gauderon says that pus may escape from the umbilicus as early as the twelfth day, but that, as a rule, it comes away between the twentieth and thirtieth days. In some cases the umbilical prominence became red and opened in its center; in other cases, after the application of poultices, there was a sudden discharge of pus, much to the surprise of the physician or attendant. If there has been much abdominal tension, the pus will naturally escape in jets until the pressure has been relieved. It varies greatly in appearance. In some cases it was spoken of as a purulent fluid; in others, as that of a serous peritonitis, while in several cases it was thick and green in color. In some cases it was odorless; in others, foul-smelling. The amount of pus also varied greatly. In some cases it was estimated that several liters escaped.

Sometimes the fistula would remain open for weeks and then close. In other cases it would seal over -and open up again, only to repeat this procedure several times.

In some cases it was found necessary to irrigate the abdominal cavity frequently before the purulent secretion could be checked. The earliest permanent closure was in eight days — in Cazaban's case. In one case the fistula remained open seven and one-half months. Gauderon said that, on an average, the fistula closed in a month.

In a few cases the umbilical swelling was incised before it had time to rupture, thus facilitating the escape of the pus.

Complications. — -In Triboulet's case a friction-rub developed at the base of the right lung. In West's case there was a purulent pleurisy with effusion, and in Baizeau's case a pleuropneumonia developed.

Recovery. — As pointed out by Gauderon, nearly all the children in whose cases the peritonitis opened at the umbilicus recovered. Those dying succumbed to lesions in no way dependent on the peritonitis.

Causes of the Peritonitis. These cases have usually been spoken of as instances of idiopathic peritonitis, and as most of the reported cases occurred before bacteriologic examinations were made, we have no way of determining absolutely their mode of origin. According to Ledderhose, Henoch's patient had been trampled on by a large dog and the peritonitis had soon followed. Cameron's Case VI, reported in 1912, was due to the pneumococcus, and in his Case VII there was probably a similar origin. From a careful study of these cases one gathers the impression that the pneumococcus may be responsible for the majority of the cases of so-called idiopathic peritonitis.


300 THE UMBILICUS AND ITS DISEASES.

Differential Diagnosis. These cases of peritonitis are occasionally simulated by deep-seated inflammations between the umbilicus and pubes. These are usually due to an infection of remnants of the urachus. If the inflammation occurs in young children, for the first few days it may be impossible to differentiate between it and a general peritonitis, the symptoms being identical (p. 567), but after an interval of four to five days the abdominal swelling diminishes, the abdomen becomes flat, and a localized tumor is felt between the umbilicus and pubes, whereas in a peritonitis the intraabdominal fluid is still evident.

Cases of General Peritonitis Opening at the Umbilicus.

These cases are of interest from a historic standpoint, showing, as they do, how nature may liberate a purulent peritoneal accumulation. In the future we shall expect to see still fewer of these cases, since, with the operative facilities that we now possess, abdominal drainage will be adopted early in the disease.

Purulent Peritonitis with Spontaneous Evacuation Through the Umbilicus; Healing.* — A girl, aged seven years and four months, was visited by Dr. Aldis on June 5, 1846. She lay on her right side; the face was emaciated and drawn, and the expression was anxious. The extremities were atrophied. The urine was scanty, the abdomen was distended, and there was a projection at the umbilicus ; fluctuation was manifest. About eleven weeks before, the child had been seized with chills and fever, vomiting, and pain in the abdomen; on the following day she was delirious. An examination of the abdomen failed to reveal any induration. On June 7th an opening occurred spontaneously in the tumor, and over 2000 c.c. of purulent material escaped from the abdomen. The child complained of pain in the hips. The urine was abundant and pale. On the following days pus continued to escape. On June 12th the abdomen was perfectly flat, and the child was visited for the last time. On September 30th she was in good condition. The abdominal girth was only 20 inches in the region of the umbilicus, and the opening was closed by a solid cicatrix.

Probably a Peritonitis, with Escape of Pus From the Umbilicus. — Bricheteauf reported a case in which a large abscess of the abdomen, simulating an acute peritonitis, opened at the umbilicus. A girl, aged seventeen, of lymphatic constitution, on May 17, 1839, complained of abdominal pain. The abdomen was sensitive, and she could not bear to be touched with the hand. The skin was hot, the pulse somewhat accelerated. There was very frequent vomiting. The expression was anxious, but the general abdominal contour was not altered. Prolonged baths were given, but eight or ten days later the abdominal pain returned and was associated with tension. The patient could not sit up. Vomiting reappeared and there was diarrhea. Thirst was marked, and there was much heat of the skin and an increase of fever. The abdomen was distended and tympanitic on the left side, and the patient lay continuously on her right side. On June 12th Bricheteau noted that the skin of the umbilicus

  • Aldis: Gaz. med. de Paris, 1848, 733. Cited by Gauderon: De la pcritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers l'ombilic. These de Paris, 1876, No. 148; obs. 25.

t Bricheteau: Des abces dans le tissu cellulaire sous-peritoneal. Arch. gen. de med., 1839, vi, 435.


THE ESCAPE OF FLUID FROM THE UMBILICUS. 301

was thin and raised, and two days later, on removal of a poultice, a jet of pus was seen escaping from the umbilicus and an enormous quantity came away. It was thick in consistence, without odor, and resembled the serous pus of peritonitis. The suppuration continued for several days, after which the opening closed. It opened again and finally closed permanently. The patient for a long period had digestive troubles with vomiting, and was not permanently cured until after a sojourn of three months in the country.

Purulent Peritonitis; Spontaneous Rupture at the Umbilicus; Abscess of the Parotid; Pleurisy; Recovery.* — ■ The patient was a boy, twelve years of age, in good health and of a strong constitution. Suddenly he complained of pain in the abdomen and fever developed. The abdomen became distended, ballooned out, and was very sensitive. The slightest pressure could not be made except near the hypogastrium. The facial expression was altered. The radial pulse was 110. The skin was burning. There was excessive thirst and incessant vomiting. The diagnosis did not offer any difficulties, but the cause of the peritonitis was not easy to determine. He showed no signs of external violence, and nothing indicating intestinal perforation. Twenty leeches were applied to the abdomen and were then replaced by fomentations. The abdomen had diminished in size by the next day, except in the region of the umbilicus, where the swelling had increased. The general condition remained the same; the fever and vomiting continued. Applications of leeches were again made. On the fifteenth day there was some improvement. The abdomen remained distended, but was less sensitive on pressure. The pulse was 100; the vomiting had ceased. There had been no movement of the bowels for two days. On the eighteenth day there was a marked change. After dinner an intense pain developed in the right hypochondriac region, reaching to the shoulder. The child cried, and the suffering was extreme. The vomiting returned, and the pulse reached 115. A right pleuropneumonia developed. The point of greatest intensity was at the right nipple. This new affection progressed. On March 15th pain was noted in the right parotid region and a large parotid abscess was opened. About March 20th the abdominal pain reappeared without appreciable cause. It was easily possible to make out an abundant quantity of fluid in the peritoneum. The umbilicus was pushed out by the fluid, and formed a small external tumor. On April 2d this broke, and several liters of greenish pus with thick, grumous material escaped. The discharge lasted for several days and improvement was noted. A drainagetube was introduced, and an injection of lukewarm water made. The suppuration diminished. At the same time, in the right nipple region, a fluctuating tumor was punctured. On April 10th about six quarts of pus escaped from the umbilicus. Toward the end of May the thoracic fistula closed. About June 21st there was severe pain in the region of the right shoulder, reaching to the lung, and accompanied by intense fever. In the course of several days a fluctuating tumor was detected, and on puncture an abundance of pus escaped. A drainage-tube was introduced and an injection of iodin was employed. The chest fistula closed on October 1st; that of the abdomen, on December 20th. The abdomen was soft and pliable. The respirations were normal.

  • Baizeau: Arch. gen. de med., 1875, 163. Quoted by Gauderon, A. E.: De la peritonite

idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers l'ombilic. These de Paris, 1876, No. 148, observation xx.


302 THE UMBILICUS AND ITS DISEASES.

Purulent Peritonitis; Spontaneous Opening at the Umbilicus.*- — The subject of this observation was a young girl of ten who had a good constitution and had previously been well. For a month preceding her illness she had spent her time quietly with her parents. On May 31, 1872, she had constant pain in the abdomen, accompanied by nausea and vomiting. The eyes were sunken and the face was drawn. There were several liquid stools, and the patient had cramps in the legs. The case suggested cholera. On the following day, at 9 a. m., the vomiting, which had been frequent during the night, stopped. The patient commenced to complain of pain in the head. This became more and more violent, and was accompanied by delirium. Ice was applied to the head. The cerebral trouble for some time completely overshadowed the lesion in the abdomen. The delirium disappeared in the course of four or five days, but the fever continued. There was great thirst, and the tongue was covered with sordes. The abdomen was also painful and distended, and a certain amount of fluid could be detected in the peritoneal cavity. On the following day the pain was referred principally to the right hypochondriac region, and some complication in the liver was thought of. The child complained continually of suffocation and palpitation of the heart. The abdomen increased in size, and was in marked contrast to the extremities, which were greatly emaciated. This condition persisted for a month without any amelioration. The digestive troubles were more and more pronounced; very frequently there was vomiting of bile and a diarrhea. For some unknown reason a plaster was applied to the abdomen, and when it was drawn back in one of the early days in July, it was noted that the umbilicus was distended by the abdominal fluid. It was red and very thin in its center. On the following clay it opened spontaneously, and about 4 liters of purulent, greenish fluid escaped. The discharge continued that night and for several days in great abundance. The child felt relieved and slept; the appetite returned, and there was a marked change for the better. This, however, did not last; the fever returned, the nights were bad, and the digestion again became disordered. Baizeau was called in consultation on July 14th. He found the infant very much emaciated and feeble, and with a continuous fever. The abdomen was markedly distended, and there was an escape of grayish, thick pus, with a strong odor, and containing greenish streaks indicating its hepatic origin. This greenish material, which escaped in large quantities, yielded biliverdin. The abdomen was painful, and at times the child complained of severe pain. The pus was secreted by the peritoneum and escaped incompletely. The umbilical opening was too narrow for the introduction of a drainage-tube. The orifice was dilated with rubber, and on the third day a drain was introduced. Injections were made morning and evening with tepid water, and the fluid appeared to pass into all parts of the abdomen. The fever ceased, and a verj^ favorable change in the general condition was noted. The activity of the stomach returned, and the child, who had been fretful and depressed, became lively. The abdomen was more supple and less painful. Suppuration stopped, and the drainage-tube was taken out on August 28th. Three days later the umbilicus was completely closed. The child had not completely recovered her usual buoyancy, but the general condition was markedly improved. The abdomen was supple and looked normal. The abnormal sensibility had entirely disappeared, and the digestive functions were regular. About September loth she left Algiers for Paris, where she continued to improve.

  • Baizeau: Quoted by Gauderon, op. cit., obs. 22.


THE ESCAPE OF FLUID FROM THE UMBILICUS. 303

Purulent Peritonitis; Escape of Pus at the Umbilicus; Persistence of the Umbilical Hernia; Healing.* — The patient was a child of five years who had been healthy. On January 4th the child presented symptoms of catarrhal fever. On January 6th signs of peritonitis had developed. Under treatment the fever diminished, but the abdomen was painful and much distended. Percussion showed that the distention was not due to the presence of air in the intestine, but to an effusion of fluid in the peritoneal cavity. The child refused absolutely to take medicine. On January 22d the umbilicus was prominent, semitransparent, and red. By the following day the tumor had increased in size to that of a hen's egg, and the skin had become thinner. The presence of fluid could be distinctly made out. On January 25th the tumor ruptured and fluid escaped in a stream the size of a goose-quill. The fluid was semipurulent ; about enough to fill a "bottle and a half" came away. On the following day the discharge was moderate in amount and the abdomen was sensitive. The febrile symptoms did not disappear. About February 12th the condition of the patient commenced to improve, but the umbilical fistula still persisted. Dr. Beonhardy attended the patient until September 15th. At that time the fistula had closed, but the child still continued to wear a bandage on account of the umbilical hernia. The destruction of the cellular tissue closing the umbilicus had favored the production of a hernia.

Pneumococcal Peritonitis Present at Umbilicus. f — Case VI. — A girl, aged five years, was admitted on April 5, 1911. Six weeks before, she had had an acute illness. At first appendicitis had been diagnosed, and later pneumonia. After a week the abdominal pain had disappeared, but the child had remained without appetite. Before admission the presence of free fluid in the abdominal cavity had been recognized. A diagnosis of tuberculous peritonitis was made, and the child was kept out-of-doors. The opsonic index to tuberculosis was 1.2. On April 30th a swelling appeared at the umbilicus and became so prominent that it was decided to operate. As soon as the peritoneum was opened pus poured out, three pints being collected. A pure growth of pneumococcus was obtained. Recovery followed, and the child was discharged well on July 8th.

Probable Pneumococcal Peritonitis Opening at the Umbilicus. ± — Case VII. — -A girl, aged eight, was admitted July 9, 1903, under Dr. Taylor's care. On April 20th she had suddenly complained of abdominal pain, and an acute illness of many weeks' duration had followed. It was supposed to be typhoid fever. In the fourth week she was still ill. On July 7 Dr. Taylor saw the child and admitted her to the hospital. The abdomen was swollen and contained fluid. On the day before her admission a fistula formed at the umbilicus. Mr. Lane operated, and one and one-half pints of greenish-yellow pus escaped. The child recovered and was discharged September 3, 1903. When heard from in March, 1905, she was well.

Abdominal Abscess Simulating Ascites; Spontaneous Opening at the Umbilicus. Recovery. § — A girl, five

  • Beonhardy: Brit, and For. Med. Rev., xiv, 549. (Cited by Gauderon, op. cit.)

f Cameron, Hector Charles: The Relative Value of Immediate and Delayed Laparotomy in Pneumococcal Peritonitis. Proc. Roy. Soc. Med., February, 1912, v, Xo. 4, 123.

± Cameron, H. C: Op. cit.

§ Cazaban: Abces abdominale simulant une ascite; ouverture spontanee par le nombril; guerison. Jour, de chirurgie, 1845, iii, 252.


304 THE UMBILICUS AND ITS DISEASES.

years old, of weak constitution, was suddenly seized with pain in the abdomen. The bowels did not move, but blood and mucus escaped by the rectum. The pulse was rapid and small, the tongue red, the skin hot, and there was pain on pressure, chiefly in the hypogastric region. On her way to the hospital there were several inclinations to stool, but only tenesmus resulted. This condition kept up for eight or ten days. The symptoms of dysentery disappeared, but the abdomen was painful and the fever persisted. The child appeared to suffer less and seemed to be improving, but the abdomen remained sore. Local applications were used, but during September the child grew thinner, and the abdomen continued to distend. In October the abdomen was much larger and was oval in form.

It was decided to puncture, but this procedure was delayed five or six days. Meanwhile a phlegmonous erysipelas developed at the umbilicus. The cicatrix became prominent, and finally, in one day, more than four liters of whitish-yellow, creamy but odorless pus escaped from the umbilicus. The abdomen still remained painful after the fluid came away. Eight days later the umbilical opening had closed completely, the fever was gone, and the child was convalescing; in one month she was perfectly well.

Peritonitis with Escape of Pus from the Umbilicus.* — This case was observed in the service of Triboulet. Maria M., aged six and one-half years, entered the hospital on April 29, 1874. Without apparent cause she had become seriously ill on April 18th. At the beginning there had been pain in the abdomen and excessive vomiting, which had lasted for twenty-four hours. For several days there had been some ten diarrheal stools daily, but without a trace of blood or pus. The diarrhea had not disappeared entirely when the child entered the hospital. She had high fever, and lay immobile in her bed. Applications were made to the abdomen. On April 26th a small, elevated tumor was noted at the umbilicus, and when he saw her, on April 28th, the physician made a diagnosis of umbilical hernia. On admission to the hospital an attempt was made to reduce the supposed hernia. There were also signs of some thoracic affection. She was transferred to Triboulet's service. The facial expression was that of peritonitis — the eyes were sunken, the facial lines drawn; the respirations were 32 to the minute. Percussion of the lungs was negative, but a friction-rub could be heard at the base of the right lung and in front. The pulse was 140, the skin moderately hot. On April 30th signs of peritonitis still persisted. The tongue was red, and its epithelium was dropping off. There was an escape in a jet of about 1500 c.c. of a yellowish, odorless pus from the umbilicus. After the flow ceased, the umbilical cicatrix could be made out; it was distended and indurated, and at the top was a small orifice from which the pus had escaped. The child had some diarrhea after this, but no vomiting, nausea, or hiccups. By the same evening the facial expression had become better, and by the next morning the child wanted something to eat. There was no vomiting, and not the slightest trace of pus by bowel. A moderate amount of discharge still issued from the umbilicus. On May 3d a certain quantity of pus escaped. By the following day the diarrhea had ceased completely, and on June 1 the child was taken to a convalescent home. She was completely cured, and the umbilical fistula had closed. At no point in the abdominal wall was there any trace of induration.

  • Gauderon: Op. cit.


THE ESCAPE OF FLUID FROM THE UMBILICUS. 305

General Peritonitis Cured by Incision of the Protruding Umbilicus. — Under date of June 3, 1910, Dr. W. D. Haggard, of Nashville, Tenn., wrote me concerning the history of a patient suffering from general peritonitis. The fluid had been evacuated through an incision into the protruding umbilicus. The patient was a girl twelve years old. She had had a violent attack of appendicitis with great initial prostration. At the end of three weeks she had improved considerably, but the temperature would reach 100° F. m the afternoon, and the abdomen, which had originally been hard and distended, was now soft and fluctuating, and showed a protruding, red, and thinned-out umbilicus. This was incised under ethyl chloricl inhalation, and fully three quarts of purulent fluid were evacuated. The umbilicus had to be reopened on account of an accumulation of a small quantity of fluid. Dr. Haggard told me that the patient was well two months later, but that an interval removal of the appendix had been advised.

Peritonitis with the Escape of Pus From the Umbilicus. — Ledderhose* says that Henoch described in his text-book the case of a girl, ten years old, who, after having been trampled upon by a large dog, had acute peritonitis which terminated by a breaking through at the umbilicus. Ledderhose adds that in grown people acute peritonitis has no tendency to break through at the umbilicus.

Purulent Peritonitis Following Scarlatina in an Infant Thirteen Months Old.f — This was the case reported by Dr. West. J A small, well-nourished girl had scarlet fever when eight months old. The eruption was not marked, but after its disappearance the child did not recover her health, continued to be restless, and had fever. Sometimes she would vomit, and the eyelids at times were swollen. Fifteen days after the appearance of the eruption she had two violent attacks of convulsions. She remained sick until she was ten and a half months old, when her mother noticed puffiness of the eyelids and swelling of the legs and of the abdomen. When the child came under West's observation there were still edema of the legs and distinct fluctuation in the abdomen. The urine was scanty and showed some pathologic changes. Three weeks later her general condition was considerably improved. The urinary secretion was more abundant, and the abdominal circumference was 4 cm. less than before. She had an attack of convulsions without any apparent cause. For a week seropurulent material escaped at the umbilicus and continued to do so, the amount varying from 150 to 200 c.c. This event was followed by improvement in the patient's condition, but after eleven days the fever and dyspnea increased and there was a dulness on percussion over the right lung and absence of the respiratory murmur in front. The discharge ceased for a week, at the time that the thoracic symptoms were most intense. Afterward there was again some discharge which was small in amount. The child at this time was very feeble and much emaciated. She was given stimulants, but forty-eight hours later died without any signs of convulsions, just five and a half months after the scarlet fever and two months after coming under observation. At autopsy a purulent pleurisy

  • Ledderhose, G. : Deutsche Chirurgie, 1890, Lief. 45 b, 122.

t Gauderon (West): Op. cit., obs. 23.

X West, Charles: Lectures on the Diseases of Infancy and Childhood. Fifth Am. Ed., Phila., 1874, 107.

21


306 THE UMBILICUS AND ITS DISEASES.

was found on the right side and an effusion of about 180 c.c. of pus in the right pleural cavity. About 1250 c.c. of a similar liquid was found in the abdomen.

Umbilical Abscess Following General Peritonitis. — Gauderon* gives the abstract of a case published by Vetu in the Jour, de msd., chir., pharmacie et de med. veterinaire de la Cote d'Or, 1846. The patient was a small girl of four years who was convalescing from acute peritonitis. A tumor the size of an almond was noted in the umbilical region on May 14th. This was soft and elastic, and there was no change in color in the skin. It was depressible, and when it had disappeared, in the depression the finger could make out clearly the hernial ring, but when the pressure was released, the tumor reproduced itself. When the child cried or moved about, it became prominent. Vetu diagnosed the condition without hesitation as an umbilical hernia. On May 18th the tumor was larger, being the size of an elongated walnut. Vetu did not notice anything extraordinary in the aspect of the abdomen. Applications were made to the abdomen, and on May 22d, four days later, the physician was not a little surprised to find the child literally bathed in creamy pus. On removal of the dressing, it was found that the tumor had disappeared and that pus was escaping from the umbilicus, the total amount being estimated as 1500 to 2000 c.c. After the pus had stopped running, an opening which admitted the extremity of the finger was noted at the umbilicus. There was not a trace of hernia. In the course of ten days the ring was completely closed and the child recovered.


LITERATURE CONSULTED ON PERITONITIS WITH THE ESCAPE OF PUS AT THE

UMBILICUS. Aldis: Gaz. med. de Paris, 1848, 733. Baizeau: Arch. gen. demed., 1875, 163.

Bricheteau: Des abces dans le tissu cellulaire sous-peritoneal. Arch. gen. de med., 1839, vi, 435. Cameron, H. C. : The Relative Value of Immediate and Delayed Laparotomy in Pneumococcal

Peritonitis. Proc. Roy. Soc. London, February, 1912, v, No. 4, 123. Castel, J.: Considerations sur la pathogenie des fistules ombilicales. These de Paris, 1884, No.

56. Cazaban: Abces abdominal simulant une ascite; ouverture spontanee par le nombril; guerison.

Jour, de chir., 1845, hi, 252. Gauderon, A. E. : De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a. travers l'ombilic. These de Paris, 1876, 148. Haggard, W. D.: General Peritonitis Cured by Incision of the Protruding Umbilicus (personal

communication). Ledderhose, G.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Nicaise: Ombilic. Dictionnaire encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv,

140. Vaussy, F.: Des phlegmons sous-peritoneaux de la paroi abdominale anterieure. These de Paris,

1875, No. 445.


THE PIECEMEAL REMOVAL OF A SUPPURATING OVARIAN CYST THROUGH

THE UMBILICUS.

From the following history it is clearly evident that the patient had an ovarian cyst. The suppuration was, no doubt, in a measure due to infection following the last abdominal puncture, and it is remarkable that the patient recovered. The woman came under observation over thirty years ago at a period when one hesi

  • Gauderon: Op. cit., obs. 17.


THE ESCAPE OF FLUID FROM THE UMBILICUS. 307

tated a long time before opening the abdomen. Now, of course, the cyst would be promptly removed.

Inflammation of an Ovarian Cyst, Abscess Formation, Opening at the Umbilicus. Recovery.* — Madame F., aged forty-seven, was the mother of several children. When examined on September 10, 1878, she had signs and symptoms of an ovarian cyst of three years' duration. Between September 10, 1878, and November 20, 1879, the abdomen was punctured 11 times and 170 liters of a clear, serous fluid were removed. Shortly afterward there were signs of acute inflammation in the abdomen, distention, high fever, a small pulse, vomiting, and the characteristic facial expression. It was thought that she would die. Four days later the patient was still alive, and redness was noted at the umbilicus over an area 3 by 4 cm. In six days there were signs of fluctuation, and three days later between two and three liters of pus came away from the umbilicus. Trepan pulled out and cut off with the scissors a large amount of necrotic tissue. About eighteen months after his first visit he found the patient perfectly well and she remained so.


LOCALIZED JAUNDICE OF THE UMBILICUS IN THE PRESENCE OF FREE BILE IN

THE ABDOMINAL CAVITY.

In April, 1915, Dr. Joseph Ransohoff drew my attention to a most unusual condition, namely, localized jaundice at the umbilicus when bile exists free in the abdomen.

In the Transactions of the Southern Surgical and Gynecological Association for 1905 Dr. Ransohoff reported the case of W. B., merchant, fifty-three years old, who had had typhoid fever six years before coming under observation. In April he had what was supposed to be a mild attack of indigestion, and in August was seized with severe colicky pain in the umbilical region. The pain disappeared in five days. Ransohoff saw him in October. The patient had had a sudden chill during the night ; he had had pain in the right hypochondrium, and on the next day had complained of abdominal distention and excruciating pain in the right lower abdomen.

On admission to the hospital it was noted that the patient was a large-framed man, with every indication of intestinal obstruction from peritonitis. He had an anxious facial expression; the pulse was 130; the temperature, 100° F. Examination of the abdomen revealed extreme tympany, with the liver dulness very much pushed up and reduced in area.

On inspection of the abdomen marked jaundice at the umbilicus was noted. The navel was of a distinct, saffron-yellow color, in strong contrast with the skin over the rest of the abdomen. There was no evidence of jaundice elsewhere. Tenderness was extremely marked over McBurney's point. It seemed probable that a peritonitis was present in the appendicular region. At operation the subperitoneal fat was found to be yellow, and when the abdomen was opened, a quart or more of bile mixed with serum was found. The common duct was ruptured behind the gastrohepatic ligament, the opening being large enough to admit the

  • Trepan: Kyste del'ovaire; inflammation des parois et issue des membranes par l'ouverture

ombilicale; guerison. Gaz. med. de Picardie, Amiens, 1883-84, ii, 16S.


308 THE UMBILICUS AND ITS DISEASES.

tip of a finger. After removal of the abdominal fluid and draining of the common duct the man made a good recovery.

Dr. Ransohoff, after reviewing the case, says: "I wish here to call attention to a sign which was adverted to in the case of ruptured duct before the incision was made, and one to which I believe attention has never before been directed. It is the localized jaundice of the umbilicus. Although a single case is not usually sufficient to warrant the assumption that something new has been observed, this feature was so marked that I cannot refrain from believing that further observation will give to this localized jaundice some value as a sign of free bile in the peritoneal cavity. In the case presented this feature gained in interest as the staining of the subperitoneal fat with bile was observed in the incision through the abdominal wall. The jaundice is doubtless purely the result of imbibition. It makes itself manifest, first, in the integument of the navel, because this part is thinner than the rest of the abdominal wall. It is possible, of course, that, by reason of the anatomic relations of the round ligament of the liver to the transverse fissure, there is a retrograde flow of bile through the lymphatics toward the navel."


Chapter XX. Fecal Fistula at the Umbilicus

Historic sketch.

Fecal fistulse at the umbilicus due to wide-spread ulceration of the large and small intestine.

Fecal fistula? at the umbilicus due to gangrene.

Fecal fistulse at the umbilicus due to external injury.

Umbilical fecal fistula? due to burns.

Tuberculous peritonitis followed by a fecal fistula at the umbilicus; report of cases.

Umbilical fistula (not fecal) due to tuberculosis of the vas deferens.

Umbilical fistulse may be due to a patent omphalomesenteric duct, to inflammatory changes commencing in the intestine and extending to the umbilicus, to carcinoma of an abdominal organ, usually of the stomach, reaching to and breaking through the umbilicus, to inflammatory conditions of the umbilicus extending to and involving the intestine, and to external injuries. All except the last two groups have been dealt with elsewhere. In the present chapter I shall refer briefly to certain cases of obscure abdominal lesions followed by fecal fistula at the umbilicus, and then describe those cases in which the fecal fistula was due to external injury of the umbilicus.

Le Cat, in 1775, reported a case of fecal fistula at the umbilicus. This case has also been recorded by Schrotter. The patient was a ten-year-old girl who had fecal masses escaping from the umbilicus. For a year before she came under observation the bowels had been sluggish. She had a poor appetite, associated with abdominal distention, and soon died. At autopsy the peritoneum was found to be as thick as a finger. The intestines were attached to the anterior abdominal wall. Below the umbilicus at one point there was an intestinal perforation, the opening communicating with the umbilicus. Between intestinal adhesions there was a considerable quantity of pus and fecal masses, and live lumbricoid worms were seen in the bowel. The mesenteric glands were enlarged, indurated, and suppurating. The intestines were ulcerated.

[At that date, of course, no histologic examination was made. The enlarged suppurating glands would naturally suggest tuberculosis. — T. S. C]

Winiwarter, in 1877, recorded a case of fecal fistula at the umbilicus. A boy, eight months old, had suffered from boils on several occasions. Fourteen days before admission to the hospital two of these had been opened. On September 20, 1875, the child looked badly; there was an infiltration, 9 cm. in diameter, in the umbilical region. This area, which was hard and covered with reddish, hot skin, formed a conic tumor with the umbilicus in the center. Poultices were applied, and after three days the swelling opened. On September 25th the opening was the size of a linseed, and from it yellowish, grumous, intestinal contents escaped. After this nothing passed by the rectum, for a time all the fecal contents being evacuated through the umbilicus. The child died on October 25th. At autopsy a localized

309


310 THE UMBILICUS AND ITS DISEASES.

peritonitis was noted at the umbilicus. Beneath the umbilicus was a hole, the walls of which were composed of intestinal loops. The fecal opening was in the colon.

As a possible cause, Winiwarter considered phlegmon of the abdominal wall. This, he said, might have tended to a localized peritonitis causing adhesions of intestinal loops. He says that an abscess in the abdominal wall may have broken into the abdomen prior to opening externally; the large bowel might thus have opened into the abscess cavity. Another explanation suggested by him was that there might have been a primary enteritis, and then a peritonitis with abscess formation near the anterior abdominal wall. No mention is made of tuberculosis, and the fact that the opening was in the colon would suggest that the original cause might possibly have been appendicitis.

Trelat, in 1883, and Nicolas in the same year, also report cases of fecal fistulse. Trelat 's patient was a girl, seventeen years of age. When the child was three years old, her mother noticed a swelling with redness and an opening at the umbilicus. As the wound would open and close from time to time, the child wore a bandage. When the umbilicus first opened the discharge had a fecal odor. The fistula was evidently of intestinal origin. There was no history of any operation. Nicolas' patient was also seventeen years of age, and it looks very much as if Trelat and Nicolas have recorded the same case. In none of these cases was it possible to determine the primary cause of the umbilical fistula.


FECAL FISTULiE AT THE UMBILICUS DUE TO WIDE-SPREAD ULCERATION OF THE

LARGE AND SMALL INTESTINE.

Knecht, in 1875, published the history of a strongly built man, twenty-nine years old. In 1873 he had had catarrh of the stomach which had become chronic, and, as a consequence, he had become anemic and had lost strength. After an acute attack of typhlitis there was some improvement, but after ten days the symptoms became severe again and there was a mild degree of peritonitis. After about three months immediately beneath the umbilicus there appeared a circumscribed, painful area of infiltration the size of a two-thaler piece. In addition there were several isolated areas of hardness in the right inguinal region and also above the umbilicus. Some time later an abscess in the mid-line opened and there escaped a large quantity of pus which had a fecal odor. After eight days a new abscess developed in the umbilical region. This opened spontaneously into the original abscess cavity. After about six weeks all the abscesses had united, forming one cavity. The overlying skin sloughed off, and the abdominal fascia lay free over an area the size of the palm of the hand. In the region of the umbilicus were numerous openings. The patient died a short while afterward. At autopsy there was a marked degree of emaciation and edema of the feet, together with much distention of the abdomen. In the mid-line was an ulcerated area, 17 cm. broad and 15 cm. long. This had raised and eaten-out margins, and in the center were the remains of the umbilicus. In the floor of the ulcer were openings with gangrenous walls which had led to an irregular cavity through destruction of the recti. Pressure upon it caused the escape of foul-smelling bubbles of gas. When the abdominal cavity was opened, about 10 liters of serum escaped. The abdominal contents were much displaced. The anterior surface of the cecum, the first fourth of the transverse colon, as well as a portion of the jejunum, had grown fast to the abdominal


FECAL FISTULA AT THE UMBILICUS. 311

wall on the inner side of the ulcer, and were also adherent to the posterior abdominal wall. The intestinal loops had grown fast to one another, as well as to the abdominal wall. Just above the ileocecal valve the mucosa of the ileum contained several ulcers which showed partial healing. In one of the intestinal loops adherent to the anterior abdominal wall was an opening through which a sound could be introduced from the outside. In the upper portion of the transverse colon were ulcers which communicated by a perforation with the anterior abdominal wall. There was a similar ulcer in the floor of the cecum, which communicated with a hole, lying behind the abdominal wall, and filled with pus and necrotic tissue. This cavity reached upward to the margin of the kidney and extended along the large vessels. The iliacus muscle on the right side had disappeared. In the apex of the left lung were several scars, but no fresh tubercles.

From the above history it is impossible to determine the exact starting-point of the disease. The evidence is, however, strongly suggestive of appendicitis or tuberculosis as the exciting factor.

The following case, reported by Martin, resembles in some particulars the one described by Knecht:

Abscess of the Umbilicus; Gangrene and Intestinal Perforation; General Peritonitis. Death. — This case was originally reported by Dr. M. E. Martin.* L. L., aged seven, entered the hospital on December 27, 1871, and died February 28th of the following year. The child, according to her mother, had coughed for about a year, and for the last three months a swelling had been noted at the umbilicus. From time to time the child had complained of pain, and on her entrance to the hospital a tumor was detected which occupied the region of the umbilicus. -This tumor was soft and fluctuating and there was redness of the skin. During January the child showed a considerable change for the worse, and on palpation an accumulation was detected deep in the abdomen and to the right of the umbilicus. On percussion dulness was noted over this area. During the process of inflammation the child complained of pain in the region of the umbilicus and in the right flank. On February 13th there was considerable distention; pain was severe on abdominal pressure, and the child vomited greenish material. The temperature rose to 39° C., the pulse to 140. The vomiting and peritonitis persisted, accompanied by diarrhea and greenish stools, for three days. On January 16th a seropurulent discharge with a definite fecal odor was noted from an orifice immediately beneath the umbilicus. On the seventeenth and eighteenth there was abundant discharge, and on the nineteenth pus, similar in character to that coming from the umbilicus, escaped from the rectum. On January 21st semisolid fecal matter commenced to escape from the umbilicus, and the fistulous opening and the tissue around the fistulous opening began to slough. On January 24th the area of sloughing had increased; the tongue was covered with sordes, and the extremities were cold.

On the following day the slough came away, and on January 27th all fecal matter was being passed by the umbilicus. The child became thinner and very weak, and died on February 28th.

Autopsy. — The lungs and heart were normal. At the umbilicus the area of sloughing was the size of a five-franc piece. The abdominal organs were bound to

  • Martin, M. E.: Abces de l'ombilic; gangrene et perforations intestinales ; peritonite

generalisee; mort. Bull, de la Soc. anat. de Paris, 1872, xlvii, 148.


312 TKE UMBILICUS AND ITS DISEASES.

one another by a false membrane, and the peritoneum was intimately adherent to the abdominal wall in the right flank. There was an intestinal perforation 60 cm. from the pylorus. A portion of the ascending colon was slightly adherent to the umbilical opening, and six other perforations were noted in various portions of the intestine.

FECAL FISTULA AT THE UMBILICUS DUE TO GANGRENE.

Prior to aseptic days gangrene of the umbilicus was not infrequently observed in infants a few days old (page 73j. At the present time it is seldom seen, and in the adult is a rarity. Ledderhose, in 1890, considered this subject somewhat fully. Gangrene of the umbilicus has followed the continuous use of the ice-bag, and has been associated with infectious diseases of the umbilicus. Ledderhose referred to a case reported by Fischer. An ice-bag was applied to the abdomen of an anemic patient. Twenty-four hours later the skin showed a slight bluish color, and fortyeight hours later, after further applications of ice-bags, the tissues were deep blue and there was a sensation of burning. In the course of three weeks 150 c.cm. of gangrenous skin came off. Skin-grafts were employed over the raw area, and the patient recovered. Undoubtedly the anemia favored the development of gangrene.

Ledderhose mentions two cases of puerperal infection under Thiede's care. Ice-bags were kept on the abdomen for fifteen days in one case and for twenty days in the other. Gangrene of the abdominal wall developed in each instance. Thiede did not think that the ice-bag was responsible for the gangrene, but that the causative factor was rather to be sought in the squeezing and probable injury of the abdominal wall which was produced every time the uterus was emptied or washed out.

Ledderhose further says that gangrene of the umbilicus may develop during the course of infectious diseases of the navel or after exhausting diseases involving the stomach or intestinal tract. Sometimes only the superficial abdominal walls are involved; in other cases the gangrene extends to the deeper layers of the abdominal wall and leads to a peritonitis and perforation into the intestine or bladder. The prognosis is, in general, unfavorable, but even in severe cases recovery may ensue.


FECAL FISTULA AT THE UMBILICUS DUE TO EXTERNAL INJURY.

Fecal fistula? as a result of external injury at the umbilicus are evidently very rare. Murchison, in 1858, recorded a very interesting case that he saw with Keith, of Aberdeen. The patient was a woman with a family history replete with nervous and mental defects. She feigned illness and tried to have her arm amputated. Later, when discovered, she made believe that she had a cardiac lesion. Finally, she produced an opening between the skin and the stomach. Through this gastric fistula some interesting experiments were made. Murchison collected the cases in which the stomach opened upon the abdomen and found that the break seldom, if ever, occurred at the umbilicus.

Grawitz and Nicolas both record examples of an umbilical fistula due to a cut. and Fronmuller tells of a fistula due to injury produced by a long finger-nail.

Grawitz showed a specimen coming from a Pole, who, in 1849. was wounded in the umbilical region with a scythe. A fecal fistula developed and persisted for the remaining thirty years of his life. The patient during his late years grew thin and


FECAL FISTULA AT THE UMBILICUS. 313

very weak, and finally died of marasmus. Several attempts were made to close the opening, but without success. (This was before 1878.) There was a defect in the abdominal wall as large as the palm of the hand. The opening was in the small bowel, about 1 meter from the stomach.

Nicolas refers to a patient who had been examined by Fromantin.* The patient was a soldier who had received a cut in the umbilical region. The opening was small, and Fromantin thought little of it, although it occasioned much pain. On the tenth day there was some discharge with a fecal odor. The opening was dilated, and a quantity of fecal matter escaped. The fistula gradually diminished in size and closed.

Fronmuller reported the case of a man, forty-eight years of age, who had long finger-nails and was of rather uncleanly habits. After an attempt to remove some foreign body from the umbilicus with his finger-nail, pain and swelling in the umbilical region came on gradually. When seen fourteen days later the patient had a yellowish discharge from the umbilical depression. The umbilicus was rather tense, red, and half-moon-shaped on its right side and painful on pressure. On the floor of the umbilicus was a large, red, fleshy mass, and fluid was seen coming from a very fine opening. A sound introduced passed two inches into the adherent bowel. When the patient lay on his right side, the amount of the discharging fluid increased. The patient had a feeling of tension in the umbilical region. Three days later silver nitrate was applied, followed by a second treatment after two days. Four days after the second treatment a pinkish-red tumor developed in the left side of the umbilicus. This was accompanied by much pain. It broke two days later and a yellowish-white, foul-smelling fluid escaped. A second fistulous opening now formed into which a sound could be carried three and one-half inches. From time to time other fistulse developed until six were counted.

When the patient was seen four and one-half months later, all these fistulse had healed, and the man was in good condition. Fronmuller reported this case on account of its unusual character and as an example of a fistula due to injury from without and not from within.


UMBILICAL FECAL FISTULA DUE TO BURNS.

In the course of a conversation with Dr. Jesse W. Hirst, of the Severance Hospital, Seoul, Korea, he told me that in Korea the most frequent umbilical lesion is a fecal fistula. This is due to the common mode of treatment in cases of abdominal pain or peritonitis.

The natives take a piece of cotton-wool and some dried fungus, roll the two into a small lump, and lay it on the painful area. A match is applied and the roll is allowed to burn. The result is a sore about three-quarters of an inch in diameter, and usually only skin deep. The desired result, namely, a running sore, is obtained. This application is made in some instances three or four times. If there is pain or swelling in the umbilical region, the application is made over the umbilicus and frequently the surface of an umbilical hernia is burned.

Dr. Hirst observed about 15 cases in which such applications had been made at the umbilicus, and in three a fecal fistula developed. The cause of the fistula is

  • Fromantin: Mem. d. l'Acad. de chir., Paris, 1743, i, 602.


314 THE UMBILICUS AND ITS DISEASES.

evident. The burning is sufficient to set up a localized peritonitis, intestinal loops become adherent, and a fistula results.


LITERATURE CONSULTED ON FECAL FISTULA AT THE UMBILICUS.

(See also literature at end of this chapter.)

Fronmiiller, G.: Kothfistel im Nabel. Memorabilien, Heilbronn, 1866, xi, 273.

Gauderon: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et

par evacuation du pus a travers l'ombilic. These de Paris, 1876, No. 148. Grawitz: Berlin, klin. Wochenschr., 1878, xv, 9. Knecht: Ausgebreitete Ulcerationen im Dick- und Diinndarm, mit Perforation der vorderen

Bauchwand. Arch. d. Heilkunde, 1875, xvi, 539. LeCat: Surun engorgement par congestion dans toute l'etendue du peritoine devenu suppura toire, complique d'adherence et d'ulceration des intestins avec issue des matieres fecales par

l'ombilic. Jour, de med., 1755, ii, 356. Also reported by Schrotter: Arch. f. Kinder heilk., 1902-03, xxxv, 398. Ledderhose: Deutsche Chirurgie, 1890, Lief. 45 b. Martin, M. E.: Abces de l'ombilic. Gangrene et perforations intestinales; peritonite genera lisee, mort. Bull, de la Soc. anat. de Paris, 1872, xlvii, 148. Murchison, C: Communication with the Stomach through the Abdominal Parietes Produced by

Ulceration from External Pressure. Med. Chir. Transactions, London, 1858, xli, 11. Nicolas, P. : Sur deux varietes de fistules ombilicales. These de Paris, 1883. Trelat: Fistules ombilicales. Jour. d. connaiss. med. pratiques et de pharm., 1883, 1, 364. Winiwarter, A. : Fistula stercoral, umbilic. Jahrb. f . Kinderheilk. und physische Erziehung, N. F.,

1877, xi, 193.


TUBERCULOUS PERITONITIS FOLLOWED BY A FECAL FISTULA AT THE

UMBILICUS.

As pointed out by Feulard, the opening at the umbilicus of a tuberculous process in the peritoneum is not rare. Fischer observed three cases, in two of which there was a fistulous opening between the bowel and the umbilical depression. The subject has been carefully considered by Nicaise, Ledderhose, Tillmanns, Ziehl, Owen, and others.

When a tuberculous peritonitis exists in children, there seems to be a definite tendency for it to open at the umbilicus. Helmreich (quoted by Schrotter) claimed that of all known cases of abdominal fistula, three-fourths developed at the umbilicus. This seems to tally with the experience of other observers. Heinrich, in 1849, drew attention to several cases in which the opening was in the abdominal wall near the umbilicus.

Ziehl, in 30 cases of abdominal fistula following tuberculous peritonitis in children, found that in 18 cases the opening was at the umbilicus.

In order that we may get a clear idea of this class of cases I have assembled a group which depicts the salient features of the disease. No attempt has been made to collect all the cases recorded in the literature. We here have records of 19 cases. Sixteen of the patients were children. The youngest was one year old. Eleven were under ten years of age, and five between ten and sixteen years of age, these figures being in accordance with the claims of previous writers that fecal fistula at the umbilicus due to tuberculous peritonitis is most common in childhood; only 3 of the 19 patients were adults.

Symptoms. — The previous history in these cases, as a rule, is colorless, but in a


FECAL FISTULA AT THE UMBILICUS. 315

few instances is of value. Crooke's patient had previously complained of pain in the hip, and was of a scrofulous diathesis. Clairmont's gave a history of a previous pulmonary affection. One of Ziehl's patients had suffered from rickets, and another from tuberculosis of the lungs. Rachford's patient also gave a similar history.

The children usually first complain of abdominal distention, with or without pain. This increases, the appetite gradually diminishes, and emaciation follows. Constipation develops, and may or may not alternate with diarrhea. As the disease advances the temperature frequently rises. The pulse becomes rapid and small, the tongue is coated, and the breath fetid. Chills may accompany the fever, and, if the lungs be involved in the tuberculous process, severe coughing and night-sweats may be present, and pleurisy may be detected.

The abdominal enlargement continues to increase, and it may be possible to detect solid masses or an accumulation of abdominal fluid. Occasionally the diagnosis of tuberculous peritonitis may be rendered more definite by a rectal examination. In two of Schmitz's cases he was able, with his finger in the bowel, to detect small nodular masses in the pelvis.

After a varying length of time the umbilicus may become altered in appearance. The changes may occur in a few months, but, as in a case recorded by Nicaise, a year and a half may elapse before the slightest difference can be detected. The picture varies considerably. In Catteau's case a tumor, 3 cm. in diameter, and forming a semicircle, was noted. There was discoloration of the skin and the tumor was transparent. In Baginsky's case there was a half-moon-shaped thickening with the convexity directed downward. The skin was tense and edematous; reddening followed, and later a fistula developed, pus and fecal matter escaping. Ziehl's patient, who was nearly four years old, had a circumscribed edema at the umbilicus, and immediately around the depression were small, shot-like nodules in the skin. The umbilicus ruptured, and a large quantity of fluid escaped. The abdomen collapsed, and later a round worm was passed through the umbilical opening. In Vallin's case there was marked abdominal reddening for a distance of 5 to 6 cm. around the umbilicus. The tissue was edematous, and the umbilical folds were distended. This condition persisted for two months. The redness then disappeared, and a nodule the size of a walnut and containing gas and fluid appeared at the umbilicus. In Crooke's case there was a marked prominence at the umbilicus, followed by the escape of pus and feces. In Rintel's case the umbilical ring opened and pus escaped with great force. In Schmitz's eleven-year-old patient the umbilical walls were exceedingly thin, and gas and fluid could be seen through the skin. Bertherand's patient had a conic umbilicus and a prominence the size of an almond. The overlying skin was mottled. The tumor contained fluid with gas, and could be reduced.

From the foregoing it will be noted that the inflammatory changes at the umbilicus are of slow development, and that the abdominal fluid reaches the surface by two methods — either by gradual disintegration of the abdominal wall or by distention of the umbilical opening, which allows the fluid to escape into the hernial protrusion. In addition to the opening at the umbilicus a secondary one may develop in the vicinity.

The tuberculous process gradually advances, and, if the lungs have not already been involved, they are apt now to be implicated. The child grows weaker and weaker, and usually dies a few weeks after the umbilicus has opened.


316 THE UMBILICUS AND ITS DISEASES.

Autopsy Findings.- — At the umbilicus the fistula found varies from one to several millimeters in diameter. The surrounding skin may or may not show marked irritation, depending upon the situation of the opening into the bowel and on the irritating character of the discharge. In some cases the skin, fascia, muscle, and peritoneum are so intimately blended as a result of the inflammation that it is almost impossible to separate them.

When the abdomen is opened, a loop of small or large bowel is often found firmly fixed to the opening at the umbilicus, and it is from this that the feces escape. Sometimes two or more loops are adherent to the umbilicus. In those cases in which the umbilicus was distended and gas and feces could be distinctly made out, there was usually a cavity of considerable size lying immediately beneath the umbilicus. At one or more points the lumen of the small bowel or of the large bowel, or the lumina of both, communicated with the cavity. The walls of the cavity were composed of intestinal loops alone, or of intestinal loops, one or more of the abdominal organs, the omentum, and the abdominal wall. When the intestinal perforation occurs, the surrounding tissue naturally tends to wall it off at once if adhesions have not already formed. The cavity may be small, or occupy fully half the abdomen. Its inner surface resembles granulation tissue, and it contains pus and fecal matter. Definite tuberculous masses have in some cases been noted in the wall of the sac. The intestinal loops throughout the abdomen are usually adherent, and between them are tubercles, accumulations of serous or flocculent material, or pus, according to the stage of the disease and the presence or absence of a mixed infection.

In those cases in which sudden death has occurred, as in those of Bertherand and Vallin, the walls of the cavity have given way, allowing fecal matter to escape into the general abdominal cavity. With the patient in an already weakened condition, the shock has been sufficient to occasion sudden death.

An associated pulmonary tuberculosis is often noted at autopsy.

Differential Diagnosis. — In making the diagnosis it is necessary to exclude the possibility of an umbilical concretion, carcinoma, other forms of peritonitis opening at the umbilicus, and other umbilical fistulse. Umbilical concretions occur during the active working period of life; tuberculous fistulse preponderate in childhood. Carcinoma is also a disease of middle life or of old age, and is thus readily excluded. Any form of peritonitis followed by an escape of pus, and possibly feces, at the umbilicus may at first be confused with tuberculous peritonitis. The onset of a purulent peritonitis is, however, usually very acute; the disease runs a rapid course, and the child either speedily dies or rapidly recovers. Umbilical fistulse due to round worms escaping through the bowel and passing out through the umbilicus may for a time occasion some confusion, but with the escape of the worms the fistula may close, while in cases of tuberculous peritonitis the condition goes from bad to worse.

Treatment. — With the early recognition of tuberculous peritonitis and its appropriate treatment — laparotomy — cases of umbilical fistula will naturally diminish in number. As emphasized by Tillmanns, poultices are to be strenuously avoided. As has been said, the umbilicus may be reddened for months without the formation of a fistula, but once feces commence to escape by this channel, the fistula remains open until death.


FECAL FISTULA AT THE UMBILICUS. 317

CASES OF TUBERCULOUS PERITONITIS WITH A FECAL FISTULA DEVELOPING AT THE UMBILICUS.

Umbilical Fecal Fistula Due to Tuberculous Peritonitis.* — A boy, one year and three months old, was admitted to the hospital on December 23, 1879, for an otitis purulenta. He was fairly well nourished and showed no signs of rickets. The abdomen was hard and distended. At the umbilicus was a half-moon-shaped thickening, with the convexity directed downward; the overlying skin was tense and edematous. The condition remained the same until February 9, 1880. At this time examination of the thorax was negative. Around the umbilicus, especially in the lower portion, there were edema and reddening. There was definite fluctuation. The abdomen itself was hard and distended, but no palpable tumor could be detected. On February 12th an opening, the size of a bean, was detected at the umbilicus, and from this a considerable quantity of fecal material and purulent fluid escaped. When the child was raised up, these fecal masses escaped readily. He died on February 13th.

At autopsy the body was markedly emaciated and anemic. The lower lobe of the right lung was reddish gray. The costal pleurae and the diaphragm and pericardium were covered with grayish miliary tubercles. The diaphragm, liver, and spleen were completely adherent to the abdominal wall. The purulent cavity beneath the umbilicus was walled off by these and the omentum, and the cavity extended into the pelvis. The pelvis was filled with feces and purulent fluid, and the intestinal convolutions of the lower abdomen were covered with a greenish, necrotic deposit, and at several points were perforated. Through one perforation the little finger could be passed into the small bowel. At this point the vermiform appendix had ulcerated. On the left side of the transverse colon were numerous ulcers, some of which had extended only through the mucosa. At other points they had perforated the entire thickness of the bowel, opening into a cavity situated at the vertebral column. The mesenteric glands were markedly swollen and caseous. In the spleen were numerous nodules.

Intestinal and Peritoneal Tuberculosis with Perforation and the Formation of a Fecal Reservoir Opening at the Umbilicus. f — A soldier came under observation on September 21, 1851, on account of obstinate diarrhea. On February 16, 1852, he had severe abdominal pain and dysuria. On May 12th of the same year for the third time he presented the picture of marked disturbances of nutrition. His pulse was rapid and small, and there was marked emaciation. Diarrhea was present, and he had a dry cough and night-sweats. The abdomen was very painful and distended. From the pubes to a point above the umbilicus was a doughy, immovable tumor of nodular character. All indications pointed to a chronic mesenteric inflammation. On June 10, 1852, there developed beneath the umbilicus a conic prominence the size of a large almond. The skin over it was mottled. The tumor was reducible and filled with fluid and gas. A few days later the prominence was incised, and there escaped blood, pus, foul-smelling gas, and a little later fecal matter. Fecal

  • Baginsky: Zur Demonstration eines Praparates. Verhandl. d. Berl. med. Gesellschaft,

Jahrg. 1879-80, xi, 90.

t Bertherand, A. : Observation d'entero-peritonite tuberculeuse avec perforations intestinales, formation d'un reservoir stercoral sous la paroi abdominale; fistule ombilicale. Gaz. med. de Strasbourg, Novembre, 1852, douzieme annee, 572.


318 THE UMBILICUS AND ITS DISEASES.

matter also passed through the rectum. During the night of June 18th the patient raised himself suddenly and died with a loud cry.

At autopsy it was found that there was a deep pus-cavity behind the umbilicus. This was filled with old pus and tuberculous masses. The anterior wall of the cavity appeared to be formed of the posterior surface of the transversalis muscle and remains of the peritoneum. The posterior wall was bounded by two thick layers of large omentum, which laterally was adherent to the peritoneum, thus fastening the intestinal loops together. The inner irregular cavity communicated behind and above with the transverse colon through two holes, 15 and 18 mm. in diameter. At the end of the ileum were three openings with sharp margins, probably resulting from freshly broken-down tubercles. From these had escaped the fresh fecal masses which were found in the abdomen, and thus the sudden death is explained. There was a direct connection between the umbilical opening and the pus-sac.

In this case there was also a pulmonary tuberculosis.

Tuberculous Peritonitis with Dilatation of the Umbilical Ring.* — A man, forty-one years of age, had a peritoneal tuberculosis. At the umbilicus was a transparent tumor, 3 cm. in diameter, forming three-quarters of a circle. There was no discoloration of the skin. The tumor was easily reducible, and the finger could be carried into the abdomen. [This was evidently a small umbilical hernia containing ascitic fluid. It is recorded here to show the early umbilical changes before a fecal fistula has developed. — T. S. C]

Fecal Fistula Probably Due to Tuberculous Peritonitis, f — A boy, fifteen years old, in 1897 had inflammation of the lungs and also of the abdomen. In June of the same year he complained of pain in the abdomen and noticed a swelling. Owing to increased pain and fever the patient went to bed in September. In October pus was found escaping from the umbilical region. After this the pain eased up, but a fistula persisted, and there was a varying degree of pain. In April, 1898, the pain became severe in the right side. In June, 1898, the boy appeared to be well developed and showed no definite changes in the chest, but the abdomen in the umbilical region was still distended. At the umbilicus the fistula still secreted a little, and occasionally a small amount of fecal matter escaped.

Operation. — Under ether below the fistula a resistant area, about the size of a five-mark piece, could be felt. Pressure on this caused a discharge of pus. The fistulous tract was dissected out, and during the manipulations a second loop of bowel was opened up, but was closed immediately. The opening in the bowel was about the size of a five-pfennig piece, and the walls of the bowel at this point were infiltrated. In addition, there were numerous loops of small bowel adherent to the anterior abdominal wall in the region of the umbilicus. The portion of the bowel forming the fistula was resected. Extraperitoneally and to the left of the umbilicus was a caseous focus, 4 cm. long and 2 cm. broad. This was drained. At operation the ends of the bowel were held in place by a Murphy button, which came away on the eleventh day.

[This case seems to be one of tuberculous peritonitis. — Ti S. C]

  • Catteau, J. F. : De l'ombilic et de ses modifications dans les cas de distension de l'abdomen.

These de Paris, 1876, obs. 10.

fClairmont, Paul: Casuistischer Beitrag zur Radicaloperation der Kothfistel und des Anus praeternaturalis. Klinik, Prof. v. Eiselsberg, Konigsberg. Langenbeck's Arch. f. klin. Chir., 1901, lxiii, 691.


FECAL FISTULA AT THE UMBILICUS. 319

Tuberculous Peritonitis Followed by Perforation at the Umbilicus.* — An eleven-year-old boy with a definite scrofulous diathesis had suffered for eighteen months from vomiting and from pain in the hip. At the umbilicus there was also pain. The child lay with his thighs drawn up. Some time later marked diarrhea was noted and severe pain in the umbilical region. This, in the course of six weeks, became markedly prominent as a result of abscess formation. About three weeks later there was a spontaneous opening at the umbilicus, with the escape of purulent fecal masses. A month later a similar tumor developed, two and a half inches below the umbilicus. This broke at three points. From the upper opening fecal matter escaped, while the lower discharged serous material. The bowels were regular, and the appetite was good. In the course of six weeks the abdomen became flattened and the pulse small; the appetite was poor. There was marked pain at the umbilicus. Three months later the child died.

At autopsy the omentum was found adherent to the abdominal wall. The underlying intestines had grown fast to one another. Tubercles were found in the left iliac region, under the descending colon, and also beneath the peritoneum of the anterior stomach-wall. In the lower part of the ileum, about six inches from the cecum, were the remains of a large tubercle which had broken down. Here it was found that the intestine had become adherent to the umbilicus and communicated with the opening from the bowel. In the peritoneum itself were several minute tubercles. The spleen was enlarged, and the mesenteric lymph-glands were hard and gritty.

Tuberculous Fistula at the Umbilicus, f — This case came under Habershon's observation. The patient was a small girl, six years old, who had had chronic peritonitis for a year. Six months before her death a tumor appeared at the umbilicus. This opened, and a fistula resulted from which pus mixed with fecal matter escaped. At autopsy pulmonary and peritoneal tuberculosis was found. The intestines were adherent; several loops had perforated, and a fecal fistula had formed, with an exit at the umbilicus.

Probable Tuberculous Fistula at the Umbilicus.! — The patient was a small Italian child. There was a fecal discharge from the umbilicus, through several openings. The child died of tuberculous peritonitis.

Artificial Anus Established Spontaneously Through the Umbilicus.§ — A boy, nine years old, had been under treatment for six months on account of a peritoneal and pulmonary tuberculosis. In February, 1891, the umbilical region was found to be sensitive, red, and more prominent than the already distended abdomen. On February 13th the boy's father came and said that the abdomen had flattened out and that the stools were coming from the umbilicus. Light pressure was made on the abdomen, and gas and fecal matter escaped through an opening, and the boy felt as well as usual. Six hours later his temperature was 99° F., and fecal matter and gas continued to escape from the

  • Crooke, E. G.: On a Case of Tubercular Peritonitis Followed by Perforation of the Abdominal Parietes. The Lancet, 1849, ii, 668.

f Nicaise: Ombilic. Dictionnaire encyclopedique des sc. med. ; Paris, 1881, 2.ser., xv, 140.

| Park, Roswell: Clinical Lecture on Congenital Fistula? and Sinuses at the Umbilicus. Med. Fortnightly, 1896, ix, 9.

§ Rachford: Arch, of Pediatrics, 1891, viii, 680.


320 THE UMBILICUS AND ITS DISEASES.

umbilicus. From the rectum no stools passed. By means of a bandage the feces could be entirely controlled. After the perforation at the umbilicus the boy felt better and developed an appetite, and his night-sweats disappeared. On March 10th he complained of sudden pain in the abdomen, collapsed, and died the next day.

Autopsy. — Only the abdomen could be examined. The intestines had been transformed into a large, hard tumor, as a result of tuberculous masses. In the transverse colon was a round perforation the size of a ten-cent piece, with thick margins. On the outer side of the intestine, around the opening, was a rough, red circle about an inch and a half in diameter, where the intestine had been adherent to the abdominal wall around the umbilicus. The umbilical opening passed into a cavity which was filled with fecal matter. From this, one opening was found entering the ileum and another the ascending loop of the transverse colon. Scattered throughout the peritoneum were tubercles. Some showed definite inflammation, others had gone on to suppuration.

The bowel had evidently torn partly loose from the abdominal wall, allowing the fecal matter to escape into the general cavity. This explains the faintness with the pain and collapse that followed.

A Case of Tuberculosis of the Intestine with Perforation of the Duodenum and Cecum into the Peritoneal Cavity. Fecal Fistula at the Umbilicus.* — A threeand-one-half -year-old girl complained of pain in the abdomen and of loss of appetite. Over the surface of the distended abdomen bluish, dilated veins were noted. There was free fluid in the abdomen. In the inguinal region on both sides the glands were enlarged. After two months pain and severe fever developed, and two days later the umbilical ring opened and there was an escape, with great force, of a purulent fluid having a foul odor and mixed with yellow fecal matter. Fecal matter continued to escape from this opening and also from the rectum until the child's death. Emaciation increased; the urinary secretion stopped almost completely. The child died a month after the umbilical opening appeared.

At autopsy the abdomen was markedly distended, especially in the vicinity of the umbilicus, where there was an opening the size of a pin-head. On pressure, clear, yellow, thin fecal material escaped drop by drop.

A fine sound could be passed directly downward to the vertebral column. On palpation very hard nodular masses could be felt around the umbilicus. When the abdomen was opened, the anterior wall above the umbilicus was found adherent to the omentum. On the opposite side the wall was united with the transverse colon by thick, firm adhesions. Here had formed the cavity that communicated with the umbilicus through the canal mentioned, and through an opening into the duodenum the size of a Groschen (five-cent piece) . Just below the opening of the bile-duct there was another perforation into the colon. The cavity produced was filled with fecal masses, and the small intestine was involved in the exudate. In the cecum was an ulcer which extended almost to the peritoneal surface, and directly at the ileocecal valve was another perforation. The vermiform appendix had also been destroyed. The upper part of the cecum and the lower part of the ileum were firmly glued to the wall of the cavity. There were numerous ulcers throughout the intestines. Both lungs were normal.

  • Rintel: Ein Fall von Darmtuberculose mit Perforation des Duodenum und Caecum in's

Cavum peritonei. Berlin, klin. Wochenschr., 1867, iv, 332.


FECAL FISTULA AT THE UMBILICUS. 321

Tuberculous Fecal Fistula at the Umbilicus.* — A girl, fourteen years old, at first complained of severe abdominal pain in the hypogastric, hypochondriac, and umbilical regions. Several months later she returned to the hospital with a round opening at the umbilicus. Its margins were slightly excoriated, and fecal matter was escaping. Her constitution had been weakened, and general tuberculosis had existed for six months.

At autopsy pelvic peritonitis was found. The intestinal loops were adherent to each other, and between them were purulent foci. A loop of small bowel had opened at the umbilicus.

Cases of Fecal Fistula at the Umbilicus Due to Tuberculous Peritonitis. f — Case 1. — A girl, eleven years of age, had been ill for three or four months. She had had abdominal distention with diarrhea and was emaciated. On admission the abdomen was much distended. At the umbilicus there was sensitiveness on pressure. The umbilicus was covered over with very thin skin, and immediately beneath were gas and fluid. The patient's temperature was subnormal.

An incision was made opening up a fecal abscess, at the bottom of which was an intestinal fistula. The child died on the tenth day.

At autopsy the organs of the lower abdomen were found grown together and forming a tangled mass. Between them were numerous caseous foci. Opening into the posterior wall of the umbilical abscess were several small holes which communicated with the intestine. There was a total adhesive pericarditis.

Case 2 . — A boy, six years old, for two and one-half months had had fever, pain in the abdomen, and vomiting. For one month he had had obstinate constipation. The abdomen had increased in size, and emaciation had become marked. For one week there had been a reddening at the umbilicus. The mesogastrium and hypogastrium were filled with nodular tumors. On rectal examination minute hard nodules could be felt. The child had intermittent fever.

Operation. — Beneath the umbilicus was a large, foul-smelling accumulation of pus. The abdomen was studded with tubercles. The omentum was markedly adherent. When the bandages were changed, an abundant quantity of fecal matter came out of the cavity. The fever continued, and the patient died three weeks later.

Autopsy. — Folds of the peritoneum were adherent to one another at many points. Between them were isolated and confluent tuberculous nodules. Similar nodules were also found in the omentum. In the ascending colon was a perforation admitting the tip of the finger. About 20 cm. above this point was a small group of miliary tubercles in the mucosa. In the lower portion of the large bowel were several flat ulcers with thickened margins. The remaining portion of the intestinal tract was normal. In the pelvis, between intestinal loops, was an isolated abscess, and the liver and spleen were covered with adhesions. There was a pleurisy on the left side. The pleurae of both lungs were studded with tubercles. The bronchial glands were swollen.

Case 3 . — A girl, nine years old, from September, 1892, had had acute

  • Rombeau: Anus contre nature, suite de peritonite. Bull, de la Soc. anat. de Paris, 1851,

xxvi, 366.

f Schmitz, A.: Ueber Bauchfelltuberculose der Kinder. Jahrb. f. Kinderheilk., 1897, xliv, 316.

22


322 THE UMBILICUS AND ITS DISEASES.

abdominal pain, fever, and obstipation, and there had been a gradual increase in the size of the abdomen. In May, 1893, a swelling at the umbilicus associated with redness was noted. The mass was of the size and form of a fist. It broke, and feces escaped. In July the patient was markedly anemic and the abdomen was enlarged and painful. At the lower margin of the umbilicus was a fecal fistula, which was discharging the contents of the small bowel. The inguinal glands were swollen. By the rectum several flat nodules could be felt.

Operation. — The omentum was adherent to the small intestine and to the parietal peritoneum. Numerous hard nodules, some as large as a pea, were found. The umbilical fistula led to a fecal opening the size of a walnut. This communicated with a loop of small bowel by an opening, 3 cm. in diameter. The patient died five days later.

At autopsy general adhesions of the intestine with the parietal peritoneum, the omentum, and liver were found. There were also numerous peritoneal tubercles. In the capsules of the liver and spleen were tubercles. The uterus was increased in size; its cavity was dilated and filled with cheesy pus, and the mucosa was covered with a cheesy membrane. In the ileum was a perforated ulcer, 1.5 cm. in diameter. The fistula in the ileum had been closed tightly at operation. The mesenteric glands had undergone caseation. The mucosa of the intestine was swollen, but free from tuberculous ulcers.

Tuberculosis of the Umbilical Region.* — A boy, sixteen years of age, was said to have had a fall in the latter half of 1895. Before admission the abdomen had become much distended. Immediately before the operation it was noted that, for his age, he was larger than usual and very thin. The abdomen was markedly and uniformly distended; the umbilicus was pushed forward somewhat like a bladder. The skin was of the thinness of paper. Surrounding the umbilicus the tissue was red and painful on pressure, and over the entire abdomen there were dulness and a sensation of fluctuation.

On April 17, 1896, an incision was made extending from the ensiform cartilage through the umbilicus to three fingerbreadths above the symphysis. There escaped between 10 and 12 liters of very cloudy, odorless fluid, which contained numerous white, grayish flocculi and a membranous network. The greater amount of fluid was found in the anterior portion of the sac. On pressure and when the patient was turned on his side, however, an abundance of fluid escaped from the posterior portion. Schrotter thought he was dealing with tuberculosis, but no tubercle bacilli were found and no tissue that histologically gave that picture. [In this case no fistula existed. — T. S. C]

Umbilical Fecal Fistula Due to Tuberculous Peritonitis. — Schrotter f (p. 415) reports an observation by Jung.

The patient was a scrofulous, emaciated child, three years and nine months old. The abdomen was distended, especially around the umbilicus, where, after the application of poultices, an abscess formed. This broke, and feces, pus, and blood escaped. The child died, and at autopsy the intestines were found adherent to one another and to the peritoneum. The intestine at one point had perforated.

  • Schrotter: Zur Kenntnis der Tuberculose der Nabelgegend. Arch. f. Kinderheilk., 190203, xxxv, 398.

f Schrotter: Op. fit., p. 415. Rhein. Generalberioht. Ref. Canstatt's Jahresbericht, 1842, ii.


FECAL FISTUL.E AT THE UMBILICUS. 323

Peritoneal Tuberculosis with Fecal Fistula at the Umbilicus.* — An eight-year-old girl had swelling of the abdomen. Her tongue was coated, the breath was fetid, and she had a severe cough. Her skin was of a dark brownish color. She had diarrhea, and there was edema in the lower part of the abdomen and in the legs. Indefinite fluctuation could be made out in the lower abdomen. Later on the lower abdomen presented a conic form, the umbilicus forming the point of the cone. It opened, and from it escaped brownish fecal material of a very foul odor. No feces passed through the rectum from that time. Three weeks later the patient died.

At autopsy the intestines were found adherent to one another and to the abdominal wall, except in the lower right side, where, between the anterior wall and the intestine, fecal masses were found. The whole of the peritoneum, both that covering the abdominal wall and that of the viscera, was riddled with tubercles^ some of which had become caseous. The mesenteric glands were enlarged and tuberculous.

In this case there was tuberculous disease of the mesenteric glands with a healthy intestinal mucosa.

Umbilical Inflammation Following Tubercular Peritonitis, f — A soldier, twenty-two years of age, who is said to have been previously healthy and strong, a month before admission noticed a swelling of the abdomen. His appetite diminished, he had obstipation alternating with diarrhea, but never vomited and had no cough. On December 8, 1867, there was abdominal distention. Palpation, however, was not painful. In the hypogastric region was a definite fluctuation. On December 20th he noticed a marked reddening around the umbilicus. The skin in the umbilical region, for a distance of 5 or 6 cm., was edematous, and the umbilical folds were distended. There was no pain, and the overlying skin was not sensitive. The reddening and edema remained unchanged for two months. At the end of January the exudate in the abdomen had disappeared, but the distention had increased and the patient was cachectic. He had fever, a dry, hot skin, and marked night-sweats. The umbilicus remained the same. Commencing February 16th a pleurisy was noticed, and the weakened condition of the patient increased. There was diarrhea. The skin at the umbilicus was not so red, but for fourteen days had taken on a yellowish color, and at the umbilicus there was a small, irreducible tumor the size of a walnut, which contained gas and fluid. On February 27, 1868, at 4 o'clock in the morning, the patient felt something tear. The umbilicus broke, and there was an abundant discharge of cloudy fluid with a feculent appearance. He died an hour later.

At autopsy marked emaciation was noted. The abdomen was sunken. The umbilical scar on the left side was irregular and torn, and there escaped on light pressure a yellow, diarrhea-like fluid. The anterior abdominal wall was difficult to loosen on account of extensive adhesions to the intestine and omentum. The muscle, aponeurosis, and skin were thickened, and had grown fast to one another, so that their separation was possible only by careful dissection with the knife. The liver, stomach, and transverse colon were firmly united to the abdominal wall.

  • Scott, John: Perforation of the Intestine with External Opening. Edinburgh Med. and

Surg. Jour., 1835, xliii, 97.

| Tallin, E.: De l'inflammation periombilicale dans la tuberculisation du peritoine. Arch, gen. de rued., 1S69, xiii, 558.


324 THE UMBILICUS AND ITS DISEASES.

Several loops of small bowel, which were tied to one another by a pseudomembrane, had been invaded by softened tubercles. These were adherent to the abdominal wall at the point mentioned. Between the umbilicus posteriorly and the ulcerated intestinal wall was an irregular cavity, through which fecal masses had passed outward into the abdominal cavity. A transverse section through the abdominal cavity at this point allowed one to see the intimate relation between the parietal peritoneum, the aponeurosis of the trans versalis, and the recti muscles. In this case the omentum and mesentery were matted together with tubercles in all stages. The mesenteric glands were markedly enlarged and some had softened. The intestinal mucosa as a whole was normal, and. as far as could be seen, not ulcerated. One could readily see that the perforation of the intestine had been from without inward. The mucosa at this point was markedly pigmented and infiltrated with blood. It was through this cavity that the intestinal contents during life had passed out at the umbilicus.

Tuberculosis of the Umbilical Region.* — Case 1. — St. W., aged six, was small and gave evidence of having outgrown rachitis. When admitted to the hospital on April 30th the child showed marked emaciation. The abdomen was greatly distended and balloon-shaped. At the level of the umbilicus the girth was 60 cm. Above the symphysis there was dulness for a handbreadth. There was no free fluid and no fever. The appetite was good. On May 16th the patient complained of pain in the lower abdominal region, and redness was noted at the umbilicus. Three days later the reddening became marked and there was some fever. On May 23d the pulse became weak and the lower part of the abdomen was painful. On the twenty-seventh, in the median line at the umbilicus, there was noted a perforation from which fecal matter and yellow fluid escaped. The abdominal measurement had diminished. On June 3d the abdominal distention had again increased somewhat and there was only a slight discharge. On the seventeenth the patient felt hot, and an accurate examination could not be made on account of severe pain. The discharge from the umbilicus contained remnants of digested food and had an acid reaction. The patient suffered from diarrhea. He died on June 22d.

At autopsy, twenty-four hours later, there was a bluish discoloration of the abdominal wall and marked emaciation. At the umbilicus was a bluish-red point, and in the center of this a fistulous opening the size of a goose-quill. When pressure was exerted on the lower abdominal wall, yellow fecal masses escaped. A sound could be passed inward for 2 cm. The discoloration of the abdominal wall indicated a cavity which extended downward from the umbilicus and occupied the greater part of the lower abdomen. It was lined with reddish grsiy, partly granular walls, which contained numerous nodules. Through softened places in the sac-wall a sound could be passed into the intestinal lumen. In the posterior wall of the cavity was a membrane which covered the indefinite intestinal loops. The cavity contained fluid, solid fecal masses, caseous products, and round worms. The intestinal follicles were markedly swollen and here and there ulcerated. The mesenteric and retroperitoneal glands were enlarged, and at certain points ulcerated to the extent of perforation.

  • Ziehl: Cited by Schrotter: Zur Kenntnis der Tuberculose der Nabelgegend. Arch. f.

Kinderheilk., 1902-03, xxxv, 398.) Ueber die Bildung von Darmfisteln in der vorderen Bauchwand infolge von Peritonitis tuberculosa. Heidelberger Dissertationschrift, 1881.


FECAL FISTULA AT THE UMBILICUS. 325

Case 2 . ■ — K. A., three years and nine months old. In January there was vomiting accompanied by swelling of the abdomen. The abdomen was markedly distended, the circumference at the umbilicus being 68 cm. There was tuberculosis of the lungs, slight edema of the lower extremities, and fluid in the lower abdomen. On March 31st the abdominal girth was 71 cm. and the inner abdominal wall appeared to be infiltrated. On April 6th the child had measles, accompanied by a mild cough without expectoration. Nine days later the skin beneath the umbilicus showed circumscribed edema. On May 8th, after the use of santonin, round worms were expelled through the rectum. On May 9th it was noted that the lower abdomen was the seat of what appeared to be a rather large tumor. It began a fingerbreadth below the free margin of the ribs on the left, and extended within two fingerbreadths of the symphysis. It was resistant and had a nodular surface. The child had attacks of fever and chills. The stools were normal. On September 13th around the umbilicus were noted small tumors, which felt like shot. In the hypogastrium was a definite tumor which impinged on the liver and which, on the left, was connected with the umbilical swelling. On October 19th the abdomen was painful, the umbilicus ruptured, and there was an escape of an abundance of purulent fluid with a fecal odor. On the following day the flow of fluid still continued, and the fistulous opening was the size of a linseed. The abdomen collapsed and was very sensitive; there was diarrhea, and the patient's appetite was very poorOn the twenty-sixth there was still a free discharge, and a round worm passed through the fistulous opening, the margins of which were reddened and inflamed. On the twenty-ninth there was vomiting of bitter masses. The skin was cool. The child died on October 30th.

At autopsy, thirty-two hours later, the abdominal walls were of a bluish-green color. At the umbilicus was a fistulous opening into which a sound could be introduced downward and to the right; on pressure there escaped yellow masses with a fecal odor and mixed with gas.

In the lower lobes of the lungs nodules were detected. The intestines were more or less firmly attached to the peritoneum of the anterior abdominal wall. In the umbilical region was a portion of intestine running transversely and intimately attached to the abdominal wall, so that its liberation was impossible. These loops communicated with the umbilical fistula. The stomach, liver, spleen, and large and small intestine had grown together and the individual loops w r ere firmly adherent to one another. Between them was a purulent exudate. In the intestinal serosa were numerous nodules, but in the mucosa itself no tubercles. Scattered throughout the small intestine were numerous ulcers.

UMBILICAL FISTULA DUE TO TUBERCULOSIS OF THE VAS DEFERENS.* While discussing the subject of umbilical diseases w^th Dr. Ramon Guiteras, of New York, he told me of a case of tuberculosis of the vas deferens which had opened at the umbilicus. I have not found the record of a similar case in the literature. Dr. Guiteras kindly sent me his notes on the case. Although no fecal fistula existed, it can be best considered in this chapter.

Umbilical Fistula Due to Tuberculosis of the Yas Deferens. f — J. G., an Italian laborer aged thirty, was first seen by Dr.

  • Although this fistula was not fecal in character it can be best considered here.

t Guiteras, Ramon: Personal communication.


326 THE UMBILICUS AXD ITS DISEASES.

Guiteras in the Columbus Hospital. He was cachectic in appearance, although fairly well nourished. His breathing was more rapid than usual, owing to an old pleurisy on the left side. He entered the hospital on account of suppuration from the umbilicus. On examination a probe entered a sinus an inch long in the lower part of the umbilicus. There was a small, blind pouch of the same length on the right side of the scrotum, although there was no evidence of communication between the two. The case was a very obscure one. Dr. Guiteras expected to find either an abscess of the urachus or necrosis of the under surface of the pelvic bone.

After the patient was anesthetized, the probe, bent in a certain way, was passed downward and outward nearly to the anterior superior spine of the ilium. An incision was made through the abdominal wall over the point of the probe, which corresponded to the site of the appendix, and Dr. Guiteras expected to find a sinus leading to an old appendiceal abscess; but such was not the case. He introduced a probe through the incision and found that it extended down to the inguinal canal. He then continued the incision down to the canal, opened it, and found that the vas deferens was tuberculous. A portion of the diseased cord was excised, the upper part of the wound was closed, and the inguinal canal was packed and drained. Dr. Guiteras, in referring to the case, thought that he might have to do a more extensive operation on the vas deferens, but ten days afterward the patient had an attack of apoplexy and died in three days.

LITERATURE CONSULTED ON TUBERCULOUS PERITONITIS FOLLOWED BY FECAL

FISTULA AT THE UMBILICUS. Baginsky, A.: Zur Demonstration eines Praparates. Verhandl. der Berlin, med. Gesellschaft,

Jahrg. 1879-80, xi, 90. Bertherand, A.: Observation d'entero-peritonite tuberculeuse avec perforations intestinales,

formation d'un reservoir stercoral sous la paroi abdominale; fistule ombilicale. Gaz. med.

de Strasbourg, Xovembre, 1852, douzieme annee, 572. Catteau, J. F.: De l'ombilic et de ses modifications dans les cas de distension de l'abdomen.

These de Paris, 1876, Xo. 210. Clairmont, Paul: Casuistischer Beitrag zur Radicaloperation der Kothfistel und des Anus praeternaturalis. Klinik, Prof. v. Eiselsberg, Konigsberg. Langenbeck's Arch. f. klin. Chir.,

1901, lxiii, 691. Crooke, E. G. : On a Case of Tubercular Peritonitis Followed by Perforation of the Abdominal

Parietes. The Lancet, 1849, ii, 668. Feulard: Fistule ombilicale et cancer de l'estomae. Arch. gen. de med., 1887, 7e ser., xx, 158. Fischer, H. : Die Eiterungen im subumbilicalen Raume. Yolkmann's Samml. klin. Vortrage,

n. F., Xo. 89 (Chir. Xr. 24), Leipzig, 1890-94, 519. Heinrich: Leber beschrankte sogenannte aussere oder tuberculose Peritonitis bei Kindern, oder

liber Entziindung der Subkutanenschicht der Bauchwand und fiber die Bildung von Absces sen und Verhartungen daselbst. Jour. f. Kinderkrankh., 1849, xii, 6. Nicaise: Ombilic. Diet, eneyclopedique des sc. med., Paris, 1881, 2. ser., xv, 140. Ledderhose, L.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Owen, E.: Surgical Diseases of Children, third ed., London, 1897, 269. Park, Roswell: Clinical Lecture on Congenital Fistula? and Sinuses at the Umbilicus. Med.

Fortnightly. 1896, ix, 9. Rachford, B. K.: Artificial anus established spontaneously through the umbilicus. Arch, of

Pediatrics, viii, 680. Richelot, L. G: Abces tuherculeuxsousombilical. L'Unionmed., 1883, xxxv, 61. Rintel: Ein Fall von Darmtuberculose mit Perforation des Duodenum und Caecum in's Cavum

peritonei. Berlin, klin. Wochenschr., 1867, iv, 332. Rombeau: Anus contre nature, suite de peritonite. Bull, de la Soc. anat. de Paris, 1851, xxvi,

366.


FECAL FISTULA AT THE UMBILICUS. 327

Scott, John: Perforation of the Intestine with External Opening. Edinburgh Med. and Surg.

Jour., 1835, xliii, 97. Schmitz, A. : Ueber Bauchfelltuberculose der Kinder. Jahrb. f . Kinderheilk., 1897, xliv, 316. Schrotter, E.: Zur Kenntnis der Tuberculose der Nabelgegend. Arch. f. Kinderheilk., 1902-03,

xxxv, 398. Tillmanns, H.: Ueber angeborenen Prolaps von Magenschleimhaut durchden Nabelring (Ectopia

ventriculi) und tiber sonstige Geschwlilste und Fisteln des Nabels. Deutsche Zeitschr. f.

Chir., 1882-83, xviii, 161. Ziehl: Cited by Schrotter. Vallin, E.: De rinflammation periombilicale dans la tuberculisation du peritoine. Arch. gen.

de med., 1869, xiii, 558.


Chapter XXI. The Escape of Round Worms from the Umbilicus

Historic sketch.

Symptoms.

Cause of the fistula.

Treatment.

Tapeworm escaping from the umbilicus.

Detailed report of cases in which round worms escaped from the umbilicus.

The passage of worms from the umbilicus is uncommon, but, as pointed out by Leuckart, it is mentioned in the Hippocratic writings, and in the literature from time to time illustrative cases have been described. One of the early ones was that of Marteau, in 1756. Then followed the articles of Hamilton '(1786), Ossiander (1795), Poussin (1817), Borggreve (1841), Hecking (1842), v. Siebold (1843), Nicolich (1846), Bottini (1855), Richter (1855), Bedel (1856), Diez (1858), Davaine (1860), Weiss (1868), Kern (1874), Leuckart (1876), Nicaise (1881), Ledderhose (1890), and others. Since 1890 very little has been written on the subject. This is but natural, as with the perfecting of surgical methods abdominal lesions have, as a rule, been treated in the early stages, thus to a large extent limiting the incidence of fecal fistulae, which were usually necessary for the escape of worms. Nevertheless, it must be mentioned that in a few cases the escape of worms from the umbilicus has not been preceded by or followed by that of fecal matter. The best articles that we possess on the subject are those of Davaine, Weiss, and Nicaise. Weiss, in his inaugural dissertation, published in Giessen in 1868, reports several very interesting cases and then gives a short historic sketch.

Weiss cites cases observed by various authors. In Capallaria's case, worms escaped from the umbilicus. In a case observed by Petrus Forestus the patient was a woman, forty years of age, who had a tumor at the umbilicus. The tumor broke and feces and several worms escaped. The later history of this patient is not given.

Frincavello's patient, a boy five years old, passed worms from the umbilicus. Cladus reported the case of a patient who passed plum-stones and worms from the umbilicus.

Creulin's patient was a girl who had an umbilical tumor, which ruptured and three worms escaped from it. Healing followed.

Boire's patient was a young girl from whose umbilicus seven worms escaped.

Weiss next reports the observations of Hamilton and Dregogirone, made on small children. In these cases worms escaped from the umbilicus. Weiss says that similar observations had been made by Pouspin* and by Cappola. He then refers to a report by Beilman,f under whose observation was a child that vomited worms. They also escaped by the rectum and from an abscess at the umbilicus. Weiss further mentions that similar cases had come under the observation of Paul of iEgina, Alix Trailer, Avicenna, Feli-Plater, and Bianchi.

  • Pouspin: Jour, de Corvisart, 1817, xi. f Beilman: Bull. d. sc. med., 1831, xxv.

328


THE ESCAPE OF ROUND WORMS FROM THE UMBILICUS. 329

Finally he reports the observation of Ambroise Pare. The patient was a woman who had an ulcer at the umbilicus, from which a number of worms escaped. The fistula remained open for a long time, and a fecal discharge persisted. Finally it closed and healing took place.

SYMPTOMS.

The majority of these patients have symptoms of a gastro-intestinal disturbance, and after a period varying from a few days to a couple of weeks develop a soreness at the umbilicus. The center of the umbilicus gradually becomes softened, and the surrounding portions are thickened and edematous. In Sanchez' case the swelling became as large as a child's head.

In the course of a few days, usually as result of the use of poultices, the abscess breaks and there is an escape of pus. Sometimes this is accompanied by fecal matter or round worms or both; occasionally fecal matter is not detected at all, the wound closing up after the pus and worms have escaped. The worms may be alive or dead. Occasionally only one worm escapes, but, as a rule, several come away at once. Closure of the wound may occur temporarily, only to be followed by more pain and the expulsion of more worms.

In two cases, those of Beilman and Heer, cited by Weiss, the patients not only passed round worms by the umbilicus and the bowel, but also vomited them.

The majority of the patients recover, but the outcome depends in a large measure on the cause of the fistula.

CAUSE OF THE FISTULA.

Davaine, in his excellent work published in 1860, gives a table of 47 cases in which worms passed through the abdominal wall. According to these figures, the point of exit was: the umbilicus in 19 cases; the groin in 21 cases; other regions in 7 cases — thus demonstrating that it is at the points, where hernia? are most prone to occur, that worms escape.

He also draws attention to the fact that in children the worms usually escape from the umbilicus, whereas in adults the inguinal region is the most common site of exit. His table gives the following:

From the umbilicus in patients less than fifteen years of age 15 cases

From the umbilicus in patients more than fifteen years of age 4 cases

From the inguinal region in patients less than fifteen years of age 2 cases

From the inguinal region in patients more than fifteen years of age ... 19 cases

The reason for this difference is obvious: in the child the umbilicus represents the weakest point in the abdominal wall, but as the child develops into adult life the umbilicus usually becomes firmly knit and the inguinal region is the area most prone to give way.

Where tuberculosis of the intestine exists, it is readily seen that an ulcerated area may become adherent to the umbilicus and that, with masses of round worms lying in the intestine, these might readily injure the friable walls, causing an abscess and the escape of fecal matter from the umbilicus. Again, where typhoid fever has recently been present, as in Diez's case, the ulceration may have extended deep into the intestinal wall, thus rendering the outer or peritoneal surface of the intestine liable to become adherent to the surrounding structures. If it becomes adherent to the umbilicus, abscess formation might readily occur. We have, however,


330 THE UMBILICUS AND ITS DISEASES.

only one example of such an occurrence. In the majority of the cases the patient first had gastro-enteric symptoms, which were followed by localized tenderness at the umbilicus.

In the older literature a spirited controversy arose as to whether the lumbricoid worm could penetrate the normal intestinal wall, some claiming that it could, others that it was not capable of doing so. Davaine, from his observations, concluded that lumbricoids do not perforate the healthy intestine, but he would not deny that a soft, ulcerated intestine might yield and perforate as a result of pressure exerted by the head of the Ascaris lumbricoides.

If a large fecal concretion is capable of causing ulceration and perforation of the intestine, it does not seem difficult to understand how masses of round worms might cause ulceration of the intestine with subsequent perforation.

In the cases reported by Hamilton, Poussin, and MacSwiney, the previous histories were strongly suggestive of the existence of a patent omphalomesenteric duct. In such cases it was only natural that the worms should escape along the preexisting fistulous tract to the umbilicus. In some cases the patent omphalomesenteric duct was so small that no fecal matter escaped until a worm was seen projecting through the umbilicus or was noted crawling on the abdomen.

TREATMENT.

This will, of course, depend on the cause of the fistula. As will be seen from a study of the appended histories, worms were expelled from time to time. Accordingly, it will be advisable, after the patient has gained in strength, to give an anthelmintic. "When the bowel shows no further trace of worms, and when the umbilical induration has disappeared, nothing but a fistulous tract remaining, the abdomen should be opened and the hole in the bowel closed. If a patent omphalomesenteric duct has been the cause of the fistula, it can readily be removed, the same technic being employed as for an appendix operation. If the previous history suggests an appendix abscess with escape of feces, abscess formation, and the escape of its contents through the umbilicus, the appendix region should also be explored, provided the dangers of a general peritoneal contamination are not too great.

In some of those cases, in which the worms seemed to escape from an intestinal loop which had become directly adherent to the umbilicus, the wound closed spontaneously after all the worms had been expelled. Where a fistula still persists, it can be readily closed by operation. In case the perforation has been followed by an abdominal abscess and this has later opened at the umbilicus, the bowel opening at the bottom of an abscess may be lined with granulation tissue. In such a case closure of the hole in the bowel is not only a difficult procedure, but, on account of the necessary drainage, is apt to be followed by failure or by a general peritonitis.

In those cases in which the fecal fistula is of tuberculous origin, one should hesitate long before attempting to close it, as on account of the friable character of the tissues the end-result may be worse than that present at the time of operation.

TAPEWORMS ESCAPING FROM THE UMBILICUS. From the foregoing we have seen that round worms may occasionally escape from the umbilicus. If a fecal fistula exists in this situation and the intestine contains a tapeworm, there is no reason why it should not escape in a similar manner.


THE ESCAPE OF ROUND WORMS FROM THE UMBILICUS. 331

Siebold, in 1843, reported such a case. In April, 1841, Siebold saw at the clinic in Erlangen a man, aged twenty-two, who had had scrofula in childhood and who had had numerous abscesses. At the umbilicus was an elevation. One day, after the patient had been given a certain decoction, a physician was called because there was something alive at the umbilicus. Six inches of a taenia solium were protruding from the umbilical opening. Traction was exerted, and the head came away. Several meters of the lower portion were drawn out; in other words, the entire worm was extracted with ease. No fecal matter or gas escaped. The man did not improve, but died of pulmonary tuberculosis.

Richter, in 1855, reported a case in which a tapeworm escaped from the anterior abdominal wall. A man, thirty years of age, had had an abdominal inflammation of unknown origin. Poultices were applied for months, and an abscess developed in the abdominal wall to the right of the mid-line. A fistulous tract passed upward toward the liver. The fistula discharged pus. Feces were never observed. From time to time living portions of tapeworms, however, escaped.

Tillmanns, in his article on Congenital Prolapsus of the Stomach Mucosa through the Umbilicus, says that v. Siebold had spoken of two cases in which tapeworms had escaped through the abdominal wall. One case was reported by Monleng, and the condition was associated with a definite fecal fistula. The second was reported by Sporing. [We have the record of only one case, namely, that of Siebold, in which a tapeworm escaped from the umbilicus itself.]

DETAILED REPORT OF CASES IN WHICH ROUNDWORMS ESCAPED FROM THE

UMBILICUS.*

Escape of Round Worms From the Umbilicus.f — Bedel mentions two cases related to him by his uncle, Dr. Bedel. The patients were two brothers, one eleven, the other thirteen. Each passed round worms from the umbilicus within one month.

Escape of Round Worms From the Umbilicus. t — The patient was a boy, four years old. The umbilicus had been transformed into a "pus-bladder," and around it was a reddening. When the child was put to bed for examination, he turned suddenly and the abscess broke. A worm was found projecting from the umbilicus. The next day the family showed the doctor three more worms. With the use of bandages and applications of carbolic acid the wound healed. Berner thought there must have been a diverticulum in this case.

Escape of a Worm Through the Umbilicus. — ■ Weiss § reports a case observed by Blanchet.|| An adult male had severe pain in the umbilical region. The umbilicus commenced to increase in size, and eight days later fluctuation was detected. At the most prominent part of the tumor a painful dark point developed. The abscess was opened, and much fluid and one worm escaped. Fourteen days later the wound had healed completely.

  • I wish to express my thanks to Dr. Charles W. Stiles, of Washington, for his kindness in

supplying me with the more recent references on this subject.

t Bedel: Bull, de therapeutique, 1856, li, 550.

J Berner, H. : Entleerung von Spulwiirmern aus dem Nabel. Aerztliches Intelligenzbl., Miinchen, 1876, xxiii, 238.

§ Blanchet (Cited by E. Weiss) : Ueber diverticular Nabelhernien und die aus ihnen hervorgehenden Nabelfisteln. Inaug. Diss., Giessen, 1868.

|| Blanchet: Acad, med., Paris, 1827.


332 THE UMBILICUS AND ITS DISEASES.

Escape of Round Worms Through the Umbilicus. — ■ In 1833 Borggreve* saw a five-year-old boy who, for fourteen days, had had pain in the umbilical region associated with general symptoms suggesting worms. Examination later showed an opening at the umbilicus, and projecting from this was the snout of a round worm. The worm was carefully grasped with forceps and drawn out. It was eight inches in length. An appropriate vermifuge was given, and 21 large worms passed from the umbilicus and five from the rectum. The umbilical opening later closed spontaneously.

Escape of Round Worms Through the Umbilicus, f- — A ten-year-old boy, who had always been healthy, developed severe gastro-enteritis. On the fourth day the umbilical region was raised and surrounded by a red zone. Warm applications were made. The umbilicus opened, and three round worms escaped. Two more came away from the umbilicus the same evening. On the fifth day the general symptoms disappeared and feces escaped from the opening. A compression bandage and frequent cauterization brought about healing in one month.

Escape of Round Worms From the Umbilicus. — ■ CasaliJ reports a case in which round worms escaped from the umbilicus.

Escape of Worms From the Umbilicus. § — A woman, sixty years of age, had had symptoms of enteritis. An abscess developed at the umbilicus and 36 worms escaped. Weiss, when speaking of this case, compares the observation to those of Borggreve, Glos, Bottini, Diez, and Finger.

Round Worms at the Umbilicus. || — A nine-year-old girl, in April, 1855, had a severe attack of typhoid fever, and during convalescence a small tumor developed at the umbilicus. Its formation was accompanied by much pain, and the skin was red. Poultices were applied, and pus having the odor of feces escaped. There was no doubt that the abscess communicated with the bowel. Daily applications of caustics caused the opening to close in fourteen days. Nine months later the child had sudden pain and the umbilicus opened in a few hours. A live round worm appeared. This was pulled out, its removal occasioning much pain. In the course of the next fourteen days nine more worms came away. The opening then closed without treatment.

In 1857 the umbilicus, which in the mean time had been closed, again opened, and in three days nine live round worms escaped. After the giving of appropriate medicine six more worms were passed, this time by the rectum. The fistula closed and gave no further trouble.

Escape of Worms From the Umbilicus. — Weiss** gives a description of a case reported by Girone. ft A fourteen-year-old boy had suffered for some time with tabes mesenterica and was confined to bed. His abdomen was swollen and he had fever. For one year he complained of pain in the side. The

  • Borggreve: Abgang von Spulwiirmern durch den Nabel. Medicinische Zeitung. 1841,

x, 117.

t Bottini, G. D.: Schmidt's Jahrbuch, 1855, lxxxv, 308.

% Casali, T.: Un caso di elmintiasi con fuorinscita di ascaridi lombricoidi dah" ombellico. II Raccoglitore medico, 1879, serie iv, xii, 281.

§ Denaire (Cited by E. Weiss) : Op. cit., obs. 4.

J| Diez: Spulwiirmer im Nabel. Med. Correspondenz-Bl. des Wurtemberg. aerztlichen Vereins, Stuttgart, 1858, xxviii, 95.

    • Girone: Cited by E. Weiss, op. cit., 1868. ft Girone: Gaz. med. de Paris, 1838, p. 231.


THE ESCAPE OF ROUND WORMS FROM THE UMBILICUS. 333

urine was cloudy and the stools liquid. The pains gradually increased, and finally an abscess appeared at the umbilicus, which opened spontaneously, and four round worms escaped. Fecal matter also came from the fistulous tract. The opening closed completely.

A Case of Worms Escaping Through an Opening at the Navel. — According to Simmons, Hamilton* made the following report in a letter : A male child, a year and a half old, was thought by the mother for several weeks to have had worms. The umbilicus protruded about an inch and appeared inflamed. The mother said that the person who had cared for the child for a few days after its birth drew the bandage from the umbilicus too suddenly, and with the bandage the remains of the cord, before it had been completely separated. She added that, though the part healed, it had always remained tender. To prevent its protruding too much, a bandage had been applied pretty tightly over it. Soon after that the child seemed to have symptoms of worms, and on untying the bandage the mother observed a worm about seven inches long crawling over the abdomen. In the middle of the umbilicus were two small holes, out of one of which the worm had just issued. Before long two more came away through the same opening. One of the worms had protruded itself two inches when she pulled it away with the fingers. The next day two more worms came away. All of these were six to eight inches long and alive when they escaped. At the end of ten days six more came away in the course of twenty-four hours. In the succeeding five weeks no more had escaped and the opening had closed. The umbilicus was the size of a walnut, and evidently diseased, but the child continued well.

Escape of Round Worms Through a Fecal Fistula at the Umbilicus. f — Weiss mentions a case recorded by Heer.i A young girl vomited worms and also passed them by the bowel. An abscess developed at the umbilicus. This was opened, and a round worm escaped. Healing soon took place. Escape of Round Worms From the Umbilicus. § — A four-year-old girl for eight days had been complaining of an inflammatory swelling at the umbilicus. After the application of poultices the swelling opened and there escaped a foul-smelling pus, together with three dead round worms. In a few days the umbilical opening closed and the child recovered. Two months later she was again ill with symptoms of worms. The umbilicus again became prominent and inflamed, opened, and discharged several more worms. The wound closed, and thereafter there were no further signs of worms.

Escape of Worms From the Umbilicus. || — The patient was a seven-year-old boy who complained of pain in the lower abdomen. An umbilical abscess developed, and from it there escaped 41 round worms. The opening closed. Four months later it opened again and 11 worms escaped. The colic disappeared; nevertheless, no closure took place and a fecal fistula developed.

Extraction of Ascaris Lumbricoides From the Umbilicus.** — A boy, four years of age, had been in good health until five months

  • Hamilton, Robert: London Med. Jour., 1786, vii, 372.

t Heer: Cited by E. Weiss, op. cit. % Heer: Revue med., 1837.

§ Hecking: Entleerung von Spulwurmern durch den Xabel. Generalber. des Konigl. Rheinischen med. Coll. fur 1839, Coblenz, 1842, 80. || Lini: Cited by E. Weiss, op. cit., p. 13.

    • Macphail, Donald: Glasgow Med. Jour., 1884, xxii, 382.


334 THE UMBILICUS AND ITS DISEASES.

before admission. Shortly before coming under observation he had been treated for thread-worms. Five months before admission he had become restless, listless, cross, and had had diarrhea. The abdomen was swollen and tender and emaciation was noted. The condition gradually grew worse. The abdomen became prominent and tense, and the superficial veins were much enlarged. He was very weak, emaciated, and apathetic. The diarrhea was severe, and there was sweating every night. At this time a thin, watery pus commenced to escape from the umbilicus. This was very offensive, but had no fecal odor. During the next three weeks the condition was still worse; the discharge from the umbilicus became more abundant and excoriating. Later there was difficulty in micturition, with retraction of the testicles. Between the umbilicus and the pubes was a diffuse, slightly elevated swelling, which was very tender, but there was no redness. A few days later the child was almost moribund, and there was edema of the feet and legs. Protruding from the umbilicus were two inches of a wriggling round worm which was easily drawn out. It was nine inches long. There was rapid improvement in the child, but he was still very thin. When the case was reported before the medical society, the possibility of an open omphalomesenteric duct was considered.

The Passage of Chyle and Worms From the Umbilicus.*' — The patient was a girl seven years old. She had a well-marked ascites. There was a historj^ of ascites on previous occasions. When two years of age she had ascites, which disappeared in three months. A few months before Marteau saw her ascites again developed. On admission there was a hard and inflamed tumor at the umbilicus. After the application of poultices the swelling became circumscribed and opened. Escaping with the pus were three lumbricoid worms. Following these, chylous material escaped. The opening persisted for six months and discharged pus, chyle, and pieces of undigested food, and from time to time round worms escaped. After six months the tract cicatrized, and thereafter there was nothing but a thin serous discharge. The child was well nourished. The exact cause of the trouble was impossible to determine.

Ascaris Lumbricoides Extracted From an Umbilical Fistula, t — A boy, seven years old, came to the hospital with an ascaris lumbricoides projecting two and one-half inches from the umbilicus. "I at once proceeded to deliver it in an artistic way, and I had to exercise some caution in the operation lest it should break, as there was considerable tension on the creature, and it was evident that its body was tightly compressed in a track or sinus, through which it was slowly making its way out." The father of the boy stated that since birth there had been a fistula at the umbilicus, and that it had constantly discharged. There were never, however, any signs of blood, bile, or feces. The discharge was clear yellow matter with no feculent odor. MacSwiney says his friend, Dr. Kelly, thought the fistula was due to an unclosed vitelline duct.

Escape of Round Worms From the Umbilicus. J — A woi i j an, twenty-five years of age, who had had two normal labors, complained of severe pain in the hypogastric region shortly after the second labor. The menses ceased, and the physician thought a new pregnancy was under way. Finally the

  • Marteau: Sur une ouverture a 1'ombilic qui donnoit passage au chyle et a des vers contenus dans les intestins greles. Jour, demed., Paris, 1756, v, 100.

+ MacSwiney, S. M.: Proc. Path. Soc. of Dublin, 1873-75, vi, 251.

% Nicolich: Abgang von Spulwurmern aus dem Nabel. Schmidt's Jahrbuch, 1846, 1, 53 (translated from Gaz. di Milano, Xo. 11, 1845).


THE ESCAPE OF ROUND WORMS FROM THE UMBILICUS. 335

abdominal wall from the umbilicus to the symphysis became bright red. Applications were made, and the umbilicus opened. There was an escape of a moderate amount of foul-smelling pus, but no fecal masses. Several days later three round worms escaped, and a few days after this six more worms passed from the umbilicus. The pain became pronounced in the inguinal regions, and pressure here caused a moderate amount of pus to escape from the umbilicus.

Fecal Fistula at the Umbilicus.* — The patient was a delicate boy who had previously passed lumbricoid worms. Toward the end of 1795 he complained of abdominal pain. There was distention and an area of inflammation at the umbilicus which seemed ready to rupture. The tumor, however, gradually receded. In March, 1796, the patient developed a severe cough. Before Easter the abdomen again became distended, and the umbilicus was very prominent, red, and painful. The skin was glistening and distended, and there was a marked degree of emaciation. On March 31st there was a rupture, with the escape of pale yellow, fetid fecal masses. The boy died on April 4, 1796. At autopsy the abdomen was found distended. The opening at the umbilicus was sealed up with dry pus. The peritoneum contained many small and large nodules, and from several openings beneath the stomach region four live round worms came away. The larger opening admitted the index-finger and was on the right, beneath the liver. Attached to the umbilicus was an intestinal loop, and from this pus had escaped. The mesenteric glands were enlarged and hardened.

Escape of Several Round Worms From the Umbilicus . f — The patient was a boy, three years of age, and of healthy parentage. The nurse made traction on the cord on the fifth day, as it had not come away. "Inflammation" followed, and a small opening developed. Sometimes this would close for three weeks or a month, but never for a longer period. On examination the mother was surprised to see a worm half an inch long crawling along the abdomen. The child, who had been sick, rapidly recovered. Several weeks later two worms similar in character were extracted from the umbilical fistula. In the intervals between the times of abdominal pain the child enjoyed good health, except for an occasional discomfort due to worms. At the umbilicus was a slight projection the size of a chestnut with an opening in the center. Escaping from this were contents resembling feces. On several occasions the physician was called to see the child when in great pain, and removed lumbricoid worms from the fistula. Some of these worms reached four and one-half inches in length.

[The history is strongly indicative of a patent omphalomesenteric duct.]

Round Worms Escaping From the Abdomen. — Richter| speaks of cases reported by Baumann, and one by Winterich, in which round worms were passed at the umbilicus, and says that such an occurrence is not rare.

Escape of Round Worms From a Fecal Fistula at the Umbilicus. § — This case came under the observation of Sanchez. || The patient was a woman who developed a tumor at the umbilicus. After two years

  • Ossiander: Neue Denkwlirdigkeiten ftir Aerzte und Geburtshelfer, i, 2. Abtheilung.

Cited by Schrotter.

t Poussin : Observation sur 1' expulsion de l'abdomen par une ouverture a l'ombilic de plusieurs vers ascarides-lombricoides. Jour, de rued., 1817, xl, 81.

t Richter: Bandwurmglieder aus einer Bauchfistel entleert. Schmidt's Jahrbuch, 1855, lxxxv, 308.

§ Sanchez: Cited by E. Weiss, op. cit., obs. 3.

|| Sanchez: Gaz. Med. Italiana, 1862, v. 284.


336 THE UMBILICUS AND ITS DISEASES.

this formed an abscess and a fecal fistula developed, from which three worms escaped. When St. Sardi saw the patient, the tumor at the umbilicus was the size of a child's head. Pus flowed from it without any diminution in size of the tumor. With a probe an intestinal stone could be felt. This was removed at operation. The nucleus of the stone consisted of hardened feces and was covered over with earthy phosphates. The patient died fourteen days after operation.

A Round Worm at the Umbilicus. — Weiss* says that in the Journal de Progres, 1834, the case of a sixteen-year-old negro was recorded. The patient had a phlegmonous tumor at the umbilicus, and gave a history of having passed 92 worms at stool. The tumor was opened, and in it was found a halfdigested worm.

  • Weiss, E.: Op. cit.

LITERATURE CONSULTED ON THE ESCAPE OF WORMS FROM THE UMBILICUS.

Bedel: Bull, de therapeutique, 1856, li, 550.

Berner, H.: Entleerung von Spulwurmern aus dem Nabel. Aerztliches Intelligenzbl., Munchen,

1876, xxiii, 238. Borggreve: Abgang von Spulwtirmern durch den Nabel. Med. Zeitung, 1841, x, 117. Bottini, G. D. : Schmidt's Jahrbuch, 1855, lxxxv, 308. Casali, T.: Un caso di elmintiasi con fuorinscita di ascaridi lombricoidi dall' ombellico. HRac coglitore medico, 1879, ser. iv, xii, 281. Davaine, C. : Traite des entozoaires, Paris, 1860, 115. Diez: Spulwiirmer im Nabel. Med. Correspondenzbl. des Wurtemberg. aerztlichen Vereins,

Stuttgart, 1858, xxviii, 95. Hamilton: Case of Worms Discharged through an Opening in the Navel. London Med. Jour.,

1786, vii, 372. Hecking: Entleerung von Spulwurmern durch den Nabel. Generalbericht des Konigl. Rhei nischen med. Coll. f. 1839, Coblenz, 1842, 80. Kern, Theo.: Ueber die Divertikel des Darmkanals. Inaug. Diss., Tubingen, 1874. Ledderhose, G.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Leuckart, R.: Die menschlichen Parasiten und die von ihnen hervorgehenden Krankheiten.

Leipzig, 1876, ii, 241. Macphail, Donald: Ascaris Lumbricoides Extracted from the Umbilicus. Glasgow Med. Jour.,

1884, xxii, 382. MacSwiney, S. M.: Proc. Path. Soc. of Dublin, 1873-75, vi, 251. Marteau: Sur une ouverture a l'ombilic, qui donnoit passage au chyle et a des vers contenus

dans les intestins greles. Jour, de med., Paris, 1756, v, 100. Nicaise: Ombilic. Dictionnaire encyclopedique des sc. med., Paris, 1881, 2 ser., xv, 140. Nicolich : Abgang von Spulwurmern aus dem Nabel. Schmidt's Jahrbuch, 1846, 1, 53. (Translated from Gaz. di Milano, No. 11, 1845.) Ossiander, F. B.: Original not located. Neue Denkwiirdigkeiten fur Aerzte und Geburtshelfer,

i, 2. Abtheilung. Reported by Schrotter. — Schrotter, E.: Zur Kenntnis der Tuberculose

der Nabelgegend. Arch. f. Kinderheilkunde, 1902-1903, xxxv, S. 413. Poussin: Observation sur l'expulsion de l'abdomen par une ouverture a l'ombilic de plusieurs

vers ascarides-lombrico'ides. Jour, de med., 1817, xl, 81. Richter, H. E.: Bandwurmglieder aus einer Bauchfistel entleert. Schmidt's Jahrbuch, 1855,

lxxxv, 308. Siebold : Abgang eines Bandwurms aus dem Nabel, nebst einigen Bemerkungen uber das Wandern

der Eingeweidewurmer. Med. Zeitung, Berlin, 1843, xii, 75. Stiles: Hygienic Laboratory, U. S. Government, Washington. (Personal communication.) Tillmanns, H. : Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia

Ventriculi) und liber sonstige Geschwulste und Fisteln des Nabels. Deutsche Zeitschr. f.

Chir., 1882-83, xviii, 161. Weiss, E. : Ueber diverticular Nabelhernien und die aus ihnen hervorgehenden Nabelfistelen .

Inaug. Diss., Giessen, 1868.


Chapter XXII. The Escape of Various Foreign Substances from the Umbilicus

Gall-stones escaping at the umbilicus; report of cases.

Hydatids at the umbilicus.

The escape of liquor amnii or of fetal remains through the umbilicus.

Escape of foreign bodies through the umbilicus.

GALL-STONES ESCAPING AT THE UMBILICUS.

The escape of gall-stones from the umbilicus is very rare. One of the earlier reported cases was that of Buettner, published in 1744. I have been unable to obtain the original article, but it was referred to by Duplay in 1833. In Buettner's case 38 biliary calculi escaped from the umbilicus. Berard, in the French Dictionary of Medicine, published in 1840, says that there were several examples of a biliary fistula opening at the umbilicus, and sometimes associated with the escape of calculi. The most exhaustive and best treatise on the subject is that of Leguelinel de Lignerolles, published in Paris in 1869. Other names closely identified with the development of the subject are Nicaise, Murchison, Courvoisier, and Ledderhose. According to Nicaise, Murchison collected 86 cases in which the gall-bladder opened in the right hypochondrium on a level with the fundus of this viscus; in other cases, in regions more or less distant in the abdominal wall. In a certain number of the cases they opened at the umbilicus. Courvoisier, in his Pathology and Surgery of the Bile-ducts, published in 1890, gives the following table of 169 cases in which the gall-bladder opened through the abdominal wall :

In the right hypochondrium '. 49 times

At the edge of ribs on the right side 36

In the right mesogastrium 17

In the right iliac region 10

In the epigastrium 6

In the neighborhood of the umbilicus 26

Through the umbilicus 12

Below the umbilicus . 11

In the left inguinal region 1 time

Multiple openings 1 "

From this table it will be noted that in 26 of the 169 cases the opening occurred in the neighborhood of the umbilicus; in 12 instances at the umbilicus, in 11 cases below the umbilicus. Thus in 49 cases it occurred at or near the umbilicus.

I have not attempted to cover the literature on the subject, but have gathered together only sufficient material to give a fairly comprehensive composite picture of this class of cases. Of course, this complication will naturally occur during the decades when gall-stones are most frequently found. The youngest patient was twenty-three years of age. The great majority of the patients were over forty years of age.

23 337


338 THE UMBILICUS AND ITS DISEASES.

Of 12 cases of biliary fistula at the umbilicus of which we have definite records. 1 was in a man and 11 were in women. This large percentage in women is rather striking, and may be due in some measure to the weakened condition of the umbilicus as a result of the stretching caused by pregnancy. I am not in a position to prove this point, however, as data on pregnancy in these cases are not available.

These patients, as a rule, give the usual history of gall-stones. Sometimes the initial pain is in the gall-bladder region, but occasionally it is first noted in the left hypochondrium, and after a time shifts to the right side. In addition to the hepatic colic noted there are sometimes nausea, vomiting, and diarrhea. After a varying length of time changes may be noted at the umbilicus. In Bramann's case fully two years elapsed before the umbilicus was involved.

Umbilical Changes. — The umbilical region usually becomes indurated, and may remain so for several weeks or months. In other cases it rapidly shows signs of reddening, becomes painful, and may soon open spontaneously.

In Clement's case the reddening around the umbilicus was treated as an eczema for some time; finally a biliary fistula developed.

In Richet's case, reported by Leguelinel de Lignerolles, a small tumor presented at the umbilicus, and in three months had grown to the size of an adult's fist and opened spontaneously.

When the abscess breaks, there is an immediate discharge of pus, sometimes, but not always, fetid. In Leclerc's case it contained sandy particles. With the escape of pus small biliary calculi may be discharged. As a rule, however, several days elapse before any are noted. If they are small, their exit may occasion little inconvenience, but when they are of any appreciable size, their expulsion is accompanied by marked abdominal contractions and much pain. In some of the cases it was only on probing the fistulous tract that calculi were detected at the bottom. When the stone is large, it may become firmly wedged in the fistula, and can then be removed only by dilating the channel and grasping the stone with forceps. With the escape of a large stone bile may for the first time appear at the umbilicus. In other instances the discharge has never showed even occult bile.

The subsequent history of the fistula depends on the contents of the gall-bladder, If the gall-bladder contains small stones, these escape from time to time, the fistula frequently being temporarily sealed over in the meantime. Where only one large stone has been present, after its expulsion the sinus usually closes permanently. In short, when once the umbilical fistula has formed, it rarely closes permanently until the gall-bladder has been completely emptied of its stones. Stones may escape at intervals for years.

The majority of the patients regain their normal health. In the case of Madame X, reported by Leguelinel de Lignerolles, the patient became emaciated and died. At autopsy a contracted gall-bladder was found which contained a calculus, and a calculus was present in the hepatic duct. In Robert's case, cited by Nicaise, dilatation of the fistulous tract was followed by peritonitis and death. In Leroy des Barres' case the patient, six years later, died of cancer of the stomach and liver.

Murchison's description of the mode in which biliary fistulse penetrate the abdominal wall in various places is most instructive and is well worth a thorough study.

When the fistula develops at the umbilicus, it is either due to perforation of the gall-bladder with abscess formation and later perforation of the umbilicus by the


THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 339

abscess; or the enlarged and prolapsed gall-bladder may become adherent to the umbilicus and open.

In some cases the gall-bladder is excessively long. In a case I saw with DrFranklin B. Smith in Frederick, Md., the greatly enlarged viscus hung over the brim of the pelvis and almost touched the uterus. The gall-bladder was distended with stones. Such a gall-bladder could very readily have become adherent to the umbilicus. A reference to Bramann's case will show that in that case the gallbladder projected downward almost to the symphysis. It had become adherent and opened at the umbilicus.

Cases of Biliary Fistula at the Umbilicus with the Escape of Gall-Stones.

In America very little attention has been paid to biliary fistulse at the umbilicus, and the literature in the English language, apart from the excellent monograph of Murchison, is so meager that I append a number of cases sufficient to give an adequate view of the subject. Furthermore, although these cases have been rare in the past, they will be even rarer in the future because of the prompt operative measures now invariably adopted, when acute or chronic inflammations of the gallbladder exist.

Case 1 . — A Biliary Tumor Forming Two Small Abscesses at the Umbilicus, Followed by Fistula and Escape of Three Biliary Calculi. Healing.* — This case was reported from the clinic given on January 11th at La Pitie, by Professor Richet. The patient had complained of abdominal pain for seven or eight months previously. For three months she had noted a small tumor at the umbilicus, but had never suffered from hepatic colic and gave no history of jaundice. The pain had been accompanied by alternating diarrhea and constipation. On her admission to Richet's service in December the patient presented a tumor situated in the umbilical region. It was the size of an adult's fist. It diminished a little as a result of fomentations and poultices, but was very red and painful on pressure. It gradually lost the character of a phlegmon. After eight or ten days it began to increase in size. The skin became thinner and broke, and there was an escape of pus and fragments of albumin and fibrin. A fistulous opening formed a few days later. A probe introduced into the two openings disappeared for a depth of 7 cm. and impinged upon a hard body. The patient at this time was pale, somewhat jaundiced, and had lost a little in weight. Richet considered in the differential diagnosis acute phlegmon, abscess of the glands, cold abscess, cancer, a syphilitic tumor, fecal fistula, and a fetal cyst.

On February 10th the tumor was opened and a large quantity of pus was evacuated. The two orifices were opened by a long incision. At the bottom was a hard body which was free, mobile, and had facets. Richet endeavored to remove it with forceps, but did not succeed. A few clays later the body had approached more and more to the surface, and on February 17th a biliary calculus escaped. Richet probed again and detected a second calculus. This escaped. A few clays later a third calculus, similar to the two others, was removed. The umbilical opening closed completely, and the patient was discharged well in the early part of March.

  • Leguelinel de Lignerolles: Quelques recherches sur la region de l'ombilic et les nstules

hepatiques ombilicales. These de Paris, 1869, No. 6, obs. 1.


340 THE UMBILICUS AND ITS DISEASES.

Fistulous Abscess of the Liver Communicating with the Gall-bladder; Dilatation and Cauterization of the Fistulous Tract; Escape of 14 Small Faceted Calculi and of Two Large Calculi Without Facets.* — In April Dr. Vacher was called to see a woman, twenty-three years of age, who had a good previous history. She said that following a cut she had had an abscess of the liver. This abscess had opened spontaneously and for two months there had been a purulent discharge from the umbilicus, with pain and fever. A fistula had resulted. Vacher found a fistulous opening about three fingerbreadths from the umbilicus. On pressure seropurulent fluid escaped from it. A sound penetrated transversely and to the right for a depth of 4 cm. Abscess of the liver was diagnosed. Crepitation was transmitted to the sound, indicating old calcareous concretions like those sometimes found in the bottom of a cyst. The consultant advised against dilatation of the fistula and gave an unfavorable prognosis. Vacher, however, dilated the fistulous tract with sponges, and then could detect with a sound distinct signs of a calculus. The calculus escaped spontaneously a few days later. It was blackish, faceted, and the size of a pea. Greenish bile also escaped with the calculus. Two and later four other calculi of the same size came away. A calculus of large dimensions presented and was removed with a polyp forceps. It was the size of a pigeon's egg, similar to the others, and consisted of cholesterin. Three or four days later a similar calculus was extracted in the same manner. From this moment the patient improved. The tract was kept dilated for fifteen days. The patient recovered rapidly, and six years after was in excellent health.

A Biliary Tumor Opening Spontaneously in the Umbilical Region, with Escape of a Calculus and Development of a Fistula. f — ■ In the first part of February, 1862, a man, aged forty-one, came saying that he had suffered with pain at the umbilicus for some time. At the umbilicus was a reddish tumor the size of a walnut, painful on pressure, and fluctuating. It was taken for an abscess. It opened spontaneously the next day, and a calculus with a small quantity of seropurulent liquid escaped. The cavity occupied by the calculus was lined with granulation tissue. On the sixth clay it presented a small opening from which a little serous pus escaped. In the course of eight days the opening was completely closed. It, however, reestablished itself, and pus escaped, but no other calculi. In May, 1868, this patient had ascites and cachexia and died in October from cancer of the liver and of the stomach.

A Cystic Tumor Opening in the Region of the Umbilicus; Escape of Biliary Calculi From the Fistula. J — This case was originally reported by Dr. John Cockle. § A woman, fifty-nine years old and well developed, had complained of very severe pain in the abdomen for nine days before her entrance to the hospital. She had had nausea and vomiting. The stools had been normal, and there had been no jaundice. At the level of the umbilical region there was a tumor which was red and inflamed, and there was also an opening. Eight days after entrance the patient discharged 14 small calculi.

  • Leguelinel de Lignerolles: Op. cit., obs. 2. [Abstract from Traite d'affections calculeuses

du foie, Fauconneau-Dufresne, 482.]

t Leguelinel de Lignerolles: Op. cit., obs. 3. [Observation by Dr. Leroy des Barres, of Saint Denis. This case was related to the author by the son of Dr. Leroy.]

X Leguelinel de Lignerolles: Op. cit., obs. 4.

§ Cockle, John: Med. Times and Gaz., May 10, 1862, p. 476.


THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 341

Several days later three more calculi came away. The redness then disappeared, but the fistula remained. At a point 2 cm. to the right and below the umbilicus was a seromucous discharge. A probe detected the presence of a hard calculus, which appeared to be the size of a hen's egg. There was also an increase in size of the liver. After some time the swelling and redness reappeared and another calculus was removed. Three weeks later still another became fixed in the fistulous tract, about 2 cm. from the opening. As a result of the disastrous experience which Robert had had after the extraction of similar calculi under like circumstances, the surgeon did not attempt to remove this calculus, but from time to time small biliary concretions escaped.

Tumor of the Umbilical Region; Abscess with Fistulous Tract; Spontaneous Escape of Several Biliary Calculi; Grave Jaundice; Marked Emaciation. Death.* — Madame X, aged sixty-five, had suffered from chronic gastritis. In 1857 she complained of vague pain in the right hypochondrium and a tumor could be made out in the region of the umbilicus. The tumor was hard, without any nodulation, and was painful on pressure. It opened at the umbilicus, and a considerable quantity of whitish pus escaped. In March, 1858, a biliary calculus appeared, and in the course of six months a large number escaped spontaneously. The opening closed after the exit of each calculus, but reopened to allow another to pass out. The patient gradually became emaciated, and died with a marked jaundice. At autopsy a sound introduced at the umbilicus passed into a cul-de-sac 3 cm. in depth. The liver was increased in size, and infiltrated with biliary material. The gall-bladder was transformed into a small, very hard tumor, round, the size of a walnut. It contained a calculus resembling those which had escaped. The hepatic duct was obstructed by a calculus.

Escape of a Biliary Calculus by an Abscess to the Left of the Umbilicus. f — This case was reported by Alle.t A woman, forty-six years of age, had had good health until 1828, when she had had what was called "nervous fever" (typhoid ?). In 1830 she commenced to complain of pain in the left hypochondrium. A tumor was detected. The patient went to take the waters at Baden, but on her way there had very severe pain in the right hypochondrium, accompanied by headache and vomiting. In July, 1831, the skin in the region of the umbilicus became inflamed. After applications of poultices an abscess developed, which opened and a considerable quantity of pus escaped. On October 24th the patient experienced a very unusual sensation. She felt as if a foreign body had broken in the cavity of the abscess, and on the twenty-seventh noticed something hard presenting at the opening. A biliary calculus the size of a pigeon's egg escaped. The general condition of the patient was grave. She was becoming markedly emaciated, and had a continuous fever with exacerbations in the evenings and night-sweats. She was also constipated. The fistulous tract did not have the dimensions of a lentil. A probe introduced impinged upon a hard, immovable body. The opening was increased in size with a sponge. On November 25th a calculus presented. The surgeon attempted to remove it with forceps, but

  • Leguelinel de Lignerolles: Op. cit., obs. 5. Abstract from L'Union med., 1859, 465.

t Leguelinel de Lignerolles: Op. cit., obs. 6.

t Alle (in Briinn) : Vier grosse Gallensteine, welche durch einen Abscess zunachst unter dem Nabel abgingen. Med. Jahrb. K. K. Oster. Staates, 1837, N. F. xii, 115.


342 THE UMBILICUS AND ITS DISEASES.

it broke into four large fragments and several smaller ones. These were extracted, and the patient's health improved. The pain was severe, but the fistulous tract closed. In May, 1835, the fourth calculus was removed. Fifteen days later the opening closed completely, and it required only one month for the patient to regain her general health. When the fragments of the extracted stone were assembled, it was found that, together, they formed one calculus.

Biliary Calculus Escaping From the Umbilical Region . * — A woman, sixty-seven years of age, had had pain in the epigastrium, in the right hypochondriac region, and in the umbilical region. At the umbilicus she developed a tumor which, by February, 1858, had reached enormous proportions. Her general condition, however, was satisfactory. At the beginning of April the tumor had a projection in its center. The skin at this point was thin and red. On the eighth day a large quantity of pus, sandy in character and fetid, escaped. Iodin and quinin were injected. Shortly afterward the patient went back to her work, but from time to time she had pain at the umbilicus and a seropurulent discharge; a fistula remained. Four years later the pain returned. In January, 1861, a blackish liquid with foul odor escaped from the fistula. At the same time at the orifice of the fistula was seen a black body, which escaped on Januarjr 23d, after violent abdominal contractions and much pain; it was hard, resistant, and the size of a pigeon's egg. A sound introduced into the opening disappeared for a distance of 5 cm. without impinging upon any solid body. The patient recovered. The body expelled without doubt was a biliary calculus which had made a channel toward the abdominal wall in the umbilical region. It was dark green in color, had the appearance and consistence of cholesterin, and burned in the flame of a candle.

A Biliary Tumor Descending Toward the Umbilicus; Escape of a Calculus; Fistula. Recovery. f — The wife of a pharmacist had been gradually weakened as a result of long suffering from hepatic colic. Reaching from the gall-bladder region toward the umbilicus was a tumor evidently containing a calculus which could be easily felt. This tumor ulcerated, bile escaped, and also a biliary calculus. The patient felt relieved and the opening closed. In the course of three months a new opening occurred in the region of the cicatrix and a second calculus escaped. It had evidently lain in the gall-bladder.

Biliary Fistula at the Umbilicus.! — The patient in Bramann's Case 2 was an unmarried woman, sixty-three years of age. She had had typhoid fever at thirteen. At forty-five years of age she had complained of a sudden abdominal pain, had had a high fever, much discomfort in the gall-bladder region, and some nausea. The abdomen was somewhat swollen. A tumor the size of a fist had been made out in the umbilical region above and to the right. It had grown slowly and tended to pass more and more downward toward the symphysis.

Two years later a large quantity of foul-smelling pus had escaped from the umbilicus. This discharge had continued, the amount varying at different times. The patient was in good condition.

On admission her abdomen was slightly distended. The skin covering the umbili

  • Leguelinel de Lignerolles: Op. oit., obs. 7. Abstract from a case reported by Dr. Leclerc, Gaz. des hopitaux, 1863, p. 48.

t Leguelinel de Lignerolles: Op. cit., obs. 8. [This case was observed by Dr. Manec and reported by Fauconneau-Dufresne.]

t Bramann, F.: Zwei Falle von offenem L'rachus bei Erwachsenen. Arch. f. klin. Chir., Berlin, 1887, xxxvi, 996.


THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 343

cus was covered with crusts and exfoliated epithelium and small cysts. The umbilicus was retracted, and a small fistulous tract was discharging foul-smelling pus.

On palpation exactly in the middle line a long, egg-shaped tumor could be felt. At the umbilicus this was 5 cm. broad. It extended almost to the symphysis, and its lower end was from 7 to 8 cm. wide. The tumor lay distinctly behind the abdominal wall, and only in the neighborhood of the umbilicus was it intimately attached. In the lower part it was somewhat movable. On pressure it was found to be of dense consistence. A sound could be passed 12 cm. toward the symphysis, and the cavity widened out as it passed downward. Calculi were detected in the bottom of the cavity. The urine was always normal.

Operation. — An incision, 8 cm. long, was made from the umbilicus downward. Four faceted calculi the size of pigeon's eggs were removed from the sac. The cavity was cureted out. Healing occurred after three months, but it was necessary to curet several times. Microscopic examination of the calculi yielded cholesterin and bile-pigment, but no urinary salts.

Fatal Peritonitis Following a Biliary Fistula at the Umbilicus.* — A woman, thirty-five years of age, had had for eight months a purulent fistula at the umbilicus. With a catheter introduced into the fistula Robert was able to detect a calculus situated at the bottom of the traet. He dilated the tract, but the patient developed peritonitis and died.

Escape of Biliary Calculi From the Umbilicus. — Clementj showed at the Medical Society two biliary calculi. The woman had had previous attacks of abdominal pain. When seen by Clement, she had a reddening around the umbilicus. This was unsuccessfully treated as an eczema. A fistula developed, and two days later a calculus escaped. On the day previous to the meeting Clement had extracted the two very small calculi from the umbilicus.

A Biliary Fistula at the Umbilicus. — Poncett saw a patient with an umbilical fistula which from time to time discharged bile. The physician, under whose care the patient was, said that in the beginning an abscess had developed and a calculus had escaped. The resultant fistula resisted all treatment.

  • Robert: Cited by Nicaise: Ombilic. Dictionnaire encyclopedique des sc. med., Paris,

1881, 2. ser., xv, 140.

t Clement: Lyon med., 1888, lvii, 53. i Poncet: Lyon med., 188S, lvii, 54.

LITERATURE CONSULTED ON GALL-STONES ESCAPING FROM THE UMBILICUS.

Berard, P. H. : Diet, de med., Paris, 1840, xxii, 66.

Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., Berlin, 1887, xxxvi, 996.

Clement: Lyon med., 1888, lvii, 53.

Courvoisier, L. G. : Casuistisch-statistische Beitrage zur Pathologie und Chirurgie der Gallenwege, Leipzig, 1890, 117.

Duplay: Arch. gen. de med., 1833, 2e serie, i, 373.

Ledderhose, G. : Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 bs

Leguelinel de Lignerolles: Quelques recherches sur la region de l'ombilic et les fistules hepatique. ombilicales. These de Paris, 1869, Xo. 6.

Alurchison, C. : Case of communication with the stomach through the abdominal parietes produced by ulceration from external pressure. Medico-chir. Trans., London, 1858, xli, p. 11.

Nicaise: Ombilic. Dictionnaire encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv, 140.

Poncet: Lyon medical, 1888, lvii, 54.


344 THE UMBILICUS AND ITS DISEASES.

HYDATIDS AT THE UMBILICUS.

The presence of hydatids at the umbilicus is exceptional. Examples have, however, been recorded by Guattani, Dupuytren, Thompson, Berard, and Roux.

The parent echinococcus cyst usually develops in the liver, and the growth gradually extends to the umbilical region. The tumors may become adherent to the umbilicus and open, fluid and daughter-cysts escaping. Dupuytren's case is particularly interesting, in that autopsy showed that the primary focus was in the lung. The fistulous tract had perforated the diaphragm; it lay between the liver and abdominal wall, and opened at the umbilicus.

Leguelinel de Lignerolles reported Guattani's case.* The patient was a man, forty-eight years of age, who had had, in the region of the liver, a tumor which was resistant, circumscribed, and tense. In the center an obscure fluctuation could be detected. Guattani was uncertain as to its character, and decided to temporize. Nine months later the tumor was prominent, the skin had become reddened, and through an opening at the umbilicus there escaped more than 300 hydatid cysts. A stilet introduced into the fistulous tract detected a large cavity which it was impossible to explore thoroughly. The fistulous tract remained open for a long time without any inconvenience to the patient. Healing took place six years afterward. [I was not able to study this case in the original. There seems to be some controversy, however, as Nicaise says the observation of Guattani cannot be considered as an example of hydatid fistula at the umbilicus. He claims that the tumor was in reality in the epigastric and not in the umbilical region, and that it ruptured, with the escape of more than 300 hydatids.]

Dupuytren reported his case in 1833. A woman entered the Hotel-Dieu in 1811 with an inflammatory tumor of the umbilicus. As fluctuation was evident, and as it was manifest that the skin would give way, Dupuytren opened it and a large quantity of pus escaped, and with it several hydatid cysts. The woman died. At autopsy a communication was found between the umbilical opening and a cavity in the lung. The fistulous tract had perforated the diaphragm and lay between the liver and the abdominal wall. The cavity in the lung contained a large number of hydatid cysts. It was evident that the lung was the primary seat of the hydatids.

Leguelinel de Lignerolles cites Thompson's case. The original appeared in the Medical Gazette, 1844, and was recorded in the Memoirs of the Medical Society, London. The patient at intervals for a period of thirty years had discharged hydatid cysts from the umbilicus. She died at the age of fifty-three. The swelling was first noted after an abdominal injury. Following an abdominal incision she discharged numerous cysts, accompanied by a peculiar liquid which was sometimes purulent. The cysts continued to escape through an opening which developed at the umbilicus, and the patient experienced a great deal of abdominal pain. She had frequent attacks of diarrhea and occasionally fell into a state of great weakness. At autopsy, at the umbilicus were found two tumors communicating with the opening. The one contained friable material mixed with "quicklime," the other had very fetid contents. The fistula passed to the upper portion of the liver, with which it had evidently communicated. Eight or nine isolated hydatid cysts were found on the surface of the liver, and there was also an abscess which contained pus and remnants of hydatids. The gall-bladder was very much dis

  • Guattani: De ext. Aneurys., Roma, 1772, 109.


THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 345

tended and contained similar cysts. In addition there were numerous hydatids between the folds of the mesentery.

Berard, in 1840, reported the case of a woman who entered his service at St. Anthony's Hospital. For eighteen months she had had an umbilical fistula. On pressure over the right hypochondrium the purulent discharge from the umbilicus increased, and with the pus escaped several empty hydatid sacs.

Nicaise refers to Roux's case, which had been reported by Cruveilhier. A woman had at the umbilicus a tumor which had been taken for a hernia and a bandage had been applied. Roux noted that the skin covering the tumor had spontaneously opened; that there was a convex surface, whitish and prominent, at the opening of the skin. He thought of a hernial sac. He made several incisions to relieve the supposed strangulation, and was surprised to find that he was dealing with hydatid cysts.

Fischer, in his article on Suppurations in the Subumbilical Space, drew attention to an isolated echinococcus cyst of the abdominal wall. This was not situated at the umbilicus, but immediately in its vicinity, and was in no way connected with the abdominal cavity. It is of such interest that I report it in detail. He says (p. 537) that he operated on a man thirty-two years of age in whom a painless, smooth, fluctuating, immovable tumor, the size of a fist, had developed beneath and to the right of the umbilicus near the mid-line. Its increase in size had been very gradual, as it took six years for development. The patient during this time had often had vomiting, but was otherwise healthy. For three weeks the tumor had been painful and increasing in size. The skin had become reddened and edematous. The tumor had the size, form, and position of the subumbilical space. Fischer made an incision in the outer wall of the rectus along the subumbilical space, and found a densely adherent echinococcus sac, which could not be extirpated on account of its firm adherence to the peritoneum. He split it, scraped it out, and packed. The patient recovered and apparently remained well.


LITERATURE CONSULTED ON HYDATIDS AT THE UMBILICUS. Berard, P. H. : Diet, de med., Paris, 1840, xxii, 66. Davaine, C. : Traite des entozoaires, Paris, 1860, 416. Dupuytren: Tumeurs hydatiques. Clin, chir., 1833, iii, 378. Fischer: Die Eiterungen im subumbilicalen Raume. Volkmann's Samml. klin. Vortrage, n.F.,

No. 89 (Chirurg. No. 24), Leipzig, 1890-94, 519. Ledderhose, G.: Chirurg. Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Leguelinel de Lignerolles: Quelques recherches sur la region de l'ombilic et les fistules hepatiques

ombilicales. These de Paris, 1869, No. 6. Nicaise: Ombilic. Dictionnaire encyclopedique des sc. med., Paris, 1881, 2. ser., xv, 140.

THE ESCAPE OF LIQUOR AMNII OR OF FETAL REMAINS THROUGH THE UMBILICUS. A tubal pregnancy of small size niay in time almost totally disappear. If it be of moderate dimensions and not operated upon, it may remain in situ, nothing but the distorted skeleton being left. I saw a most interesting example of this condition about fifteen years ago. Dr. J. Whitridge Williams received the specimen from New York, and on making a careful examination found that the tube near the uterus contained a recent small pregnancy, while in the outer end of the same tube was the skeleton of a previous tubal pregnancy. The bones of this fetus had been


346 THE UMBILICUS AND ITS DISEASES.

compressed into a rounded mass several centimeters in diameter. On May 4, 1907, at the Johns Hopkins Hospital, I operated on a colored woman (Gyn. No. 13806) who had a definite mass in the ileocecal region. Her previous history was not clear and did not give us a clue as to the exact condition. On making an incision over the mass I found a packet of bones. (See Fig. 249, p. 584.) These were gradually dislodged. The end of one femur, which was fully 5 cm. long, had projected into the bladder, and the portion of the bone that had come in contact with the urine had a phosphatic covering several millimeters thick. The lumen of the large bowel in the vicinity of this collection of bones was perforated at two points, the ends projecting into the intestinal lumen. The opening in the bladder and the apertures in the bowel were closed and the sac drained. The patient made a prompt recovery.

In the case reported by Pfeffinger and Fritze, and referred to by Kussmaul, after the fetal bones had remained quiescent in a rudimentary uterine horn for over thirty years, suppuration had developed and the patient died. The accuracy of this case was fully attested, as the patient was a life prisoner and had escaped capital punishment years before only because at the time of the trial she claimed that she was pregnant. This case Dr. George L. Wilkins and I referred to several years ago.

The passage of fetal bones by the rectum has in the past been no great rarity. Where the pregnancy has been abdominal, the fetus in many instances goes on to term and becomes encapsulated, as was well seen in a full-term pregnancy that I removed several years ago and where the child had lain in the abdomen for four years. Sometimes the child may become calcified, as was clearly evident in the case reported by Dr. John G. Clark.

In the foregoing I have briefly outlined some of the end-results of an extrauterine pregnancy. While going over the literature I found two cases in which there had been a tendency for the fetus to break through at or near the umbilicus, and to this I will add one coming under my own care.

Josenhans, in 1841, reported the case of a woman, sixty years of age, who was married at twenty and in short succession had two children. At thirty she complained of severe abdominal pain, with a rupture near the umbilicus. At first there was an escape of pus and then fecal matter, and on several occasions pieces of bone and hair. The fistula remained open and there was a prolapsus of the bowel through the opening. The patient died at sixty-four. There had evidently been an abdominal pregnancy, with escape of parts of the fetus through the abdominal wall. Had the bone and hair been due to a dermoid, a suppurating sinus would always have remained.

In 1874 Duboue reported the case of a woman, aged twenty-six, who entered the maternity hospital after being in labor for twenty-four hours. The pain diminished, and the patient complained of nausea and vomiting. On examination the enlargement suggested a seven and one-half months' pregnancy. The tumor was situated more to the right than to the left, and the nurse had previously made out the fetal heart. The patient improved and was sent home to await results. In February, at the time of the patient's admission, she was in fairly good health. A week after the labor pains had ceased, the patient lost her appetite, could not sleep, grew thinner, and had a peculiar brownish tint in her face. On February 7th she noted a considerable discharge of chocolate-colored material by the bowel.


THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 347

On March 12th she again entered the hospital. The uterus was dilated on March 27th, and to the surprise of the surgeon was found to be empty. On April 9th the sac opened at the umbilicus and the fetus was then extracted piecemeal. The general peritoneal cavity was not opened, but the cavity containing the fetus was washed out. Two days later fecal matter came out of the sac. The patient gradually improved, and was discharged on June 6th. The fistula, which persisted until September of the same year, was scarcely perceptible, but there was an occasional escape of gas.

In 1901 I saw the following case at the Cambridge (Md.) Hospital:* On February 28, 1901, Dr. Goldsborough was called in by Dr. I. N. Tannar, of Vienna, Maryland, to see what the doctor supposed to be a case of obscure pregnancy. The patient had had one child nine years before. In April, 1900, she had missed her period and since then had presented the usual signs of pregnancy — nausea, enlarged breasts, increase in size of the abdominal girth. In August, while lifting some boxes, something had suddenly given way in her left side. This had occasioned severe pain and she had remained in bed until November 1st. About the middle of September there had been a bloody uterine discharge, and accompanying it considerable pain and nausea. Subsequently, she had had several similar discharges, which may have been menstrual periods. During the month of November she had been able to be out of bed, but had had to return in December. Throughout the entire illness she had had a good appetite and had been fairly well nourished. When seen, her temperature was 101.5° F.; her pulse, 140. Immediate removal to the Cambridge Hospital was advised, and on the following day she was driven 23 miles.

On examination under anesthesia the abdomen was seen to be very prominent. There was, however, no bulging in the flanks. The umbilicus had been converted into a tumor fully 5 cm. long by 3 cm. broad (Fig. 166). The skin over it appeared to be much thinned out, and at one point had given way. From this abraded area an exceedingly offensive, chocolate-colored fluid was escaping. Around the umbilicus the tissue was markedly indurated and pitted on pressure. On vaginal examination the cervix was found intact, but it was impossible to outline the uterus. Nothing could be detected laterally. An incision was made just below the sternum, and continued down almost to the pubes. The abdominal cavity proper was not exposed; that is to say, none of the abdominal contents came into view. Filling the cavity was a large quantity of chocolate-colored fluid, a fetus between six and seven months, and a large placenta. The placenta was attached low down in the pelvis, was exceedingly friable, but came away without producing any hemorrhage. The walls of the sac were about 4 mm. in thickness and excessively friable. They reminded me very much of granulation tissue. It was impossible to determine where the pregnancy had taken place, as the pelvic organs were entirely walled off. It is probable, however, that the uterus had ruptured and that the fetus with its membranes intact had escaped into the abdominal cavity. The fetal membranes had then become attached to the abdominal wall and to the surrounding structures. After removal of the fetus and the placenta, this large sac, which extended almost from the sternum to the pubes and laterally filled the entire anterior portion of the abdomen, was thoroughly washed out with salt solution and loosely packed

  • Goldsborough, Brice W., and Cullen, Thomas S.: A Rare Form of Extra-uterine Pregnancy. Amer. Medicine, April 6, 1901, p. 32.


348


THE UMBILICUS AND ITS DISEASES.


with iodoform gauze. The upper half of the incision was closed, the lower half I left open to insure thorough drainage. At the time of operation the patient's pulse was 140. The operation occasioned no shock.

After the operation the temperature ranged from normal to 101.5° F. for the first four days, but after that time became normal. The pulse was weak and irregular for six days, but gradually regained its normal tone. The pack was removed on the seventh day, with the escape of a moderate amount of discharge. A light gauze drain was then inserted. On March 13th the abdomen was perfectly flat



Fig. 166. — Abdominal Pregnancy with Spontaneous Escape of Liquor Amnti from the Umbilicus.

The drawing, of course, is somewhat diagrammatic. It represents a longitudinal section of the body. The fetus and the fetal membranes are lying immediately beneath the abdominal wall, and are attached anteriorly to the peritoneum almost from the sternum to the pubes. At the umbilicus the fetal sac bulges into the hernial opening, and at the most prominent point this hernial sac has given way, allowing the fluid to escape externally. The fetus is well preserved, appears to be about six months old, and shows slight maceration on the face, arms, and legs. The site of the placenta is roughly outlined by the dotted lines. The cervix is normal, but on account of the marked distortion, the presence of the abdominal tumor, and the edema it was impossible to outline the uterus or appendages; hence their relation is left hazy. The bladder and rectum are in their normal positions. As will be seen from the drawing, a median incision in the abdominal wall would open directly into the sac and in no way involve the general peritoneal cavity.


and all evidence of edema had disappeared. On removal of the drain there was a slight discharge. On bimanual examination it was now possible to outline the uterus to some extent. The organ was about the size of a two months' pregnancy, and situated directly behind the pubes. It was slightly movable.

Pathological Report (Gyn. Path. No. 4744). — The specimen consists of a fetus with its accompanying placenta. The fetus, when folded upon itself, is 17 cm. in length. The distance from the occiput to the heel is 29 cm. The child is well formed, shows no external abnormality, and is a female. There is a moderate quantity of hair, but the skin has to a great extent macerated, and the pigmented


THE ESCAPE OF FOREIGN SUBSTANCES FROM THE UMBILICUS. 349

layer is readily peeled off. The umbilical cord appears to be about 8 cm. in length. It shows nothing of interest. The placenta is approximately 16 by 10 by 5 cm. It is very friable. In some places it presents the usual appearance; in others, especially in the depth, the tissue is somewhat homogeneous, hemorrhagic, and seems to be breaking down.

Histologic examination of sections from various parts of the placenta shows that it consists almost entirely of necrotic tissue and canalized fibrin. The contours of the villi are everywhere visible, but the nuclei of the epithelial cells, as well as those of the stroma of the villi, have entirely disappeared. The central portions of numerous villi are partially filled with calcareous plaques. At one point are a moderate number of disintegrated polymorphonuclear leukocytes. Otherwise the entire tissue is devoid of nuclei.

This complete necrosis of the placenta accounts for the ease with which it was peeled off and also for the absence of hemorrhage during its removal.

The discharge of bone and hair from the umbilicus, although it affords strong presumptive evidence of pregnancy, is not necessarily conclusive, as shown by Sanderson's case. Dr. S. E. Sanderson, in writing me from Detroit under date of March 31, 1913, says: "In September, 1897, I was called to see a German woman of the poorer class, aged about twenty-seven, married, with no children. She was suffering from a large abdominal tumor, and at the same time there was a bulging at the umbilicus covered with reddened skin and very compressible. This swelling evidently contained fluid.

"Several days after seeing this patient I was hurriedly called to her house. On arriving I found that rupture had taken place through the umbilicus. Several pints of a pea-soup-like fluid and two or three teeth had been discharged, while from the opening there extended a long strand of hair. The abdomen was greatly diminished in size, and the patient felt more comfortable. I advised her removal to the hospital for proper care, but she refused, and I lost track of her. About a year later I was told that she had gone to the hospital for operation and had had a large tumor removed."

As Sanderson says, this was without doubt a dermoid cyst. We all know that dermoid cysts show a peculiar tendency to become adherent, and that they are prone to suppurate. This cyst had suppurated, grown fast to the umbilicus, and part of its contents had escaped through the umbilical opening.

LITERATURE CONSULTED ON ESCAPE OF LIQUOR AMNII OR FETAL REMAINS

THROUGH THE UMBILICUS.

Clark, J. G. : A Rare Case of Lithopedion. Johns Hopkins Hosp. Bull., November, 1897, viii, 221. Cullen and Wilkins: Pregnancy in a Rudimentary Horn, Rupture, Death, Probably Migration

of Ovum and Spermatozoa. Johns Hopkins Hosp. Reports, 1897, vi, 126. Cullen, T. S.: A Series of Interesting Gynecologic and Obstetric Cases. Jour. Amer. Med.

Assoc, May 4, 1907, 1491. Duboue: Observation de grossesse extra-uterine, gastrotomie, guerison. Fistule intestinale au

niveau de 1'ombilic. Arch, de tocologie, des maladies des femmes et des enfants nouveau nes, 1874, i, 577. Goldsborough and Cullen: A Rare Form of Extra-uterine Pregnancy. Amer. Medicine, April 6,

1901, 32. Josenhans: Merkwurdiger Fall von kiinstlichem After. Med. Correspondenzbl., Wurtemberg,

1841, xi, 60.


350 THE UMBILICUS AND ITS DISEASES.

ESCAPE OF FOREIGN BODIES THROUGH THE UMBILICUS.

Blum, in his article on Tumors of the Umbilicus in the Adult, published in 1876, cites three cases — those observed by Ambroise Pare, Diemerbroeek, and Greenhill.

Ambroise Pare's patient, a woman, had swallowed a brass needle. Two years . later it passed out at the umbilicus through a small opening.

Diemerbroeck's patient, a child, had swallowed a shoemaker's awl. Later a small, painful, non-suppurating tumor presented at the umbilicus. This contained the foreign body.

GreenhilTs case was reported in the Philosophical Transactions of the Royal Society of London in 1700, vol. hi, p. 93. A woman, who had swallowed a certain number of plum-stones, finally developed a tumor in the umbilical region. This suppurated, and the stones escaped from the umbilicus. The woman died twenty days later.

"Weiss briefly referred to a case seen by Cladus. The patient was a man. Plum-stones and worms escaped from his umbilicus.

Petrequin's case, in which a uterine sound introduced through the vagina was lost and finally presented at the umbilicus, is of such interest that I shall report it in detail.

Uterine Sound Introduced Into the Uterine Cavity and Removed Through the Umbilicus.* — Madame X, mother of several children, claimed that when she was between six and eight weeks pregnant a midwife had introduced a sound to bring on a miscarriage. The sound was passed far up and could not be reached again. Miscarriage followed, but no sound came away. Six days later, after the most careful examination, no evidence of the sound could be found. Examinations on several days in succession were of no avail. Four months later the patient was in good health, but came to the hospital on account of a small enlargement at the umbilicus. It looked like a beginning umbilical hernia.

On bimanual examination with the patient standing, the upper end of the sound could be felt at the umbilicus. The uterus was dilated, and several attempts made to remove the sound from below, but without avail. An incision was finally made at the umbilicus, and by manipulation the sound was removed from above. The patient was perfectly well in seven days. In this case the sound had perforated obliquely the anterior portion of the cervix, and its lower end had slipped between the bladder and the cervix, while the upper end gradually had reached the umbilicus. Petrequin and Foltz claim this as the only case of the kind on record.

These are the only cases of foreign bodies escaping from the umbilicus which we have found in the literature.

  • Petrequin et Foltz: Extraction par l'ombilic d'une sonde de femme introduite par les

voies genitales. Lyon rued., 1869, iii, 509.

LITERATURE CONSULTED ON THE ESCAPE OF FOREIGN BODIES THROUGH THE

UMBILICUS.

Blum, A.: Tumeurs del'ombilic chez l'adulte. Arch. gen. de mod., Paris, 1876, 6. ser., xxviii, 151.

Petrequin et Foltz: Extraction par l'ombilic d'une sonde de femme introduite par les voies genitales. Lyon med., 1869, iii, 509.

Weiss, E.: Leber diverticulare Nabelhernien und die aus ihnen hervorgehenden Xabelfisteln. Inaug. Di— ., 'lie-sen, 1868.


Chapter XXIII. Umbilical Tumors

Hypertrophy of the umbilicus.

Angiomata of the umbilicus; report of cases.

Umbilical lymphocele.

Myxomata.

Fibromata; report of cases.

Papillomata; report of cases.

Lipomata.

Dermoids or atheromatous cysts; report of cases.

Umbilical tumors consisting chiefly of sweat-glands.

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

diameter. Papilloma of the umbilicus secondary to papilloma of the ovary.


Benign :


UMBILICAL TUMORS.


Hypertrophy.

Angiomata.

Lymphocele.

Benign comiective-tissue growths.

Myxomata.

Fibromata.

Papillomata. *

Lipomata. Dermoid cysts. Sweat-gland tumors.

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

Malignant :

Carcinoma of the umbilicus.

A t> • / 1. Squamous-cell carcinoma.

A. unmary. ^^ 2 Adenocarcinoma.

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

, 3. From the intestine.

B. Secondary. j 4 From the ovary _

5. From the uterus.

6. From other abdominal organs. Sarcoma.

1. Telangiectatic myxosarcoma.

2. Spindle-cell sarcoma.

3. Round-cell sarcoma.

4. Melanotic sarcoma.

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

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

t These may or may not be malignant.

351


352 THE UMBILICUS AND ITS DISEASES.

GENERAL REMARKS.

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

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


LITERATURE CONSULTED ON UMBILICAL TUMORS IN GENERAL.

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

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

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

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

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


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


ANGIOMATA OF THE UMBILICUS.

Definite literature on the subject is very rare.

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

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

  • Villar: Op. cit., p. 76.


UMBILICAL TUMORS. 353

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

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

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

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

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

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

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

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

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

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


35-1 THE UMBILICUS AND ITS DISEASES.

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

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

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

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

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

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

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

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

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


UMBILICAL TUMORS. 355

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

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

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

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

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

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

1887, lviii, 245.


356 THE UMBILICUS AND ITS DISEASES.

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


LITERATURE CONSULTED ON ANGIOMATA OF THE UMBILICUS.

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

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

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

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

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

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

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


UMBILICAL LYMPHOCELE.

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

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


BENIGN CONNECTIVE-TISSUE GROWTHS OF THE UMBILICUS.

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

Myxomata of the Umbilicus.

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

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

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


UMBILICAL TUMORS. 357

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

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

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

Fibromata of the Umbilicus.

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

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

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

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

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

1902, xxiii, 632.

f Pernice: Die Nabelgeschwulste, Halle, 1892.


358 THE UMBILICUS AND ITS DISEASES.

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

Cases of Fibroma of the Umbilicus.

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

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

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

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

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

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

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

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

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

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


UMBILICAL TUMORS. 359

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

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

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

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

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

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

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

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

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

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

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

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


360 THE UMBILICUS AND ITS DISEASES.

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

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

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

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

Papillomata of the Umbilicus.

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

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

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

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

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

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


UMBILICAL TUMORS. 361

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

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

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

Cases of Papilloma of the Umbilicus.

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

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

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

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

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

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

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

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


362 THE UMBILICUS AND ITS DISEASES.

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

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

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

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

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

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

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

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

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


UMBILICAL TUMORS. 363

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

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

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

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

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

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

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

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

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

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

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


364 THE UMBILICUS AND ITS DISEASES.

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

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

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

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

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

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

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

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

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

lxxvii, 346.


UMBILICAL TUMORS. 365

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

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

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

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

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

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

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

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

nuclear figures. In addition, the clinical history shows that

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

umbilicus.

LlPOMATA OF THE UMBILICAL REGION.

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

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

  • Cullen, Thomas S.: Personal observation.

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

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



366 THE UMBILICUS AND ITS DISEASES.

LITERATURE CONSULTED ON BENIGN CONNECTIVE-TISSUE GROWTHS OF THE

UMBILICUS.

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

Bennett: See Barton.

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

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

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

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

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

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

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

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

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

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


DERMOIDS OR ATHEROMATOUS CYSTS OF THE UMBILICUS.*

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

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

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

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


UMBILICAL TUMORS. 367

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

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

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

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

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

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

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

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

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

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

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

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

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


368 THE UMBILICUS AND ITS DISEASES.

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

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

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

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

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

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

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

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

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

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


UMBILICAL TUMORS. 369

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

LITERATURE CONSULTED ON DERMOID CYSTS OF THE UMBILICUS.

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

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

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

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

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

UMBILICAL TUMORS CONSISTING CHIEFLY OF SWEAT-GLANDS.

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

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

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

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

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


370 THE UMBILICUS AND ITS DISEASES.

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

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


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

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


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

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

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

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

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

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


UMBILICAL TUMORS. 371

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


PAPILLOMA OF THE UMBILICUS SECONDARY TO PAPILLOMA OF THE OVARY.

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

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

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

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

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

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

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

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

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

Path. No. 8417. The superficial portion consists of granulation tissue. The surface is covered with hyaline material embedded in which are a large number of polymorphonuclear leukocytes; beneath this is canalized fibrin, also containing polymorphonuclear leukocytes, and in the depth are dilated capillaries surrounded by young connective-tissue cells. The central portions are well organized. The more protected parts consist of typical papillary masses, large and small. They are covered over with one layer of cylindric ciliated epithelium. The epithelium varies considerably; in some places it is exceedingly high, and in others cuboid. The nuclei may be oval and uniformly staining, or oval and vesicular. The tumor presents the typical picture of papilloma of the ovary, although found at the umbilicus. Some of the papillary masses are well organized. In places the stroma has


372 THE UMBILICUS AND ITS DISEASES.

been replaced by hyaline tissue. In short, we have at the umbilicus a papilloma identical with an ovarian papilloma. On account of irritation from the clothing, the superficial portion has become inflamed and is partly replaced by granulation tissue. It is remarkable that the woman has lived so long, particularly with such wide-spread papillary masses. Some of these patients, however, live for a great many years. In 1894 I* reported a case of double papillocystomata of both ovaries. Fifteen years later I heard from the same patient. She was well and had gained 49 pounds.

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


Chapter XXIV. Adenomyoma of the Umbilicus

Historic sketch. Report of cases. Personal observations.

UMBILICAL TUMORS CONTAINING UTERINE MUCOSA OR REMNANTS OF

MULLER'S DUCTS.*

While gathering together from the literature the numerous cases of primary tumor of the umbilicus I found several that did not seem to belong to any of the classes hitherto recognized, and yet all of these cases in one or more points bear a certain amount of resemblance to one another. Finally, the picture of this newgroup became so firmly fixed in my mind that when reading the description of a case recorded in 1899 by Dr. Green, of Romford, England, I felt so sure that his case came under this category that I wrote him, asking if perchance he still had a section of the tumor. An examination of the slide which he kindly furnished me showed that we were right in our surmise. In brief, the clinical histories in this class of cases, coupled with the gross appearances of the tumors, leave no doubt that we are dealing with a variety of umbilical tumor never before clearly understood.

The composite picture of such tumors — which were found only in women — is as follows: At some time between the thirtieth and fifty-fifth year a small tumor develops at the umbilicus, reaching its full size in the course of a few months. It is usually described as being the size of a small nut. Sometimes it is painful, especially at the menstrual period, and in at least one instance there was a brownish, bloody discharge from the umbilicus at such times.

The overlying skin is usually pigmented, and there may be one or two bluish or brownish cysts just beneath the skin. These may rupture and discharge a little brownish fluid— old blood. On section the nodule is found to be intimately attached to the skin, is very dense, and is traversed by glistening bands of fibrous tissue. Scattered throughout the nodule one sometimes finds small spaces presenting a sieve-like appearance. These spaces are filled with brownish fluid. Occasionally there may be a small cyst, several millimeters in diameter, filled with

  • Shortly after the appearance, in Surgery, Gynecology and Obstetrics (May, 1912, 479), of

my article on Umbilical Tumors Containing Uterine Mucosa or Remnants of Miiller's Duct, I received the following, in a letter from Dr. S. W. Goddard, of Brockton, Mass., dated September 10, 1912: "After reading your recent article in Surgery, Gynecology and Obstetrics on Umbilical Tumors and noting a similarity to two I have published, I am sending you a reprint of the same in hopes that they may be of interest to you, and, if of any value, would be glad to have you make use of them in connection with your work, as I infer that you are specially interested in the subject. I have not seen any similar cases since."

These two cases reported by Dr. Goddard belong to the same group as those I have collected. That he clearly recognized the source of origin of these glands is also evident from the title of his article: Two Umbilical Tumors of Probable Uterine Origin. I had overlooked Dr. Goddard's article completely. To him undoubtedly belongs the credit for having drawn attention to the probable origin of the glands in these cases. Dr. Goddard's cases, one recently recorded by Barker, and one examined by me for Dr. Jones, of Atlanta, are recorded at the end of the chapter.

373


374 THE UMBILICUS AND ITS DISEASES.

brownish contents. Exceptionally, grayish, somewhat homogeneous areas are distinguishable in the tumor.

On histologic examination the superficial squamous epithelium is usually found intact. It may be normal or thickened. The stroma of the growth is composed of dense fibrous tissue. Sometimes a few bundles of non-striped muscle are noted here and there in the fibrous stroma. In other specimens the non-striped muscle is much more abundant than the fibrous tissue.

Scattered throughout the field are glands, round, oval, or irregular. They occur singly or in groups, and are lined with cylindric epithelium. When occurring singly, they frequently lie in direct contact with the fibrous tissue, but when found in groups, are usually surrounded by a characteristic stroma that stains more deeply and is much more cellular than the surrounding fibrous tissue. The cells of this stroma between the glands usually have oval or round vesicular nuclei. Frequently some of the glands are dilated and their epithelium is somewhat flattened. The cyst spaces, noted macroscopically and filled with brownish fluid, are likewise dilated glands, and the fluid is old blood. The stroma around the glands frequently shows fresh hemorrhage or remnants of old blood, to be recognized by the deposit of blood pigment.

From the above description it is clearly seen that the gland picture is that of the uterine mucosa with its typical glands and its characteristic stroma, and further that the typical menstrual reaction is often present, as evidenced by the pain in the nodule at the periods, the accumulation of old menstrual blood with the formation of small cysts, and in at least one instance by the occasional discharge of blood from the umbilicus. In this case (Fig. 168) one or two of the glands opened directly on the surface, thus allowing free escape of the menstrual blood.

In all, nine cases have been recorded. Green's case (Fig. 168), Mintz's first and third cases (Figs. 171 and 174), and Ehrlich's case (Fig. 177) owe their glandular origin without doubt to the uterus or to a portion of Miiller's duct from which the uterine mucosa originally comes. Although the cases reported by Wullstein, Giannettasio, von Noorden, and Mintz (Case 2) also probably belong to the same group, the evidence is not quite so clear, and without the opportunity of carefully studying the original sections I should not feel justified in including them as certain instances.

The most common glandular elements at the umbilicus are remnants of the omphalomesenteric duct. These are usually identical in structure with the glands of the small intestine, and never give rise to the cystic dilatations noted in the group of cases under discussion; moreover, hemorrhage into the stroma is exceptional. They differ totally both in their gross and histologic appearances.

We have in this group of cases glandular elements that from their histologic appearance and arrangement correspond exactly with those found in adenomyoma of the uterus, and in one case at least (Green's) the surrounding stroma was composed chiefly of non-striped muscle, making the growth essentially an adenomyoma. In the majority of the cases, however, the stroma consisted of fibrous tissue, but little muscle being present.

These growths are benign, and if removed in toto, provided no other embryonic foci exist, give rise to no further trouble. In Mintz's first case, four years after the first nodule had been removed, two others developed. These were also extirpated.

In Ehrlich's case, in addition to typical uterine mucosa, there was a definite tumor formation that had originated from sweat-glands.


ADENOMYOMA OF THE UMBILICUS. 375

In order that the reader may gain a clear insight into each of the cases, they are reported in detail, together with the comments on each case.

The descriptions of the illustrations naturally differ from those given by the various authors. I have redescribed each picture in the light of our new knowledge of the subject.

A Small Umbilical Tumor Containing Uterine Glands.* — [The author very kindly placed a section of the growth at my disposal. There is no doubt that the gland elements in this case are identical with those of the uterine mucosa, as seen from Figs. 168, 169, and 170, which have recently been made. — T. S. C]

The patient, a woman fifty years of age, had complained of irritation about the umbilicus for about two and a half years, and there had been an occasional discharge, brownish in color. When Dr. Green saw her, fourteen months before the growth was removed, there was some eczematous irritation of the skin in the neighborhood, but no projecting growth could be observed at that time. The bottom of the umbilical depression had an irregular, wart-like appearance. The surrounding eczema soon yielded to treatment, but there was from time to time an irritating discharge from the umbilicus, which the patient declared was always worse during her menstrual periods.

The umbilicus with the growth and a portion of the surrounding skin was removed. The omentum was not adherent to the umbilicus, and no intestine was seen at operation. The wound healed by first intention and there was no subsequent trouble, so far as could be learned.

On microscopic examination the skin was found to be normal. The stroma of the growth was made up of fibrous tissue and non-striped muscle, scattered among which, without any definite arrangement, were numerous gland elements. Some of these were very near the free surface, others more deeply placed. They were for the most part tubular and lined with columnar epithelium showing large, deeply staining nuclei. They were thought to be reproductions of Lieberkiihn's crypts, but differed from them in their exaggerated dimensions. Some of them were so large that they might almost have been described as cysts. [Dr. Green thought that the growth was a remnant of the vitello-intestinal tract.]

On reading this history I noted that there had been some discharge of blood from the umbilicus, as indicated by the brownish color, and, furthermore, that the patient had always been worse at the menstrual periods. This made me suspect the possible presence of uterine glands at the umbilicus. I wrote Dr. Green and early in July received the following reply:

The Ferns, Romford, England, June 22, 1911. Dear Sir: In reply to your query about my case of umbilical growth, I am pleased to be able to send you a section from the same, so that you may form your own judgment as to its histology. I did not think it was malignant. I last heard of the patient two and a half years after the operation. She was then alive and well. This, I think, shows that the growth was not secondary to an undiagnosed growth within the abdomen. Owing to removal, I have not subsequently heard of her, so I cannot say what ultimately happened to her. I inclose a copy of my paper which I happened to have kept.

Yours faithfully,

Charles D. Green.

  • Green, Charles D. : A Case of Umbilical Papilloma Which Showed Some Activity of Growth

in a Patient Fifty Years of Age and Which was Due Apparently to Inclusion of a Portion of Meckel's Diverticulum. Trans. Path. Soc. London, 1899, 1, 243.


376


THE UMBILICUS AND ITS DISEASES.


We were particularly fortunate in obtaining this specimen from Dr. Green, in the first place, because it was twelve years since the case had been reported, and,



IffF


Fig. 168. — A Small Umbilical Tumor Containing Glands and Stroma Identical with Those of the Uterine

Mucosa. The slide was kindly furnished me by Dr. Charles D. Green, of Romford, England, and is from the umbilical growth reported by him in the Transactions of the Pathological Society of London, 1899. The squamous epithelium is intact, and apart from some thickening appears normal. Scattered throughout the underlying stroma are oval, round, or irregular glands occurring singly or in groups; there are also a few cystic spaces. Some of the glands lie directly beneath the skin. At c two of the glands open directly upon the surface of the umbilicus. Area A has been enlarged and is shown in Fig. 169. The increased magnification of area B is seen in Fig. 170. The photomicrographs of this series were made by Mr. H. H. Hart.

in the second place, because it is one of the most valuable cases of this character thus far on record.

Dr. Green's specimen, No. 125. — The skin surface is intact and practically normal, although at a few points the epithelium is considerably thickened. In


ADENOMYOMA OF THE UMBILICUS.


377


one or two places directly beneath the skin there is small-round-cell infiltration, chiefly in foci. At one point the surface epithelium extends a short distance into a cavity (Fig. 168, c). In the lower portion of the cavity the lining consists of cylindric epithelium, one layer in thickness. Around this area the stroma shows a considerable amount of hemorrhage. It is from this point that there was undoubtedly bleeding at the menstrual periods. The underlying stroma consists to a large extent of non-striped muscle. Scattered here and there throughout the muscle



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Is


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Fig. 169. — Glands from a Small Umbilical Tumor. The picture is an enlargement of the area A in Fig. 168. The normal character of the surface epithelium is clearly seen. The gland spaces vary considerably in size and shape and are lined with cylindric epithelium. Those in the picture lie in direct contact with the dense surrounding stroma.


are glands. They are small, round, oblong, irregular, or large (Fig. 169). A few of them occur singly and lie in direct contact with the surrounding stroma. The majority, however, occur in groups or in chains, and are separated from the surrounding stroma by a definite stroma of their own (Fig. 170), which is recognized by its deeper stain and its abundance of vesicular nuclei, which are oval or round. Some of the glands are very much dilated. Where such dilatations have taken place the surrounding stroma frequently shows a good deal of hemorrhage.


378


THE UMBILICUS AND ITS DISEASES.


Were it not for the presence of the skin surface one would immediately diagnose the specimen as an adenomyoma of the uterus. The picture is typical, as seen from Figs. 168, 169, and 170. The growth is an adenomyoma of the umbilicus. Dr. Green at the time felt sure that the condition was a rare one, as indicated from a second communication dated August 4, 1911:

Dear Dr. Cullen: .... I am glad you found my specimen so interesting. I had some photographs prepared, but the Committee of the Pathological Society did not think them of sufficient interest to insert them in the Transactions. I was a little disappointed at the time, for I thought that the condition was uncommon.

Yours faithfully,

Charles D. Green.



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Fig. 170. — Typical Uterine Mucosa in a Small Umbilical Ttjmob. An Enlargement op Area B in Fig. 168. The three large glands in the right-hand part of the picture, in shape and arrangement, resemble those found in an adenomyoma of the uterus: separating them from the dense tumor growth is a definite and characteristic stroma. The group of glands in the middle of the picture is even more characteristic, one of the glands being dilated. All are lined with cylindric epithelium, and the contrast between the surrounding stroma and the dense growth is very clearly marked. Afl noted in the description, non-striped muscle was found scattered throughout the nodule.


[On looking up the Transactions, I found that two of the committee diagnosed the growth as a columnar-cell carcinoma, but whether primary or secondary they were unable to decide. The chairman of the committee said some of the members present who examined the specimen were not inclined to regard it as malignant. There is little wonder that at that time confusion existed, and had it not been for the specially favorable opportunity I had had of examining so many cases of adenomyoma, I should have undoubtedly overlooked the true origin. — T. S. C]


ADENOMYOMA OF THE UMBILICUS. 379

Adenomyoma of the Umbilicus.* — Case 1 . — In 1883 a woman acquired an umbilical hernia after labor. Ten years later, within the space of about two months, a dark-blue tumor the size of a hazelnut developed on the umbilical elevation. This had two cystic areas on its surface. During menstruation the tumor swelled and the cysts ruptured. They contained blood-tinged fluid. The tumor was extirpated and the hernia repaired. This tumor on section presented a cavernous appearance, but no microscopic examination was made. In 1897, four years later, there was a return of the hernia, and at the umbilicus were two hard nodules about the size of hazelnuts. On microscopic examination they were found to contain glands lined with cylindric epithelium and surrounded by a definite stroma. Here and there bundles of non-striped muscle were in evidence. The dilated glands contained blood-pigment. Mintz thought he was dealing with remains of the omphalomesenteric duct. -- "ishh^^h

[When discussing this case some three years ago, just after making the •':•••

abstract, I made the following note: "The clinical history, the macroscopic appearance, the picture of the glands, the stroma, and the contents of the dilated glands all point to acleno- )

myoma, although adenomyoma of the I ,

umbilicus has never been reported." — T. S. C]

We are fortunate in again hear- J ,,. r , „ TT

=> -blG. 171. (jr LANDS IN A SMALL I MB1LICAL TCMOR.

ing from Mintz on this subject. Ten (Mintz, Case i.)

years later he published an article The outl ying connective-tissue stroma is very ir ., , (it\ -y U 1 1 "AT regular. Occupying the lower half of the field are glands

entitled DaS JNabeladenom, Arch. showing some branching. They are lined with one layer

f. klin. Chil*. 1909 lxxxix 385. Here of cylindric epithelium and lie in a characteristic stroma

, . ., . i j. -i -i-1, l," which separates them from the fibrous tissue of the

he CieSCriDeS, more in detail, the hlS- tumor. The entire picture reminds one to a large extent

tologic findings Of the Same Case. He of adenomyoma of the uterus.

says :

' ' The ground substance of the growth consists of connective tissue not very rich in cells. They cross one another or run parallel with one another in cords. Here and there in the scar tissue one sees gland tubules in either transverse or longitudinal section. They are surrounded by young, very cellular connective tissue, which passes very gradually into the old scar tissue. The glands are lined with one layer of cylindric epithelium. Their lumina are collapsed and contain blood pigment or reddish-colored contents (Fig. 171). In some places the tubules lie close, at other points the} r are separated. The newly formed connective tissue surrounding them has changed into old connective tissue poor in cell nuclei. Some of the glands are dilated and their epithelium is flattened. The lumina appear to be filled with detritus. Here and there the cylindric epithelium is unrecognizable and the cavity contains blood-pigment (Fig. 172). W'here the dilatation has occurred, the epithelium has disappeared; in this way are to be explained the cysts with blood contents which were noted when the patient first entered the hospital. Between the glandular portion of the tumor there are at some points groups of non-striped

  • Mintz, W.: Das wahre Adenom des Xabels. Deutsche Zeitschr. f. Chir., 1899, li, 545.


380 THE UMBILICUS AND ITS DISEASES.

muscle-fibers that have no definite topographic arrangement in relation with the glands. The microscopic examination shows an adenomatous growth in the scar tissue. This has stimulated the growth of the scar tissue, and thus originated the young connective tissue surrounding the new glands. In the mean time the periphery of the nodule in the scar has been converted into sarcoma."

[After giving this description he says in a foot-note that at the time of writing (that is, ten years later) the tumor had not returned. The explanation of the origin of this tumor he gives as persistent remains of the omphalomesenteric duct which had remained latent for forty-two years in the umbilical scar, and under the influence of chronic injury (a ten-year persistent umbilical hernia) had given rise to adenoma.

It can hardly be doubted that we are dealing with an adenomyoma, although such a case had heretofore never been described. We have the increase in size at the menstrual period, the cysts with blood contents, glands resembling uterine glands, the characteristic stroma of the mucosa surrounding the glands, that was

thought by Mintz to be sarcomatous, and the fact that, after the second operation, the patient remained absolutely well for - - - U ten years. How these glands originated

at the umbilicus we do not attempt to ex\ plain. We have, however, found them in

the inguinal region, and I feel confident \ that, in the course of time, somebody will

"""-.. get a clear chain of evidence showing how

remnants of the uterus can reach the umbilicus.— T. S. C]

Fig. 172. — Dilated Glands in a Small Umbilical a a ™ „ 1 i TT m b i 1 i C 8 1 T U m O r

Tumor. (Mintz, Case 1.)

In the center of the field is a very much dilated C O n t a i 11 i 11 g U t e r 1 11 e G 1 a 11 d S .

gland. Its epithelium is flattened. The gland itself is C a S e 2 (Mintz) . The WOllian Was

separated from the surrounding stroma by a definite, , -, . , • i , r tt i '"•'" v . •.'•

was 3 cm. in diameter. Ma- v.. •'•>. 4'V : "--/ v v° /"■ ' ■ ' '".-^k. ■'.'■ "-.• f'4

croscopically, it consisted of a '* ..- V/ v v v~... ,'. . / .' . '

hard, pure white, scar-like tis- ■ ':'! ; •■+ '■'. ■ '■■'■•■. ■-■ ■. "."

sue firmly attached to the skin. ,'.'•. ' ' !-.;•'•. 'v ;

Scattered throughout the turn- m. '■' ■-•../ ..■•' .; "'■... \ .'..-.■

or were a number of pin-head- , v ••• .. . • , v..

sized spaces which contained a % . '." ' '• .< ' v

serosanguineous fluid. His- V. ' v . .. ; f .;1 : \ : ; ;•'•' . ,

tologically, the chief mass con- . /' ' '..';.'"•', KP >, .■■■.'

sisted of fibrous tissue, poor in ... • '•'.; - . . • .. "V- ( - '

nuclei and cell-elements. The OU ;'••-} • ..." "• :;,

skin covering the tumor, ex- ...■'"■ . ; . ..:-■.•

cept that it showed a marked - .-'- ^^/{uH

pigmentation of the basal layer, looked normal. The connective tissue of the skin passed directly into that of the underlying tumor. In the tumor were numerous islands of loose connective tissue which varied markedly in the number of their nuclei; and inside this were epithelial elements. There were two definite histologic pictures. In the portion lying near the skin (Fig. 176) were groups of closely compressed and tortuous gland loops lined with large cuboid epithelial cells having small, centrally located nuclei. The gland lumina and the basement membrane of the tubal glands were easily recognizable. Similar glands were also found in the connective tissue. They were undoubtedly hypertrophic sweat-glands.

Predominating in the central portion of the extirpated tumor was a second kind of epithelial tissue likewise situated in the loose connective tissue, but exceedingly rich in nuclei. This consisted of tubular glands with high cylindric epithelium; cilia and goblet-cells were not visible. Through the fork-like arrangement of the tubular glands there had originated here and there many bay-like spaces which might be mistaken for papillary formations and which had given rise to cystic formations due to the presence of fluid. Here and there the epithelium of the cystic


•V Y


Fig. 176. — A Tumor of the Umbilicus Composed Partly of Hypertrophic Sweat-glands. (After H. Ehrlich.) The glands are gathered into definite groups, reminding one of the gland arrangement in small fibromata of the breast. The individual glands bear a marked resemblance to ordinary sweat-glands. Some of them are dilated. Another portion of the tumor consisted of typical uterine mucosa (see Fig. 177).


384 THE UMBILICUS AND ITS DISEASES.

spaces had disappeared or become flattened. The contents of the cysts were hemorrhagic or showed a formless detritus, and in several places surrounding the cysts were masses of blood-pigment. Van Gieson's stain failed to bring out any smooth muscle surrounding the epithelial elements. This was found only in connection with the vessels of the connective tissue and there not abundantly.

While the glands first described are without doubt hypertrophic sweat-glands, the glands of the second group are, on account of their character and their epithelium, in all probability derivatives of the intestinal tract. Ehrlich speaks of the growth as an adenoma of the umbilicus.

[The reader will note that, judging from Fig. 176, there is no doubt that the first gland elements described by Ehrlich are sweat-glands and that the tumor consisted of sweat-glands. Fig. 177, however, shows everywhere, that the second variety of



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Fig. 177. — Uterine Mucosa in an Umbilical Tumor. (After H. Ehrlich.) To the left are characteristic uterine glands, a few of them dilated. They are surrounded by a definite stroma which separates them from the connective tissue. In the right portion of the picture are similar glands, the majority of which have become dilated. If we take the left half of the picture only, it might very readily pass without any description for a representation of an adenomyoma of the uterus.

glands can in no way be connected with remnants of the intestinal duct, but that we have here typical uterine mucosa enveloped in a definite stroma.

The cystic spaces, as noted in the text, were partly filled with blood. They are nothing more than glands that have been markedly dilated by old menstrual fluid. This is one of the cases in which the definite uterine character of the mucosa is clearly evident. — T. S. C]

A Tumor of the Umbilicus Consisting of a Cystadenoma of the Sweat-glands and a Cavernous Angioma. (Eine Geschwuht d e s N a b e 1 s . Kombination von Cystadenom d e r Schweissdrusen m i t cavernosem Angiom.) — Wullsfein* says that in the literature he has found no tumor similar to the one he is describing. In 1891 a specimen was sent to the Gottingen laboratory. This consisted of an umbilical tumor which had developed in the course of three years and

  • Wullstein, L.: Arb. a. d. Path. Inst, in Gottingen, R. Virchow, zum 50. Doctor-Jubilaum, 1893, 245.


ADENOMYOMA OF THE UMBILICUS. 385

was attached by a thin pedicle, which had not been completely removed. The pedicle had extended into the abdominal cavity. The physician in charge had made a diagnosis of myxofibroma. The patient was a sterile woman thirty-four years of age. In addition to the umbilical tumor, another growth was present in the pelvis. This was the size of a fist, was connected with the uterus, and had spread out diffusely in the neighborhood of the right broad ligament. It could not be regarded as an exudate. The physician was interested to find out whether there was any connection between the two tumors; in other words, whether the umbilical growth was a metastasis. Wullstein examined a Muller's fluid specimen. It was everywhere covered with skin. It had a semicircular form and was about the size of a thaler. The umbilicus was raised 1 cm. above the surrounding abdominal skin, and its surface showed numerous shallow furrows. The umbilical furrow was recognized as an irregular, transverse cleft, which divided the umbilicus into two unequal portions, it becoming deeper and deeper in the middle until there was a depression 11 mm. in depth. About the middle of the under surface of the tumor was a cord about 1 cm. long, hardly as thick as a straw. This was solid and composed of connective tissue. The tumor itself was about 3 cm. long and averaged 1.5 cm. in thickness. On section it was seen that the umbilicus was everywhere covered with skin, which in all portions was thickened and markedly pigmented. From the bottom of the umbilical depression and running parallel were thick bundles of dense connective tissue. The tumor consisted of numerous dense, hard, glistening connective-tissue bundles, which enclosed more or less long or round areas of loose tissue, grayish in appearance, and in the interior in places were small lumina. Subcutaneous fat was absent. In the vicinity of the umbilical scar the tissue was sieve-like. The spaces of the meshwork were filled with dark-brown masses about the size of poppy-seeds. The meshwork consisted of firm connective tissue.

Microscopic examination of a section from the middle of the tumor showed that the epidermis was thickened. The deepest cells of the stratum mucosum were granular, and contained everywhere brown pigment. Only at the base of the umbilicus, where the papillae were not markedly formed, was the pigment absent. Everywhere in the corium and in the subcutis were numerous mast cells. Hair and sebaceous glands were nowhere to be found. The deeper layers of the skin contained normally formed sweat-glands. The tumor consisted chiefly of a connectivetissue stroma and of cavities varying in size and form. The stroma, which in amount predominated over the alveolar tissue, was composed of broad, thick, dense connective tissue, which contained a few cell-elements with spindle-shaped nuclei. Only around the spaces there was present a connective tissue which was very delicate and whose fibers formed a network partly as fine bundles. The numerous nuclei were oval and frequently almost round. Immediately around the alveoli the connective-tissue threads formed a thick layer, really a membrana propria. The cavities were lined with cylindric cells placed at right angles to the basement-membrane. Their height was not always in proportion to the size of the cavity, but seemed to depend on the pressure of the gland contents. In a few places the tubules were filled with epithelium. The gland tubules were usually cut either obliquely or longitudinally. The gland lumina near the periphery of the tumor in width resembled normal sweat-glands. On the other hand, those in the middle of the tumor were markedly dilated and round; in the latter the tissue was frequently infiltrated with cells. The majority of the glands were filled with a secretion com26


386 THE UMBILICUS AND ITS DISEASES.

posed of a most delicate, rather granular network of threads mixed with epithelial cells. The entire tumor was permeated by a thick network of capillaries which surrounded the individual gland tubules. In many places in the connective-tissue stroma in the neighborhood of the blood-vessels were remnants of old and fresh blood.

In the preparations taken from the lateral portion of the tumor accumulations of round cells and blood-vessels were seen. The cystic dilatation of the canals had evidently been produced by pressure from within. The cavities were lined with endothelium, and the walls of these new cavities had projections into them. These cavities were due to the confluence of the neighboring small cavities. The origin of these in some places could be followed. At several points between the bloodspaces were dilated tubules lined with cylindric epithelium, usually filled with secretion, and surrounded by the characteristic connective tissue which sometimes reached as far as the endothelium of the blood-spaces. A few of the gland-like cavities also contained blood. At no point, however, was this adherent.

After these findings we must ask: Are we dealing here with an individual tumor or is there a combination of two tumors? Further, under what category does this tumor formation belong? Wullstein held it to be a combination of cystadenoma of the sweat-glands with cavernous angioma.

On p. 250 he says that what makes him think there is a combination of two tumors is the fact that there is a different lining to the large spaces, the one being lined with endothelium and the other with cylindric epithelium. No less typical is the relation of the surrounding connective tissue to the spaces. The differences even with the low power are easily recognized, through the various microchemical reactions in color with methylene-blue. The above already described delicate bluish connective tissue is independent of the sweat-glands and their tributaries in the specimen, and is present only in the vicinity of the tubules lined with cylindric epithelium, whereas the spaces lined with endothelium are always surrounded by a thick, fibrillated tissue which stains intensely red. He thinks that the large cavernous spaces in the first place are due to circulatory disturbances.

On p. 251 he says we must look upon the sweat-glands as the point of origin for the epithelium of the new-growth, on account of the position of the tumor beneath the skin, the presence of cylindric epithelium, and the absence of squamous epithelial nests. Its origin from the epidermis or from the hair-follicles or the sebaceous glands is excluded. On the other hand, we must ask whether it may not be due to some embryologic deposit. Three things have to be thought of: the umbilical canal, the urachus, and the omphalomesenteric duct. Have we in this mixed tumor a purely accidental combination of an adenomatous cyst of the sweat-glands and a cavernous angioma? or do the two varieties bear a causal relation one to the other? In conclusion, he says, the old and fresh hemorrhages in various portions of the tumor have followed as a result of hyperemia — perhaps the menstrual hyperemia. [Wullstein's tumor also occurred in a woman. He speaks of its characteristic connective tissue separating the glands lined with cylindric epithelium from the surrounding stroma. Further, in his last paragraph he speaks of the hemorrhage through the tumor being due to hyperemia, possibly menstrual in origin. We believe that here he has the clue and that, in all probability, the glands in this case were also uterine glands. Although the description of the histologic appearances in this case is in places somewhat involved, we have in our translation held closely


ADENOMYOMA OF THE UMBILICUS. 387

to the text in order that the points favoring the uterine origin of the glands might not be unduly accentuated. I wrote Professor Orth, of Berlin, and he in turn referred me to Dr. Wullstein, who at the time this case was published (1893) was an assistant of Professor Orth and occupied the room next to mine in the Gcittingen Laboratory. Dr. Wullstein kindly sent me the reprint of his article, but I was unable to get the specimen, and consequently cannot speak with absolute certainty.— T. S. C]

N. Giannettasio, in an article,* gives a resume of the literature on tumors of the umbilicus, and reports a case in a multipara aged forty-four. A year and a half before she came under his observation the patient noticed a small tumor the size of a walnut at the umbilicus. This was solid, immobile beneath the skin, and occasionedno discomfort. It occupied the lower andleft side of the umbilical depression. It was removed, and the patient was perfectly well twenty-five months later. He gives a very good plate, but the text is not satisfactory. The nodule, however, he says, contained "cytogenous" connective tissue. The plate shows normal skin, dilated blood-vessels, and gland-spaces lined with apparently cuboid epithelium, and surrounded by a stroma, the picture somewhat suggesting uterine glands.

Probably Uterine Glands in a Small Umbilical Tumor, f — In the beginning of his article von Noorden states that he is going to demonstrate a tumor which, from its characteristics and anatomic picture, leaves no doubt that it originated from the sweat-glands, and that, so far as he knew, no similar case was on record. On October 1, 1898, a thirty-eight-year-old multipara told him that for two months she had had a slight unevenness in the middle of the umbilicus. Eight days previously a physician had observed a pea-sized enlargement in the floor of the umbilicus. Clinically it suggested a nevus, and on account of the dark pigmentation von Noorden thought of melanosarcoma. On October 14, 1898, the tumor was larger than a pea, semicircular, and not sharply defined from the surrounding umbilical tissue. In its center it had a small, wart-like elevation. There were no inflammatory changes in the vicinity. The skin over the tumor was somewhat uneven, grayish in color, and here and there more deeply pigmented than the floor of the umbilicus. No pulsation was noted, no variation on pressure. The umbilicus was removed. Two and a half years later the patient was perfectly well.

The umbilicus on section showed a drawing in of the skin, and in the depth there was a wart-like projection. The tissue of the umbilicus itself was very hard. On section a pea-sized, light brownish, pigmented area was observed, which was not sharply defined from the surrounding tissue.

Microscopic Examination. — The nodule was made up of a loose connective tissue with numerous large cells. It contained a large number of capillaries. Within this connective tissue were slit-shaped cavities lined with cylindric epithelium which had become loosened irregularly from the wall. Some of these cavities had become dilated into irregular cystic spaces, which here and there showed clearly a lining of cylindric epithelium, while in other places they had completely lost it. The contents of these cavities had dropped out in some places; in others it consisted of cylindric epithelium, and in numerous cases of an irregular, structureless network. Further sections were made, and the squamous epithelial layer over

  • Giannettasio, N. : Sur les tumeurs de l'ombilic. Arch. gen. de nied., 1900, n. ser., iii, 52.

t von Noorden, W. : Ein Schweissdrusenadenom mit Sitz im Nabel und ein Beitrag zu den Nabelgeschwtilsten. Deutsche Zeitschr. f. Chir., 1901, lix, 215.


388 THE UMBILICUS AND ITS DISEASES.

the entire nodule was found to be intact. Over the most prominent part it was three times as thick as at the periphery. Where the cells were most abundant, the deepest layers showed pigmentation. At one point (Fig. 178) "the sweatglands ' ' could be traced almost to the surface, being covered only with a few layers of cells.

The stroma consisted of three definite kinds of tissue : normal, dense fibrous, and mucoid-like tissue. The chief interest lay in the sweat-glands ; roots of hairs were nowhere to be found, and sebaceous glands were reduced to a minimum. The search for muscle-fibers in the reticulate.d tissue was fruitless. No elastic fibers were found.

In general it ma}^ be said the sweat-glands were normal in the subcutaneous layer and were arranged in groups. Then in one section one would find two large openings and three or four glands, and in another section groups of from two to four glands. Some were cut in such a manner that 9 to 15 round lumina were in a









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Fig. 178. — A Small Umbilical Tumor Containing Numerous Glands. (After von Noorden.) This is a low-power picture of the mass. The growth is covered with squamous epithelium. Scattered throughout the stroma are quantities of glands. In form they bear a closer resemblance to uterine glands than to sweat-glands. At one point the glands almost reach the surface. (For a higher magnification see Fig. 179.)

line or in the form of a hook. The groups lay, as a rule, very close to one another. The normal sweat-glands lay partly in the fibrous connective tissue, others — and this is to be noted — were separated by a rather broad layer of cells from the normal corium. The nuclei of this zone were pale and less abundant than in the remaining corium. This zone suggested the above-mentioned mucoid tissue, in which in part the altered glands lay. This tissue appeared always to penetrate between the normal gland grouping, and had separated the glands from one another. The gland epithelium was not changed. In addition to this slightly normal and slightly changed skein-like gland there were in the corium a number of cavities and tubules. These extended from near the surface of the papillary masses to the vicinity of the subcutaneous fat. The cavities and the tubules are to be seen in Figs. 178 and 179. [We do not clearly understand what von Noorden means by corium. It seems, however, that he uses the term instead of stroma. His general description is somewhat hazy throughout. — T. S. C]


ADENOMYOMA OF THE UMBILICUS.


389


On p. 222 he gives a resume of his description: The tumor is made up of many roundish and often dilated, cyst-like portions which lie deeply seated in the corium. In intimate relation to these, or independent of them, are tubular channels with numerous corkscrew-like windings. These extend toward the epidermis. The cystic and also the tubular pictures are surrounded by dense and loose connective tissue which separates them from the surrounding connective tissue and are without any definite capsule. In the above-described coil we can with certainty recognize the sweat-glands.

On p. 229 he reports one of Mintz's cases and says that possibly the new-growth had developed from the glandular portion of the skin; for example, from the sweatglands. He says: "I will also not assume this, but will say that portions of my tumor in respect to form, grouping, contents, and relation of the cells, both in the description and in the picture, produce a very similar appearance to the case reported by Mintz, and had it not been possible to establish a relation to the sweat-glands I should in all probability have followed the views of Mintz. Mintz found smooth muscle-fibers in the connective tissue at several points. The explanation as to the origin is difficult. " In conclusion, von Noorden says: "From the above findings a true benign adenoma springing from the sweat-glands can be diagnosed."

[As will be noted from the history, the patient was a woman thirty-eight years of age. There was no evidence of inflammation. Histologic examination in some places showed groups of glands lying in a stroma differing from the ordinary surrounding stroma. These groups of glands were lined with one layer of cylindric epithelium, and the cavities of some of the dilated

spaces contained cells that had taken up blood-pigment. Yon Noorden draws attention to the fact that his case bore a marked resemblance in many ways to Mintz's case. There remains little doubt in my mind that the glands resemble those found in the body of the uterus, and the thickened, dense stroma around them bears a marked resemblance, even with the very low power, to the stroma of the uterine mucosa. The picture, at any rate, is much more suggestive of a glandular growth of uterine origin than of one coming from the sweat-glands. I endeavored, through Professor Doderlein, of Munich, to locate Dr. von Noorden, and, if possible, secure a section of this growth, but have not been successful. — T. S. C]


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Glands in a Small Umbilical Tumor. von Noorden.) . The glands in the lower half of the picture bear quite a resemblance to uterine glands. Those in the center of the field remind one of the pictures seen in the depths of uterine glands, where there is some reduplication of the folds. The gland in the left part of the field is markedly dilated and contains much detritus.


390 THE UMBILICL T S AND ITS DISEASES.

It is rather difficult to classify this tumor reported by Villar, but as it presents a few clinical and histologic points suggestive of the group under consideration, I mention it here, although it is not considered in the digest.*

L. L.. aged forty-six. entered the service of Professor Guyon September 17, 1886. In the month of December, 1885, nothing abnormal was noticed in the umbilical region, but shortly afterward her corsets produced pain in this region and she discovered a small tumor the size of a pin-head, reddish in color, in the umbilical depression. This tumor increased very slowly, and in May, 1886, she went to the hospital for examination. She continued under treatment, and in the month of August entered the hospital. At that time at the umbilical depression was a tumor the size of a bird's egg. It was conic. Its base was continuous with the cicatrix, and was somewhat constricted by the depression. It had a very narrow, but relatively large pedicle. It was in reality sessile, firm in consistence, but elastic and reddish in color. At the top was a blackish point, 2 mm. in diameter. The tumor itself was not ulcerated and did not discharge any liquid. Two or three days after she entered the hospital the blackish point ruptured and there was an escape of tarry blood. The patient experienced no pain and there was no glandular enlargement.

Histologic Examination by Clado. — The tumor is situated in the center of the umbilicus and has developed in the depth of the cicatrix. It is covered with skin. In consistence it is a little less firm than a fibroma. On section one finds a capsule which surrounds the central mass. The tumor is whitish-gray, with numerous dark spots not any larger than the head of a pin scattered throughout it. Microscopic examination shows that the tumor is formed of sarcomatous tissue, the cells being fusiform in shape.

Some of the spaces are round, others oval, and have anastomosed with one another. Some of the canals are lined with pavement epithelium. Between the cystic spaces one finds stroma containing a small number of vessels. The skin which composes the outer covering of the tumor is exceedingly thin, but presents the characteristic appearance. There has been extravasation of blood at the center of the tumor.

[This woman, as above noted, was fortj^-six years of age. The history does not convince one absolutely that this was a sarcoma. It might very well have been a fibroma. It resembles in a few particulars those tumors of the umbilicus that contain uterine glands or glands somewhat resembling them. — T. S. C]

Further Cases of Adenomyoma of the Umbilicus. These four cases have come to my knowledge since this chapter was prepared.

They bear a striking resemblance to those already discussed in the preceding

pages :

T w o U in b i 1 i c a 1 T u in o r s of Probable Uterine O r i g i n . f " In the surgical service of Drs. Munro and Bottomley, at the Carney Hospital,

there recently occurred within a few weeks of each other two examples of umbilical

tumor, the striking similarity and unusual histologic structure of which warrant

their publication.

  • Villar: Tumours de l'ombilie. These de Paris, 1886, obs. 68.

t ( roddard, Samuel W.\ Surg., Gyn. and Obst,, August, 1909, 249-252.


ADENOMYOMA OF THE UMBILICUS. 391

"Because of the comparative rarity of these cases the clinical histories are set forth in considerable detail :

"Case 1. — Miss S., a housekeeper, forty-four years of age, and born in New Brunswick, entered the Carney Hospital May 22, 1907. Her family and past history have no bearing on her condition at that time. A year previously, during a catamenial period, she noted some redness and tenderness about the umbilicus; two months later, at a similar time, a small tumor appeared in the abdominal wall close to the umbilicus. This tumor increased in size but slightly, and most of the increase came in the two weeks just preceding her admission to the hospital. The tenderness and pain, which at first were evident only during the menstrual periods, had been constant for some months, though most marked just before, during, and for a week after menstruation. Her menstrual history w r as not otherwise remarkable. An abdominal bandage, her only treatment, had given her some relief. There had been some little loss of weight and strength. For two months the tenderness had kept her from her usual work. No symptoms referable either to the gastro-intestinal or to the urinary tract had been noted.

"About and including the umbilicus was a rather deep-seated, spheric, slightly tender, fixed mass, of rather firm consistence, and about 2 cm. in diameter. In the navel itself was a thin, yellowish crust; a sinus could not be demonstrated; the skin over the tumor was not red. Examination of the abdomen was otherwise negative. Examination per vaginam showed only vaginismus and a moderately retroverted uterus.

"On May 23d Dr. Munro excised the growth (including the navel) with a portion of the adjacent peritoneum and sheath of the rectus muscle. The former was not involved in the growth; to the latter the growth was adherent. The convalescence was without note, and the patient was still free from recurrence one year after operation.

"Case 2. — Mrs. D., a housewife, entered the Carney Hospital June 23, 1907. She was born in Ireland forty-two years before that time, and came of healthy stock. Her menstrual history previous to her marriage was entirely normal in every way. Married seventeen years, she had borne four children. Following her first confinement she had had a ' milk leg. '

"For six years previous to entering the hospital a slight bloody discharge from the navel without pain or tenderness had come with each menstruation. The discharge came only at that time. Independent of the umbilical disorder she had had in the past three years attacks of sharp pain beneath the right costal border, accompanied by vomiting, chills, and jaundice.

"The patient was rather obese, and showed distinct tenderness beneath the right costal border. At the umbilicus was a small, irregularly shaped papillomatous tumor, 2 cm. in diameter, with three distinct projections covered with normal appearing skin. At the top of the largest projection was a pin-hole opening capped with dried blood. The tumor was soft, freely movable, not tender, and apparently superficial.

"On June 24th the umbilicus with the tumor was excised by Dr. Bottomley. The tumor was confined to the skin and fat outside the aponeurosis. The peritoneal cavity was opened, and the gall-bladder and stomach regions were explored; these were found normal. Convalescence was uneventful except for the development of malaria on the ninth day, which promptly yielded to treatment. The


392 THE UMBILICUS AND ITS DISEASES.

patient was discharged, relieved, on July 11th, and when heard from, one and a half 3 r ears later, there had been no recurrence.

"For the microscopic study of these tumors, in the laboratory of Dr. Henry A. Christian at the Harvard Medical School, a large number of sections were taken from different planes and four different methods of staining were used for each section.

"So closely do the tumors resemble each other microscopically that no evident difference between them can be determined. The arrangement and construction, both in general and particular, are nearly identical. For descriptive purposes a median longitudinal section of Case 2 will be used. To the naked eye it presents an irregularly convex surface covered with true skin. Underlying this at each extremity are what appear to be sweat-glands, and in another part, chiefly in the center, are numerous vacuolated structures varying in size from a pin-point to a pin-head. The intervening structure cannot be definitely determined. Microscopically, the tumor is seen to be covered with normal epidermis, but varying in thickness. Below this, at either end, are numerous sweat-glands, thickly grouped, and around these is an abundance of fibrous connective tissue. The vacuolated or glandular structures found throughout the tumor vary in size, and for the most part are of rounded contour, while some are elongated. Some, especially the larger ones, are discrete, while others are aggregated into small groups. Some are immediately surrounded by fibrous tissue, while others are embedded in cellular tissue. There are none which appear to have any connection with the epidermis. All the gland-spaces are lined with epithelium. They are either devoid of contents, or contain a granular, structureless material in which are often found groups of red bloodcells. The epithelium varies in the different glands and even in the same gland, from the low, flattened variety to the tall, columnar cells with all the intermediate forms. The tall, columnar variety is for the most part closely compacted, with long, narrow nuclei and with no visible cell membrane. Most of them have a distinct top plate, and many show cilia of considerable length and uniformity, while others have only a suggestion of striae. The cilia in some places are from onefourth to one-third the length of their cells, and in others their extremities end in a globular, deeply staining tip. At irregular intervals among the nuclei of the columnar cells are larger rounded and more faintly stained nuclei. In some places the epithelium is distinctly cuboid, the nuclei clear and rounded, and the whole cell clearly defined. There is a larger group of glands which presents the flattened epithelium. The epithelium lining the glands, whether flattened, cuboid, or columnar, is for the most part in single layers. In some places the glandular epithelium is immediately supported by fibrous connective tissue, but in others the underlying structures are decidedly cellular. The cellular tissue is more compact the nearer the glandular tissue is approached, i. e., the most cellular tissue is found in close connection with the gland-spaces. The nuclei are rounded or elongated and deeply stained, the protoplasm and cell membrane not being distinct. In the immediate neighborhood of some of the gland-spaces are large hemorrhagic areas in which large quantities of red blood-cells are scattered freely and intermingled with the cellular structures. These areas seem to have no direct relation to blood-vessels, which are not superabundant or enlarged. The fibrous connective tissue shows nothing of interest throughout the section. There is an abundance of smooth muscle which is closely interwoven with the connective tissue."


ADENOMYOMA OF THE UMBILICUS. 393

The microphotographs accompanying Goddard's article bring out clearly the structure and arrangement of the tumors, and emphasize the points mentioned above.

Adenomyoma of the Umbilicus; also a S m all Adenomyoma near the Anterior Iliac Spine.* — Case 3. — "A woman, aged thirty-seven, came to me on September 2, 1908, for advice about a small tumor of the umbilicus which she had noticed during the last few months. The lump was about the size of a filbert, and lay in the lower part of the navel. It was irregular in outline, but smooth, and was of a bluish-purple color, suggesting a melanotic sarcoma. There were no abdominal symptoms or signs and no secondary deposits in the inguinal glands or elsewhere. A few days later I removed the whole navel and adjacent skin widely between two elliptic incisions, opening the abdomen on either side and taking away the intervening peritoneum. There were no traces of growth within the peritoneal cavity. The wound was stitched up in layers and healed absolutely by first intention. The specimen was given to Air. Lawrence, the curator of our museum, for examination. Sections showed to the naked eye a hard, fibrous structure, the superficial parts of which, under the epithelial covering of the navel, were pigmented. In the deeper parts of this fibrous tissue were many islands of tubular glands lined with columnar epithelium and filled with epithelial debris. Some were cut obliquely and showed a looser areolar investing layer outside the membrana propria. The latter was not penetrated by the cells, so that one sign of the benign character of the tumor was present. Nor were there any other signs of the spread of the growth beyond the limits of the tubules. L therefore, put it down as an adenoma derived from remnants of the vitelline duct, of which I had read but never seen.

"I saw no more of this lady until January, 1913, when she consulted me about a little nodule seated in the subcutaneous fat, about two inches internal to the left anterior iliac spine. It felt about the size of a pea, and was hard. On gently pinching the skin the latter puckered over the nodule. There were no enlarged inguinal glands or other signs of infiltration. This knot was removed shortly after by Mr. F. Hinds, of Worthing, and was sent to me. Mr. Lawrence kindly prepared several microscopic sections of it. They showed precisely the same structure as the first nodule, except that the fibrous tissue, which made up the bulk of the mass, was more dense and fewer connective-tissue corpuscles were scattered through it.

"The reappearance of this small knot, repeating the structure of the first nodule at the umbilicus, suggests, of course, strongly that the first was malignant and has recurred in the lymphatics of the subcutaneous tissue of the abdominal wall. Then the question arises, Was the original lump in the umbilicus a primary growth in some of the glandular remnants of the umbilicus enumerated above, or could it be a nodule secondary to some visceral carcinoma within the abdomen? This latter view is one adopted by Mr. Shattock, to whom I sent sections of both the first nodule removed and that obtained four and a half years later, and who was kind enough to write to me fully on the subject. It may be correct, but so far the lady has shown no evidence of visceral trouble — nearly five years after the appearance of the first nodule in the umbilicus. Time alone will show. In the meanwhile I am inclined to negative the visceral theory."

  • Barker, A. E. : Three Cases of Solid Tumours of the Umbilicus in Adults. The Lancet,

London, July 19, 1913, 128.


394 THE UMBILICUS AND ITS DISEASES.

In answer to a request from me, Dr. Barker very kindly sent the only section of the umbilical tumor which the curator of the museum still possessed.

Description of the slide sent me by Dr. Barker (His No. 10,945). — The section of the umbilical nodule has a normal covering of squamous epithelium. The underlying tissue shows no evidence of glandular tissue. Dr. Barker, however, in his description of the case, says that this tumor contained glands, and, furthermore, that the glands near the anterior-superior spine were similar in character to those found at the umbilicus. Dr. Barker was good enough to also send me several slides from


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Fig. ISO. — Adenomyoma in the Abdominal Wall near the Anterior Iliac Spine. This is a photomicrograph of a portion of the small nodule furnished me by Mr. Arthur E. Barker, London, England. Near the center of the field are two glands. Their epithelium has been slightly strengthened to bring them out more distinctly. The glands are lined with one layer of cylindric epithelium. Surrounding them is a zone of stroma cells. This zone is continuous with a large, irregular area of stroma just below and to the left of the glands. In the upper part of the field is another gland, which lies in direct contact with the tissue of the tumor. The greater part of the nodule consLsts of non-striped muscle and fibrous tissue. In the outlying portions of the field is adipose tissue. The growth is a typical adenomyoma, with glands similar to those of the uterine mucosa. Mr. Barker, in his description of the case, says that the umbilical nodule and the one here depicted were identical in character; consequently the umbilical growth was also an adenomyoma with glands and stroma identical with those of the endometrium of the uterus.

the growth near the anterior-superior spine. In one section I found not only myomatous tissue, but a triangular area of stroma with tubular glands at one end Tig. 180;. This area was sharply defined from the surrounding tissue. In another section was what appeared to be fibrous tissue, and possibly a little muscle. Here we had irregular, triangular areas of stroma, sometimes without any glands, sometimes with tubular glands identical with those of the uterine mucosa. At other points the glands lay in direct contact with the muscle. Surrounding the entire growth was adipose tissue. The picture in the main is analogous to that which we


ADENOMYOMA OF THE UMBILICUS. 395

have described as representing adenomyoma of the umbilicus. Mr. Barker's case is particularly interesting in that he had not only a tumor of this character at the umbilicus, but also a nodule near the anterior iliac spine.

A Small Umbilical Tumor Consisting i n P a r t o f Sweatglands and in Part Apparently of Uterine Glands.- — While in Atlanta, at the meeting of the Southern Surgical Association in December, 1913, Dr. Edward G. Jones, of Atlanta, told me that he had recently seen an umbilical tumor in which I might be interested. On December 22, 1913, he wrote: "I am sending under separate cover a section of the umbilical tumor. Unfortunately, I cannot give you any clinical data. The nodule was three-quarters of an inch in diameter, and gave the patient some discomfort at times." Later Dr. Jones discovered that, according to the patient's account, the tumor seemed to her to enlarge at the time of menstruation.

The specimen sent me by Dr. Jones is covered over with squamous epithelium which contains pigment in the deeper layers. The underlying tissue consists in a large measure of fibrous tissue. The capillaries scattered throughout it are in many places surrounded by round cells. Here and there throughout the fibrous tissue are groups of sweat-glands. These are separated from the fibrous tissue by a definite stroma.

At other points are large glands lined with cylindric epithelium. Some of these glands lie in direct contact with the fibrous tissue; others have a definite stroma, separating them from the connective tissue. This stroma stains more deeply than the connective tissue, and its nuclei are oval and stain deeply.

The tumor is evidently made up of two distinct varieties of glands: some corresponding to sweat-glands and others bearing a marked resemblance to those of the uterine mucosa. There is little doubt that part of this growth consists of uterine glands. The section was, unfortunately, too thick to supply a satisfactory photomicrograph.

PERSONAL OBSERVATION.

In 1900 Mrs. E. J. D., aged thirty-eight, was admitted to Dr. Howard A. Kelly's Sanitarium on account of a retroflexed uterus and a relaxed vaginal outlet. A small round nodule was at the same time detected at the umbilicus. The nodule was removed, the uterus brought up into position, and the perineum repaired. Her convalescence was prolonged on account of phlebitis in both legs.

This patient was the mother of four children. Her menses began at thirteen, were fairly regular, and lasted from three to five days. About two years before admission the patient first felt a little pain in the umbilical region. During the last year this had become very severe and the small umbilical growth had developed. There was no reddening at the umbilicus, and the general health had not been affected.

This small umbilical tumor was brought over to the gynecologic laboratory of the Johns Hopkins Hospital and carefully examined. For some unforeseen reason it was not indexed, and, consequently, when we were getting together all our umbilical material, was overlooked. It was accidentally discovered when class sections were being gone over a few days ago (March 3, 1915). Dr. Elizabeth Hurdon, who examined the specimen at the time, drew special attention to the fact that the


396


THE UMBILICUS AND ITS DISEASES.


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Fig. is). — A Small Umbilical Tumor Containing Glands Similar to those of the Body of the Uterus.

Gyn.-Path. No. X'.lll. This is a low-power photomicrograph of a section of the entire umbilical nodule. The skin covering is normal. Occupying the lower half of the field is a somewhat circular growth, denser in structure than the surrounding stroma. It consisted of fibrous tissue and non-striped muscle. Scattered throughout the tumor are glands. Some occur singly, others in groups. Some of the smaller glands are surrounded by a dark zone — a zone of characteristic stroma. Many of the glands are dilated and partially filled with blood. In the upper part of the field are aggregations of sweat-glands. (For the higher power picture see Figs. 182 and 183.)


ADENOMYOMA OF THE UMBILICUS.


397


glands in the growth were similar to those of the endometrium , and that some of them were surrounded by the characteristic stroma of the uterine mucosa.

Gvn.-Path. No. 39 14. The tumor averages 1.5 cm. in diameter.




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Fig. 182. — Adenomyoma of the Umbilicus. Gyn.-Path. No. 3914. This picture gives an enlargement of the adenomyoma seen in Fig. 181. The stroma of the growth consists of non-striped muscle and fibrous tissue. Occupying the center of the field are several glands. They were lined with one layer of cylindric epithelium, on which cilia were here and there demonstrable. The glands are separated from the muscle by a definite stroma. This, with a higher power, was found to be identical with that of the endometrium of the uterus. In the left upper corner of the picture is a markedly dilated gland. This and other dilated glands contained old blood and exfoliated epithelial cells, which had taken up blood-pigment and had become spheric. The entire picture of the umbilical tumor is analogous to that of an adenomyoma of the uterus.

Its outer surface is covered with normal-appearing skin. On section it presents a dense fibrous structure.

On histologic examination the skin surface is found intact and normal. The stroma of the growth consists of fibrous tissue with a moderate amount of nonstriped muscle distributed throughout it.


398


THE UMBILICUS AND ITS DISEASES.


Scattered here and there throughout the nodule are round or tortuous glands. Some of these occur in groups, others are single (Figs. 181 and 182). The glands are lined with one layer of low cylindric epithelium, which in a few places shows definite cilia. Some of the gland cavities are empty, others are dilated and filled with old blood, and in a few are exfoliated epithelial cells which have become spheric and have taken up the blood-pigment. Some of the glands lie in direct contact with the muscle or fibrous tissue; others are separated from the dense tissue by a



Fig. 183. — A Group of Sweat-glands in an Umbilical Tumor. Gyn.-Path. No. 3914. For their relation to the adenomyoma of the umbilicus see Fig. 181.


definite stroma, which is very cellular. The picture is that of a typical adenomyoma with glands identical with those of the uterine mucosa.

At one point is an aggregation of glands of a totally different type. These glands are small, round, and have a lining of two layers of low cuboid cells. They closely resemble sweat-glands (Fig. 183).

This is another definite example of an adenomyoma of the umbilicus. It will be remembered that in several of the recorded cases the sweat-glands were markedly increased in number.


ADENOMYOMA OF THE UMBILICUS. 399


LITERATURE CONSULTED IN THE PREPARATION OF UMBILICAL TUMORS CONTAINING UTERINE MUCOSA OR REMNANTS OF MULLER'S DUCT. Barker, Arthur E.: Three Cases of Solid Tumours of the Umbilicus in Adults. Lancet, London,

July 19, 1913, 128. Cullen, Thomas S.: Umbilical Tumors Containing LTterine Mucosa or Remnants of Midler's

Ducts. Surg., Gyn. and Obstet., May, 1912, 479. Ehrlich: Primares doppelseitiges Mammacarcinom und wahres Nabeladenom (Mintz). Aus

von Eiselsberg's Klinik. Arch, f . klin. Chir., 1909, lxxxix, 742. Giannettasio : Sur les tumeurs de l'ombilic. Arch. gen. de med., 1900, n. serie, iii, 52. Goddard, Samuel W.: Two Umbilical Tumors of Probable Uterine Origin. Surg., Gyn. and

Obstet., August, 1909, 249. Green: Trans. Path. Soc. London, 1899, 1, 243. Herzenberg: Ein Beitrag zum wahren Adenom des Nabels. Deutsche med. Wochenschr., 1909,

i, 889. Mintz, W.: Das wahre Adenom des Nabels. Deutsche Zeitschr. f. Chir., 1899, li, 545. von Noorden, W. : Ein Schweissdrtisenadenom mit Sitz im Nabel und ein Beitrag zu den Nabel geschwulsten. Deutsche Zeitschr. f. Chir., 1901, lix, 215. Villar, Francis: Tumeurs de l'ombilic. These de Paris, 1886. Wullstein, L.- Eine Geschwulst des Nabels. (Kombination von Cystadenom der Schweiss driisen mit cavernosem Angiom.) Arb. a. d. Path. Inst, in Gottingen, R. Virchow, zum 50.

Doctor-Jubilaum, 1893, 245.


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.


Chapter XXVI. Sarcoma of the Umbilicus

Telangiectatic myxosarcoma.

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.


TELANGIECTATIC MYXOSARCOMA.

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


450


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

other arteries.


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,

cxxi, 513.


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.


452


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,

1890.

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.)


Chapter XXVII. Umbilical Hernia

Hernia into the umbilical cord.

Amniotic hernia.

Congenital nipping off of an umbilical hernial protrusion.

Small umbilical hernia at birth.

Serous umbilical hernia; report of cases.

Serous umbilical hernia in children.

Escape of serous fluid from the umbilicus in a case of tuberculous peritonitis.

Serous umbilical hernia associated with an ovarian cyst.

A serous umbilical hernia associated with a large cystic myoma and marked abdominal ascites.

Umbilical hernia in the adult; radical cure in a patient weighing 464 pounds.

Cysts of the umbilicus.

Umbilical hernia has been so thoroughly considered in the texi>-books on surgery that I shall here confine myself to a very brief description of the various forms of hernia in this region.

1. Hernia into the umbilical cord.

2. Amniotic hernia.

3. Congenital nipping-off of a hernial protrusion.

4. A small umbilical hernia at birth.

5. Serous umbilical hernia.

6. Umbilical hernia in the adult.

7. Cysts of the umbilicus.

HERNIA INTO THE UMBILICAL CORD.

A reference to the chapter on Embryology (Fig. 8, p. 8; Fig. 10, p. 10; Fig. 11, p. 11, and Fig. 12, p. 12), will show that in the early months of fetal life the greater portion of the small intestine lies in the umbilical cord. This extra-abdominal cavity is called the exoccelomic cavity. The intestine gradually withdraws into the abdomen, and the cavity in the cord becomes obliterated.

In rare instances, however, this opening does not close. In such cases at birth there is a cystic swelling at the fetal end of the cord. The cyst-walls are very thin, consisting, for the most part, of the amnion and of peritoneum; consequently, the intestinal loops within the sac are readily visible.

I shall refer to only three cases of this character — one mentioned by Sheen, one by D'Arcy Power, and the third reported in detail by Reed.

Sheen* mentions the case of a patient seen by Hope at Queen Charlotte's Hospital. At birth there was a hernial protrusion into the cord. It formed a mass the size of a hen's egg. The neck of the sac was covered with skin, and the fundus with the covering of the cord. The umbilical vessels were spread out over the right

  • Sheen, William: Some Surgical Aspects of Meckel's Diverticulum. Bristol MedicoChirurg. Jour., 1901, xix, 310.

459


460


THE UMBILICUS AND ITS DISEASES.


side of the sac. The sac contained large and small intestine. The small bowel was adherent to the sac, but was separated without difficulty. What appeared to be the vermiform appendix was so intimately fused with the tissues of the umbilical cord that it had to be ligated and cut off. The child recovered.

D'Arcy Power's* patient was a full-term boy. At the fetal end of the umbilical cord was a transparent sac containing several coils of small intestine (Fig. 196). Taxis was employed, but it was found impossible to push the bowel back into the abdomen. The sac was opened, and it was also necessary to cut the umbilical ring. About one foot of small intestine lay in the sac. After the bowel had been returned



I it


o o



Umb.



1^-Cyst


Fig. 196. — A Case of Congenital Umbilical Hernia. (D'Arcy Power.) The labor was quite normal. Situated in the cord near the abdomen was a transparent sac containing several coils of small intestine. The cord was ligated and divided and an ineffectual attempt was made to replace the bowel through the umbilical opening. After the application of gentle taxis for ten minutes the umbilical ring was enlarged and a foot of small intestine was then with some difficulty returned into the peritoneal sac. The edges of the ring were subsequently brought together with silver wire. The child died of peritonitis three days later. The tumor appeared to be formed of a dilatation of the covering of the cord, which was fusiform in shape and had the main constituents of the abdominal cord running as a band along its lower border. The wall of the sac consisted of a thin, soft membrane which was so transparent that the coils of intestine could be seen through it. At the apex of the tumor the cord reappeared and had on its under surface a cyst containing viscid fluid.


into the abdomen the hernial ring was closed. The child died of peritonitis on the third day.

Powers said that Scarpa and Sir William Lawrence, in their classic treatises on rupture, have given a complete account of this variety of hernia.

One of the most remarkable cases of this character on record is that furnished by Edward N. Reed,f of Clifton, Ariz. The prompt and efficient manner in which Reed treated his case shows how much can occasionally be accomplished even when the outlook is most unfavorable.

  • Power, D'Arcy: A Case of Congenital Umbilical Hernia. Trans. Path. Soc. London, 1888,

xxxix, 108.

t Reed, Edward X.: Infant Disemboweled at Birth — Appendectomy Successful. Jour. Amer. Med. Assoc, July 19, 1913, 199.


UMBILICAL HERNIA. 461


Reed says:


"I was called to attend Senora Y. A., a Mexican woman, in confinement, March 14th. I found that the head of the infant was already free, and with the next pain, a moment later, the trunk was expelled. I was astonished at finding that the whole intestine, both small and large, was outside the abdominal cavity. Examination showed that the bowels had passed along inside the cord for about two inches, at which point the walls of the cord had ruptured, allowing the bowels to escape laterally.

"No preparations for the confinement had been made; the bed was filthily dirty, and the mass of intestines was thickly sprinkled with bits of straw, feathers, crumbs of food, and fecal matter from the mother.

"I had left the bedside of a woman just about to be delivered in order to respond to this call. I hurriedly ligated the cord, delivered the placenta, and wrapping the baby in the cleanest thing I could find, returned to the patient I had left.

"Finishing this case I called my colleague, Dr. T. B. Smith, and we went together to see the disemboweled infant and took it at once to the Arizona Copper Company's Hospital. It was placed on the operating table two hours after birth. By this time the bowels were matted together with fibrinous adhesions, which included many of the particles of debris mentioned above. They were cleansed gently with sponges and warm salt solution, but this cleansing was not very thorough, of course. The appendix, three-fourths of an inch long, seemed to be contused and swollen, and a catgut ligature was thrown around its base and it was then removed. The umbilical opening admitted the tips of two fingers. It was enlarged for half an inch upward and downward, and the cord-bearing edges were trimmed off. The intestines were then replaced, and a hurried closure was made with one layer of buried catgut and one of silkworm-gut.

"The child made an uneventful recovery, save for one small stitch-abscess, and is at this date well and growing normally."

In cases of this character the wisest plan is to do a radical operation at once. If no operation be performed, the cord must be ligated at a point distal to the hernial sac, but even if the intestine can be easily replaced, the thin-walled sac still persists, and, as its walls consist merely of amnion and peritoneum, they are liable to tear and there will then be great danger of peritonitis.

AMNIOTIC HERNIA.

In 1881 Nicaise* referred to the amniotic umbilicus. He said that, according to Widerhofer, it is characterized by an absence of skin around the umbilicus, the defect being replaced by amnion which is reflected upon the abdomen from the cord. In such cases the surrounding abdominal wall is generally intact. The amniotic umbilicus does not usually interfere with the health of the child. In the case mentioned by Nicaise the amniotic disc was gradually replaced by scar tissue and the umbilicus completely closed.

R,unge,f in 1893, when discussing this subject, said that in rare instances there is a preponderance of amnion and a lack of skin at the umbilicus, and that this condition is spoken of as an amniotic umbilicus.

Where an amniotic umbilicus exists, the intra-abdominal pressure naturally tends to produce a hernial protrusion at the navel, particularly if the abdominal skin and underlying muscular walls are lacking over a wide area.

  • Nicaise: Ombilic, Diet, encyclopedique des sciences medicales. Paris, 1881, 2. ser., xv, 140.

f Runge, M. : Die Wundinfectionskrankheiten der Neugeborenen. Die Krankheiten der ersten Lebenstage, Stuttgart, 1893, 2. Aufl., 56.


462


THE UMBILICUS AND ITS DISEASES.


Stewart,* in 1905, reported the case of a well-developed male child with a hernia of the cord the size of a ver}*- large apple. The cord dropped off at the usual time, leaving the sac exposed. The child thrived well. Stewart advised non-interference, but the parents were particularly anxious that something should be clone. Consequently a plastic operation was attempted. The sac contained a portion of the intestine and the whole of the liver so firmly adherent to the apex of the sac that its separation was impossible.

In 1903 Dr. S. E. Sanderson, f of Detroit, saw a new-born babe in whom the anterior abdominal walls had failed to develop. The entire abdominal contents were visible through a thin, transparent covering. The covering, being distended, allowed the abdominal organs to press forward, forming a sort of "total hernia,"



Fig. 197. — An Amniotic Hernia. (Photograph of Dr. H. Wellington Yates' case.) The photograph is of a new-born eight-month child with a large hernial protrusion occupying the greater part of the anterior abdominal wall. The walls of the hernia were composed of a very thin membrane, which was almost transparent and which appeared to consist of amnion and peritoneum. The skin of the abdominal wall extended up the sides of the sac for a very short distance. The sac contained the greater part of the bowel.


while the partly developed abdominal wall, composed of skin, muscle, and peritoneum, was retracted.

When Sanderson first saw the child it was one day old, was strong, in good condition, and seemed to be unaffected by the physical defect. It nursed and cried, as do other new-born babes. The thin abdominal covering had, however, begun to dry, and the intra-abdominal pressure had already produced a marked protrusion. Dr. Sanderson felt that the opportune time for repairing the defect was past, but as a last resort he advised operation. This was performed at the Grace Hospital. Sanderson, after resecting half of the liver, was able to bring the muscles and skin together. The child stood the operation well, but died twenty-four hours later.

As pointed out by Sanderson, the time to operate is immediately after birth,

  • Stewart, G. C. : Hernia of the Umbilical Cord. Brit. Med. Jour., 1905, i, 247.

f Personal communication.


UMBILICAL HERNIA. 463

before there is any drying out of the thin membranous covering of the abdominal wall, and before the hernial protrusion has been increased in size by the accumulation of fluid in the stomach. As mentioned above, Sanderson was not called to see this case until twenty-four hours after birth.

In January, 1913, I gave an address in Detroit, on Diseases of the Umbilicus before the Wayne County Medical Society, and shortly afterward received the following letter from Dr. H. Wellington Yates, of that city:

"Detroit, February 1, 1913. "My dear Doctor. A short time ago I reported a case of congenital hernia of the cord in the new-born at the Wayne County Medical Society. I referred in my paper to three other cases which I had previously observed, together with references to those which had been reported in the literature up to that time. After the meeting your brother Ernest asked me if I would not send you a brief review of the cases reported, together with my reprint of 1907. I therefore take pleasure in inclosing these data, together with a copy of the picture of the case in question. I feel fortunate in having had four cases of this type come under my observation, and shall be glad if you can use the picture or case to any advantage.

"Very respectfully,

"H. Wellington Yates."

The picture referred to by Dr. Yates is reproduced in Fig. 197. The child was born on January 11, 1913. It was an eight-month child, weighed six pounds, and was 183^2 inches long. Occupying the greater part of the abdominal wall was a hernial protrusion. This was 14 cm. broad and 17 cm. long. The child was otherwise well formed. Yates says that he was, unfortunately, unable to get an autopsy. The walls of the hernial protrusion were almost transparent, and apparently consisted of merely amnion and peritoneum. At the base the skin was continued for a short distance upon the sac. From what Yates could gather, the larger part of the intestine was in the sac.

It is obvious that in all such cases the only chance of saving the child is by operating immediately after birth.


CONGENITAL NIPPING-OFF OF AN UMBILICAL HERNIAL PROTRUSION.

In our study of the embryology of the umbilical region we have seen that in the early months a large part of the small bowel lies out in the umbilical cord. Later the intestine recedes into the abdomen. The cavity in the cord becomes obliterated and the umbilical ring closes. If for any reason the bowel becomes adherent to the cavity in the cord, it may be impossible for the adherent portion to pass back into the abdomen. If such a condition exists and the umbilical ring closes, we shall have one or more loops of small bowel nipped off and lying on the abdominal wall. Fortunately, such a condition is very rare. That it may occur, however, is clearly shown by instances reported by Kern and Ahlfeld.

Kern* reports an observation made by Meckel. Meckel, in examining a four months' embryo seven inches long, found malformations of the lower extremities and of the heart, and, in addition, noted that the intestine was divided into two halves, which did not communicate with each other. The upper or stomach half consisted of the normal stomach and of 11 inches of intestine. The intestine was

  • Kern, Theo.: Leber die Divertikel des Darmkanals. Inaug. Diss., Tubingen, 1874.


464


THE UMBILICUS AXD ITS DISEASES.


Dhv


Pv.


for the most part of normal caliber, but for a space of one inch was dilated to four times the normal diameter. It then gradually became smaller and passed out through the umbilicus. It extended outward on the abdomen one inch, and then contracted down to a very fine thread. This passed over into an equally fine thread, which was continuous with the upper end of the lower portion of the intestinal canal. This is a good example of the nipping-off of the intestine outside the abdomen in early fetal life. In this case the umbilical ring was still open.

Ahlfeld.* in 1872. was asked by a midwife to examine a child with a rather unusual tumor. The child was six hours old, had passed no meconium, and cried constantly. It was well nourished and apparently healthy. At the navel was an

irregular tumor the size of an apple , v \ s (Fig. 198). This tumor was attached

^^y to the umbilicus by a very thin

jfk. pedicle.

It was clearly evident that the tumor consisted of a nipped-off intestinal convolution. The individual parts of this were firmly adherent to one another as a result of adhesions. The tumor was hard in consistence, and was attached to the umbilicus by a definite pedicle.

The anus was well formed, and a flexible catheter could be passed into the rectum for a considerable distance. The rectum, however, contained no meconium.

The tumor was removed by Professor Crede, and the pedicle was found to be solid. Under the existing circumstances it was deemed advisable to make an artificial anus above the umbilicus, but the child died.

At autopsy it was found that the stomach was in the normal position. The duodenum and jejunum were markedly dilated, while the portion of the intestine between the enterostomy opening and the umbilicus was wide and flat. At a point 1 cm. above the umbilicus the intestine ended blindly, and from there to the umbilical ring there was nothing but a delicate strand of mesentery.

The ascending colon passed toward the pedicle of the tumor and ended blindly at the umbilical ring. The remainder of the bowel to the anus was small and filled with mucus.

The condition was due to the fact that a portion of the intestine lying on the abdomen had been cut off by closure of the umbilical ring.

  • Ahlfeld: Zur Aetiologie der Darmdefecte und der Atresia ani. Arch. f. Gyn., 1873, v, 230.



Dnd.

Fig. 19S. — Several Loops of Bowel which Lay Outside the Umbilicus and were Xipped Off Dubixg Fetal Life. The Child Lived a Short Time After Birth. (After Ahlfeld.)

XI:, Umbilical elevation: Vs, umbilical cord; Dnd, small bowel; Died, large bowel; Pv, vermiform appendix. It will be noted that the pedicle of this tumor is very narrow at the umbilicus. It then expands somewhat and again becomes exceedingly narrow. The intestine forming this mass was totally cut off from the portion in the abdominal cavity.


UMBILICAL HERNIA. 465

Fortunately this complication is a great rarity. Should such a condition be noted at birth, immediate operation is indicated. After the umbilical growth has been cut off, the abdomen should be opened and the upper and lower portions of the bowel united by a lateral or end-to-end anastomosis.


SMALL UMBILICAL HERNIA AT BIRTH.

Hernise of this character are relatively common. On referring to Fig. 30 (p. 27) we see the umbilical weak spot. This is usually to the right of the umbilical vein, and above the umbilical arteries. In this connection it will be well for the reader to study the normal appearance of the umbilical ring as viewed from the peritoneal side (p. 39). A careful study of Plate VI will give a clear idea of the various appearances of umbilical herniae.

In the young infant the hernia is usually not over 1 to 2 cm. in diameter, and when an appropriate pad is applied, as a rule, gives rise to little trouble. The hernia tends to diminish gradually in size and may soon disappear. In those cases in which it persists, operation may be deemed advisable. In such cases a small longitudinal incision may be made, the edges of the ring dissected away, and the surfaces carefully approximated. It is often difficult to bring the peritoneum together as a separate layer, on account of its extreme delicacy in the infant.

One of the most ingenious and apparently the safest method of curing umbilical hernia in children is that practised by Nota, of Turin. His method has been clearly described by Brun.

Brun* expatiated on the ease, harmlessness, and effectual outcome of the method which Nota, of Turin, has applied since 1890 to 244 children from two months to nine years old. The earlier the operation, the smaller the hernia and the better the outcome. An elastic cord 30 to 40 cm. long is passed around the base of the hernia with a long curved needle worked through horizontally under the skin. The hernia is then reduced and held in place with the finger, while the elastic cord is drawn tight until the opening is entirely obliterated. The ends of the cord are then held with a clamp and tied with silk close to the skin and cut off, the short ends only being left protruding. The cord is drawn taut by an assistant, while the reduced hernia is controlled by the operator. In the course of a few days the rubber cord gradually cuts through the soft tissue in its grasp, the tissues growing together in its wake and thus solidly closing the opening. After twelve or fifteen days the entire rubber cord comes out through the hole in the skin from which the ends protrude, and a thick, solid cicatrix is left around and on the top of the old hernial opening. The dressings are not disturbed for ten days ; then a new dry dressing is applied, and it is wise to have the child wear a simple cloth binder around the abdomen for two or three months afterward. The elastic cord is sterilized by soaking for an hour in 70 per cent, alcohol containing 1.5 per cent glacial acetic acid. No complications of any kind were ever observed and the abdominal wall gradually becomes smooth and supple. Recurrence was observed in only one case — that of a young infant with a hernia 5 cm. in diameter. The hernia recurred during an attack of coughing, but was radically cured six months later by a repetition of the procedure. General anesthesia is not required for infants; for older children Nota uses a few whiffs of

  • Brun: Treatment of Umbilical Hernia. Jour. Amer. Med. Assoc, 1912, October 26,

1578. Abstract from Arch, de medecine des enfants, Paris, Sept., xv, No. 9, 641. 31


466 THE UMBILICUS AND ITS DISEASES.

ethyl chloric!. The child comes to at once after the little operation, which never takes over six minutes, and can be taken home if kept quiet.

SEROUS UMBILICAL HERNIA.

In some instances in which the abdomen contains a large quantity of ascitic fluid, the umbilicus unfolds, as it were, and becomes distended, so as to suggest an umbilical hernia. Indeed, the condition has been termed a serous umbilical hernia. While this unfolding of the umbilicus is not very common, still it is by no means rare. The reason that so little has been written on the subject is evidently due to the fact that the accumulation of ascitic fluid in the umbilical sac has been looked upon as a perfectly natural accompaniment of the abdominal distention associated with a large amount of ascitic fluid.

The chief articles on the subject are those of Catteau (1876), Gauderon (1876), Nicaise (1881), Ledderhose (1890), Gallant (1906). and Perrin (1910). Nicaise referred to cases reported by Brehm. Van Home, Xuck, and Morgagni, and Ledderhose. to one recorded by Pineo-Hyannis.

Catteau examined the umbilicus in 19 cases of ascites, with the following results:

Slight projection of the umbilicus in 11 cases

Unfolding of the umbilicus in 3 cases

True umbilical hernia in 5 cases

Perrin. discussing this subject in 1910, said that in 32 cases of abdominal ascites that he collected, the umbilicus was more or less distended in 9 cases. He also said that Bertrand, in 28 cases of abdominal ascites, had noted umbilical distention in 6 cases. It is thus clearly evident that a serous umbilical hernia is no great rarity.

Clinical Course. — The majority of the patients concerning whom we have records were women between thirty and sixty-five years of age, but the umbilical dilatation may also occur in men. The ascites was usually attributable to chronic nephritis, cirrhosis of the liver, cardiac dilatation, or to a combination of these. When the ascites was first noticed, no change in the umbilicus was detected, but with the gradual abdominal distention alterations in the navel developed.

The Umbilical Tumor. — With increased abdominal tension the umbilicus gradually unfolds and a small hemispheric prominence is noted. This


Plate VI. Umbilical Herxia.

All but the last | No. 11) of the cases of umbilical hernia here depicted were accidental discoveries made during the study of normal umbilici on patients in the hospital wards. The results of this study are pictured on Plates I-IY.

In the fetus and new-born a small hernial protrusion at the upper margin of the umbilicus, or occasionally on the upper right or left, may be regarded as entirely normal. In the erect posture and on straining or coughing this small congenital hernia always becomes more pronounced, and an invisible hernia may thus become demonstrable. There is marked diastasis of the recti muscles in Xos. 1, 2, 3, 6.

The most prominent part of the hernia may contain the umbilical cicatrix (Xos. 1, 3, 6); the usual location is below the hernia. In the course of a few years this scar gradually becomes effaced (No. 3), and may entirely disappear (No. 5). Pregnancy also has a tendency to smooth out the folds of the scar (Xo. 4). Immediately afterbirth the skin over the navel puckers up (No. 9) and remains permanently so in a woman who has had many children (Xo. 7). The herniae in both Xos. 7 and 9 were capable of much distention, but were drawn while devoid of contents. No. 11 represent- a large multilocular hernia filled with adherent masses of omentum. This also was drawn when the patient's abdominal walls were relaxed. For the further appearances in this case see Fig. 203, p. 475, and Fig. 204, p. 476. Xo-. B and 10 are small hernia in the male adult. Xote the faint parumbilical vein coursing over the hernial sac in No. 8. In Xo. 10 the hernia was covered by perfectly white skin. The patient was a very dark-skinned negro, who had leukoplakia over the thighs, genitalia, etc. Thus in this case, there was a white umbilicus in a coal-black negro.


UMBILICAL HERNIA.

PLATE VI.


467



Female, age 58, IWIbe, 7 para Female , age 35 , ^6^+lbs. 5para


468 THE UMBILICUS AND ITS DISEASES.

may be very small, or reach 2 or 3 cm. in diameter. The overhang skin looks normal, and often the sac is seen to contain clear fluid. Sometimes, however, this can be detected only by transmitted light.

As the intra-abdominal pressure continues, the umbilical tumor may become as large as a goose's egg or an orange and may be either hemispheric or lobulated. When the hernia reaches such a size, the overlying skin is usually greatly stretched, and the fluid contents of the sac are easily distinguishable. The fluid from the sac can usually be forced back into the abdomen with or without gurgling, after which the finger can usually make out the sharp, hard margins of the umbilical ring. When the pressure is released, the fluid at once flows back into the sac, producing, as pointed out by Raciborski (Xicaise), a peculiar thrill.

Occasionally, when the sac is small, it may also contain a loop of small intestine, but where the abdominal distention is marked, it contains nothing but the fluid. This is evidently due to the fact that when the abdominal distention is marked, the mesentery of the small bowel is not long enough to allow the intestine to reach the abdominal wall.

As a rule, the serous umbilical hernia is only an incident in the course of the nephritis, cirrhosis, or cardiac disease. Occasionally, however, the local condition may attract some attention. Catteau mentioned a case of Morgagni's in which an umbilical tumor the size of a goose's egg broke, each day discharging limpid fluid. It finally healed. According to Nicaise, rupture of the umbilicus distended by ascitic fluid is very rare, as he knew of only two observations, those of Brehm and Van Home. Ledderhose mentions a case recorded by Pineo-Hyannis, in which the ascitic fluid escaped from the umbilicus and recovery took place.

Perrin reported a case of a man, aged fifty-one, suffering from hepatic cirrhosis. The umbilical sac was as big as an orange. It ruptured on the right side, but cicatrized and the patient was afterward tapped 15 times, an average of 24 pints of ascitic fluid being drawn off.

As a rule, the subsequent history of the patient will depend entirely upon the pathologic lesion responsible for the ascites. In a case reported by Perrin, a woman aged fifty-two had a serous umbilical hernia. This ruptured, the sac remaining open and shrunken. Erysipelas developed around the umbilicus and proved fatal.

Perrin has studied the umbilicus in normal and ascitic subjects and finds that at least three causative factors must be taken into account. In the first place, the umbilical ring varies greatly in diameter. In the second place, the ring is much more readily distended in some cases than in others, as its fibrous and connective tissue may be abundant and firmly welded together or loose in texture; and, finally, the obturator membrane varies greatly in strength.

Cases of Serous Umbilical Hernia.

From the following cases the reader may gather a clear idea of the clinical picture. The small number of cases here recorded is, however, no index of the frequency of serous umbilical hernia.

Prominences at the Umbilicus Associated with Interstitial Nephritis, Cirrhosis of the Liver, and Ascites.* — An alcoholic woman, aged thirty-two, who had interstitial nephritis

  • Catteau: De l'ombilic ct de ses modifications dans les cas de distension de l'abdomen.

Thfefde Paris. 1*70, obs. 11, 12, 13.


UMBILICAL HERNIA.


469


and cirrhosis of the liver, had also had ascites for four weeks. The umbilicus was hemispheric, transparent, and 3 to 4 cm. in diameter. The finger could be easily introduced into the umbilical ring.

A patient, thirty-one years of age, who was suffering from Bright's disease, had an irregular umbilical tumor, 6 by 4 by 4.5 cm. It was lobulated, and the overlying skin was transparent.

A woman, aged forty-nine, had had marked abdominal enlargement for two months, and for six weeks had had at the umbilicus a tumor 3 cm. in diameter.

An Umbilical Protrusion Due to Abdominal Ascites.- — Gauderon* reports a case coming under Guyot's observation. The patient was a vigorous man, aged thirty-five, who entered Guyot's clinic with definite symptoms of Bright's disease, characterized by albuminuria, edema of the legs and of the abdominal walls, with moderate ascites. The ascites increased. The umbilicus was distended, and on March 12, 1876, an umbilical intestinal hernia developed. The hernia was irreducible, and gurgling could be made out. This man had never had an umbilical hernia before and had never used a bandage.

By April 3d of the same year the intestine had disappeared from the hernial sac and the site was occupied by serous peritoneal fluid. During this period the ascites had increased. The patient left the hospital at his own request on April 20th.


Serous Umbilical Hernia in Children.

Very few cases have been recorded, simply because ascites is much rarer in children than in adults. Were ascites just as frequent in children, we would have a much larger percentage of serous umbilical hernise in the child, as in early life the umbilicus gives way very readily. I shall here give a typical example of an umbilical hernia in an infant :

Baby H. Seen in consultation with Dr. Vogler at the Church Home and Infirmary, Baltimore, November 14, 1910. The child is eight months of age and has marked abdominal distention. Two weeks ago an umbilical hernia developed. The hernial sac is about 2 cm. in diameter and projects at least 1.5 cm. from the abdominal wall (Fig. 199). The skin over the umbilicus shows marked tension and is shiny; and one can detect clear fluid in the hernial sac. On percussion there is a distinct wave of fluctuation throughout the entire abdomen, and there is also much enlargement of the liver. Two or three days ago inguinal hernise developed on both sides. After much consideration it was felt wiser not to let the fluid out for fear that the child might develop a general peritonitis. He was taken home, but notwithstanding the most careful nursing he grew worse. He developed pneumonia about two months after leaving the hospital and died.

  • Gauderon: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et par evacuation du pus a travers rombilic. These de Paris, 1876, No. 148, 51.


Fig. 199.— A Serous Umbilical Hernia.

This represents the abdominal contour in the umbilical region of a child eight months old. The child's liver was markedly enlarged and the abdomen full of ascitic fluid. The umbilicus was unfolded and formed the projection here depicted. The overlying skin was very thin, and the fluid in the umbilical sac could be clearly seen.


470 THE UMBILICUS AND ITS DISEASES.

Escape of Serous Fluid from the Umbilicus in a Case of Tuberculous Peritonitis. Ledderhose* reports an observation by Henoch on an eight-year-old boy. On two occasions, on account of marked ascites, several liters of fluid had been removed by puncture and from time to time clear serum escaped from the distended umbilicus. This flow was followed by a diminution in the abdominal distention. Three months later, as a result of tuberculous meningitis, the child died. At autopsy tuberculosis of the peritoneum was found. In the abdominal cavity at the time of autopsy there were only about 100 c.c. of clear, light yellow fluid.

Serous Umbilical Hernia Associated with an Ovarian Cyst.

We have records of two such cases, those reported by Catteau and Gauderon. If there be ascites associated with an ovarian tumor, the development of serous umbilical hernia is easily explained. It is also easily understandable that if, through injury, rupture of the ovarian cyst occurs, the free ovarian fluid may pass into an umbilical hernia.

An Ovarian Cyst Associated with Umbilical Swelling. — Catteau, in Case 16, refers to a woman forty-five years of age, who had had an ovarian cyst for ten years. After falling on her back she vomited, and a tumor was noted at the umbilicus. Two months later there was an escape of fluid through an umbilical opening.

A Serous Umbilical Hernia Associated with an Ovarian Cyst.j — This case was communicated to Gauderon by his friend Dussaussay: Catherine S., aged sixty-five, entered the service of Dr. Millard, April 21, 1876. On admission she was found to have an enormous abdominal tumor, which had first been noticed six years previously and diagnosed as an ovarian cyst. It was complicated by the presence of ascitic fluid. When the patient entered the hospital there was a hemispheric tumor at the umbilicus. It was fluctuant and reducible without gurgling. After reduction the finger met with a hard umbilical ring. The tumor was supposed to be a serous hernia complicating ascites. The patient said that this small tumor had existed for more than a year. Several days later she developed peritonitis and died on May 2, 1876.

Autopsy revealed a multilocular ovarian cyst on the left side. There were traces of peritonitis. At the umbilicus there was a true serous hernia. The umbilicus was distended in the form of a hernia the size of a large walnut, and the hernial sac was lined with peritoneum. The umbilical ring itself was 1 cm. in diameter. The peritoneum of the sac was whitish and opalescent.

A Serous Umbilical Hernia Associated with a Large Cystic Myoma and Marked

Abdominal Ascites.

While preparing this chapter the following case came under my care at the Johns Hopkins Hospital:

Gyn. No. 18101, Gen. No. 81548. E. G., colored, aged thirty-four, was admitted fco Ward January 16, 1912, complaining of abdominal distention and shortness of breath. She has always enjoyed good health previous to the present illness. During the last winter she has had several colds, which were accompanied by persistent cough and some expectoration. Since September, 1911, the patient has had periods of suppression of urine, which have lasted for twenty-four hours, and for

  • Ledderhose: Deutsche Chirurgie, 1890, Lief. 45 b. t Gauderon: Op. cit., obs. 15.


UMBILICAL HERNIA. 471

the last four months there has been marked constipation. EleveD months ago the patient noticed that her abdomen was increasing in size. It has steadily grown larger, and she suffers a good deal from dyspnea. The limbs have become so swollen lately that whenever the patient has had to get into bed she has been obliged to have some one lift her legs for her. She has had very little abdominal pain, her main complaint being shortness of breath and abdominal swelling.

Present Condition. — The patient is a sparely nourished, rather emaciated negress. She has some trouble with dyspnea and reclines in bed on several pillows. The abdomen is markedly distended and there is an umbilical hernia. The abdomen is full and somewhat rounded. The distention extends from the xiphoid to the symphj'sis. There is a definite bowing of the xiphoid cartilage. It is pressed almost at right angles to the sternum. No masses are to be made out in the abdomen on deep palpation. There is considerable edema throughout the lower half of the abdomen and marked pitting on pressure. A definite fluctuation wave is made out. With the patient in the dorsal position, the dulness extends to either flank.

Operation. — Abdominal hysteromyomectomy, January 17, 1912.

The umbilicus was dilated, forming a hernia about 2 cm. in diameter. The walls here were very thin, and the sac, which was evidently filled with fluid, projected as a little dome about 2 cm. from the surface of the abdomen. I picked up the hernial sac on either side with forceps and opened it. A rubber hose was firmly pressed over the opening, and we removed over 17 liters of ascitic fluid from the general abdominal cavity. The incision was then increased in size, and I saw what appeared to be an ovarian cyst, with a small opening in it. I hooked my finger into this and raised it up still more. On getting it out I was surprised to find that, instead of an ovarian cyst, we had a cystic myoma, which projected from the posterior surface of a myomatous uterus. A supravaginal hysterectomy was done, and the abdomen closed without drainage. Convalescence was uneventful.

Path Xo. 16947. The multinodular myomatous uterus is approximately 12 cm. long, 10 cm. broad, 10 cm. in its anteroposterior diameter. The uterus contains numerous subperitoneal and interstitial nodules. Projecting from the fundus is a cystic nodule, approximately 14 cm. in diameter. At its upper end is a small hole from which serous fluid oozes. The tumor on section is found to be partly cystic, partly solid. There are numerous loculi which open into one another, and there are bands of tissue running from side to side in the main cyst. The right tube is the seat of a hydrosalpinx, and the entire mass is enveloped in adhesions. On the left side the tube is 9 cm. long and has been converted into a hydrosalpinx.


UMBILICAL HERNIA IN THE ADULT.

For a general consideration of this subject the reader is referred to the textbooks on surgery. I shall mention only the salient facts and refer to certain points that have particularly impressed me.

Umbilical hernia in the adult seems to be much more prevalent in the female than in the male, and not infrequently is noted after the abdominal distention consequent to pregnancy. It is more common in stout women than in thin persons. This is probable partly due to the fact that, when individuals take on adipose tissue externally, there is a coincident increase in the amount of fat in the omentum and mesentery, and therefore an increased tension on the abdominal wall.


472


THE UMBILICUS AND ITS DISEASES.


With the increase of adipose tissue there is an increased tendency toward a pendulous condition of the abdomen. If the umbilical hernia is small and can be readily reduced, the patient often experiences little or no discomfort. In those cases in which the hernia reaches a diameter of 3 to 4 cm., when the omentum is adherent



Fig. 200. — Freeing the Umbilical Hernial Sac From the Abdomen. (Head of Patient Below, Stmphysis

Above.) In this case an elliptic abdominal incision has been made around the hernia from above downward, and the adipose tissue has been reflected back on either side until the neck of the sac and the surrounding abdominal fascia are clearly exposed. In those cases in which there is much redundancy and it is deemed advisable to remove a large area of adipose tissue, the skin incisions should be from side to side. When the neck of the sac is well exposed, the fascia is cut through just above the sac, — above, because there are few if any adhesions at this point, — and a finger is introduced as indicated. With the finger as a guide the sac is cut free all the way around. The hernial mass is now isolated, and can be lifted well away from the abdominal wall and then walled off with gauze. The sac is now slit open from neck to base. If it contains intestinal loops, these are liberated and returned into the abdomen. Where the omentum is very loosely attached, it is also liberated and returned to the abdominal cavity, but when it is densely adherent, the extra-abdominal portion is tied off and removed with the sac. For the closure of the hernial opening see Figs. 201 and 202.


and the abdomen is pendulous, the patient experiences a dragging sensation if on her feet much. This is evidently due to tension on the transverse colon.

When a small umbilical hernia exists, the fat lobules occasionally present in the ring may increase in volume, thereby stretching the ring.


UMBILICAL HERNIA.


473


When the omentum has been incarcerated for a considerable time, there may be edema of the surrounding abdominal wall and a tendency for the more prominent parts of the hernia to become excoriated.



Fig. 201. — Clostjke of the Hernial Opening at the Umbilicus. A row of mattress sutures consisting of kangaroo tendon, chromicized catgut, or silk, as the operator may prefer, are so placed that the lower flap a is drawn well up under the upper flap 6. Before tying these the second row of mattress sutures is passed through the lower flap a. They are inserted now because, with the abdomen opened, one can take a much deeper bite, the finger serving as a guide to the depth of their insertion. When they are placed after the first row has been tied, the operator rarely grasps enough tissue, as he is afraid of piercing the underlying intestine. After the first row of mattress sutures has been tied, the ends of the second row of sutures are passed through the edge of the upper flap and tied. Needles have been placed on the ends of each of these sutures to facilitate the understanding of the procedure. In actual practice each pair of suture ends is temporarily clamped with forceps and rethreaded after the first row has been tied. (For the appearance of the ring when closed see Fig. 202.)


It is in the small hernia? that a knuckle of gut is liable to become incarcerated, and the patient then speedily develops the characteristic symptoms of a partial or complete intestinal obstruction.

Treatment. — Given a thin patient, the operation is usually easy. Unfortunately, however, the majority of these patients are stout, many of them quite


474


THE UMBILICUS AND ITS DISEASES.


obese, and show a marked tendency toward emphysema. Such patients are prone to develop postoperative lung complications, and this danger should be thoroughly considered before any operative interference is undertaken. I invariably follow the postoperative course of such a case for several days with some concern. The preparatory treatment of these cases has recently been admirably outlined by Alexius McGlannan (Proc. Southern Surg, and Gyn. Assoc, 1914, xxvii, 311).

The radical operation for umbilical hernia may be a most difficult procedure or a relatively simple operation, depending in large measure on the manner in which it is performed. So far as my personal experience goes, it is wise to make an elliptic incision from above downward or from side to side. A wide area is usually outlined and freed down to the fascia. The hernia and the flap of fat are dissected free until the neck of the sac stands out clearly on all sides. A small incision is then made



Fig. 202. — Closure of the Hernial Opening at the Umbilicus. For the first steps in the closure see Fig. 201. The first row of sutures has been tied, and the second row is nearly

completed.


through the fascia of the abdominal wall, at a point just above the sac — above, because the omentum is here usually free from adhesions. The opening in the abdomen should be just large enough to admit the finger. After the finger has been introduced, it acts as a guide, and the operator cuts down on it, severing the sac all the way round just at its point of attachment to the abdominal wall (Fig. 200).

When the neck of the sac has been cut loose, the hernia can be lifted out and laid on a large piece of gauze. After seeing that no intestinal loops are incarcerated in the hernia, the operator now slits up the wall of the sac to see if the omentum can be saved. Sometimes this is possible; in other cases, however, the omentum is so densely adherent to the sac that it must be removed with the sac.

Unless one has carefully dissected a series of large umbilical hernise, he has little idea of the many alcoves and channels running off from the main cavity (Fig. 204). After the omentum has been replaced or tied off, as the case may be, the peri


UMBILICAL HERNIA.


475


toneum is closed and the fascia overlapped from above downward, as advocated by Dr. Win. J. Mayo, Dr. Charles P. Xoble, and others. The fascia from the lower part of the abdominal ring is drawn up in under the fascia of the upper wall (Fig. 201). Two rows of mattress sutures in the fascia usually suffice to give a permanent cure (Fig. 202). The fat and skin are then approximated. It would be im


Fig. 203. — Ax Umbilical Herxia Associated with Marked Prolapsus of the Abdominal Wall.

The umbilical hernia was about 10 cm. in diameter. The elliptic transverse incision is indicated by the black line. The

lower figure indicates the shape and size of the piece of adipose tissue removed.


possible to lay too much stress on the importance of freeing the neck of the sac from the abdominal wall before attempting to unravel the sac-contents, and upon the ease with which this can be accomplished by using the finger in the abdomen as a guide in its liberation. I have used this method for years, and found it particularly useful in the following case:


476


THE UMBILICUS AND ITS DISEASES.


Mrs. C. J., aged thirty-five, admitted to the Church Home and Infirmary on February 11, 1914. This patient has had five children, the youngest being



Fig. 204. — An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds. This is a sketchy outline of the condition found. With the patient standing, the dependent portion of the abdomen reached the knees. As the omentum was adherent to the hernial sac, the transverse colon was markedly drawn downward. The dotted line indicates the line of dissection, the fat of the abdominal wall being removed down to the fascia. The hernial sac was divided into numerous secondary cavities. This is particularly well seen in the upper sketch, which was drawn from the hernial sac after removal.


eight months old. At the time of her marriage she weighed 225 pounds. Her weight today is 464 pounds. She complains of an umbilical hernia which is about 10 cm. in diameter. When on her feet, the abdomen hangs down to her knees.


UMBILICAL HERNIA.


477


The dragging sensation caused thereby is so great that she is forced to keep off her feet as much as possible. I was unwilling to operate, and explained the danger to her husband. The patient, who is still a relatively young woman, said that she was becoming a semi-invalid and insisted that she be relieved.

Operation. — February 12, 1914. On account of the marked redundancy of the abdominal wall, we decided to relieve her of a large quantity of fat, together with the hernia, as advocated by Dr. Howard A. Kelly. Accordingly, a large transverse elliptic area was outlined (Fig. 203). This area, when measured on removal, was 36 inches from side to side and 19 inches from above downward. The adipose tissue of the huge flap was dissected from the fascia of the abdominal wall all around as far



Fig. 205. — The Abdominal Scar After the Removal of a Vert Large Area of Fat. The abdominal wound gave a transverse measure of 36 inches. After the wound had healed, the scar had contracted down to 27 inches. Note the size of the patient relative to that of the bed. This was of the three-quarter size, the ordinary hospital bed being too small for the patient.


as the neck of the hernia. Then, with a finger in the abdomen as a guide, the neck of the sac was cut all around at its margin with the abdominal wall. The dotted line in Fig. 204 indicates the line of the dissection. The omentum in the sac was so intimately blended with the walls of the sac that this portion of the omentum was cut off and removed with the sac and redundant tissue. Max Brodel, in the upper sketch in Fig. 204, has clearly shown the neck of the sac and the numerous chambers passing off from it. The hernial opening was closed by the Mayo method — by sliding the fascia of the lower margin of the opening up under that of the upper margin. We used kangaroo tendon for the mattress sutures, and after the first row had been placed and tied, the edges of the upper flap were fastened down with


478 THE UMBILICUS AND ITS DISEASES.

a second row of mattress sutures. The abdominal wound was now approximated with interrupted silver-wire and silkworm-gut sutures. Each suture included the skin, fat, and a little of the fascia. Accurate skin approximation was obtained by using continuous black silk. At each end of the incision a protective drain was introduced.

The patient made a speedy recovery, and the abdominal wound healed perfectly. When the stitches were removed, the abdominal incision had contracted down until it measured only 27 inches from side to side (Fig. 205). Eight months later the patient was in excellent health.

Hernije Through Weak Spots in the Abdominal Wall. Where the hernia develops from a weak spot near the umbilicus it closely resembles an umbilical hernia, and clinically may be considered as such. This subject is discussed in detail on p. 55.



Fig. 206. — An Umbilical Ctst. (After Gallant.) A Scotch terrier developed a small umbilical hernia when about four months old. It enlarged so that the dog had to drag itself about on the floor. The cyst became larger and somewhat inflamed. The skin grew so thin that the fluid could be seen in the center. The ring had evidently contracted down on the omentum, and the peritoneal fluid had accumulated.

CYSTS OF THE UMBILICUS.

When an umbilical hernia exists, as a matter of course the peritoneum is carried ahead of the hernial mass and hence lines the hernial sac. If by any chance the hernial sac becomes completely separated from the abdominal cavity, peritoneal fluid may accumulate in this sac, producing a cystic tumor. Gallant and Walz report cases clearly demonstrating such a phenomenon. Gallant's* subject was a Scotch terrier that developed a small umbilical tumor when four months old. The hernia enlarged, and the puppy had to drag himself about the floor on his abdomen. The cystic mass increased in size and became somewhat inflamed. The skin covering it grew so thin that the fluid in the sac could be readily seen. At operation the condition depicted in Fig. 206 was found. Firmly plugging the hernial ring was a small piece of omentum, and the peritoneal lining had doubtless secreted the fluid found in the sac.

Walz,f on January 6, 1902, saw a gunmaker, aged fifty-one, lying in bed com

  • Gallant: Disorders of the Umbilicus with Special Reference to the New-born and the

Infant; III Umbilical Infections. Internat. Clinics, 1907, 17. series, i, 1.51.

t Walz, Karl: Ein Beitrag zur Kenntnis der Nabelcysten. Munch, med. Wochenschr., 1902, xlix, 959.


UMBILICAL HERNIA. 479

plaining of pain in the umbilical region and of diarrhea. For several years the patient had noticed a tumor the size of a walnut at the umbilicus. This could be readily pressed back, but coughing caused it to reappear. For twenty-four hours the patient had had increasing pain at the umbilicus, and the tumor had rapidly increased in size and could not be reduced. Since that time there had been diarrhea, but no vomiting. His temperature was 37.6° C; pulse 90 and regular. In the umbilical region was a half-ball-shaped tumor, the size of a hen's egg, directly to the left of the umbilicus. It overlapped and covered the umbilicus. The overlying skin was movable and somewhat reddened.

Walz thought that the nodule was due to incarcerated omentum. At operation it was found to contain clear serous fluid supposed to be peritoneal fluid. After the fluid had escaped, the cavity was found to be empty. The walls were 0.5 to 1 mm. thick, and the sac ended in a pedicle the thickness of a lead-pencil, which passed into the umbilical ring. There was no opening into the abdomen. The sac was tied off and removed, and the patient made a good recovery.

Microscopic examination of the sac shows that it was composed of fibrous tissue with an inner wall of granulation tissue ; there were a few polymorphonuclear leukocytes, and no evidence of epithelium. Walz thought it possible that a hernial sac had been nipped off from the abdomen as a result of an inflammatory process, and that the fluid had accumulated. This seems to be the correct interpretation'.

These two cases clearly demonstrate how small umbilical cysts may be the endresult of old hernise.

Caruso* reports an instance of an umbilical cyst the size of a chestnut, in a woman forty-two years of age. On histologic examination it was found to be lined partly with cuboid, partly with low cylindric epithelium. He called it a cystic adenoma. Without seeing the specimen I should hesitate to classify it, but we know that the cells covering the peritoneal surface, when protected, frequently become cuboid.

Ledderhose,f in his masterly article on surgical diseases of the umbilicus, refers to the scanty mention of umbilical cysts. He then describes Lotzbeck's case, in which a multilocular tumor the size of a fist was removed by Brun from the umbilicus in a child two and one-half years old. It was noticed immediately after the birth, and at that time was the size of a walnut. It contained partly clear, amberyellow, somewhat alkaline fluid, partly a thick, honey-brown, gelatinous substance. The tumor lay between the skin and the rectus. The connective-tissue wall of the cyst contained small, thread-like, cartilaginous deposits, and the cyst was lined with simple squamous epithelium. The cyst fluid contained fat, cholesterin, and numerous cells. The possibility that this was a dermoid cyst must not be overlooked.

For umbilical cysts of urachal origin see pages 526 and 539.

Co5'me,± in 1909, reported a case that hardly belongs to the solid umbilical tumors, and yet, on the other hand, cannot be considered as a simple umbilical cyst.

  • Caruso, F.: Contributo alio studio anatomo-patologico dei tumori cistici dell' ombelico.

Atti della Soc. Italiana di Ost. e Gin., 1901, viii, 293.

fLedderhose: Chirurgische Erkrankungen des Xabels. Deutsche Chirurgie, 1890, Lief. 45 b.

i Coj'-ne: Tumeur congenitale de l'ombilic developpee dans un vestige de la vesicule allantoidienne. Comptes rend, nebdom. des seances et Mem. de la Soc. de biol., Paris, 1909, lxvii, 383.


480 THE UMBILICUS AND ITS DISEASES.

Coyne's tumor was from a woman who had noticed it for sixteen months. She had always had some abnormality at the umbilicus. The mass was the size of an adult's head and was pedunculated. It was 20 cm. in diameter. On section it was found to contain arteries and veins in a reticulated tissue. There was one large cavity with three or four secondary cavities opening into it. These contained vegetations.

The cavities were lined with cylindric epithelium, and the vegetation was covered with cylindric epithelium. In the pedicle was found the fibrous tissue characteristic of the urachus. In the center were vestiges of the allantois. These portions of the allantois had undergone colloid cystic transformation and had been the point of departure for this cystic tumor.

Whether Coyne was right in his assumption I am not in a position to judge.


LITERATURE CONSULTED ON UMBILICAL HERNIA. Ahlfeld: Zur Aetiologie der Darmdefecte und der Atresia ani. Arch. f. Gyn., 1873, v, 230. Brun: Treatment of Umbilical Hernia. Jour. Amer. Med. Assoc, October 26, 1912, 1578. Abstract from Arch, de medecine des enfants, Paris, Sept., xv, No. 9, 641. Caruso, F. : Contribute alio studio anatomo-patologico dei tumori cistici dell' ombelico. Atti della

Soc. Italiana di Ost. e Gin., 1901, viii, 293. Catteau, J. F.: De l'ombilic et de ses modifications dans les cas de distension de l'abdomen.

These de Paris, 1876, obs. 11, 12, 13. Coyne: Tumeur congenitale de 1'ombilic developpee dans un vestige de la vesicule allanto'idienne.

Comptes rend, hebdom. des seances et Mem. de la Soc. de biol., Paris, 1909, lxvii, 383. Gallant, A. E. : Disorders of the Umbilicus with Special Reference to the New-born and the Infant ;

II; Umbilical Fistulas, Sinuses, and Cysts. International Clinics, 1906, 16. series, iii, 218.

See also International Clinics, 1907, 17. series, i, 151. Gauderon: De la peritonite idiopathique aigue des enfants; de sa terminaison par suppuration et

par evacuation du pus a travers l'ombilic These de Paris, 1876, No. 148. Kern, Theo.: Ueber die Divertikel des Darmkanals. Inaug. Diss., Tubingen, 1874. Ledderhose: Deutsche Chirurgie, 1890, Lief. 45 b.

Nicaise: Ombilic. Diet, encyclopedique des sci. med., Paris, 1881, 2. ser., xv, 140. Perrin, Maurice: Brit. Med. Jour., April 9, 1910. Epitome of Current Med. Lit., 58. Power, D'Arcy: A Case of Congenital Umbilical Hernia. Trans. Path. Soc, London, 1888,

xxxix, 108. Reed, Edward N.: Infant Disemboweled at Birth — Appendectomy Successful. Jour. Amer.

Med. Assoc, July 19, 1913, 199. Runge, M.: Die Wundinfectionskrankheiten der Neugeborenen. Die Krankheiten der ersten

Lebenstage, Stuttgart, 1893, 2. Aufl., 56. Sanderson, S. E.: Personal communication. Sheen, William: Some Surgical Aspects of Meckel's Diverticulum. Bristol Medico-Chirurg.

Jour., 1901, xix, 310. Stewart, G. C: Hernia of the Umbilical Cord. Brit. Med. Jour., 1905, i, 247. Wak, Karl: Ein Beitrag zur Kenntnis der Nabelcysten. Mtinch. med. Wochenschr., 1902,

xlix, 959. Yates, H. Wellington: Personal communication.


Chapter XXVIII. The Urachus

General consideration. Exstrophy of the bladder.

In early fetal life this structure passes as a patent duct through the umbilicus, and at birth in a few cases the canal still persists. A consideration of the umbilical portion of the urachus was accordingly essential. The subject became so fascinating that I undertook a comprehensive study of the urachus and its diseases, the results of which are given in the following pages.

In the chapter on Embryology, the development of the urachus is given in full.

Exstrophy of the bladder has been considered here because clinically it has some points of resemblance to the dilated umbilical end of the urachus occasionally noted:

A reference to the chapter on The Patent Urachus will show that now and then the urachus remains open all the way from the bladder to the umbilicus, and that in such cases, just as soon as the cord drops off, urine escapes both from the urethra and from the umbilicus.

Under remnants of the urachus I have considered small segments of the duct that have persisted in children or in adults. Such remnants are usually spindleshaped, and contain a small amount of secretion, which may be yellow and limpid or sticky and brownish in color.

Urachal cysts form a very interesting group of cases. They may be small or large. The small ones are usually not larger than a pea, and are accidentally discovered during an operation or at autopsy. The large cysts occasionally occupy not only the entire anterior abdominal wall, but also the pelvis. They naturally lie between the abdominal muscles and the peritoneum of the anterior abdominal wall.

Urachal remains occasionally communicate with the umbilicus or bladder or with both. Those opening into the bladder are particularly instructive. These patients usually give a history of vesical irritability, and from time to time pus is passed with the urine. Sometimes the urachus is in reality an alcove from the bladder, the opening being very wide and assuring complete emptying of the cavity each time the bladder is evacuated. On the other hand, if the communicating opening is very small, whenever the bladder contracts, a good deal of urine may be forced into the urachal pouch. In these cases the urine stagnates, decomposes, and the patient develops a train of constitutional symptoms.

From time to time a very hard tumor develops between the umbilicus and pubes. This usually gives the patient considerable pain, and its presence is sometimes accompanied by fever. When the growth is exposed, it is found to lie between the recti muscles in front and the peritoneum of the anterior abdominal wall behind. Its walls are dense, and its center is filled with grumous material mixed with pus. These tumors result from a low-grade infection of remnants of the urachus. 32 481


482


THE UMBILICUS AND ITS DISEASES.


I have considered acquired urinary fistulse at the umbilicus somewhat fully. They evidently occur only rarely unless remnants of the urachus exist. In these cases if the urethral canal is closed as the result of stricture, an enlarged prostate, a vesical stone, or a tumor of the bladder that blocks the inner urethral orifice, the old path from the bladder to the umbilicus may become open again and the urine escape in part or in its entirety from the umbilicus, until the urethral obstruction is removed.

I have devoted some space to a consideration of urachal concretions and urinary calculi associated with urachal remains. Urachal calculi may be multiple. They

are very small, and seem in the main to be composed of inspissated contents of the small cyst cavities. Urinary calculi are now and then associated with urachal remains, and in one instance at least a vesical stone has been removed through the umbilicus. In this case the urachus extended as a wide canal from the umbilicus to the bladder.

In a few cases malignant changes have developed in a patent urachus. The growth may be a cancer or a sarcoma.

With the careful study and publication of urachal lesions in the future, I feel sure other interesting urachal remnants or pathologic conditions caused by them will be brought to light.


EXSTROPHY OF THE BLADDER.

An extended description of exstrophy of the bladder hardly comes within the scope of this book, but, on account of its occasional proximity to the umbilicus, I shall briefly consider it.

A glance at the chapter on Embiyology (p. 17) will show that the bladder in the young embryo frequently extends upward almost to the umbilicus ; consequently, if for any reason there be a defect in the lower abdominal wall, exstrophy of the bladder may result.

Prestat,* in 1838, described the appearance of a



Fig. 207. — Exstrophy of the Bladder. (After F. A. von Amnion.) (Plate 16. Fig. 16. Copied from Froriep.) This shows the bladder opening at or near the umbilicus. The genital structures appear to be normal, and the abdominal wall immediately above the symphysis is unaltered, a, The bladder opening very high up; 6, the surrounding undulatingabdominal wall.


still-born child at the seventh month, with exstrophy of the bladder. The greater portion was open anteriorly. The bladder was represented as a slight depression covered over with mucous membrane, which was continuous with the skin of the abdomen. It extended from half an inch below the umbilicus to the pubes. In its lower part were two tubercles — the ureteral openings. The pubic bones were represented by fibrous tissue. The other pelvic structures were normal.

Yon Amnion,! in his book on Congenital Surgical Diseases, published in 1842,


1842.


  • Prestat: Bull, de la Soc. anat. de Paris, 1838-39, xiii, 69.

t von Amnion, F. A.: Die angeborenen chirurgischen Krankheiten des Menschen, Berlin,


THE URACHUS.


483


says that the umbilicus in cases of exstrophy of the bladder is inserted very

deeply.

He refers to an interesting case of bladder exstrophy reported by Froriep. The

illustrations in this case are most instructive.

Fig. 207 shows a large, almost circular opening in the umbilical region.

Through this aperture the posterior wall of the bladder is visible. The lower part of the anterior abdominal wall is intact and the genitals of the child, which was a male, are normal.

In Fig. 208 we have a lateral view of the entire urinary tract. The only abnormality is in the upper part of the bladder. The

nt





¥# '"lite ml



Fig. 208. — Exstrophy of the Bladder. (After F. A. von Ammon.) This is a side view of the case depicted in Fig. 207, and gives the relative distance from the symphysis to the opening in the abdominal wall, a, the opening; 6, 6, the margins; d, the bladder; g, the covering and peritoneum of the posterior surface; h, the ureter; h', the kidney.


Fig. 209. — Exstrophy of the Bladder. (After von Ammon.) This represents Fig. 207 turned inside out. The bladder has literally been inverted upon the abdomen, a, the bladder mucosa; d, d, are a short distance from the corresponding ureteral orifice; 6, b, indicate the margins of the opening.


top of the bladder is firmly fixed to, and opens directly upon, the abdominal wall, just below where the umbilicus should be.

Fig. 209 shows that it was possible for almost the entire bladder to prolapse through the exstrophy opening. In other words, the bladder could be turned inside out, and the ureteral orifices were then recognized as small openings just above the symphysis. Such a picture as this is, of course, exceptional.


484 THE UMBILICUS AND ITS DISEASES.

Exstrophy of the Bladder. — Recently a very interesting case of this character came under our observation:

Gyn. No. 21594. Miss A. C. H., aged twenty-nine, was admitted to the Gynecological Department of the Johns Hopkins Hospital under Dr. Howard A. Kelly's care on October 11, 1915, for a " growth in the abdominal wall."

Her father, mother, one sister, and two brothers are living and well, and she has always enjoyed relatively good health. No history of congenital malformation in any member of the family could be elicited.

The patient began to menstruate at seventeen, was irregular for five years, but has been regular since then. The flow lasts six days and is accompanied by pain on the first day. There is no intermenstrual bleeding.

Present Illness. — The patient has always had a mass in the lower abdominal wall. She does not think it has grown except in proportion to the growth of the body. The pubic bones have always been widely separated, as they are now, causing nodular elevations laterally. There is no difficulty in walking. The patient has never been very strong, but has always been well.

Her main discomfort has been a tenderness in the lower border of this mass, accompanied by an inability to hold her urine. She has always worn pads to catch it. The urine has never showed blood. The mass has not ulcerated, but slight traumatism has always been sufficient to start bleeding.

When the patient was fifteen, she had pain in the left side, the maximal intensity being in the upper left fossa. There was also great tenderness in the left superior lumbar triangle. The pain was intermittent; it was unaccompanied by nausea or vomiting, and was not sufficient to cause the patient to go to bed. These pains lasted for two years. Since then they have occurred once or twice a year, but have been relieved by hot applications. Ever since the trouble on the left side the urine from the left ureter has been cloudy and scant in amount. The flow from the right, on the other hand, has always been abundant.

Physical Examination. — The right kidney extends to the crest of the ilium, the left cannot be felt. The umbilicus is small, shallow, and situated rather low in the abdominal wall.

In the mid-line, in the suprapubic region, is a red, raw-looking mass, which is soft and contains urine (Plate VII). It looks something like a large red raspberry, with lobulations at irregular intervals on its surface. On its inferior surface are two lobulated knobs. At the apex of each knob is a small orifice. From the


Plate VII. Exstrophy of the Bladder.

The patient was twenty-nine years old. The inverted bladder is seen situated where the symphysis pubis should be. Its velvety mucous surface is rolled out and hangs over the labia minora. The prominence on each side represents the pubic ramus. Between them is a gap 7 cm. wide, which is bridged over by a strong fibrous band. Between the umbilicus and the exstrophied bladder is a flattened, triangular area, bordered on its sides by the separated recti muscles, which are inserted into their respective separated pubic bones. The triangle is divided perpendicularly by a thick, cord-like structure connecting the umbilicus and bladder — evidently the urachus. Where exstrophy of the bladder exists, the umbilicus is usually much nearer the symphysis. In this case, however, it is not far below its normal position.

In the upper left diagram the bladder has been gently raised, exposing the ureteral orifices. Urine escaped freely from the right ureter; the left was apparently functionless.

The labia minora arc widely separated above. The clitoris apparently consists of two separated portions.

The right upper picture schematically represents the abdominal topography. Note the wide separation of the pubic bones and of the anterior-superior spines, likewise the unusually wide space between the thighs.


THE TJKACHUS.


485


PLATE VII. Exstrophy of the Bladder.




X


X


\



486 THE UMBILICUS AND ITS DISEASES.

right, urine flows in a small stream on voluntary expulsion by the patient. The lower and under surface of the mass is very tender. The mass measures 4.5 x 3 x 4 cm. It cannot be reduced into the abdomen.

The pubic hairs are scanty. The labia minora are very atrophic, and diverge above, extending outward to the lateral margins of the exstrophy. Some observers are of the opinion that the clitoris is absent; others that it appears as two rudimentary portions. The urethra and the anterior bladder-wall are totally wanting. The vaginal orifice is very small; the hymen is intact.

Rectal Examination. — The sphincter tone is normal. The cervix is elongated, and its external os lies just within the hymen. The uterus is somewhat enlarged and in good position. The adnexa cannot be felt. From each uterine cornu a round cord, the size of a lead-pencil, can be felt passing downward and outward to the inguinal canal — these are apparently the round ligaments.

At the apex of the vagina, and extending laterally from the junction of the cervix and body of the uterus, firm, ligamentous structures can be palpated — these are probably the bases of the broad ligaments.

A cord can be felt extending from the upper margin of the exstrophied bladder to the umbilicus. This, undoubtedly, is the urachus.

The pelvis has a peculiar form. It is abnormally wide; it shows a flaring of the false pelvis and a wide diastasis of the anterior pelvic arch. The spines of the pubes are 19 cm. apart. For a woman of her size they should be 10 cm. apart. The mesial borders of the pubic bones are separated by a space of 7 cm., there being a tight, dense, but pliable ligament connecting them.

The following are the measurements of the pelvis :

Distance between the pubic bones in front 7 cm.

Distance between the external superior spines 19 cm.

Distance between the anterior superior spines of the ilium 32.5 cm.

Distance between the iliac crests 35 cm.

Distance between the great trochanters 39 cm.

The perineum is wide. When the legs are brought together, the space between them is not closed. With the knees together and the legs flexed, there is a space 9 cm. broad, representing the width of the perineum.

A glance at Plate VII will give the reader a clear idea of the appearance of the exstrophy.

The implantation of the ureters into the rectum was considered, but the patient refused to have anything done and returned to her home.

Kelly and Burnam,* when referring to the subject of exstrophy of the bladder, quote Spooner as saying that in 116,500 patients it was noted only four times, a clear indication that this is a very rare malformation. In Fig. 491, Vol. II, of Kelly and Burnam's work, is depicted an exstrophy of the bladder observed by Guy L. Hunner. In this case the exstrophy bears a marked resemblance to the one we are describing, but the umbilicus was situated just above the exstrophy, instead of in the relatively normal position.

  • Kelly, Howard, and Burnam, Curtis F. : Diseases of the Kidneys, Ureters, and Bladder,

I). Appleton & Co., 1914, ii, 385.


Chapter XXIX. Congenital Patent Urachus

Symptoms.

Appearance of the umbilicus.

An umbilicus without tumor formation.

An umbilicus with tumor formation. Treatment.

Patent urachus and patent omphalomesenteric duct in the same child. Detailed report of cases of children born with a patent urachus.

Occasionally an infant is brought to the physician with the history that a few days after birth a watery discharge was noted at the umbilicus and that this discharge has continued. Where the discharge is abundant, it is invariably due to a patent urachus.

Escape of Urine. — The manner in which the urine escapes from the umbilicus varies. It may come away in very small quantities or be discharged in abundance. In Jacoby's case the umbilical depression was often filled with urine. In Goupil's case it came drop by drop, as from a still. In Alric's Case 1 it came drop by drop when the child cried. In Charles' case urine would "fall" from the umbilicus. In Jahn's case urine escaped when pressure was made upon the abdomen. Stierlin's patient passed only a small quantity from the umbilicus during the day, but at night the bed was saturated. In Paget's case the urine gushed from the umbilicus, while in Marx's case it came away in jets. French's patient discharged a small umbilical stream when crying. Annandale's patient, who was thirty-nine years of age, passed two-thirds of his urine from the umbilicus in a stream, when in the upright position; when he was lying down, the urine escaped involuntarily from the umbilicus. Erdmann's patient, who was four years old, at times passed an umbilical stream 4 to 12 inches high. In Hue's case the urine escaped from the umbilicus at night.

In Pauchet's case the escape of urine from the umbilicus was intermittent, occurring at intervals of from four to five days and persisting from one to two days each time.

In Cabrol's case, in which the urethra was completely blocked, all the urine, of course, escaped from the umbilicus.

The character and size of the umbilical stream will, of course, depend on the caliber of the patent urachus, the size of the umbilical opening, and occasionally on the ease or difficulty with which urine can escape from the urethra. The urine naturally follows the path of least resistance.

On questioning the parent it will be found that the urine commenced to escape from the umbilicus just after the cord came away; and some of the more careful observers among the physicians, midwives, and mothers will have noted that the umbilical cord was unusually thick near the abdomen. In these cases, of course, the urachus was patent from the bladder to a point in the cord distal from

487


488


THE UMBILICUS AND ITS DISEASES.


the point of ligation, and naturally no urine could escape until the ligature had sloughed off.

In Delageniere's case the urachus was evidently almost patent at birth, but did not open until the child was six months old.


Membranous veil at internal urethral orifice


APPEARANCE OF THE UMBILICUS. In glancing over the detailed histories of the cases of patent urachus it will be noted that in some cases the umbilicus was but little altered (Fig. 210), while in

others a definite, tumor-like mass was found.

An Umbilicus Without Tumor Formation. — The umbilicus may show little deviation from the normal, and the urachal opening be scarcely visible. In other cases the umbilicus is a little broader than usual and has five or six radial folds. At the place where these meet the urachal opening is usually found, and sometimes there is a definite funnel-like depression. Occasionally, as noted in Huggins' case, the urachal opening may be found in the lower margin of the umbilical ring. In Stevens' case there was a small hernial protrusion at the umbilicus. Fig. 255 (p. 625) represents a small hernial protrusion associated with a patent urachus.

An Umbilicus with Tumor Formation. — As a rule, the umbilical growth is small. Sometimes it is very minute, as in Florentin's case, in which it was the size of a pea. The nodule is usually spoken of as being the size of a nut, a cherry, or small strawberry. Sometimes it is dark red, flabby, and suggests granulation tissue. In other cases it may be firm, and red or violet in color. In a few cases it resembled a mushroom or flattened button, and was attached to the umbilicus by a pedicle (Fig. 211).

In Starr's case the umbilicus was larger and more widely open than usual, and in the center of the cartilaginous, nipple-like projection was an orifice which admitted an ordinary probe. In Cabrol's case (quoted by Florentin) there was a projection at least four fingerbreadths long which resembled the crest of a turkey. In Alric's Case 1, a boy ten months old, had a bright-red umbilical projection, 3 or 4 cm. long. This also bore a marked resemblance to the comb of a turkey-gobbler.

Occasionally the umbilical tumor resembled a glans penis (Fig. 212). Meyer's patient was a child one year old. The umbilicus was thickened and, although no hernia existed, it was prominent and in contour resembled a glans penis.



Fig. 210. — Escape of Urine from the Umbilicus When the Inner Urethral Orifice is Blocked by a Membrane. (Schematic.)

At least one case of this character has been recorded. As soon as the membrane was severed, nearly all the urine escaped by the urethra, and in a short time the discharge from the umbilicus ceased.


CONGENITAL PATENT URACHUS.


489



Fig. 211. — A Patent Urachus tvith a Mushroom-like Projection at the Umbilicus. (Schematic.)


French's patient was a female infant six weeks old. At the umbilicus there was a hernia-like protrusion of the skin about three-quarters of an inch in length, surmounted by a red, fleshy outgrowth like a swollen and fungoid glans penis; whenever the child cried or struggled, this growth became very prominent and vascular. In practically all of the cases in which the umbilical tumor existed, the urachal opening was situated in the center of its most prominent point.

Size of the Umbilical Opening. — Sometimes it is not larger than a pin-point and is hardly demonstrable. In other cases it is one or more millimeters in diameter, and may admit a fine probe or a mediumsized catheter. Sometimes the probe or catheter can be carried from the umbilicus directly into the bladder, and, if the bladder extends almost to the umbilicus, the distal end of the probe can be swung as a pendulum from side to side. In some

cases, particularly in those in which the urachus is tortuous, the probe can be passed only a short distance.

Irritation. — Occasionally there is a mild or severe inflammation of the skin around the umbilicus, the degree evidently depending on the irritating qualities of the escaping urine. At times the inflammation of the skin may be so severe that small ulcerations develop.

In Hind's case, in a very young infant extravasation of urine occurred around the umbilicus and finally extended all over the abdomen. The child soon died.

Sex. — In 53 of the cases here recorded, 35 of the patients were males and 18 females. These figures seem to coincide with those of other observers in showing that a patent urachus at birth is more common in males than in females.



Fig. 212. — A Patent Urachus tvtth a Penile Projection at the Umbilicus. (Schematic.) Where the urachus remains patent the umbilical end may appear as a small depression in the floor of the umbilicus. In some instances a mushroom-like elevation occupies the site of the umbilicus. In exceptional cases a definite penile projection springs from the umbilicus, and at the end of this is the opening of the urachus, as indicated in the picture.


490 THE UMBILICUS AND ITS DISEASES.

Monod, in his splendid monograph, says that it is three times more common in males than in females.

Race. — It will be noted that both Cabell's and Stites' patients were colored. Future observations will probably demonstrate that a patent urachus is relatively as common in the colored as in the white races. The majority of our observations to date have come from countries and localities where few negroes are found.

General Condition of the Child. — - From the histories it will be seen that nearly all the children were in good health. A few were anemic or slightly emaciated, but no greater percentage than one would expect to find under ordinary conditions. The presence of a patent urachus seems to have little effect on the general health of the child.

TREATMENT.

Before undertaking the closure of the umbilical fistula the patency of the urethra must first be ascertained. In the majority of the cases the urethra has been perfectly normal. In some cases, however, a phimosis exists, and under these a circumcision should first be performed.

Goupil, in 1756, reported the case of a twelve-year-old boy all of whose urine escaped from the umbilicus. In this case there was a congenital malformation and the penis was not perforated. Draudt reports a case of urinary umbilical fistula in a child a day old. Death occurred on the fifteenth day, and at autopsy it was found that the urethra was almost totally obliterated. It is obvious that in Goupil's and in Draudt's case any attempt to close the umbilical fistula would not only have been useless, but essentially harmful.

Quite a number of the patients were never operated upon, and the urinary umbilical fistula persisted even in adult life. Spontaneous closure of the fistula is exceptional. Lugeol, however, reports the case of a female child who had at the umbilicus a small, soft, reddish- violet tumor, in the center of which was a small fistulous opening. Little by little the urinary discharge from this diminished and finally disappeared. Five months later the child was well.

Tuholske also reports a case of spontaneous healing. His patient was a man fifty-two years of age. In infancy he had passed urine from the umbilicus. This condition ceased in his fourth year without treatment, and he had no further trouble until his forty-eighth year, when, apparently without cause, the urine again commenced to flow through the navel.

Monod reports the case of a patient that came under the care of Jaboulay. A man sixty-two years of age, who was suffering with painful micturition and symptoms of an enlarged prostate, noticed urine escaping from the umbilicus. When questioned, he said that his mother had often told him that shortly after birth he was treated for the escape of urine from the umbilicus, and that this discharge had disappeared in the course of fifteen days after the application of an appropriate bandage. Jaboulay's case is another example of spontaneous closure of the fistula.

In the early days the fistulous opening was usually treated with caustics or with the actual cautery, and in quite a number of instances the fistula soon closed. ( Occasionally a simple plastic operation gave very fair results.

In those cases in which a definite umbilical tumor was present, it was in some instances transfixed with needles and ligated. The tumor would slough off in a few days, and the umbilical end of the fistulous tract usually remained closed.


CONGENITAL PATENT URACHUS- 491

Where the urachus still persists, there is always a chance of subsequent trouble, and there are at least three cases on record in which the patient later developed cancer of the urachus. Graf reported the case of a man, twenty-eight years old, who died of cancer of the urachus. This patient at birth had an umbilical fistula. It was healed with escharotics. Twenty-five years later carcinoma of the urachus developed. Hoffmann also reports a case in which the patent urachus was closed with escharotics when the child was in his third year. This man, when twenty-seven years old, developed a fatal carcinoma of the urachus.

Fischer records the case of a man of thirty-two who had an inoperable carcinoma of the urachus. During childhood this man, when voiding, had been aware of a "moisture at the umbilicus." Later this symptom had disappeared and he had noticed no further trouble until he was thirty-one years old.

In the light of our present knowledge of abdominal surgery the wise plan is always to remove the fistulous tract. The umbilicus is encircled and freed, and, together with the fistulous tract, is dissected free to the bladder. The bladder attachment of the urachus is treated in precisely the same manner that an appendix stump is dealt with, namely, by the employment of a purse-string suture. After the stump has been inverted into the bladder, the closure is reinforced with one or two more sutures and the wound closed. The purse-string suture should consist of fine black silk or of catgut that will last for several weeks. This method of treatment has been in use for several years, and has yielded excellent immediate results. It has also insured absolutely against any subsequent urachal trouble.

In those cases in which the urachus gradually broadens out into the bladder, the bladder opening is naturally large and sometimes cannot be satisfactorily closed with a purse-string suture. In such cases it may be necessary to close it with a continuous suture, as in the procedure for closing the bladder after a suprapubic operation.


PATENT URACHUS AND PATENT OMPHALOMESENTERIC DUCT IN THE SAME CHILD.

We have found numerous examples of a patent omphalomesenteric duct and of a patent urachus, but there are only two cases, as far as we could learn, in which both were patent in the same child.

Lexer, in his article on the Treatment of Urachal Fistulas, refers to the case of a boy a year old. Urine escaped in large quantities from the umbilicus. From the accompanying history it is certain that at operation a patent omphalomesenteric duct was found, in that it is stated that the fistula was lined with typical intestinal mucosa. There seems to be little doubt that both the vitelline duct and the urachus were patent.

In the second case — related to me by Dr. Heflin — at operation a fistulous tract passing directly from the umbilicus to the small bowel was found. This tract was three inches long. After it had been cut away and the bowel closed, a second tube was found extending from the umbilicus to the bladder. This was also patent.

I have had microscopic sections made from this case. One duct, the vitelline, is lined with typical intestinal mucosa, the other, the urachus, with remnants of transitional epithelium. The patency of both ducts in this case cannot be questioned (Fig. 214).

Both of these cases are of such interest that I wall cite them in detail.


492 THE UMBILICUS AND ITS DISEASES.

A Patent Urachus and Probably a Patent Omphalomesenteric Duct. — Lexer* in his article reports the case of a boy, a year and a half old. The cord came away on the fifth day and clear fluid was noticed coming from the umbilicus. It is said that at this time there was a reddish tumor, the size of the end of the little finger, at the umbilicus. This gradually became smaller and finally disappeared. When the child was six months old the fistula was closed by a physician by means of salves and plasters. It remained closed, however, for only two weeks. The child was restless, and there were general systemic disturbances. When the fistula reopened, a large quantity of watery fluid escaped, and pus was said to have come away at one time. Wnen Lexer saw the child he was somewhat weak and pale. About 5 mm. below the umbilicus was a fistulous opening surrounded by an area of inflammation. Each time the child urinated a large quantity of urine escaped from the fistula, whereas from the urethra it passed drop by drop. There was a marked congenital phimosis. The case was diagnosed as one of urachal fistula. By placing a glass at the umbilicus the observer estimated that about one-quarter to one-third of the urine escaped from the navel. With a sound it was possible to make out only a small, bay-like cavity beneath the skin.

The prepuce was cut; four weeks later the urine was flowing normally and there had been a diminution in the size of the fistula. After excision of the skin around the umbilicus there was disclosed a depression lined with granulations, and scarcely larger than a hazelnut, communicating with the fistula. From this fistulous opening a sound could be passed exactly in the mid-line of the abdomen toward the bladder region. Further examination could not be made, as the child did not take the anesthetic well. As the mucosa of the fistulous tract was exposed, it was grasped with forceps and gradually drawn out. The sac was dissected out and the wound closed.

The tube was 7 cm. long, and microscopic examination showed that it was not a patent urachus, but a persistent omphalomesenteric duct. This on cross-section showed a well-developed intestinal mucosa; the lumen increased in size as it passed inward. It was lined with cylindric epithelium, had the typical Lieberkiihn's glands, and also the circular and longitudinal muscle-fibers. Lexer said that from the above picture it was clear that he was dealing with a Meckel's diverticulum. The child remained well.

The history clearly demonstrates the existence of a urinary fistula, and the microscopic examination of the specimen shows a tube lined with intestinal mucosa. The only way in which the picture can be adequately explained is by a persistence of both the urachus and the omphalomesenteric duct.

A Patent Urachus and a Patent Omphalomesenteric Duct in the Same Child. — Wliile conversing with Dr. H. T. Heflin, of Birmingham, Ala., on May 6, 1912, he related to Dr. Cunningham Wilson and myself his experience with a child fourteen months old. He saw the patient (J. S.J on August 29, 1911. Two or three days after birth bleeding occurred from the umbilicus. This bleeding at times was moderate in amount, but at other times severe, and as a result the child became very anemic. Apart from this he was perfectly well except for a tight prepuce, which had to be released. He was often constipated and cried a great deal. The more he cried the more he bled. Dr.

  • Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73.


CONGENITAL PATENT URACHUS.


493



Fig. 213. — The Appearance of the Umbilicus in a Case in Which Both a Patent Omphalomesenteric Duct and a Patent Urachus Existed. (Heflin's case.) The umbilical depression is irregularly funnel-shaped and lobulated, and along one side is a small opening no larger than a pin-head. The picture to the right shows the cross-section of the omphalomesenteric duct in the abdominal wall. It is nearly 1 cm. in its longest diameter. It was lined with typical mucosa. To the extreme right are seen the ligated ends of the omphalomesenteric duct and the urachus. For the microscopic picture see Fig. 214.



Fig. 214. — Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same

Child. (Heflin's case.) The large cavity (a), to the right, is the lumen of the omphalomesenteric duct, which has been cut slightly on the slant. The mucosa is drawn up into long, papillary-like folds. Surrounding the lumen is a circular layer of non-striped muscle. The small cavity (6) to the left is what remains of the urachus. This cavity was partly filled with debris containing small round-cells and some polymorphonuclear leukocytes. The tissue immediately surrounding the lumen was very delicate in texture and has retracted from the surrounding dense tissue. The elongate dark area just below the lumen is a lymph-nodule. The tissue for a considerable distance around the urachus was infiltrated with small round-cells and polymorphonuclear leukocytes. (Photomicrograph by Mr. Herman Schapiro.)


494


THE L^MBILICUS AND ITS DISEASES.


Hefiin had him under observation for some time. The mother would bring him every day or two for examination. He became paler and more exsanguinated. The bleeding was stopped temporarily sometimes by pressure, sometimes by the use of the cautery, adrenalin, or hydrogen dioxid, but, instead of diminishing, the amount of hemorrhage increased. At a later date stick silver nitrate was used.

Finally, a small piece of the umbilicus was cut outrfor examination. The glands found in it suggested malignancy. From the time of his birth there had been some discharge from the umbilicus which had an odor of urine and at other times strongly suggested feces. Finally Dr. Hefiin decided that the only proper procedure was removal of the umbilicus. He made an elliptic incision, and on lifting the umbilicus out found that there was a continuous fistula about three inches long, from the umbilicus to the small bowel. He removed it, and treated the opening in the bowel precisely as if it had been the stump of an appendix. The mesentery of the small bowel opposite the point of this opening contained quite a number of large lymph-glands, some of them nearly 1 cm. in diameter.

He also found a second tube attached to the umbilicus, which passed downward toward the bladder. It was patent. He tied it off with catgut and brought it up into the abdominal incision. The abdominal wound was brought together without difficulty and the child made a good recovery (Fig. 215).

Sections through the mass removed by Dr. Hefiin from the umbilicus show two distinct tubes. One is almost circular and nearly 1 cm. across; the other about 2 or 2.5 mm. in diameter. The larger one, on histologic examination, is found to be lined with long, shaggy intestinal mucosa of the type found in the small bowel (Fig. 214) . The epithelium is everywhere intact. Surrounding the mucosa is a circular muscular layer and outside of this again a cylindric layer. The smaller tube is somewhat disorganized. Its walls are surrounded by muscle, and its inner surface consists in large measure of granulation tissue which has become organized. The nuclei have mostly disappeared. Clumps of polygonal cells are seen here and there clinging to the wall. Surrounding the lumen are large numbers of lymphoid cells, reminding one a good deal of young lymphglands. In the walls arc polymorphonuclear leukocytes and small round-cells. Un


flg. 215. a plctube of the child three

Weeks after Removal of a Patent Omphalomesenteric Duct and a Patulous Qrachus. He is Now in Good Health. (Heflin's catu.)


CONGENITAL PATENT URACHUS. 495

doiibtedly the tube represents the degenerated urachus. In this case there was a patent omphalomesenteric duct and also an open urachus.


REPORT OF CASES OF CHILDREN BORN WITH A PATENT URACHUS.

The following cases represent nearly all the cases we could find in the literature. Some in which the history was inconclusive, have been omitted.

A Patent Urachus with a Long Projection at the Umbilicus. — In Alric's Case 1* the patient was a boy ten months old, seen in 1862. He was well developed, but had at the umbilicus a tumor 3 to 4 cm. long. This was regular, round, with a diameter a little larger than that of a goose-quill. It was firm and resembled mucosa. It was bright red, and, as in Cabrol's case, bore a marked resemblance to the comb of a turkey-cock. In the center was an openinghaving the diameter of a fine probe, and when the infant cried, urine passed from the umbilicus drop by drop. Its nature was recognized by the color and odor.

The genital organs were normal, and the child urinated naturally through the urethra. This state of affairs had existed since birth.

As the child did not return to the hospital, no operation was done.

A Patent Urachus. — Alric's Case 2f was seen in 1873. The child was five years of age, and in every other respect seemed to be healthy except that it had a urinary odor. The umbilical depression was replaced by a soft, flabby, fungus-like, dark-red, somewhat rounded tumor, the size of a walnut. On manipulation it was found to have a short pedicle about the size of a pen-holder. Continually escaping from the center was a liquid, recognized by its odor as urine. When the bladder contracted, the urine escaped more freely from the umbilicus; at one time the force was sufficient to cause it to pass out in a jet. The urethra was normal.

The tumor was raised and transfixed with a needle threaded with double-waxed thread. The loop was cut, making two threads. These tied both halves of the tumor firmly. The tumor in a few minutes became dark and separated in a few days. By the fifteenth day cicatrization was complete. There was no further escape of urine and the boy remained well.

A Case of Unclosed Urachus with Umbilical Fistula. J —The patient was a big, strong, healthy, well-formed man thirty-nine years of age. He had passed a portion of his urine through the umbilicus ever since his birth. When he urinated in the upright position, about two-thirds would come out of the fistula in a full stream, the other third passing by way of the urethra, in a strong but small stream. When the patient was lying down, the urine would flow out spontaneously through the fistula — more markedly so when he was lying on his left side. He had to pass water regularly about every two hours, and in doing this he found it necessary to loosen all his clothes in front and bend forward. His health was good, but on one or two occasions he had passed fine calculous material with the urine.

The genital organs were well formed. The abdominal walls were perfect. The umbilicus was a little flatter than usual. In the center was an opening with depressed margins. The opening would admit the tip of the little finger. A No. 12

  • Alric: Sur deux cas de persistance de l'ouraque. Bull, de therapeutique, 1879, xcvii, 34.

t Alric: Loc. cit., Case 2. J Annandale, T.: Edinb. Med. Jour., 1870, xv, 680.


496 THE UMBILICUS AND ITS DISEASES.

catheter passed easily from above into the bladder. There was no excoriation. A Xo. 6 catheter passed readily through the urethra into the bladder.

Operation was suggested, but refused.

Urachal Fistula. — H. R. Wharton reports a case that came under Ashhurst's* care. The patient was a boy nine months old. At the umbilicus was an opening through which urine had escaped since birth . Occupying the position of the umbilicus was a flattened tumor the size of a filbert. It was covered over with mucosa, and in its center was a depressed opening, through which the urine escaped. There was no obstruction in the urethra.

The actual cautery was applied to the fistulous tract and the projection at the navel was ligated. Recovery followed.

Patent Urachus. — Binnief says that J. D. Griffith, in a girl fifteen years of age, split, cauterized, and packed the fistula with splendid results. In this case the mother said that there had been more or less umbilical discharge from the time the cord had separated.

A Patent Urachus. — In 1847 Cabell J examined a mulatto girl fourteen or fifteen years old. She was in good health, but had an umbilical fistula, through which she had passed urine since her earliest childhood. Most of it, however, was passed through the natural channel. She claimed to have the power of passing it either way at will.

The umbilicus presented a flattened, disc-like appearance about the size of a quarter of a dollar. The skin around it was loose and in folds, but not so much as to attract particular attention to it. In the center was a small aperture of the usual appearance, and through this urine escaped. A catheter could be passed six to seven inches downward toward the bladder, and urine escaped from it. The urethra was rather smaller than usual.

A Patent Urachus. § — The patient was a well-developed boy one year old. The urine was first noticed escaping from the umbilicus when the cord dropped off. From the urethra it was passed with difficulty, coming only in drops. No tumor was noted at the umbilicus, but the urine filled the umbilical cup and ran over.

The prepuce was long, contracted, and adherent to the glans. The child was circumcised, and the urine later was projected through the urethra some distance, very little coming away from the umbilicus.

Charles says that sometimes it is necessary to operate on the fistula. He did not do so in this case, and the cure was not complete.

A Patent Urachus. || — The patient, C. F., was five and a half years of age. The baby had at the umbilicus a small, violet-colored tumor, the size of a currant. At the age of six months this small tumor began to grow; it became prominent and enlarged considerably, until it reached the size of a strawberry. Some time later an orifice formed at its summit, from which a stream of serosanguineous fluid escaped. This was never examined. Since that time, according to the mother,

  • Ashhurst: Med. News, Philadelphia, 1882, xli, 122.

t Binnie, J. F.: Jour. Amer. Med. Assoc., 1906, xlvii, 109. % Cabell, R. G.: Amer. Jour. Med. Sci., Philadelphia, 1848, n. s., xv, 313. § Charles, J. J.: The Treatment of Patent Urachus. Brit. Med. Jour., 1875, ii, 486. || Delageniere, H.: Traitement de l'ouraque dilate et fistuleux par la resection et la suture. Une observation. Arch, provinc. de chir., 1892, i, 222.


CONGENITAL PATENT URACHUS.


497


there had been sometimes a cessation of the discharge, but then immediately there had developed a severe pain at the umbilical region. It was on acccount of this pain that the mother sought surgical aid.

On examination the child was well nourished, but rather backward in development, and looked more like a four-year-old child than one of five and a half. The umbilicus was the seat of marked irritation. It was deformed and showed a transverse furrow, dividing it into two halves, an upper and a lower, both of which were indurated and red. This furrow measured about 2 cm., and was surrounded by an inflammatory zone several centimeters broad, which presented multiple erosions of the skin and several indurated points — veritable hard nodules. The principal one was situated 3 cm. below the fold of the umbilicus. Through the furrow it was possible to introduce a probe and pass it easily downward toward the nodule mentioned. The fluid escaping from the umbilicus was usually clear and transparent, sometimes tinged with blood, chiefly when the child walked. The urine escaped from the urethra in a jet, and a short time afterward some could be seen coming from the umbilicus. When the urine ceased to pass by the urethra, the discharge from the umbilicus increased.

On May 2, 1892, a median incision was made. The tissue on section had a lardaceous appearance. The operator entered into an excavation lined with f ungosities and numerous diverticula. This cavity was cureted. In the lower part was a pocket into which a sound could be introduced. Delageniere decided to remove the sac (Fig. 216). He opened it and entered the peritoneal cavity. He then easily recognized the urachus, which showed as a duct lined with smooth mucous membrane. The duct was isolated for a distance of 3 cm. and ligated. The sac was then removed, a drain introduced, and the abdomen closed. The patient made a satisfactory recovery.

A Patent Urachus. — Draudt* describes the case of Fritz R., six months old. For several weeks a clear fluid had been escaping from the umbilicus. Whether it had begun almost immediately after birth was not known. The child was healthy and otherwise normally formed. The umbilical ring was completely closed. There was, however, an escape, drop by drop, of a clear, acid-reacting fluid from the umbilicus. After a 4 per cent, solution of indigo-carmin was introduced into the gluteus muscle, the urine from the urethra and the fluid from the umbilicus both took on a deep blue color. There was a phimosis, but the stream from the urethra was fairly well developed.

Operation. — Professor Lexer, with the patient in the Trendelenburg position, made an incision around the umbilicus and continued it to within a fmgerbreadth



(After


Fig. 216. — A Patent Urachus. Delageniere.) Anteroposterior section through the lower part of the abdomen. P, peritoneum; V, the bladder; O, the urachus; U, the urinary pouch; a, the orifice of the fistula at the umbilicus.


  • Draudt, M.

1907, lxxxvii, 487. 33


Beitrag zur Kenntnis der Urachusanomalien. Deutsche Zeitschr. f. Chir.


498


THE UMBILICUS AND ITS DISEASES.


of the symphysis (Fig. 217). The incision was deepened and the parts dissected free. On the posterior surface of the cord, passing from the umbilicus to the bladder, the peritoneum was very thin. The opening in the bladder- wall was closed with a continuous mattress suture, which was reinforced, and the abdomen was closed.

The specimen was 7 cm. long, with a canal about 2 mm. in diameter extending throughout its entire length. About 1.5 cm. from the outer skin, at the umbilicus, the lumen became wider. It was funnel-shaped and passed gradually into the skin. The portion toward the bladder was similarly arranged. The funnel-like dilatation imperceptibly passed over into the bladder mucosa. There was no evidence of a fold or of a valve.

Microscopic examination gave findings similar to those obtained by Luschka, Suchannek, and Wutz. The inner surface of the tube was everywhere lined with several layers of epithelium, usually three layers in thickness.

A Patent Urachus Associated with a Partially Obliterated Urethra.* — In the case of K. B., a male infant one day old, no evidence of a urethra was found externally and the bladder did not seem to be very full. Under these circumstances a urethral orifice was sought for in the perineum. The entire bulbus was laid free and carefully examined, but no urethra was discovered. The opening made in the perineum was not closed. The dressings a few hours later were found to be moist. Injections of indigo-carmin into the gluteus muscles did not, however, give a very clear blue color. The moisture on the clothes continued, but no opening corresponding to the urethra could be seen. After gradually becoming weaker, the child died when fourteen days old. At autopsy it was found possible to remove the urachus, bladder, and urethra intact. (Fig. 218 gives a typical picture of the condition.) The bladder itself was spindleshaped, approximately 4 cm. in length. At its broadest point it measured 2 cm. in diameter. The walls were very thick, especially near the fundus. The mucosa was folded. The ureters opened at the normal points. Projecting from the fundus was a canal 1.8 cm. long and about 5.5 mm. in diameter. This passed gradually into the funnel-like opening at the top of the bladder, and there was no evidence of a fold-like formation at the junction of the bladder with the canal. The tube was lined with epithelium, extended to the umbilicus and was open

  • Draudt, M.: Loc. cit.



Umbilicus


Urachus


Bladder


Peritoneum


X


Fig


217. — A Urachus Open from Bladder to Umbilicus. (After Draudt.) The child is in the Trendelenburg posture. The umbilicus has been encircled by the incision, and the cord dissected free to the bladder. It was cut off at the top of the bladder, and the bladder closed. The patient made a good recovery.


CONGENITAL PATENT URACHUS.


499


/


Umbilicus


Remains of umbilical arteries


Urachus


\


there. The opening, being not over 0.1 mm. in diameter, macroscopically was hardly visible, but in serial sections the condition became apparent. The inner surface was lined with a very definite epithelium, four or five layers in thickness. The superficial epithelium was also cylindric in character.

On examination of the urethra it was found that the bulbous portion followed an eccentric course and lay to the left. In the course of the urethrotomy it had been cut a little, — sufficiently to allow urine to escape, — but not enough to be recognized macroscopically. The urethra was eccentric and ended as a connective-tissue thread about 2 cm. beneath the point of the glans. This case belongs to the rather rare group of defects of the urethra in its glandular portion. Kaufmann, in 1886, could find only 11 cases of this anomaly.

Vesi co-umbilical Fistula.* — This case was also recorded by Dupuytren and Roux and also forms Gueniot's Observation 5.

Madam L. brought a male child twenty-three and one-half months old to the hospital on May 14, 1810. The child looked well. From birth he had presented a remarkable and extraordinary phenomenon. Part of the urine had passed from the urethra and part from the umbilicus. The umbilicus was radiating in form, and in the center could be seen the umbilical extremity of the urachus. At the umbilicus at birth was an oblong tumor. The cord was situated in the middle of the extremity of this tumor, which was red and bloody. After the cord had dropped off the boy had commenced to emit jets of urine from the umbilicus. The extremity of the tumor was always red, and covering it was a small quantity of pus. In the course of fifteen days the tumor assumed a more favorable aspect. It commenced to cicatrize, and after six weeks healing was complete, but the fistula persisted.

A Patent Urachus in a Child Four Years 1 d . f — In this child, four years of age, there was a leakage of urine from the umbilicus. At times the stream was from four to twelve inches high.

The boy was well nourished, had normal genital organs, and voided some of his urine from the urethra.

At the umbilicus was a large, mushroom-like eversion fully half an inch high, with a crater-like center. The entire structure was covered with epithelium, and showed no erosions. In the center there was a small cicatricial area surrounding the opening, which admitted an ordinary probe. The boy was kept under observation and was found to have a fairly good stream from the urethra.

Operation. — A probe could be passed from side to side like a pendulum, showing


Bladder


\


Fig. 218. — An Open Urachus. (After Draudt.) The bladder is spindle-shaped. The upper portion is narrow and gradually passes over into the open urachus, which can be followed up to the umbilicus.


  • Marx: Enfant de vingt-trois mois et demi, qui rendait Purine en partie par la verge et en

partie par l'ouverture ombilicale de l'ouraque. Repertoire general d'anatomie et de physiologie pathologique, 1827, iv, 120.

f Erdmann, John F.: Pediatrics, 1908, xx, 356.


500 THE UMBILICUS AND ITS DISEASES.

a rather wide urachus with a diameter of fully half an inch. A free incision was made from an inch above the pubes to the umbilicus. In dissecting the urachus free the operator made several small openings in the peritoneum. The bladder was fusiform in shape, and the urachus, which was three-quarters of an inch wide and about three inches long, was apparently continuous with the bladder itself. The umbilicus was excised, and about an inch of the urachus with the umbilicus cut off. Direct apposition sutures were then applied, followed by a circular row below, with inversion of the sutured portion, as in the case of an appendix stump. A third row of catgut sutures was placed over the inverted end, and the abdominal wound closed. A catheter was placed in the bladder and kept in three days. The boy made a good recovery, and was discharged on the seventeenth day.

A Patent Urachus. — Florentin* quotes Cabrol's case. In the year 1550, in the village of Beaucaire, there was an exhibition by the village guard before the house of Mile, de Varie. Several of the young ladies were accidentally injured. When treating these patients, Cabrol noticed a most offensive odor of urine, and tried to find out the cause. The next day he examined a girl and found at the umbilicus an elongation the length of four fingerbreadths, resembling the crest of a turkey-cock, whose urine is passed through the cloaca. The surgeon was at once impressed with the danger of closing this opening without allowing the urine to pass by the ordinary channel. The girl was eighteen years of age. He found the vesical orifice closed by a membrane. He opened this and passed a lead cannula into the bladder. The next day he closed the opening at the umbilicus. It had entirely healed by the twelfth day.

A Patent Urachus. — Florentinf reports a case of urinary fungus in a girl of four years, from the clinic of Professor Froelich. She was admitted to the surgical department for fistula at the umbilicus. At birth nothing abnormal was noted. The cord came away on the ninth day. At that time the mother noticed at the base of the umbilical cicatrix a tumor the size of a small pea. This discharged continuously a whitish liquid with the odor of urine. Since that time the tubercle had gradually increased in volume, the discharge had persisted and produced a marked erythema at the orifice of the umbilicus. This condition had persisted for four years, without any interference with the health of the child. On examination, at the base of the umbilical fold was seen a violet-colored tumor the size of a pea. A probe could be introduced downward and backward. The tumor was irreducible. There was no hernia at the umbilicus. At intervals a drop of clear liquid with a urinous odor escaped.

Operation. — The tumor was encircled and dissected down to the peritoneum. All that could be drawn out was cut off and the wound closed. Microscopic examination showed an outer coat of connective tissue, then the cell-fibers of non-striped muscle, and in the center a duct lined with pavement epithelium. The child made a good recovery.

A Patent Urachus. J — A male child, two or three months old, was brought to Professor Helmuth's College Clinic in 1885. The nurse who accompanied the child said that it passed urine through the umbilicus. On examination an outgrowth, about an inch and a quarter in length, was discovered in this locality. It

  • Cabrol: Quoted by Florentin, P.: Fongus de l'ombilic chez le nouveau-ne et chez 1'enfant. These de Nancy, 1908-09, No. 22.

t Florentin, P.: Op. fit,, obs. 9. \ Freer: Annals of Surg., 1887, v, 107.


CONGENITAL PATENT URACHUS. 501

was hollow and was connected by a completely pervious urachus with the bladder. This point was proved by the continuous discharge of urine through it. The urine excoriated the parts and rendered the child exceedingly uncomfortable. The method of treatment suggested for the deformity was ligation of the excrescence, but, owing to the absence of the child's parents, this was deferred.

A Patent Urachus. — Freer* says that in cases of vesico-umbilical fistula several methods of treatment have been devised. He cites the case of a child of five months. The urachus was completely pervious and admitted a mediumsized catheter. At its umbilical extremity was an outgrowth that resembled a strawberry. This was encircled with a subcutaneous ligature and removed; the edges were pared and sutured, and complete closure followed.

A Case of Fleshy Tumor of the Umbilicus with Patent Urachus. — French's! patient was a female six weeks old. There was at the umbilicus a hernia-like protrusion of the skin about three-quarters of an inch in length, surmounted by a red fleshy outgrowth, like a swollen and fungoid glans penis. Whenever the child cried or struggled, this growth became very prominent and vascular, and through a small opening urine was expelled.

Operation. — After it had been determined that no knuckle of intestine was in the way, a harelip pin was driven through the fleshy mass at its junction with the cuticle and transversely to the body axis. Beneath this and at right angles to it a needle armed with a stout double ligature was passed, and the threads were drawn through. These were tied tightly on each side under the pin. The fleshy mass came away with the pad on the third day. On the tenth day the wound had completely healed and was covered with skin. An umbilical truss was ordered as a simple precaution.

Escape of Urine from the Umbilicus. % — The patient was a boy of twelve who, for three years, had had an oval tumor directly above the symphysis. It was about the size of a hen's egg. The overlying skin was tender and apparently inflamed, but showing no great amount of reaction. To theleft of the tumor was an oblique cleft about 9 mm. long. It was through this opening that the child urinated, but drop by drop, as from a still. Below the tumor was a transverse opening, from which air escaped with some noise, and there was sometimes a foul odor. Immediately beneath this was another tumor, which may have been a penile gland. The penis was not perforated. Goupil asks how the urine could come from the umbilicus, but quotes Graf, Diemerbroeck, du Laurent, Fernel, and others as having seen it escaping. He wonders whether the foul odor could have been from the bowel, but says that no feces were passed through the umbilicus.

A Patent Urachus. § — This case was recorded in the Deutsche Klinik, 1864, xvi, 116. A man twenty-eight years of age had a urachal fistula at birth. This was healed after the employment of escharotics. Twenty-five years later a tumor developed between the umbilicus and the symphysis. This broke and discharged pus, then urine. Autopsy revealed a carcinoma of the mucosa of the urachus, which had perforated into the umbilicus and the bladder.

Possibly a Patent Urachus. || — This case was reported in Vaughan's article. No reference is given as to the original source.

  • Freer: Loc. cit. t French, John G.: The Lancet, London, 1882, i, 60.

t Goupil: Sur un vice de conformation singuliere. Jour, de med. de Paris, 1756, v, 108. § Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896. || Griffith, F.: See Vaughan, G. T.: Trans. Amer. Surg. Assoc, 1905, xxiii, 273.


502


THE UMBILICUS AND ITS DISEASES.


The patient was a male infant five months old, from whose navel there had been a discharge of clear fluid ever since the detachment of the cord. This fluid was colorless, limpid, and did not have a urinous odor. The parts were kept clean, dressed frequently, and adhesive plaster was used to approximate the edges. After three months recovery took place.

A Patent U r a c h u s . * — The child was presented before the Society of Surgery first at the meeting on June 5, 1872; and during the second meeting on July 10th, several days after complete healing had taken place. Gueniot says that it is incontestable. that the continuity of the vesical cavity with the persistent canal of the urachus has been confirmed in a certain number of cases in the bodies of adults.

He says that Albinus, Beudt, and Haller have reported examples of this character.

On June 1, 1872, Alfred R., ten and a half months old, was admitted to Gueniot's service. He was in good general health, but had a tumor at the umbilicus. This was dull red, had a mucous surface, was moist, and resembled a cherry in form, color, and volume. It was 2.2 cm. in diameter, and was attached at the umbilicus by a pedicle 6 to 8 mm. long and 16 mm. broad. It was rather soft and covered with delicate skin. On pressure it was irreducible. The umbilical ring was enlarged, slightly indurated, and hypertrophied, and formed a circular elevation which increased in size with any movement of the child. There was weakness at the umbilical ring. The tumor looked like a mushroom with a short pedicle. Finally — and this is the most important point — there was an expulsion of a transparent liquid from the orifice in the tumor, and the patient also urinated in the natural way. There was, in other words, a urinary fistula, with hernia and hypertrophy of the mucosa at the umbilicus. The genital organs were well developed. The testicles appeared to have been arrested at the rings. On June 10th, after several ineffectual attempts at compression and the employment of iron perchlorid and zinc chlorid, Gueniot ligated the umbilical tumor. This caused pain, and at the same time he noticed redness of the tumor. The passage of urine was not stopped. On the twelfth a second ligature was applied at the same point. On the fifteenth he noticed that the tumor had ulcerated circularly, and where the ligature had been applied there was a deep furrow. The surface of the ulcer was cauterized with silver nitrate and a new ligature applied. On the nineteenth the discharge of urine from the umbilicus still persisted ; the ulceration at the base of the tumor had increased, and the furrow had become deeper. The fourth ligature was applied and tied more tightly than the one preceding. This time the

  • Gueniot, R.: Des fistules urinaires de l'ombilic dues a la persistance de l'ouraque, et du

1 raitement qui leur est applicable. Bull, de therapeutique, 1872, lxxxiii, 299; 348.



Fig. 219. — Escape of Urine from the Umbilicus Due to a Patent Urachus. (After Gueniot.) ■

The upper picture represents the urine escaping from the umbilicus prior to operation. Surrounding the opening is a dark area where there had been a rolling out of the mucosa. The lower picture shows the umbilicus after operation. Cicatrization is perfect. There is no escape of urine.


CONGENITAL PATENT URACHUS. 503

tumor was markedly congested, and on the twentieth for the first time the urine ceased to pass from the umbilicus. The tumor was black and gangrenous. On the twenty-second there was a marked diminution in the secretion from the umbilicus and no escape of urine. The tumor was dead. On the twenty-fourth the ligature came away, and by the twenty-eighth the umbilicus had assumed a more normal conformation. The pedicle of the tumor had diminished markedly in its dimensions, and nothing but a small tubercle about the size of a pea remained. There was no farther escape of urine, and the child was discharged well.

A Partially Patent Urachus.* — This case is quoted by Simon (Obs. 4). (I have been unable to locate the original article.) He says that during the year 1648 Haran received at the Hotel-Dieu a new-born child who had at the umbilicus a tumor the size of a pigeon's egg. This contained clear fluid and was adherent to the extremity of the cord below the ligature. It was opened in the presence of several people, and there escaped a serous fluid which proved to be urine. Urine then escaped in abundance. All present thought that it came from the bladder.

A Patent Urachus. f — Case 1. — The patient was a male child who, when five weeks old, began to discharge urine from the umbilicus. There was inflammation resulting from extravasation of urine around the umbilicus. The extravasation spread all over the abdomen and the child died in a few days.

A Partially Patent Urachus. t — Case 3. — The patient was a girl four years of age who had a chronic discharge from the umbilicus and pain between the umbilicus and symphysis. A probe was passed nearly to the vertex of the bladder. The urachus was ligated and cut and then treated in exactly the same manner as the vermiform appendix. No opening was detected at the bladder. The peritoneum was accidentally opened during the operation. The child recovered.

A Patent Urachus. § — The patient was a vigorous boy, fifteen years of age. Since infancy he had sometimes lost urine at night through the umbilicus. During the day the bladder had held it better.

In a discussion following the presentation of Hue's case, one physician asked if the tract could not have been injected with some substance impermeable to the x-ray and then a radiograph made. Another suggested the introduction of milk or some coloring-matter to see if it would pass into the bladder.

A Patent Urachus. — On April 20, 1911, I received from Dr. PL H. Huggins, of Pittsburgh, the following abstract from one of his histories:

" The patient was the third child of a healthy mother. It weighed seven and a half pounds. It was well developed and apparently normal in every way. About ten days after delivery the nurse called attention to the escape of fluid, from the umbilicus. Examination revealed an opening in the lower border of the umbilical ring. This was surrounded by a small inflamed area by which urine escaped at times, not, however, in large quantities, but sufficient to saturate the bandage and neighboring clothing. A small probe was passed to a point about 4 cm. from the bladder. Repeated cauterizations for about four weeks effected a closure of the fistula and there was no further trouble."

  • Haran: La pratique des accouchements, i, 38.

fHind, W.: Diseases of the Urachus and Umbilicus. Brit. Med. Jour., London, 1902, ii, 242.

t Hind, W.: Loc. cit.

§ Hue, Francois: Persistance du canal de l'ouraque; fistule ombilicale. La Xormandie medicale, 1905, xx, 311.


504 THE UMBILICUS AND ITS DISEASES.

A Patent Urachus.* — This case was reported in Vaughan's article. I have not been able to obtain the original.

A girl, aged six years, had passed urine from the umbilicus from the twelfth day, that is, from the time that the cord dropped off.

The urachus was excised, and the lower end ligated with catgut. The wound was closed, leaving the end of the catgut ligature projecting. The patient had scarlet fever, and the wound opened superficially, but it was reunited and healed without further trouble.

A Patent Urachus. — Jacoby'sf patient was a strong, normally developed boy, but he had an unusually thick cord. Jacoby tied the cord himself. The umbilical ring was the size of a silver gulden. After the cord came away the wound was the same size. It rapidly became smaller, so that in three weeks it formed nothing but a funnel-shaped opening, but a few weeks after this the nurse casually mentioned that the umbilicus was often wet or filled with water. On investigation it was found that there was a fine fistulous opening through which fluid escaped when the bladder was full. The water came drop by drop and filled the umbilicus. The opening was so small that a sound could not be made to enter it.

Jaeoby tried compression, which answered very well until the pressure was removed. Later he tried the actual cautery, and as soon as the slough had come away he drew the surfaces together. This procedure proved successful after the second treatment. The umbilicus became ditch-like instead of funnel-shaped, and no trace of the fistula remained.

A Patent Urachus. — JahnJ reports a case coming under Mikulicz's care. A boy five years of age was seen in February, 1895. There was no hereditary taint. Soon after his birth the parents noticed that he passed little urine in the natural way, but that an abundance escaped by the umbilicus.

On examination the boy was found to be well developed. The umbilicus was the size of a mark piece, flat and prominent, and gathered into radial folds. In the middle was a funnel-shaped depression from which, when abdominal pressure was made, urine escaped. A sound 6 mm. in diameter passed without difficulty 14 to 16 cm. downward toward the symphysis, and could be moved freely in all directions, there being no indication of a septum. When the umbilical opening was closed, the boy could urinate well by the urethra, but in a small stream. A catheter could be readily carried into the bladder, and a sound introduced from above came into direct contact with it.

A cystoscope introduced from above passed into the bladder, and a careful examination of the viscus was thus rendered possible. A diagnosis of congenital umbilical fistula, due to an open urachus, was made.

Mikulicz, on February 5, 1895, cut around the umbilicus and dissected the canal free for 3 cm. Here it passed over into the apex of the bladder. During the dissection the peritoneum was opened at one point. This opening was closed. The urachus with its opening into the bladder was cut away, and the wound in the bladder closed. The abdominal walls were brought together, a small gauze drain being passed down to the bladder sutures.

  • Imbert, I..: See Yuughan, G. T.: Trans. Amer. Surg. Assoc, 1905, xxiii, 273.

t Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, xiv, 202.

+ Jahn, A.: Ueber Urachusfisteln. Beitrage z. klin. Chir., Tubingen, 1900, xxvi, 323.


CONGENITAL PATENT URACHUS.


505


The boy was able to urinate on the next day. The result was excellent, and three and a half years later the boy was still well.

Jahn gives a very good review of the literature.

A Patent Urachus.* — The patient was a child seven months old (sex not given). It had been passing urine from the umbilicus since birth. At the umbilicus was a sort of flattened, button-shaped tumor, the size of a cherry. It was red, and evidently due to everted mucosa at the umbilicus. A probe passed into the urachus three inches. The greater part of the urine was passed by the urethra.

A Patent Urachus. — Lannelongue'sf patient was a child three months old. The mother said that it had two penises, and that it urinated from both at the same time (Fig. 220). One penis was normal; the other organ was situated at the umbilicus, and looked exactly like a normal penis. The child died later. There was an umbilical hernia and a patent urachus which had been tied off with the cord; hence there had resulted a fistula when the cord came away.

A Patent Urachus.} — In the case of Meyer-Kempen the urine escaped in a stream from the umbilicus when the child cried. Ledderhose says that excoriations of the skin in the neighborhood of the fistula may or may not be present. As long as the urine is acid, the irritation of the skin is only small in amount. In some cases ecchymosis has been noted. The prognosis is good.

A Fistula of the U r a c h u s . § — The patient was a female child. On the seventh day the cord, which was still partially attached, was cut with scissors. In a few days the clothes at the umbilicus were wet. The discharge of fluid continued. Litmus

paper showed that the umbilical fluid had an acid reaction. When the child was examined, a small, soft tumor, reddish violet in color, and with a small hole in its center, was noted at the umbilicus. A probe was easily passed 3 cm. downward toward the bladder. The child was taken to the country five weeks after birth. Little by little the fluid diminished and then disappeared. Five months later the child was perfectly well.

  • Kennedy, A. : Brit. Med. Jour., London, 1899, i, 1396.

t Lannelongue : Un cas de faux penis ombilical. Lecons de clinique chirurgicale, Paris, 1905, 388.

i Ledderhose, G.: Chirurgische Erkrankungen des Xabels. Deutsche Chirurgie, 1890, Lief. 45 b, 109.

§ Lugeol : Fistule urinaire ombilicale par persistance de l'ouraque. Jour, de med. de Bordeaux, 1S79-80, ix, 3.



Fig. 220. — A Patent Urachus tvith a Penile Projection at the Umbilicus. (After Lannelongue.)

The penile projection at the umbilicus conformed in shape and size to the penis of a child. The urine escaped from the urethra and also from the umbilicus.


506 THE UMBILICUS AND ITS DISEASES.

Congenital Vesico-umbilical Fistula.* — The child, a year old, had an opening at the umbilicus through which, when it cried, the urine escaped in a stream. The opening had the form of a urethral orifice. The umbilicus was thickened and, although no hernia existed, it was prominent and in its contour resembled a glans penis. When the child was quiet, the urine passed by the urethra, but, when abdominal pressure was made or the child cried, it came in a stream from the umbilical opening. The urachus had evidently remained patent. Operation was refused by the parents.

A Patent Urachus. f — Monod, on pp. 122 and 123 of his splendid treatise, gives somewhat full tabulations of the cases heretofore recorded.

On p. 124 he reports a case of congenital urinary fistula at the umbilicus clue to persistence of the urachus: G. G., aged ten, admitted to the hospital in June, 1899. When the cord came away there was a plaque the size of a franc at the umbilicus. The urine escaped from it and also from the urethra. The flow was intermittent. He had never had any tumor at the umbilicus. The orifice was small, but admitted without pain a No. 13 bougie. Around the opening the skin was like scar tissue and showed transverse, raised folds radiating from the periphery to the center. The surrounding skin was smooth. .The sound could be introduced through the fistula into the bladder. At times the urine passed from the umbilicus, at other times from the urethra. Sometimes all of it was passed from the umbilicus and a few drops only from the meatus. At other times the reverse occurred, and occasionally all the urine passed by the urethra and none by the fistula. The child had a phimosis, but there was no obstruction in the urethra.

The entire urachal tract was removed. Histologic examination showed that the cavity was lined with a stratified squamous epithelium similar to that of the skin.

A Patent Urachus that Closed and Reopened Later in Life as a Result of Hypertrophy of the Prostate. — MonodJ describes a case seen by Jaboulay and reported in 1897. The patient was a man, sixty-two years of age, who had been in good health up to that time. He had painful micturition and symptoms of hypertrophy of the prostate, the diagnosis being confirmed on examination. One day after painful micturition he noticed that drops of urine with a fetid oclor were escaping from the umbilicus. The quantity of urine that escaped the first time was probably 150 to 200 c.c. He entered the hospital for the fistula, and said that he had never had any accident, but that his mother had often told him that shortly after birth he was treated for escape of urine at the umbilicus, and that the discharge had disappeared in the course of fifteen days after the application of an appropriate bandage.

The urachus was dissected out for 3 or 4 cm. and tied off. Later, however, it reopened.

Operation for Pervious Urachus. § — The patient was a female child four months old. The urine escaped from the umbilicus, keeping the bedclothes soaked. When the umbilical folds were drawn apart, an opening which

  • Meyer: Offenbleiben des Urachus nach der Geburt. Casper's Wochenschr. f. d. gesammte

Heilkunde, is 11, 424.

f Monod, Jean: Des fistules urinaires ombilicales dues a la persistence de l'ouraque. These de Paris, 1899, 62.

t Monod, Jean: Op. cit., 184.

§ Paget and Bowman: On an Operation for Pervious Urachus. Medico-Chir. Trans., London, 1861, xliv, 13.



CONGENITAL PATENT URACHUS. 507

would admit a lead-pencil was found and the skin was inverted. When the skin was drawn apart, urine gushed out. The circumference of the opening was denuded, and the edges coapted with a suture pin and lint, as in a case of harelip. On the third day a small amount of urine escaped by the umbilicus. The result was perfect.

A Case in Which the U r a c h u s Remained Open and the Ring-shaped Calculus that had Formed upon a H a i r in the Bladder was Extracte d T h r o u g h t h e U m bilious.* — ■ The patient, John Conquest, an ironfounder, aged forty, had for a year or more suffered from frequent and painful micturition. He also said that, when attempting to pass water or when doing strenuous work, urine would escape from the navel. On being questioned it was found that from the time of his birth some of the urine had come away from the umbilicus — a clear indication of a patent urachus.

He was admitted to the Leicester Infirmary on August 15, 1844. Paget, on sounding him, readily made out a vesical calculus, and further found that the sound could be carried up through the bladder to the umbilical opening. Hoping that it might be possible to remove the vesical stone through the umbilicus, he temporarily plugged the umbilical opening, distended the bladder with warm water, and placed the patient upon a Heurteloup table with his head lower than the pelvis; in other words, he put the patient in what we

1 ' Fig. 221. — A Rixg now call the Trendelenburg posture. The plug was now re- shaped vesical

moved, and a ringer introduced into the umbilical opening. Calculus with a

' ° ii Fine Hair in its

The tip of the finger caught in the center of the ring-shaped cal- axis. (After Paget

cuius (Fig. 221), and with care Paget was able to extract the and Bowman.)

• i i ,i i "V i • mi' i i This calculus had

stone through the umbilical opening. This calculus was ring- formed on a hair in the shaped because it had developed around a curled-up hair. bladder and was ex -n . ,i ,i i -t ,i - ii tracted through the um Paget says that at the umbilicus there was a circular de- biiicus. The calculus ficiency in the linea alba one inch in diameter. The margins was as thick as a me r ,i • ,i • i i i r ,•! t_ j i dium-sized writing quill.

of this ring were thickened and of cartilaginous hardness, and The urachus was patent through the opening protruded a hernial mass the size of a throughout, goose's egg. This hernia was covered over with mucous membrane which became dry when exposed to the air for any length of time. The patient could not pass water when this hernia was out, and when he tried to void, the projection gradually withdrew into the abdomen, and urine then forcibly escaped from the umbilicus, and in a moderate stream from the urethra.

It was clearly evident that the muscular walls of the bladder made traction on the umbilical hernial projection. Paget says that the bladder and urachus formed a urinary receptacle that in shape might be compared with a curved-necked cuppingglass.

The description of the case strongly suggests a partial exstrophy of the bladder.

After the extraction of the calculus the man was relieved of his bladder symptoms. No attempt, however, was made to repair the congenital defect.

Paget again saw the man in April, 1860. f When the patient was fifty-five years old (Paget said) the opening in the linea alba was elliptic in shape, and admitted

  • Paget and Bowman: Medico-Chir. Trans., pub. by the Royal Med. and Chir. Soc, London,

1850, 2. ser., xv, 293.

tLoc. cit., 1861, xliv, 13.


508 THE UMBILICUS AND ITS DISEASES.

three fingers. In the mean time the man had developed a second vesical calculus. This was disc-shaped and had come away. Paget, after passing a finger through the umbilical opening into the bladder, to exclude the possibility of another calculus, successfully closed the umbilical opening.

A Yesico-umbilieal Fistula. — Pauehet's* patient was a boy five vears of age. Shortly after the cord came awaj^ a large mass of "proud flesh" was noted at the umbilicus, and from it a clear fluid with a urinary odor escaped. The discharge of fluid would occur at intervals of four or five days, persist for one or two days, coming unexpectedly and never in a jet, and accompanied b}' abdominal pain. The granular area was destroyed with silver nitrate.

When seen, the boy was emaciated. A Xo. 6 bougie passed the urethra easily. The fistula admitted a bristle, which penetrated 3 or 4 cm. without giving any indication of the direction of the canal. The umbilicus occupied its normal site and was surrounded by an area of induration about 1 cm. in diameter. On palpation of the abdomen some urine escaped from the umbilicus. There existed in reality a retroperitoneal pocket, at one end communicating with the bladder, at the other with the umbilical fistula. The amount of urine discharged from the navel during the twenty-four hours was about 80 c.c. There was no cystitis. Urination was painless, not too frequent, and the urine was clear.

The existence of a retro-umbilical pocket was not known prior to operation. A median incision was made 3 cm. above the fistula, encircling the umbilicus and extending to within 2 cm. of the pubes. After obtaining good exposure b}^ separating the muscles Pauchet freed the tissues around the umbilicus and the subjacent tissue and made traction. He was easily able to detach a fibrous mass the size of a walnut from the peritoneum without opening the peritoneal cavity. The urachus was then visible as a delicate, transparent cord, resembling an empty vein. It passed to the summit of the bladder. It was tied off with catgut and severed. The stump was turned in with a catgut suture and the abdominal wound closed with interrupted sutures. Xo drainage was employed. The wound healed in ten days.

The ovoid mass was the size of a walnut. Its surface was adherent to the surrounding skin, and at its center was the fistula. The lower extremity of the mass was continuous with the urachus for a length of 3 cm. On section, the cavity resembled a small and contracted bladder. The walls were fibrous, and the mucosa presented a large number of folds.

A Patent Urachus. — In 1887 Pennyf reported the case of a healthy child, aged eleven months, who, after separation of the cord on the ninth day, had been passing urine through the navel. A probe passed into the fistula could be felt to touch a catheter passed up the urethra into the bladder.

After the cord came away the umbilicus was represented by a raised rounded mass the size of a hazelnut. Its surface was intensely red and covered with mucosa. A constriction fxistf j d at the junction with the abdomen. Surrounding the umbilicus was a dusky red areola, about one inch in width, due to irritation from the fluid. In the center was a sinus through which the urine escaped.

Operation was declined.

  • Pauchet. V.: Fistule ombilico-vesicale. Resection sous-peritoneale de l'ouraque et d'un

poche urineuse n'tro-ombilicale, guerison. Bull, et Mem. de la Soc. de chir. de Paris, 1902, xxviii, 785.

t Penny, W. J.: Bristol Medico-Chir. Jour., 1888, vi, 30.


CONGENITAL PATENT URACHUS. 509

A Congenitally Patent Urachus. — Petit's* patient in Case 4 was a young boy who, since his birth, had had an escape of urine from the umbilicus. At the navel was a kind of cushion, in the middle of which was a round opening through which the urine escaped. There was no obstruction in the urethra because the urine passed also by the natural way, and, when the patient did not wear a bandage, it escaped also from the umbilicus.

Urinary Fistula at the Umbilicus. — Pierre'sf patient was a boy with a congenital urinary fistula at the umbilicus, without any obstruction in the urethra. At the umbilicus was a ring, 2 cm. in diameter, in the center of which was an irregular opening 5 mm. in diameter. Behind this was a discoid cavity from which a small amount of urine escaped. No operation is mentioned.

A Patent Urachus. — In 1876 PrestonJ saw an infant so malformed that its sex could not be determined. It had an opening through the umbilicus from which urine came. The child weighed nine pounds. Two years later it was still passing urine from the umbilicus, but was in good health. The mother informed Preston that there was never any urinary odor on the diapers used to receive the feces, indicating that little or no urine escaped from the urethra.

A Case of Congenital V e s i c o - u m b i 1 i c a 1 Fistula — ■ Patent Urachus. § — The patient was a boy eleven years of age. At birth there was a rounded swelling in the umbilical region the size of a duck's egg. It was easily reduced and kept in place by a bandage. Urine escaped from this swelling. Up to his seventh year compresses were used, but these were of little value. On examination the boy was found to be strong. In the center of the umbilicus was an opening which admitted a uterine sound. Urine passed by the urethra and also by the umbilicus. Jacobi saw the child and passed a catheter from the umbilicus into the bladder.

Operation. — A raw surface was made above the fistula; a flap was dissected up from below and attached to the raw area. At the end of a week a small amount of urine escaped from the umbilicus, but the opening soon closed after the use of silver nitrate. A year later Jacobi introduced 12 ounces of water into the bladder through the urethra and none escaped from the umbilicus.

A Series of Cases with Patent Urachus. — Smit|| reported three cases:

Case 1: A woman, aged fifty-eight, complained of retention of urine which dribbled from the navel. A vesicovaginal fistula was established and the urachus closed spontaneously. Later the vesicovaginal fistula closed.

Case 2: A girl aged seventeen had constant dribbling of urine from the navel; also of blood at the menstrual period. The edges of the fistula were split and a purse-string suture applied, with a perfect result.

Case 3 : A boy, one and a half years old, had an offensive discharge of urine from the navel. There was also an eczematous condition at the umbilicus. The boy had marked phimosis. Circumcision failed to cure the fistula. The navel was excised and the urachus successfully closed with a purse-string suture.

  • Petit, J. L.: Traitedes maladies chirurgicales, Chap, xi, 3. Oeuvres completes. 8°. Limoges,

1837, 799. (Quoted from Simon.)

f Pierre: Bull. Soc. de med. de Rouen, 1888, 2. serie, ii, 32.

X Preston, W.: Med. Record, New York, 1898, liv, 315.

§ Rose, A.: Med. Record, 1877, xii, 516.

|| Smit, J. A. R. : Abstract from Zentralbl. f. Gym, 1904, Nr. 41.


510 THE UMBILICUS AND ITS DISEASES.

It is not stated in these cases whether the urine had passed from the umbilicus from birth. We are including them all as instances of patent urachus.

A n Ope n U r a c h us. — Smith* reported the case of a boy, aged two years, who had a papilla-like projection at the umbilicus. In the center of this was an opening from which, at all times, there transuded a fluid looking and smelling like urine. A ligature was firmly applied to this projection, and after a few days it dried up and fell off. The fistula seemed to be permanently closed.

Fistula of the Urachus. — Stadfeldt t reports a case of fistula of the urachus and gives a table of cases from the literature. [Xo translation of the article could be obtained.]

Escape of Urine fro m the Umbilicus. — Starr's i patient was a female child thirteen weeks old. Since birth the urine had escaped from the umbilicus. The urethra was normal. The flow from the umbilicus was not continuous, but occurred at intervals, regulated by the detrusive action of the bladder. The general appearance of the umbilicus was larger and more open than usual, and in the center of the cartilaginous, nipple-like projection was an orifice which admitted an ordinary probe. This passed in the direction of the linea alba toward the bladder. Starr diagnosed the condition as one of open urachus, although he pointed out that a leading authority claimed that the urachus was open only in those cases in which the urethra was closed.

The Radical Cure of a Patent Urachus. § — The patient was a tall youth, seventeen years of age, who had had urine escaping from the umbilicus since birth. The umbilicus bulged forward; there was a small hernia of subperitoneal fat and an eczematous condition around the umbilicus. The patient had always had some pain when voiding.

Operation. — The bladder was emptied and four ounces of boric solution were allowed to run in. A transverse incision was made one inch above the symphysis. The recti muscles were separated, and a good view of the bladder and its peritoneal reflection was obtained. In caliber the urachus was as large as the stem of a clay pipe. The part close to the bladder was clamped, a second clamp was applied high up and a cut made between. A purse-string of celluloid thread was placed around the vesical stump of the urachus, and the latter was invaginated as in dealing with an appendix. The umbilical end of the urachus was brought up out of the abdomen between the recti muscles and anchored to the muscle, and the sheath covered over with fat and skin. Further dissection was not made on account of the eczematous condition of the skin. The patient made a good recovery.

A Patent Urachus. — Stierlinj] reports the case of a twelve-year-old girl brought to the hospital on June 28, 1896. At the umbilicus was an opening from which urine flowed. During the daytime only a small amount escaped, but at night so much came away that practically every morning the bed was wet through. The urine escaped only drop by drop from the umbilicus. There was never any pain. This watery discharge from the umbilicus was noted as soon as the umbilical cord

  • Smith, Thomas: Mel. Times, London. 1863, new series, i, 320.

f Stadfeldt, A.: Bidrag til Laren om den medfodte Yesiko-umbilikalfistel i Urachus-fisteln) og dens Behandling. Nordiskt Mediciniskt Arkiv, Stockholm, 1871, iii, Xo. 23, 1. Starr, T. II.: Med. '1 a z., London, 1844, xxxiii, 484. 5 evens, B. Crossfield: The Lancet, London, 1904, ii, 584.

Stierlin, Ii.: Zur Casuistik angeborener Xabelfisteln. Deutsche med. Wochenschr., 1897, xxiii, 1 38.


CONGENITAL PATENT URACHUS. 511

came away. The child was well nourished. The umbilicus was flat, broad, and about 3 cm. in diameter. In its lower portion was a depression toward which the skin on all sides passed in radiating folds. The umbilical ring was wide, so that the point of the finger could be passed into it. If the patient coughed, the upper part of the umbilicus became distended. In addition, in the linea alba there was a small prominence the size of a pea. Stierlin diagnosed the case as one of hernia of the linea alba. The depression in the lower part of the umbilicus formed the entrance to a large, roomy, fistulous canal. When pressure was made upon the hypogastrium, several drops of clear fluid with a urinary odor escaped. A No. 9 bougie could be passed into the fistula with ease and entered a cavity. When a metallic sound was introduced through the urethra at the same time, both instruments were found to have entered the bladder.

Operation. — On both sides of the fistula the skin was divided in transverse directions for 1.5 cm. The walls were freshened up, and the urachus closed with continuous catgut. The abdominal walls were then brought together and a catheter was placed in the bladder. There was no hematuria, and the patient made a good recovery.

Patulous Urachus in a Child of Nine Months.* — The patient was a negro girl nine months of age. Ever since the separation of the cord she had discharged urine from the umbilicus. At the navel was a protruding mass of granulation tissue, but bulging only about one-sixteenth of an inch from the skin. In its center was an opening. In five or six weeks a cure was effected after cauterization of the orifice several times at various intervals.

A Patent Urachus That Closed in the Fourth Year and Opened Again at Forty-eight. — Tuholske's f patient was a man fifty-two years of age, who in infancy had passed urine through the umbilicus. This condition ceased in his fourth year without treatment, and he had no further trouble until he was forty-eight years of age, when, apparently without cause, the urine again commenced to flow through the navel. The margins of the opening were pared and sewed together, but without effecting a cure. Six months later the canal was exposed by incision, and half an inch beyond the margin was found to spread out into the bladder, no division existing between the bladder and urachus. The urachus was split down to what should have been the summit of the bladder and sewed across for a distance of two inches. The operation was extraperitoneal. Recovery followed.

Congenital Sinus of the Urachus. — Vander Veer,| in 1886, saw in consultation with Dr. DuBois, a female twenty years of age who, since the tenth day after her birth, had discharged urine from the umbilicus at irregular intervals. For the last two years she had had pain, the discharge had become offensive, and the parts about the umbilicus had become excoriated. A probe passed downward toward the symphysis for three inches. The sinus lay just extraperitoneally.

The operation consisted in slitting up the urachus, curetting, suturing the lower part, and packing the upper part with iodoform gauze. Recovery followed.

A Patent Urachus. — Velpeau § reports a case of a boy two years of age,

  • Stites, T. H. : Amer. Medicine, Philadelphia, 1903, vi, 136.

f Tuholske, H. : St. Louis Medical Review, February 11, 1905. (From Vaughan's article.)

t Vander Veer, A.: Med. and Surg. Reporter, 1889, lxi, 661.

§ Velpeau: Arch, de med., 1826, xi, 554. (Quoted from Gueniot, obs. 6.)


512 THE UMBILICUS AND ITS DISEASES.

who was seen in consultation by Professor Ronx for congenital tumor of the umbilicus. The child was in a condition of continuous suffering. The greater part of the urine escaped from the urethra. The umbilical tumor was the size of a walnut and resembled a fungus. It was bright red, and in its center was an orifice from which the urine continued to pass. It escaped when the child cried or moved. A small sound was left in the urethra, and in the course of three weeks, when this had done no good, an elastic bandage was put on to compress the tumor. It, however, produced an ulcer without diminishing the discharge.

Patent Urachus in a Child Five Months Old. Operation. Recovery. — Waller,* in 1884, had a male patient, five months old, who had passed urine through the umbilicus ever since the cord had separated. The aunt said that the child had a tumor growing from the navel and that this had gradually become larger since birth. Caustics had been applied several times without result. At the umbilicus was a tumor about 1 inch in diameter. This apparently consisted of a flabby granulation tissue. It was red, inflamed, and very sensitive. From a slight depression at its summit drops of urine were constantly oozing. The drops came fast when the child micturated. The skin around the tumor was excoriated. The child was otherwise well.

Under anesthesia, a catheter could be passed from the umbilicus to the bladder. The urachus formed a cord the thickness of the little finger, and during the dissection the peritoneum was opened. The upper part for one inch was removed; the lower part was ligated with silk. The parts united and recovery followed.

Operation for Open Urachus. — De Forest Willard,f in 1888, reported the case of a female child, two years of age, who had passed urine through the urachus ever since birth, about half a dram escaping during the course of the day. There was a spot two inches in diameter about the umbilicus where the epithelium was excoriated, and from which there was an offensive discharge. The urethra was free. The labia minora were adherent in front of the orifice.

Several vain attempts were made to close the opening by cauterization with silver nitrate. An operation was undertaken, and the edges of the navel were freshened up. Union resulted, but in a month the wound broke down and the discharge returned. The parts were then opened, curetted, cauterized, and a drainage-tube was put in. A cure resulted.

A Patent Urachus — Urachus Cysts. | — A woman, twentyeight years of age, from her birth up to three years of age had discharged urine from the umbilicus. The opening was closed by the use of escharotics, but in her twenty-seventh year cancer developed at the open umbilicus. This perforated into the abdominal cavity, and the patient died of acute peritonitis.

A Pervious Urachus. § — The patient was a male, three weeks old. When the cord came away a protuberance half an inch long, with blood oozing from the surface, was noted at the umbilicus. From this urine had passed ever since the cord had come away. In the center was a slight depression that freely admitted a small probe, which could be passed into the bladder.

  • Waller, C. B.: Med. Bull., Philadelphia, 1885, vii, 371.

t Willard, De Forest: Med. News, Philadelphia, 1888, liii, 710.

\ Wolff. Carl Christian: Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1 ^74, Case 3.

§ Yates, \Y. S.: Phila. Med. Journal, 1902, x, 173.


CONGENITAL PATENT URACHUS. 513

The umbilical opening was closed with a purse-string suture passed around the protruding portion subcutaneouslv; the protruding part was then cut off. The wound healed and there was no further trouble.


LITERATURE CONSULTED ON CONGENITAL PATENT URACHUS. Alric: Sur deux cas de persistance de l'ouraque. Bull, de therapeutique, 1879. xcvii, 34. Annandale, T.: Case of Inclosed LTrachus with Umbilical Fistula. Edinb. Med. Jour., 1870, xv,

680. Ashhurst: Urachal Fistula. Med. News, Philadelphia, 1882, xli, 122. Berard, P. H. : Fistules urinaires. Diet, de med., Paris, 1840, xxii, 64. Binnie, J. F.: Development of the Urachus. Jour. Amer. Med. Assoc, 1906, xlvii, 109. Cabell, R. G.: Amer. Jour. Med. Sci., Philadelphia, 1849, n. s., xv, 313. Charles, J. J.: Treatment of Patent Urachus. Brit. Med. Jour., 1875, ii, 486. Delageniere, H. : Traitement de l'ouraque dilate et fistuleux par la resection et la suture. Une

observation. Arch, provinciales de chir., 1892, i, 222. Draudt, M.: Beitrag zur Kenntnis der Urachusanomalien. Deutsche Zeitschr. f. Chir., 1907,

lxxxvii, 487. Dupuytren and Roux : Un ouraque ouvert. (Cited by Gueniot.)

Erdmann, J. F. : A Patent Urachus in a Child Four Years Old. Pediatrics, 190S, xx, 356. Florentin, P.: Fongus de l'ombilic chez le nouveau-ne et chez l'enfant. These de Nancy,

1908-09, No. 22. Freer, J. A.: Annals of Surgery, 1887, v, 107. French, J. G.: A Case of Fleshy Tumor of the Lmibilicus with Patent Urachus. The Lancet,

1882, i, 60. Goupil: Sur un vice de conformation singuliere. Jour, de med. de Paris, 1756, v, 108. Graf, Fritz: U/rachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896. Griffith, F.: Possibly a Patent Urachus. (Vaughan's article.)

Gueniot, R.: Des fistules urinaires de l'ombilic dues a. la persistance de l'ouraque, et du traitement qui leur est applicable. Bull, de therapeutique, 1872, lxxxiii, 299; 348. Haran: La pratique des accouchement s, i, 38. (Quoted by Simon.) Heflin, H. T.: Personal communication.

Hind, W.: Diseases of the L"rachus and Lmibilicus. Brit. Med. Jour., London, 1902, ii, 242. Hue, F.: Persistance du canal de l'ouraque; fistule ombilicale. La Normandie medicale, 1905,

xx, 311. Huggins, R. B.: Personal communication. Imbert, L.: See Vaughan's article.

Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, xiv, 202. Jahn, A.: Beit rage z. klin. Chir., Tubingen, 1900, xxvi, 323. Kennedy, A.: A Patent L'rachus. Brit. Med. Jour., London, 1899, i, 1396. Lannelongue: In cas de faux penis ombilical. Lecons de clinique chirurgicale, Paris, 1905,

388. Ledderhose, G.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Lexer, E.: L'eber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. Lugeol: Fistule urinaire ombilicale par persistance de l'ouraque. Jour, de med. de Bordeaux,

1879-80, ix, 3. Marx: Enfant de vingt-trois mois et demi, qui rendait Purine en partie par la verge et en partie

par l'ouverture ombiheale de l'ouraque. Repertoire general d'anatomie et de physiologic

pathologique, 1827, iv, 120. Meyer: Offenbleiben des U/rachus nach der Geburt. Casper's Wochenschr. f. d. gesammte

Heilkunde, 1S44, 424. Monod: Des fistules urinaires ombilicales dues a la persistance de l'om-aque. These de Paris,

1899, No. 62. Paget and Bowman: Medico-Chir. Trans., pub. by the Royal Med. and Chir. Soc, London, 1850,

2. ser., xv, 293. 34


514 THE UMBILICUS AND ITS DISEASES.

Paget and Bowman: On an Operation for Pervious Urachus. Medico-Chirurgical Trans., London, 1861, xliv, 13.

Pauchet, V.: Fistule ombilico-vesicale. Resection sous-peritoneale de l'ouraque et d'une poche urineuse retro-ombilicale, guerison. Bull, et Mem. de la Soc. de chir. de Paris, 1902, xxviii, 785.

Penny, W. J.: Bristol Medico-Chirurgical Jour., 1888, vi, 36.

Petit, J. L. : Traite des maladies chirurg., chap. xi. Oeuvres completes, Limoges, 1837, 799.

Pierre: Bull. Soc. de med. de Rouen, 1888, 2 e serie, ii, 32.

Preston, W.: Med. Record, New York, 1898, liv, 315.

Rose, A.: A Case of Congenital Vesico-umbilical Fistula, Patent Urachus. Med. Rec, 1877, xii, 516.

Simon, C: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales? These de Paris, 1843, No. 80.

Smit, J. A. R.: Abstract from Zentralbl. f. Gyn., 1904, Nr. 41.

Smith, T.: An Open Urachus. Med. Times, London, 1863, new series, i, 320.

Stadfeldt, A. : Bidrag til Laren om den medfodte Vesiko-umbilikalfistel (Urachus- fisteln) og dens Behandling. Nordiskt Mediciniskt Arkiv, Stockholm, 1871, iii, No. 23.

Starr, T. H.: Escape of Urine at the Umbilicus. Med. Gaz., 1844, xxxiii, 484.

Stevens, B. C. : The Radical Cure of a Patent Urachus. The Lancet, London, 1904, ii, 584.

Stierlin, R.: Zur Casuistik angeborener Nabelfisteln. Deutsche med. Wochenschr., 1897, xxiii, 188.

Stites, T. H.: Patulous Urachus in a Child of Nine Months. Amer. Medicine, Philadelphia, 1903, vi, 136.

Tuholske, H.: A Patent Urachus That Closed in the Fourth Year and Began Again at Fortyeight. St. Louis Med. Review, February 11, 1905. (From Vaughan's article.)

Vander Veer, A. : Congenital Sinus of the Urachus. Med. and Surg. Reporter, 1889, lxi, 661.

Vaughan, G. T.: Trans. Amer. Surg. Assoc, 1905, xxiii, 273.

Velpeau: Cited by Gueniot.

Waller, C. B.: Patent Urachus in a Child Five Months Old. Operation. Recovery. Med. Bull., Philadelphia, 1885, vii, 371.

Willard, De Forest: Med. News, Philadelphia, 1888, liii, 710.

Wolff, C. C. : Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873.

Yates, W. S.: Phila. Med. Jour., 1902, x, 173.


Chapter XXX. Remnants of the Urachus

Historic sketch.

Observations of Luschka.

Observations of Wutz.

Remnants of the urachus noted in various animals.

In the chapter on Embryology (p. 16) we have seen that the urachus develops primarily from the yolk-sac and that it passes from the bladder to the umbilicus. We have also learned that, although in the majority of embryos it finally forms a fibrous cord, it nevertheless shows an inherent tendency to remain patent at certain points and that the patent areas are recognized as spindle-like dilatations occurring here and there in the otherwise impervious cord.

Mery, in 1700, described two twin female fetuses. There was only one placenta, but each fetus had its cord. In each the umbilicus formed a kind of cushion elevated from one-quarter to one-third of an inch from the surface of the abdomen. In the center of each umbilicus was a hole. The colon ended at the edge of the umbilicus and formed an anus for the fetus. The fundus of the bladder was also open, forming a trough which terminated at the umbilicus.

On page 45 of his book on " Einige Krankheiten der Nieren und Harnblase," published in Berlin in 1800, Walter briefly describes the case shown in Fig. 222. He said very little is known about remnants of the urachus. He further said that Noreen, a

Swede, in a Gottingen dissertation (1749), mentioned the subject under the title "De mutatione luminum in vasis hominis nascentis, in specie de uracho.'" Noreen was probably the first person to write somewhat fully concerning dilatation of the

515



Fig. 222. — A Pabtially Patent Urachus. (After F. A. Walter.) A, the right ureter; B, the left ureter; C, represents the position of the longitudinal muscle-fibers, which have been dissected back; F, F, indicate the transverse muscle-fibers ; G, the tough submucosal H, H, bay-like dilatations of the urachus; /, indicates the prostate ; K, the nearest portion of the urethra. The specimen was from a boy twelve years of age.


516 THE UMBILICUS AND ITS DISEASES.

urachus. He believed that the urachus remained open only during childhood; that after birth the canal closed and was transformed into a solid cord.

Civiale. in 1823, saw a cadaver from which the intestine had been lifted out, but the pelvic organs were intact. The bladder made a prominent termination above, by a cylindric prolongation which had been cut across several lines above the bladder proper. The opening permitted the introduction of a finger into the bladder and corresponded exactly with the insertion of the urachus. It was smooth, roundish, and surrounded by a sort of muscle.

For many years a controversy went on as to the permeability of the urachus after birth. C. Simon, in his thesis published in 1843, says that Harvey, Noreen, Haller, and others had noted, in children born before the normal time, a cavity in the urachus extending more or less in the direction of the umbilicus. Into this it was possible to introduce a bristle or to inject mercury. These dilatations were, however, confined to children born prematurely.

Simon refers to a case observed by Albinus. The patient was a young man. The urachus was hollow and opened into the bladder. Albinus held that it was by no means rare to find the urachus in a permeable condition in adults.

According to Simon, Verdries, Beudt, and Haller had reported examples of the same character, and Haller in the cadaver of an adult found the urachus permeable and was able to introduce a bristle into it.

Simon mentions cases reported by Littre and Civiale, and refers to a case recorded by Boehmer in his thesis, "Deuracho humano." Boehmer's patient was a man aged forty, who died of an "inflammation in the chest." At autopsy, when water was injected into the bladder, the urachus swelled up and became prominent.

Probably the most important article that we possess is that of Luschka, published in 1862.

Luschka deals with the so-called obliterated urachus or median suspensory ligament of the bladder in adults under normal conditions. He says there is no doubt that in embryonic life the urachus remains patent as far as the umbilicus, and that it communicates with the bladder. He says that the views vary widely concerning its relationship, when the body is fully developed, and that the differences mainly have to do with the question whether in the adult this cord is hollow or solid. He says that the majority of writers agree that it is solid.

Luschka refers to the observations of Walter. This author thought that, as a rule, there was a persistence of the patent urachus and that the canal was frequently filled with a reddish fluid. On the other hand Noreen (De mutatione luminum in vasis, etc.. in specie de uracho, 1749) held the opposite view, although in one instance in an adult he was able to pass a bristle for two inches into the urachus. The views of Portal (Memoires de Paris, 1769) and Meckel (Handbuch der menschlichen Anatomic Bd. iv, S. 474) coincided with those of Noreen.

Luschka says that from the top of the bladder there pass a number of bundles of the deep detrusor muscle of the bladder. These extend upward for a certain distance (Fig. 223). The muscle gradually loses itself in a thick, pale yellow tissue which consists chiefly of elastic fibers and which really is the tendon of the smooth muscle bundle. Luschka says that, as a rule, this bundle can readily be followed in its course upward, and that it gradually diminishes in thickness and ends in the umbilical scar. Sometimes remnants of this tissue of the cord pass upward to the round ligament of the liver. More frequently, however, the median vesical ligament


REMNANTS OF THE URACHUS.


517


docs not reach the umbilicus, but, beginning at a point some 5 or 6 cm. above the summit of the bladder, terminates in a number of tendon-like threads, which, usually unsymmetrically, unite with the left and right vesical ligaments, or may merge into one another, forming a kind of network. If one carefully splits the longitudinal axis of the urachus from the summit of the bladder, he will in some" cases be able to see an extension of the bladder mucosa upward as a tubular projection reaching a distance of 2 mm., and a pin-point opening may be found existing between the urachus and the bladder. Usually, however, only a small depression is noted at the summit of the bladder, and very frequently even this may be lacking, so that in the examination of the free surface of the bladder mucosa no trace of the original communication between the urachus and the bladder is visible. In these cases the beginning portion of the urachus has been obliterated. Such a complete closure of the canal, however, says Luschka, is usually noted only for a short distance. The urachus soon shows the cavity again for a length of from 5 to 7 cm., or sometimes more. The urachus, however, becomes thinner and thinner, and, as a rule, varies from 0.5 to 1 mm. in breadth. Luschka says that in the adult the cavit} T of the urachus in the median vesical ligament has a manifold tortuous course with numerous large and small round bays running off from it, giving it a nodular appearance, and occasionally a configuration suggestive of the acinous type of glands (Fig. 224) . These dilatations sometimes involve the entire circumference of the tube, but more often are lateral. In such cases they may have a broad base or be more or less pedunculated. Luschka says that he has time and again noted that some of these dilatations have grown as pipe-like branches in the length of the duct. Some of the dilatations in the course of time are nipped off, and as a result of further growth develop into cysts (Fig. 225).

The early stage of cyst formation occurring from metamorphosis of the urachus is produced very frequently as a result of the urachus remaining open only at isolated points. The cysts may vary in size. As

a rule, they are so small that they are recognized only when studied between coverglasses. They may, however, be as large as millet-seeds or reach the size of a pea. They may be isolated, but are sometimes present in large numbers, and more or less closely packed together, so that they present tumors resembling bunches of grapes.

Luschka says that he has not had any individual experience with cysts of the urachus, and knows of no observations by others, but he has not the slightest doubt that large cystic tumors of the anterior abdominal wall needing surgical interference develop and that these tumors have originated from the urachus.

He suggests that, if one wishes to study the cavity formation of the interior of



Fig. 223.— A Patext Urachus. (After H. Luschka.) (Natural size; from a man fifty years old.) The outer side of the upper end of the bladder mucosa (a) has been freed from the muscle (6) , and this has been turned outward. The muscular portion (c) and the tendinous portion (d) of the median vesical ligament have been dissected free and turned back. In this way the urachus has been exposed and here and there shows marked nodular dilatations (/, /, /).


518


THE UMBILICUS AND ITS DISEASES.


i


The fluid is usually


<


X


^




r


f


the median vesical ligament, it is necessary to cut it out in sections, treat it with

acetic acid, and make firm pressure between glass plates. The structures can then be gradually dissected out. He then goes on to describe the ground membrane, the layer of fibers, and finally the epithelium of the urachus. In speaking of the epithelium he says that where the canal in the adult is well preserved, one can scrape away the thick layer, which is similar to the so-called transitional epithelium noted in the bladder, ureters, renal pyramids, and the pelves of the kidneys. All possible forms of these cells can be noted. Some are round, others polygonal, some are branched, and some resemble cylindric epithelium.

The contents of the urachus vary, pale yellow, thin, and translucent. It may, however, be cloudy, brown, or reddish in color. It contains a large number of cells of the type above described. There are also numerous fat-globules and not infrequently corpora amylacea. In the dilatations and in the isolated cysts the contents are frequently sticky and dirty brown. Scattered throughout the fluid are bodies which have a marked resemblance to prostatic concretions.

Veiel, a pupil of Luschka, published a thesis on the urachus in 1862. He gave a very extensive review of the literature, and referred to the patent urachus in the calf and pig. He also reported (Case 3) an observation on a man twenty-four

years of age. The urachus was 4.1 cm. long, tortuous, and

formed pearl-like dilatations. These dilatations were partly

central, partly eccentric, varied from 1 to 2 mm. in breadth,

and contained a 3 r ellowish, cloudy fluid. The largest was

situated just above the bladder. When the urachus was

placed between glass plates, the fluid could be forced from

one dilatation into the next.

Hoffmann, in 1870, when considering the pathologic

changes in the urinary tract, referred to the early work of

Walter. He says that Walter sought to prove that the

urachus under normal conditions in both sexes remained as

an open canal into which one could introduce a fine sound

and pass it to the bladder. This view was not accepted, and most of the later anatomists concluded that the urachus in the grown person was completely obliterated.

Hoffmann refers to the work of Luschka, in which it was demonstrated that in most


Fig. 224. — A Portion- of a Urachcs Seven Times Enlarged, with Numerous Large and Small Dilatations. From a man twentyseven years old. (After H. Luschka.)


Fig. 225. — Portion of a Urachus Ten Times Enlarged. (After H. Luschka.)

This here and there shows a tortuous course as indicated by a. At certain points (6, b) are dilatations. One of these dilatations (c) has already become completely nipped off, forming a cyst.


REMNANTS OF THE URACHUS. 519

of the cases the urachus is patent for a certain distance, even if it does not always communicate with the bladder. He also drew attention to the fact that Luschka agreed with Walter in holding that the urachus is lined with mucosa. With Luschka's statement that the caliber of the urachus is not uniform but tortuous, and that it has numerous large and small bays running out from it and giving rise to a nodular appearance, reminding one somewhat of an acinous gland, Hoffmann in general agreed.

Gruget, in 1872, published a very interesting thesis on urinary umbilical fistula? due to persistence of the urachus. He examined in all 82 bodies, and only twice did he find the urachus permeable.

Case 1 . — A human embryo, two and a half months old, was received by Dr. Gueniot. It weighed 20 grams. The distance from the pubes to the umbilicus was 7 mm. A portion of the abdominal wall was gelatinous. The walls of the bladder were transparent, and the bladder contained a few drops of a colorless liquid. When the bladder was opened a fine probe could be carried into the urachus, which was patent. In this case the urachus was open from the bladder to the umbilicus, and was continued as a pervious canal out into the cord for at least 3 cm.

[This is occasionally noted in a human embryo at this age — 7.5 cm.]

C a s e 2 was that of a female fetus born living at the end of the fifth month and dying twenty minutes after birth. This case also came under Dr. Gueniot's observation. The urachus was obliterated in its inferior or vesical portion, but open in its upper portion and also out into the cord, where it again became obliterated, forming a filament. Gruget, from his studies, came to the conclusion that persistence of the urachus is very rare. His article is very carefully written.

Nicaise assures us that a hollow urachus is not rare. He says that Haller demonstrated this condition in the cadaver of an adult, and that he had seen the urachus large enough to have a silk thread passed through it. He adds that Harvey, Moreau, Verdries, and Beudt had described examples of the persistence of the urachus.

Tillmanns says that Meckel, in 1809, described a cystic dilatation of the urachus. Next to the fundamental work of Luschka is that of Wutz, published in 1883. Wutz said that Peu, in his book on Obstetrics, in 1694, speaks of a tumor the size of a pigeon's egg situated at the umbilicus in a child two hours old. When this tumor was opened, urine escaped.

Wutz refers to the early literature on the urachus, mentioning the names of Blasius (1674), Littre (1701), Peyer (1741), Albinus (1754), Boehmer (1764), Portal (1769), Walter (1775), Meckel (1820), and finally reviews the findings of Luschka.

Wutz (p. 390) gives a description of his own work, and says that his observations are based on the examination of 74 bodies of various ages, including males and females.

He found that the distance from the top of the bladder to the lower margin of the umbilicus was as follows :

In the young and new-born 3.1 cm.

In persons from seventeen to twenty-five years 16.5 cm.

" " " twenty-five to seventy years 18.7 cm.

He says that at the top of the bladder the median vesical ligament has a thickness of from 2 to 2.5 mm. He then takes up the consideration of the urachus, and draws


520


THE UMBILICUS AND ITS DISEASES.




attention to the fact that Suchannek, in his investigations, left the urachus in hydrochloric acid for two days. As a result, the musculature and the connective tissue were then so soft that they could easily be removed.

Wutz, after using a 1 per cent solution of sodium chlorid. hardened the specimen in alcohol and then stained it with Grenadier's carmin, picrocarmin, or hematoxylin. The specimen was then passed through oil of cloves and mounted in Canada balsam. In this way it was possible to obtain a beautiful low-power picture and at the same time study the specimens under the higher power. Wutz says that after careful division of the rather tough capsule the transparent urachus is reached (Fig. 226). His examination showed that the commencing portion of the epithelial tube is frequently embedded in the musculature of the vertex of the bladder for a distance of 0.5 to 1 cm. He says that within the thickness of the bladder-wall the urachus often runs at an angle (Fig. 227) . On examination of the inner surface of the bladder at the point where the urachus begins, in the majority of cases there is a funnel-like depression, and at the point of the funnel a fine opening. ,

Fifty-one (69 per cent) of Wutz's cases presented an opening of such ."■

a character, into which a bristle could be passed for 0.3 to 0.5 mm. In 32 of these cases this could be carried upward for a distance of from 2 to 6 mm., while in 19 it penetrated from 1.1 to 4.8 cm. In 2 cases out of 74 (2.7 per cent) the surface of the mucosa was smooth and indicated no trace of a previous communication between the urachus and bladder. In the remaining 21 cases there was a very perceptible groove at the entrance of the urachal canal. In these cases it was. however, impossible to pass a sound upward, although it could be passed from above downward for a certain distance. In several of the cases in the first group, in which the sound could be passed from the bladder, a certain degree of obstruction was noted at the entrance of the canal. In other cases Wutz gathered the impression that the urachal opening was guarded by a valve-like structure

apparently supplied by a transverse fold. He says that, under normal conditions, the passage of urine through the urachus does not occur, notwithstanding the existing communication. In cases of marked dilatation of the bladder due to prostatic


B

Fig. 226. — Cysts of the Urachus Arranged Like a String of Pearls, from Case 17. (After J. B. Wutz's Plate xii, Fig. C.)

The cysts are near to the bladder. There are three of uniform size, with two smaller ones between them. In the upper portion of the urachus are several small, spindleshaped dilatations. V is the bladder. B is a bristle passing up into the urachus.


.Ear


y


■-


Fig. 227. — Spindle-shaped Dilatations of the Urachus. (After J. B. Wutz, Plate xi, Fig. E.) Case 22.

V is the bladder; Eur, the urachus. Near the bladder there is a small dilatation, then a spindle-shaped dilatation, and a little farther up the largest spindleshaped cyst.


REMNANTS OF THE URACHUS. 521

hypertrophy the dilatation of the canal was never noticed by him, and in the newborn the passage of a bristle was only occasionally possible.

Wutz measured microscopically the epithelial tube and found that the average length in the new-born was about 1.6 cm., in adults, 6.7 cm., and in one case it was 7.7 cm. He says that the greatest diameter (1.5 to 2 mm.) of the urachal tube is at or near the bladder. In the region of the umbilicus it had become smaller, being 0.5 mm. The cells forming the lining of the urachus were large, oval, and showed large nuclei. Some were long and had tails, and there were many branching, flat epithelial cells. As a rule, there were three layers of epithelium. In the upper portion there were sometimes two layers, but finally only one layer. The transverse section of the urachus was usually not round, but flattened or elliptic, and not infrequently wavy. The outer longitudinal layer of muscle Wutz found to be constant, and in all cases it extended beyond the epithelial tube above.

Wutz's summary is as follows:

1. The epithelial tube of the median vesical ligament in most cases in its lower portion can be sounded from the bladder. In other words, a probe can be passed into it from the bladder.

2. At the entrance of the urachus there is a transverse fold which makes the entrance of the sound more difficult and hinders the passage of fluid into the urachus. [This obstruction has of late years been known as Wutz's valve. — T. S. C]

3. Toward the upper end of the epithelial tube the diameter of the urachus diminishes in both its muscular and epithelial portions.

4. v The musculature under all conditions extends farther upward than the epithelial tube.

5. The beginning of the tendinous character of the median vesical ligament corresponds somewhat constantly in children to one-half, and in adults to onethird, of the distance between the umbilicus and the summit of the bladder.

Monocl, in 1899, published an interesting thesis of over 200 pages on Urinary Umbilical Fistulse Due to Persistence of the Urachus. In the historic portion of his publication he refers to the observations of Meckel, Cuvier, Pokels, Velpeau, and Robin. Monod says that he does not consider the persistence of the urachus a malformation as rare as was believed by Gueniot and his pupil Gruget, but agrees with Forgue and Morer and Trogneux that this malformation is not very frequent without being exceptional.

Meriel, in 1901, gave a very good resume of the literature, and Vaughan, in 1905, presented an interesting paper on the subject before the American Surgical Association.

Binnie, in 1906, published a paper on the development of the urachus and gave the results of Mr. Clendening's investigations. Sixteen cadavers and 7 fetuses were examined, with the following results :

1. In seven adults and six fetuses the bladder showed a distinct diverticulum from 1 to 2 cm. deep, at the point where the urachus is usually attached.

2. In one adult there was a slight projection instead of a diverticulum.

3. In eight adults and one fetus the dome of the bladder was smooth.

4. In none of the cases did Clendening find lacunae lined with epithelium in the urachus.

5. The average adult urachus was 12 cm. long and 1.5 [mm.] wide.

6. The urachus was usually adherent to the abdominal wall, but in one patient


522 THE UMBILICUS AND ITS DISEASES.

(a diabetic with frequent retention of urine) it was not close to the parietes, but lay between loops of the small intestine.

7. In all cases the urachus was well supplied with vessels.

From this review of the literature it is evident that the urachus in a certain number of cases remains patent throughout. Hence under such circumstances, as soon as the cord comes away a few days after birth, a urinary fistula exists at the umbilicus.

In other cases portions of the urachus may remain open. The vesical end of the urachus may be connected with the bladder, but more frequently small, cyst-like dilatations are found in the course of the obliterated urachal cord. These may later dilate, giving rise to urachal cysts. In some instances they become infected, and an abscess develops in the anterior abdominal wall, between the recti muscles and the peritoneum of the anterior wall of the abdomen. In those patients in whom remnants of the urachus exist, any interference with the easy passage of urine from the urethra is liable to be followed by a reopening of the urachus, with an escape of urine from the umbilicus. Such a condition may be due to a vesical calculus plugging the inner urethral orifice, to a urethral stricture or to blocking by an enlarged prostate. In quite a number of cases cystitis with its consequent vesical tenesmus has been followed by infection of the urachus and the development of a urinary umbilical fistula.

In the succeeding chapters I shall consider in detail the literature on abnormalities due to remnants of the urachus.


LITERATURE CONSULTED ON REMNANTS OF THE URACHUS.

(See also the literature of the following chapters.)

Binnie, J. F.: Development of the Urachus. Jour. Amer. Med. Assoc, 1906, ii, 109.

Civiale, J.: Traite de l'affection calculeuse, Paris, 1838, 258.

Gruget, L.: Des fistules urinaires ombilicales qui se produisent par l'ouraque reste ou redevenu

permeable. These de Paris, 1872, No. 422. Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch.

der Heilkunde, 1870, xi, 373. Luschka, H.: Ueber den Bau des menschlichen Harnstranges. Arch. f. path. Anat. u. Physiol.

u. f. klin. Medizin, 1862, xxiii, 1. Meriel: Les derives pathologiques de l'ouraque. Gaz. des hopitaux, Paris, 1901, lxxiv, 181. Mery: Hist. Acad, roy de sc. (de Paris), Amsterdam, 1700, 53. Monod, J. : Des fistules urinaires ombilicales dues a la persistance de l'ouraque. These de Paris,

1899, No. 62. Nicaise: Ombilic. Diet, encyclopedique des sci. medicales, Paris, 1881, 2. ser., xv, 140. Simon, C.: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales. These

de Paris, 1843, No. 80. Tillmanns, H.: Ueber angeborenen Prolapsus von Magenschleimhaut durch den Nabelring

(Ectopia ventriculi) und iiber sonstige Geschwulste und Fisteln des Nabels. Deutsche

Zeitschr. f. Chir., 1882-83, xviii, 161. Vaughan, G. T.: Patent Urachus. Review of the Cases Reported. Operation on a Case Complicated with Stones in the Kidneys. A Note on Tumors and Cysts of the Urachus. Trans.

Amer. Surg. Assoc, 1905, xxiii, 273. Veiel, E.: Die Metamorphose des Urachus. Diss., Tubingen, 1862. Walter, F. A.: Einige Krankheiten der Nieren und Harnblase, Berlin, 1800. Walters, F. R.: Umbilical Pocket. Brit. Med. Jour., 1893, i, 173. Wutz, J. B.: Ueber Urachus und Urachuscysten. Virchows Arch., 1883, xcii, 387.


REMNANTS OF THE URACHUS. 523

REMNANTS OF THE URACHUS NOTED IN VARIOUS ANIMALS.

I have made no attempt to cover the literature on this subject, but while studying the urachal remains noted in the human being, I have from time to time met with references to partial or complete urachal remains noted in animals.

There seems to be little doubt that urachal remains are more commonly found in the horse than in any other domestic animal. Gurlt, in 1832, in speaking of the horse, said: "It sometimes happens that after birth the bladder with the urachus separates from the umbilicus and closes up, but a vesical portion of the urachus does not disappear, but gradually develops into an open chamber as large as the bladder itself. In these cases we have, as it were, two bladders, one sitting on the top of the other, and the two communicating through a large channel." Gurlt observed this condition in a grown horse.

O'Brien, writing in 1879, quotes Cheaureau: "In a fetal horse the bladder occupies the abdominal cavity as far as the umbilical opening, the anterior extremity forming a veritable neck. At birth this anterior neck separates from the urachus and is transformed into a cul-de-sac which is gradually withdrawn into the pelvis." O'Brien, while dissecting a young colt dead of osteitis, found that the bladder extended by a funnel-shaped canal to the umbilicus.

Finch, in 1903, reported a case of pervious urachus in a colt. The colt was ten days old and had colicky pains, as was evidenced by his uneasiness. The umbilicus was much enlarged and wet, this condition being evidently due to the presence of a pervious urachus. The colt apparently had pain over the loins. The urine was clear.

Purgatives and soothing applications were employed, but the colt died in a few days. The autopsy showed that a portion of the large bowel was inflamed. The umbilical cord was thickened and contained a small amount of thick, creamy pus. The walls of the bladder were thickened and inflamed. Nothing is stated in the protocol about the urachus.

Salvisberg, in 1902, related his experience with urachal fistulse in the horse, and outlined his method of handling them. He says that when the cord is torn off too close to the body in colts, the urachus remains open, and part of the urine escapes from the umbilicus. The urachus in colts has grown fast to the umbilical ring; consequently the closure of the ring is not so easy. If the cord of every colt were properly tied, a urinary fistula at the umbilicus would be very rare.

Salvisberg says that every spring he operates on several colts with urachal fistulse. It is no art to tie the cord 3 or 4 cm. from the abdomen.

From three to fourteen days after the birth of the colt the farmer reports the fistula. The urine drops from the umbilical opening, or during urination a certain amount escapes from the umbilicus.

Where a stump is present, the surrounding skin shows little change, the urine being carried off, as it were, through a pipe. Usually the opening is on the skin level or in a small groove. It is then surrounded by a zone of granulation tissue. The hair is wet and stuck together. An area around the umbilicus is swollen, and has scattered over it many ulcers ; or it is occupied by one large ulcer from which a purulent foul discharge comes.

Salvisberg used silver nitrate, copper sulphate, etc., but some of the colts died of pyemia or polyarthritis. The use of a purse-string suture proved of no value.


524 THE UMBILICUS AND ITS DISEASES.

Dissecting out the urachus from the umbilicus and tying was fatal, as the peritoneum has to be opened.

Salvisberg finally decides upon the following procedure: The umbilical region is shaved and disinfected and injections of salt solution are made into the parts in the immediate vicinity. These should produce small elevations, the size of hazelnuts, all around the opening; two or three rows are made. The surface is then covered with an iodoform-collodion dressing. Frequently, in a few hours, the elevations disappear and a uniform swelling closes the urachus. Sodium chlorid solution, 15 per cent, is used. To this a few drops of pure carbolic acid are added. The results appear to be good.

Swain, in the Veterinary Archives for 1903, when referring to persistency of the urachus, says: "The equine family seems much more subject to this abnormality than the bovine or other domestic animals, and the breeds of draft-horses are more subject than the finer breeds; the male foal is more subject to this persistence than the female."

Bland-Sutton, in "Tumors, Innocent and Malignant," 1907, says that he had observed urachal cysts in the horse.

Recently, while conversing with my old friend and classmate, Dr. W. N. Barnhardt, about urachal remains, he told me that for years he had been interested in this subject, and that he had observed numerous abnormalities in the horse. I asked him to give me briefly the results of his observations. Under date of April, 1914, he writes:

"Living for years on a horse-breeder's ranch, I developed a curiosity as to the cause of death of foals. Among other morbid conditions I observed, by postmortem examination, a patent urachus in five foals that had died within four days of their birth. One of these showed a red thrombus about the size and shape of a small banana, and two others showed infection and inflammation within the urachus. In four of them urine had flowed quite freely from the umbilicus. In others that lived and attained a healthy maturity I have observed an occasional discharge of urine at the umbilicus in the first few days after birth."

From the foregoing it is clearly evident that urachal remains, particularly umbilical fistulae, are relatively common in the horse.

Urachal Remains in the Cow or Steer. — Gurlt, in 1831, when referring to a cyst-like pouch of the urachus seated on the top of the bladder and resembling a second bladder in a horse, said that he had once observed a similar condition in a cow. This case was seen in consultation with a veterinary surgeon named Naundorf.

Veiel, in 1862, reported several cases. In the examination of an eleven-day-old steer he found passing from the top of the bladder a urachus which could be traced for 5.6 cm. as a tube. It was 6 mm. broad and had a relatively uniform diameter. Veiel, in Case 3, refers to a sixteen-day-old calf. The top of the bladder gradually diminished in size and passed over into the urachus, which was open as far as the umbilicus.

Bland-Sutton has observed urachal cysts in the ox, in the pig, and in the mole.

Urachal Remains in the Pig. — In a sow one year old, Veiel observed at the top of the bladder a cord 7.3 cm. long and about 2 mm. broad. On carefully splitting the muscle and turning it back, he detected a small lumen. This was uniform in diameter, but at each end was a round dilatation.


REMNANTS OF THE URACHUS. 525

Hoffmann, in 1870, made an interesting observation on cysts of the urachus in a swine embryo. He first referred to an observation by Meckel, who found in a swine at term a cyst of the urachus, one inch in diameter, situated four inches below the umbilicus. At either end it was attached to the urachus.

Hoffmann said that in 1866 he received from a butcher a so-called double urinary bladder. This came from a full-grown pig and had the form of two sacs of the same size, which were separated from one another by a narrowing in the middle. When distended, both halves were elongated and rounded, and it looked as if, on the summit of the portion connected with the urethra, a second bladder was situated. In the distended condition the lower compartment was 31 cm. long and 22 cm. in diameter. The upper one was 25 cm. long and had a breadth of 24 cm. These two cavities occupied the space between the urethra and the umbilicus. Over its entire surface was a peritoneal covering. At the umbilicus the upper portion was closed. The lumen occupying the usually obliterated portion of the urachus had dilated, forming the second bladder.

Sutton observed urachal cysts in the pig.


LITERATURE CONSULTED ON REMNANTS OF THE URACHUS IN ANIMALS. Bland-Sutton, J.: Tumors, Innocent and Malignant, Chicago, 1907.

Finch, R.: Case of Pervious Urachus (in a Colt). Veterinary Record, London, 1902-03, xv, 798. GurJt, E. F.: Path. Anat. der Haus-Saugethiere, 1831, i, 213. Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch.

der Heilkunde, 1870, xi, 373. O'Brien, J. E.: Pervious Urachus, Comparative Anatomy. The Obstetric Gazette, Cincinnati,

1879-80, ii, 100. Salvisberg: Die Behandlung der Urachusfistel beim Fohlen. Sehweizer Arch. f. Thierheilkunde.

1902, xliv, 228. Swain, S. H.: Persistency of the U/rachus. Jour. Compar. Med. and Veterinary Archives, 1903.

xxiv, 95. Veiel, E.: Die Metamorphose des Urachus. Diss., Tubingen, 1862.


Chapter XXXI. Urachal Remnants Producing Tumors between the Umbilicus and Symphysis

Small urachal cysts; Historic sketch; Report of cases. Personal observations on small cysts of the urachus.

Remnants of the urachus may become distended, producing small or large cysts, which may or may not become infected. Some of them are directly connected with the bladder or with the umbilicus or with both. For convenience I have made the following tentative classification. Some overlapping, of course, is inevitable.


(1) Small urachal cysts.

(2) Large urachal cysts.


Non-infected. Infected.

(3) Urachal cavities lying between the symphysis and umbilicus and communicating with the bladder or umbilicus or both.


SMALL URACHAL CYSTS.

Small urachal cysts naturally give rise to no clinical symptoms, hence they are recognized only when the abdomen is opened for some intra-abdominal lesion or at autopsy. It is not to be wondered at, therefore, that the literature on the subject is very meager.

As has been said before, Luschka concludes that large cystic tumors of the anterior abdominal wall needing surgical interference develop, and that these tumors originate from the urachus.

Veiel, in 1862, in his dissertation on the Metamorphosis of the Urachus, cites the findings in the body of a man forty-five years of age. Passing downward from the umbilicus was a delicate cord 1 mm. broad. About 3 cm. above the bladder it grew larger, so that at the top of the viscus it was 1.2 cm. thick. At this point it was covered with a thick layer of bladder muscle. The urachus could be divided into four sections — the lowest (part 1), which was open, was 14 mm. long. In the middle it was somewhat smaller, but at each end it was 2 mm. thick. Part 2 was 7 mm. long and was closed and thread-like. Part 3 was 8 mm. long, was open, and about 1 mm. thick. Part 4 was closed and thread-like. On microscopic examination the upper open portion showed moisture and had a lining of so-called transitional epithelium. After the specimen had been treated with acetic acid, three dilatations of the canal were found. These contained yellowish concretions.

Wutz, in 1883, after reporting his Case 22, in which the urachal cyst contained a firm, stony, hard, yellowish brown, glistening body, described the following case in detail :

Case 24. — The specimen was from a man twenty years old, dead of peri 526


SMALL URACHAL CYSTS. 527

tonitis following a perforated appendix. The distance from the umbilicus to the top of the bladder was 16 cm. The bladder mucosa in the vicinity of the trigonum was diffusely reddened, and on its surface were a few blood and pus corpuscles. The bladder was small and drawn out to a point. It was 7.5 cm. in length. In the mucosa of the vertex the opening of the urachal canal had a diameter of 2 mm. ; 2.5 cm. above the bladder was a cyst 1.5 cm. long, 0.8 cm. broad, and attached to the side of the urachus; into it a sound could be passed from the urachus. About 3 mm. above this cyst were several smaller ones, some reaching the size of a pin-head. Wutz said that a probe could be passed into the urachal canal for a distance of 4.3 cm. The large cyst was filled with clear yellow fluid, which contained albumin and mucin. Microscopic examination showed polymorphous epithelium, pus-cells, and red blood-corpuscles. In the smaller cyst the epithelium was normal and there was no evidence of pus-cells.

Wutz (p. 404) sums up the results of his observations of the urachus and urachal cysts as follows:

1. All the observed cysts have been located in the lower fourth or lower third of the distance from the urachus to the top of the bladder, and originated from the normally persistent portion of the urachus.

2. In the majority of the cases they were lined with several layers of flat epithelium.

3. The cysts had a more or less strongly developed covering of smooth musclefibers.

4. The size of the cysts varied from that of microscopic objects to that of a large bean.

5. Laminated bodies contained in the cyst fluid did not stain blue with iodin, but yellow, and they did not consist of amyloid substance.

6. Concretions in the canal of the urachus or in the urachal cysts were of rare occurrence, and then reached only a small size.

7. Urachal cysts were sometimes the seat of inflammatory changes.

Morestin, in 1900, reported a case in which two small urachal cysts were discovered between the muscle and peritoneum during an abdominal operation for a left pus-tube. They were too small to be recognized before operation. They were arranged one above the other, but were independent. The cord of the urachus passed from the summit of the bladder and disappeared in the lower cyst. It was again recognized above the upper cyst, and could be followed to the umbilicus. The peritoneum was loosely attached to the cysts. The cysts were globular, smooth, transparent, of a bluish tinge, and contained a limpid, colorless fluid. Their inner surfaces were smooth and presented a serous aspect. There was an outer covering of connective tissue and an inner lining of flattened epithelium. These cysts manifestly had originated from the urachus.

Wyss, in 1870, under the title of "A Cyst Near the Umbilicus," reported his findings at autopsy. Between the peritoneum and muscle, a little to the side of the linea alba, and about one inch above the umbilicus, was a cyst the size of a bean. It contained turbid, tenacious mucus, grayish yellow in color. It was lined with cylindric epithelium. Wyss thought that the cyst had resulted from embryonic remains.

The location of the cyst, the changes in the epithelium, and the cyst contents strongly suggest that it had originated from remnants of the omphalomesenteric duct.


528 THE UMBILICUS AND ITS DISEASES.

Opitz. in his article on Urachal Cysts published in 1905, referred to a cyst of the abdominal wall and said that it looked like an appendix; that it was lined with one layer of low epithelium, and was surrounded by a circular layer of muscle, outside of which was a longitudinal muscular layer. From the description it is impossible to get a clear idea of the case.

Caruso, when operating on a woman forty-two years old for removal of a myoma, noted a small cyst at the level of the umbilicus. This was lined with cuboid epithelium. He also noted tubular glands and non-striped muscle. The location of this cyst would throw some doubt upon its urachal origin, and the presence of tubular glands suggests that it may have originated from remains of the omphalomesenteric duct or from uterine glands at the umbilicus.

Weiser, in his article, says that he received personal letters from Wm. J. Mayo, Nicholas Senn, Edwin Martin, W. A. Smith, Roswell Park, J. F. Erdmann, Howard A. Kelly, DeForest Willard, and from E. Wyllys Andrews, saying that they had personally encountered instances of cysts of the urachus.

From the foregoing it is seen that small urachal cysts are found between the bladder and umbilicus, and that they lie between the muscles and peritoneum of the anterior abdominal wall. There ma3 r be only one cyst or several in a row. They may be minute or reach a centimeter or more in diameter. They have thin walls, and may be transparent or translucent. Their inner surfaces are smooth. They are lined with transitional or cylindric epithelium. The cyst fluid contains albumin, mucin, and exfoliated epithelium, and sometimes polymorphonuclear leukocytes and red blood-cells. They are merely dilatations.

Wutz's observations on small urachal cysts are the most complete that we possess. It will be of interest to glance through the 22 cases that he has recorded.

Case 1 . — A nineteen-j^ear-old boy had had a right-sided otitis media. The urachus was the seat of several small cystic dilatations, some of which communicated with one another.

Case 2 . — A girl, twenty years of age, died of tuberculous peritonitis. The distance of the umbilicus from the vertex of the bladder was 20 cm. The length of the epithelial tube was 3.6 cm. The latter terminated in five transparent cysts the size of pin-heads.

Case 3"" — A twenty-three-year-old man died of pulmonary tuberculosis. The distance from the umbilicus to the vertex of the bladder was 17 cm., and the length of the epithelial tube, 4 cm.

The latter ran straight, could be sounded, and terminated in three cysts the size of millet-seeds.

Case 4 . — A woman, twenty-four years of age, died of pulmonary tuberculosis. The distance from the umbilicus to the top of the bladder was 26.5 cm. At a point 3.7 cm. from the bladder, lying on the left side and communicating with the canal,' was a cyst the size of a pea.

fas e 5 . — The woman, twenty-seven years of age, was suffering with "sarcomatous struma." The distance from the umbilicus to the vertex of the bladder was 20.8 fin. About 0.5 cm. above the vertex, on the side, was a transparent cyst the size of a millet-seed.

Case 6 . — The patient was a woman, thirty-one years of age, with pulmonary tuberculosis. The distance from the vesical vertex to the umbilicus was 17 cm. The epithelial tube could he sounded, the probe passing directly upward. In the


SMALL URACHAL CYSTS. 529

middle of its course the tube was obstructed, but the canal again appeared and terminated in a small cyst, conic in form, and almost 1 mm. long.

Case 7 . — The patient was a man, thirty-six years of age, who had pulmonary tuberculosis. The distance from the umbilicus to the vertex of the bladder 1 was 15.5 cm. The length of the epithelial tube was 4.4 cm. At a point 0.75 mm. from the top of the bladder was a spindle-like dilatation, 0.71 mm. long and 0.1 mm. broad.

Case 8 . — A man, thirty-eight years of age, died of tuberculosis. The distance from the umbilicus to the vertex was 25 cm. The length of the epithelial tube was 0.7 cm. At a point 3 mm. from the vertex of the bladder was a spindlelike dilatation varying from 1.5 to 0.42 mm. in diameter. About 1 mm. from this was a second, 2 mm. long, 0.67 mm. broad.

Case 9 . — The subject was a woman, thirty-nine years of age, dead of cerebral hemorrhage. The distance from the umbilicus to the vertex was 20.5 cm. The length of the epithelial tube was 4.3 cm. At a point 2.5 cm. above the vertex of the bladder was a dilatation 3.5 x 1.5 mm., filled with a yellowish, crumbly material.

Case 10. — The subject was a woman forty years of age, dead of tuberculous cerebrospinal meningitis. The distance from the umbilicus to the vertex of the bladder was 18.8 cm., and the length of the epithelial tube was 1.9 cm. About 1 cm. above the vertex of the bladder were two cysts attached to the left side of the tube. The first was roundish and measured 0.54 x 0.3 mm. The second was 0.63 x 0.49 mm. Scattered throughout the entire length of the tube were numerous small dilatations. These were somewhat pedunculated, and were situated on all sides of the tube.

Case 11. — The man, forty-three years of age, had died of delirium tremens. The distance from the umbilicus to the vertex of the bladder was 20 cm. The length of the epithelial tube was 5.6 cm. In the bladder mucosa there was a distinct groove. At a point 3.5 cm. above the bladder were three nipped-off cysts the size of millet-seeds. A short distance from the bladder the tube contained an oval body, 0.17 x 0.1 mm. This was brownish in color and homogeneous in consistence. In the further course of the tube were several diverticula and nipped-off cysts of various forms, filled with firm brown contents.

Case 12. — The man, forty-three years of age, had died of pachymeningitis. The distance from the umbilicus to the vertex of the bladder was 12 cm. Projecting from the top of the bladder were two small cystic dilatations.

Case 13. — A woman, forty-three years old, had died from degeneration of the heart. The distance from the umbilicus to the base of the bladder was 15 cm. The epithelial tube was 5.4 cm. long. The tube showed four spindle-shaped cysts; the largest was 1.5 cm. above the vertex of the bladder and measured 6x2 mm.

Case 14. — The man, forty-five years of age, had died of pulmonary tuberculosis. The distance from the umbilicus to the vertex of the bladder was 16 cm. The length of the epithelial tube was 5 cm. At a point 3 mm. above the top of the bladder was a cyst the size of a millet-seed, with a second the size of a pin-head on the top of it. The tube passed for a distance of 3 cm. and terminated with three cysts resembling a string of pearls. Besides these were numerous round, oval cysts, recognized microscopically.

Case 15. — The man, sixty-five years of age, had died of typhoid fever. 35


530 THE UMBILICUS AND ITS DISEASES.

The distance from the umbilicus to the vertex of the bladder was 26 cm. The length of the epithelial tube was 5.5 cm. From the top of the bladder the tube passed directly upward and formed at the junction of the lower middle third a beautifully spindle-shaped cyst, not nipped off. This was 1.6 mm. long and 0.4 mm. broad. Above this point the tube showed numerous diverticula extending as far up as 3 cm. Here there was a broad-based cyst projecting from the right side. It was oval and measured 2.16 x 1.62 mm. These cysts were filled with lumps of brownish yellow material.

Case 16. — The man, sixty-one years of age, had died of pachymeningitis with hemorrhage. The distance from the umbilicus to the vertex was 19 cm. The length of the epithelial tube was 3.1 cm. It showed diverticula and cysts. They were arranged in groups around the canal, and at first sight suggested acinous glands.

Case 17. — The woman, sixty-six years old, had died of an incarcerated hernia. The distance from the umbilicus to the vertex of the bladder was 22.5 cm. The length of the epithelial tube was 7.7 cm. Commencing 1 mm. above the top of the bladder were five pearl-like cysts, almost round and transparent. The first, third, and fifth were the size of small peas, while the two between them were as large as millet-seeds. The dilatations opened into one another, and the tube for several centimeters further admitted a fine bristle (Fig. 226, p. 520). The contents were yellowish-white and friable. Commencing 4.8 cm. above the bladder were six cysts of the size of pin-heads containing transparent fluid.

Case 18. — The man, sixty-seven years of age, had died of bronchopneumonia. The distance from the umbilicus to the vertex of the bladder was 16 cm. The epithelial tube was 4.8 cm. long. Situated 4.6 cm. above the bladder was a spindle-shaped cyst, 2x1 mm., with brownish-yellow contents.

Case 19. — The man, sixty-nine years of age, had died of cardiac degeneration. The distance from the umbilicus to the vertex of the bladder was 22.5 cm. The epithelial tube at the bladder had a diameter of 0.3 mm. Beyond this point were three cysts, the largest 10 mm. in diameter. The cysts communicated with one another.

Case 20. — The subject was a man, sixty-five years old, who had had softening of the brain due to an embolus. The distance from the umbilicus to the vertex of the bladder was 21.5 cm. The epithelial tube was 6 cm. long. The mucosa of the bladder at the vertex showed a definite, tent-like depression. Then there was a canal 1.6 cm. long and irregularly dilated. Situated 3 mm. above this was a spindle-shaped dilatation, 2 cm. x 4.5 mm.

Case 21. — The man, seventy-three years old, had died of carcinoma of the esophagus. The distance from the umbilicus to the vertex of the bladder was 19.5 cm. The epithelial tube was 0.6 cm. long. Situated 2 mm. from the vertex were two pin-head-sized, transparent cysts.

Case 22. — The man, seventy-three years old, had died of bronchopneumonia. The distance from the umbilicus to the vertex of the bladder was 16 cm. The epithelial tube was 6.7 cm. long. About 1 cm. from the top of the bladder was a spindle-shaped cyst, 0.7 cm. long and 0.3 cm. broad. Situated 0.3 cm. above this was a second cyst, nearly 2 cm. in length and 4.5 mm. broad (Fig. 227, p. 520).

Wutz in discussing these cysts says that the epithelium taken from the inner surface of the fresh cysts consisted of cells of various forms and sizes. A transverse


SMALL URACHAL CYSTS. 531

section through the cysts showed that they had an epithelial lining, then a structureless membrane, then a delicate connective tissue, and numerous smooth musclefibers were arranged chiefly longitudinally. In the walls were a small number of blood-vessels. The acinous glands described by Luschka were not observed by Wutz. He saw, however, quite frequently the lateral dilatations that gave a picture of a grape-like formation. The cysts contained partly transparent, partly yellowish or yellowish-brown or brownish-red masses. In the first case the contents were fluid, in several of the later ones they were firm. There were numerous fat-crystals, fat-droplets, and free fat, large fat-cells, brownish-yellow amorphous masses, isolated cholesterin crystals, and small, round, strongly glistening bodies.


LITERATURE CONSULTED ON SMALL URACHAL CYSTS. Caruso, F. : Contributo alio studio anatomo-patologico dei tumori cistici dell' ombelico. Atti

della Soc. Italiana di Ost. e Gin., 1901, viii, 293. Luschka, H.: Leber den Bau des menschlichen Harnstranges. Arch. f. pathologische Anat.

und Physiol, u. f. klin. Medicin, 1862, xxiii, 1. Morestin, H.: Kystes de l'ouraque. Bull, de la Soc. anat. de Paris, 1900, lxxv, 1040. Opitz: Verhandl. Deutsche Gesellsch. f. Gyn., Kiel, 1905, xi, 545. Veiel, E.: Die Metamorphose des Urachus. Diss., Tubingen, 1862. Weiser, W. R.: Cysts of the Urachus. Annals of Surg., 1906, xliv, 529. Wutz, J. B.: LTeber Urachus und Urachuscysten. Virchows Arch., 1883, xcii, 387. Wyss, H.: Zur Kenntnis der heterologen Flimmercysten. Virchows Arch., 1870, li, 143.

Personal Observations on Small Cysts of the Urachus.

As far back as 1895 Dr. Kelly was much interested in small urachal remains that from time to time were noted during abdominal operations; and for a year or two he removed portions of the urachus where any thickening was noted. All these I examined histologically. Sometimes the cord itself would show a uniform thickening, as in Case 6902 (Path. No. 3144). Here it varied from 3 to 8 mm. in diameter, and yet on histologic examination there was no evidence of a lumen. The center was composed of longitudinal bundles of non-striated muscle. Surrounding this was fibrous tissue, and external to the latter was a circular muscular layer. This case shows that a large urachal cord does not necessarily mean that the urachus is patent.

A survey of the accompanying cases will show that the cysts varied from some very minute ones to others measuring 1 x 0.9 cm. From our experience it seems that where the urachus appears as a single dilated tube, the duct is usually lined with several layers of transitional epithelium, as in Fig. 229 (Gyn. No. 6792) and Fig. 232 (Path. No. 17025). It may, however, have only a single layer of cylindric epithelium, as seen in Fig. 228 (Gyn. No. 3802).

Occasionally the remnants of the urachus appear as a small multilocular cyst, as noted in Fig. 230 (Gyn. No. 8250). The loculi are lined with cuboid epithelium. It is probable that such small multilocular cysts represent remnants of the acini described by various authors as projecting from the sides of the urachus.

The urachal remains were in every case surrounded by non-striped muscle.

Our experience leads us to believe that remnants of the urachus in the adult are by no means rare.

The small cysts may be filled with colorless fluid. Frequently they contain


532


THE UMBILICUS AND ITS DISEASES.


granular debris which has a yellowish-brown tinge, and swollen and granular exfoliated cells containing brown pigment.

Small Cyst of the U r a c h u s . — Gyn. No. 3802. A. P., aged twenty-five. Admitted November 19, 1895. At operation the uterus was suspended, the perineum repaired, an adherent ovary freed, and a cyst of the urachus removed (Fig. 228).

Path. No. 887. The specimen consists of fat containing a small cord 3 mm. in diameter, 1 cm. long. This ends at the upper end in an oval cyst, 1 x 0.9 cm., which has thin walls and contains clear fluid. This cyst is lined with one layer of cuboid cells, showing oval, uniformly staining nuclei parallel with the cyst-wall. In many places the epithelium appears to be two or three layers in thickness where



Fig. 228. — A Small Cyst of the Urachus. Gyn. No. 3802. Path. No. 887. This cyst measured 1 x 0.9 cm., had thin walls, and contained clear fluid. In the handling, the cyst has been somewhat flattened. It is embedded in adipose tissue, and at either end is seen a fibrous CO rd — the obliterated urachus. The definite cyst-wall is composed of fibrous tissue and non-striped muscle. The cyst was lined with one layer of cuboid cells.


cut on the bias. It is surrounded by fibrous tissue, and a moderate amount of muscle separates it from the surrounding adipose tissue.

Diagnosis: Small cyst of the urachus.

Cyst of Urachus. — Gyn. No. 6722. E. G., aged forty-six. Admitted to the Johns Hopkins Hospital February 27, 1899, with a diagnosis of uterine myoma. Operation: Hysteromyomectomy, excision of a small urachal cyst found lying between the obliterated hypogastric arteries.

Path. No. 2947. The cyst is 8 mm. in diameter. Its walls average 1 mm. in thickness. On histologic examination the little growth is found to consist of clusters of alveoli embedded in connective-tissue stroma, the entire area being surrounded by fat and fibrous tissue. The alveoli vary from a pin-point to 1 mm. in diameter. Some of them undoubtedly communicated with one another. They are lined with cuboid epithelium which is one layer in thickness.

Diagnosis: Cyst of the urachus.


SMALL URACHAL CYSTS. 533

A Partially Patent Urachus. — Gyn. No. 6739. C, aged fortynine. Admitted to Ward B, Johns Hopkins Hospital, March 6, 1899. Operation: Dilatation of the cervix and suspension of the uterus. A portion of the urachus was excised.

Path. No. 2961. The piece removed was 1.8 cm. long and varied from 2 to 3 mm. in thickness. On histologic examination the lumen of the urachus was found to be 1 mm. in diameter. It was lined with transitional epithelium two or three layers in thickness. The nuclei of the epithelial cells were round or oval, and stained uniformly. External to the epithelial lining was a varying amount of muscular and connective tissue, and surrounding the whole was adipose tissue.

A Partially Patulous Urachus. — Gyn. 6778. Mrs. S., admitted to Ward B, Johns Hopkins Hospital, March 2, 1899. During the course of the abdominal operation a portion of the urachus was removed. This piece was 1 cm. long and varied from 2 to 4 mm. in thickness.

Path. No. 3023. The small cord at first suggests a tube. It is tortuous, shows little projections into it; it is lined with one or sometimes two or three layers of epithelium and completely surrounded by non-striped muscle. Situated near the lumen is a small, gland-like space lined with cylinclric cells. Scattered throughout the muscle are quantities of blood-vessels. In many respects it resembles the Fallopian tube more than it does a urachus, but at other points the similarity is not so marked.

A Partially Patent U r a c h u s . — Gyn. No. 6792. G., Ward B. Operation: Hysteromyomectomy, drainage of gall-bladder, excision of a portion of the urachus.

Path. No. 3049. The portion of the urachus removed is in two pieces. The first (a) is 2.5 cm. long, 0.5 cm. in diameter, and removed from a point about 7 cm. above the summit of the bladder, b, the intervening part, is 7 cm. long and 1 mm. in diameter. In the first specimen there is a definite lumen 0.5 mm. in diameter, lined with two or three layers of cells of the transitional type (Fig. 229) . The nuclei are oval or round and stain uniformly. Surrounding the lumen is fibrous tissue, a small number of non-stripecl muscle-fibers, and external to this adipose tissue. There is no doubt that we have here remains of the lumen of the urachus. In the portion near the bladder the lumen has been completely obliterated.

Urachal Remains. — Gyn. No. 6902. M., nineteen years old. Admitted to Ward B, Johns Hopkins Hospital, May 8, 1899. The operation consisted of hysterotomy, curettage, and resection of an ovary, together with excision of a portion of the urachus. The part of the urachus removed was 3.5 cm. long and from 3 to 8 mm. in diameter. These measurements included some of the surrounding adipose tissue.

Path. No. 3144. Microscopically, no trace of the lumen could be made out. In the center was a stroma consisting of bundles of non-striped muscle arranged longitudinally and surrounded by fibrous tissue; external to this again was a circular layer of muscle. In other words, this cord was made up entirely of muscular and fibrous tissue without any sign of a lumen.

A Very Small Multilocular Urachal Cyst. — Gyn. No. 8250. J. W., married, aged twenty-seven. Admitted October 24, 1900. The uterus was suspended for a retroflexion, and a cyst, supposedly of the urachus, was


534


THE UMBILICUS AND ITS DISEASES.


removed. The cyst of the urachus was 3x5 mm. It was translucent and showed irregular, tiny, projections into the cavity, Fig. 230.

Path. No. 4441. The specimen was found to be a multilocular cyst, the loculi being large and small and apparently opening into one another. The epithelium in some places was cuboid. The nuclei of the epithelial cells were oval; they stained uniformly and were arranged parallel with the cyst-wall. Where the tissue was cut on the bevel, the epithelium appeared to be several layers in thickness and suggested squamous epithelium. The stroma between the cysts consisted essentially of non-striped muscle-fibers separating the cyst proper from the sur


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Fig. 229. — A Patent Urachus. Gyn. No. 6792. Path. No. 3049. This portion of the urachus was in the mid-line, about 7 cm. above the bladder. The lumen is slightly irregular and contains some granular detritus. Lining the cavity is transitional epithelium, in some places only as a single layer, but at most points two or three layers thick. Surrounding the lumen is fibrous tissue in which some non-striped muscle was recognized.


rounding fibrous and adipose tissue. This cyst was a remnant of the urachus. Whether the loculi all communicated with one channel or not it is difficult to say.

A Partially Patent Urachus. — Path. No. 3012. This patient was admitted to Dr. Kelly's sanitarium March 7, 1899. The operation consisted of an abdominal myomectomy and excision of the urachus.

Histologic Examination. — The lumen is found narrow and lined with two or three layers of columnar epithelium. External to the epithelium are bundles of longitudinal and circular muscle-fibers. The urachus is pervious.

Probable Cyst of the Urachus. — Gyn. No. 6815. Path. No. 3062. B., twenty-five years old. Admitted to Ward B, Johns Hopkins Hospital, April 8, 1899.


SMALL URACHAL CYSTS.


535



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Fig. 230. — A Multilocular Cyst of the Urachus. Gyn. No. 8250. Path. No. 4441. This cyst was 3x5 mm. and was translucent. As seen from the upper, lowpower picture, it was composed of numerous loculi. Many of these seemed to communicate with one another. Surrounding the cyst, and separating it from the adipose tissue, is a definite wall. This consisted of fibrous tissue and nonstriped muscle. The small area of the cyst-wall, blocked off and indicated by the arrow, has been enlarged and is seen in the lower picture. The cyst is lined with one layer of cuboid cells.


536


THE UMBILICUS AND ITS DISEASES.


Operation. — Exploratory laparotomy; excision of a small cyst from the anterior abdominal wall just above the symphysis. This cyst contained two small lumina, which appeared to be convolutions of the same tube. Each was lined with two or more layers of transitional epithelium. The nuclei of the epithelial cells were oval and stained uniformly, and the lumen was surrounded b} r nonstriped muscle-fibers arranged circularly. External to these were parallel bundles of non-striped muscle-fibers embedded in fibrous tissue. It seems practically certain that they were remains of the urachus.

A Partially Patent Urachus. — Gyn. Path. No. 17025. While



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Fig. 231. — Section of a Patent Urachus. Gyn. Path. No. 17025. A longitudinal section of a portion of the urachal cord. The tube has evidently been tortuous, thus accounting for the longitudinal and transverse sections of the lumen. (For the high-power picture see Fig. 232.)


collecting the literature on the urachus I found, when operating on Mrs. M. E. at the Church Home and Infirmary, February 28, 1912, a urachal cord that seemed unusually large. Longitudinal sections of this showed elongate, irregular, and round cavities embedded in non-striped muscle and fat. The low-power picture is well shown in Fig. 231. One gathers the impression that the urachus consists of one tortuous and probably slightly branching tube. It will be noted that these spaces have a distinct lining and that some of them are filled with a definite substance. From Fig. 232 we learn that the spaces are lined with transitional epithelium. The contents of the cavities were in the main brownish yellow. The


SMALL URACHAL CYSTS.


537


small oval or spheric masses are swollen, exfoliated cells, which have taken up pigment granules. This was without a doubt a patent and slightly cystic urachus.

A Small Urachal Cyst. — Gyn. No. 21255. N. D., aged twentythree, white, was admitted to the Johns Hopkins Hospital on June 4, 1915, complaining of severe abdominal pain and of backache. She was married and had had one child.



Gyn. Path. No. 1702.5.


Fig. 232. — Transverse Section of a Patent Urachus. The cavity is lined with several layers of transitional epithelium, amount of debris. Surrounding the urachus is non-striped muscle.


It contains a certain


After a careful examination it was found that she had a relaxed vaginal outlet and a retroposed uterus, chronic appendicitis, and gall-stones.

At operation Dr. J. Craig Neel, the resident gynecologist, repaired the perineum, brought up the uterus, removed the appendix, and emptied the gall-bladder of its stones. While making the median abdominal incision to bring up the uterus, he found a small cyst of the urachus in the mid-line (Fig. 233). This cyst was about


538


THE UMBILICUS AND ITS DISEASES.


1 x 1.5 cm. in diameter, and seemed to be filled with clear fluid. The cyst and about 1 cm. of the urachus on each end of it were removed.

Gyn.-Path. No. 21256. Sections from the cyst wall show that it is composed in a large measure of connective tissue with here and there a little non-striped


Obliterated urachus

Josten'or surface of Urachus cyst

faterct urachus



Fig. 233. — A Small Cyst of the Urachus. Gyn. Path. No. 212.56. This cyst was accidentally discovered when a median abdominal incision was being made. The cyst was located at a point midway between the umbilicus and symphysis. It was thin-walled, and above and below was directly continuous with the urachal cord. In the urachus just below the cyst were three slit-like openings — points at which the urachus was apparently still patent. The small drawing in the right upper corner of the picture shows the cyst after removal. The urachus above was obliterated; below, it was patent for a short distance.


muscle. The cyst is lined with one layer of almost flat epithelium. The wall in most places is smooth but here and there is slightly wavy.

The solid cord above the cyst consists almost entirely of connective tissue. The urachal cord is composed in part of connective tissue, but contains many bundles of non-striped muscle. The slit-like spaces noted macroscopically are devoid of any epithelium. There is no doubt that this cyst is of urachal origin.


Chapter XXXII. Large Urachal Cysts

Historic sketch.

Symptoms.

Differential diagnosis; personal observations on a large diffuse neuroma of the bladder.

Treatment.

Detailed report of large, non-infected urachal cysts.

The small urachal cysts that we have considered rarely reached 1 cm. in diameter, and were naturally readily overlooked clinically. Probably one of the first urachal cysts ever opened was the one observed by Peu in 1648, and recorded in his Pratique des Accouchements, 1694, p. 38, and recently referred to by Wutz. The patient was a child two hours old. Situated at the umbilicus was a tumor the size of a pigeon's egg. It was opened, and a serum-like fluid escaped. This proved to be urine, and on the following morning urine escaped in a jet from the umbilicus..

Atlee, in 1873, in his treatise on Ovarian Tumors, reported the case of a girl eighteen years old. When opening the abdomen for the removal of an ovarian tumor he accidentally incised a urachal cyst containing an ounce of fluid resembling ordinary ascitic fluid.

Von Recklinghausen in 1902 demonstrated a polycystic tumor the size of a walnut which had been excised from a man thirty years old.

E. R. LeCount found a urachal cyst the size of an orange while making an autopsy on a man fifty-two years of age.

Interesting articles on urachal cysts have been written by Rippmann (1872), Wolff (1873), Scholz (1878), Schaad (1886), Tait (1886), Dossekker (1893), Douglas (1897), and others, and in 1906 the splendid monograph of Weiser appeared.

These cysts are naturally first noted in the mid-line between the umbilicus and pubes. They lie in the anterior abdominal wall just external to the peritoneum.

Size. — In the beginning they are relatively small, as in von Recklinghausen's, Atlee's, and LeCount's cases. As a rule, the increase in size is only gradual, but in a few instances the growth has been very rapid. They rarely extend above the umbilicus, but in some instances have reached as far as the xiphoid. Among the largest cysts are those recorded by Pratt and Bond, Macdonald, Rippmann, and Tait. In Pratt and Bond's case the cyst reached upward beneath the liver. Macdonald' s patient had a markedly distended abdomen; it was firm and rather flat as far as the ensiform cartilage. In Tait's Case 1, 30 pints of fluid were evacuated at operation. Rippmann's was probably the largest on record. At autopsy the cyst was found to contain 52 liters of fluid weighing 100 pounds.

The cyst may or may not burrow beneath the bladder, and encroach on the vaginal vault. It is sometimes attached to the bladder by the urachal cord, and where the tumor has reached large proportions, it is usually adherent to the umbilicus.

The cyst-walls vary considerably in thickness. Some are verj^ thin, others may be from 1 to 4 mm. thick.

539


540 THE UMBILICUS AND ITS DISEASES.

The inner surface of the cyst is usually smooth. Sometimes coagulated cyst fluid clings to its walls. In Macdonald's case papillary masses were found springing from the inner surface of the cyst (Fig. 240, p. 559).

As these cysts are due to dilatations of the urachus, we should naturally expect to find them lined with transitional epithelium. When the cysts are small, the lining with transitional epithelium is often found, but in the large cysts, there not being enough to cover the whole surface, remnants of this transitional epithelium are often found only over certain areas on the cyst-wall. The walls are composed of fibrous tissue and contain a varying quantity of non-striped muscle. In Tait's Case XI calcareous particles were found scattered throughout the wall of the cyst.

Cyst Fluid. — The character of the fluid contained in urachal cysts varies considerably. Sometimes it is pale yellow and limpid, closely resembling ascitic fluid. In other cysts it is yellow and transparent or tenacious and ropy. The fluid may be of a pale-green color. In some cysts it is brown or of a chocolate color; or it may be thin and with a hemorrhagic tint. Whether the fluid be thin and clear, or dark and turbid, it often contains large clumps of coagulated lymph or fibrin. Such masses have been referred to by some writers as "necrotic lymph " or cheesy masses. They are strongly suggestive of the coagulated material often noted in ovarian cysts. The cyst fluid contains albumin and mucus. On histologic examination exfoliated squamous epithelium, fat-droplets, and cholesterin crystals are often noted.

SYMPTOMS.

Sex. — Of the cases of simple uncomplicated and non-infected urachal cysts here recorded, and in which we were able to obtain definite data as to the sex, 16 were in women and 5 in men.

Age. — The youngest patient was six years and the oldest fifty-four. The accompanying table furnishes the following data:

Six years of age 1 case

Between ten and twenty years 1 "

" twenty and thirty years 1 "

" thirty and forty years 7 cases

" forty and fifty years 3 "

" fifty and sixty years 2 "

The first symptom is usually enlargement of the lower part of the abdomen. This, as a rule, is in the mid-line, but the swelling, sometimes accompanied by pain, may first be noticed in the right iliac fossa, and the picture may strongly suggest an appendicitis.

With the increase in abdominal girth there may be a moderate degree of indigestion, and where the cyst has reached large proportions, there has been dyspnea. Some of the patients have become progressively emaciated and have lost in strength.

Micturition has been normal in some, frequent in others. It is but natural that the bladder should be markedly encroached upon in some cases, particularly as the excursus of the tumor is limited, on the one side by the peritoneum, and on the other by the anterior abdominal wall.

Pain has been a marked feature in some cases, absent in others. The pain is probably in a measure due to pressure on the terminal sensory nerve-trunks, owing


LARGE URACHAL CYSTS. 541

to the tension under which the cyst develops, confined, as it is, between the layers of the abdominal wall. But it must also be remembered that the cyst is separated from the abdominal contents only by a thin peritoneum, and consequently the slightest inflammation of the cyst-wall must readily extend to the peritoneum and not only produce pain, but also cause the omentum or some other abdominal structure to become adherent to the abdominal wall over the cyst. Such a condition was noted in Carroll's case, and also in one recorded by Doran.

On physical examination an abdominal swelling is noted. This may extend over the entire abdomen, or be limited to the lower portion. Although the tumor may be exceedingly large, there exists a certain amount of repression of the abdominal wall, due to the tonic contraction of the recti muscles. When the patient is anesthetized and the recti muscles are relaxed, instead of being board-like, the abdomen may become quite soft, and the cystic tumor can then be readily detected. If the abdominal walls are naturally tense, the difficulties in making an accurate diagnosis are augmented. In some cases definite fluctuation can be elicited.


DIFFERENTIAL DIAGNOSIS.

Urachal cysts have been diagnosed as a distended bladder, as ascites, as an appendicitis with abscess formation, as a cyst with or -without twisting of the pedicle, as a localized peritonitis with a serous exudate under the anterior abdominal wall, and as a tuberculous peritonitis.

The distended bladder is readily emptied, and the ascites relieved by paracentesis. With the patient asleep, it is relatively easy to outline the cyst and to differentiate it by the absence of the induration, usually associated with an appendix abscess. Furthermore, with the abscess there is likely to be a history of an elevation of temperature and of a definite leukocytosis.

An ovarian cyst, whether mobile or twisted, lies much farther back in the abdomen and can be separated from the anterior abdominal wall, particularly when the patient is under narcosis. The differentiation from a localized peritonitis or from a tuberculous peritonitis is not so easy, particularly when the patient has become emaciated. Even in these cases, however, when the patient is asleep, the sharp outlines of the urachal cyst are readily distinguishable from the rather diffuse cystic accumulation occurring with a peritonitis. Again, in the case of a urachal cyst, moving it from side to side is likely to produce traction on the umbilicus. With an aspirating needle one can readily remove some of the cyst fluid and thus usually settle the diagnosis.

The following case that recently came under my notice is of such interest in connection with the differential diagnosis of urachal cysts that I shall report its salient features.

A Tremendously Thickened B 1 a d d e r - w a 1 1 Producing a Tumor Reaching Almost to the Umbilicus and Simulating a Urachal Cyst. — The great thickening of the vesical wall was due to a diffuse neuroma. I shall refer to this case very briefly, as Dr. Welch and I will report it in detail elsewhere.

Surg. No. 34093. P. B., a colored boy three years and seven months old. was admitted to the surgical service of the Johns Hopkins Hospital on March 9, 1914. for an ununited fracture of the left tibia and fibula. Dr. Heuer wired the ununited


542


THE UMBILICUS AND ITS DISEASES.


fracture, and the boy made an uneventful recovery. When he entered the hospital it was noted that he had a firm mass extending upward from the symphysis to within 2 cm. of the umbilicus. This mass was broad below and rather narrow near



« 3 1 5


Fig. 234. — A Diffuse Neuroma of the Bladder. (After William H. Welch and Thomas S. Cullen.) The picture shows the appearance of the bladder when the abdomen was opened. The contracted viscus extended almost to the umbilicus, was large and exceedingly hard, and even after it had been brought out of the abdomen, it was almost impossible to realize that it was the bladder. When the bladder was lifted up, it was found that the right ureter was 8 mm. in diameter. The left ureter was slightly enlarged. The surface of the bladder was covered with great congeries of what appeared to be small and tortuous vessels. These were noted at once, but were particularly well seen when the peritoneum was stripped back. Subsequent histologic examination showed that most of these tortuous cords were nerves. The remnant of the urachus was larger than usual. Not knowing at the time the unusual character of the growth, I cut into it and found that the tumor was caused by a tremendous thickening of the bladderwall. For the appearance of the cut bladder-wall see Fig. 235; for the histologic picture see Fig. 236.


the umbilicus. Through the lax abdominal walls it could be readily grasped with the hand. Micturition was normal, and when the bladder was empty, this tumor diminished little, if any, in size.

It seemed to be a urachal tumor of some kind, and Professor Halsted, knowing


LARGE URACHAL CYSTS.


543


that I was much interested in urachal remains, kindly transferred the case to the Gynecologic Department.

Operation (March 28, 1914). — Feeling confident that we were dealing with a



Fig. 235. — Cut Surface of the Bladder Showing a Diffuse Neuroma of its Walls. (After William H. Welch and Thomas S. Cullen.) The figure shows the lower part of the bladder seen in Fig. 234, after the top had been removed. The bladderwalls protruded into the cavity, rendering it very small. The inner surface at this point was covered over with only.a single layer of epithelium, which stained very faintly. All trace of the transitional epithelium was wanting in the sections examined. The bladder-walls in the portion removed varied from 1 to 3 cm. in thickness, and everywhere this coarse and tortuous texture was the striking characteristic. A low-power section through the bladder-wall showed an abundance of nerves on the outer surface. There was a muscular zone with nerve-bundles scattered throughout it, and an inner zone, varying from 1 to 2 cm. broad, consisting almost entirely of nerve elements. (See Fig. 236.)


urachal tumor, I made a median incision from the umbilicus to the symphysis, and at once encountered the tumor seen in Fig. 234. It was very firm, and over a large area was covered with peritoneum. Attached to its upper end was what appeared to be the urachal cord. Immediately beneath the peritoneum of the tumor were


544


THE UMBILICUS AND ITS DISEASES.


Nerves



Tumor


Bladder muscle


Fig. 236. — A Diffuse Neuroma Forming a Mantle Abound the Cavity of the Bladder. (After William H. Welch and Thomas S. Cullen.) Surg. No. 34093. Service of Professor William S. Halsted, Johns Hopkins Hospital. The section has been taken through the top of the bladder seen in Fig. 234. It embraces both walls of the bladder, and near the center the slit-like vesical lumen is visible. This photomicrograph shows numerous nerve-trunks on the outer surface of the bladder. The white areas scattered throughout the bladder muscle are also nerves. Surrounding the bladder cavity is a mantle composed almost entirely of nerves. This nerve zone varied from 1 to 2 cm. in thickness. The mucosa of the bladder in this vicinity was in most places reduced to one layer of epithelial cells that were cuboid or flat. (Iron. hematoxylin. Photomicrograph by Mr. Herman Schapiro.)


LARGE URACHAL CYSTS. 545

numerous small, tortuous cords. The obliterated hypogastric remains were unusually large'.

The ureter on the left side was normal in size; that on the right, fully 8 mm. in diameter. It was evident that this tumor either lay as a cap on the top of the bladder or that it formed an integral part of the bladder-wall. After carefully walling it off, I cut into it and found that we were dealing with a greatly thickened bladderwall. Fig. 235 shows the proximal portion of the wall on section. The inner surface of the bladder was thrown into folds, and its mucosa was exceedingly thin. The bladder-wall was markedly changed, being coarse in texture, due to the crosssection of many cords which emerged from the surface. Only near the peritoneal surface was there any semblance of normal bladder muscle. The walls of the bladder were approximated with considerable difficulty, and sutured, and a drain was laid down to the peritoneum. After the operation the boy did well for several hours; he then developed nausea, vomiting, abdominal distention, and tenderness; his temperature ranged from 100.4° to 103.8° F. and his pulse was very rapid.

On April 1st it was deemed advisable to do an enterostomy. He was given a few whiffs of gas, but died before any operative procedure could be carried out. Much to our regret no autopsy could be obtained, but the abdomen was sufficiently opened to see that peritonitis existed.

Examination of the portion of the bladder removed showed that its walls varied from 1 to 3 cm. in thickness, the extreme degree of thickening being more marked in the posterior vesical wall and at the top of the bladder. Wherever the thickening was marked, this very unusual and coarse appearance was noted.

Fig. 236 is a photomicrograph of a section taken through the top of the bladder. It embraces both walls and the lumen of the bladder. On the outer surface of the bladder are a large number of nerves. These represent the tortuous cords noted at operation. The muscular walls of the bladder are still well preserved, but penetrating here and there are large nerves. Separating the muscle from the bladder mucosa is a zone consisting entirely of nerve elements. In other words, surrounding the bladder cavity in this region is a mantle of nerve tissue varying from 1 to 2 cm. in thickness. We are indebted to Mr. Charles Miller, the technician in Professor Mall's department, for preparing many exquisite sections showing the appearances with the various nerve-stains. These findings will be reported in detail at a later date.

The bladder mucosa in the portion removed was in some places composed of several layers of transitional cells, but in most places the epithelium was but one layer thick and almost flat, and the nerves came up to and encroached upon the epithelium.

Had I, prior to operation, for a moment dreamed that this was not a urachal tumor, 'the bladder would have been at once filled with thorium and x-rayed. Knowing what we do now, we are not in the least surprised that such a bladder would be very slow to heal after being incised. The broad inner zone consisted almost entirely of nerves, and in addition had a very meager blood-supply.

This is the only bladder tumor of this character with which we are familiar; a mistake in diagnosis of this kind will rarely occur.


36


546 THE UMBILICUS AND ITS DISEASES.

TREATMENT OF URACHAL CYSTS.

A median incision, commencing just below the umbilicus and extending to the pubes, will be sufficient to expose a urachal cyst of moderate size. As soon as the recti muscles are separated, the cyst will come into view. Sometimes it is infected and shows signs of inflammation. It is usually loosely adherent to the peritoneum, and can be readily shelled out. Sometimes it is rather firmly adherent to the posterior surface of the bladder. In those cases in which the urachus is rather thick and passes directly into the cyst, it is well to treat it as a pervious cord and to ligate it with Pagenstecher thread and cover this in turn with catgut, to prevent the possible development of a urinary fistula in the lower angle of the abdominal wound.

If the urachal cyst extends upward beyond the umbilicus, it is wise, when making the abdominal incision, to encircle the umbilicus, as this is often adherent to the cyst and should be removed with it.

In some cases it has been found possible to remove the cyst without opening the abdominal cavity. In others the cyst had become adherent to the omentum, and it was necessary to liberate the omental adhesions before the tumor could be removed.

When the cyst is exceptionally large, the peritoneum has of necessity been widely separated from the anterior abdominal wall. After operation the normal intimate relation is usually restored, but that this does not always happen is evident from Douglas's case. After drawing off 25 pints of clear fluid, Douglas readily separated the cyst-wall. The area of peritoneum separated from the parietes extended from about three inches above the umbilicus to the symphysis. It was observed that the peritoneum sank away from the parietes, but, thinking that when the abdominal wound was closed the intra-abdominal pressure would bring it into apposition with the abdominal wall, Douglas made no effort to stitch it there. The abdominal wound was closed in the usual manner and a firm compress was applied. The patient left the operating room in a remarkably good condition. Twenty-four hours later her temperature was 99.4° F., her pulse 136, respirations, 30. She was nauseated, vomited slightly, and there was some epigastric distention. She became dull and roused only when vomiting. Her condition rapidly grew worse, and she died forty-six hours after operation.

At autopsy the entire detached peritoneum on the right side was found to be gangrenous. There had been no hemorrhage, but there' was a little effusion between the peritoneum and abdominal wall. The peritoneal cavity contained a little brown serous effusion, but no pus or lymph.

Tait also reported a death in one of his large cyst cases. The cause could not beascertained, as no autopsy was obtainable.

As a rule, non-infected urachal cysts can be removed with little clanger. If very large, it may in rare instances be advisable merely to drain them and allow the sac to contract down gradually. It can then be removed with less danger of injury to the peritoneum. On the other hand, the adhesions at the second operation are liable to be much denser.

Where the peritoneum has been widely denuded, it may be tacked to the abdominal wall with several delicate catgut sutures; or one or two delicate protective drains may be carried down to the peritoneum, not only providing for the escape of any slight amount of fluid that may accumulate, but also allowing the air to escape and tending to make the abdominal walls flatten down on the peritoneum.


LARGE URACHAL CYSTS. 547

DETAILED REPORT OF LARGE, NON-INFECTED URACHAL CYSTS.

This list includes those cases in which little or no infection existed. Tait, in his article published in 1886, recorded a relatively large number of cases. The majority of these and some others were rather indefinite and have purposely been omitted.

The cyst in Schaad's case was probably urachal in origin, but it was lined with high cylindric epithelium; and as glands opened into it, its origin from remnants of the omphalomesenteric duct cannot be absolutely excluded.

A Urachal Cyst. — Atlee,* on opening the abdomen for the removal of an ovarian tumor in a girl eighteen years of age, found a urinary pouch in the linea alba. This he accidentally divided with the knife. The abdominal walls were very thick, vascular, and remarkably muscular. Between the muscle and the peritoneum he opened a small cyst from which about one ounce of yellowish liquid, resembling ordinary ascitic fluid, escaped. The posterior wall of the sac was cut through and the peritoneum opened. There were no adhesions. The bladder occupied the normal position. On the sixth day the dressings were moist, and by the end of a month Dr. Fay, who looked after the case, felt sure that the fluid was urine. The patient was advised to empty the bladder frequently, and the discharge soon ceased.

"The only conclusion possible was that we were dealing with a dilated urachus, which, although closed at the umbilicus, had from birth maintained a communication with the bladder."

A Urachal C y s t . f — "I. F., aged six years; Newcomerstown, Ohio. Physician, Dr. Hosick. The patient had been taken suddenly sick about three weeks before. The pain seemed to be in the neighborhood of the appendix, but somewhat below McBurney's point. Slight elevation of temperature. Thighs flexed. Amount of pain quite variable. Bowels regular. No appetite. A little before she came to the hospital the abdomen became much distended and painful. Pulse more rapid. Temperature, 100° F. The presumptive diagnosis had been appendicitis with enormous abscess formation. When the patient reached the hospital (May 7, 1911), the abdomen was considerably distended and tender throughout, and with distinct fluctuation. There was perhaps a little more tenderness in the appendix region than elsewhere, but this was not marked. Diagnosis, very doubtful, but the case clearly one for exploration.

"When the patient was under the anesthetic I could determine nothing more about the case. No lump in the region of the appendix. Made the usual median incision. As soon as the incision was made there was an escape of a large amountof rather thin, yellow, odorless fluid. The opening was enlarged, and the cavity thoroughly flushed out, the water bringing out a large amount of what seemed to be necrotic lymph. The cavity was found to be bounded below by the pelvis, above by probably the transverse colon and the stomach. It extended on each side clear to the flanks. The intestines were crowded back by the posterior wall of the cyst. The uterus in this case could be readily felt, though infantile in size, below the membrane. Introduced drainage, with partial closure of the incision. The patient made a smooth convalescence and returned home in the usual time, with distinct warning as to the probability of a hernia.

  • Atlee, Washington L. : Ovarian Tumors, Philadelphia, Lippincott, 1873, 50.

t Baldwin: Large Cysts of the Urachus. Surg., Gyn. and Obst., 1912, xiv, 636.


548 THE UMBILICUS AND ITS DISEASES.

" September 3, 1911, patient returned with her mother because they had noticed a beginning hernia. The hernia was operated upon the next day. I made an incision directly through the old scar, dissecting down very cautiously, as I expected to find extensive adhesions. On finally opening the peritoneum I found that the abdominal contents were in every respect absolutely normal, except for two cobweb adhesions of the omentum to the anterior abdominal wall. The appendix was brought up and found to be entirely normal; was removed on general principles. Pelvic organs normal. In fact, had one not familiar with the previous history of the case made the operation, he would have found nothing whatever to suggest any previous trouble in the abdomen. In other words, the sac had absolutely disappeared. The bladder, however, seemed to be a little higher up than usual, though even that was not positive."

Large Urachal Cysts. — Dr. Bantock* said he was sure he was expressing the sentiments of every one present when he desired to offer the thanks of the Society to their President [Lawson Tait] for the very remarkable and interesting paper which he had just read. The cases were of remarkable interest, but he feared there was no one who could discuss the subject from experience. The paper was one for future perusal and careful study. He at least was not prepared to discuss it, but he thought he might refer to two cases of which he was reminded by some of the cases related by the President.

The first case was that of a married woman, aged thirty, the mother of two children. On dividing the parietes, Bantock opened into a cyst containing 25 pints of a thick, grumous fluid, with a very decided biliary tinge. When the whole of the fluid was removed, the cyst was found to be unilocular, and looking down into the pelvis was like looking into one's hat, so completely did the walls of the cyst line the pelvic cavity. After separating what appeared to be cyst-wall from the parietes on each side, and cutting away what was thus separated, recognizing the hopelessness of proceeding further, he washed out the cyst with a solution of iodin and closed the wound, leaving a drainage-tube passing down to the bottom of the pouch. Although the separation of what was taken as cyst-wall was carried beyond the umbilicus, the peritoneal cavity was not opened. A thick, pultaceous fluid of the color of mustard came from the cavity for many weeks, but the patient was discharged quite well at the end of about two months. Bantock had lately seen this patient in perfect health. He adds that the source of the brilliant yellow color of the discharge was still a puzzle to him.

The second case was that of a married woman, thirty-seven years of age, the mother of three children. The history told that she was taken ill on January 10th with violent sickness and pain all over the stomach. She was laid up and became feverish; the pain being severe for five days and the sickness for two days. The abdomen gradually got larger, and about the end of February she was tapped of rather more than half a gallon of a thickish, pale-yellowish fluid. In about a month more she was tapped again to the extent of three pints of a thicker fluid, and recommended to apply poultices. Shortly after this the puncture-hole opened and discharge came away. She then presented herself at the out-patient department of the Samaritan Hospital, under the care of Dr. Amand Routh, with whom Bantock saw her. There was then a fistulous opening about two inches below the umbilicus, in the middle line, and an ordinary surgical probe passed in for its whole length. She

  • Bantock: From Tait's article, Brit. Gyn. Jour., 1886-87, ii, 348.


LARGE URACHAL CYSTS. 549

was admitted into the hospital on July 20th, and Bantock thought he had to deal with a multilocular tumor of which a central cyst had suppurated, as on withdrawing the probe no discharge followed. On July 27th he divided the parietes by a double elliptic incision, with the view of cutting out the fistulous tract, and was not a little surprised to find, on completing the division on one side, that he had opened directly into a unilocular cyst containing from three to four pints of a purulent-looking fluid. On further examination he found the same condition of things as in the first case, and, recognizing the inadvisability of proceeding further, he thoroughly washed out the cavity with plain warm water and closed the wound, leaving in a glass drainagetube. The patient presented herself at the hospital two or three weeks before the meeting of the society and was in perfect health. In this case the uterus was low down, pressed forward, and fixed. Bantock said that he was as much at a loss to explain the relations and origin of this cyst as in the first instance, but he thought they were worthy of being related in connection with the very remarkable cases read by the President.

Probably a Urachal Cyst. — Bryant,* in discussing Doran's paper, reported two cases. In Case 1, on operating on what had been diagnosed as an ovarian cyst, he suddenly opened into a cyst from which serosanguineous fluid escaped. This was in front of the peritoneum, and was with difficulty separated from the bladder. When this had been done, the cyst came away in his hand, and it was clear that it had no pedicle nor any connection with the broad ligament.

A Cystic Urachus. — Carroll's! patient was a woman thirty-four years old. She had been well until twenty-three. After that she had had attacks of abdominal pain, loss of weight, and on one occasion inflammation of the bladder.

On examination an induration was found extending from the umbilicus two to three inches to the right, and downward for three or four inches. The tumor was apparently too near the umbilicus to be of appendiceal origin.

Roswell Park made a median incision below the umbilicus. The tissues were very dense and difficult to cut. A sac was opened and fluid escaped. The incision was enlarged, and a finger introduced. The tumor was found to be a cystic urachus. A connection with the bladder could be traced, but a probe could not be passed. The connection was tied off and the cyst dissected out. There were a number of adhesions between the tumor and the omentum. The patient made a good recovery. "The probable explanation of the attacks seemed to be an oozing of urine into the upper or cystic part of the urachus, and as there was no egress for the fluid once gathered, it was absorbed into the system, causing a toxemia."

A Large Cyst of the Urachus. £ — The patient was a girl, twenty years of age. The tumor had first been noticed a year before admission. It had increased greatly in size in the last four months. It had commenced as a painful point in the right iliac fossa. On account of the patient's emaciation and the increase in abdominal girth the physician had diagnosed tuberculous peritonitis. On admission there was great abdominal distention, evidently due to fluid.

Operation. — An incision was first made as far as the umbilicus, and was extended upward to the xiphoid. The tumor was adherent at the umbilicus. The pedicle was attached to the summit of the bladder. It had no lumen and did not open into

  • Bryant, T. : Brit, Med. Jour., 1898, i, 1390.

f Carroll, Jane W.: Buffalo Med. Jour., 1895-96, xxxv, 869.

1 Cotte et Delore: Gros kyste de l'ouraque. Lyon med., 1905,, cv, 373.


550 THE UMBILICUS AND ITS DISEASES.

the bladder. The uterus, tubes, and ovaries were normal. The cyst was unilocular and contained between eight and nine liters of brown, hemorrhagic fluid. This was not examined microscopically. The inner lining of the cyst was made up of inflammatory tissue. On the cut surface the urachus was recognized as a cord. The authors say that the cyst had developed from the urachus. The patient made a good recovery.

A Urachal Cyst Simulating an Appendicular Abscess.* — "The patient, aged seventeen and a half years, unmarried, applied to Dr. R. Drummond Maxwell at the out-patient department of the Samaritan Free Hospital on July 16, 1908. She complained of tenderness and swelling in the right iliac fossa, associated with a history of a sudden attack of pain in that region a month previously, and she was admitted into my ward at once. After admission I found that the relations of the swelling to adjacent organs could not well be defined until I examined the patient with the aid of anesthesia, under circumstances presently to be explained. The patient's mother informed me that the catamenia were established at the age of fourteen years, without pain or constitutional disturbance. The periods were always scanty and attended with very little pain, and the interval was about five weeks. The patient had never suffered from any neurosis before, at, or after puberty. On June 16th, one calendar month before admission, the menstrual flow appeared as usual, but was accompanied by violent pain never experienced before. The pain continued for two days and then it abated. The patient at once resumed her work, but the pain returned two days later and obliged her to take to her bed again. During the whole of the week before admission she was quite incapable of attending to her duties. Roughly speaking, as regards what could be made out before anesthesia was employed, there was a fairly defined, almost spheric swelling in the right iliac fossa, slightly movable and tender to the touch. There was resonance on percussion over its outer aspect. The lower part of the swelling could be defined on rectal examination. I refrained from making a vaginal exploration until a consultation was held. Then it was found that the vagina was barely two inches deep. A kind of dimple could be defined at the blind extremity toward the right. The tumor did not bulge into the vagina. At the lower limits of the swelling was a tuberosity which lay behind the vagina and in front of the rectum. The temperature and pulse were low. The patient had never been laid up with any severe illness. Before the arrested development of the vagina had been detected, appendicular abscess was suspected, but after the examination, hematometra or hematosalpinx seemed equally probable. On July 21st the period began, as usual, about five weeks after that which had preceded it. I found that there was no palpable increase of pain or tenderness in the tumor nor any appreciable increase or decrease in size. The flow was unusually free. I decided to examine the patient under anesthesia during the period in order to discover the channel which transmitted the menstrual blood into the vagina, and for other manifest reasons.

"Examination under Anesthesia. — The perineum was markedly deep, so that the anterior commissure lay far forward. The labia, clitoris, and meatus urinarius were normally developed. There appeared, on the other hand, to be Ao hymen nor was there the least trace of carunculse."

"The vagina formed a blind pouch about two inches deep. The rugae were prominent.

  • Doran, Alban H. G.: The Lancet, 1909, i, 1304.


LARGE URACHAL CYSTS.


551



Ut?


"The vaginal pouch was distinctly deeper on the right side, whence dark menstrual blood was seen to issue. On stretching the adjacent mucosa with the fingers, a crescentic fold with the concavity toward the left was detected. It covered the aperture whence proceeded the blood. A uterine sound could be passed into this aperture and pushed onward for three inches upward, backward, and a little to the right, closely following the outer limits of the lower pole of the swelling, as could easily be defined on digital exploration from the rectum (Fig. 237). On bimanual palpation the swelling was found to be a well-circumscribed tumor, firm, pushed a little downward, yet even then its lower pole did not bulge into the vagina, but passed behind it. The tuberosity in the rectovaginal septum, discovered at the previous examination, lay to the left of the menstruating tract. It felt like a small cervix. The nature of the case remained obscure. I kept the patient at rest for a week. The period ceased, and the tumor remained stationary. There was one sharp attack of local pain on July 28th, without any rise of pulse or temperature."

"Operation. — On July 29th I operated with the assistance of Dr. R. V. G. Monckton, Dr. S. H. Belfrage administering ether and chloroform. I made an incision in the middle line. The parietes were unusually vascular. After separating the recti I came across a thick membrane of doubtful character, and lower clown I exposed the wall of the bladder, which extended for quite two inches above the pubes. The membrane was cut through, and about half a pint of a perfectly clear fluid was removed; unfortunately, none was preserved. The fluid lay in a cyst behind the recti and anterior to the parietal peritoneum, the membrane through which I had made

the incision being the anterior portion of the cyst-wall. The cyst was connected with the bladder by a thick cord half an inch in length. The upper limits of the cyst lay close below the umbilicus. In exploring the upper end of the tumor I laid open the peritoneal cavity. The omentum adhered to the peritoneum, investing the back of the cyst in this region. The intestines seemed healthy; there was no evidence of tuberculous disease, no free fluid, and no intraperitoneal tumor. Lower down some coils of ileum adhered to the parietal peritoneum behind the tumor. "I endeavored to define the relations of the cyst to the genito-urinary tract. A catheter was passed into the bladder, and a few ounces of urine were drawn off. There was no communication between the cavity of the bladder and the cavity of the cyst; the thick cord between the two was clearly a portion of the urachus, and I observed that it ran into and not over the cyst-wall.

"As might have been suspected from what could be defined before the operation, the cyst lay to the right of the middle line. On pressing against its wall on the right interiorly, from the inner side I detected a fusiform body like a uterine cornu or a small but entire virgin uterus, lying in the position of the menstruating tract along


Fig. 237. — Diagram Showing the Arrested Development of the Genital Tract and the Relation of the Malformed Parts to the Cyst of the Urachus. (After A. Doran.) Vg, vagina, its blind end rising higher on the right side than on the left; VI, valvular fold, through which a sound () passes into Rt. Ut., the right cornu; Ov, right ovary; Lft. Ut., solid body, probably left cornu; the dotted lines indicate a band, not clearly definable, connecting it with the right cornu.


552


THE UMBILICUS AND ITS DISEASES.


  • 7


I


which a sound had been passed a week before. Above this body thickened tissue could be felt — apparently a small ovary. The tuberous, cervix-like body already mentioned could be plainly defined through the walls of the lowest part of the cyst. When thus explored, it was found to be a distinct, fairly movable structure — the left ovary or uterine cornu. On further palpation through the cyst-wall the pelvic cavity felt quite free from any tumor or deposit. There certainly was no such thing as a collection of retained menstrual blood.

" At this stage of the operation it became evident that the swelling, which disappeared entirely when I opened the cavity full of fluid, was a urachal cyst. The swelling — in other words, the cyst — had been the cause of all the patient's recent trouble. As there was no trace of a hematometra or hematosalpinx, I did not feel justified in dissecting in the dark behind the cyst, amid deformed structures, in

very uncertain relations to ureters, blood-vessels, etc., merely to make out the extent of arrested development of the uterus and appendages. It was with the cyst, therefore, alone that I had to deal. I knew of several objections to the draining of a urachal cyst, nor could I dissect away its outer wall, since, as I have just observed, its positive relations to malformed structures were very uncertain. For these reasons I simply trimmed away as much of the lining membrane as could be safely removed. Then I cautiously passed several fine catgut sutures along the substance of the outer wall and tied them, so that the cyst cavity was closed in. This outer wall was the muscular sheath of the urachus abnormally thickened, so that the manceuver just described was easy and nothing was caught up behind the cyst. I transfixed the segment of the urachus, which ran between the lower limits of the cyst and the bladder, with a fine linen suture and tied it on both sides. It was then divided between the cyst and the ligature. As will be explained presently, it is fortunate that I transfixed the urachus instead of tying a single ligature around it as though it were an artery. I kept the portion attached to the cyst for microscopic examination. Lastly, the sheaths of the recti were united with interrupted fine linen sutures and the integuments closed with interrupted silkworm-gut.

"During the summer vacation Dr. Maxwell took charge of the patient in my absence. He reported that up to the day of her discharge at the end of August there was no sign of leakage of urine through the wound nor any show of blood."

Microscopic Examination of the Cord Between the Cyst and the Bladder. — A section of the cord-like structure which ran on the surface of the parietal peritoneum





Fig. 238. — Section of the Segment op Urachus which Passed Between the Bladder and the Cyst-wall, as Seen Under a Low Power. (After A. Doran.) The canal is quite unobstructed and lined with transitional epithelium; the muscular coat is very thick. (In our reproduction part of the detail has been lost — T. S. C.)


LARGE URACHAL CYSTS. 553

between the fundus of the bladder and the cyst was made at the Royal College of Surgeons of England. There could be no doubt that it was a portion of the urachus. Mr. S. G. Shattock reported that the canal was quite patulous and lined with perfect transitional epithelium of the bladder type. The lumen was free from catarrhal or other morbid products. The muscular coat was abnormally thick, but showed no evidence of inflammation or edema. Its inner portion was mostly made up of circular, and its outer portion of longitudinal, fibers, but there was some irregularity in the direction of the fibers in both portions. Some subperitoneal fat was intimately connected with the periphery of the urachus. The appended reproduction of a photomicrograph (Fig. 238) shows the above-described appearance of the urachus as seen under the microscope.

On p. 635 I have recorded another interesting case of Doran's — a cystic sarcoma of the urachus.

A Large Cyst of the Urachus. — Dossekker* reports the case of a woman, born in 1850. When forty years of age a tumor the size of a small fist was found to the right of the uterus. She had various abdominal symptoms, and finally was sent to a sanitarium. When forty-two years of age she was admitted under the care of Kronlein. She looked very pale. The abdomen was markedly distended, as with a pregnancy at the ninth month. There was, in addition, a distention at the umbilical region, with definite fluctuation. The diagnosis made was ovarian cyst, possibly from the right side, with hemorrhage into the cyst, and probably torsion of the pedicle.

Operation. — An incision was made from the umbilicus to the symphysis. As soon as the abdominal walls were cut through the knife entered a cyst cavity. The wall of the cyst was intimately attached to the abdominal wall, and a large quantity of thin, hemorrhagic fluid escaped. This was not sticky and had no odor. It amounted to between three and four liters. The tumor was gradually shelled out, with little or no hemorrhage, and the abdominal cavity proper was not opened. The cyst did not extend into the pelvis, but reached as far as the top of the bladder. At no point was the peritoneum opened. In other words, the large cyst with its contents lay between the abdominal wall and the parietal peritoneum. The patient made a splendid recovery. Examination later showed that the uterus and left ovary were normal. The right ovary could not be outlined.

Dossekker, after discussing the various points of interest, says that on histologic examination the wall was found to consist chiefly of dense connective tissue. The inner surface in most places was without any epithelial lining, but at some points this was intact. It consisted of a high, many-layered, so-called transitional epithelium. The basal nuclei were elongate or oval ; the peripheral were more roundish or flat in form. The epithelium corresponded in character to that of the bladder, and agreed with the description given by Luschka of the epithelium lining the canal of the urachus.

A Cyst of the Urachus. — On page 182 Douglasf describes the case of " Mrs. C, aged thirty-six, married eleven years, but sterile. The family and personal history is good; she has always enjoyed good health, but has never been robust. Menstruation has been scanty and painful, but regular; she has suffered with con

  • Dossekker: Klin. Beitrag zur Lehre von den Urachuscysten. Beitrage z. klin. Chir.,

1893, x, 102.

t Douglas, Richard: Trans. Amer. Assoc, of Obstet. and Gynecologists, 1897, x, 177.


554 THE UMBILICUS AND ITS DISEASES.

stipation, but the kidneys have acted freely and normally until recently. About eighteen months ago she observed a swelling in the lower portion of the abdomen, rather more prominent on the right side. The enlargement was soft and painless. It grew slowly and did not materially show until the last four months, within which time its growth has been rapid, chiefly to the right side. She has suffered from backache, some loss of flesh, slight cough, and decided digestive disorders. There has been but little pain or tenderness from the tumor, and no history indicating local peritoneal inflammation. The bladder has been somewhat disturbed, its action frequent, but the urine normal. She now complains more particularly of vomiting after eating and a sense of weight and heaviness in the epigastric region. Of late she has grown nervous and suffers from insomnia."

"Physical Examination. — -The abdomen presented a very peculiar appearance. It was symmetrically distended to about the size of a seven months' pregnancy, the greatest enlargement being on the right side; the veins were not enlarged, the skin was white and anemic-looking. By palpation the irregular swelling could be outlined. The tumor seemed to lie in the lower zone and the right half of the abdomen. It was soft, elastic, fluctuant and compressible. It was not movable; there were no irregularities or bosses upon it ; its surface was smooth; palpation was painless; the abdominal walls did not appear to glide freely over the surface of the tumor. There was dulness upon percussion over the entire tumor, yet that dulness, as was repeatedly remarked during examination, was not the characteristic flatness noted in ovarian cystoma. The dulness was absolute low down, but in the region of the umbilicus and beyond, the note became more resonant. Auscultation negative. Vaginal examination showed the uterus small, retroflexed, and rather low in the pelvis ; vaginal vault encroached upon by an elastic, fluctuant swelling. The weight of the evidence was in favor of the diagnosis of ovarian cystoma. The following peculiarities, however, were remarked upon, and were of such importance in our judgment as to render questionable the nature of the case. The appearance of the abdomen was not such as is usually noted in ovarian cystoma. While, of course, we appreciate that the shape of the abdomen varies greatly, yet in a cyst so distinctly unilocular as this appeared to be, and lying so superficially, one would expect to find the abdomen rising abruptly from the symphysis; that is, the tumor forming a distinct angle with the abdominal plane. In this case the abdomen looked more like one distended by ascitic fluid, rather flat upon the upper surface, and widely bulging upon the right flank. The next peculiar physical sign was the character of the percussion dulness.

" Operation. — An incision was made in the middle line, and in going through the linea alba and transversalis fascia I came upon the red, congested cyst-wall, which I at first thought was the peritoneum inflamed. I now aspirated the cyst and drew off 25 pints of clear fluid. An examination of the collapsed sac soon convinced me that I was not in the peritoneal cavity, and that I was dealing with a cyst of the urachus. Its attachment was not very intimate, and its enucleation was readily accomplished. Only slight hemorrhage attended its separation. As I removed the sac I recognized that I was working entirely outside of the peritoneum. The viscera could be felt through the peritoneum. The sac dipped down into the true pelvis in front of the uterus, depressing and retroflexing it. There was no apparent attachment of the sac of a ligamentous character to the bladder. Indeed, the cyst lay between the peritoneum and the transversalis fascia, with no special attachment


LARGE URACHAL CYSTS. 555

beyond a universal adhesion to all surrounding parts. The area of the peritoneum separated from the parietes extended from about three inches above the umbilicus to the symphysis, and from two inches to the left of the linea alba and through the lumbar and iliac regions of the right side. As there was no bleeding of consequence, we now prepared to close the abdominal wound. It was observed that the peritoneum sank away from the parietes, but thinking that, when the abdominal wound was closed, the force of intra-abdominal pressure would bring it in apposition with the wall, no effort was made to stitch it there. The abdominal wound was closed in the ordinary way. A good compress was applied over the abdomen, and a snuglyfitting bandage adjusted.

" The patient sustained but little shock from the operation and was placed in bed in remarkably good condition. The fluid removed measured 25 pints, was of a pale green color, and a few flocculi were observed in it. I regret to say that it was carelessly thrown away without being submitted to chemical and microscopic tests. The sac was composed of a thin, fibrous material, showing no evidence of muscular structure, and almost transparent; it was removed without tearing.

"The patient was operated upon on June 20th at 1 1 o'clock. Twenty-four hours after the operation the pulse was 136, respiration 30, temperature 99.4° F. She was nauseated and had vomited slightly; there was some epigastric distention; she had slept but little; the bowels had not moved, although active efforts were employed; the kidneys had acted sufficiently, 36 ounces of urine having been voided since the operation. The patient now became very dull, inclined to sleep, was roused only when vomiting; the vomiting was of regurgitant character, without apparent effort; the matter ejected had that ugly green color that we so much dislike to see. Her condition grew rapidly worse, the pulse became more frequent, the temperature reached 102° F. She died at 10 a. m., forty-six hours after operation.

"Autopsy. — The entire detached peritoneum on the right side was gangrenous. There was no hemorrhage, and but very little effusion between the peritoneum and wall. There was a little brown, serous effusion in the peritoneal cavity, no pus nor lymph. Death was due undoubtedly to sapremia. The detached peritoneum was not forced against the abdominal wall, as I had supposed it would be, but hung loosely, leaving quite a space between. This peritoneum was deprived of its nutrition, and had simply died from starvation."

Cysts of the Urachus.* — Ferguson says: " I do not feel, however, as has been stated by Tait, that extraperitoneal tumors in that region are all derived from the urachus. Tait's dictum was based on two cases submitted to operation, both of which resulted in death, in neither of which was there a postmortem examination, and in both of which the reported character of the cystic contents would justify the hypothesis entertained by some that cysts originating in the pelvic region may develop upward and forward in such a manner and way as to separate the peritoneum from the anterior abdominal wall, and thus become extraperitoneal. It is my conviction that I have seen at least one case of that character — one which grew to great dimensions and was cured over twenty-five years ago by excision of some of the anterior portion of the sac, and 'suture puckering' of the opening thus made, with drainage of the remainder, enucleation of the entire sac seeming too large an undertaking.

"In June, 1898, the patient, a man aged about forty-seven years, was brought to

  • Ferguson, E. D.: Phil. Med. Jour., 1899, iii, 830.


556 THE UMBILICUS AND ITS DISEASES.

my office by Dr. M. B. Hutton, of Valley Falls, New York. He had lost notably in flesh and strength, though he was not anemic. He was inconvenienced by frequent urination, and complained of considerable pain in the lower portion of the abdomen. Dr. Hutton had satisfied himself that notable abdominal enlargement had been developing lately, which he ascribed to a tumor in the hypogastric region. The first recognition of the tumor was about a month earlier, but the first sense or discomfort was felt in July, 1897, nearly a year before the discovery of the tumor.

"On examination a flat tumor was found extending from the pubes to about two inches above the umbilicus, and from near each anterior superior spine of the ilium to its opposite fellow. The upper border was slightly irregular near the umbilical region, but elsewhere the contour was quite regular. The sense of resistance was that of a very firm, solid tumor, and at no point could fluctuation or diminished hardness be found. There was, however, a sense of nearness of the mass to the surface, which led me to state that it seemed to me to be in the abdominal wall, but its flattened shape and hardness, together with some irregularity of the upper border, led me to conclude that it was probabry a malignant disease of the omentum. Though such a growth as a primary trouble must be exceedingly rare, the shape and hardness led me to that working hypothesis, while the freedom from evidence of bowel involvement, and the yet moderate constitutional effects, led me to advise an exploratory operation, the final decision as to what could and should be done with the mass being left to a consideration of the conditions found on section.

"I heard nothing further of the patient until in July, when his increasing size and discomfort led him to accept my somewhat gloomy, or at least to him unsatisfactory, view of his case, and he decided to submit to an operation. Of course, the absence of renal or other contraindication had been established. The operation was undertaken July 26, 1898, and the first surprise occurred when, on moving the antiseptic dressing after he was under the anesthesia, I found the mass to be then of a globular form. To this was added a great diminution in the sense of resistance and a manifest fluctuation, showing the cystic character of the tumor. This change in the tumor was undoubtedly due to the relaxation produced by the anesthetic in recti muscles of unusual development. My first impression now was that I was dealing with a distended bladder, for the sac evidently extended into the pelvis and seemed more remote than formerly. Having satisfied myself that it was not a distended bladder, I proceeded with the operation until I came to the wall of the cyst just under the deep fascia of the abdominal wall. At this juncture the nature of the case flashed upon me, and I was able to state to those present that we were dealing with a cyst of the urachus. This conclusion was strengthened by the water-like appearance of the fluid which was removed by an exploring syringe. It being apparent that the lower portion of the cyst extended deeply into the pelvis and was probably intimately associated with the bladder-wall, a condition that would explain the frequent urination, I exposed the wall of the cyst before opening it, from as near the umbilicus as the mergence of structures would allow, to near the pubes. This I did in order to further a plan which I had quickly formed for the management of the case. In the first place, I had determined not to try to finieleate the entire cyst, bu1 to remove the posterior portion with the underlying peritoneum so far as I could, and allow the reclosure of the peritoneum, dealing with the remainder according to circumstances. Such a procedure would require free access to the deep portions of the cyst, hence my long incision. The cyst was


LARGE URACHAL CYSTS. 557

then opened the entire extent of the overlying incision, and an unknown quantity of water-like fluid escaped. The quantity, from absence of convenience for collection (the operation occurring in a private house), could only be estimated, but it was evidently more than two quarts, and probably less than four quarts.

"It was now practicable to investigate the relation of the wall of the cyst to contiguous parts; it was found to be intimately related to the bladder over a considerable extent of the surface of that organ, for it extended deeply into the pelvis. The posterior wall of the cyst was free from evidence of adhesion or other connection with the abdominal organs, and I was about to excise that portion of the sac when it occurred to me to ascertain whether the inner and secreting layer could be removed, thereby securing a surface which would unite. Beginning at the inner edge of my incision in the wall of the sac, and near the lower end of the opening of the belly, I was surprised and gratified to find that a layer of tissue, so thin as to be diaphanous in moderate light, and so strong as to allow of considerable traction without tearing, could be removed without much trouble and with practically no hemorrhage. In that manner the entire lining of the cyst was removed except at the umbilical region, where quite a surface existed, in which digitations penetrated the abdominal wall, and a blending of the tissues prevented the removal of the lining. This surface seemed rather large for complete excision with subsequent easy closure of the belly at that point, hence it was allowed to remain while attention was given to the denuded portion of the cyst. A single deep skin suture was placed to divide the unclosed umbilical area from the subcutaneous suturing below that point. Some iodoform gauze was then placed in the pocket left at the umbilicus, where the lining layer could not be removed, and the whole was sealed with a collodion seal, except over the gauze packing, with the request that it be left for several days unless indications arose showing inflammatory processes.

"It had closed in September, and the area showed in December a perfectly normal state of affairs aside from the scar at the umbilicus."

Cyst of the Urachus.* — The patient from whom this specimen was obtained was admitted to the Cook County Hospital February 27, 1895. He was a man fifty-two years of age, white, and single. He was admitted for an illness which had begun four weeks previously, with frequent micturition and pain in the region of the kidneys. Examination revealed an enlarged prostate. He had symptoms of cystitis with retention of urine. Hydronephrosis was present, and uremia ensued. He died on April 9th.

Autopsy Abstract. — " The bladder is large, with markedly thickened walls. Each lateral lobe of the prostate is the size of an English walnut. At the summit of the bladder, and separated from the bladder cavity by a thin membrane, is a cyst, the size of an average orange. It contains a thick, turbid, viscid, brownish fluid. The lining of the cyst presents an irregular surface, but there are no distinct rugae. The irregularities of the cyst lining are present on the upper surface of the interveningseptum, between it and the bladder cavity. The rugae of the bladder are continued upon its inferior surface. The ureters are dilated, as are also the pelves of both kidneys. Careful dissection fails to reveal further urachus remains in the abdominal wall or about the navel. Microscopic examination of the septum between cyst and bladder cavities disclosed the fact that the muscular coats of the bladder-wall were

  • Le Count, E. R.: Transactions of the Chicago Pathological Society, Dec, 1895, to April,

1897, ii, 215.


558


THE UMBILICUS AXD ITS DISEASES.


not continued into the septum. This fact, taken in conjunction with the position of the cyst and the fact that the peritoneum of the abdominal wall was reflected upon the back of the cyst, and thence upon the back of the bladder, leaves no doubt that the cyst represents the obliterated and dilated lower end of the urachus."

An Enormous Cyst of the Urachus.* — - The following case is cited on account of some unusual features, and because it should be added to the list reviewed by W. R. Weiser in a most interesting and instructive article published in the Annals of Surgery for October. 1906.

Miss . aged forty. History of slowly growing abdominal tumor, beginning

in the region of the bladder and growing upward, with gradual onset of pressure symptoms, especially difficult respiration, pain, and impaired digestion. The abdomen was enormously distended, but not tender, nor did it bulge much in the flanks. It was rather firm, and was flat on percussion from the pubes to the ensifonn cartilage. Its appearance is well shown in Fig. 239.



Fig. 239. — The Abdominal Contour in a Case of Vest Large D


After T. L. Macdonald.)


"Operation (October 6. 1907). — Through the usual incision the cyst-wall was perforated and the fluid drawn off. Two-thirds came away clear: the remainder was turbid, and. lastly, thick, cheesy masses were wiped out. Investigation of the inside of the sac disclosed several thick, nodular masses which were strikingly carcinomatous in character. So far. the peritoneal cavity had not been opened, the sac being situated in front of it. The task of separating the cyst-wall from the peritoneum and viscera was begun by first stripping and cutting it from the epigastric region and from beneath the ribs, and here the peritoneal cavity was opened. It was hoped that from this point downward the dissection would be less difficult, but it was more so. The anterior surface of the peritoneum seemed to be fused with the sac, and the posterior with the viscera generally: and the character of the adhesions was the most dense ever encountered by the writer. These were followed deeply into the pelvis, in all directions, and freed: and finally the firm, fibrous

  • Macdonald, T. L.: Ann. Surg:.. July-December, 1907, xlvi. 230.


LARGE URACHAL CYSTS.


559


attachment to the bladder was severed and the sac removed. The appendix, six inches in length, bright red, and surrounded by adhesions, was also removed. The abdomen now presented a most unusual sight. With the exception of the anterior surface of the stomach, not a vestige of normal peritoneum was visible. All the abdominal contents, including tubes, ovaries, uterus, and bladder, could be seen outlined through the thin, raw film of peritoneum to which they were firmly attached. The abdominal cavity was filled with normal salt solution and closed with three layers of buried absorbable sutures without drainage.

"Fig. 240 shows some of the nodular masses. There are others on the opposite side. These were on the inner surface of the sac, which was photographed in this way. The cyst was turned inside out, and through the incision, which had served for the evacuation of the contents, a large, thin, collapsed rubber punching bag was thrust, then inflated, thus distending the sac for photographic purposes.

"The report of our hospital pathologist, Dr. Birdsall, shows the cyst-wall to be fibrous, and the nodular masses, which, during operation we feared were carcinomatous, were papillomata. Of course, in a cyst of this size, which had been growing presumably for forty years, and subjected to the ever-increasing pressure of the accumulating fluid, we could not expect to find the normal histologic features of the urachus. Naturally, all except the fibrous structures would disappear by pressure absorption ; even bone has been known to do the same.

"Postoperative Course. — The patient's condition was critical for the two following days, active stimulation and intravenous saline infusion being demanded. The wound healed by primary union. The bowels were loose. The temperature ranged from 101° to 102° F. Daily palpation of the abdomen revealed fluctuation, and the percussion-note

was flat, showing that the salt solution was not being absorbed. On the seventh day a chill occurred, followed by a rise in temperature to 104° F. Assuming that the unabsorbed solution had become infected through the raw surface of the intestines, the lower end of the now healed wound was cocainized and cut through, allowing the escape of quarts of the salt solution, which had become purulent, and which presented the colon bacillus characteristics. This was followed by prompt improvement. Drainage and irrigation were continued for a week, after which the wound closed and convalescence and return to health were satisfactory.

"Comments. — The density of the adhesions cannot be appreciated unless encountered. It is true, incision, evacuation, and drainage would probably have been successful after a long period of waiting for the cavity to undergo obliteration. The assumption, however, that portions of the sac had become carcinomatous made extirpation seem imperative.

"Extirpation is evidently not commonly resorted to. Among the 86 cases re


Fig. 240. — A Urachal Cyst Turned Inside Oct and Showing Papillary Masses, Particularly in the Lower Part of the Picture. (After T. L. Macdonald.)


560 THE UMBILICUS AXD ITS DISEASES.

viewed by Dr. Weisef, only eight were extirpated. Xone of these was said to be large, and with one or more the history and result were lacking."

Dilated Urachus Treated by Incision and Drainage.* -The patient. W. J. P.. was a man aged fifty-four who consulted Dr. Pratt on June 8. 1889. complaining of pain and distention in the abdomen and increasing general weakness. He had been quite well until the previous November, when he complained of pain in the lower part of the abdomen. He remained in bed for three weeks and in the house for four months. He could not account for the onset of the trouble in any way. There had been no blow, no lifting of heavy weights, nor straining of any kind. His occupation was that of a store-keeper and clerk near Xew York, where he had lived for many years. He had had a gonorrheal infection when twenty-one. but had never had symptoms of syphilis. He had led a very intemperate life until seven or eight years previously. Since then he had been a moderate drinker. On examination the abdomen was found to be much distended in the lower half and in front : the distended area was dull on percussion and reached as high as three fmgerbreadths above the umbilicus. The pain extended as far as the pubes. laterally, on either side, as far as vertical lines drawn through the anterior superior iliac spines. He had no trouble with micturition or defecation. The urine appeared to be normal. The prostate was not enlarged, but there was a fulness of the left side of the pelvis.

On June 15. 1889. the tumor was aspirated and about one dram of a gummy, semitransparent fluid, which blocked the tube was withdrawn. It contained only a trace of albumin, but a large quantity of mucin, as shown by the precipitate it gave with acetic acid. Microscopically it showed many leukocytes.

On July 9th Mr. Bond made a four-inch median incision midway between the umbilicus and the pubes. After division of the linea alba a very thick membrane was reached, resembling a peritoneum much thickened by tubercular peritonitis. It proved, however, to be the outer wall of the cyst. It was divided, and a very large quantity of a ropy, gummy, semisolid material came away, of which over a gallon was measured. This had the appearance and consistence of semi-decolorized fibrin, was partly squeezed and partly drawn out in stringy layers. A considerable quantity was left in the cavity, as any attempt to sponge it off the inner surface of the cyst-wall left a red. raw surface which bled freely. On exploration of the cavity with the hand and arm it was found to extend upward to and beneath the liver and downward into the pelvis. The intestines could be made out behind and at the sides of the cyst, though shut off and separated from it. The peritoneal cavity was not opened. A Keith drainage-tube was placed in the wound, and reached to the floor of the pelvis. The rest of the incision was closed.

Chemical examination showed that there was only a trace of albumin, that the fluid was practically mucus and fibrin, with a large predominance of the former. Microscopic examination showed mucus-corpuscles and blood.

The cyst-walls shrank, and the patient gradually improved. In December 1889, on his departure for America, he seemed to be in good health, could walk nine miles at a stretch, and his appetite was excellent. There still remained, however, an irregular shaped cavity with thickened walls capable of holding half a pint of fluid. Mucoid material was secreted daily. The discharge, however, was not fetid and did not seem to in any way depress his health. In a letter dated February

  • Pratt. R.. and Bond. C. J.: The Lancet. 1890, i, 898.


LARGE URACHAL CYSTS. 561

27, 1890, the patient said that the wound was still kept open by a glass tube, and that there was a discharge of clear, watery fluid, with very little of the jelly-like material. The man was in excellent health and was working thirteen hours a day.

A True Urachal Cyst. — Von Recklinghausen* demonstrated a cyst, about the size of a walnut, which had been removed from a man thirty years of age. The cyst varied from 1 to 3 cm. in diameter, and contained tenacious, colorless mucus. It was situated directly at the top of the bladder, with which it was intimately connected. It lay in the median line in the subperitoneal adipose tissue, and was completely cut off from the bladder. It was polycystic. There was a main cavity with many bays running off from it, and in addition to this there was a small cystic mass which was attached to the bladder, and which contained a labyrinth of microscopic spaces looking like gland loops, or, at any rate, like dilated crypts. The dense connective-tissue walls were nearly everywhere covered over with bundles of smooth muscle-fibers. The epithelium was several (or usually two) layers in thickness, and was definitely squamous in type. Here and there in the crypts were abundant numbers of goblet-cells. On account of the presence of goblet-cells it was necessary to consider the possibility of an enterocystoma; in other words, a derivative from the omphalomesenteric duct. But von Recklinghausen said that this could be excluded, because the tumor was entirely extraperitoneal and because it was in no way connected with the peritoneum.

Cyst of the Urachus. — Reedf cites a case (his Fig. 321) in which the sac had extended from near the ensif orm cartilage to the pubes and forced the viscera from their normal positions. The cyst was enucleated without any opening into the peritoneal cavity. He gives a schematic picture of the condition. Microscopic details are lacking.

Probably a Urachal Cyst.t — This case was also reported by Freer. A divinity student had from infancy been remarkable for his large abdomen, which had made him an object of ridicule to his companions. Thinking adipose tissue to be the cause, he had tried to reduce it by fasting, but without avail. It caused him no trouble until his twenty-fourth year, when a marked increase in size took place. This seriously impeded his respiration and led to an examination, which revealed fluctuation in and around the umbilical region. The dyspnea having increased to such a degree that relief became imperative, a puncture was made and a considerable. quantity of reddish-yellow fluid escaped. The procedure was followed by vomiting and intense abdominal pain. The puncture afforded him some relief, and with the exception of occasional fainting spells, his health remained good for a period of two years, after which his abdomen again commenced to increase in size, the dyspnea returned, and his general appearance became cachectic. He again entered the hospital and six liters of bloody fluid were withdrawn. The operation was repeated three times during the ensuing nine months — the remainder of his life. The amounts of fluid were 18^, 17, and 6 liters respectively. At his death he weighed about 192 pounds. At autopsy the contents of the cyst were found to amount to 50 liters, which weighed about 100 pounds. The cyst fluid contained

  • Von Recklinghausen: Eine richtige TJrachuscyste. Deutsche med. Wochenschr., 1902,

xxviii, Vereinsbeilage, 266.

t Reed, Charles A. L.: A Text-Book of Gynecology, 1901, 805.

i Rippmann, G. : Eine serose Cyste in der Bauchhohle, mit einem Inhalt von 50 Liter Fliissigkeit. Deutsche Klinik, 1870, xxii, 267. 37


562 THE UMBILICUS AND ITS DISEASES.

cholesterin crystals, flat epithelium, and fat-droplets. A minute examination of the cyst-wall showed it to consist of three layers, the external being a serous coat. This rested on a layer composed of elastic and fibrous tissue, and the interior was lined with pavement epithelium. The bladder contained a little yellowish urine. It was contracted, and its lining mucous membrane was pale. The urachus was found closed at the bladder end. In its course toward the umbilicus below the commencement of the large cyst, a small cyst was situated near the umbilicus. The fibrous tissue passed into the subperitoneal coat of the larger cyst, which occupied almost the whole abdominal cavity, but the cyst was absolutely independent of the abdominal cavity and the abdominal organs were normal.

Probably a Urachal Cyst. — Schaad's* patient was a married woman thirty-two years of age. Nothing was known about the condition of the umbilicus at birth. She had had two normal labors. At the last labor a tumor had been noted below the umbilicus. The patient was supposed to have had a severe inflammation of the bowels seven years before. Several fingerbreadths below the umbilicus could be felt an elastic tumor the size of a child's head. It could be sharply outlined and pushed in all directions.

A cyst the size of a five-franc piece was found situated about two fingerbreadths below the umbilicus, and attached to the abdominal wall in the mid-line. It was separated from the peritoneum and drawn out of the abdomen. The omentum was tied off; the cyst was found adherent to the appendix. The left ovary was hard and atrophic; the right ovary was normal. The patient recovered.

The cyst was oval in form, and measured 7.5 x 6 x 4.5 cm. The walls varied from 2 to 4 mm. in thickness. The outer surface was fairly smooth, except where it was adherent. The inner surface resembled mucosa and was light yellow in color, with dark spots. On the right side of the cyst was a secondary cyst opening into the larger one. The opening was the size of a pin-head. The inner surface of this second cyst was smooth and yellow; its walls were 1 mm. thick. The large cyst contained about 200 c.c. of a chocolate-colored, cloudy, tenacious fluid, showing much cholesterin, detritus, fat-droplets, etc. The contents of the small cyst were similar in character, but thicker. The wall of the large cyst consisted of connective tissue and large quantities of smooth muscle arranged in bundles. These ran in all directions. The inner surface was lined with high cylindric epithelium; there were also glands opening upon the surface. In places the epithelium and glands were absent. The small cyst was lined with granulation tissue, in which were encountered giant-cells, some containing as many as 20 or 30 nuclei, arranged at the margin or irregularly scattered or in the center. [These are suggestive of foreign-body giant-cells.] Schaad felt sure that he was dealing with an omphalomesenteric duct, a portion of which had remained open, with a resulting retention cyst. [From the cases followed in the literature the case strongly suggests a urachal cyst. The question, however, is an open one. — T. S. C]

A C y s t i c Urachus. — Scholzf reports the case of a sixteen-year-old girl who complained of difficulty in micturition and a painful tumor in the abdomen. The abdomen was prominent, the largest measurement being between the umbilicus and symphysis. The tumor was very painful. On both sides there was tympany.

  • Schaad, T.: Ueber die Exstirpation einer Cyste des Dotterganges. Correspondenzbl.

f. Schweizer Aerate, 1886, xvi, 345.

fScholz: Wien. med. Wbchenschr., 187S, xxviii, 1327.


LARGE URACHAL CYSTS. 563

After a time an opening, about the size of a hair, developed at the umbilicus, and fluid escaped from it. The opening was dilated and about 300 c.c. of colorless, transparent, thick, tenacious fluid escaped, and finally a thick yellow pus. The wound closed in the course of two months.

A Large Urachal Cyst.* — Case 1. — "This case was sent to me by Dr. Lamb, of Albrighton. She had complained of abdominal pain and tenderness, and in October, 1880, she began to suffer from somewhat serious symptoms, more particularly frequent vomiting and disinclination to take solid food. Some swelling in the lower part of the abdomen was noticed about the same time, this being then regarded as ascitic. The symptoms slowly increased in severity until February 11, 1881, when a consultation was held between Drs. Lamb, Heslop, and Saundby. As a result of this consultation she was tapped, and 10 pints of fluid were removed, although this was by no means the amount of fluid in the cavity, because large masses of flocculi obstructed the tube of the trocar and prevented the complete emptying of the cyst. Some of this fluid was submitted to me for an opinion, and from the fact that it was brown and thick and gave an abundant flaky yellow deposit, which consisted chiefly of pus, I unhesitatingly gave the opinion that it was not ascitic, but a fluid that must have been contained in some cyst cavit3 T , probably a cyst of the parovarium. I saw her on February 13th, when we found that the abdomen was quite as much distended as before the tapping. I therefore proposed an exploratory incision for the removal of the tumor, if it were possible to remove it, although the extremely exhausted condition of the patient gave no very great prospect of success. It was perfectly clear, however, that if let alone nothing but death could be the result, and therefore an operation was accepted by her attendants and relatives.

" I opened the abdomen at the usual site, and after cutting through all the layers except the peritoneum I came upon the cyst-wall. I opened the cyst and removed about 30 pints of fluid, exactly the same as that which had been removed at the tapping; and mixed up with it I found large masses of the fibrinous deposit, which accounted for the failure of the tapping to remove the whole of the fluid. I then proceeded to remove the enormous cyst, which was uniformly attached to the parietal wall on its outer aspect, and to the outer surface of the thickened peritoneum on its posterior aspect. The cyst did not dip into the pelvis at all, and the anterior parietal peritoneum did not reach the wall lower than the ensiform cartilage. The intestines and the pelvic organs could be felt through the anterior peritoneal fold, non-adherent, and, as far as could be determined, perfectly healthy. The cyst lay, therefore, entirely between the transversalis fascia on the outer side and the parietal peritoneum on the inner, the peritoneal cavity having been nowhere opened during the severe and protracted operation. The cyst was removed in its entirety, and its inner surface consisted of broken-down mucoid epithelium, infiltrated everywhere with pus, lying upon the basement membrane, wmich consisted almost entirely of muscular fibers.

"The conclusion concerning the nature of this cyst, at which I have arrived, is that it was developed from the urachus, a part of which had been occluded at both ends, but during the developmental changes of embryonic and infantile existence had not become obliterated. I entirely fail to see any other possible origin for it, and, if my explanation be correct, it is very marvelous that this structure should have re

  • Tait, Lawson: Twelve Cases of Extraperitoneal Cysts. Brit. Gyn. Jour., 1886-87, ii, 32S.


564 THE UMBILICUS AND ITS DISEASES.

mained quiescent for fifty-six years and then should suddenly undergo an inflammatory change which developed it into this enormous cyst. The patient went on very well for three days, and then rapidly sank from exhaustion. No postmortem examination was allowed, and therefore I can shed no further light upon it; and, as far as I know, the observation is unique, although it is perfectly well known, as I myself have repeatedly had occasion to observe, that small cysts of the urachus are opened in abdominal section. I do not know that any such cyst has previously been met with sufficiently large to be of pathologic importance. It was noted and published at the time that the basement membrane of this cyst consisted almost entirely of muscular fiber, an observation which is absolutely concurrent with the examination of the cyst in Case X, made by Mr. Bland-Sutton."

Probably a Large Urachal Cyst.* — Case XI. — -"This case was sent to me by Dr. T. S. Bourne, of Kenilworth, as a case of acute inflammatory disease of the abdomen, of which he said: "I find it impossible to make an exact diagnosis." When I saw her I found her with a high pulse and temperature, and abdomen distended with a large quantity of free fluid. My opinion, expressed at the time, was that it was a case of tubercular peritonitis. I made the usual section, and found it another of these cases of congenital cysts belonging to the category of the cases already described in numbers IV, V, VI, VII, VIII, IX, and X. I removed a small piece of the cyst-wall for examination, and the reports of the microscopic examination by Dr. Arthur Johnstone and Mr. J. Bland-Sutton of Cases X and XI are annexed. I used the circular drainage method, and the patient has completely recovered. The following is Mr. Bland-Sutton's report:

"Sections of the cyst-wall exhibited under the microscope a mixture of fibrous and non-striated muscle tissue arranged in fasciculi, closely corresponding to the disposition of the bundles of tissue which make up the walls of the urinary bladderScattered throughout the whole thickness of the sections were small calcareous nodules. It was difficult to make out any definite epithelial investment to the sections, but on scraping the smooth surface of the specimen with a cover-glass, the field of the microscope became crowded with flattened, rounded, and pyriform cells, similar to those found lining the interior of the urinary bladder, only very much smaller.

"As the urachus is lined with epithelium agreeing in shape, and continuous with that found in the interior of the bladder, the evidence that these cysts are allantoic seems to me to be complete (J. Blancl-Sutton)."

[Tait cites a considerable amount of literature and discusses other cases at length. It is very difficult to tell in the majority of these cases whether he was right in his assumption or not. His entire paper, however, is a very interesting one.— T. S. C]

A Urachal Cyst. — Wolff | reports two cases which came under his observation in the clinic in Marburg in 1872, and which, according to his view, were urachal cysts. I shall here report only Wolff's Case I.

Mrs. K., aged thirty-one, was always healthy in childhood. Two years before her admission she noticed a tumor in the left side of the lower abdomen. This gradually increased. In March, 1872, there was a pregnancy which terminated nor

  • Tait, Lawson: Loc. cit., Case xi.

f Wolff, C. C: Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873.


LARGE URACHAL CYSTS. 565

mally, but was followed by an acute fever, with severe pain in the left part of the abdomen. The abdomen suddenly reached enormous proportions in a few days. The patient was treated by her physician for peritonitis. Convalescence was slow, but the patient again became quite strong. On palpation of the abdomen, a tense, elastic, fluctuant, rounded tumor could be felt. This filled the entire left side of the lower abdomen, and extended over to the right a handbreadth beyond the linea alba. Upward it reached beyond the umbilicus. The tumor could not be pushed from side to side. It had a smooth surface, and apparently consisted of one mass. A median incision was made, but the peritoneum did not become visible. After careful dissection the cyst was opened and yellowish, serum-like fluid escaped. The patient was laid on her side and the contents of the cyst gradually flowed out. After 5 liters of fluid had been removed in this way, the tumor was gradually loosened. The peritoneum was thickened, evidently as a result of inflammation. In the inner part of the cyst were large, lumpy coagula of fibrin. The connection of the cyst with the peritoneum was in part firm and in part very loose. The tumor was shelled out without difficulty. It was possible to do the operation almo.st entirely extraperitoneally; only at one point was the peritoneum opened for a distance of 1 cm. This was closed with silk. The patient made a good recovery.

The cyst was egg-shaped. Its largest circumference was 63 cm. When flattened out it was 31 cm. in breadth. The cyst-walls varied from 1 to 3 or 4 mm. in thickness. The outer surface was rough, with numerous string-like processes which indicated where the adhesions to the peritoneum had been cut. It had a poor blood-supply. The cyst-wall had a tough consistence. The interior of the cyst was smooth, like a serous wall. It had over its surface fibrinous deposits. According to Lieberkuhn, who made the histologic examination, the cyst-wall consisted of fine connective tissue with fibers running in various directions; here and there were non-striated muscle-fibers. A definite epithelium was not detected on the inner surface. The fluid consisted of large granular masses of detritus and pus-cells.


LITERATURE CONSULTED ON LARGE NON-INFECTED URACHAL CYSTS. Atlee, W. L.: Ovarian Tumors, Lippincott, Philadelphia, 1873, 50. Baldwin: Large Cyst of the Urachus. Surg., Gyn., and Obst., 1912, xiv, 636. Bantock: See Tait's article.

Bryant, T.: Discussion on Doran's paper, Brit. Med. Jour., 1898, i, 1390. Carroll, J. W.: Cystic Urachus. Buffalo Med. Jour., 1895-96, xxxv, 869. Cotte et Delore: Gros kyste de l'ouraque. Lyon med., 1905, cv, 373. Doran, A. H. G.: Urachal Cyst Simulating Appendicular Abscess; Arrested Development of

Genital Tract; with Notes on Recently Reported Cases of Urachal Cysts. The Lancet,

1909, i, 1304. Dossekker: Klin. Beitr. z. Lehre von den Urachuscysten. Beitrage z. klin. Chir., 1893, x, 102. Douglas, R.: Cysts of the Urachus. Trans. Amer. Assoc, of Obstet. and Gynecologists, 1897,

x, 177. Ferguson, E. D.: Cysts of the Urachus. Phila. Med. Jour., 1899, hi, 830. Ill, E. J.: Tumors of the Urachus. Trans. Amer. Assoc, of Obstet. and Gynecologists, 1892, v,

238.— Amer. Jour. Obstr., 1897, xxxvi, 568. Le Count, E. R. : Cyst of Urachus. Trans. Chicago Path. Soc, Dec, 1895, to April, 1897, ii, 215. Macdonald, T. L.: An Enormous Cyst of the Urachus. Annals of Surg., July-December, 1907,

xlvi, 230. Pratt and Bond: Dilated Urachus Treated by Incision and Drainage. The Lancet, 1890, i,


566 THE UMBILICUS AND ITS DISEASES.

Von Recklinghausen: Eine richtige Urachuscyste. Deutsche med. Wochenschr., 1902, xxviii,

Vereinsbeilage, 266. Reed, C. A. L. : Cyst of the Urachus. A Text-Book of Gynecology, 1901, 805. Rippmann, G.: Eine serose Cyste in der Bauchhohle, mit einem Inhalt von 50 Liter Fliissigkeit.

Deutsche Klinik, 1870, xxii, 267. Schaad, T.: Ueber die Exstirpation einer Cyste des Dotterganges. Correspondenzbl. f. Schweizer

Aerzte, 1S86, xvi, 345. Scholz: Cystis urachi. Bericht des k. k. Allg. Krankenhauses, Wien, 1877 (quoted by Wutz) . Tait, L.: Twelve Cases of Extraperitoneal Cysts. Brit. Gyn. Jour., 1886-87, ii, 328. Weiser, W. R.: Cysts of the Urachus. Annals of Surg., 1908, xliv, 529. Wolff, C. G: Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873. Wutz, J. B.: Ueber Urachus und Urachuscysten. Virchows Arch., 1883, xcii, 387.


CHAPTER XXXIII.

ABSCESSES IN THE ANTERIOR ABDOMINAL WALL BETWEEN THE

UMBILICUS AND SYMPHYSIS DUE TO INFECTION OF URACHAL

REMAINS OR OF URACHAL CYSTS.

Report of a personal observation. Clinical course. Treatment.

Cases of abscess of the abdominal wall due to infection of remains of the urachus, and not communicating with the bladder.

My attention was particularly drawn to this group of cases in 1910 when Dr. L. Gibbons Smart, of Lutherville, Md., askecl me to see a boy, aged fifteen, who was complaining of a hard mass extending from the symphysis to the umbilicus in the mid-line. There was no history of abdominal injury.

Seven weeks before, the patient had begun to suffer with severe pain in the lower abdomen. On making an examination he had noted that it was very hard to the touch, but not tender. His pain had been constant during one day, and then had disappeared, only to recur every few days and last a day or two at a time. Sometimes the pain in the mid-line had disappeared; on other occasions it had been referred to the right or left side. He did not remember having had chills or fever until two weeks before entering the hospital, when he had had a chill, followed by an elevation of temperature. After this there had been several chills.

He had had no increased pain when voiding and had never passed any urine from the umbilicus, nor had he any umbilical discharge. He said he remembered having had a few night-sweats.

His appetite for the last eight weeks had been very poor, following a period of several months when he seemed unable to satisfy his craving for food.

The patient was a well-developed and healthy looking youth. He said that at the time he first noticed the condition his abdomen was just as hard as it was on the day that he entered the hospital, seven weeks later. His bowels were usually constipated ; his urine was normal.

Operation. — Church Home and Infirmary, June 11, 1910. Under anesthesia it was noted that the umbilicus was more prominent than usual, and that it welled out on both sides (Fig. 241) . The hardness in the abdominal wall also became much more evident when the patient was asleep. I made an incision commencing just below the umbilicus and extending to the symphysis. After separating the recti we found that the tumor lay extraperitoneally. It was exceedingly hard, and almost as dense as cartilage. An incision having been carefully made through this hard tissue, we encountered a sac, somewhat irregular in form, and filled with brownish, grumous contents amounting to about 50 c.c. The cavity was carefully scraped out. A portion of the thickened wall was removed for examination, and the cavity packed with iodoform gauze. The patient made a complete recovery.

Histologic examination of the tissue showed newly formed connective tissue, but without any evidence of an epithelial lining.

567


568


THE UMBILICUS AND ITS DISEASES.


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Fig. 241. — Infected Urachal Remains. The umbilicus is prominent and wells out. The recti muscles have been retracted, exposing a hard, indurated mass. Its walls were exceedingly dense, in places fully 2 cm. thick, and as hard as gristle. The cavity was irregular i r. i. iii line and contained about 50 c.c. of brownish, grumous contents. On histologic examination the walls of the mass were found to be composed of dense fibrous tissue and the cavity was lined with granulation tissue. No attempt was made to remove the mass. The cavity was wiped out and packed, and in a few weeks the mass had literally melted away, leaving a perfectly soft abdominal wall. The patient at the present time (March 1, 1916) is perfectly well.


URACHAL INFECTIONS. 569

The patient has since remained absolutely well. In this case the situation of the tumor left little or no doubt that we were dealing with remains of the urachus which had undergone a low grade of infection. The rapidity with which the inflammatory tissue literally melted away after drainage was established was remarkable.

CLINICAL COURSE.

One of the first symptoms is a feeling of pain or discomfort in the lower abdomen. As the process advances, the pain may be intermittent in character, as noted in my case, or sudden and violent, as experienced in Page's case. Arrou's patient, a soldier, had such abdominal discomfort that, when on the march, he walked with his body bent forward. Vaussy's patient experienced great abdominal pain, which was intensified on inspiration.

A moderate degree of fever was noted in Arrou's, Page's, Vaussy's cases, and in Weiser's Case I. My patient also had some fever and also night-sweats.

As often happens when pus is forming, some patients had a loss of appetite. Page's patient -was nauseated, and Baldwin's suffered a good deal from vomiting. Page's patient had diarrhea, and in Hornig's case there was loss of weight. Vaussy's . patient was markedly depressed. In those cases in which the posterior surface of the abscess causes an inflammation of the peritoneum the constitutional symptoms will be more marked.

From Weiser's Case II we get a graphic picture of the alarming symptoms that may develop: "On admission her temperature was 101.2° F., pulse 172, respirations, 30. The child was pale and emaciated, and had a dry tongue and an anxious expression. She complained bitterly of abdominal pain, and the entire abdomen was tender, especially so about the umbilicus, and the entire abdomen was greatly distended and board-like. A positive diagnosis was not made prior to operation, but tubercular peritonitis and suppurative urachal cyst were both considered."

There are, as a rule, no bladder symptoms. In Van Hook's sixmonths-old patient, however, the urine was quite turbid. In Weiser's seventyfive-year-old woman there had been frequent micturition for a month prior to operation. This absence of vesical symptoms stands out in sharp contrast to what occurs in those cases in which the urachal enlargements have a direct connection with the bladder. In the latter, vesical symptoms are the rule.

On examination of the abdomen it is often possible to detect a board -like induration between the umbilicus and symphysis. If the abdominal walls are particularly lax, one may be able to grasp the tumor in the hand and move it from side to side. As a rule, however, this is possible only when the patient is asleep and the recti muscles are relaxed.

As a rule, the abdominal skin looks perfectly normal. In Van Hook's case, however, the umbilicus had a red, inflamed appearance, and thin pus trickled from a small opening in the lower umbilical fold when pressure was made on the tumor. The right inguinal glands were enlarged.

In Weiser's Case II the umbilicus was surrounded by a zone of redness, where the abscess was ulcerating toward the surface. In Weiser's seventy-five-year-old woman there was a copious discharge of pus from the umbilicus, which had existed for fifteen years.


570


THE UMBILICUS AND ITS DISEASES.


Although the abscess usually opens at the weakest point, viz., the umbilicus, nevertheless, in rare instances, a fistulous opening may develop in the mid-line between the umbilicus and bladder, as indicated in Fig. 242.

The Abscess Sac. — The abscess walls are usually densely adherent to the recti in front and to the peritoneum behind. They vary much in thickness, some reaching in places almost 2 cm. The inner surface of the sac is usually smooth and velvety, resembling an ordinary abscess sac. The contents of the sac vary considerably. Sometimes they consist of ordinary pus; this, in Vaussy's case and also in Weiser's seventy-five-year-old woman, was very fetid. The fluid

may, however, be yellowish red, yellowish brown, or brownish in color, and be grumous or ropy in character and contain necrotic material, which Baldwin and Doran said reminded them of "disintegrating omentum."

From a careful consideration of these cases it seems to me that yellowish or brownish contents are found in those in which a very low and slumbering grade of infection has existed, the typical pus being found in the more acute inflammations.

In Arrou's case a calculus the size of an olive was found in the sac. It looked like a piece of incompletely dried mortar.

Weiser's seventy - five - year - old woman had in the abscess sac a calculus that weighed 70 grains. As noted from his personal communication to me, it was hard, had a dark-brown surface, and on section resembled a bladderstone in color and appearance.

On histologic examination the walls of the sac are found composed in a large measure of dense inflammatory tissue. In places some non-striped muscle may still be detected; all trace of transitional epithelium is usually lost, but it may occasionally be recognized in the contents of the abscess. For abscesses developing in the subumbilical space the reader is referred to the investigations of Fischer, given in detail on p. 263.



Fig. 242. — A>r Infected Urachus Opening Between the Umbilicus and Bladder. (Schematic.) When a urachal infection opens, it is usually either at the umbilicus or bladder; occasionally, however, it perforates the abdominal wall below the umbilicus, as indicated here.


TREATMENT. After the median abdominal incision has been made and the recti have been separated, the abscess wall is at once encountered. If the walls are thin, the cavity is readily reached, but at times it is necessary to cut deliberately through from 1 to


URACHAL INFECTIONS. 571

2 cm. of very dense tissue before the fluid is readied. The cavity should be wiped out, and, if it has thick walls, it should be curetted. It is then packed with gauze and allowed to close by granulation. Great care should be taken to avoid opening the peritoneal cavity. It is astonishing to see the rapidity with which the scar tissue disappears as the result of adequate drainage. In those cases in which the urachus is enlarged and adherent to the sac, and where this tube can be readily reached, it is advisable to ligate and cut it, as there is a possibility of urine escaping later from the abscess sac.

CASES OF ABSCESS OF THE ABDOMINAL WALL DUE TO INFECTION OF REMAINS OF THE URACHUS, AND NOT COMMUNICATING WITH THE BLADDER.

I have not cited all the recorded cases, but have included only those that are especially convincing.

Suppurating Cyst of the Urachus. — Arrou* reported the case of a patient operated upon by Tricot. A soldier, who gave absolutely no history of bladder trouble, complained of vague pain in the umbilical region. The pain became acute, and during his march he had to bend forward. He had no nausea or intestinal disturbances; urination was normal, the temperature unaltered.

Examination revealed a plaque as large as a hand a little below the umbilicus. This was painful, but there was neither edema nor reddening. Gradually a little swelling was noted. The patient had some pain and fever.

Operation. — An exploratory operation under local anesthesia was determined upon, the condition being thought to be due to an abscess of the abdominal wall. But almost as soon as the patient reached the operating room an escape of a small amount of pus was noted coming from the lower margin of the umbilicus. A probe introduced into the small orifice descended downward and backward into the cavity, which was 6 cm. long in its vertical direction. The patient was at once anesthetized, and a cavity was opened; this proved to be as large as a mandarin orange, and contained a calculus the size of an olive, like a piece of mortar incompletely dried. The cyst lining resembled an inflamed mucosa. Unfortunately, both sac and calculus were lost. The upper end of the sac ended at the bottom of the umbilicus; the lower extremity terminated in the closed cul-de-sac. Attached to the lower end of the sac was a cord the size of the little finger; this cord gradually became smaller and terminated in the fundus of the bladder. There is no doubt that it was the urachus.

The peritoneum was opened above and laterally, the intestine projected. The urachus was cut across with a cautery at a point several millimeters above the bladder. The sac was completely removed and the wound closed. The patient made a good recovery.

Abscess Between Umbilicus and Pubes.f- "Mrs. C. L. R., aged thirty-three, Shenandoah, Ohio. Physician, Dr. J. M. Fry. Married twelve years; one child, aged eleven years; labor normal; no miscarriages; appetite fair, but much vomiting; kidneys normal; menstruation normal. Patient had suffered from her present trouble for about a year, but no diagnosis had been

  • Arrou: Kyste suppure de l'ouraque. ' Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi,

832.

t Baldwin, J. F.: Large Cysts of the Urachus. Surg., Gyn., and Obst., June, 1912, xiv, 636.


572 THE UMBILICUS AND ITS DISEASES.

made until about three weeks before I saw her, which was March 29, 1901. In the previous July she had had a feeling of fulness and was as large as though pregnant six months. In September much of this fulness disappeared, but it again increased. When I saw her, the uterus was pushed forward and to the right by a tumor, which did not seem to involve the uterus but which extended from the pubes to the umbilicus. This tumor was cystic, and apparently about the size of an adult head. It could not be said to be movable, but did not seem to be very firmly fixed. Dr. Hunter Robb, of Cleveland, and myself saw the patient together in consultation, and assumed that the tumor was ovarian.

"She came to Columbus and was operated on April 24, 1901, Dr. Fry being present. When under the anesthetic the uterus was found, as before, pushed forward against the bladder, and the cyst could be very distinctly mapped out. On opening the abdomen we found the transversalis fascia to be much thickened. It was dissected through with great care. On getting through there was a gush of pus. With the fingers on the inside the incision was enlarged sufficiently for thorough examination. A large quantity of pus was evacuated, together with a considerable amount of more or less necrotic material, resembling somewhat disintegrated omentum (as in one of the cases mentioned by Doran). The cavity having been entirely cleaned out, the sac was found to be a smooth and rather thick membrane. The peritoneal cavity itself had not been entered. In the pelvis the uterus was found standing up, as it were, distinctly in the cavity, though covered by the membrane, as were also its appendages. The connection of the membrane with the surrounding parts seemed to be so firm as to render any attempt at its enucleation undesirable. The cavity was therefore drained, the incision being only in part closed.

"Patient stood the operation well, made an excellent operative recovery, and returned home in due time. Dr. Fry reported, under date of March 15, 1904, that the fistula which followed the drainage had closed only about four months before. Patient had been warned as to the probability of a hernia. Under date of September 17, 1911, the patient, in response to a letter of inquiry, reported that her health was as good as ever. From her letter it is evident that there is a small hernia at the point of drainage which perhaps should be operated upon, but seems to be making no special trouble. Menstruation perfectly regular." Baldwin said that the patient has had no further pregnancies.

Infection of the Urachus. — In Bryant's* Case 2 the patient was a man about thirty years of age who had a slight epispadias. He had had for many years a tumor the size of a small cocoanut lying between the umbilicus and the symphysis. He came under observation on account of great swelling and tenderness between the pubes and the umbilicus. The condition was thought to be due to an abscess. The urine was normal. After incision, very fetid material came out, bu1 there was no urinary smell. The cavity was packed with terebene, and some days later urine was discharged from the wound.

Abscess F o r m a t i o n in the Patent Urachus. f — A female child, apparently normal at birth, had abdominal pain and diarrhea and vomiting when three weeks old. When five months old she was sick again, and the mother noticed a protrusion of the abdominal wall below the umbilicus. The swelling

  • Bryant, T.: Brit. Med. Jour., 1898, i, 1390.

t Van Hook: Amer. Jour. Obst., New York, 1894, xxix, 624.


"URACHAL INFECTIONS. 573

reached the size of an orange. Hot applications resulted in an opening at the umbilicus, with the discharge of a large quantity of pus. Later on cystitis developed and pus continued to be discharged through the umbilicus.

Van Hook examined the child when it was six months old. She urinated repeatedly during the examination. The urine was quite turbid. The umbilicus projected slightly upward and forward and was apparently pushed in this direction by a tumefaction the size of a small apple, which also pushed forward the abdominal wall between the umbilicus and the pubes. The umbilicus had a red, inflamed appearance. A thin pus trickled from the small opening in the lower umbilical fold when pressure was made on the tumor. There was swelling of the right inguinal glands.

Under chloroform a probe was passed down almost to the pubes, but did not enter the bladder. The opening was dilated and a drainage-tube put in. Recovery followed in a week.

An Infected Urachal Cyst.' — Hornig* reviews the literature and reports a case from Trendelenburg's clinic.

The patient was a girl, three years and nine months old. For several weeks she had complained of painful urination. For eight days the mother had noticed swelling of the abdomen. The child had lost weight. The father said that she had often felt sick, and in the spring had remained in bed for two days.

Operation (December 4, 1902).- — The umbilicus bulged out, forming a nodule the size of a cherry. It was bluish red and covered with thin skin. From the umbilicus to the symphysis the abdomen was half-ball-shaped from tension. Palpation met with a tense resistance. The umbilical swelling collapsed while the child was being bathed, and yellowish-red, thick, fluid masses escaped. On catheterization the urine was perfectly clear and transparent; it contained no albumin nor sediment. The umbilical fluid contained staphylococci, and microscopically many flat cells. After the bladder had been emptied the half-ball-shaped swelling between the umbilicus and the symphysis became less prominent, and by rectal examination, with one hand on the abdomen, the surgeon could make out very clearly a cystic tumor.

The fistulous opening was closed to prevent infection. The incision encircled the umbilicus and extended to 2 cm. above the symphysis. The anterior wall of the cyst was exposed. On account of the danger of peritonitis total extirpation of the cyst was not attempted, but the anterior cyst-wall and the umbilicus were removed. A finger in the cyst showed that it extended downward behind the symphysis, and that it ended blindly in the pelvis. A catheter introduced into the bladder could be felt behind and to the left. The cyst-wall was curetted with a sharp curette to remove any epithelial lining. A drain was laid and the opening closed. By January 13, 1903, only a small, granulating strip, 5 mm. wide, remained.

On microscopic examination no epithelial lining of the cyst could be found. The walls were composed of connective tissue, showing marked round-cell infiltration. They also contained smooth muscle-fibers. Although the epithelium was missing, Hornig felt that the smooth muscle was all that was necessary for diagnosis.

A Case of Hardening of the Linea Alba and Umbilicus. — In some healthy persons Leggf says there may be felt in the linea alba,

  • Hornig, Paul: Zur Kasuistik der Urachuscysten. Inaug. Diss., Leipzig, 1905.

t Legg, J. W.: Saint Bartholomew's Hospital Reports, 1880, xvi, 251.


574 THE UMBILICUS AND ITS DISEASES.

between the pubes and the umbilicus, a certain thickness or firmness which is not, however, very marked. He cites an interesting case in which the linea alba between the pubes and the umbilicus was one inch thick, a new growth having its seat apparently in the subperitoneal tissue. This growth was white, dense, tough, and much thicker on the left than on the right of the mid-line. The omentum was thickened. The stomach was small, constricted, and adherent to the omentum. No microscopic examination was made. [The possibility of a malignant abdominal growth in this case cannot be excluded. — T. S. C]

A Partially Patent and Infected Urachus. — Lexer* reports a case coming under the observation of Delageniere. The patient was a boy, five and a half years old, who had a fistula dating from early childhood. At the sixth month a small tumor at the umbilicus opened. Delageniere cut around and then entered, behind the umbilicus, a pocket filled with granulation tissue. Its lower portion communicated with the urachus. In dissecting this out he opened the peritoneum and could feel a string of the urachus passing downward to the bladder. It was isolated for 3 cm. and cut across. The lumen was turned in and closed with sutures. The fistula healed as the result of this procedure, which Delageniere spoke of as partial resection of the urachus. The child remained healthy.

An Infected Cyst of the Urachus. — Page's t patient was a man thirty-six years of age, married, and previously in good health. In March, 1899, he had dull pain about the fundus of the bladder. The pain was intermittent, ceased, and reappeared the second year. In July, 1901, he had sudden violent cramps in the abdomen, followed by diarrhea. The diarrhea ceased in two weeks, but the pain continued. Page suspected appendicitis.

On admission the patient walked bent over. He had great pain in the hypogastric region. His temperature was 102.5° F., pulse 100. He was nauseated. Examination disclosed a circumscribed mass, the size of an average orange, which lay between the umbilicus and pubes, and seemed to be in the abdominal wall. The patient had had a chill the night before. Dr. F. L. Taylor suggested a suppurating cyst of the urachus.

Operation. — Incision three inches long over the mass. In cutting through the fascia the tissues were found to be dense and hard. The operator entered a cavity containing four ounces of thick, flaky fluid, yellowish-brown in color. The abscess cavity was large; the walls were smooth and very thick. In lengthening the incision the peritoneum was accidentally opened. It was at once closed.

The recovery was slow. The cavity gradually became obliterated. The sinus had to be curetted several times, but it healed permanently. The man had formerly weighed 115 pounds; he then weighed 145.

Subperitoneal Phlegmon of the Anterior Abdominal Wall Without Appreciable Cause, Opening Below the Umbilicus; Rapid Healing.! — On p. 5 Vaussy gives the history of phlegmonous subperitoneal inflammation of the anterior abdominal wall, and on p. 6 says that Velpeau, Boyer, Nelaton and Vidal, had cited in their publications

  • Lexer, K.: I'eber die Behundlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73.

f Pago, Charles C: The Post-Graduate, New York, 1902, xvii, 1094.

{Vaussy: Des phlegmons sous-periton<£aux de la paroi abdominale anterieure. These de Paris, 1875, No. 445, Obs. 2.


URACHAL INFECTIONS. 575

several examples of vast purulent accumulations developing between the peritoneum and the anterior abdominal wall. On p. 25 he gives Observation 2. A boy, aged eleven, had at first complained of malaise, fever, and lack of appetite, and later of extreme pain in the hypogastric region. This was increased on inspiration. For a time the pain became general throughout the entire abdomen. The parents soon noticed a swelling in the abdomen below the umbilicus. When admitted (October 26, 1875) to the hospital, the boy showed a great deal of depression, had fever, no appetite, but gave no history of chills or vomiting.

On inspection a tumor was found extending from the umbilicus to the pubes. It was in the median line, and extended over to the left 5 cm. and to the right as far as the crest of the ilium. The tumor was hard, possibly fluctuating, but this could not be determined on account of the patient's pain. It suggested in contour a markedly distended bladder. The skin was of normal color; there was no redness nor edema. Rectal examination was negative. It was decided that the condition was due to a subperitoneal phlegmon of the anterior abdominal wall. It was impossible to determine the cause of the phlegmon, as the child had never been injured, nor had he had typhoid fever. The hypogastric region remained painful, the tumor became fluctuating, and a small red point the size of a 50-centime piece appeared immediately below the umbilicus in the median line. Poultices were applied. The pain and redness persisted, and there developed a small tumor the size of a cherry. Fluctuation being evident, a small incision was made with a bistoury and an enormous quantity of pus escaped. This had a very fetid odor, but did not in any way suggest stercoraceous material. By the eleventh of November the fistula had closed and the child left the hospital. The cause of the inflammation in this case was not clear.

[The history, which is characteristic of such cases, suggests remains of the urachus which had become inflamed. — T. S. C]

Suppuration of a Urachal Cyst. — In Weiser's Case 2 the patient was a girl, eleven years old, who was admitted to the Mercy Hospital on April 11, 1905. The child had complained for several days of headache and vomiting and had gradually developed slight tenderness and some pain in the abdomen. At first there had been no localized tenderness and very little distention. One week prior to admission general flatness had been noted with fluctuation. The abdomen had become more and more distended. On admission her temperature was 101.2° F.; pulse, 172; respirations, 30. The child was pale and emaciated and had a dry tongue and an anxious expression. She complained bitterly of abdominal pain, and the entire abdomen was tender, especially about the umbilicus, greatly distended and board-like. The flatness extended from the umbilicus to the symphysis, and from a point two inches to the right of the median line almost completely into the loin on the left. Surrounding the umbilicus was a zone of redness l^g inches in diameter, which represented an area through which the abscess was ulcerating toward the surface. A positive diagnosis was not made prior to operation, but tubercular peritonitis and a suppurative urachal cyst were both considered.

Under anesthesia the abdomen was opened in the mid-line between the umbilicus and symphysis. Absence of the peritoneum made a diagnosis quickly possible. The abdominal cavity was divided into two compartments by the sac-wall, which

  • Weiser, W. R.: Annals of Surgery, 1906, xliv, 529.


576


THE UMBILICUS AND ITS DISEASES.


had displaced the intestines almost entirely to the right side of the cavity and walled them off. Almost the entire left side below the umbilicus was filled with the cyst, which had ruptured, as shown in Fig. 243. Except at the point of rupture, the cyst contents were entirely extraperitoneal, although occupying so large a part of the abdominal cavity. Free pus to the amount of several pints was confined to the left side, and was not in contact with the intestines. The position occupied by the mass is fairly well shown in Fig. 243. The urachus was patulous down to within three-eighths of an inch of the bladder, and was ligated at this point. So much of the sac as could be dissected out without tearing up the limiting wall was taken

away, and the abscess cavity washed out and drained with a coffer-dam drain of iodoform gauze. An area 2 x 4j/2 inches was bare of peritoneum at the site of the wound, but there was no trouble from this source.

A Small Urachal Cyst Showing Inflammation.* — ■ Case 23. Autopsy No. 260, 1881. — The body was that of a man, sixty-three years old, dead of arteriosclerosis, hypertrophy and dilatation of the heart, emboli of the lungs, general edema, hypertrophy of the prostate, catarrhal cystitis. The bladder was pear-shaped, and its vertex appeared to reach to within 4 cm. of the umbilicus. When it was opened at the upper end, tenacious and slimy pus escaped. An abscess lay above and behind the top of the bladder. The bladder itself was 11.5 cm. long, and the distance from the vertex to the umbilicus was 8.4 cm. The bladder appeared to be independent of the first abscess (a) . Above the surface of the larger abscess (a) was a smaller one (6), the size of a bean. The cavities of both of these were reddish. Above this point the urachus appeared as a cord, accompanied by the umbilical arteries. The mucosa of the bladder was pale, not ulcerated. On the mucosa of the vertex of the bladder was an extravasation the size of a pin-head, and in the middle of this was a punctiform depression through which a bristle could be passed into abscess (a). The cavity of abscess (a) was 1 cm. long, 0.6 cm. broad. From this abscess cavity a bristle could be passed into abscess h l so that the connection between the two was easily followed. From abscess (b) the urachus could be traced 0.5 cm. toward the umbilicus. Microscopic examination of the walls of the abscesses (a) and (6) showed that they were inflammatory urachal cysts. In some places the characteristic several layers of epithelium were in evidence; at other points the inner surface of the cyst was ulcerated and the connective tissue showed small-round-cell infiltration. The entire length of the urachus in this case was 4 cm.

  • Wutz, J. 15.: Tiber (Jrachus and I'raehuscysten. Virchows Arch., 1883. xcii, 387.



Fig. 243. — Urachal Cyst. 'After W. R. Weiser, Case 2, Fig. 2.) The urachus was patulous down to within three-eighths of an inch of the bladder. Above that it had dilated into a large cyst. The urachus was ligated and severed and as much as possible of the suppurating cyst-wall was cut away. The abscess cavity was washed out and drained.


URACHAL INFECTIONS. 577


LITERATURE CONSULTED ON ABSCESS IN THE ANTERIOR ABDOMINAL WALL,

BETWEEN THE UMBILICUS AND THE SYMPHYSIS, DUE TO INFECTION OF

URACHAL REMAINS AND OF URACHAL CYSTS.

Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832.

Baldwin, J. F.: Large Cysts of the Urachus. Surg., Gyn., and Obst., June, 1912, xiv, 636.

Bryant, T.: Brit. Med. Jour., 1898, i, 1390.

Fischer, H.: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, n. F., Xo. 89 (Chir. No. 2-1), Leipzig, 189-1, 519.

Heinrich: Ueber beschriinkte, sogenannte aussere oder tuberculose Peritonitis bei Kindern, oder iiber Entziindung der subkutanen Sehicht der Bauchwand und iiber die Bildung von Abszessen und Verhartungen daselbst. Jour. f. Kinderkrankheiten, 1849, xii, 6.

Van Hook, W. : Abscess Formation in the Patent Urachus. Amer. Jour. Obst., New York, 1894, xxix, 624.

Hornig, P.: Zur Kasuistik der Urachuscysten. Inaug. Diss., Leipzig, 1905.

Legg, J. AY. : Cases of Hardening of the Linea Alba and Umbilicus. Saint Bartholomew's Hospital Reports, 1880, xvi, 251.

Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 189S, lvii, 73.

Nicaise: Ombib'c. Dictionnaire encycloped. des sciences medicales, Paris, 1881, 2. ser., xv, 140.

Page, C. C. : Cyst of the Urachus. The Post-Graduate, New York, 1902, xvii, 1094.

Vaussy, F. : Des phlegmons sous-peritoneaux de la paroi abdominale anterieure. These de Paris, 1875, No. 445.

Weiser, W. R.: Cysts of the Urachus. Annals of Surg., 1906, xliv, 529.

Wutz, J. B.: Ueber Urachus and Urachuscysten. Virchows Arch., 1883, xcii, 387.


38


CHAPTER XXXIV.

URACHAL CAVITIES BETWEEN THE SYMPHYSIS AND UMBILICUS COMMUNICATING WITH THE BLADDER OR UMBILICUS OR

WITH BOTH.

General consideration. Symptoms.

Differential diagnosis. Treatment.

Instance of a urachal cavity between the symplrysis and umbilicus and communicating with the bladder or umbilicus or both.

Figs. 244 and 245 graphically illustrate urachal cavities communicating with the bladder. Fig. 246 shows in a schematic manner the way in which a distended urachus may open at the umbilicus. Dilatation of the urachus with the escape of urine from both the bladder and umbilicus is indicated in Fig. 247, while in Fig. 248 we see the tremendous quantities of stagnant urine that niay be forced little by little into the pervious urachus when the bladder contracts during micturition. Finally, the valve-like opening is overcome and there is a sudden gush of ammonia cal urine from the urethra; or an opening may develop at the umbilicus; or the urine may escape from both the urethra and the umbilicus.

Sex. — Of the cases here recorded, and in which data as to the sex are available, 14 were in males and 12 in females.

Age. — The youngest patient (Savory's) was thirteen months old. Weiser's patient, a woman of seventy-five, was the oldest. The age table is as follows:

Under ten years of age 4 cases

Between ten and twenty years of age 2 "

Between twenty and thirty years of age 7 "

Between thirty and forty years of age 1 case

Between forty and fifty years of age 4 cases

Between fifty and sixty years of age 1 case

Between sixty and seventy years of age 1 "

Over seventy years of age 2 cases

These figures are of only relative value. Bramann's patient, who came under observation at twelve, had definite symptoms when nine years old. Freer's patient came under treatment at fifty-four, but from the history it was evident that symptoms were first noted when the patient was seven years old. Newman's patient was thirty-nine years old, but he had had an enlargement in the lower abdomen as long as he could remember. Vaughan's patient, a man of forty, had experienced pain in the suprapubic region when seventeen.

SYMPTOMS. The chief symptoms are those referable to the bladder and to the development of a tumor between the symphysis and umbilicus. When infection occurs, constitutional disturbances are superadded.

578


URACHAL CAVITIES AND INFECTIONS.


579


A reference to the accompanying histories will show that the vesical s y m p t o m s varied greatly. Some patients complained of frequent micturition, others of incontinence, while others had difficult micturition, retention, or an almost total inability to void.

In some the vesical symptoms had been of short duration; others had had defi


Fig. 244. — A Dilated Urachus Communicating with the Bladder. (Schematic.) Where such a condition exists, when the bladder contracts during micturition part of the urine escapes from the urethra and part may be forced into the urachal sac. Finally the urachal sac will empty itself into the bladder.


Fig. 245. — Large Accumulation op Urine in a Partially Patent Urachus. (Schematic.) Some patients give a history of cystitis, and a few months later a hard, globular tumor is noted between the umbilicus and symphysis. After the bladder has been emptied with a catheter the tumor still persists. Finally, after a very large amount of fluid has accumulated, it may all be discharged at once through the bladder, or the urachus may open at the umbilicus, allowing the accumulated urine and pus to escape by this avenue. In these cases there is usually a periodic filling and emptying of the urachal sac.


nite bladder disturbances for years. In Patel's case, for example, a child three years old had had incontinence of urine day and night since birth, the urine being passed involuntarily and at frequent intervals. In Freer's patient, a woman fiftyfour years old, vesical symptoms were first noted when she was seven years old. Schnellenbach's patient, who was sixty-six years old, had had frequent micturition for one year and pressure was necessary to start the flow. When the patient was


5S0


THE UMBILICUS AND ITS DISEASES.


catheterized, 1500 c.c. of urine came away. Worster's patient gave a history of having developed a cystitis with incontinence after diphtheria, and eleven years before coming under observation had passed a large amount of pus from the urethra.

In some cases the urine was turbid and contained pus and occasionally blood. In other cases the urine was clear; occasionally, as in Graf's, Lexer's, and Matthias'



Fig. 24(i. — Ax Infected Urachus Opening at the Umbilicus. (Schematic.) 1 (ccasionally urachal remains become infected, and after a time open at the umbilicus. In i hose cases in which the vesical end of the urachus i- closed i here is no escape of urine from the umbilicus, the discharge being purulent or slimy in character.


Fig. 217. — A Patent Urachus Dilated in its Middle Portion. (Schematic.) In such cases the middle portion of the urachus may become markedly distended, sometimes containing a liter or more of decomposing urine. (See Fig. 248.)


cases, the patients had previously had a gonorrheal infection. This naturally confused the clinical picture to some extent.

P a i if. — More or less pain in the lower abdomen was a frequent symptom. In Bourgeois' ease there was an almost insupportable feeling of tension in the lower abdomen, and the suprapubic region was particularly sensitive after fatigue. In Matthias' case there was a feeling of pressure in the lower abdomen, accompanied by malaise. Worster's patient had to bend forward at an angle of 45 degrees to


URACHAL CAVITIES AND INFECTIONS.


581


get relief, and was incapable of stooping down to pick up anything. Newman's patient suffered much pain, walked with difficulty, and had an anxious expression. Hind's patient had a steady pain in the lower abdomen. Suddenly something gave way, there was a feeling of relief, and a large amount of pus escaped from the bladder.

The Umbilicus. — With the progress of the disease the umbilicus in about half of the cases became inflamed and ruptured, with the escape of pus, and later of urine. In Bourgeois' case a small, soft, red tumor the size of an almond developed at the navel. During micturition it would become prominent and painful. It was opened and urine escaped.

Bramann's patient, two years after vesical symptoms had been noted, had a sudden discharge of urine from the umbilicus. In Hastings' case the urine for a time ceased entirely to pass from the urethra. On one occasion, when the patient had not voided at all for a long period, there was a sudden gush of two quarts from the umbilicus.

Lexer's patient, one and a half years after the onset of symptoms, complained of pain in the umbilical region. The tissues swelled up, became red, and a quantity of purulent material escaped. On pressure pus and urine were discharged from the umbilicus. Savory's patient developed a tense umbilical

swelling two to three inches in diameter. This was tender during micturition. It was opened later, pus escaped, and finally nearly all the urine was passed by this avenue.

In Schnellenbach's case there was pain in the umbilical region, followed by the escape of pus. Vaughan's patient had poultices applied to the umbilical region. Two weeks later pus and urine passed from the umbilicus. Occasionally the opening would close for a couple of days. This closure was accompanied by much pain,



Fig. 248.


Urine in


Accumulation op a Large Quantity Urachal Pouch. (Schematic.) Occasionally the urachal pouch is very large, and when the bladder contracts, part of the urine escapes from the urethra, part is forced up into the sac. An opening may or may not exist at the umbilicus. If there be no exit at the umbilicus, the valve-like opening between the urachus and bladder is after a time temporarily overcome, and suddenly there escapes from the bladder a large quantity of ammoniacal urine mixed with pus, the urachal tumor at once disappearing. Such a sac will fill up and empty periodically.


582 THE UMBILICUS AND ITS DISEASES.

which was not relieved until the fistula reopened. The discharge was so offensive that the patient could not mingle with his friends. Worster's patient also developed a tumefaction in the umbilical region, followed by the escape of pus and urine.

The opening in Weiser's Case 3, did not develop at the umbilicus, but 2 inches below it. Urine only escaped; at no time was there any pus.

When the infection of the urachus extends up to the umbilicus, it is but natural that the latter should be secondarily involved, particularly when much tension exists in the sac.

Constitutional symptoms have not been at all prominent in these cases, evidently because there was a certain amount of drainage by the bladder, umbilicus, or both. In Hastings', Lexer's, and Morgan's cases fever was present, and in Morgan's case there was vomiting accompanied by diarrhea.

The carefully recorded case reported by Hastings in 1829- (p. 589) is well worth a thorough study. This case clearly shows that, notwithstanding most alarming symptoms, such as convulsions, the patient may recover. Savory's patient, a sickly child thirteen months old, died; in this case the inflammatory process had extended to the abdomen, as indicated by the adherent omentum. Ball's eightyear-old child died of peritonitis.

In Xicaise's (p. 597) and Roser's (p. 598) cases the patients successfully passed through a pregnancy while suffering from an infected urachal cyst. Roser's patient miscarried during a subsequent pregnancy four years later.

The urachal cyst varies considerably in size. It is attached to the bladder below and to the umbilicus above, and any great increase in size, as a rule, will be in its central portion. In Bramann's case the tumor resembled a long sausage. In Worster's patient it was recognized as a large cord, two inches in diameter. In Freer 's case, when the patient was fourteen years old, it was the size of an apple, but when she came under observation, at fifty-four, it was much larger. In Patel's case the tumor was the size of two fists. Vaughan's patient had a pyriform tumor three inches long, and having a capacity of about three ounces. Schnellenbach's tumor was the size of a head, while in Timmerman's case the sac contained about 1500 c.c. of fluid.

Urachal cysts communicating with the bladder can hardly reach as large proportions as some of those that have no external opening. In Roser's case, however, notwithstanding the opening into the bladder, the sac contained between three and four liters of fluid.

The walls of the sac may be thin or thick, depending in a large measure upon the amount of inflammatory reaction. In Newman's case the walls were thin; in Bramann's case they were several millimeters thick, and in Matthias' case they varied from 2 to 20 mm. in thickness.

The interior usually consists of but one cavity. The inner surface may be perfectly smooth, or lined with granulation tissue. On histologic examination the inner surface may have a lining of transitional epithelium, as noted in Bramann's case, or of one layer of squamous epithelium, as found by Schnellenbach. In the latter 's case the underlying stroma showed small-round-cell infiltration.

The cyst fluid in Patel's case was pale yellow. In the greater number of the cases it consisted of urine and pus. The urine in Newman's and in Roser's case was very ammoniacal. In Vaughan's case the cavity contained laminated clots.


URACHAL CAVITIES AND INFECTIONS. 583

DIFFERENTIAL DIAGNOSIS.

The history of cystitis, coupled with the development of a tumor just above the symphysis, is strong presumptive evidence of a dilated urachus, particularly if the tumor increases in size when the patient has not voided for several hours, or if it decreases markedly in size after catheterization, accompanied simultaneously by pressure on the tumor. There are some cases, however, in which the effort to void forces a large part of the urine out of the bladder into the sac, only a portion escaping from the urethra. In such cases the tumor is larger after the bladder has been emptied.

With the aid of the cystoscope the diagnosis becomes more easy. In Matthias' case, for example, on exploration of the bladder a transverse oval opening was found near the top of the anterior blaclder-wall. This passed into a funnel-shaped diverticulum, which extended upward toward the umbilicus.

Occasionally a suppurating dermoid or an inflamed appendix ulcerates through into the bladder. When the dermoid opens into the bladder, the tumor is situated in one side of the pelvis. The urachal tumor, on the other hand, is in the mid-line, and lies in the anterior abdominal wall. Furthermore, in the case of a dermoid cyst, on cystoscopic examination it may be possible to see a tuft of hair projecting from it into the bladder. When an appendix opens into the bladder, there has usually been a definite history of appendicitis and the discharge passing from the bladder has a distinctly fecal odor. The following case although not exactly germane to the subject has several points in common, and is of such interest that I shall briefly report it.

In May, 1907, I saw a very interesting case of extra-uterine pregnancy, in which, long after the death of the fetus, the sac opened into the bladder. The patient, L. S., colored, aged thirty-three (Gyn. No. 13806), was admitted to the Johns Hopkins Hospital on May 3, 1907. For the previous five years she had complained of much pain in the lower right abdomen. This was usually dull, and occasionally accompanied by nausea. Three years before admission she was supposed to be pregnant and to have proceeded to about the eighth month. Severe, labor-like pains lasting five minutes suddenly developed, and the patient passed blood from the uterus. Shortly afterward she noticed that the abdominal girth was diminishing, and that a hard, tender lump was present in the right lower abdomen. This gradually became smaller. She gave no history of chills or of fever, but had had some vomiting, had suffered from pain from time to time, and had lost in strength and in weight.

On admission the right lower abdomen was distended by an irregular nodular mass, which on palpation gave a peculiar feeling of crepitus. On pelvic examination the uterus was found slightly enlarged and lying posteriorly. On the right side was a pelvic mass attached to the side of the uterus.

On catheterization under ether a large amount of thick, tenacious urine came away, and the catheter came in contact with a substance feeling very much like a stone.

Operation. — A median incision, after liberation of the adherent omentum, disclosed a large, irregular mass in the right lower abdomen. The large and small bowel were found densely adherent to the sac. The small bowel was dissected free, but its coats were slightly injured.

The sac contained a large number of fetal bones (Fig. 249) . The bladder was


584


THE UMBILICUS AND ITS DISEASES.


densely adherent to the mass, and after it had been freed, an opening was found to exist between the sac and the bladder. One of the long bones, a femur, was seen projecting from the sac into the bladder, and the portion lying in the bladder was heavily coated with urinary salts (Fig. 250) . The vesical opening was closed.

In the cecum, near the ileocecal valve, long bones projected from the fetal sac into the lumen of the bowel.. There was a second opening into the large bowel six inches above the ileocecal valve. After closing the intestinal openings and removing the appendix, which was thickened and indurated, I also removed a parovarian cyst from the right side. The abdomen was then drained. The patient made a good recovery.

In such a case as this the previous history pointed to a pregnancy. Bimanual examination revealed an intraabdominal tumor situated on one side, and not in the mid-line. Cystoscopic examination would have determined the presence of a foreign substance projecting into the bladder.

From the foregoing it is seen that urachal tumors connected with the bladder are relatively easy to diagnose.



Fig. 249. — Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac.

Oyii. No. 13806. The bones have been roughly assembled. They are very well preserved. 'J'Ik- ends of t wo long bones projected into the lumen of the cecum :i in 1 one into I In- cavity of the bladder. The end of this bone is heavily coated with phosphates. This is particularly well shown in Fig. 250.


TREATMENT. WJiere a marked infection is present, it is advisable merely to open up and drain the sac. If possible, at the same time the bladder should be separated from the sac and the vesical opening closed. The sac is then packed and allowed to contract down.


URACHAL CAVITIES AND INFECTIONS.


585


If there is little danger of infection, the umbilicus is encircled and removed, together with the sac, and the bladder opening closed.

The vesical symptoms usually disappear as soon as the source of irritation — the dilated urachus — is eliminated.


EXISTENCE OF A URACHAL CAVITY BETWEEN THE SYMPHYSIS AND UMBILICUS, AND COMMUNICATING WITH THE BLADDER OR UMBILICUS OR BOTH.

Quite a number of the cases in the literature were not sufficiently definite to warrant citation; only those that clearly illustrate the condition have been selected.

Cystitis with Tu m o r Formation in the Bladder.— In 1882 Ball* saw a boy eight years old who had suffered from incontinence of urine at night from birth, and during the previous six weeks also by day. In March, 1882, the urine was bloody and contained pus, but the boy improved, although he was still complaining of pain in the lower abdomen. When he next came to Ball, in January, 1883, he had an umbilical fistula, which he stated had appeared three weeks previously after rupture of an abscess. Since that time all the urine had passed through the navel. The urethra was very small, but later a moderate amount escaped by this passage also.

The treatment consisted in cauterizing the opening. This was clone three times. The parts remained healed only for a short time. A fourth operation was of a plastic nature; the fistula remained closed for two months. One month later the boy died of peritonitis.

At autopsy the urinary organs were removed entire. On the next day the cavities were first injected with colored

lard through an opening in one of the ureters. A minute hole about 13^ inches below the umbilicus and 2}^ inches above the fundus of the bladder was found. From this urine had escaped into the abdominal cavity. In the upper abdomen there was abundant evidence of a recent peritonitis. The omentum was adherent to the anterior abdominal wall, apparently as the result of a long antecedent inflammation. The amount of fluid in the abdominal cavity was small, but there was an abundance of lymph matting the abdominal viscera together.

  • Ball, C. B. : Case of Pervious Urachus with Remarkable Disease of Bladder. Trans. Acad.

Med. Ireland, 1883-84, Dublin, 1884, ii, 376. This case is probably identical with that referred to by Freer in 1887. Although the age does not correspond, the findings were precisely the same.



Fig. 250. — A Phosphatic Deposit ox the End of a Long Bone. Gyn. No. 13S06. One end of this bone projected into the bladder and has a heavy covering of urinary phosphates. This is clearly evident in the lower part of the picture.


586 THE UMBILICUS AND ITS DISEASES.

The ureters and pelves of the kidneys were much dilated. The bladder was very small and firm; the walls were much thickened. From the fundus of the bladder to the umbilicus extended a tongue-like cavity, 23^ by 1% inches. This was situated between the peritoneal covering and the muscular layers of the anterior abdominal wall. It was in the anterior wall of this cavity that the fatal rupture had taken place.

During the separation of the bladder from the other pelvic contents it was found that the viscus was surrounded by cicatricial adhesions. The bladder-walls were enormously hypertrophied, and projecting into the cavity were a number of newgrowths which resembled the columnse carnese of the heart. Some were attached by one end only to the vesical wall, the other end being free in the cavity; others were attached at both ends, but were free along the sides, so that a probe could be passed between them and the bladder-wall. Microscopic examination showed that they were composed of fibrous tissue with a covering of mucosa.

The bladder was divided into two compartments by a septum. This was attached posteriorly about the middle of the trigonum. Immediately above the septum was a minute opening leading off into the cicatricial tissue in front of the bladder. There had evidently been an extravasation of urine which had become localized as the result of an inflammation.

The fundus of the bladder communicated with the cavity lying between it and the umbilicus by a wide opening. The cavity contrasted remarkably with the bladder proper. Its walls were extremely thin and the inner surface smooth. The openings by which the extravasation had taken place into the peritoneal cavity were two in number — one a small aperture, the other a rent apparently of recent origin.

\Yhether this case was one in which the urachus had remained patent up to the umbilicus and in which, upon supervention of bladder obstruction, suppuration had occurred at the umbilical cicatrix, leaving a fistulous opening, or whether, in consequence of an extravasation of urine in the neighborhood of the fundus, an abscess cavity had been formed which followed the track of the obliterated urachus, are among the interesting pathologic features of the case.

An Abscess Between the Umbilicus and Symphysis Opening at the Umbilicus. — On August 7, 1821, Bourgeois* presented to the Paris Society a young soldier, aged twenty, who had at the lower portion of the umbilical cicatrix a granular excrescence the size of a small lentil. At its summit was a minute cavity, from which there escaped, drop by drop, and sometimes in a jet, a fluid which resembled urine. The patient had pain in the anterior abdominal wall which extended from the pubes to the umbilicus. Several times after fatigue the discomfort became severe and it was necessary to apply liniments. Later he had an attack of retention of urine and complained of a feeling of insupportable tension. After several days a round tumor developed. It was the size of an almond, and was red, soft, and fluctuating. When the patient attempted to urinate, this mass became tense. He was brought to the hospital and came under the care of Larrey, who incised the tumor. The skin was very thin, and there escaped a large quantity of serosanguineous and purulent fluid of a strongly urinary odor, which suggested a communication between this cavity and the urinary tract.

  • Bourgeois: Jour. gen. de med., annee 1821, lxxvi, 219.


URACHAL CAVITIES AND INFECTIONS. 587

Tumor Formation Between the Umbilicus and Symphysis Due to Remains of the Urachus. — Bramann,* in 1887, reported a case from von Bergmann's clinic. The patient was a girl of twelve who had been normal until her ninth year. She then complained of pain and frequent micturition, and there was a discharge of pus and a little blood from the bladder. Two years later the urine suddenly came through the umbilicus and continued to pass by this route, although her physician tried to close the opening by cauterization. The urachus was dissected out and the bladder opening closed. A fistula followed, and this still persisted up to the time that the case was reported. When she came under observation a granulation the size of a pea was detected at the umbilicus; in the center of this was a depression from which urine escaped. Behind the abdominal wall, in the median line, and below the umbilicus, and reaching to the symphysis, was a long, sausage-shaped tumor, which was soft and adherent to the umbilicus, but movable low down. Rectal examination showed that the lower end passed to the bladder. The urethra was normal.

After appropriate treatment for the cystitis a radical operation was undertaken. The fistulous tract was dissected out as far as the bladder, but the peritoneum tore at one point and the omentum protruded. It was wiped off and replaced and the peritoneum closed. The urachus was several millimeters thick, dark red, yielding, and lined with a membrane resembling mucosa. Here and there it was apparently lined with granulation tissue. It opened directly into the bladder. Microscopicexamination showed that the canal was lined with transitional epithelium, next to which was connective tissue, and external to this non-striped muscle-fiber. After operation the fistula persisted.

Escape of Urine From the Umbilicus, f — The patient was a married woman, forty years of age, suffering from what was said to be a vesicoumbilical fistula. This patient came under Freer's care while he was resident surgeon at the Ward's Island Hospital. She complained of a chronic purulent discharge from the umbilicus, as a result of which she had become so exhausted that she was scarcely able to walk. Freer discovered at the umbilicus a fistulous opening. A uterine sound was introduced and glided without obstruction downward almost its entire length, and by giving it a lateral motion, Freer found that it entered a cavity which had a breadth of almost three inches in its widest portion. On removal of the probe pus welled up from the opening, and when pressure was exercised from below upward, several ounces of pus escaped. The cavity was washed out with a 2 per cent carbolic-acid solution, and it was not until the disproportion between the amount of fluid injected and that which returned was noticed that the true nature of the case was surmised. This was afterward proved by the injection of a starchy solution, after which the bladder was emptied and the iodin test applied to the evacuated fluid, which yielded the characteristic appearance of the blue iodid of starch. The patient was put on a nourishing diet, and after local treatment in a short time the purulent discharge ceased and the fistula closed spontaneously. She stated that a similar result had been achieved at other hospitals on previous occasions, but that the fistula, after remaining closed for a short time, would then reopen, with a repetition of the above symptoms. Sometimes,

  • Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir.,

1887, xxxvi, 996.

t Freer, J. A. : Abnormalities of the Urachus. Annals of Surg., 1887, v, 107.


588 THE UMBILICUS AND ITS DISEASES.

when she strained, urine would be forced up through the opening, but this was so infrequent that she considered it of slight importance. She had no difficulty in passing the urine by the natural channel.

Cyst of the Urachus Communicating With the Bladder. — Freer* cites a case reported by Helmuth in The Homeopathic Journal of Obstetrics, 1884, vi, 24. This patient was a married woman, fifty-four years of age, of small stature and slight build. At the age of seven years her abdomen appeared to be enlarged; at fourteen a tumDr the size of an apple appeared at the umbilicus and burst, sending forth a stream of fluid with considerable force. Her menses ceased at the age of forty-four, after which her abdomen became enlarged and sensitive to pressure. Incontinence of urine was a source of great discomfort to her, especially at night, when the dripping would awaken her. Helmuth withdrew with the aspirator about a quart of viscid, dark fluid, which showed "inflammatory" and pus corpuscles. Subsequently, when performing an ovariotomy, after dividing the peritoneum, he says: "I came upon a substance which puzzled me. It looked something like a cyst- wall, but was so densely adherent to the abdomen at the umbilicus that it was impossible to separate the adhesions. Laterally, on each side of the incision, the substance disappeared. After vainly endeavoring to push this sufficiently aside, I determined to incise it, which I did. A gush of fluid followed, and for a moment I believed I had opened the sac. Upon introducing my finger into the incision I soon discovered that the canal communicated directly with the bladder. I then forcibly drew this emptied sac aside, and without difficulty removed the [ovarian] tumor. From some experience in suprapubic lithotomy I determined to bring the wall of the bladder-cyst together with carbolized catgut, which I did. A self-retaining catheter was placed in the bladder and the woman put to bed. The patient died on the evening of the fifth daj' from peritonitis." Helmuth says the patulous and cystic urachus, leading from the fundus of the bladder to the umbilicus, accounts for many peculiar symptoms detailed by the patient.

That the bursting of the umbilicus in early life, when the "water spouted up to the ceiling," was due to the rupture of the external wall of the cyst was proved by the cicatrix, smooth and white, which occupied the site of the umbilicus.

Persistence of the Urachus in Adult Women. — Garriguest did an autopsy on a woman aged forty-five. He found that, owing to the presence of a dilated urachus, the bladder extended as far as the navel, where it was closed. The patient had been operated on for myoma ten days before and had died of nephritis. The urachus was noted at the time of operation. The bladder extended to the umbilicus and lay between the aponeurosis of the abdominal muscles and the transversalis fascia on one side, and the peritoneum on the other.

An Infected Urachus Communicating With the Bladder and U m b i 1 i c u s . — Graft cites the case of a man aged twenty. At twelve years of age he had inflammation of the diaphragm, and four years later gastric fever. A year and a half before Graf saw him he had noticed that the urine escaped from the umbilicus. The tissue in the vicinity of the umbilicus was somewhat swollen, reddened, and painful. He did not know whether he had had fever. On admission he was found to be pale and anemic. He had a frequent desire to

  • Freer, J. A.: Op. cit. t Garrigues, H. J.: Med. Record, New York, 1899, lvi, 720.

% Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896, 16.


URACHAL CAVITIES AND INFECTIONS. 589

urinate. He had pain in the abdomen, and from time to time fluid escaped from the umbilicus. Passing downward in the mid-line from the umbilicus was a hard cord, as wide as two fingers, which could be felt going toward the bladder. The symptoms indicated a vesical catarrh, and there was a gonorrheal inflammation of the urethra. After lavage of the bladder, carried out for three weeks, the patient was better. The pus had stopped escaping from the umbilicus.

Operation. — The umbilicus was cut around and the cord dissected out. The peritoneum was opened over an area of 10 cm. It was walled off with iodoform gauze; the bladder opening, which was about 0.5 cm. in diameter, was closed. The patient made a good recovery.

The inner surface of the fistula consisted of granular tissue. In places it had grown into the lumen. Only near the umbilical opening had the cavity an epithelial lining, the cells being of the squamous type.

A Singular Case of Ischuria.* — "On the 9th of April, 1814, M. H., aged twenty-three, was admitted an in-patient of the Worcester Infirmary. She represented herself as having been particularly healthy. Within the last week she had been exposed to cold, whilst the catamenia were flowing abundantly. For the first day or two she appeared to suffer only from feverish symptoms; soon afterward, however, the secretion of urine became very deficient, and she had difficulty in passing it.

"On the evening of her admission she became much worse, and complained specially of pain and tenderness over the whole of the lower part of the abdomen and in the loins. There was vomiting and a disposition to convulsions. The lower part of the abdomen was much distended. A catheter was introduced, and ten ounces of urine were drawn off, after which the pain was relieved. She was ordered to take a scruple of cathartic extract immediately, and one drachm of sulphate of magnesia, dissolved in camphor mixture, three times a day.

"The next morning the bowels had not been moved. She was afflicted with severe headache, as well as the abdominal pains. She had passed no water, and was delirious during the night.

"She was cupped on the back, and had a blister applied, and took cathartic mixture every four hours till the bowels moved freely; after which she w T ent into a warm bath.

"The symptoms remained for several days very much in the same state. Delirium usually came on during the night. No urine was passed by the natural effort, but about three ounces were drawn off by the catheter in the course of twenty-four hours. She very frequently vomited, and suffered much from pain, tenderness, and tension of the lower part of the abdomen.

"On the evening of the 17th insensibility came on, for which a blister was applied to. the back of the neck; the pulse was sixty. An active aperient was given.

"On the 19th no improvement had taken place, for the vomiting was incessant, and the pain in the abdomen and back was more severe. Pulse, 80. She was bled three days in succession, with some alleviation of the pain, but the abdomen became generally enlarged and very tender; there also ceased to be any urine drawn from the bladder by the catheter. This continued to be the case for five days. The bowels were open. She took saline diuretics without avail.

  • Hastings, Charles: London Med. and Phys. Jour., 1829, X. S., vi, 515.


590 THE UMBILICUS AND ITS DISEASES.

"On the 25th there was much vomiting, pain, and distention of the abdomen, but she passed a little urine. Pulse, 80. She was bled to eight ounces.

"On the 27th a bloody discharge appeared at the umbilicus, after which the abdominal pain and tension were relieved. She also passed some urine by the urethra. The vomiting was, however, worse than it had previously been.

"The bloody discharge from the umbilicus and the other symptoms continued very much the same till the 2d of May, when there was a discharge, of urinous appearance and smell, from the umbilicus. She had passed no urine by the urethra for three days. The head was very painful, the pupils dilated; pulse, 56; bowels costive. Some leeches were applied to the temples, and a blister to the back of the neck; a brisk purge was administered. The catheter was introduced, but no urine found in the bladder.

"The discharge of urine from the umbilicus continued till the 5th, when the catamenia appeared, but quickly vanished. The abdomen became less tense and tender; there was not so much vomiting ; the bowels were open.

" From the 7th to the 9th there was no discharge of urine from the umbilicus, nor was there any passed by the urethra; as a consequence, the abdomen became much distended and severe pain followed, with vomiting. The tension was most remarkable at the umbilicus, forming a circumscribed tumor.

"On the 10th, in the morning, six ounces of urine were drawn off by the catheter; and in an hour after, two quarts of urine of the same appearance gushed from the umbilicus. This was followed by much relief of the abdominal pains. The discharge of urine from the umbilicus continued for three days and was accompanied with great improvement of the general symptoms.

"The amendment, however, did not last, for the discharge from the umbilicus again ceased, and for three days the vomiting, the headache, the abdominal tension and pain returned with their former severity.

"On the 17th the catheter was introduced into the bladder and no urine was found. In an hour after this, two quarts of urine passed from the umbilicus, and soon afterward great relief was experienced.

"From this time to the 25th there was little variation; but the young woman suffered during that interval very much from vomiting and daily passed urine from the umbilicus. The catheter was passed every day, and no urine was found, but the bladder contracted strongly on the instrument; sometimes, immediately after the catheter was removed, a discharge of urine would take place by the umbilicus, and once as much as three quarts were thus passed.

"On the 26th, for the first time after many days, four ounces of urine were drawn from the bladder. Each succeeding day this quantity was now increased and the quantity passed by the umbilicus was diminished. There was also a general improvement of the symptoms, with the exception of vomiting; this continued obstinate. All this time the medicine that she took was confined chiefly to the class of purgatives; blisters were also applied to the neck and epigastrium.

"The bladder was regularly emptied every day by the catheter for more than a month after this date, during which time the abdominal pain and vomiting subsided, and there was no discharge from the umbilicus. Early in July she began to pass some urine, and the power over the bladder was gradually restored. She was


URACHAL CAVITIES AND INFECTIONS. 591

discharged in the middle of July in tolerable health, but still often complained of pain in the pelvic region. She menstruated.

"Observations. — This curious case of ischuria is well worthy of consideration. The remarkable sympathy observable between the brain, the stomach, the kidneys, is common to all cases of this description, and is so obvious as not to require any further comment.

"The very remarkable feature in the case is the occurrence of the urinary discharge from the umbilicus many days after the ischuria had been noticed. Such instances, although rare, are not without parallel in the annals of medicine. Schenck relates two instances of this kind. In the one, a male, the urine was discharged in consequence of an obstruction at the neck of the bladder, 'tanquam mictione ex umbilico,' for many months without any detriment to health. In the other, a female, and more resembling the one now related, 'cum suppressa per multas dies fuisset urina, tandem per umbilicum urinam profuclit.' (Schenck, Obs., Lib. iii, deUrina, p. 489.)

"The interesting question is to determine in what manner the urine is conveyed to the umbilicus in these instances. The urachus offers itself as a means by which the discharge may be determined to that part, and it seems probable that, in the case of mechanical obstruction related by Schenck at the neck of the bladder, a channel of communication was formed by the urachus between the bladder and the umbilicus. But, in the case we now remark upon, there had been no urine secreted into the bladder long before its appearance at the umbilicus, nor was there for some time after; and the first discharge from the umbilicus was not of a urinary but bloody nature. We must consequently, I think, regard the urinary discharge in this instance as vicarious, and as proceeding probably from the peritoneal surface. This view seems confirmed by the great abdominal distention, which took place for some time previous to the discharge from the umbilicus, when it was invariably found, from introducing the catheter, that the bladder was empty, and that it contracted on the instrument.

"Some cases of this description have been placed upon record by eminent men worthy of great credit. There is none, perhaps, more deserving of attention than that by Platerus, which is thus related by the renowned Sennertus: 'Puellae cuidam annos natae tredecim, cum aliquando copiose minxisset, urinam subito suppressam esse, atque tunc aquam serosam ex aure dextra adeo affatim coepisset effluere, ut una vice mensurae duae ssepe emanarint, idque dies aliquot.' He then adds that, on diuretics being administered, the urine was passed freely from the bladder, and the discharge from the ear ceased; but as soon as the diuretics were discontinued, the discharge again took place from the ear, but was altogether removed by general terebinthinate remedies, and local repellents to the ear. The health did not suffer. (Sennerti Opera, Lib. iii, p. 8, § ii, cap. ix.)

"In our case it was evident that much inflammatory action was going on in the pelvic viscera previous to and during the discharge of urine from the umbilicus; and there was a considerable sympathy of the general health with the local inflammatory action.

"I may further add, as a notice to this case, that the young woman was again admitted into the infirmary in May, 1827, for paralysis of the lower extremities, from which she recovered by appropriate remedies. The urine for a time was drawn off by the catheter, but there was no return of the former disease."


592 THE UMBILICUS AND ITS DISEASES.

Umbilical Urinary Fistula in a Middle-aged Man.* — ( lase IV. — The patient was a middle-aged man, who complained of a tender and irritable bladder when he was jolted. A fixed pain developed just above the pubes, and he noticed an increased desire to urinate. A hardness could be detected above the pubes. Suddenly the patient felt something give way, and pus passed from the bladder through the urethra. He was greatly relieved. Recovery followed, and three years later he was well. Hind thought that in this case there had been an abscess of the patent portion of a urachus.

Cyst of the Urachus. — In discussing Douglas's paper Illf said that recently he had removed a cyst of the urachus as large as two fists without difficulty. The patient was a woman who had some prolapse of the anterior vaginal wall, and when she attempted to pass her urine, some of it passed into the cyst and some escaped through the urethra. This did not have the effect, however, of producing an inflammatory condition about the cyst. The condition was annoying to her, because she had to pass her urine in installments, as it were.

The operation consisted in removal of the cyst and ligation of that portion of the duct which entered the bladder. As he was closing the wound he said to himself: This is a dangerous procedure, and it is likely that this ligature will not destroy the epithelium and that the bladder will open in a short time." Some infiltration of urine taking place, he removed the ligature, cut the duct very short, turned in the edges, and closed it over, as a surgeon would do with an appendix stump.

Cystitis Followed by the Opening Up of a Partially Patent Urachus, Producing a Urinary Fistula at the Umbilicus. — Lexer! reports the case of a poorly developed young man, twenty years old, who said that previously he had never noticed anything abnormal at the umbilicus. A year and a half before admission, after several weeks of difficulty in urinating, the urine being cloudy, he had pain in the region of the umbilicus, the tissue in the vicinity of the navel swelled up and became red. Shortly after a quantity of purulent fluid escaped from the umbilicus. The bladder discomfort became more severe; he frequently had fever and chills and became thinner. In addition to a marked degree of cystitis there was blennorrhea of the urethra. Gonococci were isolated from the urethral discharge. On account of the swelling and inflammatory infiltration, the fistula at the umbilicus was not visible, but the umbilical funnel filled up when pressure was made by the patient, and when pressure on the bladder was exerted the umbilical cavity filled up with pus and foulsmelling urine.

The cystitis was first treated. In the washing-out of the bladder purulent flocculi escaped from the umbilicus, so that finally the entire fluid escaped from the umbilical opening. Nevertheless, it was impossible to introduce a sound farther than 2 cm. into the fistula. By the third Aveek the patient had improved greatly. He had no further fever, the urine was passed without pain, he looked well, and the escape of pus from the umbilical fistula had ceased. Urine, however, continued to escape from the umbilicus as soon as the bladder contained an appreciable amount of fluid.

On account of the gonococcus infection it was felt wiser not to leave in a perma

  • Hind, \V.: Diseases of the Urachus and Umbilicus. Brit. Med. Jour., 1902, ii, 242.

t 111, Edward J.: Amer. Jour. Obst., 1897, xxxvi, 568.

X Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1893, lvii, 73.


URACHAL CAVITIES AND INFECTIONS. 593

nent catheter. The abdominal walls were not so painful on pressure, and one could now make out a hard cord, the thickness of a finger, in the mid-line, extending from the umbilicus to the bladder. After the cystitis had subsided, closure of the umbilical fistula was considered. As it was impossible to introduce a sound far, an excision of the upper portion of the cord was undertaken. The umbilicus was dissected free, and the fistulous tract about 2 cm. below this point was opened. Here there was a small lumen into which a sound could be introduced without difficulty and carried toward the bladder region. The farther dissection of the cord was easily accomplished without injury to the peritoneum. Midway between the umbilicus and symphysis, however, it was impossible to avoid entering the abdominal cavity. From the opening in the peritoneum one could see the relation of the bladder very well. This cord spread out and passed without any definite margin gradually into the upper portion of the bladder, just as is the case in the embryo. Care was taken not to injure the general peritoneal cavity. The urachus was freed to the point where it entered the bladder. It was then cut across transversely, so that the entire tract from the umbilicus to the bladder was excised. A funnel-like opening, 1.5 cm. wide, was left in the bladder. Examination of the inner surface of the bladder showed that this organ was a long, thick-walled tube, similar to that noted in Bramann's case. The opening in the bladder was closed, and a drain laid into the incision. The wound had healed completely in four weeks.

At the end of two and a half years there was no evidence of any fistula, and the patient was completely cured, the only discomfort being frequent urination.

A Case of Patent Urachus Over One Inch in Diameter Forming a Tubular Prolongation of the Bladder. — Marshall* reports the case of a woman, aged forty-three, who had complete procidentia. On opening the abdomen to suspend the uterus, and while making a short incision midway between the pubes and umbilicus, he found the subperitoneal fat very abundant. On dividing this he could see what appeared to be peritoneum. A nick having been made into it, a pair of scissors was passed upward and then downward to enlarge the incision.

On lifting the retroflexed uterus up to the abdominal opening and thus compressing the bladder, Marshall noted an escape of some clear fluid into the lower part of the wound. This aroused his suspicions. A bougie introduced into the bladder through the urethra entered the abdominal incision through a large opening. What was at first thought to be peritoneum was in reality the anterior wall of a patent urachus. The first cut upward had slit through the upper blind end in the peritoneum into the abdominal cavity. The downward cut had opened the peritoneum and both walls of the urachus.

The urachal opening was V/i inches in diameter and formed a large opening in the conic-shaped bladder. The bladder was closed with a double layer of continuous catgut sutures and a catheter was kept in for one week. The patient made a good recovery.

Suppuration of the Persistent Urachus With Rupture into the Bladder and the Abdominal Wall.f — In November, 1901, a forty-eight-year-old man came to Mikulicz's clinic. He had had a gonococcal

  • Marshall: Jour, of Obst. and Gyn. of the Brit. Empire, 1907, xi, 259.

t Matthias, F. : Vereiterung des persistierenden Urachus mit Durchbruch in die Blase und in die Bauchdecken. Beitrage z. khn. Chir.; herausg. von Paul Bruns, Tubingen, 190-1, xlii, 339. 39


594 THE UMBILICUS AND ITS DISEASES.

infection ten years before, which had not been promptly treated. For the last few years he had had an abundant discharge from the urethra. Apart from this the patient had been well. Six months before admission, he began to have a pressure in the lower abdominal region and suffered from a general feeling of malaise. The urine was cloudy and contained whitish threads and flocculi. There was a cramp-like, sticking pain in the urethra. During the three months following this the patient lost weight and the urine was cloudy. Two months later there was again pain in the lower abdomen, and a tumor could be felt above the top of the bladder. Mikulicz found a firm, ill-defined tumor lying below the umbilicus. This occupied the mid-line and extended a little more to the right. It commenced three fingerbreadths below the umbilicus, and ended 5 cm. above the symphysis. There was a cord passing from the tumor to the umbilicus. The umbilicus itself appeared normal. , Mikulicz thought that he was dealing with an abscess of the abdominal wall, and one that communicated with the bladder, and that its origin was due to the extension of a cystitis by way of a persistent urachus. Bladder irrigations were employed. When there was a large quantity of pus in the urine, the tumor became smaller and the patient felt better. The reverse was the case when the urine contained but little pus. The difference in the size of the tumor was manifested in its transverse diameter. When a large amount of pus escaped in the urine and the tumor had diminished to half its volume, a cystoscopic examination was made. In the anterior bladder-wall, in the neighborhood of the top of the bladder and in the mid-line, was a transverse oval opening passing into a funnelshaped diverticulum. The walls of this could be seen for some distance, but the point ended in darkness.

Operation. — A median incision was made. The skin was dissected free from the tumor, which was covered with thick and edematous fascia, and on the left side the peritoneal cavity was opened. From this point the tumor was separated from the abdominal wall, and in the lower angle of the incision the bladder was recognized by means of a metal catheter which had been introduced from below. The tumor sat on the top of the bladder, and on the right and on the left, between the tumor and bladder, was a loop of small bowel which was separated without injury. The tumor was the size of a billiard ball, and sat as a cap on the top of the bladder. The muscular covering of the bladder extended over on it, particularly on the posterior surface. The peritoneal cavity was well walled off and the tumor opened. Its walls were 12 mm. thick, and the cavity was the size of a walnut. From it escaped an old clot mixed with pus. An attempt was made, by filling the bladder with 300 c.c. of salt solution, to find a communication with the abscess cavity. In this the operator was unsuccessful ; no fluid escaped, but a sound could be passed from the cavity into the bladder. The tumor was separated from the bladder. The small opening in the bladder-wall was closed with catgut, and the muscularis, which formed two flaps over the tumor, was brought together. A retention catheter was introduced into the bladder and kept in place for ten days. The urine then came away spontaneously, and the pus disappeared almost completely. The extirpated tumor was the size of an apple and irregularly round. Its walls varied from 2 to 20 mm. in thickness, and there were irregular dilatations in the interior. It consisted of striated, dense connective tissue. Here and there were citron-yellow portions, undoubtedly fatty tissue. The inner surface of the sac, apart from dilatations, was uneven; no mucosa was visible.


URACHAL CAVITIES AND INFECTIONS. 595

Microscopic Examination. — Sections showed that the wall was made up of smooth muscle-fibers, connective tissue, and an inner zone consisting of old connective tissue containing many round-cells and small blood-vessels. There were hemorrhages, and here and there the tissue was necrotic. There was no evidence of epithelium. Mikulicz found a small opening in the wall of the tumor. This was lined with epithelium. It could be traced for a distance of 2 mm. in serial sections, and had a breadth of 1 mm. The epithelium lining the canal was several layers thick; only in a few places did it consist of a single layer.

In conclusion Mikulicz said that very probably the normal dilatation of the opening of the urachus in the bladder, being funnel-shaped, had allowed the cystitis to extend to the urachus, and through breaking of the wall there had resulted abscess formation in the musculature of the bladder-wall and of the abdominal wall to the umbilicus. Since the abscess originally lay within the bladder musculature, its rupture into the interior of the bladder near the actual opening of the urachus was not exceptional.

[There is no doubt in this case that there was an abscess between the bladder and the umbilicus. It was probably of urachal origin, but Matthias's description is not particularly clear. — T. S. C]

Escape of a Calculus From the Umbilicus.* — This case had been reported by Gennaro in 1890. After a mucopurulent discharge from the umbilicus had lasted several days, a calculus escaped from the umbilical opening. It consisted of urate of soda, phosphate of lime, and magnesia. The urachus was a diverticulum of the bladder. Gennaro thought that the calculus was due to fermentation of the stagnant ammoniacal urine.

A Case of Dilated Urachus Accidentally Opened During an Abdominal Section for Peritonitis. Recovery. f — A boy, aged five, was brought to the Children's Hospital, Brighton, on February 18, 1896. There was a history of vomiting and diarrhea for two days. On admission he was suffering with severe abdominal pain, but there was no marked tenderness. His temperature was 102° F. The next day he was much worse, and lay on his left side, with his thighs fully flexed. The distention, tenderness, and pain were more severe. There was no localized swelling. His diarrhea was almost constant. His temperature was 103.6° F., his pulse, 108. In the next five days there was some improvement in his general condition. The abdomen was still distended, but the vomiting and diarrhea were improved. On the ninth day, in the region of the bladder and extending nearly to the umbilicus, there could be made out a certain amount of resistance that was fairly sharply defined. Micturition was frequent, but there was no dribbling. On the suspicion that the swelling might be the bladder, a catheter was passed, but only about half an ounce of urine was drawn off. This did not affect the size or position of the hypogastric fulness. On February 27th the general condition was better, except that he was passing a large quantity of mucus by bowel. The distention and hypogastric fulness were less marked. On the evening of the next day, twelve days after the first symptoms, the boy was much worse, his vomiting had returned, and the distention was

  • Monod, Jean: Des fistules urinaires ombilicales dues a. la persistance de l'ouraque. These

de Paris, 1899 (obs. 47), 168.

t Morgan, G.: The Lancet, 1896, ii, 1154.


596 THE UMBILICUS AND ITS DISEASES.

very severe. His temperature was 103° F. and his condition so critical that it was decided to operate at once.

An incision was made extending from the umbilicus to a point near the pubes. The deeper abdominal layers were divided carefully over a director. An incision was made into what was taken for the subperitoneal fat and peritoneum, and there was a gush of about one ounce of clear urine. The wound was at once clamped and a catheter was passed. The bladder was found to be quite empty and lying in the pelvis, but the catheter could be passed up into the wound in the cyst where the clamp was. After carefully dissecting around the cyst, Morgan opened the abdominal cavity and found signs of recent peritonitis, with flakes of lymph, but no pus. The abdominal cavity was flushed with hot water, and the intestines were carefully sponged. The boy was too ill to have a prolonged examination or have the mass dissected out, but it was certain that the cyst was in the mid-line, running up to the umbilicus and communicating with the bladder. After the bladder and cyst had been washed out with boric acid solution, the wound in the bladder was closed with a double row of silk sutures, the stitches not penetrating to the mucous membrane. The abdominal wall was also carefully closed. On the following day the boy was much better, but on the fourth day pus began to well up from the suture line. Three stitches were taken out and the pus cavity was irrigated. For ten days after this there was some escape of urine from the abdominal wound, but this became less and less, and the boy's general condition improved. Twentysix days after operation the wound was closed and the boy was quite well.

A Rare Variety of Cyst of the Urinary Bladder, Probably Arising From the Urachus, Cured by Operation.* — A. M'V., a miner, aged thirty-nine, was admitted to the Glasgow Royal Infirmary on October 21, 1895. He complained of severe pain in the hypogastric region. This had commenced four days before, and had continued ever since. Coincident with the onset of the pain he found that he was unable to micturate, and his doctor had to pass a catheter. When the urine was drawn off, it contained a large quantity of blood. Vomiting came on soon after the onset of the pain and was followed by attacks of diarrhea.

On admission he was suffering considerable pain, had an anxious expression and walked with difficulty. The skin over the region of the bladder was red and blistered from the use of hot fomentations and applications of mustard. The abdomen was considerably swollen, very tense over the region of the bladder, and from the umbilicus to the pubes it was absolutely dull on percussion. After admission a catheter was passed and 20 ounces of urine, containing a large quantity of blood, were drawn off. This gave the patient considerable relief, but even after the bladder had been completely emptied, the dulness in the hypogastric region did not disappear. From the 1st until the 8th of November the patient's condition steadily improved, and at the latter date he was able to pass his urine without difficulty. On examination the abdomen still showed a considerable amount of swelling in the hypogastric region. The swelling in appearance greatly resembled a distended bladder.

Operation. — A free incision was made in the mid-line, midway between the pubes

  • Newman, D.: Throe Renal Cases, a Case of Cyst of the Urachus, and a Case of Strangulated Hernia, Treated in the Surgical Wards of the Glasgow Royal Infirmary. Glasgow Med.

Jour., 1896, xlvi, 20.


URACHAL CAVITIES AND INFECTIONS. 597

and the umbilicus. On incision into the transversalis fascia, a large quantity of gelatinous fluid escaped which had a strongly ammoniacal odor. The cyst-wall was thin and smooth, and its anterior wall was not covered with peritoneum. The cyst extended from the apex of the bladder to the umbilicus. After evacuation of the contents the cyst was washed out with carbolic acid solution, and a drainagetube inserted. In the evening the dressing was found to be soiled with urine which had a strongly ammoniacal odor.

On November 16th the greater part of the urine was passing through the abdominal wound and a retention catheter was now introduced into the urethra. Notwithstanding this the urine continued to escape from the wound, and not until December 16th did the cyst become completely obliterated and the wound in the abdomen close. On careful inquiry into the history of the patient it was found that he had noticed a swelling in the hypogastric region as long as he could remember, but until this occasion it had never given him any trouble.

Probably a Partially Patent Urachus with Infection.* — This patient was observed by Chopart. She was pregnant, and had suffered from retention of urine for some time. The abdomen became tender and painful. Fluctuation was felt, and was specially marked in the region of the umbilicus. An incision was made between the right rectus muscle and the umbilicus, and much pus escaped. On the following clay the bed and the apparel of the patient were soaked with urine. This escaped for some time by the umbilicus until, after repeated catheterization, the urine commenced to pass through the urethra and the umbilicus closed.

Dilatation of the Urachus; Communication with the Bladder. — Patel'sf patient was a child three years of age who, from birth, had incontinence of urine both day and night. The urine did not escape drop by drop, but at frequent intervals and involuntarily. There were no malformations.

Below the umbilicus was a voluminous tumefaction, fusiform, and prominent in its central portion. In its middle portion it was the size of two fists. It was exactly in the median line; above it reached the umbilicus, and below passed into the pelvis, although its termination could not be felt. It was movable. Catheterization yielded a small glass of clear urine. There was evidently a tumor lying behind the abdominal walls, adherent to the umbilicus, and clinically independent of the bladder.

A median incision was made below the umbilicus. The tumor was found adherent to the umbilicus. Half a liter of pale-yellow fluid escaped, which contained large quantities of albumin. The sac was lined with an irregularly wrinkled muscular layer. Above the finger impinged on the umbilicus. The inferior end was very narrow and was dilated with difficulty. It led to a small circular cavity in which the vesical trigonum was recognized. Removal of the diverticulum was not undertaken on account of the size of the tumor and of its probable adhesion to the peritoneum, and on account of the patient's age. The walls of the sac were sutured much in the way that cavities resulting from removal of hydatids of the liver are obliterated. The walls were brought together and a catheter was left in the blad

  • Xicaise: Ombilic. Diet, encycloped. des sci. med., Paris, 1881, 2. ser., xv, 140.

| Patel: Malformation congenitale de 1'ouraque. Dilatation kystique de la partie interieure de 1'ouraque demeure en communication avec la vessie; incontinence d'urine symptornatique. Capitonnage de la poche. Rev. mens, des maladies de l'enfance, Paris, 1904, xxii, 77.


598


THE UMBILICUS AND ITS DISEASES.


der. During the five days that the catheter remained in place there was some discharge from the abdominal wall. When the child left the hospital, the abdomen was soft. The bladder was large enough and the child urinated about every three hours. There was no incontinence. Recovery was permanent. This case was also reported by Gabriel Renard.*

The Diagnosis and Treatment of a Case of Patent Urachus. f — The patient was a woman twenty-five years of age. Six months previously she had begun to have pain in the umbilical region. Two weeks later a swelling had appeared at the umbilicus. This had ruptured, and since then pus had been discharging, except during occasional intervals of a week. A probe was

passed through the umbilicus into the bladder, and the end emerged at the external urinary meatus.

The urachus was opened on a director about two inches above the symphysis. It showed a dilatation in the middle, with a constriction above, and below, where it connected with the bladder. The actual cautery was used to destroy about one inch of the lower portion of the urachus. The portion above was packed, a piece of iodoform gauze being passed through the fistula to the umbilicus. The bladder was accidentally opened, but at once closed with catgut. The patient made a good recovery.

Urachal Cyst Communicating with the Bladder. — Robinson+ says: " I worked several years in the dissecting room, paying special attention to visceral and pelvic anatomy, but did not see any urachal cyst in but one autopsy (Fig. 251)." In this case the urachus was dilated, forming a fusiform tumor. It opened into the bladder and extended upward as far as the umbilicus. . . . "I understand from veterinarians that the horse is one of the most typical animals to show urachal cysts, and that quite late in horse fetal life the urachus is found often quite a distance above the bladder."

A Urachal Cyst Communicating With the Bladder. — In Roser's § case the urachal cyst had a small opening into the bladder (Fig. 252) . When the patient wished to void, the contraction of the bladder muscles forced the

  • Etenard, Gabriel: Sur un kyste de l'ouraque. These de Lyon, 1905, No. 89.

fReid, \Y. L.: Glasgow Hosp. Reports, 1899, ii, 76. % Robinson, F. Byron: Annals of Surg., 1891, xiv, 336.

§ Roser, W '.: Ueber Operation der Urachuscysten. Langenbeck's Arch. f. klin. Chir., 1877, xx, 47:;.



Fig. 251. — A Dilated Urachus Communicating With the Bladder. (After F. Byron Robinson.) The urachus (6) is patent from the bladder (a) almost to the umbilicus. It is markedly dilated, and its cavity communicates directly with the bladder. It resembles a secondary bladder.


URACHAL CAVITIES AND INFECTIONS.


599


urine into the cyst more easily than through the urethra. The cyst, therefore, became more and more distended, until three or four liters of urine accumulated. When it was desired to empty the bladder, a catheter had to be introduced into it and the cyst was then pressed upon. In order to keep the patient free from trouble catheterization several times a day was necessary.

The patient had what appeared to be a greatly distended bladder when she was three months pregnant. A puncture was made in the linea alba above, and a large amount of urine removed. The pregnancy went to term. Four years later she had a similar attack when she was again pregnant. The old cyst had refilled. It was tapped from above, and the patient miscarried. The cyst again filled, and operation became necessary. The urine was ammoniacal, owing to stasis in the sac. There was foul urine in the cyst, which at that time had reached the umbilicus.

An extraperitoneal opening, about 3 cm. long, was made in the mid-line, and two chambers full of stinking ammoniacal purulent fluid escaped. There was temporary relief. A retention catheter failed to bring about closure of the bladder, and when last seen, the patient still had the urachal cyst opening into the bladder.

Polypus of the Urinary Bladder with the Development of a Urinary Fistula at the Umbilicus. — ■ Savory's* patient was a male, thirteen months old and sickly. Immediately beneath and partly surrounding the umbilicus was a firm, tense swelling, two or three inches in diameter. Its limits were not well defined. It was very tender, and pain was increased by attempts to void. The urine merely dribbled away. The child had been ill eight weeks. The first thing noticed was that micturition caused pain in the lower abdomen, followed by an almost constant desire to void rupted temporarily and then started again.

The umbilical induration was incised and pus escaped; later urine appeared, and nearly all came this way Autopsy. — On section of the abdomen an abscess was found between the posterior surface of the abdominal parietes and the peritoneum and extending from the umbilicus almost to the symphysis. The omentum was adherent to the abdominal wall. The growth in the bladder stretched across behind the ureteral orifices, which were dilated. This mass was attached at each side, but was free in the center, and could block the urethra. It was a polyp. It was impossible to find the opening between the bladder and the abscess by which the urine escaped from the umbilicus.

A Partially Patent Urachus.t — Simon reports the case of a

  • Savory, W. S.: Med. Times, London, 1852, N. S., v, 106.

t Simon, Charles: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales? These de Paris, 1843, No. SO (obs. 12), 26.



Fig. 252. — Urachal Cyst. (Redrawn by August Horn after W. Roser.) The bladder itself looks normal, except that at the upper part anteriorly there is a small opening which communicates with a large cyst extending as high as the umbilicus.


The stream was often inter


600 THE UMBILICUS AND ITS DISEASES.

patient of Portal, a man forty-five years of age, who died shortly after a fall on the abdomen resulting in a severe injur}' to the bladder. Some time after the accident he had noticed that the urine was escaping at the umbilicus. Portal says: "On opening the bod}' I found a tube which extended from the umbilicus to the bladder. This was cone-shaped. Its diameter toward the umbilicus was ^4 inch and 1^2 inches at the bladder. The thickness was unequal. The volume of the bladder did not exceed that of a small apple."

An Infected Urachal Cyst Communicating With the Bladder.* — This patient, a man sixty-six years of age, came under Trendelenburg's observation on July 3, 1887. For a year or more he had had frequent urination. The urine was cloudy, and often much pressure was necessary to start it. Six months before he had noticed a swelling in the lower abdomen, above the symphysis. For three or four days he had had pain in this region, and soon after a spontaneous opening had appeared at the umbilicus from which a purulent fluid had escaped. Recently he had become weaker.

On admission to the hospital he showed, in the hypogastric region, a marked swelling about the size of a head. This began just above the symphysis and reached to the umbilicus. Rectal examination revealed an enlarged prostate, especially on the right, and above this a distended bladder. A very fine sound was passed from the umbilicus and entered into a large cavity. The fluid from the umbilicus showed round-cells undergoing fatty change. After catheterization with the removal of 1500 c.c. of cloudy urine the swelling to a large extent disappeared, but there persisted a long tumor reaching from the umbilicus to the symphysis.

Operation. — An incision was made between the umbilicus and the symphysis. Immediately behind the fascia was a sac containing about a liter of urine mixed with pus. A piece of the wall was removed, and the wound closed with drainage. A purulent fluid continued to escape from the sac. Microscopic examination of the wall showed it to be lined with one layer of squamous epithelium resembling that of the bladder. There was no muscle in the wall. The connective tissue contained many round-cells.

A Dilated Urachus Communicating With the Bladder . f — The patient was a very frail woman, weighing probably 85 pounds. At labor she had had a bad tear and developed a fever, from 100° to 101.5° F., for nearly six weeks. In the following spring she entered the hospital for operation, but later developed pain and swelling in the right side.

A median incision, 2^ inches long, was made. The peritoneum was exposed and cut, but the bladder was opened. The patient had just voided before the operation. The wound was closed, but the operator, in attempting to enter the peritoneum, got into the same cavity again. It proved to be an accessory bladder — really a dilated urachus — and contained l}/£ to 2 pints of urine. A catheter introduced into the urethra could be passed into this cavity. It was closed and the patient recovered.

Escape of Urine From the Umbilicus. — UnterbergerJ reporter! the case of a woman, twenty-three years of age. She was supposed to have

Schnellenbach: [Jeber die (Jrachuscysten. Inaug. Diss., Bonn, 1888. f Timmerman, C. F.: Trans. Med. Soc. State of New York, 1904, 331.

tTJnterberger: Retroversio-flexio uteri gravidi partialis incarcerata. Urachus-fistel. Monatssohr. f. Geb. u. Gyn., 1900, xi, 657.


URACHAL CAVITIES AND INFECTIONS. 601

had an ovarian cyst that had ruptured through the umbilicus, and for three weeks clear fluid had continued to escape from the navel.

The trouble had begun with pain in the lower abdomen. This had become so severe that the patient had been forced to remain in bed and local applications had been applied. Urination and defecation at this time were normal.

The patient had fever and gradually became weaker. One month before her admission to the hospital urinary disturbances developed, and after a time the urine commenced to escape through the umbilicus and the pain disappeared. Pus sometimes escaped from the umbilicus with the urine.

For fourteen days before the patient entered the hospital no urine had been passed from the urethra. The umbilical opening had the caliber of a hair, and was surrounded by a small red zone. The abdominal walls were somewhat infiltrated. A catheter passed into the bladder entered for its entire length and about 2000 c.c. of urine mixed with pus were removed. The uterus, which contained a pregnancy, was retroverted and partially incarcerated. No operation was performed, but Unterberger regarded the case as one of patent urachus.

A Dilated and Infected Urachus Communicating With the Bladder and Umbilicus.* — A. W., white, male, aged forty, was admitted to the Georgetown University Hospital, June 21, 1904. When twenty years old he had gonorrhea, from which he made a good recovery. His present trouble began when he was seventeen years of age, with pain in the suprapubic region extending to the umbilicus. There was induration and tenderness of the parts on pressure. These symptoms grew worse; poultices were applied, and two weeks later an opening appeared at the umbilicus through which was discharged a moderate amount of pus. From this time the fistula remained patulous almost constantly, with a discharge of pus and urine. Occasionally it would close — never longer than for two days, during which time there would be considerable pain, especially on urination. When the opening closed, the area around and below the navel would become inflamed, and when it was reestablished, spontaneously or by the patient, there would be immediate relief from pain and the escape of a large quantity of dark, offensive-smelling fluid. The odor was worse after the fistula had been closed a day or two than when it was discharging freely, but at all times it was offensive, to a great extent barring the patient from the society of his friends. The discharge had always been most profuse during urination, and in the morning, when the patient would begin to move about, but there was at all times enough to keep his clothing soiled. At thirty-four years of age he had an attack of pain in the region of the right kidney, with nausea, vomiting, and elevation of temperature, and he had to keep to his bed for three weeks. Since then he had had other attacks of less severity, usually beginning with pain in the loin and extending to the testicle, sometimes accompanied by vomiting and the passage of blood through the urethra. The attacks had always been most severe after exertion.

Examination showed a large, robust, well-nourished man, with good color and apparently in excellent health. At the umbilicus was a flat area of scar tissue of a bluish color, containing a small opening through which a probe could be passed

  • Vaughan, George T. : Patent Urachus. Review of the Cases Reported. Operation on a

Case Complicated with Stones in the Kidneys. A Note on Tumors and Cysts of the Urachus. Trans. Amer. Surg. Assoc, 1905, xxiii, 273.


602 THE UMBILICUS AND ITS DISEASES.

downward and slightly backward for a distance of three and one-half inches into a pouch which lay in front of the bladder.

The urine from the bladder contained urates and epithelial cells. A diagnosis of patent urachus with dilatation into a pouch and infection of its contents was made, and operation was advised.

Operation (June 25, 1904). — The bladder was distended with water through the urethra, and a grooved director was passed through the umbilical fistula to the bottom. The cavity was opened, and a considerable amount of bloody pus, with an offensive urinary odor, was evacuated. The sac was pyriform in shape, with the small end above: it lay in front of the peritoneum, and above and in front of the bladder, with which it communicated through a very small opening. The sac was about three inches in length, and had a capacity of about three ounces; it contained many laminated clots and resembled very much a small urinary bladder, the walls containing muscular and fibrous tissue and being lined with mucous membrane. The sac was carefully dissected out, the peritoneum being opened in two places accidentally, and the walls were brought together. Recovery was without incident except for the high temperature that occurred on the day after operation (107° F. in the axilla), and he was well three weeks after the operation.

On August 13, 1904, just a month after leaving the hospital, the patient had a severe attack of renal colic on the right side, with chills, vomiting, blood}^ urine, dehrium, and swelling of the face and extremities. His pulse was 140, the temperature 104° F. On August 21st the right kidney was incised, and a round stone, half an inch in diameter, was removed. After this the patient had no further trouble until February, 1905, when he had an attack of renal colic on the left side, with the passage of several small, pea-sized calculi from the bladder. A month later he had another attack, which was much more severe and was complicated with almost complete suppression of urine for forty-eight hours, delirium, chills, and a temperature of 106° F. On May 1, 1905, the left kidney was incised and two stones were removed. Up to June 27, 1905, the patient had had no further trouble with his bladder, but had had an attack of appendicitis which he managed to pass through without operation.

Under date of May 12, 1915, Dr. Vaughan writes: "After an operation on both kidneys for stone the patient got along pretty well until December 6, 1906, when I had to operate on the left kidney again, removing a large oval stone. Patient recovered, but had trouble again during the summer of 1914 (during my absence), and Dr. Fowler removed stones from the right kidney. He is in pretty good condition now, but evidently has stones, probably in both kidneys. Since June 25, 1904, patient has had five operations — excision of urachus and two operations on each kidney.'"

Suppuration of a Urachal Cyst. — In Weiser's* Case 3 the patient was a man aged seventy-three, who had always been well except for an attack of orchitis four months before the present sickness. For six months he had suffered with pain and soreness in the abdomen, but had noticed no tumor. Two weeks before Weiser's visit the abdominal wall had opened spontaneously two inches below the umbilicus, and discharged urine. There had never been any pus. When the patient was lying down quietly, the urine did not escape, but as soon as he assumed an upright position, there was a constant discharge. The old gentleman

  • Weiser, W. R.: Annals of Surg., 1906, xliv, 529.


URACHAL CAVITIES AND INFECTIONS.


603


OOTteo LINE REPRESENTS UVACHUS *-* CYST WALLS



appeared perfectly well aside from this urinary sinus, which in caliber was about

the size of a pencil, and entered immediately into a large sac, the lower limit

of which Weiser could not reach with an eightinch probe.

Weiser entered the peritoneal cavity above the

sinus, and found the sac anterior to the parietal

peritoneum. The sac extended to within one inch

of the umbilicus, above which the urachus was not

patulous (Fig. 253), and downward into the pelvis.

It was intimately connected with the bladder at the

point of urachal attachment, and was densely adherent to the posterior bladder-wall as well as to

the intestines, the greater part of the sac being made

up of abdominal viscera. After freeing the anterior

wall of the cyst sufficiently, he made a plastic closure

of the original point of rupture through the abdominal wall. A catheter was placed in the bladder through the urethra and allowed to remain for several days. The abdominal wound was closed without drainage. The patient made a good recovery, and was about the house on the fourteenth

day. Two months later Dr. Stowell, under whose care the patient had been originally, told Dr. Weiser that the abdominal wall had given way again a trifle lower down toward the symphysis, and urine was again discharging through a small sinus. Later the opening closed spontaneously.

A Very Large Abscess-sac Extending into the Pelvis, Opening a t t h e Umbilicus, and Containing a Calculus. — This case in many respects suggests an umbilical abscess that reaches very large proportions and contains a concretion. On the other hand, it makes one think of certain cases of abscess of the urachus. I wrote Dr. Weiser* as to the character of the calculus. From his reply it was evidently of urinary origin, and probably made up largely of oxalates. A woman, seventy-five years of age, had for fifteen years suffered inconvenience

from a discharge of pus from the umbilicus. The discharge was constant and at

  • Weiser, W. R.: Annals of Surg., 1906, xliv, 531.


Fig. 253. — Urachal Cyst. (After W. R. Weiser, Case 3, Fig. 3.) Male, aged seventy-three. The abdominal wall opened spontaneously two inches below the umbilicus and urine was discharged. The sac extended upward to within an inch of the umbilicus ; downward into the pelvis. It was intimately attached to the fundus of the bladder.


Fig. 254.


(After


-Urachal Cyst. W. R. Weiser.)

Revised from Case 1. At the operation Weiser tapped the cyst, evacuating five ounces of horribly fetid pus, followed by a calculus weighing 70 grains. The cyst had a thick and indurated wall and dipped well down into the pelvis. It was extraperitoneal. [Dr. Weiser tells me that in his article two of his pictures were not properly placed, hence the "revision."— T. S. C.l


604 THE UMBILICUS AXD ITS DISEASES.

times profuse. At various times she had consulted a physician in reference to the condition, but, aside from prescribing various washes and ointments, no treatment or diagnosis was offered.

She finally consulted Dr. Weiser. The patient at this time was well nourished and active for her age. The abdomen was very fat, and a tumor the size of a cocoanut presented in the median line, between the umbilicus and the symphysis. The mass could be raised with the abdominal wall and was apparently attached thereto.

There was a copious discharge of foul-smelling pus from the umbilicus, and an eight-inch probe, passed into the sinus, failed to reach the lower wall of the sac. The temperature was 101° F., her pulse, 100. She volunteered the information that the condition was no worse than usual, but that she was not feeling well generally, and during the past month there had been very frequent micturition.

Under ether Weiser excised the umbilicus and unhealthy skin surrounding it, and cutting down through two inches of fat, came upon a bulging mass extending from the umbilicus as far down as he could feel toward the symphysis (Fig. 254). This he tapped, and evacuated about five ounces of horribly fetid pus, followed by a calculus weighing 70 grains. Exploration with the finger demonstrated the fact that the cyst had a thick and indurated wall, and dipped well down into the pelvis. Up to this point in the operation he had not opened the peritoneal cavity. He now washed out the sac. packed it with gauze, and entered the peritoneal cavity, above the location of the tumor. To his surprise he found the mass densely adherent to the intestine posteriorly, and on passing his hand down into the pelvis on the outside of the cyst, discovered it to be closely associated with the bladder. He now concluded that he was dealing with a urachal cyst, and, as the posterior wall was almost entirely made up of intestines, he concluded to cut away such portions of the sac as seemed safe. He left the posterior wall intact, as well as that portion which dipped down into the pelvis. The wound was closed as- far as the peritoneum, and the rest was walled off with a coffer-dam drain of iodoform gauze. Her recovery was uneventful, but it required three months for the sinus to close.

March 11, 1912. My Dear Dr. Cullen: Replying to your letter of the eighth inst. and referring to the urachal calculus: The stone was quite hard, and the surface was dark brown, resembling in color a type of gall-stone. Upon cutting open, the substance of the stone resembled a hard bladder stone in color and general appearance.

Unfortunately, this stone was lost before reaching the laboratory, but I think it was probably made up largely of oxalates. My opinion was that this was a urinary calculus which became discolored on its outer strata by lying in a bed of foul pus and being exposed through the discharging sinus at the umbilicus.

Cordially yours,

Walter R. Weiser.

Case of Vesico-umbilical Fistula of FourteenYears' Standing. — Wbrster* reports the case of Miss H., aged twenty-one. She had good health until a severe attack of diphtheria when eight years old. Following this she had incontinence of urine and cystitis. From about this time she could not straighten herself up properly and had a habit of standing with the body bent forward at an angle of 45 degrees. She was also incapable of stooping to pick up any

  • Worster, Joseph: Med. Record, 1877, xii, 196.


URACHAL CAVITIES AND INFECTIONS. 605

thing. Two years after the diphtheria she suffered from a cystitis, accompanied by a copious flow of purulent matter from the urethra, and shortly afterward a swelling was noted in the umbilical region, the appearance of which was followed by large and repeated discharges of pus from the umbilical opening, and subsequently of urineThe umbilical inflammation subsided, but pus escaped from time to time, and the urine continually. In her eleventh year, as a result of a contusion, an opening occurred below the umbilicus, from which urine escaped. Extending from the bladder to the umbilicus was a hard, cord-like mass, two inches in diameter and uniform in size.

Operation (April 14, 1875). — Two elliptic incisions were made and the umbilical area removed. Eight days after the operation urine escaped from the wound. A second operation was undertaken at once, with good results.


LITERATURE CONSULTED ON URACHAL CAVITIES COMMUNICATING WITH THE BLADDER OR UMBILICUS OR WITH BOTH.

Ball, C. B. : A Case of Pervious Urachus with Remarkable Disease of Bladder. Trans. Acad.

Med. Ireland, 1883-84, Dublin, 1884, ii, 376. Bourgeois: Jour. gen. de med., 1821, lxxvi, 219. Bramann, F. : Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., 1887,

xxxvi, 996. Freer, J. A. : Abnormalities of the Urachus. Annals of Surg., 1887, v, 107. Garrigues, H. J.: Persistent Urachus in an Adult Woman. Med. Record, New York, 1899, lvi,

720. Graf, F. : Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896. Hastings, C: A Singular Case of Ischuria. London Med. and Phys. Jour., 1829, N. S., vi,

515. Hind, W. : Diseases of the Urachus and Umbilicus. Brit. Med. Jour., 1902, ii, 242. Ill, E. J.: Tumors of the Urachus. Trans. Amer. Assoc. Obst. and Gyn., 1892, v, 238. Amer.

Jour. Obst., 1897, xxxvi, 568. Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. Marshall, G. B. : Case of Patent Urachus over One Inch in diameter, forming a Tubular Prolongation of the Bladder. Jour. Obst. and Gyn. of the Brit. Empire, 1907, xi, 259. Matthias, F. : Vereiterung des persistierenden Urachus mit Durchbruch in die Blase und in die

Bauchdecken. Beitriige z. klin. Chir.; herausg. von Paul Bruns, Tubingen, 1904, xlii, 339. Monod, J. : Des fistules urinaires ombilicales dues a la persistance de l'ouraque. These de Paris,

1899, No. 62. Morgan, G. : A Case of Dilated Urachus Accidentally Opened Whilst Performing Abdominal

Section for Peritonitis; Recovery. The Lancet, 1896, ii, 1154. Newman, D.: Three Renal Cases, a Case of Cyst of the Urachus, and a Case of Strangulated

Hernia, Treated in the Surgical Wards of the Glasgow Royal Infirmary. Glasgow Med.

Jour., 1896, xlvi, 20. Nicaise: Ombilic. Diet, encycloped. des sci. med., Paris, 1881, 2. ser., xv, 140. Patel, M.: Malformation congenitale de l'ouraque; dilatation kystique de la partie interieure de

l'ouraque demeure en communication avec la vessie; incontinence d'urine symptomatique.

Capitonnage de la poche. Rev. mensuelle des mal. de l'enfance, Paris, 1904, xxii, 77. Reid, W. L.: On the Diagnosis and Treatment of a Case of Patent Urachus. Glasgow Hosp.

Rep., 1899, ii, 76. Renard, Gabriel: Sur un kyste de l'ouraque. These de Lyon, 1905, No. 89. Robinson, F. B.: Cysts of the Urachus (Congenital Cysts, Extraperitoneal Cysts, or Dilatation

of Functionless Ducts). Annals of Surg., 1891, xiv, 336. Roser, W.: Ueber Operation der Urachuscysten. Langenbeck's Arch. f. klin. Chir., 1877, xx,

473. Savory, W. S.: Polypus of the Urinary Bladder. Med. Times, London, 1852, N. S., v, 106.


606 THE UMBILICUS AND ITS DISEASES.

Schnellenbach: TJeber die Urachuscysten. Inaug. Diss., Bonn, 1888.

Simon, C: Quels sont les phenoinenes et le traitement des fistules urinaires ombilicales? These de Paris, 1843, No. 80.

Timnierman, C. F. : Dilated Urachus. Trans. Med. Soc. State of New York, 1904, 331.

Unterberger: Retro versio-flexio uteri gravidi partialis incarcerata. Urachus-fistel. Monatsschr. f. Geb. u. Gyn., 1900, xi, 657.

Vaughan, G. T.: Patent Urachus. Review of the Cases Reported. Operation on a Case Complicated with Stones in the Kidneys. A Note on Tumors and Cysts of the Urachus. Trans. Arner. Surg. Assoc, 1905, xxiii, 273.

Weiser, W. R. : Cysts of the Urachus. Annals of Surg., 1906, xliv, 529.

Worster, J.: Case of Vesico-abdominal Fistula of Fourteen Years' Standing. Med. Record, 1877, xii, 196.


CHAPTER XXXV. ACQUIRED URINARY FISTULA AT THE UMBILICUS.

General consideration.

Acquired umbilical urinary fistula, when no urethral obstruction exists.

Umbilical urinary fistula following partial or complete blockage of the urethra.

Urinary fistula at the umbilicus, with absence of the urethra.

Congenital phimosis, with a urinary umbilical fistula.

Umbilical urinary fistula following stricture of the urethra.

Umbilical urinary fistula associated with a growth in the bladder.

Vesical calculi obstructing the urethra and associated with escape of urine from the umbilicus;

report of cases. Umbilical urinary fistula associated with an enlarged prostate; report of cases. Apparent escape of urine from the umbilicus, the breasts, and other parts of the body.

We have already considered (p. 487) congenital umbilical urinary fistulse due to a patent urachus, and also fistulse resulting from the opening of a urachal sac (p. 578). We shall now discuss acquired umbilical urinary fistulse, occurring apparently independently of urachal cyst formation.

These cases naturally fall into two classes :

1. Umbilical urinary fistulse when no urethral obstruction exists.

2. Umbilical urinary fistulse associated with partial or complete blockage of the urethra.

Monod, in his splendid thesis on Umbilical Urinary Fistulse Due to Persistence of the Urachus, mentions a case recorded by Laurentius in 1600. A young woman had retention of urine for several days; this was followed by an escape of urine from the umbilicus. He also refers to an observation published by Fernel in 1638. A man, thirty years old, developed an umbilical urinary fistula following an obstruction at the neck of the bladder. In the same thesis reference is made to a case recorded by Peyer in 1721, in which, following retention of urine, a calculus escaped from the umbilicus. Scattered throughout the literature are isolated cases of acquired urinary umbilical fistulse.

We have seen (p. 515) that remnants of the urachus are by no means rare. The urachus may remain as a small, patent filament connected with the bladder. In other cases the urachus at the bladder has been obliterated, but here and there along its course are small, spindle-like dilatations. In after-life these small bays or lakes may become connected up so that finally there is produced a fistulous tract between the bladder and umbilicus. Where there is obstruction of the urethra, it is only natural that the old channel through the urachus should open, but in those cases in which the urethra is of normal caliber, the reason for the reestablishment of the urachal channel is more difficult to explain, unless the urachus has always been patent or unless there has been an inflammatory reaction in the urachal region.

607


608 THE UMBILICUS AND ITS DISEASES.


ACQUIRED UMBILICAL URINARY FISTULA WHEN NO URETHRAL OBSTRUCTION

EXISTS.

In none of the cases here recorded was any abnormality noted at the umbilicus at birth. Five of the patients were males and one was a female. The youngest was a small boy; the oldest, eighty. In all the cases the urine escaped from both the umbilicus and the urethra. The recognition of the condition was eas3 r on account of the escape of urine from the umbilicus. In Binnie's case there was a line of induration between the symphysis and umbilicus. In Leveque-Lasource's case the eightyyear-old patient had been passing his urine at intervals from the umbilicus for twenty-five years. In this case the possibility of an enlarged prostate cannot be excluded.

Florentin thought his patient had a urinary fistula at the umbilicus. The history, however, is not very conclusive.

A Partially Patent Urachus That Finally Opened at the Umbilicus, Causing a Urinary Fistula. — Binnie,* in 1905, saw a woman twenty-nine years of age who for six years was supposed to have had cystitis of unknown origin. All her life she had complained of pain and tenderness in the hypogastrium, and Binnie found a line of induration between the bladder and umbilicus. Pus was escaping from the umbilicus. A little mass of granulation tissue was present at the umbilicus, and through this Binnie could pass a probe into the bladder. He excised the fistula, which was so closely attached to the peritoneum that the abdomen had to be opened. The fistula led into a small diverticulum at the fundus of the bladder.

On histologic examination the walls were found to consist of very vascular granulation tissue, together with sclerosed tissue. The lumen was lined with necrotic material. No epithelium was observed.

A Urinary Umbilical Fistula.! — ■ The man was thirty years old. The urine escaped in jets from the umbilicus, but some of it was passed through the urethra.

Possibly a Urinary Fistula at the Umbilicus. — Florentine reports a case narrated to him by Professor Froelich. A small boy, two years of age, was examined at the hospital of Nancy in January, 1906. At the umbilicus was a tumor the size of a gooseberry or currant. It had not increased in size. In the beginning there had been no discharge, but after several months a purulent fluid had commenced to escape in moderate amount from a small ulceration situated at the margin of the elevation, and still persisted. On examination there was seen at the base of the umbilical cicatrix a small, reddish tumor attached to the skin by a broad, short pedicle, from the base of which a little drop of pus was being discharged. The tumor was irreducible. There was a small ulceration with violet margins. In the center was a small depression, into which a probe could be introduced for 3 cm.

Operation. — The tumor was continuous with a fibrous cord, which extended down the median line. It was dissected out and tied off, the outer portion being removed. Healing took place. No microscopic examination was made. Floren

  • Binnie, J. F.: Development of the Urachus. Jour. Amer. Med. Assoc., 1908, ii, 109.

t Civiale, Jean: Traite de 1' affect ion calculeuse, Paris, 1838, 261.

t Florentin, P. : Fongus de l'ombilic chez le nouveau-ne et chez l'enfant. These de Nancy, 1908-09, No. 22 (obs. 8), 108.


ACQUIRED URINARY FISTULA AT THE UMBILICUS. 609

tin diagnosed the condition as a urinary fistula, but the case would seem to be doubtful.

Escape of Urine From the Umbilicus in an Old Man, * — The patient was a farmer, eighty years of age, of stout build. He had a double inguinal hernia. He had also had for a long period an umbilical hernia, which was not larger than a chestnut. For twenty-five years at times the urine had passed from the umbilicus, and sometimes from the urethra. It did not escape as a jet, as the opening was too small, but there was enough urine to keep the clothes wet. Xo method of control had thus far been discovered. Leveque-Lasource said that the condition was due to the reopening of the urachus.

A Case of Fistula of the Urachus. f — The patient was a soldier in active service, and had always been free from discomfort except that the pressure of the belt of his sword on the full bladder caused urine to escape from the umbilicus. At the umbilicus the opening was no larger than a hair in caliber, and even with a full bladder only a small amount of urine escaped. He was given a small quantity of potassium iodid and the urine soon contained an appreciable amount of iodin. The reaction was obtained from the umbilical urine by adding calomel, which at once gave it an intense yellow color.

A Vesico-umbilical Fistula. ± — -A boy, aged nine, had had incontinence of urine, and from time to time had complained of pain in the lower abdomen. For about six weeks urination had been frequent, and, three weeks before Trogneux saw him, moisture had been noted at the umbilicus, and later a few drops of urine had passed from the navel. The urine escaped both by the urethra and the umbilicus. Sometimes a large quantity came away from the navel, especially when the patient moved. The umbilical orifice was oval, elongated transversely, and the urine escaped from the bottom. The urethra was permeable. The bladder held 20 c.c. of fluid, and when more was introduced, it at once escaped by the umbilicus. The same result was obtained in the reverse direction. The urine contained pus.

Operation. — The tract was dissected out for 2 cm. and tied off. The upper part of the wound was closed. The canal was lined with what seemed to be macerated skin. On the tenth day the urine infiltrated the abdominal wall and escaped. The boy had tuberculosis in the apices of both lungs and was supposed to have tuberculosis of the bladder.

In this case the urachus did not open until the ninth year. The presence of the cystitis naturally hindered efforts at rectifying the condition.


UMBILICAL URINARY FISTULA FOLLOWING PARTIAL OR COMPLETE BLOCKAGE OF

THE URETHRA.

Although in the majority of the cases the definite type of obstruction to the escape of urine from the urethra has been stated, in a few cases it is merely recorded that an obstruction existed.

Monod refers to an observation made b} T Fernel in 1638. A man, aged thirty,

  • Leveque-Lasource: D'un cas particulier ou les urines sortaient par l'ombilic. Jour, de

med., Paris, 1811, xxi, 121.

t Starcke: Deutsche militararztliche Zeitschr., 1883, xii, 211.

% Trogneux, Albert: Contribution a l'etude des fistules ombilico-vesicales. These de Paris, 1897, No. 129. 40


610 THE UMBILICUS AND ITS DISEASES.

developed an umbilical urinary fistula following an obstruction at the neck of the bladder.

Littre* reported the case of a boy twelve years of age who had passed nearly all his urine by the umbilicus. At autopsy an obstruction was found at the neck of the bladder and the urachus had remained as a patent canal. Littre, in the same article, says that he knew a man thirty years old from whom the urine escaped forcibly from the umbilicus, no doubt as the result of an obstruction at the neck of the bladder.

Simon (obs. 14) records a case reported by Chopart.f I have attempted to find the original article, but was unable to locate it. It is, however, probably correct, as Chopart has many cases scattered throughout his excellent book.

The patient was a woman, thirty-seven years of age. Shortly after the beginning of pregnancy she suffered from retention of urine, and twelve days later several drops of puriform urine escaped. The abdomen increased in size day by day, and when she entered the hospital on September 7, 1781, she complained of abdominal tenderness. The skin was inflamed, and there was marked fluctuation around the umbilicus; the patient voided only in small quantities. She had high fever. Anthelme, surgeon-in-chief of the hospital, made an incision in the linea alba between the umbilicus and the muscle on the right, and a good deal of pus and a large quantity of fetid urine escaped. On the following day the symptoms were less acute. The clothes and the body were inundated with urine, and a large quantity of pus also escaped. On the next day the clothes were soaked with urine. The fever and other symptoms had disappeared, and the surgeon attempted to establish the return of the urine by the urethra. He was unable to introduce a sound into the bladder on account of some obstruction. Later on he was able to pass an elastic catheter into the bladder. The amount of urine escaping from the umbilicus diminished, and the pus in the urine gradually decreased. The pregnancy continued, and the patient left the hospital perfectly well. Normal labor took place in February, 1782.

Simon J says that at the meeting of the Medical Society in Florence, July 13, 1828, Betti reported a case seen by Falaschi, in which, as a result of a complete occlusion of the urethra at its vesical orifice, there was an escape of urine from the umbilicus in a patient very advanced in years. This phenomenon was observed for several months before death.

The various causes of blockage of the urethra have been:

1. A congeni tally closed urethra.

2. A congenital phimosis.

3. A stricture following gonorrhea.

4. New-growths of the bladder.

5. A vesical calculus.

6. An enlarged prostate.


URINARY FISTULA AT THE UMBILICUS, WITH ABSENCE OF THE URETHRA. The only case of congenital absence of the urethra with the escape of urine from the umbilicus with which I am familiar is that reported by Petit in 1837.

  • Littre: Histoire de l'Academie Royale des Sciences de Paris, Amsterdam, 1701, 27.

t Chopart: Maladies des voies urinaires, Paris, 1792. X Simon: Obs. 17, p. 33.


ACQUIRED URINARY FISTULA AT THE UMBILICUS. 611

Urinary Fistula at the Umbilicus, With Absence of the Urethra.* — The child was born with a closed urethra. At the umbilical cicatrix was a tumor the size of a cherry, from which urine escaped. A bandage was applied. The bandage retained the urine very well, but she was often obliged to remove it in order to relieve herself. The bladder was sensitive and did not hold more than half a glass of urine. As soon as it reached this degree of dilatation the child suffered from pain in the abdomen, particularly in the region of the bladder and the kidneys.


CONGENITAL PHIMOSIS WITH A URINARY UMBILICAL FISTULA. Freer, in his article on Abnormalities of the Urachus, refers to an article appearing in the Medical Record of August 18, 1871. A boy, a year old, commenced to pass his urine through a vesico-umbilical fistula. A few drops only passed by the urethra. An examination revealed a congenital phimosis with an orifice so small that the vis a tergo required to force the urine through it had exerted itself in an upward direction and had opened up the urachus, rendering that structure patent throughout. After this fistula had persisted for some time the cause was discovered, • circumcision was performed, and the urachus closed spontaneously.

Freer says this case emphasizes the importance of examining carefully the urethra before proceeding to operate for the closure of the fistula.


UMBILICAL URINARY FISTULA FOLLOWING STRICTURE OF THE URETHRA.

This is a very rare condition, considering the enormous number of patients who suffer from urethral stricture. Jacoby reported a case in 1877, and Guisy two cases in 1903. One of Guisy's patients also had an enlarged prostate which was probably a contributory factor to the urethral obstruction.

Umbilical Fistula Following a Urethral Stricture. f — The patient was a boy, eighteen years of age, who had contracted gonorrhea a year before and had developed a stricture. Later there was a perineal fistula. After taking balsam of copaiba he improved somewhat, but three months later the urine stopped completely for twenty-four hours. He suffered great pain and the umbilicus opened. Pus escaped, and then large quantities of urine, the continuous flow confining him to bed. When Jacoby saw him he had tuberculosis and syphilis. All the urine came from the umbilical fistula and none from the urethra. The fistula in the perineum was dry.

The umbilicus was flat. There was a very narrow fistula. Once the fistula closed and a small amount of urine escaped from the urethra. At the end of thirty hours, when the patient bore down heavily, the fistula reopened, and fully a quart of urine came away. This was mixed with pus and blood. The boy soon died. No autopsy is recorded.

An Umbilical Urinary Fistula Developing in a Man with Urethral Stricture and Enlarged Prostate. — • Guisy'sJ

  • Petit, J. L.: Traite des mal. chirurg., Chap, xi, 3. Oeuvres completes, 8°. Limoges,

1837. (Quoted by Simon, obs. 8.)

t Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, 202.

J Guisy, B.: Deux cas de permeabilite congenitale de l'ouraque. Ann. d. mal. d. org. genito-urin., Paris, 1903, xxi, 986.


612 THE UMBILICUS AND ITS DISEASES.

patient was a man sixty years of age, who, for five years, had been passing urine from the umbilicus. His previous history showed that he had suffered many years before with gonorrhea, and later with severe attacks of renal colic, accompanied by the passage of gravel from the urethra. He also had a urethral stricture. He developed pain and swelling about the navel. A physician opened the swelling and evacuated urine and pus, and thereafter the urine continued to flow by this route, as well as through the urethra. External urethrotomy was performed, and two large stones were removed from behind the stricture. The prostate was large. The urine ceased completely to flow from the umbilicus and recovery took place.

Escape of Urine from the Umbilicus Following Stricture of the Urethra. — Guisy's* second patient was a man aged thirtytwo years, who, on account of stricture following gonorrhea, had had great difficulty in passing urine and for two years had suffered pain at the umbilicus. Later a swelling appeared, and one day, during complete retention, the tumor ruptured and urine and bloody mucus escaped. Thereafter for several months there was constant leakage from the navel. A small sound could be passed through the navel into the bladder. The urethral stricture was treated by internal urethrotomy and dilatation, and the escape of urine through the navel diminished materially.


UMBILICAL URINARY FISTULA ASSOCIATED WITH A GROWTH IN THE BLADDER.

The only case of this character with which I am familiar is the one reported by Cadell in 1878.

Marked Cystitis in a Young Girl Followed by Escape of Urine from the Umbilicus. f — The patient was a delicate girl eight years of age. From her earliest childhood she had difficulty in making water. Micturition was frequent, and only a small amount of urine was passed. When she was six months old the lower abdomen and genitals became black and blue. The child went to school at four, but was taken home on account of pain and frequent urination. After an attack of typhoid fever at six years of age the other symptoms became more marked. Eight months before admission blood was noted in the urine. After a few days of great pain and swelling and hardness of the abdomen, the urine was observed to come in a small stream from the umbilicus. Nothing abnormal was noted in the appearance of the umbilicus or of the genitals. In the center of the umbilical depression was a fistulous opening into which a probe could be easily introduced and passed toward the bladder. A No. 2 elastic catheter introduced through the urethra was blocked by tenacious, mucopurulent masses in the bladder. The urethra was normal. No urine escaped by the urethra for several days. Later the urethra was dilated under anesthesia, and the procedure was followed by incontinence of urine.

The child died a few months later. At autopsy the bladder was found contracted and showed great thickening of the mucous and submucous coats. Protruding into the cavity were rounded nodules the size of peas. At the upper end of the bladder was the unobliterated urachus. It admitted the point of the little finger, gradually became narrower, and at the umbilicus admitted a No. 5 or No. 6 catheter. The

  • Guisy, B.: Loc. eit.

t Cadell, F.: Notes on a Case of Umbilical Urinary Fistula. Edinburgh Med. Jour., 1878, xxiv, Part i, 221.


ACQUIRED URINARY FISTULA AT THE UMBILICUS. 613

mucous membrane of the urachus was thin and pale. Between the umbilicus and the bladder were evidences of an old peritonitis, and the omentum was adherent to the anterior abdominal wall along the course of the urachus. There were dense adhesions binding the uterus to the posterior surface of the bladder.

The right kidney was twice the natural size, cystic, and filled with putrid and ammoniacal pus. There was complete atrophy of the kidney substance. The left kidney was one and a half times the natural size. The calices were distended with putrid pus, but the kidney substance had been only partially destroyed. Both ureters were dilated. Cadell says the urachus must have been partly open at birth.


VESICAL CALCULI OBSTRUCTING THE URETHRA AND ASSOCIATED WITH ESCAPE OF URINE FROM THE UMBILICUS.

Cases of this nature have been reported by Littre (1701), Raussin (1752), d'Auxiron (1766), Eustache (1789), Civiale (1838), Simon (1843), and Lexer (1898). In seven cases in which the sex was mentioned, five were in males and two in females. The ages varied from two and a half to seventy years. The age at which the patient came under observation is, however, no index as to when the symptoms first developed. For example, d'Auxiron's patient came under observation when he was seventy years old, but from the history it will be seen that he had had vesical symptoms since childhood. Eustache's patient, a boy six years old, had vesical symptoms shortly after birth.

The symptoms were usually those referable to a vesical calculus, and after various periods of time urine commenced to escape from the umbilicus. In some cases the umbilical fistula was preceded by an inflammatory reaction in the umbilical region; in other cases this phenomenon was apparently lacking.

Some of the patients were relieved by lateral lithotomy, and in Simon's case the stone was successfully removed suprapubically. After removal of the stone the umbilical fistula usually closed.

With our present mode of treatment these patients would naturally be operated upon soon after symptoms develop. If there be little or no infection, the fistulous tract should be dissected out and excised, and the stone removed suprapubically at the same time. When the inflammatory reaction is marked, the stone may be removed and the tract dissected out after the inflammation has subsided.


CASES OF VESICAL CALCULUS WITH ESCAPE OF URINE AT THE UMBILICUS. Vesical Calculi Followed by Escape of Urine at the Umbilicus.* — The patient was a priest, seventy years of age, who had suffered with vesical stone since childhood. He had piercing pains in the lower abdomen at times, and suffered from retention of urine, which sometimes lasted for several days.

For four or five years stones had blocked the urethra, and the urine had at times escaped from the umbilicus. There was a small opening with reddish margins at the umbilicus, out of which the urine oozed. Sometimes it came as a stream and could be caught in a vessel. When the urine escaped by the ordinary channel, the umbilical opening would close.

  • d'Auxiron: Une observation sur un homme qui rend ses urines par le nombril. Jour, de

m£d., Paris, 1766, xxiv, 58.


614 THE UMBILICUS AND ITS DISEASES.

Escape of Urine from the Umbilicus Due to a Vesical Calculus.* — In a patient seventy years old the urine escaped from the umbilicus in jets, in spite of the fact that the bladder was not extremely full. Each time it was found that a stone was obstructing the neck of the bladder.

Escape of Urine from the Umbilicus, Due to the Presence of a Vesical Calculus. — Civiale f says that Fourquet, of Toulouse, narrated to him the history of a child, thirty-one months of age, who was relieved by lithotomy. The vesical stone was voluminous, weighing 5.5 "gros," and enveloped in a covering of mucus and calcareous material. After about two months, as a result of considerable effort, the child expelled urine. It developed a urinary fistula at the umbilicus, from which three quarts or less of urine escaped. This closed after the operation.

Umbilical Urinary Fistula Associated With Stone Situated in the Neck of the Bladder. — Civiale also reports a case related by Covillard. The patient, a girl fifteen years of age, passed her urine from the umbilicus, and a stone was detected in the neck of the bladder. A lateral lithotomy effected an entire cure.

Urachal Fistula at the Umbilicus Associated With a Stone in the Bladder. — Lexer J reported a case that came under Goldschmidt's care. Goldschmidt operated on a ten-year-old boy on account of the gradual appearance of a fistula without signs of inflammation. This case was looked upon as one of urachal fistula of the abdominal wall, although no microscopic examination could be made. The boy had a large stone in the bladder. The fistula had produced an abscess-like dilatation below the umbilicus, and had been previously opened. At another time, when the cystitis had disappeared, the umbilical opening closed.

[This case is not particularly clear. — T. S. C]

Blockage of the Neck of the Bladder by a Stone; Partially Patent Urachus. — ■ Littre § demonstrated before the Paris Academy the body of a young man of eighteen. The neck of the bladder was occupied by a stone, and the urachus at the neck of the bladder was open for five fingerbreadths. He says that when the urine finds great difficulty in passing along its ordinary route, it commences to travel through its ancient channel.

A Renal Calculus Associated with Escape of Urine b y the Umbilicus. — Raussin|| reported before the Academy the case of a man, aged thirty-two years, who had had a renal calculus. In making an effort to urinate, while an attendant held the vessel, expecting to see a small stone fall into the vessel, he was greatly surprised to see urine passing from the umbilicus and from the penis at the same time. The umbilical stream was well formed, and made an arch over the shoulder of the servant, who at the time was kneeling. The umbilicus of the patient was represented as a tumor the size of a medium-sized walnut, with an opening in it which discharged a little blood. The patient continued to urinate by the

  • Civiale, Jean: Traitc de l'affection calculeuse, Paris, 1838, 257.
( Jiviale, Jean
Op. cit.

% Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. § Littre: Sur un foetus extraordinaire. Histoire de l'Academie Royale des Sciences de Paris, Amsterdam, 1701, 27.

1 1 Raussin : L'urine rendue par le nombril. Mem. de l'Acad. de Chir., Paris, 1752, ih, 10.


ACQUIRED URINARY FISTULA OF THE UMBILICUS. 615

umbilicus more than by the urethra, and claimed to be able to urinate by one or the other, as he desired. After a time most of the urine passed by the urethra.

Escape of Urine by the Umbilicus Due to Blockage of the Urethra by a Vesical Calculus.* — Dr. Eustache, surgeonin-chief of the Hotel-Dieu of Beziers, reported before the Academy of Surgery, in 1789, the case of a new-born boy who developed severe abdominal pain a few days after his birth. He was thought to have colic, but the usual remedies were given without success. At the thirteenth month he was weaned. The manner in which he urinated led to the supposition that he had a stone. When he was three years of age he drank to excess, and one day he consumed a pint of wine and became unconscious. The difficulty in urination increased. Sometimes he would have incontinence of urine, sometimes a dozen hours would pass without there being the escape of a drop. When five years of age he had complete retention of urine, and his abdomen was tender and painful, especially in the hypogastric region. His pulse was small and rapid, and the respiration was embarrassed. He had continual nausea. Pistre saw him on the third day, and at that time he had around the umbilicus a tumor which was inflamed, tender, and painful. Poultices were applied, and on the fourth day the child had not passed a drop of urine and was unconscious. On the fifth day there formed in the center of the umbilical tumor an opening about half an inch in diameter, and from this urine with pus escaped. Little by little the symptoms disappeared. The stomach retained nourishment, and he returned to the condition that he was in before the retention. The umbilical opening remained as a fistula and was the only passage by which the urine escaped. On the twenty-fourth of April, 1787, Eustache saw this patient, who was then six and a half years old. He had a slight fever and marasmus. Eustache confirmed the opinion of Pistre of the existence of a stone in the neck of the bladder, because a sound was arrested at this place and came in contact with a hard body. On the seventh of May of the same year, in the presence of several surgeons, Eustache extracted the stone through an incision in the perineum. It was in the shape of a large horn, and the lower extremity was engaged in the urethra. It was a little less than three inches long and 13^ inches in diameter. It was slightly concave toward the pubes, convex toward the rectum. After the extraction of the stone the urine commenced to escape through the wound, and in a short time the fistulous opening, which had been present for a year, closed. The urine contained much mucus. On the thirty-second day after the operation the urine commenced to pass by the urethra, and ten days later it passed entirely through this channel. The child made a good recovery.

Escape of Urine From the Umbilicus Due to Blockage of the Urethra by a Vesical Calculus. — Simon f reports the case of Marguerite P., aged twelve years, who had urinated by the umbilicus for four years. During this time not a drop of urine had escaped by the urethra. She had an enlargement of the abdomen, due to the escape of urine into the cellular tissue of the skin and of the muscle. She was brought to the hospital in May, 1786. With a sound an obstruction was found in the canal, which was preventing the flow of urine. The opening in the umbilical region offered a channel which communicated with the bladder. By this means it was possible to detect a stone fixed in the inner orifice of the urethra. The surgeon decided to pass a sound into the bladder by way of the urachus. The child was laid upon the table, the head and the buttocks being a little

  • Simon: These de Paris, 1843 (obs. 19), 34. f Simon: Op. cit. (obs. 25), 44.


616 THE UMBILICUS AND ITS DISEASES.

elevated. After the sound had been introduced into the bladder by way of the urachus an incision was made in the skin for about the length of three fingerbreadths in the linea alba, and ending at the pubes. The sound acted as a guide. The bladder was opened. The stone was the size of a pigeon's egg. After the extraction of the stone the child was promptly put to bed, and a sound was introduced through the urethra. At the end of four months the urine escaped regularly by the urethra.


UMBILICAL URINARY FISTULA ASSOCIATED WITH AN ENLARGED PROSTATE.

Levie, Lexer, and Monod have recorded cases in which a urinary fistula developed at the umbilicus in patients suffering from an enlarged prostate.

In this connection it may be mentioned that, according to Kirmisson, Horion observed an umbilical fistula that had developed after retention caused by a prostatic abscess.

A P a t e n t U r a c h u s A s s o c i a t e d W i t h an Enlarged Prostate.* — The patient was a man seventy-nine years of age. After several years of dysuria due to an enlarged prostate, the urine commenced to escape from the umbilicus. At autopsy the urachus. was found open. The opening into the bladder was tubular. The opening was from 1 to 1.5 mm. broad.

Markedly Enlarged Prostate, Followed by Cystitis and Escape of Urine From the Umbilicus. — Lexer f reports the case of a man, aged sixty-seven, who came to the clinic for three years on account of a prostatic hypertrophy and a resulting cystitis. He came whenever retention of urine developed. The urine was removed with a soft catheter, and the bladder washed out each time. The patient, on coming to the hospital later, said that, after there had been a stoppage of urine for twenty-four hours, it had commenced to come away by the umbilicus. He had noticed no unusual pain, and there was no inflammation in the region of the umbilicus. The entire flow of purulent, slimy urine escaped from the umbilicus.

On examination the patient was found to have a markedly enlarged prostate. A sound could be carried from the umbilicus for 6 cm. toward the bladder. From the umbilicus to the symphysis in the middle line a cord-like mass could be felt. [In such a case it would now be very easy to use bismuth paste and get a clear picture of the character of the fistulous tract by means of the x-ray. — T. S. C]

Lexer said that the almost complete lack of symptoms in the development of the fistula was a strong indication against perforation of the bladder with infiltration of the urine. He says that, in view of the slow development and the fact that the position of the fistulous tract was exactly in the mid-line, the whole picture tends to prove that the case was one of urachal fistula.

[With the present brilliant results obtained by prostatectomy, as carried out by Young and others in this country, the first thing would be to remove the prostate; this would materially improve matters, and later, if necessary, the fistulous tract could be closed.— T. S. C]

With a sound in the tract Lexer divided it. It was surrounded on all sides by very firm connective tissue, and about 5 cm. above the symphysis he found a cavity

  • Levie, L. : Een geval van profluvium urinae per umbilicum ab uracho patente bij een

volwassen persoon. Nederlandsch. Tijdschrift voor Geneeskunde, 1878, xiv, 501. t Lexer, E.: Loc. cit.


ACQUIRED URINARY FISTULA AT THE UMBILICUS. 617

the size of a walnut lined with slimy granulations and filled with purulent urine. This lay behind the abdominal wall and reached to the symphysis. The sac communicated with the bladder by a fistulous opening, the size of a lead-pencil. The entire wound was packed with iodoform gauze and a retention catheter left in.

The patient died fourteen days later with signs of uremia and fever. At autopsy a marked pyonephrosis was found on both sides. The small, thick-walled, ulcerated bladder ended in a small funnel just in the mid-line. Here it communicated with the opening in the abscess-sac. On the inner side of the abdominal wall was the median vesical ligament, appearing as a prominent cord 2 cm. broad.

From the results of the operation and from the autopsy specimen, it is clear that the bladder and umbilical fistula lay in the mid-line, and in the very markedly thickened median vesical ligament. The opening in the bladder was situated exactly in the middle of the vertex and in front of the peritoneum. In the fistulous tract it was impossible to make out any epithelium.

Lexer comes to the conclusion that these fistulous tracts should be dealt with early, before there is much inflammation; that is, in childhood.

Umbilical Urinary Fistula Associated With Hypertrophy of the Prostate.* — This case is particularly interesting. In a man, sixty-two years of age, the umbilical fistula developed after a prostatic hypertrophy. On looking into the history it was found that the patient had urinated from the umbilicus from the time of birth until he was three weeks old. The fistula had then closed spontaneously after the application of appropriate bandages.

Enlargement of the prostate is relatively common, and notwithstanding the tension under which the bladder labors in some of these cases, the escape of urine from the umbilicus is exceptional. It really seems as if the umbilical fistula only develops in those cases in which the urachus has remained partially patent, or where its lumen has persisted almost to the umbilicus.

- Bardeleben and Chapin have also reported cases in which an enlarged prostate probably existed. Bardeleben's patient was ninety-two, Chapin's was sixty-six, years old.

A Urinary Fistula at the Umbilicus Developing in a Man Ninety-two Years of Age. — ■ Bardelebenf says that, in the Memoires de l'Academie des Sciences for 1769, there is a report of a man, ninetytwo years old, who had severe pain in the neck of the bladder for several days. After the pain had ceased, he noticed that he voided less urine than usual and that his umbilicus was wet. A clear fluid (urine) was found escaping from the umbilicus. In fourteen days the urine by the urethra ceased. He died in six months. The fistula persisted until his death.

Escape of Urine from the Umbilicus in a Man Sixtysix Years of Age. — Chapin's f patient was a man, sixty-six years of age, who was seen in June with retention of urine. He suffered a great deal of pain and passed no urine for forty hours. The urine then began to dribble, and finally the bladder was emptied with a catheter. He suffered agony beyond expression during

  • Jaboulay: Reported by Monod, Obs. 53.

f Bardeleben: Lehrbuch der Chirurgie und Operationslehre, 1882, iv, 223. t Chapin, Edward: A Case of Open or Patent Urachus. North Amer. Jour, of Homoeopathy, New York, 1897, third series, xii, 286.


618 THE UMBILICUS AND ITS DISEASES.

the retention. The catheter was used for several days, after which he developed a great deal of soreness over the upper part of the bladder. Palpation over this region was painful. His pulse was slightly accelerated, but he had no fever. He voided small quantities of strongly ammoniacal urine containing mucus. Later excoriations were noted around the umbilicus, and some pus escaped from this opening. The discharge became more watery and had the odor of urine. The amount of urine escaping gradually increased, and by November 5th fully three-fourths of the urine was coming from the umbilicus. A small stream came from the urethra, a large one from the umbilicus.


APPARENT ESCAPE OF URINE FROM THE UMBILICUS, THE BREASTS, AND OTHER

PARTS OF THE BODY.

The accompanying remarkable case, recorded by Lynker in 1836, is difficult to interpret. I have found no similar case in the literature.

Lynker* reports the case of a woman, aged twenty-four, who in 1831 had a bad fall and became sick. In 1833 she had paralysis of the lower extremities. Later she had dysuria and passed hardly any urine. Her breasts swelled up, and she passed what looked like urine from them, then from the umbilicus, and later from the legs, the rest of the body skin meanwhile being dry. She had marked pain and swelling in the lower abdomen.

Up to the time of writing no clue as to the cause had been obtained. The patient was still alive.

  • Lvnker: Retention d'urine suiviede 1' excretion de ce liquide par des voies inaccoutumees.

Gaz. mid. de Paris, 1836, vii, 602.


LITERATURE CONSULTED ON ACQUIRED URINARY FISTULA AT THE UMBILICUS. d'Auxiron: Une observation sur un homme qui rend ses urines par le nombril. Jour, de med.,

Paris, 1766, xxiv, 58. Bardeleben: Lehrbuch der Chirurgie und Operationslehre, 1882, iv, 223. Binnie, J. F.: Development of the Urachus. Jour. Amer. Med. Assoc, 1906, ii, 109. Cadell, F.: Notes on a Case of Umbilical Urinary Fistula. Edinburgh Med. Jour., 1878, xxiv,

Part i. 221. Chapin, E.: A Case of Open or Patent Urachus. North Amer. Jour, of Homoeopathy, New York,

1897. third series, xii, 286. Civiale, J.: Traite de l'affection calculeuse, Paris, 1838, 261. Florentin, P.: Fongus de l'ombilic chez le nouveau-ne et chez l'enfant. These de Nancy, 1908-09,

No. 22. Freer, J. A.: Abnormalities of the Urachus. Annals of Surg., 1887, v, 107. Guisy, B.: Deux cas de permeabilite congenitale de l'ouraque. Ann. d. mal. d. org. genito-urin.,

1903, xxi, 986. Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, 202. Kirrnisson: Maladies congenitales de l'ombilic. Traite des mal. chirurg. d'origine cong6nitale,

Paris, 1898, 208.

' 1 ue-Lasouree : D'un cas particulier ou les urines sortaient par l'ombilic. Jour, de m6d.,

Paris, 1811, xxi, 124. Levie, L. : Een geval van profluvium urinaj per umbilicum abs uracho patente bij een volwassen

persoon. Nederlandsch. Tijdschrift voor Geneeskunde, 1878, xiv, 501. Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. Littre: Sur un fcetus extraordinaire. Histoire de l'Academie Royale des Sciences de Paris,

Amsterdam, 1701, 27.


ACQUIRED URINARY FISTULA AT THE UMBILICUS. 619

Lynker: Retention d 'urine suivie de l'excretion de ce liquide par des voies inaccoutumees. Gaz.

med. de Paris, 1836, vii, 602. Monod, J.: Desfistules urinaires ombilicalesdues a la persistance de l'ouraque. These de Paris,

1899, No. 69. Petit, J. L.: Traite des malad. chirurg., Chap, xi, 3. Oeuvres completes, 8°. Limoges, 1S37. Raussin: L'urine rendue par le nombril. Mem. de l'Acad. de Chir., Paris, 1752, iii, 10. Simon, C: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales. These

de Paris, 1843, No. 80. Starcke: Fall von Urachusfistel. Deutsche militararztliche Zeitschr., 1883, xii, 211. Trogneux, A.: Contribution a l'etude des fistules ombilico-vesicales. These de Paris, 1897, No. 129.


CHAPTER XXXVI.

URACHAL CONCRETIONS AND URINARY CALCULI ASSOCIATED WITH URACHAL REMAINS.

Historic sketch.

Urachal stones or concretions.

Urinary calculi in the urachus.

Removal of vesical stones through the umbilical opening.

Other calculi in the umbilical region.

Phillips, in an article in Todd's Cyclopaedia of Anatomy and Physiology (1835), said that in January, 1787, Boyer exhibited a bladder taken from a man thirty-six years of age. The urachus formed a canal 1^2 inches long, and contained 12 urinary calculi each the size of a millet-seed. It was demonstrated that this canal was not a vesical sac or a prolongation of the vesical mucous membrane.

In 1838 Civiale, in his treatise on calculous affections, called attention to the fact that the anatomist Colombus had observed calculi at the umbilicus. Civiale refers to the case of a woman coming under Hagendorn's care, who had a very painful abdominal abscess which contained two calculi. He also refers to Vallisnieri, who spoke of stones escaping from the umbilicus. In Helwig's case, cited by the same author, a woman seventy years old had an umbilical abscess; it broke, and several stones escaped, one of which weighed 15 grains. In another case a man discharged from the umbilicus a calculus which weighed about an ounce and was as large as a pigeon's egg. Civiale also referred to cases observed by Tolet, Rhodius, and Roesler. The stones varied from the size of the kernel of an olive to that of a hazelnut. They escaped from the umbilicus.

Simon, in 1843, mentioned the fact that calcareous concretions had been found along the course of the urachus and had also escaped through the umbilical ring. He said that Colombus, Donatus, Harder, Bartholin, and Cruveilhier had reported such cases. '

Simon said that Rhodius and Helwig had reported cases similar in character. In the case of Helwig's patient, a man, the stone was the size of a pigeon's egg.

Concretions or calculi escaping from the umbilicus may originate from several sources. They may be formed in the bladder or in the urachus, which communicates with the bladder, and where, consequently, urinary salts can become concentrated, or, again, in a urachus, that is completely isolated from the bladder. Finally we have umbilical concretions. The escape of gall-stones from the umbilicus has been considered elsewhere.

Calculi developing in a urachus communicating with the bladder are identical in their composition with vesical stones. Those developing in the urachus, when no connection exists between it and the bladder, are very small; umbilical concretions are cheesy in character. These last have been considered in detail in Chapter XV (p. 247).

The majority of the cases mentioned in the historic sketch just given are not

620


CALCULI ASSOCIATED WITH URACHAL REMAINS. 621

sufficiently clear to enable one to determine with any degree of accuracy to which group they belong.

URACHAL STONES OR CONCRETIONS.

The careful and painstaking investigations of Luschka, published in 1862, give us a very comprehensive knowledge of the urachus. He says the urachal contents are not all alike. The fluid is usually pale yellow, thin, and translucent. It may, however, be cloudy, and brown or reddish in color. It contains a large number of cells, numerous fat-globules, and not infrequently corpora amylacea. In the dilatations and in the isolated cysts the contents are frequently sticky and of a dirty brown color, and scattered throughout the field are bodies which have a marked resemblance to prostatic concretions.

Urachal concretions were also described by Hoffmann in 1870.

Suchannek, in 1879, when describing the contents of a patent portion of the urachus, discussed the granular bodies. These, he said, judging from their reaction to acetic acid, are due to a degeneration of the epithelium, which is probably colloid or amyloid in character.

Wutz briefly details his findings in the cyst contents of the many cases he examined.

In Case 11 he noted that, a short distance from the bladder, the urachus contained an oval body 0.17 x 0.1 mm. It was brownish in color and homogeneous in consistence. In the further course of the tube were several diverticula and nippedoff cysts of various shapes. They contained firm brownish contents.

In Case 15 Wutz says that the cysts were filled with lumps of brownish and yellow material.

In Case 17 the cyst contents were yellowish white and friable.

In Case 18 Wutz found a spindle-shaped urachal cyst, 2x1 mm. Its contents were brownish yellow in color.

Wutz, in summing up his observations on cyst-contents, said that they consisted of fat-crystals, fat-droplets, free fat, large flat epithelial cells, brownish-yellow amorphous masses, isolated cholesterin crystals, and small, round, very glistening bodies. In one of the cysts in Case 22 he found a small, firm, stony hard, yellowish-brown, glistening body. Under the microscope this was irregular, nodular,\ and partly transparent. It was 0.37 x 0.36 mm. in diameter. On the addition of hydrochloric acid free carbonic acid escaped.

Ledderhose referred briefly to urachal concretions in 1890.

In Boyer's case, which we have already considered and In which 12 millet-seedsized stones were found in the urachus, these bodies were urinary stones.

Rokitansky (1861) referred to a case in which 21 calculi the size of linseeds were found in a urachal dilatation 0.6 mm. above the top of the bladder.

Veiel, one of Luschka's pupils, in his dissertation on the urachus published in 1862, described his findings in the body of a man forty-five years old. "Passing downward in the mid-line from the umbilicus was a delicate cord 1 mm. broad. Three centimeters above the bladder it commenced to get thicker, and at the bladder was 1.2 cm. broad. The urachus could be divided into four sections. The lowest section, situated nearest the bladder, was 14 mm. long and patent. The next was 7 mm. long, solid, and thread-like. The third was 8 mm. long and was also patent. The fourth section— nearest the umbilicus— was solid. After the urachus had been


622 THE UMBILICUS AND ITS DISEASES.

treated with acetic acid, three dilatations of the canal could be seen. They contained yellowish concretions.

Arrou, in 1910, in an article entitled A Suppurating Cyst of the Urachus, reported a case in which an abscess contained a stone or concretion the size of an olive; it was like a piece of incompletely dried mortar. [I should be inclined to look upon it as a simple umbilical concretion accompanied by inflammation, were it not for the fact that the lower end of the sac bore a definite relation to the urachus. — T. S. C]

Suppurating Cyst of the Urachus. — Arrou* reports the case of a patient operated upon by Tricot. A soldier with absolutely no history of bladder trouble complained of vague pain in the umbilical region. The pain became acute, and the patient when marching had to bend forward. There was no nausea and no intestinal disturbance. Urination was normal; there was no fever.

Examination revealed a painful plaque, as large as the palm of the hand, a little below the umbilicus. There was no edema or redness. Gradually a little swelling was noted over the painful area; this was accompanied by some fever.

Operation. — An exploratory incision was made under the supposition that there was an abscess in the abdominal wall, but when the patient was in the operatingroom, there was an escape of a small amount of pus from the lower margin of the umbilicus. A probe introduced into the small orifice passed downward and backward into a cavity, measuring 6 cm. in its vertical direction. The patient was at once anesthetized and the cavity incised. It proved to be the size of a mandarin orange. It contained a calculus the size of an olive, that was like a piece of incompletely dried mortar. The cyst lining resembled an inflamed mucosa. Unfortunately, both sac and calculus were lost.

The upper end of the sac ended at the bottom of the umbilicus. The lower extremity terminated in a closed cul-de-sac. Attached to the lower portion of the sac was a large cord, the size of the little finger, which became smaller and terminated in the fundus of the bladder. Arrou was sure that it was the urachus. The peritoneum was opened above and laterally. The intestines were protected and the urachus was cut across with the cautery at a point several millimeters above the bladder. The sac was completely removed and the wound closed. The patient made a good recovery.

From the data at hand it is evident that urachal concretions or stones are very rare. They are usually no larger than linseed grains or millet-seeds. They are usually yellowish brown or brown in color, and may resemble corpora amylacea. They are too small to be a surgical factor, and are of interest only to the pathologist.


URINARY CALCULI IN THE URACHUS. In 1877 Vosburgh reported his observations on a man aged fifty, who had been complaining of a soreness and constant pain at the navel. Examination showed redness, tenderness, and a hard swelling around the umbilicus. The tumor was incised, and at the depth of half an inch a stone, the size of a hickory-nut, was felt and at once removed. The stone was phosphatic in character and had a strong urinary odor. The wound healed. The patient stated that, about twenty years before, a stone had been removed in a similar manner from this location.

  • Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832.


CALCULI ASSOCIATED WITH URACHAL REMAINS. 623

Monod, in 1899, referred to the stagnation of urine in the interior of the urachus as giving rise to calculi. He said that Colombus, Marcellus, Donatus, Harder, and Bartholin had cited examples of this kind. He added that the calculi may be eliminated through the umbilicus, as was noted by Hagendorn, Rhodius, and Hehvig.

The same author mentions a case recorded by Peyer in 1721, in which a calculus escaped from the umbilicus after retention of urine. In the chapter on Urachal Infections I have referred to a case reported by Weiser (p. 603). The patient, a woman seventy-five years of age, had had a purulent discharge from the umbilicus for fifteen years. When Weiser saw her she had a tumor the size of a cocoanut situated in the mid-line, between the umbilicus and symphysis. When this was opened, five ounces of very fetid pus escaped, and also a calculus weighing 70 grains. The wound healed in three months. Wishing to find out the character of this stone, I wrote Dr. Weiser, and from his reply it appears probable that it closely resembled a vesical calculus, but, as noted from the history, there was no opening into the bladder and no urine escaped from the incision during the patient's convalescence.

Probably one of the most interesting cases is the one recorded by Dykes. It might be claimed that the extravesical portion of the stone developed in a diverticulum of the bladder, but the location of the opening in the top of the bladder and in the median line leaves little doubt that the cavity was a dilated portion of the urachus, especially as the probe in the cavity could be carried up to within two inches of the umbilicus.

Patent Urachus and Encysted Urinary Calculi.* — "This case, which both in its clinical and pathologic bearings I believe to be of some interest, came under observation on January 27, 1908, at Rae Bareli Oudh:

"The patient was a Hindu male, aged about thirty years, apparently healthy apart from his urinary complaint, which dated back some five years or more. Owing to pressure of work I had not seen him until he was on the operating table, prepared for litholapaxy. The urine, I was informed, was acid and free from albumin. Several small concretions lay free on the base of the bladder, but on commencing to crush the first, the beak of the lithotrite impinged upon what appeared to be a much larger calculus, occupying a position at the apex of the half -distended bladder. After the first stone had been crushed the projecting portion of this larger calculus was easily seized between the blades of the lithotrite, but was found to be fixed to the bladder- wall.

"To crush this calculus in situ appeared dangerous, if not impossible, so lateral lithotomy was performed and the forefinger passed into the bladder. The calculus was now found j ust within reach of the finger. With the forefinger on the tip of the calculus and the other hand on the abdominal wall, it was estimated to be of considerable size, and its upper portion seemed very close under the examining hand beneath the abdominal wall in the middle line. It was evidently an 'hour-glass' stone, the deeper half being considerably larger than the projecting portion felt by the finger. The projecting portion being steadied in the grasp of the lithotomy forceps, the perforated end of a long probe was insinuated alongside the neck, and gradually manceuvered around the whole circumference, loosening the retaining tissue, until, by gentle traction and rotation of the forceps, an 'hour-glass' calculus was safely delivered. A second calculus immediately dropped from the same pocket into the bladder cavity. It, together with the three small concretions, the presence

  • Dykes, Campbell: The Lancet, 1910, i, 566.


624 THE UMBILICUS AND ITS DISEASES.

of which, on the bladder floor, had already been detected, was now removed, and the debris of the small stone, first crushed, washed out. In case other concretions might still be lying in the pocket its recesses were explored with a probe. Nothing further was found, but the probe passed up in the middle line, easily palpable through the abdominal wall, to a point two inches below the umbilicus. At the upper end the pocket seemed to be contracted to a mere sinus. Convalescence was rapid and uncomplicated.

"The ' hour-glass ' calculus weighed over l^ ounces. Its neck was of about the thickness of a cedar pencil, but somewhat flattened. The deeper lobe was larger than the projecting head, which was capped by a pea-sized, rough, dark-colored concretion, easily broken off, when drj", from the head proper. This terminal concretion resembled exactly, in color and approximately in size, the four small concretions which had been found free in the bladder, differing only in being rough and not polished or faceted by attrition. This resemblance strongly suggested that these four also owned the same source, from the head of the ' hour-glass ' calculus. Each weighed about 10 or 12 grains. The second encysted calculus showed a large oval facet corresponding to a like facet on the base of the 'hour-glass' calculus. Its longer axis had lain at right angles to that of the diverticulum in which it lay. It weighed just over half an ounce.

Neither in recorded cases nor in museum specimens have I come across any instance in which an encj^sted calculus had occupied the apex of the bladder. All the records I have found refer to basal or lateral sacculi, such as are commonly associated with enlarged prostate and chronic cystitis. This is so, for instance, in all the cases of encysted calculus included in the late Sir Henry Thompson's series of over 800 cases, the specimens of which are now in the museum of the Royal College of Surgeons of England. From the position and relations of the diverticulum this case appears to be an example of persistent patency of the lower end of the urachus, with calculus formation following, presumably on the accidental lodgment of a small concretion in it.

"While urachal cysts are much commoner in the female than in the male, a patent condition of the urachus leading to urinary umbilical fistula is much commoner in the male."

A Patent Urachus; Vesical Calculi; Sac-like Dilatations in the Urachus Containing Urinary Calculi; Removal of All the Calculi; Recovery. — During the meeting of the Southern Surgical and Gynecological Association held in Cincinnati on December 13, 1915, the President, Dr. Bacon Saunders, of Fort Worth, Texas, told me of the following interesting case that came under his care several years ago.

The patient was a boy about eleven years of age. He had had all the classic symptoms of stone in the bladder since infancy. Examination disclosed a fistulous opening at the umbilicus through which escaped quantities of foul-smelling urine. On a line from the umbilicus to the pubic region were five nodules ranging in size from a hazelnut to an almond.

A number of small calculi, resembling prostatic stones were removed from the bladder. An incision was made over each of the nodules in the mid-line below the umbilicus and a stone removed from each. These stones were of the same character as those found in the bladder. Urine escaped from the multiple openings for a while, but these openings eventually all closed, and the boy made a satisfactory recovery.


CALCULI ASSOCIATED WITH URACHAL REMAINS.


625


REMOVAL OF VESICAL STONES THROUGH THE UMBILICAL OPENING.

In the chapter on Congenital Umbilical Urinary Fistula (p. 507) I have quoted the well-known case of Paget and Bowman. The patient, John Conquest, an iron founder, forty years old, had had a urinary fistula at the umbilicus since birth. Paget detected a stone in the bladder. The umbilical opening being rather large, he introduced a finger, engaged the stone in the urachus, and brought it out through the umbilicus. This stone was irregularly ring-shaped, having developed around a curled-up hair (Fig. 221, p. 507). It was by getting the tip of his finger into the central hole in the stone that he was enabled to remove it by this route.

Nicaise refers to a case published by Faivre in the Journal de mecl. et chir., 1786. The patient, a small girl of twelve, had for four years passed her urine from the umbilicus. The urethra was obstructed by a calculus. Finally there was considerable engorgement of the surface of the abdomen, due to the urine escaping into the cellular tissue. Faivre entered the bladder through the umbilicus and removed the stone. A sound was introduced into the urethra, and the child made a complete recovery.

If urinary calculi develop in the urachus, they will naturally be found near the bladder, as indicated in Fig. 255.



Fig. 255. — A Patent Urachus Containing a Vesical Calculus. (Schematic.) The urachus is recognized as an open channel from the upper part of the bladder to the umbilicus. Just above the bladder it contains a spheric and rough vesical calculus. In the upper part of the umbilicus is a small umbilical hernia.


OTHER CALCULI IN THE UMBILICAL REGION.

On p. 337 we have discussed at length the escape of gall-stones at the umbilicus. The following cases, reported by Kostlin and by Bramann, while not strictly germane to the subject, are of considerable interest.

Communication Between the Gall-bladder and the Urinary Bladder, With Escape of Gall-stones Through the Urinary Tract. — Kostlin* cites the case of a patient whose history Faber had already reported in an inaugural dissertation. This woman first had

  • Kostlin, O.: Verbindung zwischen Gallenblase und Harnblase, mit Abgang von Gallensteinen durch die Harnwege. Deutsche Klinik, 1864, xvi, 116.

41


626 THE UMBILICUS AND ITS DISEASES.

trouble when thirty-five yea,vs of age. In the autumn of 1834 she had signs of peritonitis, with pains in the umbilical region. Later the pain was more marked above the symphysis. In October, 1835, she was again ill, this time with bronchopneumonia. On the fourth day there was pain over the symphysis, and the urine was blackish green (bile). The patient soon passed gall-stones, large and small, by the urethra. The gall-stones were examined chemically. The patient was kept under observation for years. She died, at sixty-three, with symptoms of bronchial catarrh and asthma.

Autopsy. — The liver was normal, but the entire organ was situated lower than usual. From the middle of the lower edge a rounded cord extended to the base of the bladder, passing in front of the intestine and pushing the transverse colon downward and to the left. The cord consisted of two portions — the lower and larger half was 1" 7.6"' (about one and three-fourth inches long) and was composed of the urachus. The upper, shorter half belonged to the lower portion of the gall-bladder. The entire length of this was 3" 1.5"' (about 3}4 inches long). The route which the bile and gall-stones traveled was from the gall-bladder through the urachus to the urinary bladder.

Kostlin mentions a similar case, reported by Pelletan.* In this case there was no autopsy.

Probably a Distended Gall-bladder Opening at the Umbilicus.! — The patient was a single woman, sixty-three years of age. She had had typhoid when thirteen. At the age of forty-five she had had sudden abdominal pain, accompanied by high fever, and there was much discomfort in the gall-bladder region. There was a tendency to vomit, and the abdomen was somewhat swollen. A tumor could be made out above and to the right of the umbilicus. It was the size of a fist and painful. The tumor persisted, grew slowly, and tended to pass more and more downward toward the symphysis.

Two years later a large quantity of foul pus escaped from the umbilicus. Pus continued to be discharged in varying amounts from the umbilicus for about sixteen years. The patient was otherwise in good condition.

On admission the abdomen was found to be slightly distended. The skin surrounding the umbilicus was covered with crusts, exfoliated epithelium, and small cysts. The umbilicus was drawn in, and in its center was a small discharging fistula. The escaping pus was foul-smelling. On palpation exactly in the mid-line a long, egg-shaped tumor was noted. At the umbilicus this was 5 cm. broad. It extended almost to the symphysis, and in its lower portion it was 7 to 8 cm. wide. The tumor lay distinctly behind the abdominal wall, and only in the neighborhood of the umbilicus was it intimately attached. In the lower part it was somewhat movable. On pressure it was found to be of dense consistence. A sound could be passed 12 cm. toward the symphysis and the cavity widened out. Calculi were detected at the bottom. Urination was always normal.

Operation. — The abdominal wall was incised for 8 cm. from the umbilicus downward. Four faceted calculi the size of pigeon's eggs were removed, and the tract was curetted out. Healing occurred after three months, but in the mean time it was necessary to curet the cavity several times. After several vain attempts Bramann found in some places many layers of squamous epithelium.

  • Pelletan: Jour, de chimie med., 2. ser., ii, Nos. 11 et 12.

t Bramann, F.: Arch. f. klin. Chir., 1887, xxxvi, 996.


CALCULI ASSOCIATED WITH URACHAL REMAINS. 627

Microscopic examination of the calculi yielded cholesterin and bile-pigment ; no urinary salts.

[The condition might well be explained by a gall-bladder extending into the pelvis and at the same time becoming adherent to the umbilicus. Everything points to this explanation, although Bramann considered the case to be one of open urachus. — T. S. C]


LITERATURE CONSULTED ON URACHAL CONCRETIONS AND URINARY CALCULI

ASSOCIATED WITH URACHAL REMAINS. Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832. Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., 1887,

xxxvi, 996. Civiale, J.: Traite de l'affection calculeuse, Paris, 1838, 257.

Dykes, C: Patent Urachus and Encj r sted Urinary Calculi. The Lancet, 1910, i, 566. Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch, der

Heilkunde, 1870, xi, 373. Kostlin, O.: Verbindung zwischen Gallenblase und Harnblase, mit Abgang von Gahensteinen

durch die Harnwege. Deutsche Klinik, 1864, xvi, 116. Ledderhose, G.: Chir. Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Luschka, H.: Ueber den Bau des menschlichen Harnstranges. Arch. f. pathologische Anatoniie

u. Physiologie u. f. klin. Med., 1862, xxiii, 1. Monod, J.: Des fistules urinaires ombilicales dues a la persistance de l'ouraque. These de Paris,

1899, No. 62. Nicaise: Ombilic. Diet, encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv, 140. Phillips, B.: Persistence of the Urachus. Todd's Cyclopaedia of Anatomy and Physiology,

1835, i, 393. Rokitansky, C: Pathologische Anatomie. 3. Aufl., Wien, 1861, hi, 372. Simon, C: Quels sont les phenomenes et le trait ement des fistules urinaires ombilicales. These

de Paris, 1843, No. 80. Suchannek, H.: Beitrage zur Kenntnis des Urachus. Inaug. Diss., Konigsberg, 1879. Veiel, E. : Die Metamorphose des Urachus. Diss., Tubingen, 1862. Vosburgh, H. D. : Patent Urachus with Calculus. Medical Record, New York, 1877, 606. Weiser, W. R.: Cysts of Urachus. Annals of Surg., 1906, xliv, 529. Worster, J.: Case of Vesico-abdominal Fistula of Fourteen Years' Standing. Medical Record.

1877, xii, 196. Wutz, J. B.: Ueber Urachus und Urachuscysten. Virchows Arch., 1883, xch, 387.


CHAPTER XXXVII. MALIGNANT CHANGES IN THE URACHUS.

Carcinoma of the urachus.

Historic sketch.

Symptoms.

Report of cases. Sarcoma in the urachal region. An extraperitoneal abdominal tumor.

A large multilocular carcinomatous cyst of the urachus; secondary growths in the pelvis (personal observation). A rare umbilical cyst.

CARCINOMA OF THE URACHUS.

I have been able to find three cases of carcinoma of the urachus recorded in the literature.

Sex. — All of the patients were men. Two of the patients had had congenital urinary fistula? at the umbilicus, and in each of these the discharge of urine had ceased after the use of escharotics. The third patient also evidently had a congenital fistula, as he gave a history of "moisture at the umbilicus" during childhood. This had ceased without treatment.

Age. — The patients were twenty-five, twenty-seven, and thirty-two respectively, indicating that, when carcinoma of the patent urachus develops, the malignant change occurs in early adult life.

Hoffmann and Fischer gave very careful and full histories of their cases. Hoffmann's patient, when twenty-seven years of age, noted a raised hardening between the umbilicus and symphysis. It was the size of a goose's egg, non-painful, and movable from side to side. It gradually extended toward the symphysis and right inguinal region.

Shortly after the tumor was noticed the patient experienced pain on urination. At times the urine was abundant, at times it came drop by drop. The man rapidly grew weaker and lost 25 pounds in four months. When Hoffmann saw him. the umbilicus presented a peculiar radiating appearance, while in the mid-line, just below the umbilicus, was a roundish, nodular tumor, 8 to 10 cm. long, adherent to the umbilicus and very painful. After the patient had urinated an area of tympany could be elicited between the tumor and the symphysis. On account of tenesmus, the patient urinated every hour. The urine contained pus and aggregations of epithelial cells.

The tumor became fluctuant, ruptured, and a large amount of purulent and bloody fluid escaped, but the growth did not diminish in size. From time to time onion-like balls escaped with the pus. These consisted of quantities of squamous epithelial cells that had become agglutinated. Precisely similar balls escaped in Fischer's case.

The urethra was normal.

628


MALIGNANT CHANGES IN THE URACHUS. 629

The umbilical opening closed temporarily, but soon reopened, and in the late stages of the disease the inguinal glands were swollen.

As noted in the autopsy report, the cavity between the umbilicus and bladder had walls 1 cm. thick. Its inner surface had an irregular, ulcerated, and eaten-out appearance (Fig. 256). The bladder-wall had been involved by continuity, and also contained secondary nodules. The growth was a squamous-cell carcinoma.

Fischer's patient, when thirty-one years old, first noted a small, hard tumor the size of a pigeon's egg below the umbilicus. Seven or eight months later he had pain on micturition, and noticed a sediment in the urine. The nodule was incised on the supposition that it was fluctuant, and slimy, necrotic tissue escaped. The tumor soon grew out of the incision, bled a great deal, and finally left an ulcerated area, the walls of which were raised and hard, while the floor consisted of hard nodules. From the ulcerated area onion-like balls of epithelial cells escaped.

The inguinal glands on both sides became swollen. At autopsy the bladder mucosa showed a catarrhal swelling, but no involvement by the malignant growth. The prostate was normal. The growth was a carcinoma, evidently of the squamouscell type, as indicated by the onion-like balls.

Death in these cases may occur from gradual weakening as a result of the disease, or from a perforation of the growth posteriorly into the abdominal cavity, causing a peritonitis. The occurrence of three cases of carcinoma of the urachus is another point in favor of the early removal of the patent urachus.

In the future cancer of the urachus, when met with, will undoubtedly be operated on early. The growth can be given a relatively wide berth, and the block dissection should include the inguinal glands on both sides.

Cases of Carcinoma of the Urachus Developing Years After the Closure of a

Congenital Patent Urachus.

Carcinoma Evidently D e v e 1 o p i n g F r o m Remains of the Urachus. — Fischer* saw this patient in consultation with Hanuschke in 1874. The man, thirty-two years of age, sought treatment on account of an ulcer of the umbilicus. During his childhood, when voiding, there was a moisture at the umbilicus. Later these symptoms disappeared and there was never any trouble with urination. Early in 1873 he casually noticed below the umbilicus a hard tumor the size of a pigeon's egg. This gave rise to no symptoms. It gradually grew, and seven or eight months later there were pain and a burning sensation on micturition and sediment in the urine. Toward the end of 1873 he consulted a physician. The difficulty in urination had increased, and the tumor had grown markedly. His general condition was not satisfactory. Hanuschke thought that the tumor was soft, and that he could make out fluctuation. Accordingly he made an incision, and purulent, slimy masses escaped — evidently pieces of necrotic tissue. The tumor mass grew out of the incision wound ; it very soon broke down, with a good deal of bleeding, and an ulcer resulted. When Fischer saw the patient, he was pale and weak, had difficulty in micturition, and suffered from strangury. The ulcer was situated 2 cm. below the umbilicus, and formed a deep crater, which was heart-shaped. Its walls were elevated, hard, and extended below the level of the skin about 4 cm. Its greatest breadth was 8 cm. Its greatest length, 7 cm. The floor was very irregular

  • Fischer: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, n. F. No. 89 (Chir. No. 24), Leipzig, 1894, 519.


630 THE UMBILICUS AND ITS DISEASES.

and covered with hard nodules. It reached a depth of 5 cm. below the skin surface. Surrounding the ulcer the tissue was hard. On pressure there escaped a thin, bloody, foul-smelling pus from the ulcer, and there were also portions of the tumor forced out as small balls suggesting onions. These were composed of quantities of flat epithelial cells.

The urine was acid, slightly cloudy, and had a purulent sediment. The inguinal glands on both sides were swollen.

Complete removal of the growth was impossible. The abdominal walls, however, were split in the mid-line as far as the symphysis, and beneath the muscle thick, pork-like tumor masses were found adherent. As much of the tumor as possible was removed, and the cautery was employed. The patient died fourteen days after the operation. Microscopic examination of the tumor mass showed it to be a carcinoma. At autopsy the inner surface of the bladder was found to show catarrhal swelling. It was intact. There was no abnormality in the prostate. The intestines were normal.

A Patent Urachus, Closure; Later Carcinoma of the Urachus.* — This case was also mentioned in the Deutsche Klinik, 1864, xvi, 116. The patient was a man, twenty-eight years of age, who had a urachal fistula at birth. This was healed with escharotics. Twenty-five years later a tumor developed between the umbilicus and the symphysis. This broke and discharged pus and later urine. The autopsy revealed a carcinoma of the mucosa of the urachus, which had perforated into the umbilicus and into the bladder.

A Patent Urachus Partly Closed by the Use of Escharotics; Later, Carcinoma of the Urachus. — Hoffmannf first reports the case of Hermann R., in which there was an enormous sac formation and accumulation of fluid outside of the abdomen. This Hoffmann attributed to a dilated urachus.

Hoffmann reports the case of Alexander Wanner, a postal employee, who was born in 1841 with an opening at the umbilicus through which urine escaped, while it also passed from the urethra. This condition lasted until his third year, when the opening closed after the use of escharotics. The patient had no further difficulty, and with the exception of several inflammations of the eye was perfectly well. About the middle of the year 1868 he noticed between the umbilicus and the symphysis, near the umbilicus, a raised hardening of the abdomen about the size of a goose's egg, which was not painful and could be pushed from side to side. This gradually grew and extended toward the symphysis, and spread toward the right inguinal region. Shortly after the appearance of the tumor the patient began to have pain on urination. The urine sometimes came in an abundant stream; at other times only in drops. As a result the patient had a continuous desire to urinate. The pains became severe and he grew weaker. He had lost weight — in the last four months, 25 pounds. On admission to the hospital, November 10, 1868, he weighed 99 pounds, was poorly nourished, anemic, and had a peculiar radiating formation of the umbilicus, in the folds of which no opening could be discovered. Immediately below the umbilicus was a tumor, 8 to 10 cm. long, situated in the middle line. It

  • Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896.

t Hoffmann: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch. d. Heilkunde, 1870, xi, 373.


MALIGNANT CHANGES IN THE URACHUS. 631

was roundish, nodular, very painful, and adherent to the umbilicus, but on both sides it was free. After urination, between the tumor and the symphysis was an area of tympany. On account of the tenesmus the patient urinated every hour, and the urine contained pus and aggregations of epithelial cells. The patient drank quantities of soda-water and local applications were made. His pain diminished, but the tumor continued to grow. The umbilicus became prominent, fluctuation was detected, and on December 1st the swelling broke and a large quantity of thick, purulent, bloody fluid escaped. The tumor, however, did not diminish in size, although the pain became less and less. In the fluid numerous onion-like balls were found. These consisted of large quantities of squamous epithelial cells which had become agglutinated.

Examination of the urethra with a bougie yielded nothing abnormal. The prostate was not enlarged, the bladder-wall was thick and did not contract completely after the escape of urine. From September 4th urine and purulent fluid often escaped from the umbilicus, and the urine passed from the bladder from that time on was cloudy. The opening at the umbilicus gradually contracted, and for some time only purulent fluid escaped from it. The tumor became smaller, and toward the middle of January, 1869, the umbilicus closed completely.

Diarrhea developed and marked emaciation. At the end of January the opening at the umbilicus reappeared, and a purulent-like material escaped. The pain became more severe. The inguinal glands were swollen and the patient grew weaker. On January 31st he weighed 88 pounds. He died in the middle of May, 1869.

Only an incomplete autopsy could be obtained. The family physician who made it said there were appearances of peritonitis. The umbilicus had a peculiar, radiating, stellar appearance, and there was an opening 3 mm. in diameter. Through this there was a passage going downward and backward into a canal which gradually widened. The cavity had walls 1 cm. thick. It extended from the umbilicus to the top of the bladder. It was 10 cm. in length, and in its middle portion was 2.5 cm. broad. The entire inner surface presented an ulcerated, irregular, much eaten-out, reddish appearance (Fig. 256).

At its lower part this cavity communicated with the bladder by an opening 3.3 cm. broad, and the posterior wall of the bladder was invaded by this ulcerated growth over an area 4 cm. in diameter. The bladder-walls, where invaded, were 1.8 cm. thick, while the unchanged portions were 0.8 cm. thick. At the point where the cavity communicated with the bladder posteriorly was a perforation, the exact size of which could not be determined on account of the tearing of the specimen. The bladder mucosa, on the whole, looked normal, but at one point in the anterior wall was a round nodule, 1 cm. in diameter; in the posterior wall were several smaller ones.

Microscopic examination showed that the growth of the urachus was a squamouscell carcinoma, and that the secondary nodules were also carcinomatous.

Hoffmann says that this patient was born with a patent urachus. The opening at the umbilicus had closed after the use of escharotics in the third year. In the twenty-seventh year a carcinoma developed in the urachus and extended to the bladder. The perforation caused by the cancer led to a local peritonitis.

A Urachal Cyst and Cancer of the Bladder Occurring Independently. — ■ Rotter's case may well be considered here. The urachus


632


THE UMBILICUS AND ITS DISEASES.



J- 'ig. 256. — Carcinoma of the Patent Ubachus. (After C. E. E. Hoffmann.) A is a partially diagrammatic picture: ", The anterior abdominal wall; b, the opening of the urachus at the umbilibe urachus, which is occupied by a carcinoma; at d the growth has broken through into the abdominal cavity; < , the bladder. At points /, /, /, /, on the bladder mucosa are small secondary carcinomatous masses. B represents the appearance of the umbilicus with the opening of the urachal fistula in its center.


MALIGNANT CHANGES IN THE URACHUS. 633

was the seat of a cyst and the bladder showed a carcinoma. The one was absolutely independent of the other.

Rotter's* patient was a forty-three-year-old man, who, for nine months, had had bleeding from the bladder. Cystoscopic examination showed a tumor in the upper portion of the bladder. This did not grow rapidly. Above the symphysis, and reaching to the umbilicus, was another tumor, which on aspiration yielded a fluid containing cholesterin. This tumor was diagnosed as a urachal cyst. At operation the upper tumor was found lying between the peritoneum and the abdominal muscles. In its upper portion it was free, but over the lower half it was so intimately blended with the peritoneum that it was necessary to remove a portion of the peritoneum with the tumor. The urachal tumor pressed so into the bladder muscle that it was also necessary to open this viscus.

The cancer of the bladder was removed, and a defect 7 by 8 cm. in the bladder closed by layers. This patient was shown by Rotter at the Berlin Surgical Society. Microscopic examination demonstrated carcinoma of the bladder. This had perforated at the point where the cyst was found. The cyst contained many polymorphous epithelial cells. There was no doubt that it was a urachal cyst.

Possibly an Adenocarcinoma of the Urachus. — I am at a loss where to place this case of Koslowski's.f The situation of the tumor suggests a urachal growth. Furthermore, the variation in the size of the glands might very readily correspond to the cyst-like spaces we have noted where isolated segments of the urachus have persisted. The invasion of the rectus sheath and of the rectus muscle naturally points toward malignancy. We shall accordingly leave this case among those of carcinoma of the urachus. Whether it really belongs here or not is problematic.

The patient was a man, fifty-five years of age, who five weeks before had noticed in the mid-line, between the symphysis and the umbilicus, a small, painful tumor which grew to the size of a walnut. This man was markedly emaciated, looked to be seventy years of age, had frequent diarrhea, and was bent over from guarding the abdominal muscles. Between the umbilicus and symphysis, near the mid-line, was a tumor which suggested a patella. The overlying skin was free. The tumor was slightly movable and very painful. It felt very tense, and gradually merged into the surrounding tissue. Passing from the tumor toward the umbilicus was a cord the size of a goose-quill. Koslowski thought the tumor was a malignant epithelial growth developing from remains of the urachus.

Operation. — A median incision showed that the linea alba and sheath of the rectus had been penetrated by the tumor. An elliptic incision encircled the umbilicus and the tumor. Removed with the tumor were portions of the sheath of the recti and some of the rectus muscle, the transversalis fascia, and peritoneum. After the abdomen was opened, the tumor was drawn up and brought into view fibrous cords passing to the umbilicus. The upper cord was the size of a goose-quill, firm, and infiltrated. The lower cord was less firm and contained veins; these passed into the vesico-umbilical ligament. The peritoneum covering the posterior surface of the tumor showed evidence of scar and of ulceration. The patient made a good recovery. The tumor in form resembled a patella. The peritoneum was firmly

  • Rotter: Blasencarcinom combinirt mit Urachuscyste. Centralbl. f. Chir., 1897, xxiv, 604.

t Koslowski, B. S.: Ein Fall von wahrem Nabeladenom. Deutsche Zeitschr. f. Chir.. 1903, lxix. 469.


634 THE UMBILICUS AND ITS DISEASES.

attached to it. The surrounding muscle was penetrated by the tumor. Microscopic examination showed that it was made up of glands of various sizes. They varied from the size of urinary tubules to those large enough to be noted with the naked eye. The diagnosis was fibro-adenoma submalignum. The glands resembled intestinal glands.

[It is difficult to establish the exact character of this tumor. — T. S. C]


SARCOMA IN THE URACHAL REGION.

Frank, in 1893, recorded a very interesting case of sarcoma probably developing in the sheath of the urachus in a young lad. Unfortunately, the subsequent history of the case is lacking, but the histologic picture of the growth, the invasion of the muscles of the abdominal wall, and the secondary nodules in the omentum leave no doubt as to its malignancy.

Alban Doran reports a case of sarcoma developing in the wall of a cyst of the urachus. This is so interesting that I shall also record it in detail.

Sarcoma Probably Developing in the Sheath of the Urachus. — Frank* gives a good resume of the literature and reports the case of a boy eleven years of age. For several weeks he had had loss of appetite and was losing weight. About fourteen days before the boy came under observation the father noticed a swelling in the umbilical region, and from a small opening at the umbilicus a little pus could be pressed. There was no urinary difficulty and no discomfort on defecation. The urine, however, had recently became cloudy and stringy. The child's mother had died of pulmonary disease, otherwise the family history was good.

On examination the boy was found to be strong and well nourished. In the umbilical region was a hard, circumscribed thickening, only slightly painful on pressure, reaching about a fingerbreadth above the umbilicus. Here it could be traced three fingerbreadths to the right and to the left of the linea alba. Below it extended almost to the symphysis. The skin over the tumor was only slightly movable. A sound introduced into the sinus passed from 4 to 6 cm. downward. With a sharp curette friable, sanguineopurulent masses were removed. These on examination were found to consist of pus-cells, granulation tissue, and debris.

Operation. — An elliptic incision was made, commencing 3 cm. above the umbilicus. The recti muscles at the umbilicus were found to be infiltrated by the growth. The incision was then carried through healthy muscle to the peritoneum. Loops of small bowel were adherent to the peritoneal surfaces of the tumor, and nodules were found scattered throughout the omentum. The tumor was gradually turned out ward and was removed without much difficulty. Its lower end was intimately adherent to the bladder, and the outer walls of this viscus were removed and the small opening in it was closed. The omentum was removed on account of the tumor nodules. The abdomen was closed with difficulty. The patient's recovery was slow.

The tumor, on section, was found to have invaded the recti in all directions. Its chief extension was along the course of the urachus as far as the bladder. The tumor itself, with the surrounding parts, was as large as a man's fist, and was nodular and uneven.

  • Frank, Theodor: Zur Casuistik der Urachustumoren. Inaug. Diss., Wurzburg, 1893.


MALIGNANT CHANGES IN THE URACHUS. 635

On microscopic examination the sarcomatous character of the tumor was evident. In the center of the tumor the intercellular substance was most marked, but toward the periphery it consisted almost entirely of spindle-cells with little connective tissue. The growth of the spindle-cells into the recti and into the bladder was especially evident. The entire picture indicated that the tumor had developed in the connective-tissue layers of the urachus and that it had then spread out in all directions.

The case is perfectly clear, but there is no after-history beyond two months, and no description of the omental nodules.

AUniqueSpecimenofCystic Sarcomaof the Urachus.* — Alban Doran says: "Mr. F. S. Eve has presented to the Museum of the Royal College of Surgeons of England a unique specimen of cystic sarcoma of the urachus, and has kindly supplied me with the following notes :

' ' A man, aged thirty-eight years, was admitted into the London Hospital with a swelling in the hypogastrium noticed for several weeks and associated with pain after micturition. A cystic tumor filled the lower part of the abdomen, especially to the right, where it extended toward the loin. It did not dip into the pelvis. On puncture, dark blood came away; a few days later a rigor occurred, with vomiting and a rise of temperature to 104° F. Mr. Eve then operated, exposing a large cystic tumor; the parietal peritoneum was reflected over its anterior and superior surfaces. Five pints of dark, bloody material were removed. The cyst adhered to the omentum, which bore engorged veins, and to an inch and a half of small intestine which was infiltrated where adherent. The adherent portion of the wall of the gut was excised, and the wound closed with sutures. The lower part of the cyst was intimately connected with the bladder, the serous coat of which organ was reflected onto its surface. This peritoneal covering was divided, and the cyst carefully dissected away from the bladder. During the process the bladder was opened, for the vesical wall at this point was so thin that the cavities of the cyst and the bladder were only separated by the vesical mucous membrane covered by a few muscular fibers. The opening was sutured, but not without great difficulty, owing to the thinness of the walls at this point. The sutures were further protected by gauze packing. A gauze drain was passed into the pelvis, and a catheter retained for a while in the bladder. Neither flatus nor feces could be made to pass after the operation, and the patient died on the fourth day. There was no general peritonitis, but the pelvic peritoneum had become inflamed at the point where the gauze had been applied.'

"Mr. Eve examined the specimen and found that it was a large allantoic cyst separated from the posterior superior surface of the bladder by nothing except a very much thinned mucous membrane. Their cavities, however, did not. communicate. The inner wall of the cyst was lined at certain points with very vascular polypoid masses, which proved to be, on microscopic examination, sarcomatous. The most unusual feature of this cyst was its malignancy, but its peritoneal relations were of greater importance in respect to the subject of this communication."


AN EXTRAPERITONEAL ABDOMINAL TUMOR. The following interesting case, the specimen from which was exhibited by Dr. Aveling, may be considered here, although from the description one could not say

  • Doran, Alban H. G.: The Lancet, 1909, i, 1304.


636 THE UMBILICUS AND ITS DISEASES.

that the growth was a sarcoma. It may serve, however, to form the nucleus around which similar cases may be collected.

Dr. Aveling* exhibited before the British Gynecological Society a subperitoneal tumor which had grown in the anterior abdominal wall and reached from two inches above the umbilicus to the pubes. It was removed after death, the patient having succumbed after an exploratory operation. Sir Spencer Wells, who saw the tumor, said he had seen only two similar cases, and he classified the tumor, according to Virchow, as a fibroma molluscum cysticum abdominale. The specimen was referred to Mr. Bland-Sutton and Dr. Aveling for further examination.

The tumor was ovoid in shape, and measured 10 inches in length, 7 inches in width, and weighed 4% pounds. It was surrounded by a distinct, thick, fibrous capsule. On section the tissue was of a dirty white color, and the cut surface looked like a sponge. The loculi were filled with gelatinous tissue, which readily broke down on scraping the cavities with the handle of a scalpel. Inside the growth six or seven hard nodules, of the size of walnuts, could be felt. These, when dissected out and divided, looked like small leiomyomata, such as occasionally exist in the uterus. They presented the same whorled arrangement of the fibers, and corresponded with them histologically. On microscopic examination of the tumor the outer portion was found to consist of non-striped muscle-fibers, some of large size. Internal to this the cells assumed more the shape and characters of those seen in spindle-cell sarcomata, while the gelatinous material contained in the loculi was the result of mucoid degeneration of the sarcomatous elements.

Sutton and Aveling then go on to say that the specimen was of great interest from an etiologic standpoint. "Man, in common with other mammals, possesses a persistent pedicle of the allantois, familiar under the name of the urachus. This structure is frequently found dilated into a cyst, usually of small size. An account of these allantois cysts, with reference to a few recorded cases, will be found in the Path. Soc. Trans., xxxvi, 523." They drew attention to the fact that Mr. Lawson Tait, in his work on Diseases of the Ovaries, had described certain growths which he regarded as probably originating in the urachus, and which attained such considerable dimensions as to require operative interference.

They thought that, in the present case, they had to deal with an allantois cyst, the walls of which had become sarcomatous, thus affording another illustration of the great tendency exhibited so often by aberrant and ill-developed structures to become the seat of morbid growths, such as sarcoma or carcinoma.

[After a somewhat careful study of the literature on the subject of umbilical tumors, the interpretation of Bland-Sutton and Aveling is not altogether clear. It would rather seem as if we are dealing with a myoma. The gross description speaks of non-striped muscle, and this the histologic picture substantiates. The gross and histologic appearance of the nodule coincides with the appearances presented by uterine myomata. The areas that were supposed to be sarcomatous and inclosed cavities presenl ing a m ucoid appearance might very readily have been due to hyaline degeneration. Without an opportunity of examining their specimen we should hesitate to express any definite opinion as to this case, further than that their interpretation does not seem to tally with the recorded cases of secondary growths attributed to the allantois. — T. S. C]

Doran* says that Aveling and Bland-Sutton had already reported a case of

  • Aveling: Brit. Gyn. Jour., 1886-87, ii, 56 and 187.

t Doran, Alban H. G. : The Lancet, 1909, i, 1304.


MALIGNANT CHANGES IN THE URACHUS.


637


multilocular myxosarcoma of the sheath of the urachus, but it did not involve the urachal canal, and was quite unconnected with the bladder. The specimen (No. 417 b) in the pathologic series of the Museum of the Royal College of Surgeons of England was supposed, when first examined, to have developed in the urachus, but Mr. J. H. Targett considered that it was a myxosarcoma which had originated in the connective tissue surrounding the bladder.

After I had made my comment on Aveling and Bland-Sutton's case, Alban Doran's note on the case came to my notice, clearly showing a lack of unanimity of opinion among those who had examined the specimen, not only as to the exact character of the tumor, but also as to its precise source of origin.


Multilocular urachus cvsi


Omentum, adherent" to tumor



Fig. 257. — A Multilocular and Malignant Cyst of the Urachus. Gyn.-Path. Nos. 10368 and 1048S. The cyst lay between the abdominal muscles and the peritoneum of the anterior abdominal wall. Below it was attached by a pedicle near the top of the bladder. Upward it extended for a considerable distance above the umbilicus. The omentum was densely adherent to its upper surface. The cyst -wall anteriorly was so thin that I cut it, thinking that it was peritoneum. The cyst is composed of one large and many smaller cavities. Projecting into the large cyst are many smaller cysts, and papillary and solid growths spring from the inner surface of the cyst. Some of the smaller cysts have smooth walls, as is well seen in the one near the pedicle of the tumor. Cross-sections of other small cysts show that they are partially filled with secondary growths. It will be noted that the uterus, tubes, and ovaries are absolutely independent of the cystic tumor. They are, however, partially covered over with secondary cancerous nodules. (For the histologic appearances in this case see Figs. 261, 262, 263.)


A LARGE MULTILOCULAR CARCINOMATOUS CYST OF THE URACHUS; SECONDARY

GROWTHS IN THE PELVIS.

I saw Mrs. W. W., aged thirty-seven, in consultation with Dr. E. S. Mann, of Dallastown, Pa., and had her admitted to the Johns Hopkins Hospital, October 6, 1906. This patient had never been pregnant. Her menses had commenced at fourteen and had always been regular until the previous year. Her last period had occurred sixteen months before admission. About two years before I saw her,


638


THE UMBILICUS AND ITS DISEASES.


she had noticed, on moving, a sharp, sticking pain in the left lower abdomen. For about a year and a half she had had some abdominal enlargement, and eight weeks before admission the abdomen had commenced to swell a great deal. The feet and legs had also been swollen. The patient gave a history of having lost 20 pounds in


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the past six months. She had had dysuria, and had had to void four or five times during the night.

On admission it was noted that she was a well-nourished woman, weighing 172 pounds. The abdomen was markedly distended. It rose rather abruptly from the symphysis to the umbilicus, and then gradually shaded off to the xiphoid. On


MALIGNANT CHANGES IN THE URACHUS.


639


percussion fluid was evident in all parts of the abdomen. About two months before she had noticed large and small lumps in various parts of the abdomen. Some of these were fully an inch in diameter, and they had sharp edges.







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Fig. 259. — Giant-cells in the Wall of an Adenocarcinoma of the Urachus. ( X 90 diam.) Gyn.-Path. Nos. 10368 and 104SS. At a is a slit-like space lined on both sides with a large giant-cell. The nuclei of the giant-cells are irregularly distributed and stain deeply. Extending from one end of the space to the other is a delicate strand. This, under a higher power, was found to contain two small nuclei. At b is an irregular oblong space with a large giant-cell in the center of its upper margin, and an irregular mass of protoplasm containing numerous nuclei bordering its lower margin; projecting into the cavity from either end are delicate filaments of stroma devoid of nuclei. At c is a series of parallel slits. The tissue at this point consists of hyaline material. Most of these slits have no lining whatsoever, but both the upper and lower slit have small giant-cells attached to their margins. At d is a slit-like space lined with giant-cells, e is a giant-cell that could be clearly focused at another level. It was irregularly triangular in shape, and contained a quantity of oval, uniformly staining nuclei arranged chiefly at one end of the cell. There were other giant-cells scattered throughout the field. The protoplasm of some of these was brownish in color, apparently owing to the absorption of old blood-pigment. The stroma of the cyst-wall in this region consisted of fibrous tissue. In the vicinity of these giant-cells and in the neighborhood of the slit-like spaces it showed a great deal of hyaline trans formation; many of the small round-cells that still persisted were swollen and contained a yellowish or brownish pigment — undoubtedly caused by old hemorrhage.


On pelvic examination the cervix was found to be perfectly normal; nothingfurther could be made out.

Operation (October 8, 1906). — On opening the abdomen I immediately came


640


THE UMBILICUS AND ITS DISEASES.


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MALIGNANT CHANGES IN THE URACHUS. G41

in contact with the contents of a cyst. This cyst was large, multilocular, and intimately adherent to the anterior and lateral abdominal walls (Fig. 257). At first I thought it was impossible to remove it, but on continuing the incision upward we entered the general peritoneal cavity. I then delivered the tumor from above downward. Its pedicle sprang from the top of the bladder. This pedicle was 1 cm. broad and 2 mm. thick. Raw areas were left, both on the anterior and lateral abdominal walls. The bleeding was checked by sliding over the peritoneum as far as possible, thus bringing the raw areas together and diminishing the size of the denuded space.

Both ovaries were normal in size, but were somewhat glued down to the pelvic floor. As the pedicle of the cyst sprang from the bladder, I thought it advisable to turn it in, fearing that there might be an opening between the bladder and the cyst. In the pelvis were metastatic deposits, some of them very minute, others irregular, somewhat translucent, and fully 1 cm. in diameter. The appendix was removed, and the abdomen closed. The patient was discharged November 5, 1906. In answer to an inquiry Dr. Mann wrote me that the patient died January 8, 1908.

Gyn.-Path. Nos. 10368 and 10488.— The cyst-walls vary considerably in thickness. At some points they are thin and transparent; at others they reach the thickness of about 2 cm. These solid areas also contain cysts, and in the small cysts is a blackish-colored fluid. The entire specimen is vascular, and in some places friable and apparently malignant.

On histologic examination the walls are found to consist in part of fibrous tissue, with a definite laminated arrangement. In many places necrosis has taken place, and the tissue presents a homogeneous appearance or takes the stain very poorly. At other points in the walls the connective-tissue cells have taken up much brown pigment, evidently from a long-standing hemorrhage. Here and there throughout the walls are slit-like spaces, the smaller ones surrounded by giant-cells * (Fig. 258) . The giant-cells really consist of large masses of protoplasm containing oval or round, deeply staining nuclei (Fig. 260), and some of these nuclei are four or five times the size of the surrounding ones. Where the cavities are larger, giant-cells may be seen clinging to one side of the cavity, other portions of the cavity being devoid of a lining (Fig. 259). At certain points are aggregations of giant-cells, and interspersed are small, slit-like spaces. One is instantly reminded of the giant-cells and slit-like spaces noted by Bondi, and on careful examination we found here and

  • I am fully aware of the frequency with which foreign-body giant-cells are prone to occur

in the walls of certain cysts and elsewhere, but the giant-cells in this case are rather unusual, hence I have described them more or less in detail.


Fig. 260. — Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Ukachus. ( X 90 and 300 diam.) Gyn.-Path. Nos. 10368 and 10488. A. a seems to be a large, gland-like space filled with coagulated blood and exfoliated epithelium. It is lined with one layer of low cuboid epithelium, well seen at b. c is a large blood-vessel. Scattered throughout the stroma of the cyst-wall are giant-cells and quite a number of slit-like spaces lined with giantcells. Traversing the slit-like spaces (d) are delicate strands, one of which contains very small nuclei.

B. This shows an enlargement of the oblong area in A. The stroma consists of fibrous tissue. At a is a nest of cancer-cells which has retracted from the surrounding connective tissue. 6 is a deposit of calcareous material near the wall of a blood-vessel, c and d are slit-like spaces, c is lined with a ribbon of protoplasm showing nuclei scattered fairly evenly throughout it. It is impossible to detect any division of the protoplasm into individual cells. The space d is lined with a wide zone of protoplasm showing many nuclei, uniform in size and staining properties, equally distributed throughout the protoplasm, e is another slit-like space lined with a ribbon of protoplasm containing only a single row of nuclei. 42


642


THE UMBILICUS AND ITS DISEASES.


there crystals lying in the cavity, such as were also found by Bondi. Other portions of the tumor show gland-like spaces lined with one or more layers of epithelium (Fig. 261). The nuclei of the epithelial cells are oval and vesicular, or are deeply staining, and the epithelium itself is of the low cylindric variety. In some places the epithelium has proliferated to a moderate extent. The gland arrangement in




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Fig. 261. — Adenocarcinoma op the Urachus. ( X 90diam.) Gyn.-Path. Nos. 10368 and 10488. The growth at this point bears considerable resemblance to a papillocystoma of the ovary; it consists of large and small irregular spaces lined almost exclusively with one layer of cuboid or low cylindric epithelium, a is a very good example of one of the spaces with a projection into it from the side. This space is lined with one layer of cuboid epithelium containing relatively round and deeply staining nuclei. These nuclei are particularly well seen at 6. The granular contents in the gland-spaces consist of coagulated epithelial secretion. The epithelial elements in the left lower part of the picture have to a large extent melted away. The fibrous stroma of the growth contains very few nuclei, c is one of the blood-vessels in the stroma. From this picture alone one could not tell definitely whether the growth was malignant or not. That it is malignant, however, is definitely settled by a reference to Kig. I'll:',, and also by the fact that at operation metastases were found.


some places suggests a papillary formation (Fig. 262), and the gland cavities are filled with a homogeneous material that takes the eosin stain. The epithelial cells at other points are almost flat. There does not seem to be much variation in the size of the cells, and such a picture alone would suggest a papillocystoma. At other points the epithelium has proliferated markedly, so that we have what


MALIGNANT CHANGES IN THE URACHUS.


643


appears to be solid nests; or the epithelium has melted away, as is noted in colloid carcinoma.

There is no doubt we are dealing with a multilocular cyst that has become malignant. This cyst certainly belongs to a rare type. Of the malignancy, there can be no doubt, because metastases in the pelvic peritoneum were noted at operation (Fig. 263). It did not spring from the ovaries, as they were perfectly normal in






Fig. 262. — A Papillary- like Area in an Adexocarcixomatous Cyst of the Urachus. (X 90 diam.) Gyn.-Path. Nos. 10368 and 10488. The picture is a rather confused one. At a the complex papillary mass is seen covered with one layer of cuboid epithelium having round, uniformly staining nuclei. At b are two definite glandlike spaces. At c is a bluntish projection of the stroma into a gland-space, d indicates the stroma, consisting of spindleshaped connective-tissue cells. The gland-spaces are filled with a granular, homogeneous material seen at e. (For the appearances of the metastases see Fig. 263.)

size and distant from the growth. Its pedicle, as noted from the history, sprang from the top of the bladder. It will further be noted that during the removal of the tumor a large part of the peritoneum of the anterior and lateral abdominal walls had to be sacrificed. This tumor evidently originated from the urachus.

The mode of origin of the giant-cells has been of especial interest to me. It will be noted that these giant-cells have been found almost entirelv in the outer con


644


THE UMBILICUS AND ITS DISEASES.


nective-tissue wall of the large cyst, and that the cavities that they line are slitlike. This is particularly well seen in Fig. 258. Furthermore, in the vicinity of these slit-like spaces are well-formed giant-cells lying completely surrounded by stroma (Fig. 258, b). On examining the space b in Fig. 259, one gathers the impression that the tissue has been especially brittle, and that during the process of hardening the giant-cells may have split lengthwise; this impression is still further strengthened by examining the area c in Fig. 259. Here the protoplasm has apparently been split up into several long strands. At the upper end of this



Fig. 263. — Metastasis from Adenocarcinoma of the Urachus. ( X 90 diam.) Gyn.-Path. Nos. 10368 and 10488. o and a are blood-vessels. Scattered throughout the field are nests of epithelial cells. Although originally the growth was glandular, the metastases have tended to form solid nests. At 6, however, two gland-like spaces can be faintly made out. During the process of hardening the cancerous tissue tended to retract from the stroma. This is especially well seen at c. The stroma of the growth showed considerable small-round-cell infiltration.


area there is an intact giant-cell. The finer structure of the giant-cell is well seen in Fig. 260, B, d.

In an examination of a large number of ovarian cysts I have never seen a picture analogous to the one here depicted. To be sure, in very young dermoid cysts of the ovary, giant-cells are the rule, but here they are invariably lining or clinging to the walls of small cysts — such giant-cells are the embryonic stages of squamous epithelium.

Dr. William H. Welch informed me that he had occasionally seen giant-cells


MALIGNANT CHANGES IN THE URACHUS.


645


similar to these in the walls of cysts and elsewhere, and suggested that they might be foreign-body giant-cells. He further suggested the possibility of their developing around crystals. On careful examination of many giant-cells I found just one crystal. This was irregular in form. Whether the giant-cells in this case are foreign-body cells or not I cannot say. This point, of course, is of interest only to the pathologist.

Bondi reported a small umbilical cyst of unknown origin. He found quantities of giant-cells analogous to those here depicted (Fig. 266), and in his case some of the giant-cells surrounded crystals. Although his cyst was not malignant, it is of such interest in connection with my case that I shall here report it somewhat in detail.


A RARE UMBILICAL CYST. Bondi* reports this case from Schauta's clinic. The patient was a woman, sixty-two years of age. She had had three normal labors. About twenty months before coming under observation she noticed that the umbilicus was larger than usual,




pi.


>F


Fig. 264. — An Umbilical Cyst. (After Bondi.) The original tumor was 5 cm. in diameter. The drawing has been made from the hardened specimen, which was much contracted. Nearly two years before operation the patient had noted an enlargement at the umbilicus. The overlying skin was brownish in color, tense, and elastic. It was slightly compressible. H is the skin covering the cyst; Nr, the confines of the umbilical depression; P, a prolongation of the peritoneal cavity into the mass. The walls of the cyst were composed of two layers — an outer, consisting of whitish tissue, and an inner, homogeneous zone, grayish brown in color. The cyst contents were spongy, yellowish brown, and soft. (For the histologic picture see Figs. 265 and 266.)


Fig. 26.5. — Wall of an Umbilical Cyst. (After Bondi.) This is a section of the cyst-wall seen in Fig. 264. H represents the skin, with connective tissue immediately beneath it ; B, a dense layer of connective tissue. Rx, granulation tissue. In this are areas containing small spaces. These spaces, as seen in Fig. 266, are lined with giant-cells. The cells in this layer contain blood-pigment. The inner surface (F) consists of coarse and fine threads of fibrin.


and that the abdomen had increased in size. She had never noticed a tumor projecting outward beyond the level of the umbilicus.

At operation, at the umbilicus was a tumor 5 cm. in diameter, the skin over it being brownish in color. It was tense and elastic, showed no marked fluctuation, and was slightly compressible. The abdominal enlargement was due to a multilocular ovarian cyst the size of a man's head, with torsion of the pedicle to the extent of 180 degrees; the wall of the cyst was partially necrotic.

  • Bondi, J.: Zur Kasuistik der Nabelcysten. Monatsschr. f. Geb. u. Gyn., 190.5, xxi, 729.


646 THE UMBILICUS AND ITS DISEASES.

In the hardened specimen the umbilical cyst was 2.5 cm. in diameter. It lav over an outward prolongation of the abdominal cavity, much as a cap

would fit (Fig. 264). The walls of the

.v^^T^^- c y s ^ nac * two layers, the outer consist ■ > .'! "•' <. j n g f whitish tissue 2 mm. thick. It

V, ' /Sl'Vi* y&SZ?' "I "".s*' "' was adherent to the skin and to the

  • ." 'Mi' 1 ^,^ *is*» peritoneum, and the inner zone consisted

\ ii ^ v -F~'~' u; $?l£'Z •^N;* of a broad, homogeneous, gray-brown H%» . -, - : ^ tissue. The cyst contents were spongy, % %\Sj ! /<?^j.- M ?^ ,; l||-: yellowish brown, and soft. Its length } » ;f ' "^/v^C — *^^ in the hardened specimen was 2.5 cm., ^ l*^/j§^- '^" "<#^ : f and its greatest thickness, 1.5 cm. The v\'%fj|&/^/; )' ^,;f.-."--^'* *£• V outer wall of the cyst consisted of fibrous ,Ui ^ ^-^^^'v^^ tissue, which gradually passed over into s^- •*'-'* v *|^' the inner, homogeneous lining, consist'* V *'^ ;* 'o» '"■* ing of young fibrous tissue. This gradu"*%t£ j , v-** ally merged into the granulation tissue

  • " **- bx which lined the cavity. The granulation

fig. 266.— Giaxt-cells in the Wall of an u.mbili- tissue here and there contained blood-pigon i.) ment. Here and there near the inner

Scattered throughout the inner wall of the cyst

(Fig. 26.5) were aggregations of small, siit-iike spaces. surf ace were numerous spaces, often oc Some of these are lined with one layer of epithelium, CU lTmg ill groups. These Were regularly

others with giant-cells. The nuclei of the giant-cells .... ,-,-,. __ _ . o^^x

are uniform and fairly evenly distributed throughout lmed With giailt-CellS (t lgS. 265 and 266) .

the protoplasm. j n t nese spaces were crystals showing that

the spaces were not artefacts. Bondi says that it was not a dermoid, but a peritoneal cyst, into which a hemorrhage had occurred.

It is possible that these giant-cells were foreign-body giant-cells. As already pointed out, they bear a marked resemblance to those noted in the malignant cyst of the urachus I have just recorded so fully. (See Figs. 258, 259, and 260.)


LITERATURE CONSULTED ON MALIGNANT GROWTHS OF THE URACHUS AND URACHAL REGION.

Aveling: Brit. Gyn. Jour., 1886-87, ii, 56, 187.

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

Doran, A.: Stanley's Case of Patent Urachus with Observations on Urachal Cysts. St. Bartholomew's Hospital Reports, 1898, xxxiv, 33.

Doran, A. H. G.: Urachal Cyst Simulating Appendicular Abscess; Arrested Development of Genital Tract; with Notes on Recently Reported Cases of Urachal Cysts. The Lancet, 1909, i, 1304.

Fischer, H.: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, N. F., No. 89 (Chir. No. 24), Leipzig, 1894, 519.

Frank, T.: Zur Casuistik der Urachustumoren. Inaug. Diss., Wurzburg, 1893.

Graf, F.: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896.

Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch. der Heilkunde, 1870, xi, 373.

Koslowski, B. S. : Ein Fall von wahrem Nabeladenom. Deutsche Zeitschr. f. Chir., 1903, lxix, 469.

Rotter: Blasencarcinom kombinirt mit Urachuscyste. Centralbl. f. Chir., 1897, xxiv, 604.

Wolff, C. C. : Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873.


CHAPTER XXXVIII. BLEEDING FROM THE URACHUS INTO THE BLADDER.

The literature on this subject is a negligible quantity. W. Ramsay Smith * reports a case which, although somewhat obscure, may be mentioned here.

The patient, a female infant, was born August 3d. The labor was short, and the child brought away with forceps. The cord appeared to be normal. On the second night, August 5th, a large quantity of bright-red blood was noticed on the infant's binder. It appeared on that night only, and the nurse noticed that it was coming not from the cord,- but from the umbilicus at the side of the cord. Two days later (August 7th) the child had an attack of diarrhea, and there was a good deal of blood in the stools, and it was noticed that this blood was coming from the urethra. On August 8th the bleeding was very severe, there being over two teaspoonfuls at a time. The blood always appeared when the bowels moved, but it came from the urethra. The diarrhea ceased, and the bleeding stopped on August 9th. Smith thought that the bleeding took place from the hypogastrics, and escaped to the bladder along the urachus. Ballantyne felt somewhat reluctant to accept this explanation, but said that, under the circumstances, it was difficult to suggest any that was more satisfactory.

A few years ago, while discussing diseases of the umbilical region with Dr. Edward Reynolds, of Boston, he mentioned the fact that on several occasions he had noted bleeding from the urachus into the bladder. Later I wrote asking him kindly to furnish me with the data he had bearing on the subject. His reply was as follows :

"With regard to my recent hematuric case, the patient was a physician about thirty-five years old, from whom I removed the appendix about two years ago. She came to me on the seventh of February, saying that, after very hard and long automobiling over rough country roads a few days before, she had been seized by a sudden urgent desire to urinate, and had passed a quantity of bloody urine. Since then urination had been normal, but the urine was slightly blood-stained. She informed me that she had noticed that the first part of the urine was clear and that the blood came with the last few drops. When I first looked into her bladder the small amount of urine was clear (she had just emptied it). I inspected the trigonum and fundus of a normal bladder carefully in the knee-chest position, and, on turning the point of the cystoscope forward, found that in the interval the urine had become distinctly pink. I then emptied the bladder thoroughly with the evacuator, and saw a small stream of blood flowing from the orifice of the urachus. The patient has written me since that the hematuria stopped within forty-eight hours after her visit to me, and that there was no recurrence. I told her that I thought there was no other treatment than the removal of the urachus; that I should not advise that unless the symptoms were persistent; that I should advise

  • Smith, W. Ramsay: Obstet. Trans., Edinburgh, 1892-93, xviii, 53.

647


648 THE UMBILICUS AND ITS DISEASES.

it if the hematuria were recurrent. I asked her to keep me informed of her progress, and I think that she will do so.

This is not my first case of the kind. A good many years ago, when I was doing a large out-patient clinic and making a great many cystoscopic examinations, I saw a number of cases, I should guess from half a dozen to a dozen, in which minor vesical symptoms seemed to be associated with a reddened, eroded condition of the vesical mucous membrane immediately about a small orifice in the upper and anterior part of the bladder, which, after some study, I grew to consider as the orifice of a patent urachus, and which, on close inspection, I could recognize in a considerable proportion of bladders in which it was not making trouble. I believe that this slight anomaly is very common, and that it is a not unimportant lurking-place for bacteria in infected bladders. In at least two cases in these old days I saw bleeding from this orifice; I think in more than that number, but the conditions of the clinic made careful record keeping very difficult. I should say that the hematuria was transient but recurrent. I do not know the ultimate outcome. The patients in that clinic were all of a class which it is difficult to follow up afterward."

Dr. Reynolds' observation clearly demonstrates that in some cases blood does escape from the persistent urachus into the bladder. His suggestion that the urachal opening is probably the lurking-place of bladder infections is fully borne out by the cystitis frequently noted where a partially patent urachus exists.


CHAPTER XXXIX. TUBERCULOSIS OF THE PATENT URACHUS.

I have been able to find only two cases of this character in the literature. The first case was recorded by Briddon and Eliot, the second by Eastman.

Dr. Thacher, who made the pathologic report on the extirpated urachus in Briddon and Eliot's case, after giving a very careful and guarded description, decided that the condition was probably tuberculous. Dr. Eastman sent us his specimen and we have been able to demonstrate tubercle bacilli in the urachus.

"Tubercular Degeneration of the Patent Urachus in the Adult.* — R. M., aged nineteen, Roumanian; married. Admitted July 17, 1899. No tubercular family or personal history. The patient has always been well until five weeks ago, when she began to have slight pain, with heat, redness', and swelling in the region of the umbilicus, the navel having previously been always normal in appearance. The symptoms increased for two weeks, at the end of which time there was a small red tumor, the size of a pea, in the region of the umbilicus. During this time the patient suffered intensely from severe, sharp pain, almost constantly present, in the hypogastric region, with well-marked vesical tenesmus, increased frequency of micturition (often voiding urine every hour), and occasionally a small amount of blood in the urine. At the end of the two weeks the swelling opened spontaneously, discharging some cloudy fluid with a uriniferous and foul odor, the pain and swelling soon subsiding. About four days after the discharge of fluid at the umbilicus, she ceased to pass water normally, and since then she has had a constant discharge of cloudy fluid of a uriniferous odor, at times slightly blood-stained, through the opening at the umbilicus. She has lost considerable flesh and strength during the period of five weeks.

"Physical Examination. — The patient is markedly anemic and is apathetic. The facies is flushed; the tongue is moist and not heavily coated. The superficial glands are not enlarged. In the heart there is a hemic murmur over the pulmonic area, systolic in time. Percussion of the lungs is normal, but the breathing is rather poor. The abdomen is soft, retracted, and no masses can be felt. At the inferior portion of the umbilicus is a small sinus with everted and ulcerated edges, which discharges a seropurulent fluid of uriniferous odor. A probe introduced into the sinus goes downward and extends evidently as far as the bladder. The bladder does not percuss high, but there is some tenderness on pressure over the suprapubic region. Urine analysis at the time of admission showed very turbid and cloudy urine, with specific gravity of 1014, 15 per cent of sediment, reaction strongly alkaline, and odor foul and ammoniacal. There was 10 per cent of albumin, no blood, a large amount of mucus, much pus, and many vesical cells, with many crystals of triple phosphate. No casts were found. She was placed upon bladder irrigations twice daily, with warm 0.5 per cent, boric-acid solution, and salol (gr. v)

  • Briddon, C. K., and Eliot, E.: Med. and Surg. Reports, Presbyterian Hospital, New York,

January, 1900, iv, 30.

649


650 THE UMBILICUS AND ITS DISEASES.

three times a day. There was no improvement under this treatment, either in the character of the urine or in the patient's general condition, except that she had slightly less pain. At the end of a week the bladder irrigation was changed to carbolic acid, in strength of 1 : 120. This also seemed to have no effect upon the urine, frequent examinations up to the time of operation giving about the same result. As at the first analysis, the specific gravity never rose above 1014; the urine always remained alkaline and was full of pus and mucus. The temperature course was irregular, varying between 99.5° F. and 102° F., and did not seem to be influenced in any way by the bladder washing. During a period of several days of fairly constant low temperature the patient gave a moderately characteristic tuberculin reaction. The average daily amount of urine voided by the urachus varied from 15 to 20 ounces. At intervals of several days she voided a few drams or an ounce of urine per urethram.

" Owing to the obstinate, unyielding cystitis, it was thought advisable to do a suprapubic cystotomy for purposes of drainage.

" Operation (August 25th) . — Dr. Eliot. Nitrous oxid and ether; asepsis; dorsal position. A catheter was introduced through the urethra into the bladder and urine was withdrawn. Four ounces of warm 1 per cent boric-acid solution were then gently thrown into the bladder by a fountain syringe, six ounces of water, injected into a Barnes dilator, having been previously inserted into the rectum. A 23^-inch median incision was then made above the pubis and deepened down to the space of Retzius. The soft cellular tissue here being pushed aside and the bladder presenting, two silk sutures were passed in a longitudinal fashion through its wall, separated by a distance of one inch, these sutures being placed for purposes of traction. The bladder was then opened between the silk sutures, the boricacid fluid pouring out into the wound. The incision in the bladder-wall being subsequently enlarged upward, disclosed the urachus opening into the fundus of the bladder. There were several small areas of ulceration on the posterior wall of the bladder, and parts of the ulcers, together with a portion of the urachus, were secured for microscopic examination. The ulcerated areas upon the bladder-wall were cauterized with a thermocautery. The lumen of the urachus was packed with a strip of iodoform gauze, the cavity of the bladder being drained through the suprapubic wound in the usual way by means of a tube.

"Report by J. S. Thacher, Pathologist.- — A. Minute fragment of tissue from urachus. Microscopic examination shows a mass of smooth muscle and connective tissue. The muscle-cells vary somewhat in size and shape, and are irregular in arrangement.

"B. Minute fragments from base of bladder. The epithelium is partly destroyed, and the tissues are much inflamed. The inflammation appears to be of some standing.

"The bladder was drained very satisfactorily for ten days by the siphon drainage apparatus, the suprapubic wound remaining comparatively clean and dry. The patient's temperature was increased for six days following the operation. Recovery was uneventful. Bladder irrigation with carbolic acid, 1:40, was employed, when the drainage apparatus was dispensed with, the urine clearing up slightly and the pain becoming much less severe. She seemed to improve in general health to a moderate degree. Urine was not voided normally after the suprapubic operation had been performed.


TUBERCULOSIS OF THE PATENT URACHUS. 651

"September 25th: Urine, for about one week, has had much less pus and mucus in it, and hypogastric pain has been much less severe. It was then decided to attempt an extirpation of the patent urachus, leaving the suprapubic wound unmolested.

"Operation (September 27th). — Dr. Briddon; nitrous oxid and ether; asepsis; dorsal position. A median incision was made from the umbilicus down to the suprapubic wound of the previous operation, exposing the linea alba, which was split up in the line of the incision, exposing granulation tissue forming the wall of the patent urachus. By blunt dissection this tissue was then dissected free from the underlying thickened peritoneum, during which process the urachus was opened longitudinally through a portion of its extent. The walls of the urachus were nearly a quarter of an inch thick, and their diameter was about half an inch. At its point of junction with the bladder it was cut transversely and removed, the general cavity of the peritoneum not being opened. A clean surface was thus left, whose floor was formed by the thickened peritoneum, and its sides by the divided portion of the linea alba. This tract was closed by eight interrupted chromic catgut sutures, passing from one side to the other through the skin and linea alba, thus approximating the raw edges of the tract. A sterile dressing was placed on the sutured wound, a rubber drainage-tube and iodoform gauze being left in the suprapubic wound.

" Report of J. S. Thacher, Pathologist. — Extirpation of patent urachus. Microscopic examination : Granulation tissue ; spots of marked infiltration by leukocytes; several small necrotic spots; many giant-cells; some tissue resembling tubercle tissue — probably tubercular.

" Recovery from the operation was uneventful. The bladder was drained satisfactorily for ten days, the wound for urachus extirpation healing by primary union without complication. Her general health rapidly improved, and she had gradually less hypogastric pain and discomfort. For a few weeks the patient voided no urine normally, all being discharged through the suprapubic wound. Since then she has passed almost every day one or more ounces of urine per urethram, in gradually increasing quantity. Her general condition is very much improved, the suprapubic wound is steadily closing, and urinary analysis now gives but 3 per cent, of albumin, with much less pus and mucus.

"Repeated examination of urine failed to discover any tubercle bacilli, and careful physical examination by G. A. Tuttle failed to detect any evidence of pulmonary or other visceral tuberculosis.

"Examination conducted by Dr. Tuttle, in the pathologic laboratory, of the small ulcers which were excised from the wall of the bladder at the time of the first operation, failed to yield positive indications of tuberculosis; conclusive evidence at last was furnished by the examination by Dr. Thacher of the urachus itself, removed by Dr. Briddon at the time of the second operation. Inferences are always uncertain, and although the statement that the tubercular process originated in the patent remnant of the duct itself is not entirely justifiable, nevertheless, the fact remains that examination of its wall after removal showed much more abundant evidence of tuberculosis than did the portion of the bladder-wall removed earlier by suprapubic cystotomy."

In the case under discussion the removal of the urachus was accomplished without opening the general peritoneal cavity.


652


THE UMBILICUS AND ITS DISEASES.


I was particularly anxious to see a section from this case, and accordingly wrote Dr. Thacher. In his reply, dated New York, April 8, 1914, he gave me the results of his examination, but said the original slide could not be located.

Tuberculosis of the Urachus.* ■ — Dr. Eastman has just recorded a very interesting case of tuberculosis of the urachus in a girl aged nineteen.

"Family History. — Father died of cancer of the stomach at the age of fifty-one; one brother died during infancy of meningitis; history otherwise negative, particularly as relates to tuberculosis or neoplasms.



Fig. 267. — Tuberculosis of the Urachus.

This is a low-power photomicrograph from Dr. J. R. Eastman's case. At a is an area of caseation surrounded by tissue closely resembling that found in tuberculosis. The outer walls are composed of non-striped muscle and fibrous tissue. Scattered throughout this tissue are localized foci more or less characteristic of those noted in tuberculosis. The areas b and c are very suggestive of tubercles.

The high-power picture of the area b is shown in Fig. 268; that of the area c, in Fig. 269.


"Personal History. — Typhoid at seventeen with good recovery; history otherwise negative; patient married two years and four months; one pregnancy, child living and well; at no time night-sweats or protracted cough; no characteristic temperature history; no other evidences of tuberculosis.

"Menstrual History. — Menstruation began at twelve; regular; duration five days and free; no change in type since marriage or labor.

"Urination. — No increase in frequency, no nocturnal urination. Three diurnal urinations; never any blood or burning or stinging.

"History of illness for which patient entered hospital. — This trouble began ten

  • Eastman, Joseph Rilus: Amer. Jour, of Obstetrics, 1915, lxxii, 640.


TUBERCULOSIS OF THE PATENT URACHUS.


653


months before entrance. While working in the garden, pain was felt at a point in the mid-line of the abdomen between the symphysis pubis and the umbilicus. At this time patient noticed a lump at the point designated, the size of a small apple. There was not much actual pain nor soreness. The mass did not increase in size but the tenderness remained. This condition persisted for three months when a pin-point opening appeared in the mid-line of the anterior abdominal wall, half-way between the symphysis pubis and the umbilicus. This opening discharged a clear watery fluid for about a week. Then a serous crust closed the opening. The opening again discharged after about a week, continuing to do so for one week and again the crust was formed. This process of closing and opening continued for several months. The size of the tumor did not change. The tenderness still persisted. There had never been any disturbance of the bladder, intestines or uterus.


a

•1


b


x






d c

Fig. 26S. — An Area Suggesting a Tubercle. This picture is a high-power magnification of the area b in Fig. 267. Its confines are indicated by x and x. Scattered throughout this area are spindle cells and round cells. At a and b are giant-cells. At c the cells are so arranged as to suggest a small gland. At d is a large cell bearing a strong resemblance to a squamous cell.


The discharge had always been free from odor. She is positive that the discharge never had a urinous odor.

"Status Prsesens. — The patient's general health was unimpaired. Urinalysis and physical examination of the chest and abdomen were negative. There were no evidences of pulmonary tuberculosis nor of tuberculosis elsewhere. Through the discharging sinus below the umbilicus a small sound could be passed downward behind the symphysis pubis.

"Operation. — The fistulous tract, upon being dissected free, was found to pass downward from the discharging orifice, coursing in front of the peritoneum, crossing the space of Retzius and terminating in a thin cord attached to the anterior bladder wall in the median line and near to the vesico-urethral junction. Upon being split open the definite tube-like structure was found to be thin-walled, showing no evidence of inflammation or other pathological condition except near the external discharging orifice, where an ulcerated mass about 2 cm. in width was situate upon the dorsal wall of the tube.

"Cystoscopic Examination. — Bladder distended with 8 ounces of water for


654 THE UMBILICUS AND ITS DISEASES.

examination: vesical sphincter normal in outline; trigone normal; both ureteral openings and the mucosa surrounding them were normal as to contractility and rhythm. There were no ulcers, tubercles, or any other abnormalities upon the floor of the bladder. The vesical roof was examined carefully and this portion of the bladder was found to be absolutely devoid of any ulcer, tubercles, opening, or any other abnormality of the vesical mucous membrane; and there was not the slightest hint of any communication with the patent urachus.

"•Chemical and Microscopic Urinalysis. — After operation as before the urine was normal.

••Clinical Course since Operation. — "Wound closed slowly; there have been no






Fig. 269. — A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus.

This L= a high-power picture made by Mr. H. Schapiro from Fig. 267 at c.

The tubercle is oval in form and is fairly well differentiated from the surrounding stroma. The cells of the tubercle are spindle-shaped, oval, round, or irregular. In the lower part of the tubercle is a large giant cell containing a large number of nuclei arranged chiefly in its center. The grouping of the nuclei in this giant cell resembles to some extent that usually found in foreign-body giant cells, but the picture as a whole is strongly suggestive of tuberculosis.

symptoms of any kind relating to the genitourinary organs; there is no evidence of return of the disease."

I wrote Dr. Eastman asking if he could send me sections of the urachus. This he promptly did. An examination of them shows the following:

The central portion of the specimen consists of granular tissue containing a few cells. It looks very much like caseous tissue (Fig. 267a). External to this is a tissue made up of young connective-tissue cells and fairly large round cells with small round nuclei, and beneath this a zone containing a few giant cells. The outer wall apparently consists of non-striped muscle and connective tissue infiltrated with small round cells. In this are round or oval areas containing aggregations of epithelioid cells with giant cells scattered here and there throughout them [Figs. 208 and 269;. External to this zone is the surrounding adipose tissue. The entire picture strongly indicates tuberculosis of the urachus.

Dr. Benjamin O. McCleary and Dr. George L. Stickney have each independently demonstrated tubercle bacilli in the sections; consequently this is a definite of tuberculosis of the urachus.

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